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Patient Profiles & Nurse Practitioner Perspectives

Could it be bipolar depression? Know what to look for as your patient's story unfolds.


Get the clinical facts behind each patient's story and a nurse practitioner's perspective on each case. Learn to recognize the signs that differentiate bipolar depression and the types of patients who may be appropriate for treatment with LATUDA.

Click on the patient's photo below to review their medical profile and access a nurse practitioner's commentary on the case.

PATIENT PROFILE
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Patient Profile: Jane

A 10-year journey to a bipolar disorder diagnosis

Jane is a 30-year-old elementary school teacher who has been referred to a psychiatric nurse practitioner (NP) by her primary care provider after she expressed frustration with her lack of response to antidepressant therapy as prescribed by a previous psychiatrist. When asked how she is doing in general, she responds that this year has been tough. When urged for specifics, Jane divulges that she has experienced on-and-off bouts of depression for about 10 years. Jane complains that she has low energy and has had increasing difficulty coping with the demands of her job, which she used to love. Part of Jane’s frustration with her previous psychiatric provider is that she is tired of trying one antidepressant after another.

Jane’s psychiatric NP uses the Patient Health Questionnaire–9 item (PHQ-9)1 to screen her for depression and the Mood Disorder Questionnaire (MDQ)2 to screen for a lifetime history of mania. The results of the MDQ point to a history of manic episodes, but more information is required. The psychiatric NP conducts a full diagnostic interview with Jane to come to a definitive diagnosis. Jane denies feeling “unusually good” in the past. With her permission, the psychiatric NP speaks with Jane’s husband to gather collateral information to supplement the full diagnostic interview. Jane’s husband reveals that Jane has had several periods of unusual behavior in the past, during which time she was uncharacteristically short-tempered and jeopardized the couple’s finances with impulsive decisions. On the basis of the PHQ-9, the MDQ, the full diagnostic interview, and collateral information, the psychiatric NP diagnoses Jane with bipolar I disorder and initiates therapy with a mood stabilizer. Jane returns for an office visit 3 weeks after starting the mood stabilizer for an assessment of her symptoms. Despite the mood stabilizer, she continues to complain of finding little enjoyment in her daily activities. She relates that she has been taking the medication as prescribed.

Jane returns for a second follow-up 3 weeks later, reporting that her depressive symptoms have still not improved since she began the medication. Plasma levels obtained at this time confirm treatment adherence.

The psychiatric NP keeps Jane on the mood stabilizer, and after discussing all available treatment options with her, decides to add LATUDA for the treatment of her major depressive episodes associated with bipolar I disorder (bipolar depression).

NP CASE COMMENTARY
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Case Commentary: Diane Snow, PhD, APRN, PMHNP-BC, FAANP, FIAAN

Clinical Professor and Director, PM-HNP Program
University of Texas at Arlington College of Nursing and Health Innovation Arlington, Texas

Unfortunately, it is not uncommon for individuals with bipolar disorder to go undiagnosed or misdiagnosed for long periods of time. When Jane* presents to her psychiatric NP, her primary complaint is her depression, and we know that she is tired of trying one antidepressant after another. This account of failed antidepressant therapy is a red flag that the patient may have bipolar disorder. She has not expressed any symptoms other than those of a depressive nature thus far, which can mask the need to investigate further into her history. In fact, I would urge primary care and psychiatric providers to rule out bipolar disorder in any patient who presents with depressive symptoms to help prevent a misdiagnosis and possible inappropriate treatment. A straightforward way to do that is via screening tools, such as the MDQ, which screens for a lifetime history of mania. This tool can provide feedback to the patient, who may start to recognize his or her symptoms through the screening tools. Following a positive screen, assessment of mood symptoms using the DSM-5 criteria and asking about sudden switches in mood over time is important. It is also helpful to ask the patient to cite any previous diagnoses, as patients are not always sure of their diagnostic history. Asking specifically about a family history of bipolar disorder in first- and second-degree relatives may help to confirm a diagnosis of heritable bipolar disorder.

Jane’s denial of feeling “unusually good” in the past is not as much a denial as it is a lack of self-awareness and insight. To gain insight from an outside source, the psychiatric NP speaks with Jane’s husband. If Jane had not been willing to include her husband in the conversation, the psychiatric NP could have asked Jane, “Has your family ever mentioned that you were acting out of character?” An account of family members’ responses could provide additional clues into Jane’s own bipolar symptoms.

Once Jane is diagnosed with bipolar I disorder, she begins therapy with a mood stabilizer. It is important to follow up—even by phone—to make sure her depression does not get any worse. As with any medication, if there is no improvement, a change in dose or treatment may be warranted. In this case, after 6 weeks, the psychiatric NP adds LATUDA to the mood stabilizer to treat Jane’s bipolar depression.

