The management of bipolar disorder in primary care: a review of existing and emerging therapies

Recent evidence suggests that the prevalence of bipolar disorder is as much as fivefold higher than previously believed, and may amount to nearly 5% of the population, making it almost as common as unipolar major depression. It is, therefore, not unrealistic to assume that primary care or family physicians will frequently encounter bipolar patients in their practice. Such patients may present with a depressive episode, for a variety of medical reasons, for longer-term maintenance after stabilization, and even with an acute manic episode. Whatever the reason, a working knowledge of current trends in the acute and longer-term management of bipolar disorder would be helpful to the primary care physician. In addition, an understanding of important side-effects and drug interactions that occur with drugs used to treat bipolar disorder, which may be encountered in the medical setting, are paramount. This paper will attempt to review existing and emerging therapies in bipolar disorder, as well as their common drug interactions and side-effects.     

Undiagnosed Bipolar Disorder: New Syndromes and New Treatments

Recent studies have indicated that bipolar disorder is more common than previously believed. The socioeconomic and personal burdens of this illness are significant, and the lifetime risk of suicide attempts by patients with bipolar II disorder is high. It is not uncommon for patients with bipolar disorder, especially those presenting with depression, to be seen first in a primary care setting; therefore, primary care physicians need to be ready to diagnose and manage patients with these mental illnesses. The diagnosis of bipolar disorder or bipolar spectrum disorder is easily missed, or these illnesses may be misdiagnosed. A systematic and detailed initial history from the patient and a reliable family member is essential to making the correct diagnosis. The Mood Disorder Questionnaire, a validated screening instrument for bipolar disorder, may help primary care physicians make an appropriate diagnosis. Long-term management of patients with bipolar disorder should involve close liaison with a psychiatrist.     

Use of health care services among persons who screen positive for bipolar disorder

OBJECTIVE: This study examined patterns of diagnosis, consultation, and treatment of persons who screened positive for bipolar disorder. METHODS: An impact survey was mailed to a representative subset of 3,059 individuals from a large U.S.-population-based study that utilized the Mood Disorder Questionnaire (MDQ). RESULTS: Respondents who screened positive on the MDQ (reported the presence of seven of 13 symptoms of bipolar disorder, the co-occurrence of at least two symptoms, and moderate or severe symptom-related impairment) (N=1,167) had consulted a health care provider more often in the previous year than those who screened negative (reported six or fewer symptoms regardless of symptom co-occurrence or impairment) (N=1,283). Psychiatrists and primary care physicians failed to detect or misdiagnosed bipolar disorder among 53 percent and 78 percent of patients, respectively, who screened positive for bipolar disorder. The most commonly used psychotropic medications during the previous 12 months among those who screened positive were antidepressants alone (32 percent), followed by lithium and anticonvulsant mood stabilizers (20 percent), antidepressants in combination with other psychotropics (19 percent), hypnotics (19 percent), and antipsychotics (9 percent). In the preceding 12 months, respondents who screened positive on the MDQ had greater use of psychiatric hospitals, emergency departments, and urgent care centers and also had more outpatient visits to primary care physicians, psychiatrists, and alcohol treatment centers than those who screened negative. CONCLUSIONS: The results of this study suggest that bipolar disorder is an underdiagnosed and often inappropriately treated illness associated with significant use of health care resources.     

Design and implementation of a randomized trial evaluating systematic care for bipolar disorder

