PBA and Depression

Actor portrayal of a patient with PseudoBulbar Affect (PBA) crying symptoms

Are your patients with depression also experiencing PBA?

Pseudobulbar affect (PBA) is commonly comorbid with depression or other mood and behavioral disorders. Screen for PBA when patients with neurologic conditions or brain injury are diagnosed with and treated for depression but are still experiencing involuntary, sudden, frequent laughing and/or crying episodes.1-4

57.5% OF PATIENTS

In a clinical study, more than half of patients who were diagnosed with PBA had comorbid depression (N=367).5,a,b

70.8% of patients in the study were taking psychopharmacologic medications.

aPRISM II was a 90-day, open-label, single-arm, 74-site, US trial in adult patients with dementia, stroke, or TBI. All patients received a clinical diagnosis of PBA by their physician and had a Center for Neurologic Study-Lability Scale (CNS-LS) score ≥13 at baseline. CNS-LS is a 7-item self-report rating scale that measures perceived frequency and control over laughing and/or crying episodes. It was validated as a PBA screening tool in ALS and MS populations. CNS-LS ≥13 may suggest PBA but does not confer a PBA diagnosis.4-8

bBased on Patient Health Questionnaire-9 (PHQ-9), a 9-item assessment of depressive symptoms. Scores range from 0 to 27, with higher scores indicating increased depression severity.5

Nurse Practitioner Cathy Yaggi talks differentiating depression from PseudoBulbar Affect (PBA)
PBA and Depression: how to tell the difference
Nurse Practitioner Cathy explains how she differentiates between depression and PBA in her residents.

Differentiate PBA from depression by recognizing the characteristics of crying9

CRYING IN DEPRESSION
  • Matches how the patient feels
  • Mostly controllable; stops when mood changes
  • Onset and duration defined by mood
CRYING IN PBA
  • Disproportionate to or inconsistent with how the patient feels
  • Uncontrollable
  • Happens frequently, suddenly, and may be brief

These are not all the diagnostic features of depression.7 Formal diagnosis of depression or PBA can only be made by a qualified healthcare practitioner.

Various mood and behavioral disorders can affect patients with neurologic conditions or brain injury2

Depression is only one of many behavioral disorders that have symptoms similar to PBA. Crying or other outbursts are common among these disorders as well, which can complicate the diagnosis of PBA.1,3,4,9-11

Behavioral disorders with symptoms similar to PseudoBulbar Affect (PBA)

References: 1. Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. 2. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798. 3. Parvizi J, Arciniegas DB, Bernardini GL, et al. Diagnosis and management of pathological laughter and crying. Mayo Clin Proc. 2006;81(11):1482-1486. 4. Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS ONE. 2013;8(8):e72232. 5. Hammond FM, Alexander DN, Cutler AJ, et al. PRISM II: an open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurol. 2016;16:89. 6. Moore SR, Gresham LS, Bromberg MB, Kasarkis EJ, Smith RA. A self report measure of affective lability. J Neurol Neurosurg Psychiatry. 1997;63(1):89-93. 7. Smith RA, Berg JE, Pope LE, Callahan JD, Wynn D, Thisted RA. Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients. Mult Scler. 2004;10(6):679-685. 8. Smith RA, Berg JE, Pope LE, Thisted RA. Measuring pseudobulbar affect in ALS. Amyotroph Lateral Scler Other Motor Neuron Disord. 2004;5(suppl 1):99-102. 9. Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diagnosing involuntary emotional expression disorder. CNS Spectr. 2006;11(S6):1-7. 10. Engelman WA, Hammond FM, Malec JF. Diagnosing pseudobulbar affect in traumatic brain injury. Neuropsychiatr Dis Treat. 2014;10:1903-1910. 11. Crumpacker DW, Engelman WA. Identifying pseudobulbar affect in Alzheimer’s disease and dementia. US Neurol. 2014;10(1):10-14.

INDICATION AND USAGE

NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) is indicated for the treatment of pseudobulbar affect (PBA). PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

Quinidine and Related Drugs: NUEDEXTA contains quinidine, and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.

Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (eg, rash, hives).

MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.

Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (eg, thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

WARNINGS AND PRECAUTIONS

Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes–type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (eg, syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.

ADVERSE REACTIONS

The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA. Please see Full Prescribing Information.

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