While the sample patient did seem to be a strong candidate for a diagnosis of mania with mixed specifiers, Doctor Erfurth pointed out that the overlap of symptoms with ADHD and OCD, particularly with regard to the patient’s obsessive features, should prompt a further investigation of the diagnosis.
After our staged insight into a consultation this correspondent found it fascinating to see the other side of the clinical picture, with a talk on living with the anxiety, irritation and agitation by a bipolar patient.
As a child of two psychologists, the patient in some ways straddled two worlds: as an individual dealing with an intensely personal experience of mental disorder, but also bringing an intriguing level of clinical insight.
Perhaps the strongest theme of her talk was the importance of considering the patient as more than the individual who appears in front of the psychiatrist when they are in the grip of an episode. The person the patient considers the ‘real’ them, will often be dramatically different. This point was emotionally brought home by the patient’s mother, who described her daughter being ‘returned’ to her when her bipolar was brought back under control.
The patient also spoke of the importance, if possible, of involving family and close friends in the process, as they can give a clearer impression of the patient’s ‘normal’ state and may be able to help convince them of the necessity for treatment. This struck a chord with a number of delegates, including Professor Schultz, whose question prompted the discussion.
While there was generally agreement between the patient and the delegates, an interesting contrast occurred when Dr Erfurth pointed out that the patient’s positive, optimistic and creative temperament may help protect her from her condition (referring back to the morning’s discussion on resilience). While the patient didn’t necessarily dispute this, she felt strongly that once the onset of psychoses did occur, her creative and imaginative temperament actually made them far worse.
Having heard from the patient about living with bipolar, we smoothly segued into Dr Erfurth‘s talk on the burden and identification of bipolar mania. He started with a brief background on the history of mixed state identification, focusing on the work of Emil Kraeplin, who (unsurprisingly, given his contributions to the field) is fast becoming one of the most-mentioned names of the conference.
Dr Erfurth restated the need for rapid, effective treatment, as patients with mixed states are at higher risk of hospitalisation, dissatisfaction with life, suicidality and longer hospital stays.
He also pointed out that despite anxiety, irritability and agitation being the most common symptoms of patients in a mixed state, they can also confound accurate diagnosis. He therefore encouraged the delegates to make use of tools such as the MINI module to support their assessment.
Professor Young’s presentation naturally followed on from the discussion of the burden of bipolar mania with depressive symptoms by examining the management options for these patients.
He started by reiterating the common nature of mixed features, which occur in approximately a third of patients suffering from a manic episode. In particular, anxiety, irritability and agitation are seen to be significantly more common and more severe in patients displaying more than three depressive symptoms in their latest manic episode (the definition of a mixed state, according to DSM-5).
Moving onto treatment, Prof Young strongly advised against the use of antidepressants in these patients, going so far as to say that he felt there was not enough focus on their dangers in manic patients.
He had kinder words for the second-generation antipsychotics though. However, while there is copious evidence for their manic symptom efficacy in patients with mixed features, there is relatively little for depressive symptom efficacy in these patients.
Prof Young highlighted asenapine as a potential exception, due to the data showing efficacy in manic symptoms and improvement in depressive symptoms in patients with mixed features. As such, he felt this indicates that it may be possible to target treatment to mixed states with this compound. He also noted that the effects are not transient, with evidence at one and three weeks.
The session closed with questions from the delegates. One answer that really struck home for me came from the patient, in response to her experiences of discrimination; unsurprisingly she has experienced it throughout her life, but more shockingly, she also noted that she has commonly experienced it at mental health conferences.
It goes to show that even those of us who work in the mental health arena need to be aware of the prejudices that we, like everyone else, bring to our daily lives and do our best to overcome them.
In the humble opinion of this correspondent, this was an engaging, informative session, and judging by the packed room, I wasn’t alone in this opinion.