Treating Bipolar Disorder in a Primary Care Setting

Last year, I collaborated with a team of researchers at the University of Washington to describe the clinical characteristics of 740 patients with bipolar disorder treated in primary care settings.¹ We found that bipolar disorder occurred commonly among patients treated in collaborative care treatment programs, and that the patients demonstrated moderately severe depression symptoms and co-occurring psychiatric illnesses such as post-traumatic stress disorder. Additionally, patients also commonly had psychosocial problems and barriers such as homelessness and lacked dependable transportation.

John Kern, MD, the chief medical officer at Regional Mental Health Center in Merrillville, Indiana, recently described in Psychiatry Advisor how his “depression in primary care” treatment program surprisingly led to his team of clinicians often treating patients with bipolar disorder in primary care.² He outlined how in the federally qualified health center (FQHC) he works in, patients with bipolar disorder ended up being treated in primary care for several reasons.

For example, some patients received treatment by default — meaning they had already been treated in the FQHC for depression and were only now being diagnosed with and treated for bipolar disorder. Another reason was that some patients preferred receiving treatment in primary care due to convenience or a perceived lack of stigma of receiving psychiatric treatment in a primary care environment rather than a mental health setting.

Our research study included many FQHCs in Washington State who participated in a statewide program called the Mental Health Integration Program (MHIP). MHIP uses a collaborative care model to support primary care clinicians in providing mental health care to primary care patients with psychiatric illness. Like Kern’s clinic, those participating in MHIP originally planned to primarily treat patients with depression or anxiety disorders.

Over time, however, clinicians in MHIP realized that patients with illnesses such as bipolar disorder, post-traumatic stress disorder, and substance use disorders were presenting to primary care. Reasons such as a lack of other treatment options, patient preference, or a need to initiate treatment due to patients’ symptom severity led to patients being treated in a primary care setting. 

Collaborative care programs like MHIP and Kern’s program incorporate psychiatric consultants and care managers who can help primary care clinicians treat the patients they are encountering daily. In the case of FQHCs in Washington and other states, primary care clinicians were seeing and treating patients with bipolar disorder with the support of psychiatric consultants. We sought to understand patients’ clinical characteristics to inform the clinical practice of the psychiatric consultants working in primary care.

Our initial step was to decide how to identify individuals with bipolar disorder using information collected on patients during the course of usual collaborative care. Patient registries used in collaborative care include information on patients’ symptoms and treatments over time, and results of standardized clinical assessments. Many psychiatric consultants working in the MHIP had started suggesting that their care managers use brief semi-structured interviews to assess for bipolar disorder — with many psychiatrists favoring the Composite International Diagnostic Interview 3.0 (CIDI).³ We decided to use results of the CIDI measure and clinicians’ diagnoses to identify patients with bipolar disorder who were receiving treatment in primary care.

About 15% of the patients in the MHIP who were administered the CIDI measure had results consistent with bipolar disorder and had a clinician diagnosis of bipolar disorder. We were surprised that a significant minority of patients had bipolar disorder since, like in Kern’s clinic, clinicians in MHIP initially set out to treat patients with depression or anxiety disorders. Additionally, the patients had levels of symptom burden, co-occurring illnesses and substance use, and psychosocial impairment with severity similar to patients seen in specialty mental health settings.

Our aim was to describe the population of patients with bipolar disorder already receiving treatment in primary care so clinicians could use the information when working with individual patients. Now we are thinking about how to use the information from our initial study to understand how to care for populations of patients with bipolar disorder treated in primary care clinics.

Joseph M. Cerimele, MD, MPH, is an acting assistant professor in the Department of Psychiatry & Behavioral Sciences at the University of Washington School of Medicine. He is also a psychiatric consultant for Washington State’s Mental Health Integration Program.

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