Friday, December 07, 2007

Should PCPs be treating bipolar disorders?

Dr. Smak raised a great point in response to my last post on treating depression, namely whether or not we, as primary care doctors, should be treating bipolar disorder. I've been reluctant to do so through the years as the treatment for bipolar troubles has become so complex, and I hate to prescribe meds with which I have little experience. Now, armed with Dr. Stephen Stahl's excellent textbook "Essential Psychopharmacology," I often start treatment, referring on to psychiatrists when patients have an incomplete response to my efforts. This for several reasons:

1) Finding a psychiatrist who is accepting new patients under any given insurance plan is a daunting task, one that would stop any energetic soul much less someone struggling with depression.

2) Finding a psychiatrist who can see a patient in a timely fashion is near impossible.

3) Pharmaceutical companies are directing educational efforts on medications for bipolar depression towards primary care physicians. That may make some of you wince lest my choice of drugs be based solely on who's taken me out to a free dinner lately. I can assure you that I don't venture out in the evening after a long day at work in search of free food, but rather welcome the opportunity to hear clinical research data on drugs that may be helpful to my patients.

Many of my appointments no matter what they're billed as (fatigue, stomach pain, insomnia, back pain) are, in fact, about depression. Once I've identified the mood disorder, I feel like I'm in a good position to propose non-pharmacological fixes (see tomorrow's post) as well as discuss the pros and cons of medical treatment. If I immediately refer to a specialist that the patient doesn't know, needs to call to schedule an appt., and may or may not be able to afford, chances are good that the patient won't follow up, and they will be back again in my office with ongoing depression.

That said, Dr. S., I agree I too am a bit of a wuss once I've gotten the patient on two different meds and they're not yet in remission. I tell everyone up front that we may end up calling on a specialist to perfect the plan.


rlbates said...

You have my respect for trying / caring enough.

Dr. Smak said...

Your points regarding the barriers to psychiatric care of so important. There's the social stigma of seeing a shrink that people seem not to assign to getting medications from their PCP for mental illness. Even more profound are the access issues: first there's find a psych, then there's find a good psych, then find a good psych that takes my insurance, and if you get past that, your appointment is in 6-8 weeks.

My sense, after learning about some of the bipolar meds, is that they aren't really that complicated. I think for me the fear is that as a group of patients, people with bipolar disorder tend to require more resources than most PCPs can muster. I don't have counselors, and my schedule isn't set up to accommodate extended sessions for crises. Bipolar patients have a higher rate of comorbid substance abuse, and suicidality. Is it less of a "med" issue, and more of an acuity issue?

If that is the case, then in the situation you described it seems a PCP could handle things well. Maybe there is a nitch in bipolar treatment for patients whom we know well, and therefore can comfortably screen for some of the comorbidity that makes bipolar disorder to difficult to treat.

smalltowndoc said...

In India, we are at least better off in that, you can get a psychiatrist quiet easily. Since there is no (99% of the people do not have one)insurance they see without much difficulty. But treating depression is another story all together. Where i studied it was not much concentrated in our curriculum and the result, if one anti-depressant do not work, i refer them to a psychiatrist who can definitely handle it far better than me -

Mauigirl said...

My PCP prescribed Prozac for me at my request as I have been moody and mildly depressed off and on most of my life and depression runs in my dad's side of the family. It got worse as I approached menopause and I've been on Prozac now for two years and am very happy. Tried Lexapro first as it is supposed to be good for anxiety (which I have a lot of) but it made me feel blah and didn't seem to help much. Prozac, however, did the trick. I only use a low dose and it's enough.

I'm sure if I had severe, intractable depression my PCP would have referred me to a psychiatrist but since mine was mild and possibly menopause-related, she felt OK with prescribing it for me.

I think more people are bi-polar than many realize. My dad, who was definitely depressive in his old age, suddenly developed a manic phase when he got even older. Looking back at his behavior throughout my childhood, I am wondering if he was mildly bi-polar even back then.