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Recognizing and meeting the needs of patients with mood disorders and comorbid medical illness: a consensus conference of the Depression and Bipolar Support Alliance
COMMENTARY Recognizing and Meeting the Needs of Patients with Mood Disorders and Comorbid Medical Illness: A Consensus Conference of the Depression and Bipolar Support Alliance The articles contributed to this issue of Biological Psychiatry were prepared for a Consensus Conference convened by the Depression and Bipolar Support Alliance (DBSA)1 in November of 2002. As the largest organization advocating for patients with mood disorders, DBSA has long been concerned about the lack of medical knowledge and patient awareness regarding the consequences of mood disorders coexisting with medical illnesses. The Depression and Bipolar Support Alliance brought together leading experts to explore the connection between “mental” and “physical” illnesses, with the goal of increasing physician and patient knowledge regarding the co-occurrence of these illnesses and their impact on course and outcomes. Because 48% of the general public have never heard of bipolar disorder (Depression and Bipolar Support Alliance 2002), thousands, perhaps millions, are undiagnosed and that millions more are misdiagnosed. If an individual is not aware he or she has a mood disorder, the possibility of uncovering a medical comorbidity is slight. It is obvious that these people have no knowledge of the impact medical illnesses have on mood disorders and vice versa. The Depression and Bipolar Support Alliance doubts, that the majority of those diagnosed have any greater understanding of this impact. This lack of knowledge is critical. If patients know that by treating mood disorders concurrently with their heart disease, diabetes, cancer, or other illness, the course and outcomes of both illnesses can significantly improve, their willingness to accept and adhere with treatment can improve. Likewise, if doctors know the importance of 1
The Depression and Bipolar Support Alliance (DBSA) is the leading patientdirected national organization focusing on the most prevalent mental illnesses— depression and bipolar disorder. The Depression and Bipolar Support Alliance’s mission is to improve the lives of people living with mood disorders. Incorporated in 1986 as a 501(c)(3) organization, DBSA fosters an environment of understanding about the impact and management of these life-threatening illnesses by providing up-to-date, scientifically based tools and information, written in easy to understand language. The Depression and Bipolar Support Alliance has more than 1000 peer-run support groups across the country. Assisted by a Scientific Advisory Board comprised of the leading researchers and clinicians in the field of mood disorders, DBSA supports research to promote more timely diagnosis, to develop more effective and tolerable treatments, and to discover a cure. The organization works to ensure that people living with mood disorders are treated equitably. Over 2 million people request and receive information and assistance from DBSA each year.
© 2003 Society of Biological Psychiatry
treating both illnesses concurrently, they can create better, more effective treatment plans leading to better adherence and better outcomes. While there are primary care providers and medical specialists who are knowledgeable about the connection between mental and physical health, DBSA believes the majority of physicians need additional education that includes the most recent research findings. We base this supposition on the lack of knowledge physicians have about mood disorders, particularly bipolar disorder. A DBSA survey found a 10-year gap between onset of symptoms and correct diagnosis of bipolar disorder. Of those who were misdiagnosed, 79% reported that a psychiatrist made at least one of the misdiagnoses (Depression and Bipolar Support Alliance 2001). Misdiagnosis of bipolar disorder by primary care physicians could be as high, if not higher, as 73% of primary care physicians report it is somewhat or very difficult to diagnose bipolar disorder (National Depressive and Manic-Depressive Association 2000). A lack of knowledge about mood disorders among the general public makes it even more important that primary care physicians and medical specialists ask their patients if they have any co-occurring illnesses, including any mental illnesses. Psychiatrists also need to ask their patients about their general health. There is a belief that psychiatrists never look below the neck, yet as these articles show, this is critical. If comorbidity exists, treatment plans must be amended accordingly. At this time, psychiatrists need to be certain that patients understand the relationship between their mood disorder and their comorbid illnesses. By having this information, patients can better understand changes to their treatment plans and make certain all is being done to help them. Because comorbidity involves a third party, the primary care physician or medical specialist, DBSA encourages physicians to talk to their patients about the importance of collaboration among all the professionals treating them. Request permission to contact their other professionals and then follow through with a call. A common complaint is that doctors and therapists do not talk to each other. This is especially important once patients and their families are 0006-3223/03/$30.00 doi:10.1016/S0006-3223(03)00567-5
