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10 Tips for Prescribing in the Perinatal Period

Perinatal person with baby

Psychiatric disorders are common during pregnancy and postpartum. For example, rates of perinatal depression and anxiety are 15-20%. Twenty percent of people with postpartum depression have a bipolar spectrum disorder. In addition, many people have pre-existing psychiatric conditions and are already taking psychotropic medications when they become, or are planning to become, pregnant. The overall goal of treatment during pregnancy is to use the lowest number and dosages of medications possible, while effectively treating the underlying psychiatric disorder(s).

Although the Perinatal PCL receives questions about diagnoses, non-medication treatments, and resources and referrals, many calls are about prescribing and the effects of medications during pregnancy and lactation. Here, we provide some general guidelines about prescribing during the perinatal period and some resources to find information about risks of specific medications.

What are some general guidelines about prescribing during the perinatal period?

1. Consider risks during pregnancy whenever prescribing medication for someone of childbearing potential.
About 50% of pregnancies are unplanned. Considering, and informing people of childbearing potential about, risks of their medication(s) during pregnancy helps to maximize prescribing of safer medications and avoid patients’ suddenly discontinuing needed medication if they find out they are pregnant.

2. Make any medication changes before pregnancy if possible.
This minimizes the number of exposures for the baby and maximizes stability for the parent. Changing a newer medication with less data regarding safety in pregnancy to an older medication with more safety data can be done before pregnancy, if desired. Making this change once the patient is already pregnant involves exposing the baby to two medications instead of one and potentially causing worsening of the parent’s psychiatric condition during pregnancy.

3. Ideally, the patient should be psychiatrically stable for at least 3 months before trying to conceive.
Although this is not always possible, it decreases the risk of relapse and exposure of the baby to risks of untreated/undertreated psychiatric illness.

4. Avoid polypharmacy whenever possible.
Prescribing the fewest medications possible to effectively treat the patient’s psychiatric disorder reduces exposures for the baby. Reviewing the need for each medication is especially important when someone is taking multiple medications and/or more than one medication in a class (e.g., two or more antidepressants, two or more antipsychotics, multiple antianxiety/hypnotic medications, etc.).

5. Avoid Depakote.
Depakote (valproic acid) is a commonly prescribed mood stabilizer for patients with bipolar disorder. Depakote is a known teratogen (rate of malformations elevated in all dosage ranges and 25% at doses above 1450 mg/day) and is associated with significantly decreased IQ in children exposed in utero.

6. Optimize non-medication treatments.
At all times, and especially during the perinatal period, we want to maximize the use of evidence-based non-medication treatments such as psychotherapy. Even if someone requires medication for effective treatment of their condition, non-medication treatments can help minimize numbers and dosages of medications and increase effectiveness of treatment.

7. Remember that an untreated/undertreated psychiatric disorder also poses risks to the parent and the baby.
Untreated/undertreated psychiatric disorders pose significant risks for parents and babies. For example, perinatal depression is associated with higher rates of preterm birth, low birth weight, problems with attachment and bonding, and increased rates of psychiatric disorders in childhood and adolescence. For this reason, it is important to treat psychiatric disorders effectively during the perinatal period.

8. If you are thinking of stopping your patient’s psychotropic medications because they are pregnant, please call us first.
Discontinuing medications abruptly can precipitate relapse (another exposure for the baby and risk for the parent). Also, stopping some medications can cause withdrawal symptoms that are potentially dangerous (e.g., benzodiazepines) or unpleasant (e.g., antidepressants). We would be happy to help you sort out which medications to discontinue and safe tapering schedules.

9. Prescribing during the perinatal period requires a risk-risk discussion.
Informed consent during the perinatal period involves collaborating with the patient in discussing and weighing risks of medication for the fetus/baby, risks of the psychiatric disorder, and possible alternative treatments.      

10. Use a patient-centered and team approach.
In addition to collaborative decision-making with, and support of, the patient, this includes involving family members and communicating with other care providers. It is important to educate the partner and/or family members about the risks and benefits of treatment as well as warning symptoms of relapse. Communication with obstetric and pediatric providers minimizes the patient’s hearing conflicting opinions and being confused and concerned.   

The Perinatal PCL is a free, state-funded, provider-to-provider consultation line like the Psychiatry Consultation Line (PCL) but focused on behavioral health disorders and symptoms during the perinatal period (pregnancy and the first 12 months postpartum). We are available at 877-725-4666 or by email at ppcl@uw.edu, weekdays 9-5. Like PCL, we also offer scheduled consultations.

Any healthcare provider in Washington State can call us with any behavioral health-related questions about a patient/client who is pregnant, planning pregnancy, postpartum, or who has pregnancy-related complications (e.g., infertility, pregnancy loss). Perinatal PCL is staffed by University of Washington perinatal psychiatrists, an addiction psychiatrist with expertise in the perinatal period, and our program coordinator, who is trained in social work. We offer psychiatric consultation and local perinatal mental health resources. For more information about Perinatal PCL, and to access our online Perinatal Mental Health Care Guide, please visit our website.

Author

Deb Cowley, MD
Board-certified psychiatrist at UWMC-Roosevelt
UW professor of Psychiatry and Behavioral Sciences
Medical director, Perinatal PCL

Dr. Cowley has expertise evaluating and treating women who have mental health issues during pregnancy and postpartum, and throughout their life cycle, including premenstrual and menopause-related psychiatric symptoms. Her clinical interests include anxiety disorders, depressive disorders, obsessive compulsive and related disorders, panic disorder, postpartum depression, evidence-based medicine, maternal mental health and women’s health.

