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DIAGNOSIS AND TREATMENT OF MENTAL DISORDERS: Pitfalls for Primary Care Physicians in Treating Bipolar Disorders and Schizophrenia

OVERVIEW

Patients with mental illnesses are more likely to present to their primary care physician than to a psychiatrist. This poses many challenges to the primary care physician, specifically when diagnosing bipolar I (mania and depression), bipolar II (hypomania and depression), bipolar not otherwise specified (NOS), and schizophrenia (Wang, 2005). Pitfalls to caring for patients with mental illness include the diagnosis or screening process, treatment with new generation atypical antipsychotics, and adherence to treatment.

A study evaluating the screening of patients with mental illnesses by primary care physicians recorded evidence of depression in 47% of patients who carried the diagnosis of bipolar disorder. In some situations, comorbid diagnoses may occur; in the same study, 68% of those who were diagnosed with bipolar disorder also had a current diagnosis of depression, anxiety, or a substance abuse disorder (Das, 2005). The misdiagnosis of depression in a patient who actually has bipolar disorder can lead to inaccurate monotherapy with antidepressants, costly treatment, increased hospitalizations, and risk of suicide (Bauer, 2005). Attention-deficit/hyperactivity disorder (ADHD) has been a diagnostic challenge for pediatricians, who may misdiagnose children who have prodromal symptoms of bipolar disorder. Persons with comorbid ADHD and bipolar disorder show symptoms 5 years earlier than persons with bipolar disorder alone (Nierenberg, 2005). Anxiety disorders, including panic disorder and generalized anxiety disorder, may also be confused with bipolar disorder. Bipolar disorder can present in a state of refractory anxiety, and the symptoms of schizophrenia can overlap with obsessive compulsive symptoms. Personality disorders in the cluster B category (eg, borderline, histrionic, narcissistic) can be associated with bipolar disorder and can exacerbate the severity of episodes.

Bipolar disorder and schizophrenia can present in similar ways. The psychotic symptoms of mania can be mistaken for schizophrenia, and the symptoms of bipolar depression can be mistaken for the symptoms of unipolar depression (Citrome, 2005). Symptoms of bipolar disorder or schizophrenia that would otherwise be obvious can be muted or absent in the presence of substance abuse. It is not uncommon for persons with mental illnesses to self-medicate with drugs and alcohol. Studies have identified substance abuse in 60% of patients with bipolar I and 50% of patients with bipolar II (Sonne, 1999). In a study of patients presenting for a first episode of schizophrenia, patients with schizophrenia were twice as likely to have experienced a substance abuse disorder as were control subjects (Bühler, 2002).

Using the criteria from the revised Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-R) for the diagnosis of bipolar I and bipolar II, the lifetime prevalence is around 1%. When accounting for the less obvious symptoms and using broader criteria for bipolar spectrum disorders, the lifetime prevalence rates increase to 2.8-6.5% (Bauer, 2005).

The disability related to social withdrawal and negative symptoms characterize the prodromal period of schizophrenia, which may develop several years before the onset of psychotic symptoms (Hafner, 1999). This prodromal period, which often begins in adolescence, can last up to 5 years before treatment is initiated for schizophrenia. Up to 90% of schizophrenic patients have described changes in their perceptions and beliefs, decline in mood, and changes in behavior prior to psychosis (Yung, 1996).

SCREENING

Early diagnosis and intervention can influence the overall outcome of persons with mental illness (Loebel, 1992). Screening in the primary care setting is best achieved by performing a complete history and physical examination, with specific focus on previous episodes of mania and family history of mental illness. Given the stigma associated with mental illness, patients may omit a history of mania. Screening tools can be helpful to screen for bipolar disorder in those who are being treated for depression, as evidenced by Hirschfield’s 2005 study at the University of Texas at Galveston. In this study, the Mood Disorders Questionnaire (MDQ) and the Structured Clinical Interview for DSM-IV Disorders (SCID) were used as screening instruments in the primary care setting for patients with depression; they identified bipolar disorder in 21.3% of patients enrolled in the study. Roughly 60% of those patients had no history of being diagnosed with bipolar disorder. Patients with bipolar I were more likely than those with bipolar II to acknowledge a history of bipolar disorder. This result is most likely related to the different experiences in social and occupational impairment between bipolar I and bipolar II. Of those who did not acknowledge a history of bipolar disorder, 21.9% were diagnosed with bipolar I, bipolar II, or bipolar NOS (Hirschfeld, 2005).

Several screening tools are available for the primary care setting, including the following:

• Structured Clinical Interview for DSM-IV Disorders (SCID)
• Primary Care Evaluation of Mental Disorders (PRIME-MD)
• Early Signs Questionnaire (ESQ)
• Present State Examination (PSE-9)
• Achenbach System of Empirically Based Assessment (ASEBA), which includes the Adult Behavior Checklist (ABCL) and the Adult Self-Report (ASR)

The SCID, ABCL, and ASR are computerized, and the ABCL and ASR can be completed online prior to or after a visit. These screening tools can be helpful in the initial assessment of new patients or those with recent mental status changes. Some screening tools are more specific for bipolar disorder and schizophrenia, including the 13-item self-report MDQ or the Bipolar Spectrum Diagnostic Scale (BSDS). These tools can be helpful when trying to differentiate a bipolar disorder spectrum disorder (Hirschfeld, 2004; Nassir, 2005). To help identify schizophrenia in the prodromal state, the Comprehensive Assessment of At-Risk Mental State (CAARMS), the Structured Interview of Prodromal Symptoms, and the 40-item Schizophrenia Prediction Instrument – Adult Version (SPI-A) may be helpful (Yung, 2003). Although these screening tools aid in the diagnosis, positive results do not constitute a diagnosis.

