Separating the subtleties: Mental illness in primary care

Primary care physicians often face diagnostic challenges because of overlapping symptoms and the limited amount of time they have with each patient.

By Kathleen Phalen Tomaselli amednews correspondent — Posted Oct. 15, 2007

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Picture a patient throwing $100 bills around the waiting room, urging other patients, "take them, take them." His voice is loud; his affect, frenzied. Another image: The young man who keeps talking about Mr. Maloney. "Mr. Maloney says this, Mr. Maloney says that." Later, his girlfriend reveals that Mr. Maloney doesn't exist. Or what about the concerned mother who calls every day, demanding more of the physician's time. One day overtly complimentary; the next, visibly angry.

It's a familiar refrain of symptoms -- the histrionics, the mania, the auditory hallucinations, the unstable relationships -- common to such mental illnesses and disorders as bipolar, schizophrenia and borderline personality.

"The family doctor is likely to see these people first," says Sheldon Miller, MD, former director of the American Board of Psychiatry and medical director of Timberline Knolls, a residential treatment center near Chicago. "They need to have an incredibly high level of suspicion."

Schizophrenia, bipolar disorder and borderline personality disorder are distinct conditions with separate treatments but similar behaviors.

The classic cases are easy to spot. But unraveling a diagnosis from a subtle set of diffuse clues -- headaches, insomnia, unexplained joint pain, anger -- can be a challenge for time-crunched primary care physicians.

"Often, they have thematic complaints. They don't say, 'I'm depressed,' " says Rick Kellerman, MD, president of the American Academy of Family Physicians and professor and chair of the Dept. of Family and Community Medicine, University of Kansas School of Medicine. "They might be tired, have all sorts of aches. These patients are difficult because they have undifferentiated problems."

And because patients increasingly are opting for specialty care, the complete story often gets buried under the presenting complaint. Patients can go undiagnosed for years, says Pamela Kushner, MD, a family physician and clinical professor at University of California, Irvine, College of Medicine. "With bipolar there can be a 10-year delay. This is where the value of knowing the patient comes into play."

Bipolar disorder

The primary care physician is in a good position to intervene, says David Baron, DO, chair and professor of behavioral sciences and psychiatry at Temple University School of Medicine in Philadelphia. "They are more likely to see these patients during the depressive stage," he says. "But if you put them on an antidepressant, they can flip into mania."

The classic form -- recurrent episodes of mania and depression known as bipolar I -- is the most severe. During the acute manic phase, patients can appear psychotic and are sometimes misdiagnosed as having schizophrenia.

Even harder to diagnose is the bipolar II patient who never develops severe mania but instead experiences milder episodes of hypomania, alternating with depression.

Dr. Baron suggests asking the depressed patient: "Have you had episodes of energy?" "Fast thoughts?" "Gone on a spending spree?" "Did others notice?"

In the manic phase, patients say things like, "Hey doc, you should get some of what I have." Their energy and euphoria make intervening a difficult proposition. "I've had, in my office, acutely manic patients feeling great. They don't understand what the problem is," Dr. Kellerman says. "They feel like they are on top of the world, and it's difficult to refer."

Gary Sachs, MD, director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston, explains it this way: Someone in an acute manic state is similar to someone who is having a heart attack. "When they're feeling crushing chest pain, you're not going to talk to them about lifestyle changes," says Dr. Sachs, also an associate professor of psychiatry at Harvard Medical School. "When a patient comes in with an acute manic episode, this is not the best teaching moment."

The latest research demonstrates a change in conventional wisdom about bipolar.

"Ten or 15 years ago it was thought it came from bad parenting, childhood trauma," says Jair C. Soares, MD, psychiatry professor at University of North Carolina at Chapel Hill School of Medicine. "But now research suggests subtle changes in the brains of people with bipolar."

But Dr. Soares says earlier interventions can lead to better outcomes. "There is a window of opportunity in the primary care setting to help them get treatment. I emphasize how important it is to be attentive to this."

Lithium, the gold standard of treatment, sometimes comes with unpleasant side effects, and other medications such as Depakote (divalproex sodium), Zyprexa (olanzapine) and aripiprazole, combined with psychotherapy, are gaining popularity.

According to the National Institute of Mental Health, stabilizing daily routines with schedules -- interpersonal and social rhythm therapy -- helps people with bipolar improve and sometimes prevent recurrence of episodes.

Borderline personality disorder

The borderline patient may idealize their primary care provider, forming an intense interest in the physician's personal life and eventually offering social invitations. They may call the office excessively, asking questions. And no matter how much time is given, it's never enough.

"They can be complimentary, then accusatory, and take up a lot of resources," Dr. Kellerman says. "But if you can understand that they have a personality disorder, if you recognize and understand what that means, that alone can help."