Related Resource

Management of Psychotropic Drugs During Pregnancy
Psychiatric conditions (including substance misuse disorders) are serious, potentially life threatening illnesses that can be successfully treated by psychotropic drugs, even during pregnancy. This review presents an up to date and careful examination of the most rigorous scientific studies on the effects of psychotropic drugs in pregnancy.

Other Resources

InfantRisk for Healthcare Providers
This collection of apps is for healthcare providers and parents about the safety of medications during pregnancy and breastfeeding. 

LactMed
This database of drugs and other chemicals provides information about the safety of exposure during breastfeeding.

Reprotox
This database of medications highlights their effects during pregnancy, breastfeeding, and development. (Requires subscription.)

MotherToBaby
These fact sheets are for parents regarding risks of drugs (including non-prescribed drugs) during pregnancy and breastfeeding. 

Perinatal Support Washington
This non-profit organization provides a warm line, support groups, peer support, resources, and therapy referrals to support emotional wellbeing for new parents. 

Suicide Risk Assessment

Guidelines on suicide care from national organizations such as The Joint Commission provide recommendations on suicide risk assessment. Implementing these in health care settings rapidly leads to an array of administrative questions. Who should conduct the assessment?   What is the optimal clinical tool? How often should the patient be assessed? 

Because we work in complex systems, answers to these questions are necessary to support consistent care. Here, I hope to balance these administrative questions of who, what, and how with a focus on the therapeutic question of why to conduct a suicide risk assessment. If we have an outcome in mind of a range of options to support a patient at risk of suicide – i.e. the why of assessment – this will influence what information we want and how to obtain it – i.e. the what and how of assessment. 

The Purpose of Suicide Risk Assessment

Suicide risk assessment is not known to predict suicide or to provide useful categories of low, moderate or high risk to guide clinical interventions. As such, national guidelines outside of the United States have recommended a shift from “risk assessment” to individualized “needs assessment” that works with patients to determine what is needed to maintain physical and psychological safety.

From this principle, I will offer a statement on the purpose of suicide risk assessment: The purpose of a suicide risk assessment is to gather information for shared decision-making in developing an individualized, dignifying and respectful plan to manage suicide risk. The management plan will include specific interventions drawn from four broad categories of intervention: facilitating connectedness, addressing mental health and substance use disorders, safety planning, and reducing access to lethal means. Below, I will expand on these categories. 

Facilitating Connectedness

Facilitating connectedness refers to our efforts to promote connections and supports that direct the patient towards life. The suicidal state has been characterized as an experience of “mental pain or anguish and a total loss of self-respect.” When we facilitate connectedness, we try to convey a sense of belonging, value and hope to provide relief from these negative emotional and psychological states. During a suicide risk assessment, this means inviting the patient to “tell the story” of how the current crisis developed. Listening with open attention conveys messages that I’m here with you, you matter to me, and I have hope for you. As the patient talks, we will listen for opportunities to facilitate connectedness based on their background, circumstances, mental health symptoms, and existing strengths.

For example, the Trevor Project provides 24/7 crisis support for LGBTQ+ youth. For patients whose circumstances include actions that have damaged or destroyed relationships, a clinician’s compassionate engagement with devastating shame can represent a crucial inflection point that begins to restore dignity and hope. Patients with psychiatric symptoms might benefit from referrals for medication treatment and psychotherapy to decrease isolation and increase hope. Patients who prioritize spiritual coping can be engaged to explore how connections to internal images, metaphors and beliefs and external rituals and communities might support coping and a pathway towards recovery.  Patients who refuse treatment remain candidates for connectedness-based interventions. For example, the caring letters intervention demonstrated that non-demanding caring contacts – simply conveying care and support without any expectations from the patient – reduced suicide deaths by approximately half among patients who declined treatment. 

Addressing Mental Health and Substance Use Disorders

Some suicide decedents – though not all – have been found to have psychiatric or substance use disorders. Regardless of whether a patient meets criteria for a specific mental disorder, addressing psychiatric symptoms and substance use represents an important aspect of managing suicide risk. When present, anxiety, agitation, and insomnia might represent particular priorities. Addressing mental health conditions may have different benefits for suicide risk. For some patients, simply learning that they have a diagnosis with effective treatments available provides de-stigmatizing relief that counters isolation, worthlessness, and helplessness. Alternatively, effective control of severe psychiatric symptoms might provide stability to participate in psychotherapy to focus on suicide-related thoughts of despair and self-hate. For others, effective treatment of a mental disorder reduces the destructive, alienating effects that the symptoms may have had on relationships.

Existing treatment settings for substance use disorders can also be a place for patients to learn how to recognize and respond to suicide risk in themselves or peers, an online training for $100. During a suicide risk assessment, we will listen for the patient’s background to learn of any history of mental health treatment and for current psychiatric symptoms and/or substance use, as this information will help us discuss treatment options with the patient. Patients who refuse treatment for mental disorders remain candidates for interventions targeting ambivalence, such as motivational interviewing. For example, exploring the pros and cons of medication treatment with a patient with opioid use disorder would be considered an intervention for suicide risk by addressing an important risk factor for suicide.

