Monday, August 15, 2005

Bipol*r disease, unrecognized epidemic or drug company hype

Several months ago at a local internist's club meeting we had a presentation by a psychiatrist about bipolar disorder. He is a co-director of a mood disorder program at a local medical school. (yes, it was sponsored by a pharmaceutical company)The take home messages appeared to be, it is far more common than generally recognized, suspect it if a young person is "depressed" or has a history of depression as a teenager, or has ' racing thoughts" and some of these newer atypical antipsychotic drugs are useful.In 35 plus years of practice, in one form or another, I have probably been aware of less than 10 patients with manic-depressive disorder.The other five internists at my table expressed a similar experience. I do realize that these patients can be very difficult to manage and may impose considerable burden on their family and friends. Typically,internists do not come home at the end of the day saying "another day, another 4 bipolars in the office". Ads from a major drug company (Astr*Zen**ca) tell us that 49% of people with bipolar disorder are undiagnosed and send the reader to a web site for a "validated screener" This screen is 13 questions ending with "have you ever been told you have bipolar disease?" It is said to be based on a paper by PM Hirschfield in Am. J. Psy 2000: 157 (11) 1873- 1875).That web site then can send you to a dosing schedule for an atypical antipsychotic manufactured by that drug company.I cannot imagine an internist or FP doctor taking on the assignment of treating a bipolar patient with a relatively new drug which it is very likely that he has only recently heard of. At the meeting re bipolar, a number of the internists were surprised to learn that if a patient with bipolar disorder is clinically depressed that the treatment is not an antidepressant but a mood stablizer. This might give you some hint as to the general level of expertise an internist has in this area.
But I cannot but wonder that if we see a obviously depressed patient in the office maybe we should use that or some other screen for bipolar and if there is any hint of it on the answers get the patient off to a psychiatrist rather than reaching for the SSRI prescription.
If any psychiatric bloggers out there could offer a puzzled internist some thoughts on this I would appreciate it.