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bipolar disorder and GPs

Perrotfish

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    Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?
     

    vistaril

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      Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

      first, there is no such thing(for the most part) as a GP.

      I suspect this answer isn't going to be popular, but a lot of primary care physicians don't refer suspected mild bipolar spectrum patients to us because they fear we will automatically dx the pt as having bipolar 2, start them on a mood stabilizer and some other meds, make them fat, etc.....that's a question we should be asking ourselves everytime we start a med- is this really going to have a net positive effect on the pt's life *after* including all the negatives of being on medication....not just ones like metabolic effects, physical side effects, etc

      So let's say your the pdoc and you have a pt you are thinking about starting Depakote on. The first question is is Depakote likely to help this pt at all? If you feel the answer to that question is yes, the second question is usually more difficult: is the benefit to the pt large enough to overcome the medication's

      -cost of the med itself
      -inconvenience of taking the medication
      -inconvenience and cost of going to separate doc appts to have the med filled
      -inconvenience and cost of getting labwork/levels related to the medication if applicable
      -nonmetabolic/lab side effects that may bother the pt like tremor, hair loss, etc
      -metabolic/lab side effects that may harm the pt

      and there are probably some others Im forgetting!

      So you can see...the question isn't 'will this work at all'(and the answer is sometimes probably not to even that question).....the real question is will this work by such a large amount to overcome all the negatives?
       

      snarfer

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        Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

        Please refer these patients to psychiatry asap and kindly do not prescribe them Xanax or Klonopin TID with or without Paxil.
         
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        vistaril

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          Please refer these patients to psychiatry asap and kindly do not prescribe them Xanax or Klonopin TID with or without Paxil.

          I do realize that there are a lot of candyman pcps out there(as well as a lot of really great psychiatrists), but I think a lot of good pcps(who simply dont have the time and/or knowledge to best manage many such patients) worry that if they refer them to a psychiatrist the pt will be started on a benzo and mood stabilizer and maybe even an atypical and they will from then on out be a 'psych pt' for the next two decades.......going every few months to have the psychiatrist refill their psych polypharmacy.
           

          DebDynamite

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            Well, it shows that I am a psychiatrist in that I actually find bipolar 2 more challenging to treat than bipolar 1. There are so many different ways I would approach bipolar 2, that I would not even venture to start naming them on this board. For example, BP2 can have a primary mood component of hypomania or irritability - so, I would really want to approach each patient differently. As a pcp, if you can refer and the patient is willing to go, please do so. This is good for everyone involved. Of course if your patient just won't go, then you are in more of a bind. My best friend from med school is a pcp and she has patients who simply won't go to see a psychiatrist. She calls me. As others have stated, please don't just rx benzos. Especially short and intermediate acting benzos.
             

            hamstergang

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              first, there is no such thing(for the most part) as a GP.

              What? Is GP really not a well understood term?

              I suspect this answer isn't going to be popular, but a lot of primary care physicians don't refer suspected mild bipolar spectrum patients to us because they fear we will automatically dx the pt as having bipolar 2, start them on a mood stabilizer and some other meds

              So you're saying that if they suspect the pt has a certain diagnosis, they won't refer them to a psychiatrist because we might also diagnose them with that diagnosis and then treat them appropriately?
               

              heyjack70

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                Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

                Being a cynic, and based on what I see most often, I think PCP's give too many benzo's and call bipolar 2 what is really cluster B reactivity ("mood swings..I must have bipolar"). These folks may benefit slightly from the tranquilizing effects of meds, but what they really need is therapy. It's gotta be tough in a 10 minute visit when the patient is demanding more oxycontin for their fibromyalgia and also complaining of bipolar disorder. How can you possibly hope to succeed in that scenario.

                My anecdotes are limited, but the IM docs seem to want to refer to psych more. The family docs get a little more cavalier and load the pt's up with Klonopin TID plus ambien (or 6 mg of xanax a day). Or they crank the Wellbutrin in a patient with anxiety and wonder why they continue to have panic attacks. Then the referral happens and I'm there debating with the patient about pulling meds off.

                Sorry about the generalizations, I know that the majority of PCPs don't do this.
                 

                vistaril

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                  What? Is GP really not a well understood term?



                  So you're saying that if they suspect the pt has a certain diagnosis, they won't refer them to a psychiatrist because we might also diagnose them with that diagnosis and then treat them appropriately?