Safety Planning

Safety planning refers to the process of collaborating with a patient to generate coping strategies for use during periods of elevated suicide risk. “Brand name” safety planning interventions include Crisis Response Planning and the Safety Planning Intervention. While these interventions result in a written document that details personal warning signs of a crisis and coping strategies, both of them hinge on an initial narrative interview during which the patient is invited to “tell the story” of a recent suicidal crisis. The clinician then reflects back what the patient has described, highlighting that suicidal crises are time-limited events with a beginning, middle and end. The crises include intoxicating, preoccupying thoughts of suicide, wrenching emotional states and urges to bring an end to suffering by ending one’s life. This shared understanding of the nature of suicidality forms the foundation of safety planning: Do you see how the risk goes up and then comes down? I want you to feel confident with choices and skills to survive those dark moments so that we’ll have time to work on the longer-term problems that have caused so much pain. During a suicide risk assessment, we will listen for specific crises and details of circumstances, thoughts, negative emotional states and actions. We will also listen for strengths and resources the patient has used to cope with crises. This information will help us discuss with a patient their personal warning signs of a crisis and potential coping strategies. 

As described here, safety planning occurs as a collaborative process where the patient participates in self-recognition and self-management of suicide risk. For some patients, the extent of their suicidal preoccupation precludes the ability to maintain safety independently. For these patients, a higher level of care in an inpatient setting may be needed for external support. During a suicide risk assessment, we will listen for the patient’s level of suicidal intent and planning to inform whether the patient has the willingness and ability to self-manage suicide risk with safety planning. Patients who refuse collaborative safety planning remain candidates for receiving information about crisis resources and when to use these: These are two resources that can help when people feel overwhelmed and have thoughts of suicide. One is 988 Suicide and Crisis Lifeline where you or a loved one can talk with a crisis counselor; the other is the Crisis Text Line where you can text with a crisis counselor. 

Reducing Access to Lethal Means

The “means” for suicide refers to the tools, instruments or objects that can be used to inflict self-injury. When people at risk for suicide do not have ready access to lethal means for use in a suicide attempt, this allows time to pass for a crisis to resolve and for risk to decrease. In lethal means counseling, clinicians have collaborative discussions with patients to motivate actions that reduce access to lethal means: I’m glad we’re talking today, and I believe your life can get better. A concern I have is that it sounds like there are times when the suicidal thoughts are especially intense. During those times, if you have immediate access to [means] we might lose you before we have enough time to work on the problems in your life. Can we talk about some ways to reduce your access to [means] so that you can survive to see things improve?

For firearms, which are especially lethal when misused in suicidal behavior, culturally-aligned counseling optimally occurs in a dignifying and respectful manner that resonates with the patient’s values. In Washington, it is legal to transfer firearms out of the home temporarily to manage suicide risk. For medications, clinician-initiated changes may also play a role: reducing the dose or amount dispensed of medications, selecting medications with lower toxicity, or discontinuing medications. During a suicide risk assessment, we will listen for background information that might suggest knowledge of or familiarity with particular means, suicide methods the patient has considered, and access to lethal means. In Washington, patients who refuse collaborative efforts to reduce firearm access and who are judged to be at high risk of harming themselves and/or others may be candidates for an extreme risk protection order as a legal process to recover firearms and prevent firearm acquisition.

Returning to “What” and “How”

In the sections above, I have described ways to manage suicide risk and the information needed from a suicide risk assessment to tailor these interventions for an individual patient. To summarize, we will need information about the patient’s background, life stressors, psychiatric symptoms, substance use, suicidal ideation, suicidal behavior, strengths and resources. In the language of risk assessment, these represent demographic, situational, symptomatic and suicide-specific risk factors, and protective factors.

To obtain this information in a way that facilitates connectedness and builds the rationale for safety planning, we will use a narrative interviewing technique that invites the patient to “tell the story” of how the current crisis developed: I’ll want to hear more about the suicidal thoughts, but first would you tell me (briefly) the story of what has brought you to think about suicide? Often the patient’s initial description does not include all of the elements of suicidal ideation and behavior we need to guide decision-making for managing suicide risk. To address this, we “back fill” with a suicide-specific assessment that asks specific questions about suicidal ideation, method, intent, planning, and suicidal behavior: Thank you for talking to me about this. I’d like to ask some specific questions about the suicidal thoughts, if that’s alright? With this range of information, we can proceed with shared decision-making to discuss a plan for improving safety using interventions from the categories previously described. 

I hope this post has helped to clarify the role of risk assessment in suicide care. For future training opportunities and information on suicide care, please visit the Center for Suicide Prevention and Recovery.


Author

Jeffrey C. Sung, M.D.  
Clinical Assistant Professor
UW Department of Psychiatry and Behavioral Sciences

Dr. Sung earned his M.D. at Northwestern University in Chicago, Illinois. His clinical interests focus on psychotherapy. He has taught psychodynamic theory, suicide risk assessment and managing response to patient suicide. Dr. Sung is a board certified psychiatrist and provides training and consultation through Forefront Suicide Prevention and the Center for Suicide Prevention and Recovery.

Learn More

Caring Contacts Training
This is a free one-hour, interactive, self-paced training course developed for medical professionals and client-facing staff in WA state, and open to everyone. It is designed to address the public health crisis of suicide and give providers and client-facing staff additional tools to prevent suicide.

