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To compare medication treatment of individuals with bipolar disorder in two primary care-based integrated care models.Participants were randomized to 12-months of treatment with direct care by co-located psychiatrists in primary care, or collaborative care (primary care clinicians supported by psychiatrists). Medication data at initial and last treatment visits were extracted from the clinical registry for 191 patients diagnosed with bipolar disorder.Participants receiving no medication treatment decreased from 28% to 11% (direct co-located) (χSimilar patterns of medication treatment were observed in participants with bipolar disorder receiving either direct care from psychiatrists, or medication treatment by primary care clinicians supported by psychiatrists.

BACKGROUND: Measurement-based care is an effective clinical strategy underutilized for bipolar disorder partly due to lacking a widely adopted patient-reported manic symptom measure. OBJECTIVE: To report development and psychometric properties of a brief patient-reported manic symptom measure. DESIGN: Secondary analysis of data collected in a randomized effectiveness trial comparing two treatments for 1004 primary care patients screening positive for bipolar disorder and/or PTSD. PARTICIPANTS: Two analytic samples included 114 participants with varied diagnoses and test-retest data, and 179 participants with psychiatrist-diagnosed bipolar disorder who had two or more assessments with the nine-item Patient Mania Questionnaire-9 [PMQ-9]). MAIN MEASURES: Internal and test-retest reliability, concurrent validity, and sensitivity to change were assessed. Minimally important difference (MID) was estimated by standard error of measurement (SEM) and by standard deviation (SD) effect sizes. KEY RESULTS: The PMQ-9 had high internal reliability (Cronbach’s alpha = 0.88) and test-retest reliability (0.85). Concurrent validity correlation with manic symptom measures was high for the Internal State Scale-Activation Subscale (0.70; p

Purpose Availability of mental health services is limited in the rural United States. Two promising models to reach patients with limited access to care are telehealth referral and collaborative care. The objective of this study was to assess telepsychiatrist‐ and telepsychologist‐level facilitators and barriers to satisfaction with and implementation of these 2 telehealth models in rural settings. Methods Focus groups were held in 2019 using a semistructured interview guide. Participants were off‐site telepsychiatrists (N = 10) and telepsychologists (N = 4) for primary care clinics across 3 states (Washington, Michigan, and Arkansas) involved in a recent pragmatic comparative effectiveness trial. Qualitative analysis occurred inductively by 2 independent coders. Findings Participants were satisfied with the models partly owing to good patient rapport and expanding access to care. Teamwork was highlighted as a facilitator in collaborative care and was often related to work with care managers. However, participants described communication with primary care providers as a challenge, especially in the telehealth referral arm. Barriers centered on variability of logistical processes (eg, symptom monitoring, scheduling, electronic medical record processes, and credentialing) among sites. Staff turnover, variable clinic investment, and inadequacy of training were possible explanations for these barriers. Conclusions Participants described high motivation to provide team‐based, remote care for patients, though they experienced operational challenges. Centralized credentialing, scheduling, and record keeping are possible solutions. These findings are important because consulting psychiatrists and psychologists may play a leadership role in the dissemination of these models.

ImportanceOnly one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.ObjectiveTo compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.Design, Setting, and ParticipantsThis pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.InterventionsTwo approaches were compared: (1) telepsychiatry/telepsychology–enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.Main Outcomes and MeasuresSurvey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.ResultsOf 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 3 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.7; 95% CI, 0 to 3.4; P = .05). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.79; 95% CI, 0.65 to 0.94; TER: Cohen d = 0.87; 95% CI, 0.73 to 1.02). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, −1.6 to 5.7; P = .28).Conclusions and RelevanceIn this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.Trial RegistrationClinicalTrials.gov Identifier: NCT02738944

