The Bipolar Express Makes a Stop at Primary Care
Abstract & Commentary
Comment by Allan J. Wilke, MD, Associate Professor of Family Medicine, Medical College of Ohio, Toledo, OH, and Associate Editor, Internal Medicine Alert.
Synopsis: Screening for bipolar disorder in primary care settings can aid in its diagnosis.
Source: Das AK, et al. JAMA. 2005;293:956-963.
The United States Preventive Services Task Force (USPSTF) recommends screening for depression in primary care practices,1 and it is not uncommonly performed.2 However, screening for bipolar disorder (BD) is unusual. Das and colleagues set out to determine the lifetime incidence of BD in their urban, academic internal medicine practice in New York. They also compared the characteristics of patients who screened positive for BD to those who did not, examined the health functioning and impairment of BD patients, and reviewed the charts of these patients to see if their physicians were aware of any symptoms of mania. The study was conducted between December 2001 and January 2003. Inclusion criteria were a previously seen patient, aged 18 to 70 years, who spoke English or Spanish and could complete the survey, making a visit to his/her usual primary care physician. A systematic sample was identified and, after appropriate exclusion and consent, 1146 patients participated. They provided demographic data and completed the Mood Disorder Questionnaire (MDQ); patients scoring 7 or greater were considered to have screened positive. They also completed the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ). They were assessed for suicidal ideation, drug abuse, physical and mental health functioning, and disability. Their medical records were reviewed for evidence of awareness by their physicians of BD symptoms in the last 6 months. The patients were predominantly poor, Hispanic females with an average age of 51 years. They were poorly educated and unemployed or disabled.
Screening revealed that 9.8% of patients scored positive for BD. Their most common symptoms were irritability, feeling "hyper," being easily distractible, having racing thoughts, and being more talkative. Being more social or outgoing, being more interested in sex, and needing less sleep occurred less frequently, but were still common. There was an inverse relationship between the likelihood of screening positive for BD and household income. Almost all patients who screened positive for BD had previously been diagnosed with a mental illness, but very few were diagnosed with BD. Substance abuse and anxiety disorders and suicidal ideation were common among patients scoring positive for BD. In the month before screening, 44% of BD patients reported taking psychotropic medications, but only 6% reported taking a mood stabilizer (lithium, valproate, or carbamazepine). In the medical record evaluation, 49% of charts of BD patients noted depressive symptoms, but there was no mention of BD.
Comment
The lifetime incidence of BD in this study, 9.8%, is an order of magnitude greater than that reported in previous studies.3 Das et al speculate that this is related to the high rate of poverty in their population. The ethnic and socioeconomic make-up of this population may make application of its results to other settings difficult.
The poor showing of primary care physicians in diagnosing BD is disappointing. It is possible that the setting of this study may have contributed to this. The study did not look at the experience of the physician as a variable. Certainly, residents are less skilled than attending physicians in diagnosing and treating bipolar disorder. Generalist physicians of all stripes face difficulties with this. Most of us know that treating a depressive episode with an antidepressant can initiate a manic or hypomanic event. Perhaps we are reluctant to use BD medications. We have less experience with mood stabilizers than antidepressants. There are fewer mood stabilizers than antidepressants from which to choose, and treating with mood stabilizers involves monitoring blood levels.
The MDQ (available at the Depression and Bipolar Support Alliance, www.dbsalliance.org/questionnaire/screening_intro.asp) is a validated, 15-item questionnaire4 that patients can complete in your office. The PRIME-MD PHQ is another validate self-report questionnaire.5 The availability of these tools cannot be underestimated. There is too little time for physicians to do all the office screening the USPSTF recommends.6
References
1. www.ahrq.gov/clinic/uspstf/uspsdepr.htm. Accessed 05/05/2005.
2. Edlund MJ, et al. Med Care. 2004;42:1158-1166.
3. Waraich P, et al. Can J Psychiatry. 2004;49:124-138.
4. Hirschfeld RM, et al. Am J Psychiatry. 2000;157: 1873-1875.
5. Spitzer RL, et al. JAMA. 1999;282:1737-1744.
6. Yarnall KS, et al. Am J Public Health. 2003;93: 635-641.
Screening for bipolar disorder in primary care settings can aid in its diagnosis.
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