Diane Snow is a paid consultant of Sunovion Pharmaceuticals, Inc.


Access a full issue of A Clinical Expert Approach to the Management of Bipolar Depression, which includes an article on bipolar depression and treatment with LATUDA along with the above Patient Profile and Case Commentary.

PATIENT PROFILE
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Patient Profile: Jeannette

Her first diagnostic workup

Jeannette is a 27-year-old musician who was referred to a psychiatric nurse practitioner (NP) after regular counseling sessions revealed a history of mood swings, depression, and “performance jitters.” The psychiatric NP begins by asking Jeannette about her current and past experiences. Jeannette says that her increasing time in what she calls her own “dark days” causes her family and friends to be concerned. She has trouble convincing herself to leave the house or even get out of bed. She is often irritable, fights with her band members, and is considered brilliant but unreliable. She adds that she becomes anxious prior to band performances and occasionally drinks before a show to calm her nerves.

After the conversation with Jeannette, the psychiatric NP suspects that Jeannette may actually be experiencing a major depressive episode, but wants to first assess her symptoms of anxiety. The psychiatric NP administers the GAD-7.1 According to the GAD-7, Jeannette’s total score of 3 is not suggestive of an anxiety disorder.

To further guide the diagnostic process and confirm the initial impression that Jeannette is experiencing a major depressive episode, the psychiatric NP administers the PHQ-9,2 which provides insight into Jeannette’s “dark days”—periods of time when she has  little to no interest in performing and, as a result, “feels like a failure.” Next, the psychiatrist employs the MDQ,3 which further underscores Jeannette’s irritability and prompts Jeannette to admit to periods of distractibility and racing thoughts.

At this time, the psychiatrist believes that Jeannette has bipolar disorder and conducts a comprehensive diagnostic interview for more information. A detailed family history reveals that a maternal grandfather and uncle have been diagnosed with bipolar disorder. A history of childhood development, social relationships, employment, substance use, and possible emotional/physical/sexual abuse are also obtained, as these elements are vital to the assessment. Of note, Jeannette’s history of childhood development seems normal and is unremarkable for past abuse. With the results of the screening tools and the information from the diagnostic interview, the psychiatric NP establishes that Jeannette is experiencing a major depressive episode associated with bipolar I disorder (bipolar depression).

Based on the diagnosis of bipolar I disorder, the psychiatric NP opts to initiate monotherapy with LATUDA, which is indicated for the treatment of bipolar depression. To help monitor for bipolar symptoms, the psychiatric NP asks for and obtains permission to occasionally follow up with Jeannette’s close friend and band member, who is eager to help Jeannette by looking out for key symptoms.

NP CASE COMMENTARY
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Case Commentary: Diane Snow, PhD, APRN, PMHNP-BC, FAANP, FIAAN

Clinical Professor and Director, PM-HNP Program
University of Texas at Arlington College of Nursing and Health Innovation Arlington, Texas

It is not unusual for a patient with bipolar I disorder to present with confounding symptoms. In this case, Jeannette* demonstrates performance anxiety, preventing her from functioning in her career as a musician. Clinicians must be prudent in assessing all symptoms, but recognizing that patients with bipolar disorder can indeed present with one or more psychiatric comorbidities, such as anxiety disorders, as reported in STEP-BD.1 The clinician uses the GAD-7, the PHQ-9, and the MDQ to screen for anxiety, depression, and a history of mania. Although very helpful as screening tools, these screeners do not replace the clinical interview in making a diagnosis. A comprehensive interview is required.

Jeannette reveals in the interview that she has had a history of episodes that appear to be mania. She is currently depressed (specifically, experiencing at least 2 weeks of depressed mood along with other criteria from the Diagnostic and Statistical Manual of Mental Disorders. 5th ed. [DSM-5]).2 If the psychiatric NP had not determined that Jeannette had a manic episode with at least 7 days of elevated mood, racing thoughts, decreased need for sleep, and/or other symptoms, such as distractibility, excess energy, and inflated self-esteem, it is very possible that Jeannette would have been treated with an antidepressant. Antidepressants are not first-line treatment for bipolar depression; they can often precipitate a switch to mania.3

In addition, the clinician needs to confirm the extent of Jeannette’s drinking. Alcohol and drugs can affect mood and impulsivity, challenging the clinician to sort through intoxication and withdrawal symptoms to establish a clearer clinical picture.

Finally, this patient has a supportive friend who can be a valuable asset for monitoring symptoms and being alert to changes in mood and anxiety. This advocacy role can provide tremendous benefit to the clinician. Furthermore, Jeannette may benefit from psychotherapy to improve coping skills in handling stress and to ensure she maintains a normal daily routine.