Objectives: Everyday care of bipolar disorder typically falls short of evidence‐based practice. This report describes the design and implementation of a randomized trial evaluating a systematic program to improve quality and continuity of care for bipolar disorder. Methods: Computerized records of a large health plan were used to identify all patients treated for bipolar disorder. Following a baseline diagnostic assessment, eligible and consenting patients were randomly assigned to either continued usual care or a multifaceted intervention program including: development of a collaborative treatment plan, monthly telephone monitoring by a dedicated nurse care manager, feedback of monitoring results and algorithm‐based medication recommendations to treating mental health providers, as‐needed outreach and care coordination, and a structured psychoeducational group program (the Life Goals Program by Bauer and McBride) delivered by the nurse care manager. Blinded assessments of clinical outcomes, functional outcomes, and treatment process were conducted every 3 months for 24 months. Results: A total of 441 patients (64% of those eligible) consented to participate and 43% of enrolled patients met criteria for current major depressive episode, manic episode, or hypomanic episode. An additional 39% reported significant subthreshold symptoms, and 18% reported minimal or no current mood symptoms. Of patients assigned to the intervention program, 94% participated in telephone monitoring and 70% attended at least one group session. Conclusions: In a population‐based sample of patients treated for bipolar disorder, approximately two‐thirds agreed to participate in a randomized trial comparing alternative treatment strategies. Nearly all patients accepted regular telephone monitoring and over two‐thirds joined a structured group program. Future reports will describe clinical effectiveness and cost‐effectiveness of the intervention program compared with usual care.     

Gastric Bypass Surgery: A Survey of Primary Care Physicians

Gastric bypass surgery has become an increasingly recognized treatment option for individuals suffering from morbid obesity. However, no previous empirical studies have examined the beliefs and attitudes of primary care physicians with regard to this type of intervention. Using a cross-sectional survey approach, we queried 99 primary care physicians about their beliefs and attitudes. With the exception of queries about insurance coverage, the response patterns evidenced a clear majority for most items. For several items, there were some interesting inconsistencies, which may suggest physician ambivalence. In the final analysis, 84% of respondents supported the recommendation of gastric bypass surgery for qualifying patients. However, there was a significant gender difference, with female physicians being less supportive than male physicians. We discuss the implications of these results.     

Knowledge About Recommended Treatment and Management of Major Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder Among Family Physicians

BACKGROUND: Concerns have been raised about whether primary care physicians appropriately manage mental disorders. We assessed family physicians' knowledge of appropriate management of major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD). METHOD: Active members of the Texas Academy of Family Physicians (N = 3553) were mailed a questionnaire in 2002 asking them to indicate which treatments they felt were effective for MDD, panic disorder, and GAD and also to indicate how they had treated their last patient with each disorder. Their treatment strategies were then compared with current guidelines. RESULTS: 574 physicians (16%) responded. The percentage of respondents scoring at or above 80% for knowledge of effective treatments was 88.3% for MDD, 16.8% for panic disorder, and 12.5% for GAD (p <.001 for MDD vs. panic disorder or GAD). Only 0.3% of MDD patients, 1.4% of panic disorder patients, and 4.0% of GAD patients were not prescribed at least 1 of the effective treatments. Referral rates to mental health providers were high for all 3 conditions. CONCLUSIONS: There were significant gaps in physician knowledge of current guidelines on treating panic disorder and GAD, but not MDD. However, most patients with one of the disorders were either referred to a mental health provider or treated with an effective modality.     

Awareness of metabolic concerns in patients with bipolar disorder: a survey of European psychiatrists.

PURPOSE: An online survey of European psychiatrists assessed awareness of the metabolic syndrome and its influence on the management of bipolar disorder. MATERIALS AND METHODS: Psychiatrists in the United Kingdom, France, Germany, Spain, and Italy were surveyed from April to June 2006. Eligibility criteria w ere 4-30 years in practice, >or=50% of time in direct patient care, had seen >or=10 bipolar patients in the preceding month. Aggregate data were weighted to represent the practicing physician population per country. RESULTS: Of 718 respondents, 56% had diagnosed metabolic syndrome. Respondents reported that metabolic syndrome prevalence was higher in bipolar patients (25%) than in the general population (20%). Seventy-two percent felt that metabolic syndrome poses significant health risks, warranting monitoring/treatment, and were most concerned with the bipolar medication adverse effects of weight gain, cognitive impairment, and glucose intolerance. Survey respondents recognized clear differences among psychotropic agents in the propensity to induce metabolic adverse effects. Sixty-five percent of respondents indicated that they had made interviewing and monitoring changes in the past three years as a result of metabolic concerns. CONCLUSIONS: European psychiatrists view metabolic syndrome as highly prevalent in the general population and in bipolar patients; two-thirds have changed their management of bipolar patients because of metabolic health concerns.     

Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach

Early treatment can favorably impact the course of bipolar disorder, a lifelong illness. Because bipolar disorder can masquerade as various mental and physical illnesses-primarily major depressive disorder-patients with this condition frequently go unrecognized for years. During this recognition lag, such patients may present to their primary care physician on multiple occasions. Accordingly, primary care physicians would benefit from knowing the "clues" to early recognition of the disorder, because early recognition and management can reduce disability, improve social and employment stability, and result in improved functional outcomes. This review describes 3 pathways to the diagnosis of bipolar disorder relevant to the primary care setting: detection of mania or hypomania, differential diagnosis of recurrent depressive episodes, and identification of interepisode disorder and its comorbidities. We summarize these pathways in terms of a practical tool that a primary care physician can use to trigger further evaluation or referral.     

A first national survey of knowledge, attitudes and behaviours towards schizophrenia, bipolar disorders and autism in France

ABSTRACT: BACKGROUND: In order to support evidence-based policies for reduction of stigma, a better understanding of its components: ignorance (knowledge), prejudice (attitude) and discrimination (behaviour) is necessary. This study explores public perceptions and quantifies stigma for three chronic mental disorders: autism, schizophrenia and bipolar disorders in France. METHODS: Survey of 1000 adults selected from an established market research panel. The 21-item questionnaire explored knowledge, attitudes and behaviours toward each disorder. RESULTS: Although 95% respondents recognized the names of each disorder fewer than 70% could report specific characteristics and only 33% considered that publically available information was adequate; most respondents identified the media as their main resource. Labeling of conditions in a negative way was frequent (61%) when referring to mental disorders in general, but fell significantly (18%) when linked to an individual with a disorder. Individuals with schizophrenia are assumed to be dangerous; 65% respondents would engage in social distancing from such an individual, versus 29% for bipolar disorders and 7% for autism (p < 0.001). In contrast to other disorders, discrimination against schizophrenia was only partly attenuated in those with familiarity with mental disorders (through personal or family illness). CONCLUSION: This first population-based survey in France shows that attitudes towards bipolar disorders and autism are less prejudicial than towards schizophrenia. However, most public attitudes and behaviours towards different disorders appear to be based on assumptions rather than knowledge or evidence suggesting a generic information or anti-stigma programme is unlikely to be effective.     

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

OBJECTIVE: This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. METHOD: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. RESULTS: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. CONCLUSIONS: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.     

Gastric bypass surgery: a survey of primary care physicians

Gastric bypass surgery has become an increasingly recognized treatment option for individuals suffering from morbid obesity. However, no previous empirical studies have examined the beliefs and attitudes of primary care physicians with regard to this type of intervention. Using a cross-sectional survey approach, we queried 99 primary care physicians about their beliefs and attitudes. With the exception of queries about insurance coverage, the response patterns evidenced a clear majority for most items. For several items, there were some interesting inconsistencies, which may suggest physician ambivalence. In the final analysis, 84% of respondents supported the recommendation of gastric bypass surgery for qualifying patients. However, there was a significant gender difference, with female physicians being less supportive than male physicians. We discuss the implications of these results.     

Agitated depression in bipolar I disorder: prevalence, phenomenology, and outcome

OBJECTIVE: The study aimed to explore how prevalent agitated depression is in bipolar I disorder, whether it represents a mixed state, and whether it differs from nonagitated depression with respect to course and outcome. METHOD: From 313 bipolar I patients with an index episode of major depression, the authors selected those fulfilling Research Diagnostic Criteria for agitated depression. These 61 patients were compared to 61 randomly recruited bipolar I patients with an index episode of nonagitated depression and 61 randomly recruited bipolar I patients with an index episode of mania regarding demographic, historical, and clinical features. The two depressive groups were also compared regarding time to recovery from the index episode, treatment received for that episode, percentage of time spent in an affective episode during a prospective observation period, and 5-year outcome. RESULTS: Patients with agitated depression were consistently not elated or grandiose, but one-fourth had the cluster of symptoms with racing thoughts, pressured speech, and increased motor activity, and one-fourth had the paranoia-aggression-irritability cluster. Compared to patients with nonagitated depression, they had a longer time to 50% probability of recovery from the index episode, were more likely to receive standard antipsychotic drugs during that episode, and spent more time in an affective episode during the observation period. CONCLUSIONS: The occurrence of agitated depression in bipolar I disorder is not rare and has significant prognostic and therapeutic implications. Whether the co-occurrence of a major depressive syndrome with one or two of these symptomatic clusters makes up a "mixed state" remains unclear.     

