J. Sloan Manning

Tools to Improve Differential Diagnosis of Bipolar Disorder in Primary Care

Among patients seen in a primary care setting for depressive and/or anxiety symptoms, 20% to 30% are estimated to have bipolar disorder. Although relatively common in primary care settings, bipolar disorder is still underrecognized, primarily due to misdiagnosis as unipolar depression. Patients often seek treatment when they are depressed but uncommonly present with mania or hypomania, the specific markers of bipolar spectrum disorders. An awareness of the prevalence, characteristics, and predictors of bipolar disorder can help the primary care physician to properly differentiate between bipolar depression and unipolar depression. Completing a differential diagnosis of bipolar disorder requires obtaining a comprehensive patient history that investigates symptom phenomenology and associated features, family history, longitudinal course of illness, and prior treatment response. In addition to the clinical interview, the Mood Disorder Questionnaire and the World Health Organization Composite International Diagnostic Interview 3.0 can be useful tools for evaluating patients for bipolar disorder. Screening patients at risk for bipolar disorder will help to avoid the use of unproductive or possibly even harmful treatments.

Assessing Effects of l-Methylfolate in Depression Management: Results of a Real-World Patient Experience Trial

Objective: l-Methylfolate has been shown in retrospective and prospective studies to enhance antidepressant response. The aim of this study was to prospectively assess change in depression severity and medication satisfaction in patients prescribed l-methylfolate within a naturalistic setting. Method: Between November 2010 and April 2012, patients who reported being treated for major depressive disorder rated their experiences before and after 3 months on the prescription medical food l-methylfolate (Deplin) 7.5 mg or 15 mg, through an automated telephone system. Survey questions included the 9-item Patient Health Questionnaire (PHQ-9), as well as quality of life and medication satisfaction questions. The primary outcome was change in depression severity from baseline to endpoint. Results: Of 554 patients, 502 reported that l-methylfolate was added to their existing antidepressant and 52 were treated with l-methylfolate alone, without an antidepressant. Enrolled participants reported a mean reduction of 8.5 points (58.2% decrease) in their PHQ-9 score (mean baseline PHQ-9 score = 14.6, mean follow-up PHQ-9 score = 6.1; P = .000); 376 (67.9%) responded to treatment (50% reduction in baseline PHQ-9 score) and 253 (45.7%) achieved remission (follow-up PHQ-9 score < 5) after an average of 95 days of therapy. In addition, patients achieved significant reductions in self-reported impairment in their work/home/social life (P = .000). Medication satisfaction with l-methylfolate (mean satisfaction score = 7.0) was significantly higher than with prior medication (mean satisfaction score = 5.2; P = .000). Conclusions: Results show that in a naturalistic setting, patients managed with l-methylfolate achieved statistically significant improvements in self-reported depression symptoms and functioning and greater satisfaction with their medication treatment.

Strategies for Managing the Risks Associated With ADHD Medications

College students with ADHD may need help to overcome symptoms that make studying, organizing and completing projects, and managing their time a challenge. In order to properly treat these patients, clinicians must correctly assess ADHD and comorbid conditions using rating scales and educate patients about their responsibility to reach their treatment goals and to properly use and protect their medication. Patients with past substance use may require treatment options that are less likely to be misused, such as a nonstimulant or long-acting stimulants. Throughout the treatment process, clinicians should continue to monitor symptoms and side effects with regular office visits and random testing, watching for signs of drug misuse.

Treating Bipolar Disorder in the Primary Care Setting: The Role of Aripiprazole

OBJECTIVE The objective of this article is to present practical strategies for detecting and diagnosing bipolar disorder in the primary care setting and to review the evidence for the efficacy and safety of aripiprazole treatment for bipolar disorder. DATA SOURCES A review of the literature from 1980 to 2007 was conducted from November 2006 through February 2007 using a MEDLINE search and the key words bipolar disorder, primary care, detection, diagnosis, and aripiprazole. STUDY SELECTION A total of 100 articles that focused on the accurate detection and diagnosis of bipolar disorder and the evidence of the efficacy and safety of aripiprazole in the treatment of bipolar disorder were selected. DATA SYNTHESIS Patients with bipolar disorder often present to primary care physicians with depressive or mixed symptoms as opposed to purely hypomanic or manic symptoms. Accurate diagnosis of bipolar disorder is essential in order to provide timely and appropriate treatment. One treatment option available is aripiprazole, a partial agonist of dopamine (D)₂ and D₃ and serotonin (5-HT)(₁A) receptors and an antagonist of the 5-HT(₂A) receptor. Clinical trial data have shown aripiprazole to be effective in treating manic and mixed episodes associated with bipolar I disorder, both in the acute phase and over an extended period of treatment lasting from 6 months to 2 years. CONCLUSIONS Accurate diagnosis and treatment of bipolar disorder are challenges increasingly faced by primary care physicians. Strategies geared toward detection, diagnosis, and management of bipolar I disorder and other bipolar spectrum disorders may improve the treatment outcome for patients. Aripiprazole may be considered as another first-line choice for the treatment of bipolar I disorder; however, its utility in patients with bipolar spectrum disorders is yet to be determined.