                  1) GP is typically a misunderstood term depending on the company. Most people have family medicine physicians or internists as their primary care physicians. These are not 'gps'. A 'gp' is a term that could imply one didn't do much of any training after medical school, which is not true. the approoriate term is to call them either primary care physicians or family medicine physicians/internists(depending on which they are)

                  2) you missed a key word(automatically) in my post when you wrote about diagnosing them with that diagnosis
                   

                  vistaril

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                    Being a cynic, and based on what I see most often, I think PCP's give too many benzo's and call bipolar 2 what is really cluster B reactivity ("mood swings..I must have bipolar"). These folks may benefit slightly from the tranquilizing effects of meds, but what they really need is therapy. QUOTE]

                    exactly....so the pcp's best bet is to refer to someone who does therapy
                     
                    first, there is no such thing(for the most part) as a GP.

                    I suspect this answer isn't going to be popular, but a lot of primary care physicians don't refer suspected mild bipolar spectrum patients to us because they fear we will automatically dx the pt as having bipolar 2, start them on a mood stabilizer and some other meds, make them fat, etc.....that's a question we should be asking ourselves everytime we start a med- is this really going to have a net positive effect on the pt's life *after* including all the negatives of being on medication....not just ones like metabolic effects, physical side effects, etc

                    So let's say your the pdoc and you have a pt you are thinking about starting Depakote on. The first question is is Depakote likely to help this pt at all? If you feel the answer to that question is yes, the second question is usually more difficult: is the benefit to the pt large enough to overcome the medication's

                    -cost of the med itself
                    -inconvenience of taking the medication
                    -inconvenience and cost of going to separate doc appts to have the med filled
                    -inconvenience and cost of getting labwork/levels related to the medication if applicable
                    -nonmetabolic/lab side effects that may bother the pt like tremor, hair loss, etc
                    -metabolic/lab side effects that may harm the pt

                    and there are probably some others Im forgetting!

                    So you can see...the question isn't 'will this work at all'(and the answer is sometimes probably not to even that question).....the real question is will this work by such a large amount to overcome all the negatives?
                    Its a BRITISH TERM you ****
                     

                    Salpingo

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                      Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

                      As far as bipolar I goes, I feel that few people are going to initially present in an outpatient office. Don't have the numbers, but they first end up in a psych ED, jail or morgue.

                      As far as bipolar II goes, treatment is a little iffy. Seroquel has been approved for bipolar II depression, but RCT shows no real effect on hypomania. Also, there's a 50% chance that we will be horribly ashamed of ourselves in 20 years when we look back and realize the "bipolar II" and "rapid cycling" diagnoses were just ways keep the neurasthenia/hysteria populations under medical care. GPs don't want to be any part of that
                       

                      heyjack70

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                        Being a cynic, and based on what I see most often, I think PCP's give too many benzo's and call bipolar 2 what is really cluster B reactivity ("mood swings..I must have bipolar"). These folks may benefit slightly from the tranquilizing effects of meds, but what they really need is therapy. QUOTE]

                        exactly....so the pcp's best bet is to refer to someone who does therapy

                        Which could be a psychiatrist/ologist...or social worker...um...where can you get legitimate DBT these days?
                         
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                        Armadillos

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                          first, there is no such thing(for the most part) as a GP.


                          Its gotten to the point where its easier to just reply to your posts with your own posts.


                          sheeesh....when you were a kid and your mom told you to put a jacket on so you wouldn't catch a cold, did you give her a lecture on microbiology and how cold weather doesn't transmit bacteria?.
                           

                          NYCMS2

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                            Well, it shows that I am a psychiatrist in that I actually find bipolar 2 more challenging to treat than bipolar 1. There are so many different ways I would approach bipolar 2, that I would not even venture to start naming them on this board. For example, BP2 can have a primary mood component of hypomania or irritability - so, I would really want to approach each patient differently. As a pcp, if you can refer and the patient is willing to go, please do so. This is good for everyone involved. Of course if your patient just won't go, then you are in more of a bind. My best friend from med school is a pcp and she has patients who simply won't go to see a psychiatrist. She calls me. As others have stated, please don't just rx benzos. Especially short and intermediate acting benzos.

                            Just curious, Deb, but for the BP2 you describe with a primary mood component of hypomania or irritability (I assume meaning no serious problems with depression) how would you typically proceed? What does evidence based psychiatry suggest be done here?

                            On a related (and loaded) question, is BP2 over or under diagnosed, and where diagnosed, is it treated properly and effectively by most physicians? I ask because I read somewhere that a BP2 patient on meds experiences another episode of depression or hypomania 40 percent of the time as opposed to the untreated BP2 who experiences the same 50 percent of the time, which on the surface seems like not much of a net benefit to the drug therapies given the laundry list of negative side effects.