Preventing Addiction Related Suicide (PARS)
PARS is a prevention intervention provided to addiction treatment patients who are at higher risk of suicide. The PARS web training costs $100 and is an interactive psychoeducational suicide prevention program that was designed to be used within community addiction group therapy treatment by addiction specialists and counselors, like SUDPs in Washington.

Suicide Risk Assessment and Documentation
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenters: Jeffrey Sung, MD and Amanda Focht, MD
The objectives of this presentation are to: 1) distinguish categories of risk and protective factors for suicide; 2) identify categories of intervention for management of suicide risk; and 3) describe components of suicide risk assessment and management documentation. 

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Treatment of Adult Patients with Obsessive-Compulsive Disorder

Image for OCD treatment

The lifetime prevalence of obsessive-compulsive disorder (OCD) amongst adults in the United States is 2-3%. While most providers can list the most common symptoms of OCD, the diagnosis is rare enough that it may have been a while since you got an update on useful screening tools and treatment recommendations. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a good place to start, and you can find this document on the Resources section of our website. The Y-BOCS contains a list of symptoms that can be helpful for making the diagnosis, as well as a rating scale that can be used to track treatment efficacy.

There are a wide range of obsessions and compulsions that can be seen in OCD and thus the symptom checklist on the third page of the Y-BOCS document can be very helpful when trying to establish the diagnosis. Moreover, the rating scale on the first two pages not only helps with establishing the diagnosis but is also useful for tracking the improvement seen with treatment.

The first-line treatment for adults with OCD is cognitive behavioral therapy (CBT) with exposure and response prevention. When medication is added to CBT, the usual first choice is an SSRI. Though an 8-week trial of an SSRI is adequate for some behavioral health diagnoses, patients with OCD may see better results from SSRIs at 16 weeks. Moreover, some patients with OCD require SSRI dosing that is titrated up toward the higher end of the usual dosage spectrum. This might mean, for example, a final daily sertraline dose of 150-200mg, rather than 50-100mg, if the patient can tolerate the higher dose. 

For patients who have not responded to one or two different SSRI trials, clomipramine is sometimes trialed. SSRIs and clomipramine are not used together since the combination increases the risk of serotonin syndrome. In terms of efficacy, some clomipramine studies suggest this medication is superior to SSRIs in OCD. However, clomipramine is a tricyclic antidepressant and thus has more side effects than SSRIs, with anticholinergic side effects especially intolerable for some patients. Tricyclics also have a higher risk of cardiac side effects, even at normal doses, and are more lethal on overdose than SSRIs.

Atypical antipsychotics have some data as an augmentation strategy for patients who have a partial response to SSRIs or clomipramine. Lamotrigine and topiramate have a small amount of data for augmentation in refractory cases, as well. Clonazepam and lorazepam, on the other hand, do not generally demonstrate efficacy in studies of augmentation or monotherapy for OCD.

If you are considering using a medication for OCD, please first review your own reference material for full details on indications, side effects, dosing, monitoring requirements, and drug interactions. For reference, we most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington providers at heal-wa.org/professions.

If you would like more information on the spectrum of medications for OCD, please call the Psychiatry Consultation Line (877-WA-PSYCH / 877-927-7924) and one of our psychiatrists would be happy to review the data with you.


Author

Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line


Learn More

OCD: Diagnosis and Treatment
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Deborah Cowley, MD
The objectives of this presentation are to: 1) review the diagnosis of OCD and related disorders; 2) discuss the epidemiology, differential diagnosis, and comorbidity; and 3) discuss treatment of OCD and related disorders. 

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Antipsychotic-associated Metabolic Syndrome

Colorful image to show range

When providers reach out to the PCL program with questions about antipsychotics, we often include a document that outlines a schedule for monitoring metabolic side effects in our write-ups. While we follow this monitoring schedule for all antipsychotics, there are certain second-generation antipsychotics that are more notorious than others.

Olanzapine and clozapine, for example, are associated with the most weight gain. On the other end of the spectrum, ziprasidone and aripiprazole are associated with the least. Beyond the long-term cardiovascular risks, tracking the metabolic syndrome is also important because patients are understandably reluctant to continue taking medications that cause weight gain. 

While there have been studies to suggest that metformin may have a modest, short-term benefit for olanzapine-associated weight gain, there is also data that switching from olanzapine to aripiprazole or ziprasidone can result in the loss of some of the weight gained while on olanzapine. There is a risk of decompensation when switching from one antipsychotic to another and the decision to switch is thus ultimately based on a variety of patient-specific factors. There are not yet any published, placebo-controlled trials on the use of semaglutide or tirzepatide for antipsychotic-associated weight gain.

Antipsychotics can also cause glucose dysregulation and lipid disturbance. These abnormalities can arise even in patients who are not gaining weight, which is why we monitor fasting labs as a matter of course. For a useful way to visualize the spectrum of antipsychotics in terms of their metabolic side effects, I’d recommend looking at Figure 3 of Pillinger’s article on antipsycohtics in Lancet Psychiatry 2020; 7: 64-77. In this “heat map,” red are the worst offenders and yellow the least, though you can see that no antipsychotic is wholly innocent.

If you would like more information on the spectrum of antipsychotic side effects, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review the data with you.


Author

Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

New Generic Option for Treating Bipolar


Within the last few months, a generic formulation of Latuda (lurasidone) has become available. Should you consider prescribing it for adult Bipolar I Depression?