Background In the United States, most patients who require behavioral health care do not receive it owing to an overall shortage of behavioral health specialists. The Collaborative Care Model (CoCM) is a team-based, highly-coordinated approach to treating common mental health conditions in primary care that has a robust evidence base. Several recent randomized controlled trials have demonstrated the effectiveness of remote CoCM teams. As telehealth technology advances and uptake expands, understanding the evidence for remote CoCM becomes increasingly crucial to inform CoCM practice and implementation. Objective The objective of this study was to systematically review randomized controlled trials regarding the effectiveness of remote CoCM teams in treating common psychiatric conditions in primary care and medical settings. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure our review. Our search strategy and development of search terms was informed by knowledge and review of the CoCM literature. Articles were reviewed by 3 authors, and once selected, they were sent to 2 authors for further data extraction to describe various study characteristics and process measures relating to remote CoCM. Results The literature search identified 13,211 articles, 9 of which met inclusion criteria. The 9 studies collectively demonstrate effectiveness of remote CoCM in treating a range of behavioral health conditions (depression [n = 7], anxiety [n = 2], and PTSD [n = 1]), across various populations and settings. Sample sizes ranged from 191 patients to 704 patients, publication dates from 2004 to 2018, and studies were conducted from 2000 to 2014. Various process measures were also reported. Conclusions As the 9 studies included in our systematic review demonstrate, remote CoCM can be effective in treating a range of behavioral health conditions in various primary care and specialty medical settings. These findings suggest organizations may have more flexibility in building their CoCM team and drawing upon wider workforces than previously recognized. As recent shifts in telehealth policy and practice continue to motivate telehealth approaches, further research that can inform best practices for remote CoCM will be useful and valuable to those making organizational decisions when implementing integrated care models.

Objective To describe the design and delivery of a curriculum in research methods for clinical fellows in integrated care. Method To design the curriculum, a standard curriculum development approach was applied through an iterative improvement process with input from researchers, clinical educators, and the first cohort of fellows. The curriculum has three central goals: (1) develop fellows' capacity to interpret the integrated care literature and apply findings in practice; (2) develop fellows' capacity for conducting quality improvement programs informed by knowledge of clinical research methods; and (3) enhance workforce capacity for practice-based research partnerships by increasing research understanding among clinical providers. A variety of educational strategies were employed to introduce each research method and apply these to the integrated care literature. Results A description, rationale, and resources for each content domain is presented. The curriculum was delivered to two cohorts of fellows. Evaluation data supports the curriculum's relevance and quality. Conclusions A rigorous development process yielded a brief research curriculum targeting the needs of clinical fellows in integrated care. The curriculum is well-received by fellows and adaptable for other subspecialties. It may serve as a model for other clinical training programs seeking to enhance their fellows' fluency in research methods.

Introduction Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. Method Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. Results Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive-behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%-70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%-83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. Discussion Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest. (PsycINFO Database Record

Objective To describe clinical diagnoses from telepsychiatrist consultation in safety net primary care settings for adult patients screening positive for bipolar disorder, PTSD, or both. Methods Patients were administered the PTSD Checklist (PCL-6) and the Composite International Diagnostic Interview 3.0 (CIDI) for bipolar disorder. Positive screening result definitions were PCL-6 score of ≥14 and CIDI positive stem question responses and score of ≥8. Patient characteristics were assessed by survey. Psychiatrists consulted in primary care via telehealth and recorded clinical diagnoses. Results Among 767 patients attending consultation with a telepsychiatrist, 495 (65%) screened PCL-6 positive only, 249 (32%) screened both PCL-6 and CIDI positive, and 23 (3%) screened CIDI positive. Approximately two-thirds screening PCL-6 positive were diagnosed with PTSD, and most had comorbid mood disorder diagnoses, with bipolar disorder diagnosis occurring more often in those screening CIDI positive compared to negative (42% vs. 15%). Positive predictive values were 64.9% for PCL-6 and 43.8% for CIDI. Conclusion Most individuals screening positive for PTSD and/or bipolar disorder had two or more psychiatric diagnoses; misclassification exists for both instruments but was greater for CIDI. Psychiatrist consultation early in treatment for individuals screening positive on the PCL-6 and/or CIDI could help clarify diagnoses and improve treatment planning.

Collaborative care (CoCM) is an evidence-based model for the treatment of common mental health conditions in the primary care setting. Its workflow encourages systematic communication among clinicians outside of face-to-face patient encounters, which has posed financial challenges in traditional fee-for-service reimbursement environments. Organizations have employed various financing strategies to promote CoCM sustainability, including external grants, alternate payment model contracts with specific payers, and the use of billing codes for individual components of CoCM. In recent years, Medicare approved fee-for-service, time-based billing codes for CoCM that allow for the reimbursement of patient care performed outside of face-to-face encounters. A growing number of Medicaid and commercial payers have followed suit, either recognizing the fee-for-service codes or contracting to reimburse in alternate payment models. Although significant challenges remain, novel methods for payment and cooperative efforts among insurers have helped move CoCM closer to financial sustainability.

