Current Treatment Options in Psychiatry

, Volume 5, Issue 4, pp 441–451 | Cite as

Bipolar Disorder in Primary Care: Considerations in Management

  • Hilja RueggEmail author
  • Suzanne Watson
  • Melissa DelBello
  • Caleb Adler
  • L. Rodrigo Patino Duran
Invited Commentary


Purpose of review

Bipolar disorder is a chronic mental illness that has significant morbidity and mortality implications globally. Increasingly, as with many mental health disorders, patients are being identified in primary care settings.

Recent findings

In this overview, we discuss screening and case identification, making the case for judicious use of screening tools coupled with follow-up clarifying questions. We review the main modalities of treatment including pharmacother-apy and the evidence for non-pharmacotherapy adjunctive approaches. We discuss recommendations and cautions regarding the use of antidepressants in this population. Finally, we explore the role of new models of care and pharmacogenetic testing.


As primary care providers play a critical role in the care of patients with bipolar disorder there are a number of important considerations both in the identification of patients as well as initiating and monitoring treatment.


Bipolar disorder management Primary care mental health Genetics and bipolar disorder Bipolar disorder screening 

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: ••Of major importance

  1. 1.
    Kilbourne AM, Cornelius JR, Han X, Pincus HA, Shad M, Salloum I, … Haas GL (2004). Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord, 6(5), 368–373. doi:
  2. 2.
    Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64(5):543–52. Scholar
  3. 3.
    Ferrari AJ, Stockings E, Khoo JP, Erskine HE, Degenhardt L, Vos T, et al. The prevalence and burden of bipolar disorder: findings from the Global Burden of Disease Study 2013. Bipolar Disord. 2016;18(5):440–50. Scholar
  4. 4.
    Cerimele JM, Chan YF, Chwastiak LA, Avery M, Katon W, Unutzer J. Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder. Psychiatr Serv. 2014;65(8):1041–6. Scholar
  5. 5.
    Miller C, Bauer MS. Excess mortality in bipolar disorders. Curr Psychiatry Rep. 2014;16(11):499. Scholar
  6. 6.
    Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64(2):161–74.CrossRefGoogle Scholar
  7. 7.
    Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry. 2011;199(1):49–56. Scholar
  8. 8.
    Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22(11):1596–602. Scholar
  9. 9.
    Daigneault A, Duclos C, Saury S, Paquet J, Dumont D, Beaulieu S. Diagnosis of bipolar disorder in primary and secondary care: what have we learned over a 10-year period? J Affect Disord. 2015;174:225–32. Scholar
  10. 10.
    Weisler RH, Keck PE Jr, Swann AC, Cutler AJ, Ketter TA, Kalali AH, et al. Extended-release carbamazepine capsules as monotherapy for acute mania in bipolar disorder: a multicenter, randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2005;66(3):323–30.CrossRefGoogle Scholar
  11. 11.
    Zimmerman M. Screening for bipolar disorder: confusion between case-finding and screening. Psychother Psychosom. 2014;83(5):259–62. Scholar
  12. 12.
    Phelps JR, Ghaemi SN. Improving the diagnosis of bipolar disorder: predictive value of screening tests. J Affect Disord. 2006;92(2–3):141–8. Scholar
  13. 13.
    Zimmerman M, Posternak MA, Chelminski I, Solomon DA. Using questionnaires to screen for psychiatric disorders: a comment on a study of screening for bipolar disorder in the community. J Clin Psychiatry. 2004;65(5):605–10 discussion 721.Google Scholar
  14. 14.
    Cerimele JM, Chwastiak LA, Dodson S, Katon WJ. The prevalence of bipolar disorder in primary care patients with depression or other psychiatric complaints: a systematic review. Psychosomatics. 2013;54(6):515–24. Scholar
