Bipolar Patients in Integrated Systems May Need More-Intensive Care

Primary care patients with bipolar disorder may require more-intensive services—including direct psychiatric care—than is currently provided in a collaborative care primary care model.

That’s the finding from the study “Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder,” published April 15 in Psychiatric Services in Advance.

“Primary care patients with bipolar disorder experienced persistent depressive and anxiety symptoms despite higher-intensity collaborative care treatment, but they were infrequently referred to a community mental health center,” the researchers stated. “Successful treatment of bipolar disorder in primary care may require additional clinical interventions aimed at either further improving the care delivered to patients in primary care or through more effective referrals to community mental health centers.”

The authors were Joseph Cerimele, M.D., Ya-Fen Chan, Ph.D., Lydia Chwastiak, M.D., Marc Avery, M.D., Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., of the University of Washington, who have pioneered the development of collaborative care models integrating behavioral and general medical care.

They identified 740 primary care patients with bipolar disorder in the statewide mental health integration program (MHIP) between January 2008 and December 2011 using the Composite International Diagnostic Interview and clinician diagnosis. The MHIP uses collaborative care based on the IMPACT model (Improving Mood–Promoting Access to Collaborative Treatment), which was developed at the University of Washington to improve recognition and systematic treatment of patients with psychiatric disorders in primary care settings.

Primary care patients with bipolar disorder had high symptom severity on both depression and anxiety measures using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder scale. Only about one-third of patients with bipolar disorder with baseline PHQ-9 scores of 10 or more experienced significant clinical improvement in depressive symptoms (with a PHQ score of less than 10 or a reduction in PHQ-9 score by 50 percent or more) during the time from initial MHIP assessment until treatment in MHIP or until the study ended.

Psychosocial problems were common, with approximately 53 percent reporting concerns about housing, 15 percent reporting homelessness, and 22 percent reporting lack of a support person. Yet only 26 percent of patients were referred to specialty mental health treatment. The average time from initial assessment to psychiatric consultation was 5.7 weeks among patients with bipolar disorder.

Courtesy of Wayne Katon, M.D.

Katon, vice chair of the Department of Psychiatry at the University of Washington, told Psychiatric News that the study indicates that these patients may need more-intensive care than is currently provided in a collaborative care model, in which a care manager, supervised by a psychiatrist, provides the direct patient care.

“The importance of this article is that the U.S. federally qualified primary care clinics, as well as many primary care clinics that treat both uninsured and Medicaid patients, are likely to have a significant percentage of patients with bipolar illness, especially bipolar II illness,” Katon said. “This article emphasizes that despite the fact that only about one-third improve with treatment in these clinics, few are being referred to community mental health clinics or actually attend when referred. These clinics already had integrated collaborative care—that is, the use of a care manager supervised by a psychiatrist—so the inference is that these patients may need more-intensive psychiatric treatment, which could occur if psychiatrists are integrated into the clinics either in person or via telemedicine. Alternatively, the clinics need to establish better links with community mental health.” ■