TREATMENT

In 2005, the Texas Implementation of Medication Algorithms (TIMA) was updated to address the latest research published for the many new compounds used to treat acute bipolar I disorder that presents as hypomanic/manic, mixed, and depressed episodes. The algorithm addresses treatment options for the hypomanic/manic and mixed episodes in 4 stages (Suppes, 2005).

• Stage 1a - Monotherapy for the euphoric state using lithium (Li), valproic acid (VPA), aripiprazole (ARP), quetiapine (QTP), risperidone (RIS), or ziprasidone (ZIP); monotherapy for mixed states using VPA, ARP, RIS, or ZIP.
• Stage 1b - Monotherapy alternatives to nonresponse in Stage 1a, including olanzapine (OLZ) or carbamazepine (CBZ)
• Stages 2 and 3 - Two-drug combinations of the above-mentioned agents
• Stage 4 - Electroconvulsive therapy, clozapine alone, or a 3-drug combination

• Stage 1 - Lamotrigine (LTG) with or without an antimanic agent
• Stage 2 - QTP or olanzapine/fluoxetine combinations (OFC)
• Stage 3 - Two-drug combinations of Li, LTG, QTP, or OFC
• Stage 4 - Li, LTG, QTP, OFC, VPA, or CBZ, along with a selective serotonin reuptake inhibitor (SSRI), bupropion, venlafaxine, or electroconvulsive therapy
• Stage 5 - MAOIs, tricyclics, pramipexole, other atypical antipsychotics, oxycarbamazepine, inositol, stimulants, and thyroid supplements

Olanzapine and carbamazepine are considered monotherapy alternatives when concerns exist for the presence or development of obesity and other metabolic disorders.

Because of the metabolic and other health concerns associated with atypical antipsychotics, monitoring guidelines have been established by the American Diabetes Association (ADA) and the Mount Sinai Conference (ADA, 2004; Marder, 2004). These guidelines include a baseline screening for family history of metabolic disorders, obesity, hypertension or cardiovascular disease, body mass index, waist circumference, blood pressure, and lipid profile.

ADHERENCE

Even with accurate diagnosis of bipolar disorders and the less detrimental adverse effects and greater tolerability of atypical antipsychotic medication, nonadherence is still a major concern. After the initiation of treatment for bipolar disorder, up to 50% nonadherence can occur because of several factors, including denial of illness, to which 20% of nonadherence is attributed. Other common reasons for nonadherence include the adverse effects of medication, fear of addiction to the medication, or the stigma associated with mental illness. The stigma or fear of having a mental illness is seen as a reason for nonadherence more often in African American patients than in white patients (Fleck, 2005). In a study published in 2002, 32% of patients acknowledged missing over 30% of their prescribed medication (Scott, 2002). Nonadherence is more often due to a patient’s behavior and attitudes toward mental illness and psychotropic medications than it is due to adverse effects (Scott, 2002). This suggests the need to provide psychoeducation to every patient at the time of diagnosis and throughout the follow-up.

References

American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004;27:596-601.

Bauer M, Pfennig A. Epidemiology of bipolar disorders. Epilepsia 2005;46 Suppl4:8-13.

Buhler B, Hambrecht M, Löffler W, et al. Precipitation and determination of the onset and course of schizophrenia by substance abuse--a retrospective and prospective study of 232 population-based first illness episodes. Schizophr Res 2002;54(3):243-51.

Citrome L, Goldberg JF. The many faces of bipolar disorder. How to tell them apart. Postgrad Med 2005;117(2):15-6, 19-23.

Das AK, Olfson M, Gameroff MJ, et al. Screening for bipolar disorder in a primary care practice. JAMA 2005;293(8):956-63.

Fleck DE, Keck PE, Corey KB, Strakowski SM. Factors associated with medication adherence in African American and white patients with bipolar disorder. J Clin Psychiatry 2005;66(5):646-52.

Hafner H, Loffler W, Maurer K, et al. Depression, negative symptoms, social stagnation and social decline in the early course of schizophrenia. Acta Psychiatr Scand 1999;100:105-18.

Hirschfeld RM. Bipolar depression: the real challenge. Eur Neuropsychopharmacol 2004;14 Suppl 2:S83-8

Hirschfeld RM, Cass AR, Holt DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract 2005;18(4):233-9.

Loebel AD, Lieberman JA, Alivir JM, et al. Duration of psychosis and outcome in the first-episode of schizophrenia. Am J Psychiatry 1992;149:1183-8..

Marder SR, Essock SM, Miller AL, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004;161:1334-49.

Nasr S, Popli A, Wendt B. Can the MiniSCID improve the detection of bipolarity in private practice? J Affect Disord 2005;86(2-3):289-93.

Nassir Ghaemi S, Miller CJ, Berv DA, et al. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord 2005;84(2-3):273-7.

Nierenberg AA, Miyahara S, Spencer T, et al. Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry 2005;57(11):1467-73.

Scott J, Pope M. Nonadherence with mood stabilizers: prevalence and predictors. J Clin Psychiatry 2002;63(5):384-90.

Sonne SC, Brady KT. Substance abuse and bipolar comorbidity. Psychiatric Clin North Am 1999;22:609-27.

Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the algorithms for the treatment of bipolar I disorder. J Clin Psychiatry 2005;66:870-886.

Wang PS, Berglund P, Olfson M, et al. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:603-13.

Yung AR, McGorry PD. The initial prodrome in psychosis: descriptive and qualitative aspects. Aust N Z J Psychiatry 1996;30:587-99.

Yung AR, Phillips LJ, Yuen H, et al. Psychosis prediction: a 12-month follow-up of a high-risk ("prodromal") group. Schizophr Res 2003;60:21-32.