Up to 20% of women who screen positive for depression in the perinatal period in primary care and obstetric settings may have bipolar disorder, but little is known about best practices for this population. This column describes clinical programs that support identification and management of depression and bipolar disorder among women in non-mental health settings. The programs use diverse management strategies, including referral to specialty mental health, collaborative care, and consultation and care coordination. Most mental health programs based in primary care and obstetric settings are designed for depression treatment. Assessment and treatment strategies need to be refined to ensure that women with bipolar disorder receive appropriate care.

Objective To summarize the current literature on epidemiology, clinical correlates, and treatment of individuals with co-occurring bipolar disorder and posttraumatic stress disorder (PTSD). Data sources We conducted a focused, time-sensitive review called "rapid review" in November 2015, using keyword searches (including keywords bipolar disorder, post-traumatic stress disorder, PTSD, and others) in PubMed for studies of adults with co-occurring bipolar disorder and PTSD. Study selection Results were sorted and systematically searched. An article was excluded if it did not describe adult patients with co-occurring PTSD and bipolar disorder or did not report original data on epidemiology, clinical correlates, or treatment. Data extraction Information on study characteristics including population studied and key findings were extracted onto a data collection tool. Results Thirty-two articles were included. Over two-thirds of articles reported epidemiology of co-occurring bipolar disorder and PTSD. Prevalence of PTSD among individuals with bipolar disorder ranged from 4% to 40%, with women and those with bipolar I versus bipolar II disorder experiencing higher prevalence of PTSD. Prevalence of bipolar disorder among individuals with PTSD ranged from 6% to 55%. Baseline PTSD or bipolar disorder was associated with incidence of the other illness. Individuals with co-occurring bipolar disorder and PTSD experienced high symptom burden and low quality of life. No studies evaluated prospective treatment of patients with co-occurring bipolar disorder and PTSD. Conclusions Bipolar disorder and PTSD commonly co-occur and result in greater symptom burden than either condition alone. Few published treatment strategies exist for patients with both conditions.

OBJECTIVE: Measurement-based care can improve outcomes across a range of psychiatric conditions. However, utilization of measurement-based care for treating individuals with bipolar disorder is limited, in part due to uncertainty regarding available bipolar disorder symptom measures. The current aim was to synthesize the literature on patient-reported and clinician-observed measures of symptoms of bipolar disorder for potential use in measurement-based care. METHOD: A systematic review was conducted searching multiple databases to identify validated measures. The literature was searched in June 2017 in PubMed, Embase, PsycINFO, Cochrane Library, and other grey literature sources. Extracted data included the psychometric properties of each measure which was then used to assess a measure’s clinical utility based on established guidelines. RESULTS: Twenty-eight unique measures were identified in 39 studies, including 10 measures assessing manic symptoms (4 patient-reported, 6 clinician-observed), 8 measures assessing depressive symptoms (3 patient-reported, 5 clinician-observed), and 10 measures assessing both manic and depressive symptoms (6 patient-reported, 4 clinician-observed). Clinical utility of measures varied. Measures with highest clinical utility in each category included the Altman Self-Rating Mania Scale, Bech-Rafaelsen Mania Rating Scale, Quick Inventory of Depressive Symptoms, Internal State Scale, and Bipolar Inventory of Symptoms Scale. CONCLUSIONS: Patient reported and clinician observed measures assessing manic symptoms, depressive symptoms, or both manic and depressive symptoms exist. Clinical utility scores could inform measure selection. Choice of a measure may also depend on how clinicians or practices weigh each category of the clinical utility scale, and on the clinical setting and presenting problem.

Received November 8, 2015; revised December 24, 2015; accepted December 28, 2015. From Department of Psychiatry and Behavioral Sciences,University ofWashington, Seattle,WA(LDP, JMC,AND). Send correspondence and reprint requests to Laurel Pellegrino, M.D., Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195; e-mail: lpelleg1@uw.edu & 2016 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved. Introduction

Objective Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. Interventions Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. Methods Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. Results A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. Discussion We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.