Previously, this medication cost >$1,200/month and was thus out of reach for most patients and/or required insurance pre-authorization. Now that the price of lurasidone has fallen dramatically, it is worth comparing this medication to quetiapine, which is also generic and also has an FDA indication for adult Bipolar I Depression.

There aren’t very many head-to-head trials, but in meta-analyses of monotherapy for adult Bipolar I Depression, both lurasidone and quetiapine appear to be efficacious. Several published treatment algorithms consider both medications to be first-line options as monotherapy for this indication. In other studies, lurasidone has demonstrated efficacy for adult Bipolar I Depression when used as an adjunct to lithium or divalproex and, indeed, Latuda garnered FDA-approval for adjunct use for this indication.

FDA package inserts are available on the FDA approved drugs site. Package inserts contain a lot of useful information and are likely underutilized in our era of quick, app-based, medication references. When comparing the data reported in the package inserts for lurasidone and quetiapine, lurasidone appears to have a lower incidence of the antipsychotic-associated metabolic syndrome (weight gain, new-onset diabetes, new-onset hyperlipidemia, etc.). Lurasidone, at least at low doses, is also felt to be less sedating than quetiapine. However, when compared to quetiapine, lurasidone appears to have a higher incidence of parkinsonism, akathisia, and other D2 blockade-mediated side effects. For more details on the side effects of these medications, including information on the Black Box warnings, QTc prolongation, monitoring of the metabolic syndrome, and other adverse effects, please refer to your own medication reference material or the free sites available via Heal WA.

Another important difference between lurasidone and quetiapine is that lurasidone needs to be taken with a >350 calorie meal. This dramatically increases the absorption of lurasidone. However, food insecurity is a problem experienced by many people in our society, and it is important to ask your patients if they have regular access to a >350 calorie dinner.

Lurasidone dosing is usually initiated at 20mg/day. Though the FDA max dose is 120mg/day, some studies of adult Bipolar I Depression suggest that high-end dosing does not necessarily increase efficacy but might increase the risk of side effects. The mean (SD) lurasidone dose was 64.1 (14.4) mg in a 24-week open label study authored by Ketter et al for the journal Depression and Anxiety. Thus, rather than automatically pushing the lurasidone dose to the top end, it could be useful to first give the patient a good trial in the middle of the dosing range.

If you would like more information on the treatment of adult Bipolar I Depression, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review the options with you.


Author

Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line


Learn More

Bipolar Disorder — Screening and Diagnosing in Primary Care
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Joseph Cerimele, MD, MPH
The objectives of this presentation are to describe1) the clinical epidemiology of individuals with bipolar disorder in primary care settings; 2) techniques to improve the recognition of bipolar disorder in primary care patients; and 3) clinical characteristics of patients with bipolar disorder in primary care. 

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Lack of Evidence: Gabapentin in Bipolar Disorder

When it comes to treating adults with bipolar disorder, gabapentin appears to be everything you’d want in a medication…except for efficacy.

Prescribers wish that gabapentin had utility in bipolar disorder because gabapentin isn’t a P450 substrate, is renally excreted, and is generic and thus relatively affordable. Unfortunately, gabapentin does not demonstrate efficacy in randomized trials for bipolar disorder and current treatment guidelines do not emphasize its use. Despite of the lack of evidence, reviews of gabapentin prescribing patterns in the United States show that this medication is still being used with alarming frequency for bipolar disorder.

There are now five medications with specific, FDA approval for acute bipolar depression. Moreover, there are at least a dozen medications with FDA approval for acute mania. Many of these options are available in generic formulations.

Instead of reaching for gabapentin as a potential intervention for bipolar disorder, please call the Psychiatry Consultation Line (877-WA-PSYCH) and one of our psychiatrists would be happy to review treatment options that have better evidence.

You can also call the PCL for advice regarding differential diagnosis, non-pharmacologic interventions, and treatment monitoring. In complicated clinical scenarios, discussing a patient’s care with a colleague can help you formulate a more comprehensive treatment plan.  

The PCL is a free resource for healthcare providers in Washington State to consult with a psychiatrist about their adult patients with mental health or substance use conditions. Learn more at pcl.psychiatry.uw.edu.

If you are considering using a medication for bipolar disorder, please first review your own reference material for full details on indications, side effects, dosing, monitoring requirements, and drug interactions. For reference, we most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington providers at heal-wa.org/professions.


Author

Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line


Learn More

Managing Bipolar Depression in Primary Care
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: John S. Kern, MD
The objectives of this presentation are to 1) recognize the predominant role of depressive episodes in the morbidity associated with bipolar disorder; 2) summarize the outcomes of the SPIRIT study; and 3) apply an orderly approach to the care of bipolar depression.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Addressing sleep-related difficulties

“I’m having trouble sleeping” is a common concern of patients who report co-morbid mental health concerns like anxiety or depression and/or have a history of trauma, but sleep issues can be reported independently of other conditions as well. Though it can be tempting to suggest using melatonin or another medication to aid with sleep,  there are simple behavioral interventions that may be just as – if not more – effective in the long-term for addressing sleep-related concerns. 

One of the simplest ways to gain a better understanding of what sleep-related concerns our patients are facing is to ask. Is it that they aren’t sleeping as much as they would like to? Are they sleeping too much? Is their sleep interrupted? Asking about environmental factors is important, too. Do they have a new baby at home? Did they recently change jobs? Do the other people in their home sleep on different schedules than they do? Even clarifying what their sleep schedule looks like can help you to decide what to recommend.

