arrow Log In to View Account     |      
HOME
Johns Hopkins Medicine
Hopkins Logo


Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


More Than Just Depression: Recognizing Bipolar Disorder In Primary Care


GOAL
To provide primary care physicians with up-to-date information on the diagnosis and treatment of patients with bipolar disorder.

TARGET AUDIENCE
This activity is designed for primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Explain bipolar disorder (BD) as a spectrum of diseases with overlapping symptoms and the difficulties in diagnosing it in the primary care setting.
  • Identify the diagnostic boundaries between BD and other psychiatric disorders and how diagnosis affects treatment selection.
  • Demonstrate a focus on long-term recovery rather than relapse prevention in patients with BD.
  • Describe risk factors and red flags in the routine primary care visit.
  • Discuss the advances and barriers that exist in the pharmacologic and psychosocial management of the patient with BD.
  • Formulate therapeutic goals and benefits of the use of concomitant cognitive behavior therapy and antipsychotic medication in patients with BD and management in the primary care setting.
  • Define resources for patients, families, and healthcare providers.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
The estimated time to complete this educational activity: 3 hours.

Release date: June 15, 2006.
Expiration date: June 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from AstraZeneca LP.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Glenn Treisman, MD, PhD
Associate Professor of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Director of AIDS Psychiatry
Johns Hopkins Hospital
Baltimore, Maryland
Dr Treisman reports having no financial or advisory relationships with corporate organizations related to this activity.


PARTICIPATING FACULTY

Gillian K. Adams, MD
Private Practice
Plumtree Family Health Center
Family Practice
Franklin Square Hospital
Baltimore, Maryland
Dr Adams reports having no financial or advisory relationships with corporate organizations related to this activity.

Neil S. Kaye, MD, DFAPA
Assistant Professor of Psychiatry and  Human Behavior
Assistant Professor of Family Practice
The Thomas Jefferson University College of Medicine
Special Guest Lecturer
Widener University School of Law
Philadelphia, Pennsylvania
Dr Kaye reports receiving grants/research support from Eli Lilly and Company and GlaxoSmithKline; serving as a consultant for AstraZeneca, GlaxoSmithKline, and Pfizer Inc; and receiving honoraria from AstraZeneca, GlaxoSmithKline, and Pfizer Inc.

Ellen Leibenluft, MD
Clinical Associate Professor of Psychiatry
Georgetown University School of Medicine
Chief, Unit on Affective Disorders
Mood and Anxiety Disorders Program
National Institute of Mental Health
Bethesda, Maryland
Dr Leibenluft reports having no financial or advisory relationships with corporate organizations related to this activity.

Husseini K. Manji, MD
Visiting Professor of Psychiatry
Columbia University
Duke University
Chief, Laboratory of Molecular Pathophysiology
Director, Mood and Anxiety Disorders Program
National Institute of Mental Health
Bethesda, Maryland
Dr Manji reports having no financial or advisory relationships with corporate organizations related to this activity.

J. Sloan Manning, MD
Private PracticeÐFamily Physician
PrimeCare of Greensboro
Codirector, Mood Disorders Clinic
Moses Cone Family Practice Residency
Moses Cone Hospital
Greensboro, North Carolina
Dr Manning reports serving as a consultant for AstraZeneca and Eli Lilly and Company.

Brad B. Moore, MD, MPH, FACP
Associate Professor of Medicine and Health Policy
George Washington University
Washington, DC
Dr Moore reports having no financial or advisory relationships with corporate organizations related to this activity.

Michael J. Ostacher, MD, MPH
Associate Medical Director
Bipolar Clinic and Research Program
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
Dr Ostacher reports receiving honoraria from AstraZeneca, Bristol-Myers Squibb Company, Concordant Rater Systems, GlaxoSmithKline, Janssen, and Pfizer Inc.


Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.
Dr Kaye—role of antipsychotics in the treatment of mood disorders.
Dr Manji—riluzole and tamoxifen.
Dr Manning—lamotrigine and quetiapine.
Dr Ostacher—lamotrigine and quetiapine.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices. Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Integrating Psychiatric Care Into Primary Care: Focus On Bipolar Disorder
Glenn Treisman, MD, PhD

I have spent the past 15 years researching and developing models of integrating medicine and psychiatry. Psychiatry is, in fact, a discipline of medicine, although they are physically and conceptually separated in the American healthcare system. Despite this chasm between psychiatry and medicine, some 60% to 70% of psychiatric care is delivered by primary care physicians (PCPs).1,2 This is due to 2 prevailing problems: the stigma associated with psychiatric disorders, and the reality that much of psychiatric care is driven by financial circumstance (ie, whether the patient has insurance coverage for mental health services). As a result, patients with mental health disorders who are susceptible to these influences are some of the most vulnerable, yet receive the least adequate healthcare.

