Dr. Shirah Vollmer and Dr. Michael Ziffra host a Question & Answer Session addressing common inquiries about mental health treatment in the primary care setting.
At Pri-Med West 2022, Michael Ziffra, MD, Associate Professor, Department of Psychiatry, Northwestern University Feinberg School of Medicine, led a presentation on the initial diagnosis and management of bipolar disorder.
Afterward, he was joined by Shirah Vollmer, MD, Clinical Professor of Psychiatry, David Geffen School of Medicine at UCLA, for an "Ask the Experts" segment where they addressed submitted questions about depression and bipolar disorder.
Vollmer spoke on the challenges providers often face in a primary care setting when their patients aren't responding to SSRIs or other treatments in her presenation "Beyond the SSRI: Treating and Managing Major Depression."
The usefulness of genetic testing as a guidance tool for decision-making during treatment, was discussed. According to Vollmer, precision medicine is "the holy grail", however, "we're not there yet." Genetic testing mostly tests the liver metabolism of the patient and therefore how the patient metabolizes the drug.
“For these patients, you start low, go slow for every patient,” Vollmer said. “And when you do that, you learn about the metabolism of the drug for sensitivities. So, I do think that the genetic testing is not helpful.”
Ziffra stated that he agreed with Vollmer and that the information provided by genetic testing is limited in its usefulness. He said that if a patient wants to get genetic testing done there’s no harm and that it sometimes “eases their mind a little bit” but most of the time it doesn’t provide a lot of useful information.
“So, it might tell you ‘this person metabolizes this drug slowly,’ or ‘this person might have more side effects from this drug.’ So, we’re talking about drugs that might be a little bit more problematic, and a little bit less problematic, but that’s the best it can do,” he said.
When asked about the overlap of anxiety disorder and ADHD, Ziffra said there’s a lot of complicated pieces that come into play and can all occur together, but that learning the patient's history is key.
“So, ADHD by definition, it starts in childhood,” he said. “You really should be able to get a good, clear history of ADHD symptoms starting at a young age.”
As for anxiety, Ziffra stated that clarifying the nature of the anxiety is important. “Is this really anxiety, or is this something else,” he asked. “This is where patients will use terms that, to them means one thing, and to us and means something different.”
If a patient says they have racing thoughts all the time, that could align with bipolar disorder but according to Ziffra, this is where providers “need to dig and find out what they mean.” The patient might elaborate and say that they’re worrying or obsessing a lot, which could mean something different.
When asked if she ever takes a patient off of therapy like antidepressants or SSRIs to asess if they need that therapy or if they need an increased regimen, Vollmer said, absolutely.
“When patients have been in remission for over 6 months, then I actively and agressively taper the medication,” she responded. “I go slowly down, as I went slowly up.”
Vollmer explained that while some people do need lifelong medication, she wants to transition those who don’t, off their regimen. And she’ll communicate this to patients in treatment, telling them that “this is a long but temporary intervention.”
“Some people become psychologically dependent on medication to the point where they don’t understand their own power to get well,” she said, “their own power of coping skills, and their own power of resilience.”