Inside the hidden mental health network. Examining mental health care delivery of primary care physicians

Mental disorder diagnoses among 51 patients, made by a group of 20 family physicians, were compared with diagnoses generated by the Diagnostic Interview Schedule (DIS). Processes of diagnosis, decision making, and treatment planning were then examined through structured physician interviews and chart audits. In this study, 75 of 94 DIS diagnoses (79%) were undetected. During interview and chart audit, the physicians were found to have consistently underestimated, misinterpreted, or neglected psychiatric aspects of care among a majority of patients in the study. These physicians had all satisfactorily completed a psychiatry curriculum designed for family physicians. Analysis of these results suggests that a mental health role is often not integrated into primary care practice, regardless of physician performance during psychiatric training experiences. Assumption of this role appears to be state dependent on involvement with a psychiatric treatment setting. Primary care practice patterns do not seem to result in application of appropriate skills and therapeutic attitudes to detect, diagnose, and correctly manage the majority of mental disorders that occur. The need is reaffirmed for active collaboration between mental health professional and primary care providers in training and in incorporation of psychiatric skills into primary care practice.     

Mood Disorders in Family Practice: Beyond Unipolarity to Bipolarity

Primary care physicians increasingly have treated depressive disorders over the last decade. Unrecognized bipolar disorder, sometimes misdiagnosed as unipolar depression, may lead to treatment resistance or nonresponse. We describe differences between unipolar and bipolar disorders, focusing on recognition, diagnosis, and treatment of bipolar spectrum disorders such as bipolar I, bipolar II, antidepressant-induced mania, and cyclothymia. Broadening the understanding of these different disorders and their presentation in primary care settings can enable earlier and more targeted treatment. Though 3 mood stabilizers are U.S. Food and Drug Administration-approved for treatment of acute mania, no medications are currently approved for treating bipolar depression.     

Mental health literacy in rural Queensland: results of a community survey

OBJECTIVES: The aim of this study was to assess the awareness of, and attitudes to, mental health issues in rural dwelling Queensland residents. A secondary objective was to provide baseline data of mental health literacy prior to the implementation of Australian Integrated Mental Health Initiative--a health promotion strategy aimed at improving the health outcomes of people with chronic or recurring mental disorders. METHOD: In 2004 a random sample of 2% (2132) of the estimated adult population in each of eight towns in rural Queensland was sent a postal survey and invited to participate in the project. A series of questions were asked based on a vignette describing a person suffering major depression. In addition, questions assessed respondents' awareness and perceptions of community mental health agencies. RESULTS: Approximately one-third (36%) of those surveyed completed and returned the questionnaire. While a higher proportion of respondents (81%) correctly identified and labelled the problem in the vignette as depression than previously reported in Australian community surveys, the majority of respondents (66%) underestimated the prevalence of mental health problems in the community. Furthermore, a substantial number of respondents (37%) were unaware of agencies in their community to assist people with mental health issues while a majority of respondents (57.6%) considered that the services offered by those agencies were poor. CONCLUSION: While mental health literacy in rural Queensland appears to be comparable to other Australian regions, several gaps in knowledge were identified. This is in spite of recent widespread coverage of depression in the media and thus, there is a continuing need for mental health education in rural Queensland.     

