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Addressing sleep-related difficulties

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“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

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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

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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.

Treating Generalized Anxiety Disorder with buspirone

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A common question to the Psychiatry Consultation Line is around treatment of Generalized Anxiety Disorder (GAD) in patients with a history of substance use disorders and for whom a Selective Serotonin Reuptake Inhibitor has not been effective. First-line treatments for Generalized Anxiety Disorder include Cognitive Behavioral Therapy (CBT), Serotonin Reuptake Inhibitors (SRI), or a combination of both. In cases where adjunctive CBT and multiple trials of SRIs have failed, buspirone can be given some consideration.

In 1980s-era, double-blind studies of GAD, buspirone’s efficacy was shown to be similar to benzodiazepines. An important difference between benzodiazepines and buspirone is that it takes buspirone longer to start working. Buspirone requires a multi-week or multi-month trial to assess efficacy. Compared to benzodiazepines, buspirone is less likely to cause sedation and, importantly, is not associated with the development of tolerance or dependence. Common side effects of buspirone include dizziness, nausea, and headache.

The FDA max dosing is 60mg/day and while some patients require a high dose, average therapeutic doses are in the range of 20 to 45 mg/day. Buspirone has a short half-life and some patients benefit from TID dosing.

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/.

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, Psychiatric Consultation Line

Learn more
How do I address emerging anxiety during substance use recovery?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) discuss characteristics between a substance induced anxiety disorder and a primary anxiety disorder, and 2) to talk through different treatment options for anxiety symptoms.

CBT for Anxiety (CBT-A): What can I do with my patient instead of giving them a PRN benzodiazepine?  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Patrick Raue, PhD
The objectives of this presentation are to 1) understand the CBT model of anxiety symptoms, 2) describe how to give the “treatment pitch” to patients, and discuss the difference between treatment with exposure vs. anxiety management strategies, 3) understand how to develop and work on an exposure hierarchy with patients and 4) describe anxiety management strategies that use physical and cognitive approaches.

Anxiety: fast facts and skills for the primary care physician  (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Ryan Kimmel, MD
A brief overview of diagnosing and treating anxiety 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.

Diagnosing and treating bipolar disorder

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Clinicians call the Psychiatry Consultation Line with a range of questions about individuals with suspected or diagnosed bipolar disorder, which affects an estimated 4.4% of U.S. adults at some time in their lives. 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.

Assessment and Diagnosis

Common PCL Question: How can I assess for bipolar disorder in my primary care practice?

  • A structured assessment can help collect information that any clinician would need to inform diagnosis of bipolar disorder.
  • The Composite International Diagnostic Interview (CIDI) instrument can contribute to a structured assessment by assessing for lifetime experience of manic symptoms. It is important to remember that positive screening results do not equal a clinical diagnosis. In one study in primary care, about 45% of people screening positive on the CIDI, and 15% of people screening negative, were diagnosed with bipolar disorder by a psychiatrist. However, this instrument can help to collect information that might lead clinicians to ask more questions about bipolar disorder in those with a positive screen. PCL psychiatrists can assist with questions about administering structured tools such as the CIDI.
  • Some clinicians also find it useful to have structured tools to assess age of onset of mood symptoms, past mood symptoms and episodes, peripartum mood symptoms, response to medications including to antidepressant medications, family psychiatric history, drug and alcohol use, and other clinical problems, since historical points other than manic symptoms might raise clinical suspicion for bipolar disorders.

Common PCL Question – What questions can I ask patients about past manic symptoms?

  • One strategy to consider in clinical questioning is to ask about discrete periods of concurrently elevated or irritable mood AND increased energy. Then, once identifying a period when that occurred, inquiring about associated hypomanic or manic symptoms.

Common PCL Question – Is there a bipolar disorder spectrum, and does this apply to my patient?

  • Some individuals experience hypomanic symptoms that do not reach the level of severity of a hypomanic or manic episode.
  • Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classification includes categories of cyclothymia (subsyndromal hypomanic and depressive symptoms most days over two years), and Other specified bipolar and related disorder due to short-duration hypomanic episodes (i.e. 2-3 day duration), and insufficient number of hypomanic symptoms to reach episode-level (i.e. 3 symptoms). 
  • Additionally, major depressive episodes in major depression can occur with mixed features (concurrent hypomanic symptoms) though the difference in this case is that the individual with major depression with mixed features has never previously experienced a hypomanic or manic episode.
  • Mood fluctuations or ‘swings’ can occur in the absence of bipolar disorder diagnosis. Consider alternate explanations.
  • Visit Psych Education for more information on bipolar spectrum.

