For 20 years, psychiatrist James Phelps, MD, felt that patients with bipolar disorder were not being diagnosed with the condition because they weren’t severely afflicted.
“Our system is set up to say either yes, the patient has bipolar disorder or no, they don’t,” he said. “I’ve strongly felt throughout my career that we need data to show polarity, that bipolar disorder can be spread out from slight to severe.”
One issue with that, Phelps said, is that patients who have bipolar disorder but are diagnosed instead with depression are usually prescribed antidepressants which can make bipolar disorder worse.
Phelps and the team at Samaritan Mental Health recently completed a study in which they screened nearly 1,500 consultations for depression. Behavioral health specialists, who are embedded in primary care clinics, conducted screening interviews of these patients as part of Samaritan’s collaborative care model.
“Samaritan’s model includes a screening developed by the University of Washington, but we added to that,” Phelps said. “We gather information on factors like family history, medical history and any history with postpartum depression or trauma that are not part of the UW screening. These factors have been associated with the onset of bipolar disorder.”
In addition to the screening questions, two psychiatry residents and Olivia Pipitone, biostatistician with Samaritan, reviewed the answers from each patient. Phelps received a John. C. Erkkila Endowment grant through the Good Samaritan Hospital Foundation to assist with the labor costs of the project.
The result was an impression of “bipolarity” in 35% of the 700 patients. This was higher than the University of Washington screening tool, which suggested bipolar depression in 21% of patients. Was this an “overdiagnosis”? If so, an inaccurate diagnosis would presumably lead to inaccurately targeted treatment and poor outcomes, compared to other consult patients. But Phelps’ group showed this not to be the case.
“I thought we might have shown that these ‘overdiagnosed’ patients improved even more than everyone else because they got a new treatment approach,” Phelps said. “Our data trended in that direction. But to show that, we’d need a bigger sample.”
The team published their results in the American Psychiatric Association’s journal Psychiatric Services. Along with Phelps and Pipitone, the team included fourth-year psychiatry residents Jonathan Bale, DO, and Kenneth Squires III, DO, who reviewed 700 charts to extract the necessary data.
From the same data, the team has also written a paper describing treatments patients received, including bipolar-specific medications like lamotrigine and lithium. They’ve shown that primary care providers use these medications appropriately when they guidance from psychiatric consultants.
This paper has completed review in a British journal, Family Practice.
Phelps has gone on to develop another team that is examining the tapering of antidepressants.
“Some people experience severe withdrawal symptoms when stopping their antidepressants,” Phelps said. “I think we’ll find that tapering is not as routine as perhaps it should be.”
Phelps said the results so far are gratifying as they support what he has believed for 20 years, and because the study showed it’s possible to screen for bipolar disorder in the primary care setting.
“I’m also excited that Samaritan has been able to make a significant contribution to the literature,” he added.