What Alternatives to First-Line Therapy for Depression Are Effective?

Depression is often a chronic illness that requires a methodical, long-term approach to manage it optimally. A single antidepressant trial is often insufficient for patients to achieve remission. Remission rates for selective serotonin reuptake inhibitors are about 30% to 35%. Using successive treatment steps with optimal medication dosing and making measurement-based treatment decisions can help patients achieve remission, but, at each step, remission is less likely than at the first step. Depression is considered treatment-resistant if 2 adequate trials of medication fail. Clinicians can use validated symptom checklists such as the 16-Item Quick Inventory of Depressive Symptomatology, 9-Item Patient Health Questionnaire, Global Assessment of Functioning, and Sheehan Disability Scale to identify patients with treatment-resistant depression. Treatment resistance is likely in patients with a history of depressive chronicity and concurrent psychiatric and medical disorders and may be mistakenly suspected in patients who have had an inadequate trial of medication or who have been misdiagnosed. Strategies that can be effective to combat treatment resistance include optimizing treatment, switching to another antidepressant, combining antidepressants, and augmenting antidepressants with nonantidepressant treatments such as buspirone, lithium, liothyronine, atypical antipsychotics, or other agents. In addition, clinicians need to cultivate strong therapeutic alliances with patients, use objective measurements, practice evidence-based medicine, and educate patients about the disease and its treatments.

Identify bipolar spectrum disorders.

Patients with bipolar spectrum disorders commonly present with depressive symptoms to primary care clinicians. This article details bipolar spectrum disorder assessment, treatment, and treatment response. By intervening early in the course of depressive and hypomanic episodes, you can help decrease the morbidity and suffering associated with bipolar spectrum disorders.

Selecting Appropriate Treatment for Patients Who Are Nonresponsive to Initial Therapy

Depression can be a chronic illness, and several treatment steps are often needed to achieve sustained symptom remission and return patients to premorbid levels of functioning. Patients with chronic depressive illness, early onset, concurrent psychiatric or medical conditions, difficult psychosocial problems, or comorbid melancholic and anxious features may require additional treatment steps. Next-step strategies, after optimizing the dose and extending the treatment trial of the initial antidepressant, include switching antidepressants, adding another antidepressant, and augmenting with a nonantidepressant agent.

Welcome! Why This Journal?: (Editorial)