Objective To understand primary care patients' and clinicians' experiences with diagnosis and treatment of patients with bipolar disorder in primary care. Methods We conducted a qualitative study using thematic content analysis of individual interviews with nine primary care clinicians and six patients from Federally Qualified Health Centers to understand their experiences with the diagnosis and treatment of bipolar disorder. Results Themes of bipolar disorder detection, referral to specialty mental health care and medication treatment emerged from individual interviews with primary care patients and clinicians. Clinicians and patients faced challenges deciding to continue with care in primary care that is easier to access, but less intensive, than specialty care that can be harder to access but at times of higher quality. Conclusions Potential next steps in research include identifying ways to support primary care clinicians in detection of patients with bipolar disorder, and strategies to support treatment of patients in primary care with easier access to specialty care including consultation in primary care or co-management with specialty care.

OBJECTIVE: This study aims to examine whether, in a large implementation program of collaborative care in safety net primary care clinics, psychiatric case review is associated with depression medication modification. METHODS: Registry data were examined from an implementation of the collaborative care model (CCM) in Washington State and included adults from 178 primary care clinics with baseline Patient Health Questionnaire-9 (PHQ-9) scores ≥10 (n = 14,960). Psychiatric case reviews and depression medications were extracted from the registry. Rates of new depression medications and psychiatric case reviews were calculated for all patients and in the subset of patients not improving by 8 weeks of treatment (defined as not achieving a PHQ-9 score of

Primary care clinics are increasingly implementing collaborative care models to care for patients with psychiatric illnesses in primary care. The evidence base for the effectiveness of collaborative care has largely been derived from the care of patients with depression or anxiety disorders, although psychiatrists working in primary care may encounter patients with illnesses other than depression or anxiety disorder, notably bipolar disorder. Patients with bipolar disorder report having received treatment in primary care in equal proportions as those in specialty care settings over the past 12 months, although quality of care is lower in primary care than in specialty care settings. For patients already presenting to primary care, collaborative care is one population-based care model that may increase the proportion of individuals with bipolar disorder who are exposed to high-quality psychiatric care, such as appropriate medication treatment and laboratory monitoring. The primary care setting may even present unexpected strengths in caring for patients with bipolar disorder. Solutions to barriers to expanding the scope of collaborative care to include patients with bipolar disorder may apply to the care of patients with other complex disorders in the primary care setting.

We present three cases of patients attempting suicide by ingesting over-the-counter (OTC) medications diphenhydramine, salicylate, and acetaminophen. We then provide clinical guidelines for management of toxicity in pregnancy. Two cases resulted in fetal demise. Preventive strategies through an interdisciplinary team approach to screen for and treat patients with psychiatric illnesses resulting in suicidal thoughts are also discussed.

Objective To understand collaborative care psychiatric consultants’ views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care. Method We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary-care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed. Results Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry and effective care. Conclusion Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care and perceiving the care delivered through collaborative care as high quality.

Objective To obtain an estimate of the prevalence of bipolar disorder in primary care. Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed. Results We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients. Conclusion In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings. Prevalence estimates from studies using screening measures that have been found to have low positive predictive value were generally higher than those found using structured interviews.

OBJECTIVE This study compared program measures of assertive community treatment (ACT) with standards of accreditation for the patient-centered medical home (PCMH) to determine whether there were similarities in the infrastructure of the two methods of service delivery and whether high-fidelity ACT teams would qualify for medical home accreditation. METHODS The authors compared National Committee for Quality Assurance PCMH standards with two ACT fidelity measures (the Dartmouth Assertive Community Treatment Scale and the Tool for Measurement of Assertive Community Treatment [TMACT]) and with national ACT program standards. RESULTS PCMH standards pertaining to enhanced access and continuity, management of care, and self-care support demonstrated strong overlap across ACT measures. Standards for identification and management of populations, care coordination and follow-up, and quality improvement demonstrated less overlap. The TMACT and the program standards had sufficient overlap to score in the range of a level 1 PCMH, but no ACT measure sufficiently detailed methods of population-based screening and tracking of referrals to satisfy "must-pass" elements of the standards. CONCLUSIONS ACT measures and medical home standards had significant overlap in innate infrastructure. ACT teams following the program standards or undergoing TMACT fidelity review could have the necessary infrastructure to serve as medical homes if they were properly equipped to supervise general medical care and administer activities to improve management of chronic diseases.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Research has shown the majority of individuals with bipolar disorder do not receive treatment from a psychiatrist in a 12 month period. A large proportion of individuals with bipolar disorder in the United States seek treatment in primary care, rather than specialty mental health care, settings. Individuals with bipolar disorder seen in primary care settings have high symptom severity and functional impairment, but are less likely to receive treatment with mood stabilizing medications for bipolar disorder. We have found in clinical practice one-third of patients with bipolar disorder improved after receiving treatment in primary care in a statewide collaborative care program. The collaborative care approach originally developed for treating patients with depression in primary care may need to be strengthened or adapted for treating patients with bipolar disorder. Strategies such as telehealth or enhanced collaborative care also addressing psychosocial needs may be needed to effectively treat the patients with bipolar disorder already seeking treatment in primary care.

