Integrating Bipolar Disorder Management in Primary Care
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There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care.
KeywordsBipolar disorder Mood disorder Co-occurring conditions Primary care Integrated care Collaborative care Chronic Care Model CCM Screening Diagnosis Treatment Access Mental health services Psychiatry
This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Clinical Sciences Research and Development [CSRD S06], the VA Health Services Research and Development Center for Organization, Leadership, and Management Research (COLMR), the National Institute of Mental Health [RO1 MH 79994 and R01 74509] and the University of Michigan Comprehensive Depression Center (Director’s Innovation Fund). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
A.M. Kilbourne is the author of the workbook Overcoming Bipolar Disorder: A Comprehensive Workbook for Managing Your Symptoms & Achieving Your Life Goals (New Harbinger Publications, Inc., 2008), which was the basis for many of the current study interventions cited and for which she receives royalties; D.E. Goodrich: none; A.N. O’Donnell: none; CJ. Miller: none.
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- 4.• Malhi GS, Bargh DM, McIntyre R, Gitlin M, Frye MA, Bauer M, et al. Balanced efficacy, safety, and tolerability recommendations for the clinical management of bipolar disorder. Bipolar Disord. 2012;14 Suppl 2:1–21. A comprehensive and practical review of clinical recommedations for treating each phase of bipolar disorder with emphasis on helping providers balance issues of treatment efficacy, safety, and tolerability with real world issues of managing complex comorbidity and shared decision making. PubMedCrossRefGoogle Scholar
- 5.• McIntyre RS, Rosenbluth M, Ramasubbu R, Bond DJ, Taylor VH, Beaulieu S, et al. Managing medical and psychiatric comorbidity in individuals with major depressive disorder and bipolar disorder. Ann Clin Psychiatry. 2012;24(2):163–9. An overview of the CANMAT task force consensus and evidence-based recommendations for treating comorbid conditions in patients with major depressive disorder or bipolar disorder. PubMedGoogle Scholar
- 6.Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults. 2010. www.healthquality.va.gov. Accessed July 1 2012.
- 7.Yatham LN, Kennedy SH, Schaffer A, Parikh SV, Beaulieu S, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. Bipolar Disord. 2009;11(3):225–55.PubMedCrossRefGoogle Scholar
- 9.• Gill JM, Chen YX, Grimes A, Klinkman MS. Using electronic health record-based tools to screen for bipolar disorder in primary care patients with depression. J Am Board Fam Med. 2012;25(3):283–90. Authors find that EHR-based tools can facilitate the diagnosis and prescription of mediction for bipolar depression through electronic screening and decision support tools. PubMedCrossRefGoogle Scholar
- 11.•• Kilbourne AM, Goodrich DE, Clogston J, Bauer MS, Waxmonsky JA, VanDeusen Lukas C, et al. Randomized controlled trial of the Replicating Effective Programs implementation framework: the Recovery-Oriented Collaborative Care Study. Implement Sci. 2012; In review. Rationale and description of a randomized effectiveness trial comparing two different implementation strategies to deliver an evidence-based chronic care model for bipolar disorder in community settings that optimizes fidelity to active intervention components while allowing for local practice adaptation. Google Scholar
- 12.• Kilbourne AM, Goodrich DE, Lai Z, Post EP, Schumacher K, Bramlet M, et al. Randomized trial to reduce cardiovascular disease risk for patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT). J Clin Psychiatr. 2012; In review. The second randomized controlled trial demonstrating the effectiveness of an integrated chronic care model for bipolar depression to reduce blood pressure and manic symptoms compared to usual treatment in a VA healthcare setting. Google Scholar
- 13.Kilbourne AM, Goodrich DE, Lai Z, Clogston J, Bauer MS, Waxmonsky J. Randomized controlled pilot study of Life Goals Collaborative Care for patients with bipolar disorder and cardiovascular disease risk from community-based practices. Psychiatr Serv. 2012; In press. doi:10.1176/appi.ps.201100528.
- 15.Bauer MS, Leader D, Un H, Lai Z, Kilbourne AM. Primary care and behavioral health practice size: the challenge for health care reform. Med Care. 2012.Google Scholar
- 16.• Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. Am J Psychiatry. 2012. A systematic review and meta-analysis of the effectiveness of collaboratve chronic care modesls for mental health conditions to improve health outcomes acrosss a variety of treatment settings. CCMs were found effective for improving depressive symptoms, mental and physical quality of life, and social role function across settings and disorders and CCMs were also found to be cost neutral including for treatment of bipolar disorder. Google Scholar
- 19.• Hsieh MH, Tang CH, Hsieh MH, Lee IH, Lai TJ, Lin YJ et al. Medical costs and vasculometabolic comorbidities among patients with bipolar disorder in Taiwan—a population-based and matched-control study. J Affect Disord. 2012. This national study of Tawainese patients diagnosed with bipolar disorder found total medical costs that were 11 fold greater than matched controls without a bipolar diagnosis. Non-psychiatric medical costs were 1.7 times higher in bipolar patients compared to controls and driven by a greater burnden of vasculometabolic morbidity which led to recommendations for greater preventive and integrated care for this population. Google Scholar
- 23.Stephenson JJ, Tuncelli O, Gu T, Eisenberg D, Panish J, Crivera C, et al. Adherence to oral second-generation antipsychotic medications in patients with schizophrenia and bipolar disorder: physicians’ perceptions of adherence vs. pharmacy claims. Int J Clin Pract. 2012;66(6):565–73.PubMedCrossRefGoogle Scholar