Treatment

Common PCL Question – Where do I start with choosing a medication treatment for a patient diagnosed with bipolar disorder?

  • Consider the current mood state. The most commonly experienced mood state in individuals with bipolar disorder is depression with one or more concurrent hypomanic symptoms.
  • There are relatively few FDA-approved or evidence-based medication treatments for bipolar depression and guideline-suggested first-line treatments include quetiapine, lurasidone, lamotrigine and lithium.
  • A greater number of medication treatment options exist for treatment of manic episodes, and guideline-suggested first-line treatments include lithium, quetiapine, risperidone, olanzapine, divalproex (avoid use of divalproex in women of reproductive potential) and aripiprazole.

Common PCL Question – My patient is diagnosed with bipolar disorder. Can I prescribe treatment with an antidepressant?

  • Uncertainty remains about effectiveness of antidepressant medications in treatment of individuals with bipolar disorder. Expert guidelines suggest avoiding antidepressant treatment when two or more concurrent hypomanic symptoms are present, when past antidepressant treatment was associated with onset or worsening of hypomanic symptoms or anxiety symptoms, during an episode with mixed features or in individuals who experience predominantly mixed features episodes, or as monotherapy.
  • If someone is already taking an antidepressant medication, and is not experiencing remission of depression or is experiencing anxiety symptoms or hypomanic symptoms, a reasonable next step is to taper and discontinue treatment with the antidepressant medication.

Common PCL Question – What can I add to this treatment plan that is not a medication?

  • Consider other treatment options including bright light therapy for bipolar depression (administered in midday rather than upon awakening). This treatment was not associated with treatment-emergent hypomanic symptoms in a clinical trial.
  • Psychotherapy options include treatments specific to bipolar depression, and maintenance treatment psychotherapies including strategies to normalize life patterns to reduce risk of mood episode recurrence and improve quality of life.

Monitoring

Common PCL Question – I started this treatment, what can I do next?

  • When caring for individuals diagnosed with bipolar disorder it is important to monitor the effect of any treatment decision. The patient may also have specific treatment goals to monitor.
  • Mood episode recurrence is common, and subsyndromal mood symptoms can occur chronically, which are associated with recurrence.
  • Monitoring symptom severity and frequency as part of measurement-based care could be accomplished with validated patient-reported measures such as the Patient Health Questionnaire-9 for depressive symptoms, and the newer Patient Mania Questionnaire-9 for manic symptoms.

Common PCL Question – What laboratory studies or other monitoring should I do?

  • Some medication treatments such as lithium, quetiapine and other antipsychotic medications require monitoring treatment for a therapeutic medication serum concentration (lithium and divalproex), and for adverse effects such as serum metabolic studies, weight/ body mass index, tremor, or other motor phenomena such as akathisia or involuntary movements. These measurements are usually done at baseline, and every 3-6 months depending on the clinical circumstance. Some individuals treated with antipsychotic medications should have baseline and interval EKG monitoring to measure QTc interval.

Conclusion
Assessment, diagnosis, treatment selection and monitoring can be complicated when caring for individuals with suspected bipolar disorder.  Psychiatrists on the Psychiatry Consultation Line can help clinicians reason through next steps in assessment, treatment decisions, and monitoring. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

For additional reading on bipolar disorder, visit Psych Education by Dr. Jim Phelps.

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

References
Pacchiarotti I, et al. The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders. Am J Psychiatry. 2013;170:1249-1262.

Goodwin GM, et al.  Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016;30:495-553.

Yatham LN, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. 2018;20:97-170.

Cerimele JM, et al. Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care. Gen Hosp Psychiatry. 2020;65:28-32.

Cerimele JM, et al. The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms. J Gen Intern Med. 2021; Jun 18. doi: 10.1007/s11606-021-06947-7. Online ahead of print.

How to help patients experiencing dementia with behavioral disturbance

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Forgetfulness, memory impairment and difficulty with self-care are a major challenge for people living with dementia. But the neuropsychiatric symptoms of dementia can cause the most distress for patients and their caregivers.