                            I am just trying to learn something here as an MS3.
                             

                            vistaril

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                              Whereas psychiatrists never do this...

                              most of these cluster B patients on a benzo, mood stabilizer, atypical, and maybe an AD as well are on those from psychiatrists. Most primary care physicians aren't going to prescribe any of their patients 3 different psychotropics(if you don't count sleep aids)....

                              So anytime a borderline is on a jacked up polypharm regimen, you can usually blame psychiatry.
                               

                              nancysinatra

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                                Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

                                I think it would depend on how good your diagnostic skills are. Like others have said, BPII can get confused with other things, including anxiety. It takes one or more good evaluations to sort it out, and we can still be wrong. If the dx is wrong, then that's bad because the patient will continue to "list" it for the rest of their life. And especially if your patient is high functioning or a professional, remember that bipolar anything has a stigma, and be careful about labeling someone with a potentially inaccurate diagnosis. (Imagine if the patient was you, and you had to "report" things to a medical board? You'd want an accurate diagnosis, right?)

                                The trouble with starting something is that you will have to devote follow up visits to the psych complaint. Are you able to do that? You can't just start the med but never revisit the issue. And bipolar patients tend to be pressured so they talk a lot! Now if they can't get into see a psychiatrist then that's different.

                                I would have no trouble with a PCP starting a bridge medication as long as it's not a completely messed up benzo prescription like others have mentioned. Starting lithium--I admire you for thinking about it, and it's a possibility for some patients but it depends, and atypicals are easier to work with if you're not experienced. The trouble with a lot of mood stabilizers is that you can't just start them and wait--you have to titrate, or get labs and watch levels, or monitor for side effects. We don't even see our own patients soon enough to do this very well in psych--I'd guess that in primary care, it will be harder.

                                All that said I admire you for asking and showing interest. Only you can know your own comfort level!
                                 

                                nancysinatra

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                                  most of these cluster B patients on a benzo, mood stabilizer, atypical, and maybe an AD as well are on those from psychiatrists. Most primary care physicians aren't going to prescribe any of their patients 3 different psychotropics(if you don't count sleep aids)....

                                  So anytime a borderline is on a jacked up polypharm regimen, you can usually blame psychiatry.

                                  You make a good point. Although I'd expand it to anyone, not just a borderline, being jacked up on a polypharm regimen. Usually internists etc want to decrease psych meds.

                                  I'd rather deal with a borderline labeled as BPII and on Xanax TID and Paxil from a PCP than the same patient on Seroquel, Depakote, Abilify, Wellbutrin, Zoloft, and the ubiquitous trazodone, who has seen 3 other psychiatrists and has tried all the other atypicals, SSRIs and SNRIs.

                                  The poor PCPs out there who are trying to manage this stuff are probably just trying to help the patients get by--certainly we can't blame them or expect them to sort everything out.

                                  If trends in psych continue I may start asking patients what meds they're not taking...
                                   
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                                  F0nzie

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                                    most of these cluster B patients on a benzo, mood stabilizer, atypical, and maybe an AD as well are on those from psychiatrists. Most primary care physicians aren't going to prescribe any of their patients 3 different psychotropics(if you don't count sleep aids)....

                                    So anytime a borderline is on a jacked up polypharm regimen, you can usually blame psychiatry.

                                    It is very frustrating to work with these personality disordered patients when they switch providers because they're accustomed to interacting with their psychiatrist or NP in a very meaningless way ie. "How is mood? sleep? energy? appetite? SI/HI? Ok let's increase the Seroquel. See you in 3 months." It's very hard to break this habit and get them to engage in any type of meaningful interaction once they've been working like this in the system for years. Even if someone does not fit in the cookie cutter DSM criteria for a personality disorder, a lot of axis I patients have sprinkles of personality disorder that can benefit from therapy. This is where I see psychotherapy training helping us make better decisions regarding our prescribing methods. We can't give up therapy or expect that somebody else will do the job for us.
                                     

                                    Perrotfish

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                                      First to the above debate about the term GP, I've always heard it used similary to PCP: a term including Pediatricians, IM docs, and FPs who see primarily outpatient clinic.