Diane Snow is a paid consultant of Sunovion Pharmaceuticals, Inc.


Access a full issue of A Clinical Expert Approach to the Management of Bipolar Depression, which includes an article on bipolar depression and treatment with LATUDA along with the above Patient Profile and Case Commentary. 

PATIENT PROFILE
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Patient Profile: Dave

A new treatment plan for persistent symptoms

Dave is a 47-year-old obese information technology specialist who was diagnosed with bipolar I disorder 15 years ago. He has been seeing a new psychiatric nurse practitioner (NP) for the past few months. Dave is currently taking an atypical antipsychotic and a mood stabilizer—the same regimen that a psychiatrist prescribed 5 years ago. At a recent visit to the psychiatric NP, Dave states that he had initially improved when on the regimen, but lately, he is depressed, and his wife thinks he seems sad.

Dave’s wife, who accompanied him to the appointment, confirms that he had improved when he started his medication regimen, explaining that he had regained interest in spending time with his friends. However, she states that, more recently, he seems to be unengaged and unhelpful with tasks at home or on errands with the kids, which is creating strain in their marriage. She says that she does not believe his current therapy is working anymore. In reply, Dave acknowledges that he sometimes lacks the motivation to do things his wife asks him to do, adding that “no one understands [him].” When asked how work is going, he responds that he does well with his “actual job” but sometimes takes too long filling out paperwork.

The psychiatric NP delves into Dave’s treatment and medical history. Dave’s initial treatment for bipolar I disorder at the time of diagnosis was a first-generation antipsychotic and a mood stabilizer. Although Dave has not experienced a manic episode since his diagnosis, he has had several major depressive episodes, marked by overeating and lethargy. He has gained weight, which contributes to his lack of energy and interest in getting out of the house. His previous psychiatrist subsequently switched Dave to a different atypical antipsychotic. However, at this visit, Dave reports a worsening in depressive symptoms and “not enough energy” to follow an exercise regimen.

While noting Dave’s history, the psychiatric NP observes that Dave was breathing heavily and sweating during the first portion of the appointment after walking up a short flight of stairs. The psychiatric NP takes Dave’s pulse and blood pressure and measures his weight and waist circumference, keeping in mind that individuals with bipolar disorder are at higher risk for metabolic abnormalities and cardiovascular disease, compared with the general population.1 Further, weight gain and undesirable alterations in lipids have been observed with atypical antipsychotic use; patients treated with atypical antipsychotics should be monitored for unfavorable changes in metabolic parameters. The psychiatric NP talks to Dave about the importance of managing his physical health and arranges to work with a primary care colleague to monitor and address Dave’s cardiometabolic risk factors.

Noting Dave’s persistent depressive symptoms, the psychiatric NP decides to keep Dave on his current mood stabilizer and switch his atypical antipsychotic to LATUDA for the treatment of his major depressive episodes associated with bipolar I disorder (bipolar depression).

Before Dave and his wife leave the office, the psychiatric NP expresses that Dave and his entire family can be involved in improving their lifestyle, starting with simple dietary changes, and reiterates that atypical antipsychotics can cause unfavorable weight and metabolic changes. If necessary, referral to a nutritionist can provide additional knowledge and support. Increased activity is an important lifestyle modification, as well; family participation in activities, such as a nature walk or bike ride, can offer rewards beyond those of physical well-being.

NP CASE COMMENTARY
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Case Commentary: Diane Snow, PhD, APRN, PMHNP-BC, FAANP, FIAAN

Clinical Professor and Director, PM-HNP Program
University of Texas at Arlington College of Nursing and Health Innovation Arlington, Texas

The first step in a comprehensive follow-up by the primary care clinician would be to run a standard lab workup to assess a new baseline of values, including, but not limited to: thyroid, cholesterol, and triglycerides. These values can provide a point of reference for ongoing appointments. Next, the clinician should delve into the patient’s sleep habits, which could be affecting his motivation and energy levels. If Dave’s sleep habits do require further investigation, the clinician may take this opportunity to refer Dave to a sleep laboratory or another healthcare professional. To address Dave’s physical health, the psychiatric NP or primary care clinician should discuss basic lifestyle modifications (ie, dietary change, increase in exercise) with Dave and his wife.

Keeping family members active in the discussion and treatment plan can be valuable, as they can provide support and serve as another perspective on a patient’s health status and overall functioning. Collaboration should continue between the psychiatric NP and primary care clinician as these health care providers track Dave’s progress in regards to his depressive symptoms and results from his periodic physical exams. Improvements of any kind—no matter how big or small—can help the patient, so working with Dave while incorporating changes agreed upon by him and his wife can be a good start toward improving overall health practice.

