REVIEW
Available screening tools for adults suffering from bipolar affective disorder in primary care: An integrative literature review Staci Hoyle, FNP-C (Graduate Student)1 , Lydia Elliott, DNP, FNP-BC (Assistant Professor)2 , & Linda Comer, PhD, RN, CNE, LPC (Interim Associate Dean)3 1
School of Nursing, Western Carolina University, Cullowhee, North Carolina MS(N) Family Nurse Practitioner Program, School of Nursing, Western Carolina University, Cullowhee, North Carolina 3 Graduate Programs, School of Nursing, Western Carolina University, Cullowhee, North Carolina 2
Keywords Bipolar disorder; manic; depressive; screening; diagnosis; primary care; mental health. Correspondence Staci S. Hoyle, FNP-C, 28 Schenck Pkwy, Ste 309, Asheville, NC 28803. Tel: 828-654-6499; Fax: 828-654-6507; E-mail: [email protected] Received: 26 February 2013; accepted: 4 March 2014 doi: 10.1002/2327-6924.12214
Abstract Purpose: To assess the efficacy of six tools utilized in primary care for the screening of bipolar affective disorder (BPAD). BPAD has historically been underdiagnosed or misdiagnosed followed by inappropriate treatment leading to detrimental relapses, suicide, and increased risks for comorbidities. Data sources: An electronic search was conducted to identify articles in the following databases: MEDLINE, CINAHL, Cochrane Library, ERIC, National Guideline Clearinghouse, PsycINFO, Psychology and Behavioral Sciences collection, and PsycARTICLES. Other information was also collected from the NIH, CDC, Healthy People 2020, the Black Dog Institute, and the Center for Quality Assessment and Improvement for Mental Health. Conclusion: Evidence indicates that primary care providers are often the first and sometimes sole provider, which signifies the importance of early detection and screening of BPAD in primary care. By implementing the use of appropriate screening tools and following recommended treatment and intervention guidelines, the prevention of relapse is increased, and comorbidities are more frequently diagnosed leading to an overall improved quality of life. Implications for practice: Primary care practitioners play a vital role in appropriately screening for BPAD and implementing the recommended treatments to increase prevention of relapse and promote a healthier and more socially successful quality of life.
Bipolar affective disorder (BPAD), once called manic depression, affects 2.6% of the population in the United States but less than 50% of this population receives treatment for the illness (National Institute of Mental Health [NIMH], 2011). It is one of the leading causes of disability and highly related to premature mortality or suicide (Healthy People 2020, 2011). BPAD is a mood disorder characterized by alternating periods of depression and mania or hypomania, and sometimes a mixed state of mania and depression. The mania phase of BPAD is manifested in a combination of psychotic symptoms and grandiosity in addition to the symptoms of hypomania, which makes it often more recognizable by the provider. Signs and symptoms of hypomania include reckless behavior, excessive activity, decreased need for sleep, racing thoughts, rapid speech, and elevated mood, but do not include psychosis and/or 280
grandiosity. Often the symptoms of hypomania are very subtle, and some people may describe themselves as having an “up-beat personality” or being “hyper,” making BPAD more concealed and challenging to identify. However, patients with BPAD most commonly present in the depressive phase, which makes identification and treatment all the more difficult. Some of the signs and symptoms of depression include persistent sadness, loss of appetite or overeating, loss of interest in activities, feelings of hopelessness, feelings of guilt or worthlessness, and thoughts of suicide. According to The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), the criteria for unipolar depression (UD) and the depressive phase in BPAD are the same, which often leads to a misdiagnosis of BPAD as depression (Kim, Wang, Son, Kim, & Joo, 2008). According to Miller (2006, p. 369), “unipolar depression is commonly Journal of the American Association of Nurse Practitioners 27 (2015) 280–289 C 2015 American Association of Nurse Practitioners
S. Hoyle et al.
diagnosed within the primary care setting, but research suggests that 30% of depressed and/or anxious patients in primary care may have a BD [bipolar disorder] instead....” Primary care providers (PCPs) are often familiar with the most commonly used screening tools for depression, including the Patient Health Questionnaire-9 (PHQ-9), the PHQ-2, and the Beck Depression Inventory. If PCPs are regularly using screening tools for depression, are there screening tools for BPAD readily available for use in primary care? With 26.2% of the U.S. adult population suffering from one or more mental illnesses, the primary care setting is the battleground under which screening for such illnesses must take place (NIMH, 2011). There are a limited number of BPAD diagnostic screening tools available in primary care including (a) the mood disorder questionnaire (MDQ), (b) the hypomania checklist-32 (HCL-32; Poon, Chung, Tso, Chang, & Tang, 2012), (c) the bipolar spectrum diagnostic scale (BSDS; Ramsley, 2007), (d) the mood swings questionnaire (MSQ; Black Dog Institute, 2012), (e) the composite international diagnostic interview (CIDI) screening scale for bipolar spectrum disorders (Center for Quality Assessment and Improvement for Mental Health [CQAIMH], 2007), and (f) the my mood monitor checklist (M-3; Gaynes et al., 2010). It is both reasonable and recommended for patients who present with depressive symptoms to be simultaneously screened for both BPAD and depression (Miller, 2006). There are multiple comorbidities associated with BPAD, such as hypertension, high cholesterol, diabetes, metabolic syndrome, coronary artery disease, and other mental illnesses (Kiraly, Gunning, & Leiser, 2008). People who suffer from BPAD often have problems with substance abuse, increased early mortality because of high-risk behaviors and comorbidities, and overall diminished healthy lifestyles (Kiraly et al., 2008). Treating BPAD alone can be overwhelming, but the combination of treating BPAD along with treating the multitude of accompanying problems can be a massive undertaking for any provider. Treatment for the BPAD client often includes the use of an antipsychotic or mood-stabilizing medication, which differs from treatment in the unipolar depressive client. If a client with BPAD is given antidepressants without an antipsychotic and/or mood stabilizer, then the risk for lapsing into a manic episode or committing suicide is highly increased. Thus, it is essential to diagnose BPAD as soon as possible to increase the likelihood of better outcomes for the patient. It is often necessary to pair drug therapy with adjunctive behavioral interventions, such as “cognitive behavioral therapy, caregiver support, [and] psychoeducation regarding the early warning signs of mood relapse” (Price & Marzani-Nissen, 2012, p. 488).
