The structured assessment used by the collaborative care team, including specific evaluation for bipolar disorder, lends itself to making sure all the right questions get asked and the mechanics of follow-up visits. In a primary care setting, you can always get an urgent follow-up appointment when you need one, and getting labs done is no big deal. The trick is to retain psychiatric oversight and input in the right places — at diagnosis and in treatment decisions.
In our setting, we did this by requiring that all diagnoses of bipolar disorder and all treatment changes in patients diagnosed with bipolar disorder be made in tandem with the consultant psychiatrist, occasionally in person but usually according to the collaborative care model by phone.
In fact, some patients with bipolar disorder are much too serious and complex to be managed in an outpatient setting, and in those cases we do our very best to move them along to a specialty mental health center. In our hands, this is about 20% of the patients we diagnose as bipolar.
Our program began in early 2007 and has been applied to more than 750 patients. What have we learned in seven years?
First, a partnership model with primary-care providers and behavioral-health providers embedded in the primary care setting is safe and works. The primary care providers can get used to this expansion of scope when they have confidence in the behavioral health provider and the consultant psychiatrist, though they tend not to take the reins, and manage bipolar conditions on their own, as they sometimes do with more straightforward depressions.
In our setting, about 30% of these patients continue with treatment on an ongoing basis. We use the standard medication armamentarium, according to the evidence base. We are able to provide treatment to hundreds of people who would not otherwise take themselves to a mental health provider. Patients give this form of care very high ratings on satisfaction scales.
The question of diagnosis — particularly in the fraught borderland of subsyndromal mood disturbance, trauma, substance abuse, character pathology, and the environmental stressors associated with safety net populations — remains difficult, and about a third of the people we assess in the bipolar realm are in this “mood disorder not-otherwise specified (NOS)” group.
Our treatment effectiveness and retention are least among these patients, who from a certain point of view would be thought of as the least disturbed from an affective point of view. We had hoped that some of these people would respond to mood stabilizers, even short of a formal bipolar diagnosis, but almost none have. Furthermore, these are the most likely patients to drop out of treatment.
We have also struggled to engage patients in nonmedication therapies, and in joining us in self-management strategies, even with measures as simple as mood charting.
At the American Psychiatric Association’s recent Institute on Psychiatric Services meeting in San Francisco, a group of people starting to do this collaborative-care work got together to start to move toward a standard of care, mostly by sharing experiences to date, as little has been published so far.
I think my experience is worth sharing, and I look forward to improving our outcomes based on the experience and research of others.
John Kern, MD, is Chief Medical Officer at Regional Mental Health Center in Merrillville, Indiana. He began and has supervised a behavioral health consultant program providing mental health services to a partner Federally Qualified Health Center, NorthShore Health Center, since March 2007.