  15. 15.
    Paterniti S, Bisserbe JC. Factors associated with false positives in MDQ screening for bipolar disorder: insight into the construct validity of the scale. J Affect Disord. 2018;238:79–86. Scholar
  16. 16.
    Zimmerman M, Galione JN. Screening for bipolar disorder with the Mood Disorders Questionnaire: a review. Harv Rev Psychiatry. 2011;19(5):219–28. Scholar
  17. 17.
    Zimmerman M, Ruggero CJ, Galione JN, McGlinchey JB, Dalrymple K, Chelminski I, et al. Detecting differences in diagnostic assessment of bipolar disorder. J Nerv Ment Dis. 2010;198(5):339–42. Scholar
  18. 18.
    Kessler RC, Akiskal HS, Angst J, Guyer M, Hirschfeld RM, Merikangas KR, et al. Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0. J Affect Disord. 2006;96(3):259–69. Scholar
  19. 19.
    Kessler RC, Santiago PN, Colpe LJ, Dempsey CL, First MB, Heeringa SG, et al. Clinical reappraisal of the Composite International Diagnostic Interview Screening Scales (CIDI-SC) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Int J Methods Psychiatr Res. 2013;22(4):303–21. Scholar
  20. 20.
    Culpepper L (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. Prim Care Companion CNS Disord, 16(3). doi:
  21. 21.
    Swann AC, Geller B, Post RM, Altshuler L, Chang KD, DelBello MP, et al. Practical clues to early recognition of bipolar disorder: a primary care approach. Prim Care Companion J Clin Psychiatry. 2005;7(1):15–21.Google Scholar
  22. 22.
    Bowden CL, Perlis RH, Thase ME, Ketter TA, Ostacher MM, Calabrese JR, … Sachs GS (2012). Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD). CNS Neurosci Ther, 18(3), 243–249. doi:
  23. 23.
    Kupfer DJ. The increasing medical burden in bipolar disorder. JAMA. 2005;293(20):2528–30. Scholar
  24. 24.
    Ghaemi SN. Antidepressants in bipolar depression: the clinical debate. Aust N Z J Psychiatry. 2012;46(4):298–301. Scholar
  25. 25.
    Vieta E. Antidepressants in bipolar I disorder: never as monotherapy. Am J Psychiatry. 2014;171(10):1023–6. Scholar
  26. 26.
    Biederman J, Mick E, Spencer TJ, Wilens TE, Faraone SV. Therapeutic dilemmas in the pharmacotherapy of bipolar depression in the young. J Child Adolesc Psychopharmacol. 2000;10(3):185–92. Scholar
  27. 27.
    Viktorin A, Lichtenstein P, Thase ME, Larsson H, Lundholm C, Magnusson PK, et al. The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. Am J Psychiatry. 2014;171(10):1067–73. Scholar
  28. 28.
    Sidor MM, MacQueen GM. An update on antidepressant use in bipolar depression. Curr Psychiatry Rep. 2012;14(6):696–704. Scholar
  29. 29.
    Fornaro M, Anastasia A, Novello S, Fusco A, Solmi M, Monaco F, et al. Incidence, prevalence and clinical correlates of antidepressant-emergent mania in bipolar depression: a systematic review and meta-analysis. Bipolar Disord. 2018;20(3):195–227. Scholar
  30. 30.
    Frank E, Soreca I, Swartz HA, Fagiolini AM, Mallinger AG, Thase ME, et al. The role of interpersonal and social rhythm therapy in improving occupational functioning in patients with bipolar I disorder. Am J Psychiatry. 2008;165(12):1559–65. Scholar
  31. 31.
    Hollon SD, Ponniah K. A review of empirically supported psychological therapies for mood disorders in adults. Depress Anxiety. 2010;27(10):891–932. Scholar
  32. 32.
    Swartz HA, Swanson J. Psychotherapy for bipolar disorder in adults: a review of the evidence. Focus (Am Psychiatr Publ). 2014;12(3):251–66. Scholar
  33. 33.
    Frias A, Palma C, Farriols N. Comorbidity in pediatric bipolar disorder: prevalence, clinical impact, etiology and treatment. J Affect Disord. 2015;174:378–89. Scholar
  34. 34.
