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Bipolar disorder in general practice: challenges and opportunities

Leon Piterman, Kay M Jones and David J Castle
Med J Aust 2010; 193 (4): S14. || doi: 10.5694/j.1326-5377.2010.tb03891.x
Published online: 16 August 2010

Abstract

Initiatives to improve the management of high-prevalence disorders in general practice have been extensive, but the same cannot be said for the mental health disorders which are of lower prevalence, such as schizophrenia and bipolar disorder. Nevertheless, many general practitioners are involved in providing continuing care for a large number of people affected by chronic mental illnesses.1

There is general acknowledgement that managing acute exacerbations of chronic mental illness — acute psychoses or severe exacerbation of a major depressive disorder in particular — may be beyond the realm of most GPs (with the exception of some working in rural and remote areas).2 However, GPs are involved in the shared care of patients with chronic mental illness, particularly those who have common comorbid psychiatric conditions (such as anxiety and depression) and comorbid physical disease. Psychiatrists are particularly reliant on GPs to monitor and treat a range of medical conditions apart from the psychiatric condition that necessitates specialist care.

Bipolar disorder falls into this category. Other articles in this Supplement describe the nature and management of bipolar disorder. Here, we focus on the very specific challenges that face GPs who manage patients with bipolar disorder, and examine opportunities that exist within the current health care system in Australia to improve quality of care for these patients in general practice settings. We also provide information on what is new in the management of this condition as it pertains specifically to general practice.

Prevalence and management of bipolar disorder in general practice

While the community prevalence of bipolar spectrum disorders is 4%–5%,3 and this group of disorders is the sixth leading cause of disability, the true prevalence of bipolar disorder in general practice is unknown. Based on the most current available Bettering the Evaluation and Care of Health (BEACH) data (2007–2008),4 36 of 3374 GP–patient encounters sampled included a history of bipolar disorder; this represents 1.1% (95% CI, 0.6%–1.5%) of the sample. The reasons for the lack of accuracy of GP data relate to a number of factors, which include: the failure to diagnose the disorder altogether, or incorrectly diagnosing the disorder as unipolar depression; poor and erratic attendance of patients with the condition; presence of comorbid psychosocial problems, particularly those related to drug and alcohol, that may override the diagnosis of bipolar disorder; and limitations associated with methods of collecting the BEACH data.

The management of bipolar disorder in general practice is compromised by a number of factors, including problems with differential diagnosis, dual diagnosis, physical comorbidity, erratic attendance and poor compliance with treatment. Differential diagnosis may include psychiatric disorders, namely unipolar depression, anxiety states, drug and alcohol dependence, attention deficit hyperactivity disorder, personality disorders and eating disorders. Physical disorders presenting as bipolar disorders include: hyperthyroidism and hypothyroidism, acquired brain injury, cerebrovascular accidents, dementia, and multiple sclerosis. Diagnosis may therefore be delayed, particularly when there is late onset or atypical onset of bipolar disorder.

Although it is common for GPs to provide repeat prescriptions, supervise use, encourage adherence and periodically check blood levels of medications,1 it is unlikely that they would commence pharmacological treatment for bipolar disorder, particularly during an acute phase of mania or hypomania. Experience with the use of atypical antipsychotics in general practice may therefore be limited, and regimens involving combined use of mood stabilisers and antidepressants may be continued but seldom commenced by GPs.

Nevertheless, GPs have an important role in promoting and overseeing adherence with psychotropic medication in this group of patients, who commonly cease medications once they are stable, often in the misguided belief that levels of hypomania are more acceptable than “normality”. It is therefore important for GPs to encourage patients to accept the chronic and relapsing nature of this disorder, to optimise adherence with treatment.

Patients with bipolar illness are prone to seek alternative remedies to try to stabilise mood or alleviate symptoms of depression, or to generally enhance wellbeing. This may lead to difficulties in interpersonal relationships between GPs and patients, particularly if the GP is not sufficiently patient-centred or is judgemental about “health provider shopping”. Also, patients with bipolar illness often search the internet for alternative explanations for their symptoms or to seek alternative remedies. Negative attitudes to these patients and a failure to undertake motivational interviewing during the course of a consultation, as well as failure to apply the principles of gradual behaviour change, may result in patients becoming alienated from general practice, therefore compromising continuity of care.

