As a behavioral health consultant (BHC) embedded in a primary care clinic, one of the most frustrating things I can see in a patient's chart is the diagnoses of depression and anxiety. Too often these diagnoses are assigned to patients based their presentation and in some cases screening tool scores such as the PHQ9 (depression screening tool) and GAD7 (anxiety screening tool). Unfortunately, assessment stops once a medical, behavioral health, or psychiatric provider provides the diagnosis. When patient symptoms or PHQ9 scores do not improve, antidepressant doses are increased to ineffective levels, additional antidepressants are added, or patients are switched to a different medication.
At my clinic we utilize our electronic health records system to run reports based on PHQ9 scores. When I first ran the report, I was shocked by the number of patients with excessively high depression scores with accompanying depression and anxiety diagnoses whose scores/symptoms have not decreased after years of treatment. The ineffectiveness of treatment goes beyond pharmacological. There are too many patients on the report with depression and anxiety diagnoses who have engaged in mental health therapy for years and are still functioning at baseline. If there are so many patients whose depressive symptoms are not improving, and their lives are in disarray why do we as professionals keep adding more meds that do not work and applying interventions that are not effective?
This is the first article in a series that will explore how to break these cycles of ineffective treatment through more thorough diagnostic screening and utilization of psychiatric clinical pharmacists in primary care settings. The article will also examine two diagnoses that are very often mistaken for depression and anxiety, bipolar 2 disorder and attention deficit hyperactivity disorder. Both diagnoses are often underdiagnosed and undertreated leaving many people to receive unnecessary treatment, while living with guilt, shame, and frustration because their lives are not getting any better despite following their treatment plans.
Among people seeking treatment for an episode of major depression, there is a growing percentage struggling with bipolar 2 depression. Yet, many of these patients are misdiagnosed and treated for depression because previous episodes of hypomania or mania are missed by providers. Bipolar 2 disorder is often easy for providers to overlook because less severe hypomanic or manic episodes are frequently difficult for patients to remember during the visit. Some patients with bipolar depression may never have a manic episode. While family history and age of onset of depressive symptoms (childhood and preteen years) are often only indicators that patient presentation is more than unipolar depression (O'Donovan & Alda, 2020).
In one study nearly two-thirds of patients with bipolar disorder who initially sought treatment for their symptoms were diagnosed with depression and anxiety and only 8% received a diagnosis of bipolar disorder. Another study of a cohort of close to 110 patients originally diagnosed with depression and anxiety in a primary care clinic identified 26% of the patients having a form of bipolar disorder (Manning, 2010).
In the US most antidepressants are prescribed by primary care providers (PCP). SSRIs are the most prescribed antidepressants and are commonly prescribed at higher doses than recommended dosing supported in peer reviewed literature. Higher SSRI doses are associated with adverse effects including anxiety, agitation, and insomnia which often lead to co-prescribing of sedating medications such as benzodiazepines, antipsychotics, and additional antidepressants (Johnson et al., 2017). Unfortunately, there are too many people who have lived for decades being ineffectively treated for depression, taking medications that are unnecessary and often exasperate symptoms of mania and hypomania. It is not uncommon for a patient to be prescribed more unnecessary medications to treat the symptoms created by excessive dosing of antidepressants.
A recent study found that a significant population of people with a bipolar disorder changed their diagnosis after fifty years (O'Donovan & Alda, 2020). As a behavioral health provider, I was not surprised by this study. In my experience people living with bipolar 2 disorder are often much higher functioning than patients with major depressive disorder. Periods of mania or hypomania can be subtle, and patients often seek treatment only when experiencing depressive episodes. However, being treated for depression is not enough to manage their symptoms or improve their lives where most impairment is seen in their interpersonal relationships.
Most of the current research indicates that ADHD is the most underdiagnosed and undertreated disorder in adult populations. In the United States only 11% of adults with ADHD were receiving treatment. Many adults with ADHD are misdiagnosed with mood disorders due to overlapping symptoms like emotional dysregulation. According to a recent study 34% of patients referred for treatment of resistant depression met criteria for ADHD. While nearly 80% of adults with ADHD have at least one comorbid mental health condition including mood (depression/bipolar disorder) disorders, autism, anxiety, substance use disorders, and personality disorders (Katzman et al., 2017).