Diane Snow is a paid consultant of Sunovion Pharmaceuticals, Inc.


Access a full issue of A Clinical Expert Approach to the Management of Bipolar Depression, which includes an article on bipolar depression and treatment with LATUDA along with the above Patient Profile and Case Commentary. 

*Not an actual patient. The Licensed Material is being used for illustrative purposes only. Any person depicted in the Licensed Material, if any, is a model.

References: 
1.
Simon NM, Otto MW, Weiss RD, et al. Pharmacotherapy for bipolar disorder and comorbid conditions: baseline data from STEP-BD. J Clin Psychopharmacol. 2004;24(5):512-520.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
3. Valentí M, Pacchiarotti I, Bonnín CM, et al. Risk factors for antidepressantrelated switch to mania. J Clin Psychiatry. 2012;73(2):e271-e276.

Important Safety Information & Indications

INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHTS AND BEHAVIORS

Increased Mortality in Elderly Patients with Dementia-Related Psychosis
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. LATUDA is not approved for the treatment of patients with dementia-related psychosis.

Suicidality and Antidepressant Drugs
Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior in patients over age 24. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. LATUDA is not approved for use in pediatric patients with depression.

 

CONTRAINDICATIONS
LATUDA is contraindicated in the following:

WARNINGS AND PRECAUTIONS
Cerebrovascular Adverse Reactions, Including Stroke: In placebo-controlled trials with risperidone, aripiprazole, and olanzapine in elderly subjects with dementia, there was a higher incidence of cerebrovascular adverse reactions (cerebrovascular accidents and transient ischemic attacks) including fatalities compared to placebo-treated subjects. LATUDA is not approved for the treatment of patients with dementia-related psychosis.

Neuroleptic Malignant Syndrome (NMS): NMS, a potentially fatal symptom complex, has been reported with administration of antipsychotic drugs, including LATUDA. NMS can cause hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure. Management should include immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy, intensive symptomatic treatment and medical monitoring, and treatment of any concomitant serious medical problems.

Tardive Dyskinesia (TD): TD is a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements that can develop in patients with antipsychotic drugs. There is no known treatment for established cases of TD, although the syndrome may remit, partially or completely, if antipsychotic treatment is withdrawn. The risk of developing TD and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses. Given these considerations, LATUDA should be prescribed in a manner that is most likely to minimize the occurrence of TD. If signs and symptoms appear in a patient on LATUDA, drug discontinuation should be considered.

Metabolic Changes

Hyperglycemia and Diabetes Mellitus: Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug.

Dyslipidemia: Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics.

Weight Gain: Weight gain has been observed with atypical antipsychotic use. Clinical monitoring of weight is recommended.

Hyperprolactinemia: As with other drugs that antagonize dopamine D2 receptors, LATUDA elevates prolactin levels. Galactorrhea, amenorrhea, gynecomastia, and impotence have been reported in patients receiving prolactin-elevating compounds.

Leukopenia, Neutropenia, and Agranulocytosis: Leukopenia/neutropenia has been reported during treatment with antipsychotic agents. Agranulocytosis (including fatal cases) has been reported with other agents in the class. Patients with a preexisting low white blood cell count (WBC) or a history of drug-induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy, and LATUDA should be discontinued at the first sign of a decline in WBC in the absence of other causative factors.

Orthostatic Hypotension and Syncope: LATUDA may cause orthostatic hypotension. Orthostatic vital signs should be monitored in patients who are vulnerable to hypotension, in patients with known cardiovascular disease or history of cerebrovascular disease and in patients who are antipsychotic-naїve.

Seizures: LATUDA should be used cautiously in patients with a history of seizures or with conditions that lower seizure threshold (e.g., Alzheimer’s dementia).

Potential for Cognitive and Motor Impairment: Patients should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that therapy with LATUDA does not affect them adversely.

Body Temperature Regulation: Disruption of the body’s ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing LATUDA for patients who will be experiencing conditions that may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration.

Suicide: The possibility of suicide attempt is inherent in psychotic illness and close supervision of high-risk patients should accompany drug therapy. Prescriptions for LATUDA should be written for the smallest quantity of tablets consistent with good patient management in order to reduce the risk of overdose.

Dysphagia: Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer’s dementia. LATUDA and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia.

ADVERSE REACTIONS
Commonly observed adverse reactions (≥5% incidence and at least twice the rate of placebo) for LATUDA:

Indications

LATUDA is indicated for:

 

Before prescribing LATUDA, please read the full Prescribing Information, including Boxed Warnings.