Transcript:
TM: Hello and welcome. I am Tina Matthews-Hayes, a dual-certified family and psychiatric nurse practitioner working in the psychiatric setting.
TB: And I am Tricia Bursnall. I am also a dual-certified family and psychiatric mental health nurse practitioner working at a federally qualified health center, which is considered a primary care practice. Tina and I are glad you joined us today for our discussion on the positive impact that a collaboration between primary care practices and psychiatric mental health nurse practitioners, or PMHNPs, can have on patient care, particularly on improving accuracy in the diagnosis of bipolar disorder, or as we will call it, BP, in primary care settings.
TM: Tricia, as we both know, and as we both see everyday, bipolar is a mood disorder characterized by a spectrum of mood states. And it can manifest as manic, hypomanic, depressive, and mixed episodes. Bipolar is also a complex disorder that can have a significantly negative impact to the patient’s quality of life.1 It is associated with high rates of comorbidities, including anxiety and substance abuse disorders, increased risk of suicide, functional impairment, metabolic syndrome, and cardiovascular diseases.2 Therefore, achieving an accurate and timely diagnosis is critical in the management of bipolar disorder.
TB: For sure, Tina. I believe one of the biggest challenges we, as mental healthcare practitioners, face in achieving a diagnosis of bipolar is really trying to make that accurate diagnosis. Typically, patients with bipolar present during a depressive episode, so symptoms are identical to those of major depressive disorder, or MDD.3,4 On the other hand, many BP patients who are experiencing manic or hypomanic episodes may not recognize that they should seek help with their symptoms. This results in a significant proportion of bipolar patients being initially misdiagnosed with MDD – 60%, in fact, according to 1 research survey of 600 bipolar patients.5
TM: So, Tricia, those numbers always stop me in my tracks because we know that the high rate of misdiagnosis of bipolar can result in a considerable delay for those patients in receiving the appropriate treatment that they need. In that same study you mentioned, bipolar patients reported receiving an average of 3.5 inaccurate diagnoses before receiving an accurate diagnosis of bipolar disorder.5 So, on average, Tricia, it can take up to 5 to 10 years after the initial onset of symptomology for bipolar patients to receive an accurate diagnosis.6 So, I often ask myself, Tricia, where else in medicine is it okay to say that it’s gonna take 5 to 10 years to correctly diagnose you?
TB: That’s so true, Tina. It is such a long period of time. And that delay in the diagnosis and management of BP can lead to poor patient outcomes, including increased morbidity, and reduced quality of life, impaired cognition and functioning, and increased risk of recurrence.1,7,8 Additionally, when bipolar patients are misdiagnosed with MDD, they are often initially treated with antidepressant monotherapy.8 That treatment is really not recommended for patients with bipolar, and in fact, it can lead to an affective switch from a depressive state to triggering mania or hypomania.9
TM: And, Tricia, I can understand that because when they are presenting as depressed, you think we need to treat the depression. But, oftentimes, these patients are started on antidepressant as monotherapy and their symptoms don’t improve, then the patients end up receiving multiple lines of treatments, which then leads to polypharmacy.10 To avoid consequences of misdiagnosed BP, it is critical that we, the healthcare providers, thoroughly evaluate each patient presenting with depressive symptoms to have a potential of a bipolar diagnosis.
TB: For sure, Tina. We know that primary care providers, or PCPs, are among the most front-line to our mental health patients, so it is particularly important that PCPs are able to appropriately screen for and recognize bipolar in this setting. In a large-scale study of over 3000 bipolar patients, fully 41% of those patients sought consultation from primary care. However, the same study reported that primary care practitioners incorrectly diagnosed or did not identify BP 78% of the time.11
TM: Again, Tricia, such an impactful point. So, while primary care practices may be where most bipolar patients seek help most, there is still significant room for improvement in making accurate diagnoses of bipolar in every single care setting, including primary care. So, what ways do you think we can improve the accuracy of bipolar diagnosis?
TB: I’m so glad you asked that, Tina. Because I believe one of the most effective ways is utilizing screening tools that can help primary care practitioners identify patients with probable bipolar.12 The American Psychiatric Association, or APA, recommends using validated screening tools to potentially detect BP in patients displaying symptoms of depression and irritability.13
TM: So, Tricia, we know that the APA recommends that we use the screening tools, but we also know that they are very underutilized. In a study implementing evidence-based practices for bipolar, only 15% of patients with depressive symptoms were screened for bipolar disorder.14 Interestingly, in another study, 82% of HCPs, or healthcare providers, reported using a major depressive screening tool, while only 32% reported using a bipolar screening tool.8
TB: Ah, that is a hard number to hear. Evidently, there is room for improvement. With that in mind, we would like to share with you the results of a quality improvement project that I was involved in. We evaluated the impact of collaboration between PCPs and PMHNPs on improving the knowledge on and increasing the practice of screening for bipolar disorder in a primary care setting.