Someone can have sleep-related problems that don’t rise to the diagnostic criteria for insomnia, or they may be experiencing primary or secondary insomnia. Once you’ve gathered information about what problems they are encountering, you’ll have a better sense of whether the difficulties are related to sleep onset, sleep maintenance, or early awakening (or some combination). It’s also a good idea to assess for other sleep disorders, not just insomnia. According to the Center for Disease Control, the most common sleep disorders, in addition to insomnia, are narcolepsy, Restless Leg Syndrome, and Sleep Apnea. An important note about sleep apnea – be sure to assess for it even in your patients who are not classified as obese, as apnea may occur in individual with normal or low BMI.

After clarifying what sleep-related difficulties your patient is reporting – and attending to any potential sleep disorders aside from insomnia – it’s a great time to begin talking about sleep hygiene. Consistency is key when it comes to sleep hygiene. Going to bed at the same time every night (when possible, of course) and getting up at the same time each morning can go a long way. Yes – even on non-workdays!

Another important sleep hygiene tip: the bed is for three things – sleep, sex, and sick. It can be tempting to read or watch TV in bed. And who among us hasn’t played on our phones instead of going to sleep? However, maintaining the sanctity of the bed for sleep, sex, and/or sick – and only these three things – encourages strong sleep-bed associations. Something else that encourages strong sleep-bed associations? Getting out of bed within 10-15 minutes of waking or if unable to fall asleep for approximately 15-20 minutes. The longer you are in bed and awake, the weaker your sleep-bed association will be.

Other sleep hygiene tips:

  • Avoid napping (unless it’s a safety concern). It can be tempting, especially when someone is very tired, but it ultimately decreases one’s “sleep appetite” and makes it harder to sleep at night.
  • Implement a wind-down routine, preferably without screens (TV, phones, computers, etc.). Try to avoid screens for an hour or more before bed.
  • Keep your bedroom cool and dark.
  • Avoid exercise, eating, or drinking close to bedtime. If someone wakes due to hunger, trying a small snack before bed could help – but it’s best to avoid a large meal.
  • Avoid alcohol, cigarettes, and other substances close to bedtime. For those individuals who smoke cigarettes – a gentle reminder that nicotine is a stimulant and therefore counterproductive to sleep can be helpful.
  • If waking in the middle of the night, avoid eating, drinking, or smoking. Our bodies become habituated to patterns and if you eat a snack every night at 2:00am, 2:00am may officially become snack time!
  • Don’t go to bed unless you’re tired. This might run counter to “consistent bedtime” however, getting into bed just because the clock (but not your body) says it is time can make it harder to sleep.

Individuals who are not able to correct their sleep difficulties with sleep hygiene alone may benefit from completing a course of Cognitive Behavioral Therapy for Insomnia. This treatment typically occurs across 4-8 sessions, though individuals may begin to see positive results in as few as 3 weeks. This treatment can be completed with a trained therapist or via a self-paced online course. CBT-I can be tried before sleep medications and, in many cases, may end up making medication unnecessary.

CBT-I provides education about sleep, sleep hygiene, and helps to identify specific strategies to improve an individual’s sleep. It may involve sleep restriction – the practice of restricting when a person gets into bed and gets up – which helps consolidate sleep into a more solid block. As sleep becomes consolidated (and sleep efficiency improves), more time in bed is added based on individual need and bedtimes/wakeups are adjusted.

One last caveat – if you are seeing a patient who has been diagnosed with ADHD and is reporting sleep-related concerns, you may want to explore the possibility of Delayed Sleep Phase Syndrome (DSPS), in which the sleep/wake phase occurs later than “normal.”

Sleep is extremely important to health – and when we’re not getting enough of it, it shows. Hopefully this information will prove helpful in working with patients with that ever-present concern of, “I’m having trouble sleeping!” You can always call the Psychiatry Consultation Line (877-927-7924) for clinical advice when sleep issues co-present with mental health concerns like anxiety, depression or ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Call us anytime – we are a part of your team!

Author
Koriann Cox, PhD
Acting Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences

Learn More:
UW Psychiatry and Addictions Case Conference series (UW PACC)*

When should I use sleep aids in my patients with sleep disorders… (and when should I not?)
Presenter: Catherine McCall, MD
The objectives of this presentation are to 1) learn about different ways in which insomnia can manifest; 2) understand the pathophysiology of insomnia; and 3) explore different ways to address and treat
insomnia effectively.

Psychological and behavioral treatments for insomnia
Presenter: Katherine Palm-Cruz, MD
The objectives of this presentation are to 1) develop an understanding of psychological and behavioral treatments for insomnia disorder; 2) understand recommendations for first line treatments for chronic insomnia; and 3) appreciate the evidence of how CBT-I compares to pharmacologic treatments for insomnia.

My patient has good sleep hygiene. What should I counsel them to do next to improve their poor sleep?
Presenter: Barbara McCann, MD
The objectives of this presentation are to 1) conduct a 24-hour interview to identify problem areas in need of remediation to address insomnia; 2) identify two broad areas of sleep-interfering cognitions and suggest strategies for dealing with each type; and 3) make use of stimulus control principles to address sleep-interfering behaviors.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Learn More: other resources

Mirtazapine in major depressive disorder in adults

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Mirtazapine garnered FDA approval as an antidepressant in 1997. It has been generic for so long that it no longer has an advertising budget and thus you won’t see commercials for it on late-night television. Mirtazapine impacts serotonin and norepinephrine systems in the brain but is not a reuptake inhibitor. While SSRIs are generally considered first-line in major depressive disorder, mirtazapine is a medication worth remembering in certain situations. 