    •• Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, …, Berk M (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord, 20(2), 97–170. doi: (Guidelines for treatment).
  35. 35.
    Girard R, Joober R. Treatment of ADHD in patients with bipolar disorder. J Psychiatry Neurosci. 2017;42(6):E11–2.CrossRefGoogle Scholar
  36. 36.
    Kilbourne AM, Brar JS, Drayer RA, Xu X, Post EP. Cardiovascular disease and metabolic risk factors in male patients with schizophrenia, schizoaffective disorder, and bipolar disorder. Psychosomatics. 2007;48(5):412–7. Scholar
  37. 37.
    Goldstein BI. Bipolar disorder and the vascular system: mechanisms and new prevention opportunities. Can J Cardiol. 2017;33(12):1565–76. Scholar
  38. 38.
    Nousen EK, Franco JG, Sullivan EL. Unraveling the mechanisms responsible for the comorbidity between metabolic syndrome and mental health disorders. Neuroendocrinology. 2013;98(4):254–66. Scholar
  39. 39.
    Perron BE, Howard MO, Nienhuis JK, Bauer MS, Woodward AT, Kilbourne AM. Prevalence and burden of general medical conditions among adults with bipolar I disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2009;70(10):1407–15. Scholar
  40. 40.
    Thompson WK, Kupfer DJ, Fagiolini A, Scott JA, Frank E. Prevalence and clinical correlates of medical comorbidities in patients with bipolar I disorder: analysis of acute-phase data from a randomized controlled trial. J Clin Psychiatry. 2006;67(5):783–8.CrossRefGoogle Scholar
  41. 41.
    Fagiolini A, Frank E, Houck PR, Mallinger AG, Swartz HA, Buysse DJ, et al. Prevalence of obesity and weight change during treatment in patients with bipolar I disorder. J Clin Psychiatry. 2002;63(6):528–33.CrossRefGoogle Scholar
  42. 42.
    Vancampfort D, Stubbs B, Mitchell AJ, De Hert M, Wampers M, Ward PB, … Correll CU (2015). Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta-analysis. World Psychiatry, 14(3), 339–347. doi:
  43. 43.
    Goldstein BI, Schaffer A, Wang S, Blanco C. Excessive and premature new-onset cardiovascular disease among adults with bipolar disorder in the US NESARC cohort. J Clin Psychiatry. 2015;76(2):163–9. Scholar
  44. 44.
    Krishna VN, Thunga R, Unnikrishnan B, Kanchan T, Bukelo MJ, Mehta RK, et al. Association between bipolar affective disorder and thyroid dysfunction. Asian J Psychiatr. 2013;6(1):42–5. Scholar
  45. 45.
    Pisanu C, Heilbronner U, Squassina A. The role of pharmacogenomics in bipolar disorder: moving towards precision medicine. Mol Diagn Ther. 2018;22(4):409–20. Scholar
  46. 46.
    Squassina A, Pisanu C. Personalized medicine in bipolar disorder: how can we overcome the barriers to clinical translation? Perinat Med. 2013;10(8):765–8. Scholar
  47. 47.
    Budde M, Degner D, Brockmoller J, Schulze TG. Pharmacogenomic aspects of bipolar disorder: an update. Eur Neuropsychopharmacol. 2017;27(6):599–609. Scholar
  48. 48.
    Ielmini M, Poloni N, Caselli I, Espadaler J, Tuson M, Grecchi A, et al. The utility of pharmacogenetic testing to support the treatment of bipolar disorder. Pharmgenomics Pers Med. 2018;11:35–42. Scholar
  49. 49.
    Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illness. N Engl J Med. 2010;363(27):2611–20. Scholar
  50. 50.
    Kilbourne AM, Li D, Lai Z, Waxmonsky J, Ketter T. Pilot randomized trial of a cross-diagnosis collaborative care program for patients with mood disorders. Depress Anxiety. 2013;30(2):116–22. Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Hilja Ruegg
    • 1
    Email author
  • Suzanne Watson
    • 1
  • Melissa DelBello
    • 1
  • Caleb Adler
    • 1
  • L. Rodrigo Patino Duran
    • 1
  1. 1.Departments of Psychiatry and Behavioral Neuroscience and Community and Family MedicineUniversity of CincinnatiCincinnatiUSA

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