                                      I think it would depend on how good your diagnostic skills are. Like others have said, BPII can get confused with other things, including anxiety. It takes one or more good evaluations to sort it out, and we can still be wrong. If the dx is wrong, then that's bad because the patient will continue to "list" it for the rest of their life. And especially if your patient is high functioning or a professional, remember that bipolar anything has a stigma, and be careful about labeling someone with a potentially inaccurate diagnosis. (Imagine if the patient was you, and you had to "report" things to a medical board? You'd want an accurate diagnosis, right?)

                                      The trouble with starting something is that you will have to devote follow up visits to the psych complaint. Are you able to do that? You can't just start the med but never revisit the issue. And bipolar patients tend to be pressured so they talk a lot! Now if they can't get into see a psychiatrist then that's different.

                                      I would have no trouble with a PCP starting a bridge medication as long as it's not a completely messed up benzo prescription like others have mentioned. Starting lithium--I admire you for thinking about it, and it's a possibility for some patients but it depends, and atypicals are easier to work with if you're not experienced. The trouble with a lot of mood stabilizers is that you can't just start them and wait--you have to titrate, or get labs and watch levels, or monitor for side effects. We don't even see our own patients soon enough to do this very well in psych--I'd guess that in primary care, it will be harder.

                                      All that said I admire you for asking and showing interest. Only you can know your own comfort level!

                                      So, I guess the reason that I'm asking about this is that I feel like its often very hard to get our patient's integrated with the psych service. Once they're there I think I speak for PCPs everywhere when we say we're happy leaving them to psych. However I've seen a psych referal range from a three month wait to flat out impossible, depending on the system I'm working in (in a lot of the poorer side of a civilian PCP clinic its impressive just to get them into a PCP). Its difficult letting patients sit for that long, but most PCPs I've work with (I'm an Intern) feel like anything beyond an SSRI/SNRI/benzo is completely beyond their comfort level, and obviously we don't want to prescribe those when we get a history that strongly suggests mania. So I'm wondering what I should do while I'm waiting for our overwhelemed psych colleagues to have an opening, and especially what (if anything) I should feel comfortable doing with patients who don't have a practical option for seeing a psychiatrist at all.

                                      BTW, may I ask why lithium seems to be such a second line drug with Mania? I know that as a PCP weight gain is one of our biggest concerns with the atypicals, and I know that Lithium doesn't have that as a major part of its side effect profile. Even considering the rest of its side effect profile I'm surprised it isn't used more. Why has it fallen out of favor so much, and why is it harder to manage than an atypical?
                                       
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                                      vistaril

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                                        You make a good point. Although I'd expand it to anyone, not just a borderline, being jacked up on a polypharm regimen. Usually internists etc want to decrease psych meds.

                                        I'd rather deal with a borderline labeled as BPII and on Xanax TID and Paxil from a PCP than the same patient on Seroquel, Depakote, Abilify, Wellbutrin, Zoloft, and the ubiquitous trazodone, who has seen 3 other psychiatrists and has tried all the other atypicals, SSRIs and SNRIs.

                                        The poor PCPs out there who are trying to manage this stuff are probably just trying to help the patients get by--certainly we can't blame them or expect them to sort everything out.

                                        If trends in psych continue I may start asking patients what meds they're not taking...

                                        i've found that it is generally a good idea to simply assume that BP2/borderline types who have long psych histories have at some point been on Seroquel and Lamictal. In fact, it is safe to assume that even if they say they haven't been on those two meds in the past, they likely just can't remember. Now that doesn't mean you can neccessarily draw any conclusions on whether seroquel or lamictal might be a decent option for the borderline in question, simply because the pt was on so many other psychotropics while they were on seroquel and/or lamictal that it would be impossible to determine which medication it was that was helping or not helping the pt.

                                        Next, behind the uniquitous Seroquel and Lamictal, is Abilify and Klonopin. It isn't a 100% sure thing the borderline in question has been on these meds at some point(as it is with seroquel and lamictal), but it's more like 80-85%

                                        Next behind this is Effexor or Cymbalta. More likely Cymbalta because another rule in borderline polypharm is that cost is no issue and expensive drugs are actually preferred. One local psychiatrist had a borderline/BP2 pt on(in medicare costs) $1900 worth of psych meds per month. Yes, almost 2000 dollars in medicare costs(not self pay) per month for meds that werent helping at all. The 25mg qhs seroquel the pt was on and just 'had to have' was priceless....

                                        Strangely enough, one drug that isn't all that likely to show up is the drug where there is actually decent evidence that it reduces suicide apart from efficacy as a mood stabilizer- Lithium.
                                         

                                        vistaril

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                                          First to the above debate about the term GP, I've always heard it used similary to PCP: a term including Pediatricians, IM docs, and FPs who see primarily outpatient clinic.