These patients have a morbid fear of abandonment, generally stemming from a childhood trauma, such as sexual abuse. They may become hostile, demanding or suicidal if needs are not met.

Dr. Baron recalls a patient who took a paper clip, and, after cutting herself, drew a blood "X" on the office door because she could not be seen that day. "You want to be consistent, warm and limit-setting," he says.

Borderlines have a pervasive pattern of instability; mood swings; impulsivity; acting out; self-mutilating or attention-seeking behaviors; unstable, intense interpersonal relationships; and intense anger. They can have a history of doctor shopping, legal suits against physicians or other professionals, previous suicide attempts and multiple marriages.

Treatment remains challenging, Dr. Baron says. "[These patients] are much more difficult."

The preferred approach, dialectical behavior therapy, helps patients manage day-to-day skills. "There is nothing proven better," says Brian Wise, MD, MPH, a Denver psychiatrist. "It's important for primary care physicians to know about DBT groups in the community and to stay in contact with the patient's mental health team."


Contrary to media accounts, prime-time TV shows and made-for-TV films, schizophrenics are not necessarily raging madmen. "It's a myth that they are so much different, that they are acutely dangerous," Dr. Baron says. "Schizophrenic patients can look quite normal."

Schizophrenia is a chronic, severe and disabling brain disease characterized by delusions and hallucinations.

"Hallucinations are almost always auditory," says John R. Elpers, MD, professor emeritus of clinical psychiatry and behavioral sciences at UCLA. If the hallucinations are visual, he recommended considering drug use or drug abuse as the cause. Dr. Elpers is also a former chair of Mental Health America, an advocacy organization based in Alexandria, Va., that changed its name last year from the National Mental Health Assn.

"Most go a number of years before being diagnosed," Dr. Elpers says. "They may appear normal and then have a sudden breakdown. Look for a change in patterns."

The first break usually occurs in adolescence. The patient may hear voices, believe that others are reading their minds, controlling their thoughts, or plotting to harm them. Some people try to blame the break on a precipitating event, but it would have occurred no mater what, Dr. Elpers says. "With the first break, they return to baseline. We try to keep them from having more episodes, because we see a deterioration with each one."

NIMH cites these advances as offering hope for people with schizophrenia and for their families. And researchers are developing more effective medications. In September the Food and Drug Administration approved Risperdal (risperidone) for this purpose.

"Schizophrenics can do very well now. We have learned so much," Dr. Elpers says.

"I have seen people severely ill rehabilitated. A diagnosis is not a sentence to an awful life. Schizophrenia can be treated."

Collaborating with patients

It's important for physicians to communicate with patients confronting these conditions -- to help them understand medications and to empower them to take care of their illness.

"We've learned from our [patients] they do best when we let them take charge of themselves," Dr. Elpers says. "Medications are helpful but only helpful when the client understands how to take them. We need to teach patients how to manage symptoms, give them the freedom to adjust them. In this way the physician becomes a consultant for the patient."

And many physicians are moving beyond "compliance" to "concordance" or "aiming for agreement," Dr. Sachs says. "We are mapping out together, asking patients, 'How do we get here?' The key is to formulate a menu of choices for the patient and then negotiate."

But sometimes there's a disconnect, and what physicians are saying isn't what patients are hearing.

A recent survey of primary care physicians, psychiatrists and bipolar patients by researchers at Massachusetts General Hospital found that about 70% of patients wanted physicians to provide more information about treatment expectations and medication options.

"Patients didn't have the information the doctors thought they were giving them," Dr. Sachs says. "We need to find ways to get information to patients."

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Advice on suicidal risk

The Kansas Academy of Family Physicians asked a select group of family physicians their advice for peers regarding the identification and care of patients at high risk for suicide. Here's what they said:

  • You won't forget the ones you miss; don't miss.
  • Take serious attempts seriously, especially in the elderly.
  • Be proactive. Identify risk factors. Establish a support system early. Schedule routine appointments. Use community resources.
  • Screen all patients with known affective disorders.
  • If someone appears at risk, make a referral right away. Don't wait to see if they feel better or if the antidepressant works.
  • Insist on appointments rather than refilling meds by phone.
  • Don't assume the mental health community will take adequate care of the patient; remain closely involved in the case.
  • Find out who will help you without having to wait three hours for a return call.
  • Be prepared to give patients the time they need, and listen more than talk. Establish reasonable follow-up and don't be afraid to refer for inpatient psychiatric evaluation and treatment during the acute phase.

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Tips for dealing with borderline patients

Physicians with experience in this area offer the following advice:

  • Educate office staff about the disorder so they understand the patient better.
  • Encourage the patient to make appointments for regular office visits instead of unscheduled drop-ins.
  • If the patient's phone calls are excessive, form a contract with him or her for a certain number of calls.
  • Understand that no matter what, these patients may move on to another doctor.

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