Common neuropsychiatric symptoms include behavioral issues such as aggression, agitation and wandering. Mood, psychotic and sleep-related disturbances are also very common. Usually, patients have a combination of symptoms making it very challenging to know how to intervene.

A family who wants to care for a beloved parent at home can become demoralized and burned out when their loved-one is combative, awake all night or prone to wandering. Experienced caregivers in elderly care settings can struggle with keeping patients safe when they are distressed, pacing and paranoid of staff.

In the past, providers routinely prescribed antipsychotic medications to manage even mild symptoms. Today’s providers try to use these medications sparingly, informed by the current FDA warnings about the risks of use of these medications in the elderly. Without medications, providers might feel they have little to offer patients and families in these situations. But in many cases, significant improvements in symptoms and quality of life can be made for these patients without a prescription.

So, how do you best approach your patient with concerning neuropsychotric symptoms?

First, assess the situation: Is there a risk of harm to self or others? If so, ensure safety first by considering increasing the level of care through the addition of caregivers, one-on-one supervision, or hospitalization. In cases with the risk of severe harm, short-term pharmacologic treatment will likely be indicated along with hospitalization.

More commonly, the risk level is lower. In these cases, thinking through a few key areas can have a major positive impact:

1. Identify and treat the underlying cause. Most often, these symptoms do not occur in a vacuum. Pain, distress and underlying illness can be a driver, and one that when properly identified can be alleviated. Below is a list of commonly found underlying causes:

  • Delirium: assess for untreated medical illnesses, new medications, metabolic issues.
  • Medication side effects: have a high suspicion for this with the prescribing of benzodiazepines, anticholinergics and opioids.
  • Pain: a patient with major neurocognitive disorder may not be able to tell you they are in pain, so look at other clues such as body language and facial expression. Scheduled instead of as-needed non-narcotic pain medications can be helpful.
  • Depression and anxiety: assess for this with the help of the caregiver. Consider a trial of an SSRI.
  • Sleep disorders: sleep-wake disturbance is common in dementia. Emphasize good sleep hygiene, exposure to morning light, consistent schedule.
  • Sensory deficits: Poor vision and hearing can worsen confusion and lead to agitation as well as worsened fall risk.

2. At times, simple interventions can go a long way:

  • Implement daily, scheduled activities. Instruct families and caregivers to find activities that are soothing to the patient. Some patients will spend hours sorting through pictures, rearranging a silverware drawer or sweeping. Empower families and caregivers to get creative and try a variety of different strategies.
  • Environmental interventions such as reducing clutter, improving lighting and adding soothing features such as music or pets can help.

As a provider, helping a family discover that their mom loves to arrange silverware, can do so for hours and is able to remain calm and content throughout the day can be satisfying and bring a sense of relief in not having to add a new medication to an elderly person’s already long list. As a prescriber working with geriatric patients, less is always more when it comes to medications.

Author
Amanda Focht, MD
Clinical Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Medical Director, University of Washington Medical Center, Outpatient Psychiatry Clinic

References
Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA 2012; 308:2020.

Lyketsos CG, Steinberg M, Tschanz JT, et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry 2000; 157:708.

Gitlin LN, Winter L, Dennis MP, et al. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 2010; 58:1465.

How to ask about substance use

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If you struggle with asking patients about their alcohol and/or drugs use, you are not alone. Asking sensitive questions in a way that makes it more likely a patient will respond honestly can be challenging, and defensiveness or resistance to answering are not uncommon. Complicating this is the need to build a connection with your patient, and fear that a negative response to being asked will alter your rapport. For some, the challenge lies in asking the question; for others, it is what to do if you suspect a patient has a substance use issue.

Why, then, should providers ask about substance use? The pandemic has fueled escalating rates of both mental health and substance overuse, with one in 10 people reporting they started or increased their substance use during the. Suicide rates are up, as are overdose rates in our state. Before the pandemic, The National Institute on Drug Abuse estimated that there were over 20 million adults in the US with a substance use disorder. Of those, 38% of them also had mental illness.  Substance use disorder has a significant impact to personal health, and early intervention is key to preserving patient health and lowering health care costs. And, primary care is the de facto setting where many patients access mental health and substance use care.

There are over a dozen evidence-based screening tools for substance use, including the DAST, AUDIT-C, and CAGE. While the screening tools set a clear framework for what to ask, it’s important to know how to ask — how to set the stage — so the patient’s answers are more likely to be reliable and valid. Setting the stage includes managing our own anxiety, mitigating the patient’s anxiety, and being mindful of the wording, order and form of the questions you are asking.