Thank you for taking the time to read the inaugural issue of The Primary Care Companion to The Journal of Clinical Psychiatry. The Primary Care Companion is a publication that seeks to focus on primary care psychiatry and neurology in a way that is clinical in its orientation while maintaining standards of peer review that will make it a logical, attractive place to report on original research. We will strive to be eminently practical for clinicians and present current information on psychiatry and neurology in a logical and usable format. Those involved in academic and practice-based research will find a home for reports on deserving investigations that involve clinical practice or have the potential to be translated into patient care in a way that improves our understanding of illness and the quality of our practices. My own journey into practice and academic medicine underscores some of the intersecting issues that led to the creation of The Primary Care Companion. My final year of family practice residency brought several poignant experiences in primary care psychiatry. One of my “problem” patients, a woman with dysthymia, was trying my patience. Anxious, somatic, relentless, she was making my life miserable with phone calls, emergency room visits, and office calls—even an admission for a chronic obstructive pulmonary disease exacerbation that was actually a panic attack. With her, it was always something, but never anything. My residency had a very strong behavioral emphasis; I had wonderful attending physicians. I learned a great deal about family systems theory and psychodynamics. Dysthymia, according to everything I understood then, was a characterological illness … weak people making bad decisions and complaining about the consequences … no wonder the resulting depression was chronic. One day in a fit of frustration, I gave the aforementioned dysthymic patient nortriptyline samples, with terse instructions to take 50 mg at night for 1 week, then increase the dose to 100 mg. She was to see me in 3 weeks; this just to get the visit to an endpoint. Imagine my surprise when in 3 weeks she returned smiling, sleeping well, and in less somatic pain than she had experienced in 10 years. She eventually made a complete recovery. Stunned, I reconsidered the validity of my education and began to actively screen for and treat depressed patients. Initially, the experience was filled with scenarios and results like my first dysthymic patient, but as I identified and treated more patients, I quickly began to realize that a full response to antidepressant therapy was a coin flip in terms of predictiveness. Half of my depressed and anxious patients got excellent results, another fourth improved little or not at all. Most surprising, however, was the presence of a good 25% that responded erratically or at times got worse, particularly if I titrated the dosages of medication used! I certainly was not interested in complicating an illness, and there was nothing in standard texts or other materials on depression management that explained the phenomenon. Careful questioning for subtleties of vegetative and cognitive symptomatology made it apparent that complicated psychosocial contexts were not the sole culprit. Later, through the mentorship of 2 gifted psychiatrists, I learned that the cause of much of my confusion and poor management was the result of the effects of antidepressants on undiagnosed bipolar illness. This knowledge led to a deeper journey into psychopharmacology, clinical research, and many satisfying experiences treating complicated illness, while remaining a family physician at heart. Where did my training fail me? Two weaknesses come to mind. My residency taught a biopsychosocial view of psychiatric illness that downplayed biological underpinnings in favor of systems theories and psychological constructs. As a result, psychopharmacology was relegated to second-line treatment for situations in which “superior” behavioral therapies were impractical. Second, since the complexity and heterogeneous nature of those biological realities have only recently come to light in the psychiatric literature, no consensus view embracing these data existed to be passed on to generalists. This was compounded by a training program that limited exposure to psychiatrists who practiced effective psychopharmacology in favor of interactions with nonphysicians whose philosophies neither stressed inherited biological vulnerability nor modeled such interventions. This view is still the predominant paradigm for psychiatric training in family medicine. In time, my experience in private practice led to research questions and a desire to teach physicians in training some of the things that I have learned. I can testify to the fact that the paradigm can be changed. Generalist physician experts in primary care psychiatry are the natural role models for a fresh approach to practice and the development of new curricula. We have integrated these ideas in our department in part through the development of mood disorder clinics that function as teaching laboratories. In these clinics, family physician experts, nonphysician behaviorists, and resident physicians meet together with patients who are treatment resistant, present diagnostic dilemmas, or are in need of acute care. The result is a unique opportunity to model an advanced approach to the care of our patients and a rich experience where biopsychosocial contexts are assessed and used to design balanced treatments. Our residents learn about family systems theory, brief psychodynamic therapies, and how to use lithium and valproate. Our research has yielded fruit, but we have not always found existing primary care journals open to novelty, even when based on evidence from practice. Many others have similar experiences. Not only did we find mind-body dualism impractical, we discovered that discarding the concept brought significant rewards. Some, like me, have returned to “clinical academics,” hoping to become insiders with a chance to educate young physicians and translate newer concepts of illness and treatment into the language of practice. Not surprisingly, the experience of practice brings great power to education. For all of these reasons, a new forum for dialog is vital. This editorial board pledges a journal that will always retain a clinical focus true to your practice experience. We will bring you information on new concepts in diagnosis and treatment that offer expertise within the reach of interested generalists. The Companion will be academically sound. We will welcome contributions from frontiering researchers. We believe in a balanced biopsychosocial view of illness. We will be multidisciplinary, inviting contributions from others who have insights to share regarding primary care psychiatry. The Companion is very interested in publishing reports on the integrated delivery of general and behavioral health care and would like to be an advocate for such approaches. This inaugural issue is targeted to family physicians and internists identified as already providing an advanced level of psychiatric care. Your comments are appreciated. We are open to communication and invite your input; this journal is a work in progress. Finally, I would like to thank those on the editorial board for participating in a new venture. Their commitment to the advancement of clinical science is also greatly appreciated. Enjoy The Primary Care Companion to The Journal of Clinical Psychiatry.