Mirtazapine does not inhibit P450 enzymes and thus can be useful in depressed patients who have complex medical histories and are on complicated (and ever changing) medication regimens. 

Mirtazapine does not cause sexual dysfunction greater than placebo, making it a potentially useful alternative for patients with depression and intractable, SSRI-associated, sexual dysfunction. Sexual side effects are seen in as many as 50% of patients on SSRIs and are frequently cited by patients as a reason for medication discontinuation.

Per the original package insert, 17% percent of patients taking mirtazapine experienced appetite stimulation. “Weight gain” is often all that prescribers remember about mirtazapine. It is true that this medication has a higher risk of weight gain than SSRIs, that this issue needs to be discussed with patients, and that weight needs to be closely monitored. However, it is also notable that only a minority of patients have this side effect. On the other hand, for patients who experience a profound loss of appetite as a feature of their depression, the potential for appetite stimulation with mirtazapine might be seen as an advantage. 

Mirtazapine is a strong antihistamine and, indeed, the original package insert notes that 54% of patients on mirtazapine reported sedation, compared to only 18% for placebo. This side effect can represent a hindrance or a benefit, depending on the specific features of the patient’s depression and on the degree of sedation. For example, psychiatrists sometimes use mirtazapine as an augmentation strategy for patients who have had a partial response to SSRIs and whose depressive symptoms include prominent initial insomnia. It should be noted that oversedation can impair performance and thus this side effect needs to be monitored by the patient and the prescriber.

Unlike the SSRIs and SNRIs, mirtazapine’s only FDA indication is for major depression. In the intervening 25 years since its FDA approval, the bulk of mirtazapine’s positive data remains for its use in major depression. There is some mixed data (variable strength of study and variable results) in generalized anxiety disorder and social anxiety disorder. However, we do not usually consider mirtazapine as a first- or second-line agent for monotherapy in anxiety disorders.

If you are considering using mirtazapine, please refer to your own reference material for full prescribing information regarding medication dosing, risks, benefits, side effects, monitoring requirements, and drug interactions.  We most often use Micromedex, UpToDate, or Epocrates.  Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/. You can also call the Psychiatry Consultation Line (877-927-7924) for clinical advice on using mirtazapine in the treatment of major depressive disorder in adults as well as assessment, treatment decisions and monitoring of mental health conditions in general. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

Learn More
Treatment Resistant Depression
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss pros and cons of treatment guidelines, 2) walk through cases to determine best options, and 3) Improve confidence in decision making around treatment resistant depression.

Using Stimulants to Augment Depression Treatment
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ramanpreet Toor, MD
The objectives of this presentation are to review evidence of psychostimulant use in the treatment of depression.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.

Using the PMQ-9, a new patient-reported manic symptom measure

Many clinicians regularly use the Patient Health Questionnaire-9 (PHQ-9) to monitor treatment of individuals with depression. Using the PHQ-9 consistently is part of a clinical strategy called measurement-based care (MBC). In MBC, symptom measures are administered to patients, which are then reviewed by clinicians, compared to prior results, and used to inform clinical decision making.

Symptoms in bipolar disorder
In bipolar disorder, depressive and manic symptoms often occur concurrently. Many people think of manic symptoms as occurring during a full episode of hypomania or mania, though manic symptoms commonly occur during other times in individuals with bipolar disorder. For example, during bipolar depression, almost three-quarters of people experience concurrent manic symptoms, most commonly faster thinking and distractibility. “Subsyndromal” symptoms (i.e., depressive and manic symptoms not reaching the severity of an ‘episode’) also occur frequently; in two landmark studies participants experienced subsyndromal symptoms almost half of days over a decade of follow-up. The presence of subsyndromal symptoms is also associated with a shorter time until syndromal mood episode (i.e. number of symptoms and severity consistent with a mood episode) recurrence, making it especially important to detect symptoms.

A patient-reported measure for manic symptoms
Because many clinicians already use the PHQ-9 to monitor depressive symptoms, a team based at the University of Washington decided to develop a similar symptom measure for manic symptoms that could be easily combined with the PHQ-9. The result is a new patient-reported measure, the Patient Mania Questionnaire-9 (PMQ-9), that includes 9 items each scored 0 to 3 based on severity, assessing manic symptoms. The team tested the PMQ-9 in 12 Federally Qualified Health Centers in three states with primary care clinicians, psychiatrists and care managers working in collaborative care. More recently, they found the PMQ-9 has ‘sound’ psychometric properties which were recently reported in the Journal of General Internal Medicine.

How is the PMQ-9 used?
The PMQ-9 is a patient-reported symptom measure, which means it can be given to a patient to complete ahead of an appointment time. It can also be read to a patient if that is preferred. Clinicians can use the PMQ-9 in combination with the PHQ-9 to monitor manic and depressive symptoms, and track response to treatment. Higher total scores indicate greater severity of manic symptoms. Cut-offs for symptom severity were determined based on clinical judgement using the measure in trial, with a score of less than 10 identified as ‘lower severity’ or ‘subthreshold’ (with less than 5 as ‘remission’). A change of approximately 3 points indicates a ‘minimally important difference’ meaning a 3-point decrease in score is likely a ‘meaningful improvement’.

