Improving outcomes in patients with bipolar disorder through establishing an effective treatment team.

A treatment gap exists between the efficacious treatments available for patients with bipolar disorder and the usual care these patients receive. This article reviews the evolution of the collaborative care treatment model, which was designed to address treatment gaps in chronic medical care, and discusses the efficacy of this model when applied to improving outcomes for patients with bipolar disorder in the primary care setting. Key elements of collaborative care include the use of evidence-based treatment guidelines, patient psychoeducation, collaborative decision-making with patients and with other physicians, and supportive technology to facilitate monitoring and follow-up of patient outcomes. Integrating psychiatric and medical health care can assist in achieving the goal of bipolar disorder treatment, which is full functional recovery for patients.

Reinvention of depression instruments by primary care clinicians.

PURPOSE: Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use. METHODS: Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators' field notes on office practice environments complemented individual interviews. RESULTS: The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients' acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician's time, the lack of objective evidence of depression, and the clinician's familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions. CONCLUSIONS: Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making-primarily to suggest, tell, or convince patients to accept the diagnosis of depression.

What comprises clinical experience in recognizing depression?: the primary care clinician's perspective.

PURPOSE: Depression is a highly prevalent condition in primary care settings. In our previously reported work, we investigated the processes and conditions that influence primary care clinicians' recognition of depression. Three conditions influence the recognition of depression: familiarity with the patient, time available, and clinical experience. This article further describes the role of clinical experience in depression care. METHODS: The grounded theory method was used to guide data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed. RESULTS: We identified 3 areas that comprise clinical experience relevant to depression care: (1) knowing one's professional role, (2) knowing oneself, and (3) knowing one's patients. In knowing one's professional role, 4 subdimensions were identified: (1) becoming familiar with illness patterns and clinical skills, (2) learning what works in the real world, (3) understanding what being a doctor is about, and (4) thinking of the whole person. The analysis indicated that clinical experience results from professional and personal growth during interactions with patients. The outcome of this developmental process was the achievement of comfort with depression care, a critical mediating variable that influenced primary care clinicians' recognition of depression. CONCLUSIONS: The developmental process of attaining comfort in managing depression warrants further exploration. Developing interventions to speed this process offers another approach to enhancing care for the management of depression.

Understanding comorbidity with depression and anxiety disorders.

Comorbidity is the rule with anxiety and depressive disorders. Anxiety and major depressive disorder are often comorbid with each other; these disorders are commonly associated with other psychiatric disorders; and they are frequently found coexisting with long-standing chronic medical conditions such as cardiovascular disease and diabetes mellitus. The comorbidity of major depressive and anxiety disorders is associated with barriers to treatment and worse psychiatric outcomes, including treatment resistance, increased risk for suicide, greater chance for recurrence, and greater utilization of medical resources. Effective recognition and treatment of anxiety and depression may be associated with functional improvement in the medical disorders (eg, lower HbA1c level in patients with diabetes). Paying careful attention to the development of anxiety and depression may also positively impact the economic burden of these disorders. To help primary care physicians better understand the comorbidity of depression and anxiety and medical disorders, the authors describe three case scenarios.

The recognition of depression: the primary care clinician's perspective.

PURPOSE: The purpose of this study was to explore the responses of primary care clinicians to patients who complain of symptoms that might indicate depression, to examine the clinical strategies used by clinicians to recognize depression, and to identify the conditions that influence their ability to do so. METHODS: The grounded theory method was used for data collection and analysis. In-depth, in-person interviews were conducted with a purposeful sample of 8 clinicians. All interviews were audiotaped and transcribed. RESULTS: This study identified 3 processes clinicians engage in to recognize depression-ruling out, opening the door, and recognizing the person-and 3 conditions-familiarity with the patient, general clinical experience, and time availability-that influence how each of the processes is used. CONCLUSIONS: The likelihood of accurately diagnosing depression and the timeliness of the diagnosis are highly influenced by the conditions within which clinicians practice. Productivity expectations in primary care will continue to undermine the identification and treatment of depression if they fail to take into consideration the factors that influence such care.

Simplifying the language of evidence to improve patient care: Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature.

Several taxonomies exist for rating individual studies and the strength of recommendations, making the analysis of evidence confusing for practitioners. A new grading scale-the Strength of Recommendation Taxonomy (SORT)-will be used by several family medicine and primary care journals (required or optional), allowing readers to learn 1 consistently applied taxonomy of evidence. SORT is built around the information mastery framework, which emphasizes the use of patient-oriented outcomes that measure changes in morbidity or mortality. Levels of evidence from 1 to 3 for individual studies also are defined. An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.