Text below adapted from The patient who has mania in Psychiatry in primary care by Roger S McIntyre, (CAMH, 2019).
Bipolar disorder is a prevalent, progressive condition associated with inter-episodic dysfunction. People with bipolar disorder often use primary care services, but there is typically a long delay between symptom onset and correct diagnosis and treatment. Patients are more likely to present in primary care settings during an episode of depression than hypomania or mania, so they are often misdiagnosed with unipolar depressive disorder (Das et al., 2005). This means that many patients with bipolar disorder receive inappropriate treatment (McIntyre & Konarski, 2004).
Most people with bipolar disorder have other psychiatric and medical comorbidities. For example, anxiety and substance use disorders are common and often obscure the underlying mood disorder. The most common comorbid medical condition is overweight/obesity, which often presents with other features of the metabolic syndrome (McIntyre et al., 2006). Comorbidity is often associated with greater illness severity, which can lead to a less optimal response to treatment.
Despite the challenges, primary care practitioners are in a unique position to screen for, diagnose and treat bipolar disorder.
What is Reasonable to Expect of a Primary Care Practitioner?
- Screen for and establish a diagnosis of bipolar disorder:
- Screen for secondary causes of mania.
- Rule out substance use disorder by taking a history and, if necessary, conducting toxicology screening.
- Provide psychoeducation and offer psychosocial/behavioural strategies.
- Begin treatment with antimanic pharmacotherapy.
When to Refer to a Specialist
- Hospital admission required
- Questions about a patient’s capacity to make treatment decisions
- Unfamiliarity with the use of bipolar medications
- Complex and uncertain clinical presentations
- Diagnostic dilemmas
- Treatment-resistant mania
- Problematic adverse events and safety concerns with medication
- Electroconvulsive therapy is being considered