Psychiatrists Answer Questions on Depression, Bipolar Disorder in Primary Care Setting

Michael Ziffra, MD

Even for experienced clinicians, diagnosing bipolar disorder can be complicated. Since it’s a common disorder, affecting about 1% of the population, many people seek help through primary care.

Michael Ziffra, MD, Associate Professor, Department of Psychiatry, Northwestern University Feinberg School of Medicine, addressed common and uncommon presentations of bipolar disorder as well as advice regarding initial diagnosis and treatment strategies at Pri-Med West 2022.

Afterward, he was joined by Shirah Vollmer, MD, Clinical Professor of Psychiatry, David Geffen School of Medicine at UCLA, for an "Ask the Experts" segment where they addressed submitted questions about depression and bipolar disorder.

In her presentation "Beyond the SSRI: Treating and Managing Major Depression" Vollmer discussed challenges providers often face in a primary care setting when their patients aren't responding to SSRIs or other treatments.

Overcoming Limited Access to Psychiatric Care

Access to care is still something many patients and primary care providers struggle with in the field of psychiatry. A question raised by a PCP asked Ziffra how to compensate for the lack of specialists available, and if there’s a provider or resource that he taps into for support, especially when dealing with a complicated condition like bipolar disorder.

Ziffra said that developing a relationship with a pharmacist can be beneficial, especially for providers who may not have as much knowledge on medications used to treat these conditions. Vollmer suggests that providers tap into the knowledge of the specialists who are available, as a way to expand their own understanding of these conditions.

“My encouragement to you, in primary care,” she responded, “is to develop relationships with maybe 5 or 6 psychiatrists who are willing to see patients as a one time basis and give guidance about what to do.”

Transitioning Between Drug Classes

According to Ziffra, it’s helpful to have overlap in medications when transitioning from one drug class to another. The one exception he mentioned was sodium valproate (Valproic) and lamotrigine (Lamictal) because of the possibility to develop a life-threatening rash when these 2 anticonvulsants interact.

As a general rule, it’s not a great idea to stop mood stabilizers, he explained. But switching from something like lithium to sodium valproate, he used as examples, should be okay. Ziffra recommended a gradual transition by slowly coming off one and onto the other.

When a similar question was asked about treating depression and the best method to switch off of SSRIs, Vollmer said that aside from Prozac, all of these medications need to be tapered off. SSRIs in particular are “vulnerable to withdrawal effects” and the safest way to cease the use of the medication or switch it, is to gradually taper off.

Treatment Adherence is a Challenge with Bipolar Disorder

Ziffra explained that there are a couple of reasons as to why adherence to medication is a challenge for patients with bipolar disorder. The first reason he mentioned has to do with the treatments for bipolar disorder.

These medications are slightly more complex than those used to treat depression–they’re usually associated with more side effects, which require regular monitoring. Another time he finds adherence to be an issue with patients is during manic episodes.

“For people who have this sort of euphoria and hypomania, they like that,” Ziffra said. “They're more active, they’re more creative, and more productive and they want to get that back.”

Ultimately, he said, in order to promote adherence to treatment among his patients, Ziffra helps them develop an appreciation of the benefits of being on the medication. Pointing out examples of times when a patient was off their medication and it didn’t go well, or when they were on it and it did–even finding a treatment that’s more palatable for them–can help with motivation for adherence.

Vollmer’s advice included 2 interventional tasks, the first is to encourage the patient to get a weekly box for their pills so they have a “concrete representation” of the adherence practice. Then, she said, a close follow-up with the patient, whether it’s an appointment, phone call or texting.

The more communication between provider and patient, the more likely the patient will take their medicine, she said.