In my experience it seems like many medical and psychiatric communities are stuck with the view that ADHD is still a childhood disorder and little effort is made to identify it in adult populations. However, new evidence is showing that children diagnosed with ADHD do not outgrow the disorder in adulthood and adult ADHD is not always a continuation of childhood ADHD. The evidence demonstrates that there are many people who experience an onset of symptoms in adulthood without any history of childhood ADHD (Katzman et al., 2017).
Compared to their male counterparts' females with ADHD are disproportionately underdiagnosed even in childhood. Males are usually recognized due to the outward symptoms of hyperactivity. While females with ADHD are more likely to have internalized symptoms, resulting in a later diagnosis and greater emotional/intellectual impairment compared to males with the disorder (Katzman et al., 2017). Women are frequently told the restless energy that is associated with ADHD is anxiety. Regrettably, because of misdiagnosis many women are prescribed benzodiazepines to treat “anxiety.” Not only are benzodiazepines ineffective in treating ADHD symptoms; they also carry the risk of dependence to a medication that could be fatal if patients are not tapered off it properly.
Untreated ADHD in adults is correlated with acute functional and social impairments that lead to severe personal and societal costs. Adult ADHD can impact self-esteem and interpersonal relationships. Adults with ADHD are more likely to have been divorced than those without the disorder. College students with ADHD are more prone to have poorer grade point averages and are less likely to graduate than those without.
Untreated adults with ADHD are more likely to experience income disparities than those without it ranging from $9000 to $15000 annually (Katzman et al., 2017). ADHD also is associated with earlier onset, greater severity, and increased acuity of chronic substance abuse. Studies have shown that by treating ADHD in adults with cooccurring substance use disorders significantly reduced rates of relapse (Kaye et al., 2016).
The societal costs of undiagnosed and untreated ADHD are significant. Adults with ADHD are more likely to be unemployed and were 42% less likely to be employed fulltime. The disorder's under-recognition profoundly impacts the economy. The associated loss of workforce productivity is estimated between $70 and $115 billion dollars annually. Adult ADHD is also associated with higher rates of criminality, exasperating societal costs. Recent evidence indicates that 47% of adults with ADHD have at least one criminal sentence and 40% of inmates serving long-term prison sentences have the disorder. In all it is estimated that the total cost of untreated adult ADHD in the United States is between $140 and $270 billion dollars annually (Katzman et al., 2017).
Untreated bipolar disorder can be incredibly destructive to lives of those with the disorder. People with undiagnosed or untreated bipolar disorder experience dysfunction in multiple areas of their lives. Including multiple divorces, tempestuous interpersonal relationships, romantic instability, cooccurring substance use/eating disorders, employment difficulties, involvement with law enforcement, financial problems (Manning, 2010). One study indicated that bipolar disorder was associated with significant economic burden to the US. Specifically, the total costs associated with bipolar disorder were estimated between $119 and $202 billion annually. The largest contributors to the estimation were caregiving costs, direct healthcare costs, and unemployment costs (Cloutier et al., 2018).
Until recently, the federally qualified health center (FQHC) where I work as a BHC was like most primary care practices and utilized informal screening methods. Specifically, semi-consistent use of depression (PHQ9) and anxiety (GAD7) screening tools which often seemed like they were used more to meet reporting measures than patient care. With the increase in patient acuity due to the covid19 pandemic and the collapse of the area's community mental health center (CMHC), the days of our PCPs treating mild to moderate depression and generalized anxiety have gone the way of the dinosaur. Over the past year the FQHC has become the de facto CMHC treating patients with significant mental health diagnoses like bipolar disorder, schizophrenia, complex PTSD, substance use disorders, and personality disorders.
To address the influx of patients with significant mental health issues we have made a consistent effort to improve our ability to accurately identify behavioral health conditions using a variety of structured and evidence-based instruments. Like many other primary care practices, we have patient populations with multiple behavioral health conditions as well as comorbid physical health issues which necessitate utilization of best practice screening tools (Mulvaney-Day et al., 2017). Included in our assessment cache are the standard tools to measure depression (PHQ9), anxiety (GAD7), and SUD (Audit10/DAST10) as well as additional screening tools to track mania (MDQ), ADHD (ASRS), PTSD (PCL-C), and a homebrew Family History screening tool. We also have an extensive library of tools at our disposal to identify other conditions like autism, schizophrenia, and personality disorders. Our efforts have increased the likelihood that our patients are correctly diagnosed and receive appropriate treatment.