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Commentary
BIOL PSYCHIATRY 2003;54:181–183
educated about the interaction of mood disorders and co-occurring medical illnesses. The Depression and Bipolar Support Alliance believes patients must be equal partners in the treatment of their mood disorders to achieve optimal wellness. Establishing such a partnership has its challenges, and as DBSA’s data show, there is a discrepancy between doctors’ and patients’ perceptions of partnership and communication in treatment. When asked how decisions are actually made about the treatment of depression, 71% of primary care physicians say they make treatment decisions jointly with their patients, yet only 54% of patients say that this is the way their treatment decisions are managed (National Depressive and Manic-Depressive Association 2000). Sixty-six percent of those diagnosed with depression or bipolar disorder indicated they would like their psychiatrist to listen better (Depression and Bipolar Support Alliance 2003). A DBSA survey of 1000 patients treated for depression in a primary care setting revealed that treatment adherence is directly proportional to treatment satisfaction. In the same survey, 75% of patients who were very satisfied with their physician reported fully understanding the issues surrounding their illness (National Depressive and ManicDepressive Association 2000). When treatment includes empathy, concern, patience, respect, and kindness on the part of physicians, patients are more likely to be satisfied with treatment and more likely to adhere to it. This is especially significant when there is a medical comorbidity. Talking with a medical specialist can be particularly frightening for a person with a comorbidity, and patients often do not hear what their physicians are saying. An empathic “bedside manner” takes little or no time and does not cost the patient anything. The results are well worth this approach. Physicians should uncover patients’ unique needs through direct questions. To help patients focus, targeted questions should be asked. And, when patients ask their physicians targeted questions, physicians should suggest the patients write the answers down. The Depression and Bipolar Support Alliance acknowledges that discussions about mood disorders and comorbid illnesses can be time-consuming and that patients are not always forthcoming about their symptoms; however, as these articles indicate, it is critical that the treatment of a patient’s mood disorder be included in the development of any treatment plan. Physicians often believe that asking the simple question, “How are you feeling?” will initiate conversations in which their patient will discuss all their concerns; however, for the depressed patient, mood is so integrated into all aspects of his or her life, their depression may not seem abnormal. Asking more direct questions such as, “Have
you been sad or irritable?” or “Are you depressed?” can be effective in identifying depressed mood. Alternately, doctors who are effective in identifying depressed mood may not be asking questions that would identify periods of mania. Simply asking, “Have you had periods of restlessness or racing thoughts?” when faced with a patient with a depressed mood can go a long way in indicating the possibility of bipolar disorder. The stress and anxiety of having a medical comorbidity can mean difficulty in retaining important information. A DBSA survey indicated that 84% of patients would like to receive written materials, yet only 42% report having received any (Depression and Bipolar Support Alliance 2003). All physicians, primary care and medical specialists, as well as psychiatrists, should provide written information about the issues of medical comorbidity. The Depression and Bipolar Support Alliance offers a variety of printed materials on mood disorders that can be obtained free of charge by calling (800) 826-3632. In addition, our excellent web site—www.DBSAlliance.org— offers fact sheets about depression and more than 1 dozen co-occurring medical illnesses, and, like all our printed materials, the fact sheets can be downloaded free of charge. Because DBSA is patient-directed and patient run, all our materials resonate with patients’ emotions and needs, and all are written in a language patients and their families can understand. We need your help. The circulation of Biological Psychiatry is approximately 1700 with greater than 90% of its readers psychiatrists. Because this journal is primarily focused on psychiatric neuroscience, few physicians outside of psychiatry will see these articles. Those with the greatest need to know must have access to this information. Biological Psychiatry is readily accessible through institutional subscriptions and the internet, and copies of this issue are available by calling DBSA at (800) 8263632. Please share this information with your colleagues and those who may otherwise not have it.