                                          So, I guess the reason that I'm asking about this is that I feel like its often very hard to get our patient's integrated with the psych service. Once they're there I think I speak for PCPs everywhere when we say we're happy leaving them to psych. However I've seen a psych referal range from a three month wait to flat out impossible, depending on the system I'm working in (in a lot of the poorer side of a civilian PCP clinic its impressive just to get them into a PCP). Its difficult letting patients sit for that long, but most PCPs I've work with (I'm an Intern) feel like anything beyond an SSRI/SNRI/benzo is completely beyond their comfort level, and obviously we don't want to prescribe those when we get a history that strongly suggests mania. So I'm wondering what I should do while I'm waiting for our overwhelemed psych colleagues to have an opening, and especially what (if anything) I should feel comfortable doing with patients who don't have a practical option for seeing a psychiatrist at all.

                                          BTW, may I ask why lithium seems to be such a second line drug with Mania? I know that as a PCP weight gain is one of our biggest concerns with the atypicals, and I know that Lithium doesn't have that as a major part of its side effect profile. Even considering the rest of its side effect profile I'm surprised it isn't used more. Why has it fallen out of favor so much, and why is it harder to manage than an atypical?

                                          all good points/questions.....

                                          1) be suspicious of most histories that 'stongly suggest mania'. Here are good reasons to strongly suspect mania- you see the patient manic(and when you see it you'll know it) or the pt was documented by a law enforcement officer or medical/,mental health person to be doing something that was manic.

                                          2) Even if you aren't sure a pt's mood d/o is unipolar, don't hesitate to give them an AD. If you 'flip' someone with an AD(and the likelihood of that we could spend forever debating as well), it's not like you have done the worst thing in the world.

                                          3) Lithium isn't used as much as it should be because it is inconvenient(for both the pt and the practitioner). Sad, but true.

                                          4) most importantly, try to find out what groups/psychiatrists throw polypharm haphazardly at patients and avoid sending your borderline types to these people. I know a lot of really smart internists who have a borderline in front of them and just refer them to a person or group who they are well aware will put them on the polypharm train(eventually). They know it's bs and they know it wont help(and will only hurt) the pt. Stand up for your patients, and do what's right(even if it's not convenient and may ruffle some feathers)
                                           

                                          Perrotfish

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                                            1) be suspicious of most histories that 'stongly suggest mania'. Here are good reasons to strongly suspect mania- you see the patient manic(and when you see it you'll know it) or the pt was documented by a law enforcement officer or medical/,mental health person to be doing something that was manic.

                                            So a history I hear at least a few time a month:
                                            Alternating periods of deep dark depression (sleeping 18+ hours a day, crying jags, etc) and boundless self confidence w/ irrepressible energy (sleeping less than 2 hours a night for days on end without any drug use, friends complain about pressured speech, accomplishing enormous amounts of work,taking risks, sexually active etc), spaced by periods of 'normal' mood and energy where patient is highly functional (stong social support, top student/worker, etc). The two things was told was especially typical for mania were that history of not sleeping at all for days on end without anxiety or feels of exhaustion, and also the history of being really highly functional in between these highs and lows, vs the more confusing patient who seems to be a mess all the time. Is that often a normal history for personality disorders and/or anxiety?

                                            3) Lithium isn't used as much as it should be because it is inconvenient(for both the pt and the practitioner). Sad, but true.

                                            Why is lithium monitoring so inconvenient? How often do you need to see them vs. a patient on atypicals?
                                             
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                                            vistaril

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                                              So a history I hear at least a few time a month:
                                              Alternating periods of deep dark depression (sleeping 18+ hours a day, crying jags, etc) and boundless self confidence w/ irrepressible energy (sleeping less than 2 hours a night for days on end without any drug use, friends complain about pressured speech, accomplishing enormous amounts of work,taking risks, sexually active etc), spaced by periods of 'normal' mood and energy where patient is highly functional (stong social support, top student/worker, etc). The two things was told was especially typical for mania were that history of not sleeping at all for days on end without anxiety or feels of exhaustion, and also the history of being really highly functional in between these highs and lows, vs the more confusing patient who seems to be a mess all the time. Is that often a normal history for personality disorders and/or anxiety?



                                              Why is lithium monitoring so inconvenient? How often do you need to see them vs. a patient on atypicals?

