Management of Bipolar Disorder in Primary Care Versus Psychiatric Settings

Abstract

Sir: Dr. Ira Glick's article1 well summarized the clinical challenges faced by primary care providers as information on the bipolar spectrum of mood disorders grows. I appreciate his reference to our work on the prevalence of bipolar disorders in this setting.2 The information on burden of illness, longer-term consequences, and the consequences of missed diagnosis and misdiagnosis is well said. Primary care physicians, who have been referred to as the “de facto U.S. mental and addictive service system,” must begin to see depressed and anxious syndromes as an opportunity for differential diagnosis. When bipolar illness is identified, it demands focused treatments of proven efficacy. I must disagree with Dr. Glick, however, when he characterizes bipolar illness as one “best managed in a psychiatric setting” and referral as the “best course of action.”1(p30) Dr. Glick did not identify his specialty area, but a cursory look at the prevalence data, the sad state of affairs regarding bipolar illness in psychiatry itself, and the obstacles to referral suggest that uniformly referring bipolar patients is not a practical solution. If current estimates of a 3.7% bipolar prevalence in the U.S. population3 are correct, a policy of uniform referrals for bipolar patients is practically impossible, especially in rural settings where community mental health centers are already overwhelmed. Moreover, estimates suggest that psychiatrists miss bipolar illness most of the time on patients' initial presentation. In one published survey by Hirschfeld et al.,4 bipolar illness was misdiagnosed on 70% of initial opportunities—usually as major depression—and 35% of patients treated by psychiatrists waited 10 years for a correct diagnosis. The mean number of misdiagnoses was 3.5. The mean number of psychiatric consultations needed to correctly diagnose bipolar illness was 4. In another cohort examination by Goldberg and Ernst,5 poor functioning and suicide attempts made the correct diagnosis of bipolar disorder by psychiatrists less likely! Generalists are well placed to diagnose bipolar disorder and perfectly capable of performing the advanced pharmacotherapeutic interventions necessary to treat bipolar patients. Competent clinicians should always practice within the boundaries of training, experience, and proven ability. Whether it is antide-pressants in the 1990s or mood stabilizers in 2004, motivated clinicians can and do take on new skills to benefit their patients and improve the quality of their practice. Many in our setting already regularly screen and treat bipolar patients, reserving consultations and referrals for those who remain diagnostic dilemmas, refractory to first- or second-order interventions, or too ill to be cared for in a primary care setting. I welcome the time when psychiatry and primary care integrate into a seamless delivery system to offer services when and where they are best applied. Until professional training programs and the payers of health care “grow up” into the reality of mental health and health care, I will assess depressed and anxious patients, make rational diagnoses, triage, treat, and adjust both diagnosis and treatment as indicated based on symptoms, treatment response, and acuity—always seeking to improve my game for the benefit of my patients.