We developed a Family History Screening Tool because the most robust predictor of bipolar disorder is a family history of bipolar disorder and age of onset of depressive symptoms (O'Donovan & Alda, 2020). Family history is also a strong predictor of ADHD with the disorder being highly inheritable. Studies show between 70%-80% people with ADHD have at least one close relative diagnosed with ADHD (Kaye et al., 2016). Not only has the screening tool helped patients with bipolar disorder and ADHD be appropriately diagnosed it has been instrumental in providing lines of diagnostic questioning that have identified patients with high functioning autism who have been misdiagnosed with bipolar disorder for decades.
Clinical pharmacists typically support integrated teams by providing education on patient medications, monitoring side effects, support medication adherence, and performing patient follow-ups which can optimize care while increase patient access to the proper expertise (Gallimore et al., 2018). To address extensive wait times for psychiatric providers and PCP lack of comfortability with prescribing psychotropic medications we have found an innovative way to utilize psychiatric clinical pharmacists.
I have been fortunate to partner with our psychiatric clinical pharmacist. In doing so we have decreased wait times for patients to be treated with appropriate psychotropic medications while increasing PCP ease with prescribing mental health medications. Our process begins with patient's meeting with me (BHC) for a diagnostic clarification assessment utilizing a data driven approach with evidence-based screening tools and extensive chart reviews to illuminate the patient's diagnosis. Once patient receives an appropriate diagnosis the assessment is sent our clinical pharmacist who completes a medication/chart review and provides a report with medication recommendations to the PCP who prescribes and manages the patient's medications.
Through better assessment/screening practices, thorough medication reviews/recommendations by a psychiatric clinical pharmacist, and increased PCP confidence in prescribing psychotropic medications we hope to reduce unnecessary prescribing and adverse drug effects that often require additional prescriptions. By adopting this process we also hope to improve patient outcomes by treating the right condition and increase revenue for the clinic by treating patients with mental health concerns in house instead of referring them to specialty psychiatric services.
Cloutier, M., Greene, M., Guerin, A., Touya, M., & Wu, E. (2018). The economic burden of bipolar i disorder in the united states in 2015. Journal of Affective Disorders, 226, 45-51. Link
Johnson, C. F., Williams, B., MacGillivray, S. A., Dougall, N. J., & Maxwell, M. (2017). 'doing the right thing': Factors influencing gp prescribing of antidepressants and prescribed doses. BMC Family Practice, 18(1). Link
Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult adhd and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 17(1). Link
Mulvaney-Day, N., Marshall, T., Downey Piscopo, K., Korsen, N., Lynch, S., Karnell, L. H., Moran, G. E., Daniels, A. S., & Ghose, S. (2017). Screening for behavioral health conditions in primary care settings: A systematic review of the literature. Journal of General Internal Medicine, 33(3), 335-346. Link
O'Donovan, C., & Alda, M. (2020). Depression preceding diagnosis of bipolar disorder. Frontiers in Psychiatry, 11. Link
Manning, J. (2010). Tools to improve differential diagnosis of bipolar disorder in primary care. The Primary Care Companion to The Journal of Clinical Psychiatry, 17-22. Link
Gallimore, C., Corso, K. A., Robinson, P., & Runyan, C. N. (2018). Pharmacists in primary care: Lessons learned from integrated behavioral health. Medical Practice Management. Link
Kaye, S., Ramos-Quiroga, J., van de Glind, G., Levin, F. R., Faraone, S. V., Allsop, S., Degenhardt, L., Moggi, F., Barta, C., Konstenius, M., Franck, J., Skutle, A., Bu, E.-T., Koeter, M. J., Demetrovics, Z., Kapitány-Fövény, M., Schoevers, R. A., van Emmerik-van Oortmerssen, K., Carpentier, P.-J.,...van den Brink, W. (2016). Persistence and subtype stability of adhd among substance use disorder treatment seekers. Journal of Attention Disorders, 23(12), 1438-1453. Link