                                              did the pt volunteer that information about the manic symptoms or was it prompted more by the line of questioning? If it's the former, they probably warrant psych ref....but those pts shouldnt be all that common.

                                              As for lithium, the inconvenient part is getting the levels as you titrate to therapeutic dose....that is typically going to require more than 1 level today after initiation. Much much more inconvenient to monitor than atypicals.
                                               

                                              nancysinatra

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                                                So a history I hear at least a few time a month:
                                                Alternating periods of deep dark depression (sleeping 18+ hours a day, crying jags, etc) and boundless self confidence w/ irrepressible energy (sleeping less than 2 hours a night for days on end without any drug use, friends complain about pressured speech, accomplishing enormous amounts of work,taking risks, sexually active etc), spaced by periods of 'normal' mood and energy where patient is highly functional (stong social support, top student/worker, etc). The two things was told was especially typical for mania were that history of not sleeping at all for days on end without anxiety or feels of exhaustion, and also the history of being really highly functional in between these highs and lows, vs the more confusing patient who seems to be a mess all the time. Is that often a normal history for personality disorders and/or anxiety?

                                                But that sounds like it's right out of some textbook!!! Why have I never had a patient say those things? Most of the patients I see tend to say they have mood swings every 3 hours to every day with no functional gaps in between. They're never clear cut in terms of just manic/hypomanic periods and just depressive periods. There's always anxiety or anger on top of the mood problems and almost always there's a substance abuse problem. The patients I see almost never, and I mean almost never, will admit to a sexual indiscretion! Even if they have 6 kids from different partners... (They'll admit to poor money management but so does everyone, and chronically so.) The vast majority of my patients are permanently unemployed and do not accomplish things during their "up periods." (I can't even get patients to tell me what they do with their time when they're feeling normal.) And the depressed people I see can't sleep. They rarely sleep too much.

                                                Now that I think about it I don't think I have ever seen a textbook Bipolar II case in the outpatient clinic, and maybe not anywhere ever.



                                                Why is lithium monitoring so inconvenient? How often do you need to see them vs. a patient on atypicals?

                                                More often at first just to make sure you have the right labs, and are monitoring the level until it's therapeutic but not toxic.

                                                I'm not saying an atypical is better -- I was just saying lithium is more complicated. Also, if the patient fails their "trial" of lithium, they'll forever say that they tried it and they didn't work. But you have to make sure it's a real trial.

                                                Another thing is this--if the patient gets renal problems from Lithium, the MD who prescribed the lithium is responsible for addressing that (i.e. stopping Lithium). If a patient gets metabolic syndrome from Seroquel, it seems like nothing ever gets done. From your perspective, Lithium might actually be an easier choice...
                                                 

                                                Perrotfish

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                                                  But that sounds like it's right out of some textbook!!! Why have I never had a patient say those things? Most of the patients I see tend to say they have mood swings every 3 hours to every day with no functional gaps in between. They're never clear cut in terms of just manic/hypomanic periods and just depressive periods. There's always anxiety or anger on top of the mood problems and almost always there's a substance abuse problem. The patients I see almost never, and I mean almost never, will admit to a sexual indiscretion! Even if they have 6 kids from different partners... (They'll admit to poor money management but so does everyone, and chronically so.) The vast majority of my patients are permanently unemployed and do not accomplish things during their "up periods." (I can't even get patients to tell me what they do with their time when they're feeling normal.) And the depressed people I see can't sleep. They rarely sleep too much.

                                                  To be fair, I have only ever gotten a history like that as a pediatric Intern talking to 16-20 year olds in a fairly affluent patient population, and even then you're right that there was usually a baseline anxiety issue, though it was sometimes a highly functional baseline anxiety. I've only gotten a history as clear as the one I gave above twice in my entire Intern year ( and one of the two times the patient was specifically asking to be evaluated for bipolar disorder). And you're right that when I was in medical school talking to adults it was never even that close to simple. Maybe the trick is to find some way to screen them before they get old enough to self medicate? I wonder if anyone has ever tried to develop a true screening exam for biplar sympoms in the Pediatric population. At the very least something like the Vanderbilt forms for ADHD?

                                                  Or maybe I'm just leading/overreading my patients, and y'all right that they're crazy in entirely different ways. Wouldn't be the first time.
                                                   
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                                                  SuperSoccer19

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                                                    Out of curiosity, how do you guys in the psych community feel about GPs managing bipolar disorder? Does ever bipolar patient need a psych referral or can 'simple' type 2 bipolar be managed by a GP in the office like depression? If it does need psych management should a GP give a med to bridge the patient until psych eval or leave it alone? When we do start a med, which one is best to start on? Is Lithium generally a good choice?