The need to more heavily integrate some level of psychiatric practice into primary care is increasingly recognized. Numerous models are being tested, including simplified screening methods for some of the most common psychiatric illnesses, such as depression and anxiety disorders, and telemedicine.3-5 The Moore Clinic at Johns Hopkins Hospital provides medical care to more than 3000 HIV-infected patients, and the AIDS Psychiatry Service is a model for integrating psychiatric care into an HIV clinic to address the myriad and idiosyncratic needs of HIV-infected patients. The Moore Clinic sees various stages of HIV infection. It is staffed by 8 mid-level practitioners (nurse practitioners and physician assistants) and 18 primary care providers, primarily from the faculty in the Division of Infectious Diseases. There are 7 major specialty services: gastrointestinal, neurology, psychiatry, gynecology, obstetrics, ophthalmology, and dermatology. Our experience at the Moore Clinic has shown that if a psychiatrist is present in a primary care setting and available to teach, PCPs will quickly increase the rate at which they treat those psychiatric disorders, as they become more comfortable and confident in diagnosis and treatment.

Bipolar disorder is one of the most treatable psychiatric conditions, yet it is under-recognized and undertreated by psychiatrists and primary care providers. A recent sample of nearly 1200 primary care patients revealed that of the 81 patients who screened positive for bipolar disorder, only 8.4% reported receiving a diagnosis of bipolar disorder by a health provider.6 It is under-recognized in part because its pathognomonic symptomÑmanic (or hypomanic) episode(s)—may not appear until several episodes of severe depression have occurred, which can be years into the disorder progression. Indeed, it can take, on average, approximately 10 years for a patient with bipolar disorder to obtain the correct diagnosis. In the interim, the patient is often misdiagnosed as having depression, possibly with a comorbid anxiety disorder. Bipolar disorder is undertreated because it is often misdiagnosed. Depression is far more common, and the depressive phase of bipolar disorder is treated by PCPs with the panoply of antidepressant drugs we now have available.7 However, bipolar disorder requires a different pharmacotherapeutic approach than major depressive disorder (or unipolar depression), and the distinction is essential for achieving the desired patient outcomes.

With regard to diagnosing and managing bipolar disorder in primary care, PCPs face several issues. First, primary care is removed from mental health, but primary caregivers need support from the mental health system to more effectively identify and manage psychiatrically ill patients, especially if financial or societal constraints will continue to limit patient exposure to psychiatrists. Second, recognition of bipolar (or even unipolar) depression in primary care is lacking because PCPs do not have the tools to diagnose and treat affective disorders. Third, psychiatrists need to provide those tools to our primary care colleagues, particularly for discriminating between the psychiatric disorders that are well defined and easily identified (using The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and those that are not, those that are treatable with pharmacotherapy and those that emerge more out of life experiences (and are better addressed through psychotherapy), in addition to the way temperament and IQ can affect the extent to which an individual patient will respond to an intervention.

Fortunately, bipolar disorder provides an excellent opportunity for psychiatrists to interact with PCPs because it has well-defined diagnostic criteria and several options for successful therapy. It is a disease, and like other diseases, we are able to offer evidence-based recommendations for first-line treatments (and experience-based recommendations for second-line treatments) with the understanding that some patients will not respond (just as some patients with lymphoma will not respond to first-line treatment).

In an effort to address these challenges with bipolar disorder and to begin to integrate psychiatry and primary care, we convened a panel of 3 PCPs with an interest in affective disorders and 3 psychiatrists who specialize in bipolar disorder for a 1-day roundtable. All of these physicians share my goal of more completely integrating psychiatry and primary care, based on the recognition that psychiatrically ill patients in medical settings fare worse (medically and psychologically) and incur higher healthcare costs than patients without psychiatric comorbidities. These patients are less likely to adhere to their medication regimens, less likely to benefit medically, and less likely to meet their treatment targets. Thus, the more we can integrate psychiatric care into primary care, the better served are our patients and our healthcare system.