Tina, I am super excited to talk to you about the results of this project. It was a 9-month quality improvement project conducted at 3 pilot clinics to screen for adult bipolar patients using the Rapid Mood Screener, otherwise known as the RMS. The patients had positive Patient Health Questionnaire, or PHQ-9, scores for MDD and no previous diagnosis of bipolar.15
TM: Yeah, Tricia, I was equally as excited to talk to you about this because I was an early adopter of the RMS screening tool. I have found it to be exceptionally beneficial since its publication. The RMS is a 6-item screening tool that was developed to screen patients that are diagnosed with MDD for the potential of bipolar. It consists of 3 items focused on depressive symptoms and 3 items focused on manic symptoms. The RMS is a useful screening tool in the primary care setting, as it can be completed by patients in under 2 minutes.8 So, therefore, I routinely suggest providers incorporate the questions into their existing patient interview format, which would have a minimal impact on their time utilization. Also, it can help HCPs to quickly identify patients who may have bipolar disorder and require further evaluation.
TB: Absolutely, Tina. I really agree that one of the characteristics of a good screening tool is that it can be administered easily and quickly, especially in a busy clinical setting.
TM: Absolutely, and in addition to it being a brief screening tool, the RMS is a reliable screening tool for bipolar I disorder. When patients respond “yes” to 4 or more questions, it indicates a positive screen for bipolar I disorder, which may require further evaluation. The RMS has a sensitivity of 88% and a specificity of 80%.16 Tricia, it’s important to note though that that screening tool has been validated in patients with bipolar I disorder, and not bipolar II disorder.
TB: That’s absolutely right, Tina. So, this quality improvement project to implement BP screening with the RMS was conducted at a federally qualified health center called Peak Vista Community Health Center in Colorado.15 The project was conducted to provide primary care providers with education on the use of the RMS, as well as on screening, diagnosing, and managing bipolar. Educational intervention was provided to the HCPs, and consisted of current clinical guidelines and information on FDA-approved bipolar medications, as well as a treatment algorithm and a handout outlining the approved medications. The education was delivered live in a group setting.15
TM: So, Tricia, correct me if I’m wrong, but from my understanding of your project, following the educational intervention, each clinic developed a workflow for screening for bipolar disorder using the RMS and then referring those patients to a psychiatric NP or PMHNP for diagnostic evaluation and consultation, if it was indicated.15
TB: That’s absolutely right, Tina. So, our goal for the project was in 3 parts: first, to increase the initial use of the RMS in adults with a positive PHQ-9 by 10%; second, to increase HCPs’ knowledge on the screening, diagnosis, and management of BP by 10%; and lastly, to help increase the accuracy of bipolar disorder referrals to those PMHNPs by 3% by the end of the project.15
TM: I also understand that in total, 32 providers received the education. So, in that group that consisted of 17 NPs, or nurse practitioners, 8 behavioral health providers, 4 physician assistants, or PAs, and 3 physicians.15 And, from what I understand, the improvements observed were significant.
TB: They really were, Tina. During that 9-month project, BP screening with the RMS increased from 1% before the educational intervention to 77% after. BP knowledge, which was measured by the increase in scores for surveys taken before versus after that educational intervention, increased by nearly 30%—from 63% before to 92% after.15
In addition, the accuracy of bipolar referrals, which was calculated by dividing the number of people who were referred from primary care for BP by the number of people who were determined to have a bipolar diagnosis after a psychiatric evaluation, increased by a third. So, from 33% before the educational intervention to 67% after. That was a 4-fold increase in the accuracy of the diagnosis of bipolar disorder after that educational intervention in the project.15
TM: Yes, Tricia, I would call that significant! So, Tricia, overall, the collaboration between HCPs increased from 18% in the first 3 months of your project to 63% at the conclusion of your project.
Additionally, this helped to accurately identify more patients with bipolar disorder. It’s interesting to note that from the results of this project, the accuracy of bipolar diagnosis increased with more consultations between primary care providers and the PMHNPs.15
TB: That’s absolutely right, Tina. I really believe it shows the important role that we as PMHNPs can play in facilitating the accurate diagnosis of mental health conditions, particularly bipolar, which may be really challenging to recognize in the primary care setting. The results of the quality improvement project that I was involved in underscore the importance of educational intervention and multidisciplinary collaboration on screening, diagnosing, and managing patients with bipolar.15
TM: Again, I completely agree with you. And in the theme of partnership, I have to say that I found this discussion about the positive impact of the collaboration between primary care providers and PMHNPs to be quite informative and empowering. This is such an important alliance that can potentially improve the patient journey for all of our patients with bipolar disorder. So, Tricia, thank you so much for joining me today to discuss this topic.
TB: Well, thank you, Tina. I really appreciate it. It’s been such a pleasure. And thank you, our listeners, for joining us on NP Psych Navigator!