                                                    Parrotfish, I know you practice in the military and I have not read all the replies above. I also know I've either responded negatively or rolled my eyes at a lot of your premed posts, but I am responding seriously here. For a lot of reasons, if you suspect there might be a bipolar pic in an active duty patient I would recommend a referral to psych for a few reasons. 1. most MTFs actually have shrinks available to do an evals, unlike some remote rural areas that don't 2. the diagnosis often affects military career. Bipolar disorder--even II is a boardable condition, Meanwhile, borderline traits--which often overlap with Bipolar II is an ADSEPable disorder if it interferes with service. Even among psychiatrists there is disagreement in regards to the diagnosis and all branches have different opinions on this matter.

                                                    If you are strictly talking about dependent children, then go to your comfort level, but don't be afraid to curbiside. Never a bad idea to get an extra set of eyes.

                                                    I see nothing wrong with a PCM who has experience with this managing the condition, but at the same time make sure you recognize it when you see it. If not it opens the door for misdiagnoses, getting the run around, or merely driving the provider to want to start cutting as a coping technique.

                                                    Even though I may come across as condescening on SDN I am actually very approachable in the real world and if you are sent to GMO land and need a navy psych back up feel free to contact me.

                                                    Edit: even if you are not sent to GMO land and need this info for patients don't hesitate to contact me, feel free to do so, although I am not a child psychiatrist
                                                     
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                                                    Psychiatrized

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                                                      1) GPs/PCPs are miserable at accurately diagnosing bipolar disorder. They just don't have the time to do a proper interview and rely on checklists and yes/no questions. Anyone they think is bipolar should be referred to a trained psychiatrist for evaluation. This is a pet topic I have been researching and I have been quite appalled to see the misdiagnosis rates.
                                                      2) They are uncomfortable and unfamiliar with mood stabilizers in my experience and prefer psych to be in control of them.
                                                      3) They freak out whenever someone complains of a symptom or seems not well controlled and throw meds at it leading to lots of polypharmacy - most patients don't magically respond to the first med regimen they get, tweaking things to work well is the art that a psychiatrist practices.

                                                      Psychiatry is a 4 year residency, enough psychiatrist suck at their jobs that we don't need PCPs playing psychiatrist. When I end up getting these patients they are usually a hot mess.
                                                       
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                                                      notdeadyet

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                                                        As for lithium, the inconvenient part is getting the levels as you titrate to therapeutic dose....that is typically going to require more than 1 level today after initiation. Much much more inconvenient to monitor than atypicals.
                                                        Yes, the "inconvenience" of Lithium.

                                                        The reason many psychiatrists will opt for atypicals rather than Lithium is much more to do with the extra steps required of them rather than for the benefit of the patients. Ordering Lithium requires a handful of labs and a few follow-ups as you get to the right dose. Then it's periodic monitoring done with a blood test.

                                                        But many psychiatrists will instead opt to treat with antipsychotics not because their shown to be more effective (definitely not for maintenance therapy) but because they feel that you don't have to order labs to follow up on (psychiatrists are not always great about following up on metabolic effects). Never mind that with the antipsychotics prescribed for bipolar patients tend to gain weight, often significant amounts (as in 20-40 lbs). Never mind that Lithium is shown to be protective vs. suicide, the big fear with bipolar patients.

                                                        The "inconvenience" of Lithium is a pet peeve of mine. The use of Lithium is more often limited by the laziness of the psychiatrist than the effective use of the drug.
                                                         

                                                        notdeadyet

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                                                          For a lot of reasons, if you suspect there might be a bipolar pic in an active duty patient I would recommend a referral to psych for a few reasons.
                                                          Big time agreement. Military pediatricians should not be diagnosing, let alone initiating treatment, for bipolar disorder. It can have big repercussions for those serving and bipolar disorder in children is challenging to diagnose and can often lead to unnecessary medicating with devastating side effects. If you suspect bipolar disorder, refer out.
                                                           

                                                          Psychiatrized

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                                                            Yes, the "inconvenience" of Lithium.
                                                            The "inconvenience" of Lithium is a pet peeve of mine.