Perspectives on public awareness of stroke and aphasia among Turkish patients in a neurology unit

Recent studies on awareness have drawn attention to the fact that aphasia is a little known disorder to the public, in spite of all the publicity about this frequently occurring neurogenic language disorder. Being a very new concept, studies of awareness are rare in Turkey. This survey study assessed the extent of public awareness of neurological disorders, including aphasia, and information sources to answer questions about such disorders. A survey questionnaire consisting of 22 brief questions divided into three sections of awareness was administered to a convenience sample of 196 adults at a University Hospital in 2004. The results indicated that epilepsy and dementia are “the most well‐known”, and Multiple Sclerosis (MS) is “the least‐known” among the surveyed diseases/disorders. Aphasia awareness was also low. The respondents preferred doctors as the most reliable information source. Speech and language therapists were found to be one of the information sources in advocating publicity as well. Most respondents expected to receive information from the doctors; who, in Turkey, are totally occupied with the physical aspects of health care provision. Neurologists, in collaboration with speech and language therapists, should be in a position to develop educational programmes to increase public awareness.     

Obsessive-compulsive-bipolar comorbidity: a systematic exploration of clinical features and treatment outcome

BACKGROUND: Notwithstanding the emerging literature on comorbidity between obsessive-compulsive disorder (OCD) and bipolar disorder, relatively few systematic data exist on the clinical characteristics of this interface and its treatment. The aim of the present study is to address this challenge as it appears in a setting of routine clinical practice. METHOD: The sample comprised 68 patients with comorbid DSM-IV diagnoses of OCD and major depressive episode admitted and treated at the day-hospital in the Department of Psychiatry at the University of Pisa (Pisa, Italy) during a 3-year period (January 1995-December 1998). Thirty-eight patients (55.8%) showed lifetime comorbid bipolar disorder (12 [31.6%] bipolar I and 26 [68.4%] bipolar II). Diagnoses and clinical features were collected by means of structured (Structured Clinical Interview for DSM-IV) and semistructured interviews (OCD-Interview). Assessments of drug treatments, clinical outcome, and adverse effects were made prospectively as part of routine clinical care throughout the course of their day-hospitalization. RESULTS: In contrast with non-bipolar OCD patients, OCD-bipolar patients showed a more episodic course with a greater number of concurrent major depressive episodes. They reported a significantly higher rate of sexual obsessions and significantly lower rate of ordering rituals. Furthermore, they reported more frequent current comorbidity with panic disorder-agoraphobia and abuse of different substances (alcohol, sedatives, nicotine, and coffee). Drug treatment with clomipramine and, to a lesser extent, with selective serotonin reuptake inhibitors was associated with hypomanic switches in OCD-bipolar patients, especially in those not concomitantly treated with mood stabilizers. A combination of multiple mood stabilizers was necessary in 16 OCD-bipolar patients (42.1%) and a combination of mood stabilizers with atypical antipsychotics was required in 4 cases (10.5%). OCD-bipolar patients tended to show a less positive outcome for mood symptomatology and general functioning. Three patients required hospitalization for severe mixed episode. CONCLUSION: In a tertiary care center, comorbidity between OCD and bipolar disorder is a significant clinical problem affecting a large number of patients and has a substantial impact on the clinical characteristics and treatment outcome of both disorders.     

The reluctance to seek treatment for neurotic disorders

In previous papers from the National Survey of Psychiatric Morbidity in Great Britain, we have demonstrated that people with neurotic disorders rarely present their symptoms to primary care physicians and when they do, are quite likely not to be given treatment. In this paper, we examined survey respondents' reports of specific instances of reluctance to seek help in relation to sociodemographic, socio-economic and clinical attributes of our subjects. All people in the National Household Survey assessed as having a neurotic disorder were asked if at any time in the previous year they had avoided seeking appropriate treatment. Clinical measures included diagnosis, symptom severity, and deficits in carrying out tasks of daily living. Of nearly 1400 respondents, a quarter said they had not been to see a doctor at some time in the past year when they or their family felt they should have. The major determinant of this reluctance was symptom severity: more severe cases were more likely to report an episode of reluctance. Reasons included those related to ignorance of neurotic disorders and the effectiveness of treatment and to stigma. The attitudes detected in our subjects with neurotic disorder help to explain why people do not always seek effective help for their mental disorders, and are indicators of a worrying public education gap that will be hard to bridge.