Available screening tools for adults suffering from BPAD
Cognitive behavioral therapy (CBT), developed by Dr. Aaron T. Beck, is a form of psychotherapy in which a therapist or provider work together with the client to learn patient-specific skills, which help them function better in society, such as “identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors” (Beck Institute for Cognitive Behavior Therapy, 2012, CBT Q&A, para. 2). Education regarding the “early warning signs of mood relapse include sleep disturbance, agitation, increased goal orientation, and a disruption in usual routine” (Price & Marzani-Nissen, 2012, p. 488) is paramount for both the client and the client’s family. Families and/or caregivers of client’s with BPAD often experience extreme stress and even depression, so it is important to remember that they are part of the client’s support system and may require assistance and encouragement from the provider. There are a multitude of support groups available for both the client and the caregiver ranging from local chapters to online social networking groups often dependent upon location. Other adjunctive therapies include electroconvulsive therapy (ECT), ultrabrief pulse treatment, social rhythm therapy, and some complementary alternative therapies such as meditation, yoga, and acupuncture (Valente & Kennedy, 2010). ECT may be utilized for both unipolar and bipolar patients, but it is more commonly used with severe cases of UD and mixed states where depression and mania coexist. Ultrabrief pulse treatment is “a therapy in which the pulse width of the electrical stimulus is much briefer (
Available screening tools for adults suffering from bipolar affective disorder in primary care: An integrative literature review Staci Hoyle, FNP-C (Graduate Student)1 , Lydia Elliott, DNP, FNP-BC (Assistant Professor)2 , & Linda Comer, PhD, RN, CNE, LPC (Interim Associate Dean)3 1
School of Nursing, Western Carolina University, Cullowhee, North Carolina MS(N) Family Nurse Practitioner Program, School of Nursing, Western Carolina University, Cullowhee, North Carolina 3 Graduate Programs, School of Nursing, Western Carolina University, Cullowhee, North Carolina 2
Keywords Bipolar disorder; manic; depressive; screening; diagnosis; primary care; mental health. Correspondence Staci S. Hoyle, FNP-C, 28 Schenck Pkwy, Ste 309, Asheville, NC 28803. Tel: 828-654-6499; Fax: 828-654-6507; E-mail: [email protected] Received: 26 February 2013; accepted: 4 March 2014 doi: 10.1002/2327-6924.12214
Abstract Purpose: To assess the efficacy of six tools utilized in primary care for the screening of bipolar affective disorder (BPAD). BPAD has historically been underdiagnosed or misdiagnosed followed by inappropriate treatment leading to detrimental relapses, suicide, and increased risks for comorbidities. Data sources: An electronic search was conducted to identify articles in the following databases: MEDLINE, CINAHL, Cochrane Library, ERIC, National Guideline Clearinghouse, PsycINFO, Psychology and Behavioral Sciences collection, and PsycARTICLES. Other information was also collected from the NIH, CDC, Healthy People 2020, the Black Dog Institute, and the Center for Quality Assessment and Improvement for Mental Health. Conclusion: Evidence indicates that primary care providers are often the first and sometimes sole provider, which signifies the importance of early detection and screening of BPAD in primary care. By implementing the use of appropriate screening tools and following recommended treatment and intervention guidelines, the prevention of relapse is increased, and comorbidities are more frequently diagnosed leading to an overall improved quality of life. Implications for practice: Primary care practitioners play a vital role in appropriately screening for BPAD and implementing the recommended treatments to increase prevention of relapse and promote a healthier and more socially successful quality of life.