This issue of Johns Hopkins Advanced Studies in Medicine is the result of our roundtable presentations and discussions. Michael J. Ostacher, MD, MPH, discusses the burden of bipolar disorder in a review of the disease progression, antidepressant-induced mania/hypomania, and the psychiatric and medical conditions that are frequently comorbid with bipolar disorder. As he notes, the cost, in terms of morbidity and mortality, of untreated or undertreated bipolar disorder is high.

Husseini K. Manji, MD, looks at the molecular and cellular changes in patients with bipolar disorder to understand not only the pathophysiology of this disorder but also the mechanisms of action of some of our most commonly used and effective treatments. As he notes, affective disorders have been described over the past decade as resulting from neurotransmitter deficits, but the true etiology may be paradoxically more complex, yet simpler, than what we currently understand. He reviews the preclinical and clinical evidence that suggests that the spectrum of bipolar disorders may result from anomalies in common intracellular signaling cascades, which may explain not only the wide range of symptoms but also comorbid conditions with bipolar disorder.

Ellen Leibenluft, MD, reviews the 2 main challenges PCPs face in diagnosing bipolar disorder: distinguishing unipolar from bipolar depression and eliciting a past history of manic or hypomanic symptoms, with useful information on how to do so in a primary care setting.

Neil S. Kaye, MD, DFAPA, provides an overview of recommended management practices for bipolar disorder that can be implemented in a primary care setting, including a review of pharmacotherapy options and clinical pearls for using atypical
antipsychotics, dealing with medical comorbidities as potential treatment confounders, off-label use of medications, and key patient messages for optimal outcomes.

To reinforce the link between psychiatry and primary care, we interviewed J. Sloan Manning, MD, a PCP with extensive experience in identifying and managing bipolar disorder in primary care settings. Dr Manning offers his insights into recognizing bipolar disorder, eliciting a history of manic symptoms, convincing patients to see a psychiatrist, and building relationships between PCPs and psychiatrists. He shares our optimism and enthusiasm for better integrating psychiatry into primary care practice: "Physicians who don't care to invest the time and effort to learn are never going to be interested, but that's not most PCPs. Most PCPs are simply unaware of the importance of bipolar disorder and if they were aware, most would say, I can learn to do this."

With mounting evidence of the prevalence and burden of bipolar disorder, and the current constraints on our healthcare system, we cannot continue to overlook or undertreat this disorder. Even asymptomatic patients experience health, social, family, and occupational dysfunction. In fact, this holds true for patients with a wide range of psychiatric disorders.8 Psychiatrists and PCPs need to do better in terms of diagnosis and treatment for our patients with bipolar disorder, thus we can enrich the quality and length of patients' lives.


References

1. Harpaz-Rotem I, Rosenheck RA. Prescribing practices of psychiatrist and primary care physicians caring for children with mental illness. Child Care Health Dev. 2006;32:225-237.
2. Watson DE, Heppner P, Roos NP, et al. Population-based use of mental health services and patterns of delivery among family physicians, 1992 to 2001. Can J Psychiatry. 2005;50:398-406.
3. Fraguas R Jr, Gonsalves Henriques S Jr, De Lucia MS, et al. The detection of depression in medical setting: a study with PRIME-MD. J Affect Disord. 2006;91:11-17.
4. Hilty DM, Yellowlees PM, Cobb HC, et al. Models of telepsychiatric consultation-liaison service to rural primary care. Psychosomatics. 2006;47:152-157.
5. Fortney JC, Pyne JM, Edlund MJ, et al. Design and implementation of the telemedicine-enhanced antidepressant management study. Gen Hosp Psychiatry. 2006;28:18-26.
6. Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA. 2005;293:956-963.
7. Olfson M, Das AK, Gameroff MJ, et al. Bipolar depression in a low-income primary care clinic. Am J Psychiatry. 2005;162:2146-2161.
8. Katerndahl DA, Larme AC, Palmer RF, Amodei N. Reflections on DSM classification and its utility in primary care: case studies in "mental disorders." Prim Care Companion J Clin Psychiatry. 2005;7:91-99.

*Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Director of AIDS Psychiatry, Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: Glenn Treisman, MD, PhD, Associate Professor of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Director of AIDS Psychiatry, Johns Hopkins Hospital, Meyer 4-119, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: glenn@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.