We had no intention of treating patients with bipolar disorder in our “depression in primary care” program. But they kept showing up.
Sometimes they didn’t know they were bipolar patients. They were coming because they were anxious, or they were there for a headache or their blood pressure, and they lit up a depression screen that we give at the first appointment. Or they had been treated for years for depression but had never been diagnosed with bipolar disorder.
Sometimes these patients knew perfectly well that they had bipolar disorder and what kind of medication they should be prescribed, but they just wanted to be seen in a convenient place that didn’t frighten them. It didn’t seem inappropriate to them to seek “specialty” care in a primary-care office, and many of them actually had no idea that we had a special behavioral health program going on at all. They were just “going to the doctor.”
Several of them told me that they would never pursue treatment if it meant going to our mental health center, because they didn’t want to chance running into their neighbors, or deal with a different bureaucracy, or maybe end up hospitalized.
Our program is an IMPACT model collaborative care behavioral health program, embedded in a local federally qualified health center, with me serving as the consulting psychiatrist and employing behavioral health providers also provided by my community mental health center.
We had initially just planned to see people with depression and anxiety, assisting the primary care providers in this task with a structured system of immediate consultation with a mid-level, structured evaluation, treatment by algorithm, use of a registry to permit population-based care, and availability of a psychiatric consultant.
I had always believed that the care of bipolar disorder was a “specialty” activity, to be done in psychiatric settings by psychiatrists. But by the time this treatment need became clear, we had years of experience in using extenders — in this case the behavioral health providers that make up part of the collaborative care team — with great success. In my view, this was more effective than the care many of the patients in my mental health center were receiving.
I thought of all the steps involved: Asking all the right questions, making certain behavioral observations, getting collateral information where it is needed, and making a diagnostic decision. These steps would then be followed by synthesizing a treatment plan, educating and engaging the patient, and following up.