                                                            True that! I hate seeing patients stabilized on Li as inpatients taken off by their psychiatrists or becoming toxic or subtherapeutic due to lack of monitoring. Being able to manage these drugs is part of being an effective psychiatrist.
                                                             

                                                            heyjack70

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                                                              there is one big practice in town who throws out tons of cyclothymic d/o diagnosis....whatever that is supposed to be.

                                                              I read a 'Current' article (which I found in between ads for Risperdal Consta) talking about the ultra rapid cycling, and ultra-ultra rapid cycling bipolar (aka ultradian bipolar). They were talking about patients having mood cycles within the course of day...and then there are folks saying bipolar and borderline PD are a spectrum, with borderline PD being the most rapid cycling bipolar you can get. I don't buy it...

                                                              So if bipolar and schizophrenia are a spectrum...then if you follow this to it's conclusion...schizophrenia and borderline PD are on opposite ends of some spectrum of mental illness. I know this is just somebody's way of making sense of the symptoms we see.

                                                              I think it's also a way to justify treating borderline with bipolar/schizophrenia drugs and not doing or referring patients to therapy.
                                                               

                                                              vistaril

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                                                                I read a 'Current' article (which I found in between ads for Risperdal Consta) talking about the ultra rapid cycling, and ultra-ultra rapid cycling bipolar (aka ultradian bipolar). They were talking about patients having mood cycles within the course of day....

                                                                to the extent that that is occuring, these people are almost certainly in a mixed episode......I see mediocre psychiatrists miss that a lot(ie label someone as ultra rapid cycling and missing the bigger picture which that this is a mixed episode)
                                                                 

                                                                Perrotfish

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                                                                  I'd like to thank everyone on this thread, the answers have been very helpful. So to review what I've gotten:

                                                                  1) To the question of whether a 'classic' bipolar type II is safe to diagnoses and/or manage in an outpatient PCP clinic without psych referral the answer seems to be a resounding no. I got a lot of good info about possible confounding diagnoses, guess I'll be reading more.

                                                                  2) To the question of whether to start a mood stabilizer to 'bridge' a patient who is refered to psych but who can't get in for a few months the answer seems to be a 3:1 ratio of no to yes, so I guess I'll stick with no on that as well. I did think it was interesting to hear the poster say that the possibility of 'flipping' a suspected but undiagnosed biopolar patient into mania with a trial of SSRIs might not be a huge deal, considering what a life ending scenario that is on every medical school exam. Still I'll probably continue to shy away from SSRIs if a patient gives me a history that I think is consistent with mania.

                                                                  3) It was interesting to hear the debate on which mood stablizer to start, even if I'm not the one starting them. I've seen a LOT of patients on atypicals with really severe metabolic syndrome, maybe I'll start making more of an active effort to talk to psych and get them switched to lithium.

                                                                  4) As to the question of what to do with patients who cannot see psych (such as the uninsured) I still feel like I don't have a clear answer in terms of managing them myself with mood stabilizing vs ignoring them vs trying to manage them with more 'typical' drugs.. However as another poster pointed out I'm currently at the start of a fairly long military contract and unemployed civilians are a problem that are at least several years away and may never be a problem in my lifetime. So I will cross that bridge when I come to it.
                                                                   
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                                                                  digitlnoize

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                                                                    Yes, the "inconvenience" of Lithium.

                                                                    The "inconvenience" of Lithium is a pet peeve of mine. The use of Lithium is more often limited by the laziness of the psychiatrist than the effective use of the drug.

                                                                    Agreed. What about freaking Coumadin?!? Now THAT is an inconvenient titration, yet PCP have no problem with that.

                                                                    My EZ PCP-friendly formula would be:

                                                                    1. "Traditional" bipolar with manic and depressive phases, or more depressive phases = Lithium
                                                                    2. "Manic" bipolar with few depressive episodes = Depakote.
                                                                    3. Anything else, or those are contraindicated = Refer.
                                                                     

                                                                    michaelrack

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                                                                      michaelrack

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                                                                        Agreed. What about freaking Coumadin?!? Now THAT is an inconvenient titration, yet PCP have no problem with that.

                                                                        My EZ PCP-friendly formula would be:

                                                                        1. "Traditional" bipolar with manic and depressive phases, or more depressive phases = Lithium
                                                                        2. "Manic" bipolar with few depressive episodes = Depakote.
                                                                        3. Anything else, or those are contraindicated = Refer.

                                                                        That's reasonable for bipolar 1, though I think either depakote or lithium are acceptable options for #'s one and two above.

                                                                        For bipolar II, lamictal or depakote +/- SSRI
                                                                         
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