Comorbidity

Patients with bipolar disorder may be prone to a range of other psychological, social and physical problems (see Parker).11 GPs providing continuity of care for these patients need to be vigilant to detect and manage comorbidity as part of the overall management plan.6,12,13

Drug and alcohol dependence

Drug and alcohol dependence are common in patients with bipolar disorder.4 Patients suffering from bipolar depression may seek to elevate their mood with stimulants such as amphetamines; others may use various “designer drugs” and, on occasions, become addicted to cocaine or heroin. Indeed, drug dependence may be a manifestation of an underlying bipolar disorder; it is therefore essential for GPs with patients who have a history of drug dependence to question these patients appropriately about past episodes of hypomania or a clinical pattern that is suggestive of cycling between poles or bipolar depression.

Along with illicit drug dependence, alcohol dependence is a common accompaniment of bipolar disorder; it may take the form of binge drinking, particularly among adolescents and young adults. Again, GPs who treat this patient population need to enquire about symptoms that are suggestive of bipolar disorder.4,16

Other psychological comorbidities include personality disorders, eating disorders and general disruption of social and intimate relationships.

Physical comorbidities

Patients with bipolar disorder have an increased cardiovascular risk; this is associated with the condition itself,17 as well as obesity related to poor diet and some antipsychotic and mood-stabilising medications (see Malhi et al).18 Thus, patients with bipolar illness require regular checks for diabetes and hyperlipidaemia, along with the usual checks of blood pressure and body mass index. Patients taking lithium require regular renal function and thyroid function tests. In cases where illicit drug use is a problem, checks for hepatitis B, hepatitis C and HIV should also be carried out.

There is also a higher incidence of cigarette smoking among patients with chronic mental illness and this exacerbates the cardiovascular risk.6 Mortality and morbidity associated with physical conditions are therefore higher in this group of patients, who find lifestyle change difficult. To manage lifestyle change and promote wellbeing, GPs need to take advantage of their long-term relationships with these patients, particularly while these patients are in remission from their bipolar illness.

Conclusions

Despite many of the difficulties mentioned here, opportunities exist for GPs to play a vital and ongoing role in the management of patients with bipolar disorder. Taking advantage of their unique position in the provision of long-term continuing community-based care, GPs who can establish a working relationship with patients with bipolar illness may be well placed to monitor patient compliance with medication, facilitate patient self-monitoring (using patient-held diaries), detect exacerbation of symptoms (hypomania or depression) at an early stage, and carefully monitor related physical illness.

As in any chronic condition, team-based care is essential, as is patient education and self-management.22,23 Under current funding arrangements related to chronic disease management and mental health care plans, GPs are better rewarded financially for managing patients with bipolar illness than they have been in the past, and need to be familiar with the benefits of using a “chronic disease model” approach for patients with bipolar illness.

GPs can also play an integral role in supporting and engaging family members of patients with bipolar disorder — this includes those with direct involvement in patient care and extended family members — as well as community members and agency staff, all of whom can assist in providing patient care.

  • Leon Piterman1
  • Kay M Jones2
  • David J Castle3,4

  • 1 School of Primary Health Care, Monash University, Melbourne, VIC.
  • 2 Department of General Practice, Monash University, Melbourne, VIC.
  • 3 Department of Psychiatry, University of Melbourne, Melbourne, VIC.
  • 4 St Vincent’s Hospital, Melbourne, VIC.


Correspondence: leon.piterman@monash.edu

Competing interests:

Leon Piterman has received funding and payment from AstraZeneca for membership on an advisory board for GP education, developing a bipolar education program for GPs, developing an AstraZeneca online education program and travelling to Sydney and Stockholm for meetings. Kay Jones has received funding and payment from AstraZeneca for developing a bipolar education program for GPs and developing an AstraZeneca online education program. David Castle has provided consultancy services to AstraZeneca, Pfizer, Eli Lilly, Lundbeck and Boehringer, and has received research grants, honoraria, speaker fees and funding to attend scientific conferences from AstraZeneca, Pfizer, Eli Lilly, Lundbeck and Boehringer.

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