Other points
The PMQ-9 is not a ‘screener’ meaning it is not used to ‘find’ people who might have bipolar disorder. So far it has only been used to monitor the treatment of individuals already diagnosed with bipolar disorder. Notably, the PMQ-9 was widely used by clinicians and patients in a large clinical trial even though they were not required to use it, suggesting wide acceptability. The research team also surveyed clinicians (primary care clinicians, psychiatrists, psychiatric ARNPs, social workers, psychologists) about symptom measures and found the most preferred measure to use in measurement-based care for bipolar disorder was the combination of the PHQ-9 and PMQ-9.

Conclusion
The clinical need to monitor depressive and manic symptoms, the ease of scoring and interpretation, the acceptability and perceived helpfulness by clinicians, and similarities with the PHQ-9 make the PMQ-9 plus PHQ-9 a reasonable choice for those looking to adopt measurement-based care for bipolar disorder.

Author
Joseph Cerimele, MD
Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Director, Psychiatry and Behavioral Sciences Grand Rounds

Learn More
Patient Mania Questionnaire-9 (PMQ-9) – pdf
The Patient Mania Questionnaire (PMQ-9) is a nine-item scale used to assess and monitor manic symptoms. The PMQ-9 Mania Questionnaire complements use of the PHQ-9 for depressive symptoms to inform measurement-based care. It is also suited for use in mental health care settings.

The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms 
Journal of General Internal Medicine. Volume 37, pages1680–1687 (2022)
Joseph M. Cerimele MD, MPH, Joan Russo PhD, Amy M. Bauer MD MS, Matt Hawrilenko PhD, Jeffrey M. Pyne MD, Gregory W. Dalack MD, Kurt Kroenke MD, Jürgen Unützer MD MPH & John C. Fortney PhD

The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.

Diagnosing and treating bipolar disorder
PCL News | September 15, 2021
Bipolar disorders, sometimes referred to as manic-depressive disorders, are mood disorders that include manic or hypomanic symptoms and depressive symptoms. Accurate diagnosis of bipolar disorder can be difficult, and once a diagnosis is made, clinicians can face numerous decisions regarding acute episode treatment, maintenance treatment, monitoring response, monitoring for adverse effects, and treatment adjustments. These “points to consider” may help as you encounter similar clinical scenarios.

Non-stimulants for adult ADHD

While the data on the efficacy of stimulants in adult ADHD is robust, we have had numerous calls to the PCL program from providers seeking information on medications that have a lower misuse and abuse potential.

Atomoxetine has an FDA indication for adult ADHD. Atomoxetine is often thought of as the first-line medication for adult ADHD in patients with a history of substance use disorder. There are several studies that demonstrate an improvement in quality of life ratings, for example, with longer term use in patients with ADHD. Atomoxetine selectively inhibits norepinephrine reuptake and medications with this mechanism of action convey a risk of psychosis and mania, especially in patients with a personal or family history of bipolar disorder or psychosis. Like many medications with an antidepressant-like mechanism of action, atomoxetine has a black box warning for increased suicidality in children, adolescents and young adults.

Bupropion does not have an FDA indication for ADHD, though there are meta-analyses that suggest it has some utility. Bupropion is FDA-approved for major depressive disorder. The symptom of poor concentration can be magnified when patients with ADHD experience a major depressive episode. For some of these patients, bupropion might help both disorders. Providers should keep in mind, however, that bupropion is not effective for anxiety disorders. Moreover, some patients with anxiety disorders find that bupropion worsens their anxiety symptoms. Like atomoxetine, bupropion has a black box warning for suicidality in patients under the age of 25. Bupropion can also cause mania and psychosis, particularly in patients with a personal or family history of bipolar disorder or psychosis. Bupropion can increase the risk of seizure and is contraindicated in patients with eating disorders.

While guanfacine has an FDA indication for pediatric ADHD, it does not have an FDA indication for adult ADHD. Some authors are pessimistic about its utility in adult ADHD. Overall, the data is mixed and there have only been a few controlled studies, though research is actively being done and the efficacy (or lack thereof) of guanfacine in adult ADHD may be more clearly articulated in the next few years. Guanfacine is an alpha-2 agonist that is used to treat hypertension and thus it has a unique side effect profile compared to atomoxetine or bupropion.

If you are considering using any of the medications discussed above, please first review your own reference material for full details on side effects, dosing, adjustment in the setting of renal or hepatic impairment, cautions/contraindications, monitoring requirements, and safety in pregnancy and lactation. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/. You can also call the Psychiatry Consultation Line (877-927-7924) for clinical advice on using these medications in the treatment of adult ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

Learn More
Cognitive Behavioral Therapy (CBT) for adult ADHD: does ADHD need therapy (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Kristen Lindgren, PhD, ABPP
The objectives of this presentation are to 1) review diagnostic criteria for ADHD, 2) understand the Role of CBT in the Treatment of adult ADHD, and 3) describe how combined medication and CBT can benefit adults with ADHD

Treating ADHD in SUD patients: how do I treat patients with ADHD and SUDs without making them addicted to stimulants? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Robert Sise, MD, MBA, MPH
The objectives of this presentation are to 1) review general considerations in diagnosis of adult ADHD, 2) explore multimodal treatment for adult ADHD with co-occurring SUDs, 3) discuss risks and benefits of pharmacotherapy, and 4) explore how ADHD treatment should be coordinated with SUDs treatment.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.