To begin, be aware of your own anxiety and fears about asking sensitive questions. What’s driving them? What feels uncomfortable about asking these questions? To quell their own anxieties, some people find it helpful to practice and to ground themselves in the reasons why the answers are so important. Asking sensitive questions eventually becomes more natural, but until then, take a minute to check in with yourself and what you need to feel confident.

The words you use to ask sensitive questions, and how you set up the structure of asking, is key. Where does asking about drug and alcohol use fall in your assessment? Your psychosocial assessment should have flow, and it can be helpful to ask less loaded habit questions before asking about drug/ETOH use. For example, consider asking about diet and exercise before asking about other habits around smoking, alcohol and drugs. Starting off with questions about more socially acceptable substances like caffeine, tobacco, and then alcohol can be helpful in normalizing this line of questions.

As you head into the more sensitive questions, it can be helpful to start off with close-ended or fixed choice questions. “Have you ever drank alcohol?” or “Have you ever used any drugs or Cannabis?” This can then be followed up by asking “How often do you use?”, “How much do you use?”, and “How do you use?” if appropriate.  Asking additional questions to identify potential harms associated with their use can identify potential areas of intervention and education. “How often do you use a fresh needle when you inject…never, sometimes, almost always, always?” Asking about access to Narcan is important if the patient is using opioids or methamphetamine which may have opioids like fentanyl mixed in.

Be careful to use words that are less loaded—don’t use the term “illegal” when referring to drugs, for example, and try to ask about each drug specifically. “Have you ever used cocaine” is better than “have you ever used street drugs.” When talking with patients, be careful too about terms that are defined by each of us individually, like “drunk,” “high,” “frequently,” etc. Ask specific, quantifiable questions.

After you have a thorough substance use history from your patient and it turns out they have some concerning use patterns, what do you do now? Behavioral interventions have shown effectiveness in reducing substance use in those who are at risk for developing dependence. Commonly used elements for engaging in behavioral interventions are described in the FRAMES acronym—Feedback of risk, encouraging Responsibility for change, Advice, a Menu of options, therapeutic Empathy and enhancing Self Efficacy. Motivational interviewing can help you engage with patients who have more problematic use, but who are not yet expressing interest in change, or are contemplating change but not stating a readiness to change.

Remember, you can always call the PCL for advice on what to do once you have determined a patient does have some concerning substance use habits. Many providers feel ill-equipped to treat substance use and mental health conditions and the PCL adult psychiatrists and addiction psychiatrists are there to support you in the care of your patient. Call us anytime – we are a part of your team!

Author
Jennifer Magnani, MSW, LICSW, is the Assistant Program Director of the Psychiatry Consultation Line.

Learn more
Screening, Diagnosis, and Medication Assisted Treatment for Alcohol Use Disorders (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) identify the current screening tools and recommendations for alcohol use disorders, 2) discuss what to consider in diagnosing alcohol use disorders, and 3) review the current medications used for alcohol use disorders.

What Are Some Behavioral Strategies to Help My Patient Stay Sober? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Mark Duncan, MD
The objectives of this presentation are to 1) review the importance of behavioral strategies for relapse prevention, 2) describe which behavioral strategies can be incorporated, and 3) learn when to use these strategies in a clinical situation.

*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.

Resources provide guidance on psychotropic medications

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Many providers who lack formal training in mental health or addictions find themselves caring for patients with behavioral health conditions, but prescribing medications for mental health and/or substance use disorders can be daunting. To help bridge this gap, the UW AIMS Center developed a summary of Commonly Prescribed Psychotropic Medications that providers can use to familiarize themselves with effective medication treatments used in primary care.

The AIMS Center also created a collection of Brief Medication Prescribing Directions for common psychotropic medications used to treat adult patients. The succinct protocols are organized into three sections — dosing information, monitoring and general information — and are tailored to the outpatient setting.

Both resources are intended to facilitate the best possible prescribing practices in the outpatient setting. They should always be used with discrimination and, where questions arise (e.g., as new prescribing information comes out about a medication), in consultation with a pharmacist, current FDA drug label guidelines and/or an on-call UW psychiatrist staffing the Psychiatry Consultation Line.