Bipolar affective disorder (BPAD), once called manic depression, affects 2.6% of the population in the United States but less than 50% of this population receives treatment for the illness (National Institute of Mental Health [NIMH], 2011). It is one of the leading causes of disability and highly related to premature mortality or suicide (Healthy People 2020, 2011). BPAD is a mood disorder characterized by alternating periods of depression and mania or hypomania, and sometimes a mixed state of mania and depression. The mania phase of BPAD is manifested in a combination of psychotic symptoms and grandiosity in addition to the symptoms of hypomania, which makes it often more recognizable by the provider. Signs and symptoms of hypomania include reckless behavior, excessive activity, decreased need for sleep, racing thoughts, rapid speech, and elevated mood, but do not include psychosis and/or 280
grandiosity. Often the symptoms of hypomania are very subtle, and some people may describe themselves as having an “up-beat personality” or being “hyper,” making BPAD more concealed and challenging to identify. However, patients with BPAD most commonly present in the depressive phase, which makes identification and treatment all the more difficult. Some of the signs and symptoms of depression include persistent sadness, loss of appetite or overeating, loss of interest in activities, feelings of hopelessness, feelings of guilt or worthlessness, and thoughts of suicide. According to The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), the criteria for unipolar depression (UD) and the depressive phase in BPAD are the same, which often leads to a misdiagnosis of BPAD as depression (Kim, Wang, Son, Kim, & Joo, 2008). According to Miller (2006, p. 369), “unipolar depression is commonly Journal of the American Association of Nurse Practitioners 27 (2015) 280–289 C 2015 American Association of Nurse Practitioners
S. Hoyle et al.
diagnosed within the primary care setting, but research suggests that 30% of depressed and/or anxious patients in primary care may have a BD [bipolar disorder] instead....” Primary care providers (PCPs) are often familiar with the most commonly used screening tools for depression, including the Patient Health Questionnaire-9 (PHQ-9), the PHQ-2, and the Beck Depression Inventory. If PCPs are regularly using screening tools for depression, are there screening tools for BPAD readily available for use in primary care? With 26.2% of the U.S. adult population suffering from one or more mental illnesses, the primary care setting is the battleground under which screening for such illnesses must take place (NIMH, 2011). There are a limited number of BPAD diagnostic screening tools available in primary care including (a) the mood disorder questionnaire (MDQ), (b) the hypomania checklist-32 (HCL-32; Poon, Chung, Tso, Chang, & Tang, 2012), (c) the bipolar spectrum diagnostic scale (BSDS; Ramsley, 2007), (d) the mood swings questionnaire (MSQ; Black Dog Institute, 2012), (e) the composite international diagnostic interview (CIDI) screening scale for bipolar spectrum disorders (Center for Quality Assessment and Improvement for Mental Health [CQAIMH], 2007), and (f) the my mood monitor checklist (M-3; Gaynes et al., 2010). It is both reasonable and recommended for patients who present with depressive symptoms to be simultaneously screened for both BPAD and depression (Miller, 2006). There are multiple comorbidities associated with BPAD, such as hypertension, high cholesterol, diabetes, metabolic syndrome, coronary artery disease, and other mental illnesses (Kiraly, Gunning, & Leiser, 2008). People who suffer from BPAD often have problems with substance abuse, increased early mortality because of high-risk behaviors and comorbidities, and overall diminished healthy lifestyles (Kiraly et al., 2008). Treating BPAD alone can be overwhelming, but the combination of treating BPAD along with treating the multitude of accompanying problems can be a massive undertaking for any provider. Treatment for the BPAD client often includes the use of an antipsychotic or mood-stabilizing medication, which differs from treatment in the unipolar depressive client. If a client with BPAD is given antidepressants without an antipsychotic and/or mood stabilizer, then the risk for lapsing into a manic episode or committing suicide is highly increased. Thus, it is essential to diagnose BPAD as soon as possible to increase the likelihood of better outcomes for the patient. It is often necessary to pair drug therapy with adjunctive behavioral interventions, such as “cognitive behavioral therapy, caregiver support, [and] psychoeducation regarding the early warning signs of mood relapse” (Price & Marzani-Nissen, 2012, p. 488).
Available screening tools for adults suffering from BPAD
Cognitive behavioral therapy (CBT), developed by Dr. Aaron T. Beck, is a form of psychotherapy in which a therapist or provider work together with the client to learn patient-specific skills, which help them function better in society, such as “identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors” (Beck Institute for Cognitive Behavior Therapy, 2012, CBT Q&A, para. 2). Education regarding the “early warning signs of mood relapse include sleep disturbance, agitation, increased goal orientation, and a disruption in usual routine” (Price & Marzani-Nissen, 2012, p. 488) is paramount for both the client and the client’s family. Families and/or caregivers of client’s with BPAD often experience extreme stress and even depression, so it is important to remember that they are part of the client’s support system and may require assistance and encouragement from the provider. There are a multitude of support groups available for both the client and the caregiver ranging from local chapters to online social networking groups often dependent upon location. Other adjunctive therapies include electroconvulsive therapy (ECT), ultrabrief pulse treatment, social rhythm therapy, and some complementary alternative therapies such as meditation, yoga, and acupuncture (Valente & Kennedy, 2010). ECT may be utilized for both unipolar and bipolar patients, but it is more commonly used with severe cases of UD and mixed states where depression and mania coexist. Ultrabrief pulse treatment is “a therapy in which the pulse width of the electrical stimulus is much briefer (