- 25.• Rouillon F, Gasquet I, Garay RP, Lancrenon S. Impact of an educational program on the management of bipolar disorder in primary care. Bipolar Disord. 2011;13(3):318–22. This observational cohort study found that general practitioner participation in an educational program desiged to improve the diagnosis and treatment of bipolar depression was associated with an increase in differential diagnosis of bipolar depression, an increase in prescription of mood stabilizers, and a reduction in anti-depresseants compared to practitioners who did not undergo the educational program. PubMedCrossRefGoogle Scholar
- 26.Sansone RA, Forbis JS, Sosa T. Primary care perspectives on treating bipolar disorder: a cross-sectional survey. The primary care companion to CNS disorders. 2011;13(2).Google Scholar
- 27.Sansone RA, Sansone LA. Managing bipolar disorder in the primary care setting: a perspective for mental health professionals. Innov Clin Neurosci. 2011;8(10):10–3.Google Scholar
- 28.•• Malhi GS, Bargh DM, Cashman E, Frye MA, Gitlin M. The clinical management of bipolar disorder complexity using a stratified model. Bipolar Disord. 2012;14 Suppl 2:66–89. A practical and stratified treatment model is presented with the goal of helping providers in routine care settings understand and better treat, the complex presentations of bipolar disorder that are often overlooked in research and clinical guidelines.PubMedCrossRefGoogle Scholar
- 29.• Price AL, Marzani-Nissen GR. Bipolar disorders: a review. Am Fam Physician. 2012;85(5):483–93. A succint summary of evidence-based treatment practices and issues related to the treatment of bipolar disorder in primary care settings that was written from the perspective of a primary care provider. PubMedGoogle Scholar
- 30.Ramasubbu R, Taylor VH, Samaan Z, Sockalingham S, Li M, Patten S, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and select comorbid medical conditions. Ann Clin Psychiatry. 2012;24(1):91–109.PubMedGoogle Scholar
- 33.Bond DJ, Hadjipavlou G, Lam RW, McIntyre RS, Beaulieu S, Schaffer A, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid attention-deficit/hyperactivity disorder. Ann Clin Psychiatry. 2012;24(1):23–37.PubMedGoogle Scholar
- 34.Rosenbluth M, Macqueen G, McIntyre RS, Beaulieu S, Schaffer A, Canadian Network for M, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid personality disorders. Ann Clin Psychiatry. 2012;24(1):56–68.PubMedGoogle Scholar
- 35.McIntyre RS, Alsuwaidan M, Goldstein BI, Taylor VH, Schaffer A, Beaulieu S, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid metabolic disorders. Ann Clin Psychiatry. 2012;24(1):69–81.PubMedGoogle Scholar
- 37.• Culpepper L. Does screening for depression in primary care improve outcome? Curr Psychiatry Rep. 2012. A succinct history of depression screening and treatment in primary care settings that makes a compelling case for better integrating screening, diagnosis, and treatment of medical and psychiatric conditions. Google Scholar
- 46.• De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138–51. Consensus recommendations from European health organizations that stress the importance of treating physical illness among persons with serious mental illnesses including recommendations on how to improve health outcomes for common physical health comorbidities in this population by considering system- and individual-level barriers to accessing care. PubMedGoogle Scholar
- 48.Calkin CV, Gardner DM, Ransom T, Alda M. The relationship between bipolar disorder and type 2 diabetes: more than just co-morbid disorders. Ann Med. 2012.Google Scholar
- 51.Judd LL, Schettler PJ, Akiskal H, Coryell W, Fawcett J, Fiedorowicz JG, et al. Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord. 2012;138(3):440–8.PubMedCrossRefGoogle Scholar
- 57.Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry. 2011.Google Scholar
- 58.• Mitchell AJ. Clinical utility of screening for clinical depression and bipolar disorder. Curr Opin Psychiatry. 2012;25(1):24–31. A review of the utility of commonly used screening tools for depression and bipolar depression that concludes that tools for bipolar disorder are not yet accurate enough to be used widely in clinical practice and that more sophisticated tools are needed. PubMedGoogle Scholar
- 62.Beaulieu S, Saury S, Sareen J, Tremblay J, Schutz CG, McIntyre RS, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid substance use disorders. Ann Clin Psychiatry. 2012;24(1):38–55.PubMedGoogle Scholar
- 63.Ramasubbu R, Beaulieu S, Taylor VH, Schaffer A, McIntyre RS, Canadian Network for M, et al. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid medical conditions: diagnostic, assessment, and treatment principles. Ann Clin Psychiatry. 2012;24(1):82–90.PubMedGoogle Scholar
- 70.Bauer MS, Leader D, Un H, Lai Z, Kilbourne AM. Primary care and behavioral health practice size: the challenge for healthcare reform. Med Care. 2012; In press. doi:10.1097/MLR.0b013e31825f2864.
- 72.Todd NJ, Solis-Trapala I, Jones SH, Lobban FA. An online randomised controlled trial to assess the feasibility, acceptability and potential effectiveness of ‘Living with Bipolar’: a web-based self-management intervention for bipolar disorder: trial design and protocol. Contemp Clin Trials. 2012;33(4):679–88.PubMedCrossRefGoogle Scholar
- 73.Lauder S, Chester A, Castle D, Dodd S, Berk L, Klein B, et al. Development of an online intervention for bipolar disorder. www.moodswings.net.au. Psychol Health Med. 2012.
- 74.Todd NJ, Jones SH, Lobban FA. What do service users with bipolar disorder want from a web-based self-management intervention? A Qualitative Focus Group Study. Clin Psychol Psychother. 2012.Google Scholar
- 85.Vieta E, Sanchez-Moreno J, Bulbena A, Chamorro L, Ramos JL, Artal J, et al. Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32). J Affect Disord. 2007;101:43–55.PubMedCrossRefGoogle Scholar