Conclusion Although part of the human body, the brain is far too often treated as a separate entity. The consensus statement DBSA will publish will be a critical step in breaking down the stigma and ignorance that erroneously separates “physical” and “mental” illnesses by showing their integral connection. Because of physicians’ time constraints and lack of knowledge about the connections, DBSA believes that the empowered, knowledgeable patient must be the catalyst for exploring mood disorders in the medically ill. Once the dialogue has been initiated, we strongly believe that a positive patient/physician relationship is key to successful outcomes and urge all health care providers to incorporate
Commentary
these patient suggestions to help every one of their patients with medical comorbidities receive the best treatment possible. Lydia Lewis President Depression and Bipolar Support Alliance 730 North Franklin Street Chicago, IL 60610
BIOL PSYCHIATRY 2003;54:181–183
183
References Depression and Bipolar Support Alliance (2002): General Public Survey (Report). Chicago, IL: DBSA. Depression and Bipolar Support Alliance (2003): Treatment Satisfaction Survey (Report). Chicago, IL: DBSA. National Depressive and Manic-Depressive Association (2000): Beyond Diagnosis: Depression and Treatment (Report). Chicago, IL: NDMDA.
The Depression and Bipolar Support Alliance (DBSA) is the leading patientdirected national organization focusing on the most prevalent mental illnesses— depression and bipolar disorder. The Depression and Bipolar Support Alliance’s mission is to improve the lives of people living with mood disorders. Incorporated in 1986 as a 501(c)(3) organization, DBSA fosters an environment of understanding about the impact and management of these life-threatening illnesses by providing up-to-date, scientifically based tools and information, written in easy to understand language. The Depression and Bipolar Support Alliance has more than 1000 peer-run support groups across the country. Assisted by a Scientific Advisory Board comprised of the leading researchers and clinicians in the field of mood disorders, DBSA supports research to promote more timely diagnosis, to develop more effective and tolerable treatments, and to discover a cure. The organization works to ensure that people living with mood disorders are treated equitably. Over 2 million people request and receive information and assistance from DBSA each year.
© 2003 Society of Biological Psychiatry
treating both illnesses concurrently, they can create better, more effective treatment plans leading to better adherence and better outcomes. While there are primary care providers and medical specialists who are knowledgeable about the connection between mental and physical health, DBSA believes the majority of physicians need additional education that includes the most recent research findings. We base this supposition on the lack of knowledge physicians have about mood disorders, particularly bipolar disorder. A DBSA survey found a 10-year gap between onset of symptoms and correct diagnosis of bipolar disorder. Of those who were misdiagnosed, 79% reported that a psychiatrist made at least one of the misdiagnoses (Depression and Bipolar Support Alliance 2001). Misdiagnosis of bipolar disorder by primary care physicians could be as high, if not higher, as 73% of primary care physicians report it is somewhat or very difficult to diagnose bipolar disorder (National Depressive and Manic-Depressive Association 2000). A lack of knowledge about mood disorders among the general public makes it even more important that primary care physicians and medical specialists ask their patients if they have any co-occurring illnesses, including any mental illnesses. Psychiatrists also need to ask their patients about their general health. There is a belief that psychiatrists never look below the neck, yet as these articles show, this is critical. If comorbidity exists, treatment plans must be amended accordingly. At this time, psychiatrists need to be certain that patients understand the relationship between their mood disorder and their comorbid illnesses. By having this information, patients can better understand changes to their treatment plans and make certain all is being done to help them. Because comorbidity involves a third party, the primary care physician or medical specialist, DBSA encourages physicians to talk to their patients about the importance of collaboration among all the professionals treating them. Request permission to contact their other professionals and then follow through with a call. A common complaint is that doctors and therapists do not talk to each other. This is especially important once patients and their families are 0006-3223/03/$30.00 doi:10.1016/S0006-3223(03)00567-5
182
Commentary
BIOL PSYCHIATRY 2003;54:181–183
