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.