Background The collaborative care model has been found to be effective for depression management in various primary care populations; however, no review has synthesized trials tailored to treat women. Objective The purpose of this systematic review is to evaluate the current evidence for collaborative depression care for women. Methodology We searched for English language articles via MEDLINE, CINAHL, PsycINFO, EMBASE, Cochrane Library, and reference lists of key articles. Published English language studies were included if they described collaborative care models that targeted women, regardless of study design. Studies were excluded if components of collaborative care were absent (based on criteria described by the Advancing Integrated Mental Health Solutions Center at the University of Washington), if the focus of the intervention was not women, if the studies were not conducted in primary care or gynecological settings, or if there were no outcome data. Results This review resulted in 7 articles that met the inclusion criteria. Included studies were 6 randomized controlled trials and 1 observational study. Among those, 4 studies focused on pregnant or postpartum women. In general, collaborative care interventions focusing on women were more effective than usual care for the management of depressive disorders in women with 5 of the 6 randomized studies showing positive depression outcomes. Conclusions There is evidence that collaborative care interventions are effective for treating depressed women in nonmental health settings. Future studies should examine differences in implementation of collaborative care in "real world" settings and define modifications needed based on a woman's reproductive life stage.

Background: Hospitalizations for ambulatory care-sensitive conditions (ACSCs) and early rehospitalizations increase health care costs. Objectives: To determine if individuals with serious mental illnesses (SMIs) (eg, schizophrenia or bipolar disorder) are at increased risk for hospitalizations for ACSCs, and rehospitalization for the same or another ACSC, within 30 days. Research Design: Population-based cohort study. Participants: A total of 5.9 million Danish persons aged 18 years and older between January 1, 1999 and December 31, 2013. Measures: The Danish Psychiatric Central Register provided information on SMI diagnoses and the Danish National Patient Register on hospitalizations for ACSCs and 30-day rehospitalizations. Results: SMI was associated with increased risk for having any ACSC-related hospitalization after adjusting for demographics, socioeconomic factors, comorbidities, and prior primary care utilization [incidence rate ratio (IRR): 1.41; 95% confidence interval (95% CI), 1.37-1.45]. Among individual ACSCs, SMI was associated with increased risk for hospitalizations for angina (IRR: 1.14, 95% CI, 1.04-1.25), chronic obstructive pulmonary disease/asthma exacerbation (IRR: 1.87; 95% CI, 1.74-2.00), congestive heart failure exacerbation (IRR: 1.25; 95% CI, 1.16-1.35), and diabetes (IRR: 1.43; 95% CI, 1.31-1.57), appendiceal perforation (IRR: 1.49; 95% CI, 1.30-1.71), pneumonia (IRR: 1.72; 95% CI, 1.66-1.79), and urinary tract infection (IRR: 1.70; 95% CI, 1.62-1.78). SMI was also associated with increased risk for rehospitalization within 30 days for the same (IRR: 1.28; 95% CI, 1.18-1.40) or for another ACSC (IRR: 1.62; 95% CI, 1.49-1.76). Conclusion: Persons with SMI are at increased risk for hospitalizations for ACSCs, and after discharge, are at increased risk for rehospitalizations for ACSCs within 30 days.

Objective The objective was to describe the process of care and treatment outcomes of a 36-year-old man with bipolar disorder treated using a collaborative care model in primary care. Methods We reviewed and summarized relevant clinical data describing the patient’s care including the medical record, consultant’s reports and discussions with treating clinicians. A meeting was held with experienced consulting psychiatrists to discuss the case. Results Several barriers to delivery of high-quality care existed including initial loss to follow-up, few social supports and lack of follow-through at the community mental health center existed, along with presence of factors that negatively influence bipolar disorder outcomes including initial unopposed antidepressant use at baseline, concurrent alcohol use and co-occurring anxiety symptoms. Despite these barriers, the collaborative care team was able to engage the patient in care and achieve the patient’s and team’s treatment goals. Conclusion Delivery of primary-care-based collaborative care was associated with reduction of bipolar disorder symptoms and improved functioning in a patient with bipolar disorder.