educated about the interaction of mood disorders and co-occurring medical illnesses. The Depression and Bipolar Support Alliance believes patients must be equal partners in the treatment of their mood disorders to achieve optimal wellness. Establishing such a partnership has its challenges, and as DBSA’s data show, there is a discrepancy between doctors’ and patients’ perceptions of partnership and communication in treatment. When asked how decisions are actually made about the treatment of depression, 71% of primary care physicians say they make treatment decisions jointly with their patients, yet only 54% of patients say that this is the way their treatment decisions are managed (National Depressive and Manic-Depressive Association 2000). Sixty-six percent of those diagnosed with depression or bipolar disorder indicated they would like their psychiatrist to listen better (Depression and Bipolar Support Alliance 2003). A DBSA survey of 1000 patients treated for depression in a primary care setting revealed that treatment adherence is directly proportional to treatment satisfaction. In the same survey, 75% of patients who were very satisfied with their physician reported fully understanding the issues surrounding their illness (National Depressive and ManicDepressive Association 2000). When treatment includes empathy, concern, patience, respect, and kindness on the part of physicians, patients are more likely to be satisfied with treatment and more likely to adhere to it. This is especially significant when there is a medical comorbidity. Talking with a medical specialist can be particularly frightening for a person with a comorbidity, and patients often do not hear what their physicians are saying. An empathic “bedside manner” takes little or no time and does not cost the patient anything. The results are well worth this approach. Physicians should uncover patients’ unique needs through direct questions. To help patients focus, targeted questions should be asked. And, when patients ask their physicians targeted questions, physicians should suggest the patients write the answers down. The Depression and Bipolar Support Alliance acknowledges that discussions about mood disorders and comorbid illnesses can be time-consuming and that patients are not always forthcoming about their symptoms; however, as these articles indicate, it is critical that the treatment of a patient’s mood disorder be included in the development of any treatment plan. Physicians often believe that asking the simple question, “How are you feeling?” will initiate conversations in which their patient will discuss all their concerns; however, for the depressed patient, mood is so integrated into all aspects of his or her life, their depression may not seem abnormal. Asking more direct questions such as, “Have
you been sad or irritable?” or “Are you depressed?” can be effective in identifying depressed mood. Alternately, doctors who are effective in identifying depressed mood may not be asking questions that would identify periods of mania. Simply asking, “Have you had periods of restlessness or racing thoughts?” when faced with a patient with a depressed mood can go a long way in indicating the possibility of bipolar disorder. The stress and anxiety of having a medical comorbidity can mean difficulty in retaining important information. A DBSA survey indicated that 84% of patients would like to receive written materials, yet only 42% report having received any (Depression and Bipolar Support Alliance 2003). All physicians, primary care and medical specialists, as well as psychiatrists, should provide written information about the issues of medical comorbidity. The Depression and Bipolar Support Alliance offers a variety of printed materials on mood disorders that can be obtained free of charge by calling (800) 826-3632. In addition, our excellent web site—www.DBSAlliance.org— offers fact sheets about depression and more than 1 dozen co-occurring medical illnesses, and, like all our printed materials, the fact sheets can be downloaded free of charge. Because DBSA is patient-directed and patient run, all our materials resonate with patients’ emotions and needs, and all are written in a language patients and their families can understand. We need your help. The circulation of Biological Psychiatry is approximately 1700 with greater than 90% of its readers psychiatrists. Because this journal is primarily focused on psychiatric neuroscience, few physicians outside of psychiatry will see these articles. Those with the greatest need to know must have access to this information. Biological Psychiatry is readily accessible through institutional subscriptions and the internet, and copies of this issue are available by calling DBSA at (800) 8263632. Please share this information with your colleagues and those who may otherwise not have it.
Conclusion Although part of the human body, the brain is far too often treated as a separate entity. The consensus statement DBSA will publish will be a critical step in breaking down the stigma and ignorance that erroneously separates “physical” and “mental” illnesses by showing their integral connection. Because of physicians’ time constraints and lack of knowledge about the connections, DBSA believes that the empowered, knowledgeable patient must be the catalyst for exploring mood disorders in the medically ill. Once the dialogue has been initiated, we strongly believe that a positive patient/physician relationship is key to successful outcomes and urge all health care providers to incorporate
Commentary
these patient suggestions to help every one of their patients with medical comorbidities receive the best treatment possible. Lydia Lewis President Depression and Bipolar Support Alliance 730 North Franklin Street Chicago, IL 60610
BIOL PSYCHIATRY 2003;54:181–183
183
References Depression and Bipolar Support Alliance (2002): General Public Survey (Report). Chicago, IL: DBSA. Depression and Bipolar Support Alliance (2003): Treatment Satisfaction Survey (Report). Chicago, IL: DBSA. National Depressive and Manic-Depressive Association (2000): Beyond Diagnosis: Depression and Treatment (Report). Chicago, IL: NDMDA.