This study aimed to describe the characteristics of primary care patients with bipolar disorder enrolled in a statewide mental health integration program (MHIP).With the Composite International Diagnostic Interview (Version 3.0) and clinician diagnosis, 740 primary care patients with bipolar disorder were identified in Washington State between January 2008 and December 2011. Clinical rating scales were administered to patients at the time of enrollment and during treatment. Quality-of-care outcomes were obtained from a systematic review of the patient disease registry and compared with a previous study of patients with depressive symptoms in an MHIP. Descriptive analysis techniques were used to describe patients' clinical characteristics.Primary care patients with bipolar disorder had high symptom severity on depression and anxiety measures: Patient Health Questionaire-9 (mean±SD score of 18.1±5.9 out of 27) and the seven-item Generalized Anxiety Disorder scale (15.7±4.7 out of 21). Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Only 26% of patients were referred to specialty mental health treatment. Patients with bipolar disorder had a greater amount of contact with clinicians during treatment compared with patients with depressive symptoms from a prior study.Primary care patients with bipolar disorder enrolled in MHIP had severe depression, symptoms of comorbid psychiatric illnesses, and multiple psychosocial problems. Patients with bipolar disorder received more intensive care compared with patients with depressive symptoms from a prior study. Referral to a community mental health center occurred infrequently even though most patients had persistent symptoms.

The prevalence of smoking is higher in patients with psychiatric illness compared with the general population. Smoking causes chronic illnesses, which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with a psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques for implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider when treating tobacco use disorders in patients with psychiatric illness.

Objective To systematically review the literature to determine if health risk behaviors in patients with schizophrenia or bipolar disorder are associated with subsequent symptom burden or level of functioning. Method Using the PRISMA systematic review method we searched PubMed, Cochrane, PsychInfo and EMBASE databases with key words: health risk behaviors, diet, obesity, overweight, BMI, smoking, tobacco use, cigarette use, sedentary lifestyle, sedentary behaviors, physical inactivity, activity level, fitness, sitting AND schizophrenia, bipolar disorder, bipolar illness, schizoaffective disorder, severe and persistent mental illness, and psychotic to identify prospective, controlled studies of greater than 6 months duration. Included studies examined associations between sedentary lifestyle, smoking, obesity, physical inactivity and subsequent symptom severity or functional impairment in patients with schizophrenia or bipolar disorder. Results Eight of the 2130 articles identified met inclusion criteria and included 508 patients with a health risk behavior and 825 controls. Six studies examined tobacco use, and two studies examined weight gain/obesity. Seven studies found that patients with schizophrenia or bipolar illness and at least one health risk behavior had more severe subsequent psychiatric symptoms and/or decreased level of functioning. Conclusion Tobacco use and weight gain/obesity may be associated with increased severity of symptoms of schizophrenia and bipolar disorder or decreased level of functioning.

Objective To review published cases and prospective studies describing the use of varenicline in patients with schizophrenia and schizoaffective disorder. Data sources PubMed, PsychINFO, and the Cochrane Database were searched in July 2011 using the key words schizophrenia, schizoaffective disorder, psychosis, positive symptoms, negative symptoms, aggression, hostility, suicidal ideation AND varenicline to identify reports published between January 2006 and July 2011 in English. Study selection Five case reports, 1 case series, 1 retrospective study, 10 prospective studies (17 publications), and 1 meeting abstract describing the use of varenicline in patients with schizophrenia or schizoaffective disorder were identified. Review articles and articles describing findings other than the use of varenicline in patients with schizophrenia or schizoaffective disorder were excluded. Thirteen reports were included in the final analysis. Data extraction Information on each study's patient population, age, diagnosis, medication treatment, tobacco use history, adverse effects, and outcome was collected from the published reports. Results Of the 260 patients with schizophrenia or schizoaffective disorder who received varenicline in these published reports, 13 patients (5%) experienced the onset or worsening of any psychiatric symptom, although 3 of the 13 patients experienced a very brief negative effect after 1 dose. No patients experienced suicidal ideation or suicidal behaviors. Conclusions Published reports suggest that, in most stable, closely monitored patients with schizophrenia or schizoaffective disorder, varenicline treatment is not associated with worsening of psychiatric symptoms. Current, prospective studies are assessing effectiveness and further assessing safety in this population.