We feel the need to raise two key issues regarding the management of depression at a primary care level. First, the importance of recognising occult bipolar II disorder (depression with episodes of hypomania) in a primary care setting. Such patients often present with episodes of major depression and thus screening for symptoms of hypomania may be overlooked. Moreover, there may be a lack of recognition by the patient of their, often quite brief, hypomanic episodes particularly in their depressed state. The treatment for bipolar II disorder, however, differs significantly from that of patients with major depression: mood stabilisers versus antidepressants. Besides, treating bipolar II patients with the standard cocktail of antidepressants runs the risk of driving such individuals into rapid cycling and mixed affective states. Notably, these states are associated with a high risk of suicidality and hence the importance of not missing bipolar II disorder.
Second, there is a growing body of evidence suggesting the adoption of a collaborative (shared care) model in depression management. This involves the introduction of case managers (mental health workers who are responsible for regularly following up patients, offering psychotherapy, and medication management) working with GPs. From our own experience in Luton, we found the deployment of community mental health nurses in both the primary and secondary care settings acting as both case managers and as a liaison between both teams produced high levels of patient satisfaction, and GPs felt a reduced need for referral to specialist services.1 Such an approach to care would help to better manage potential occult bipolar II patients as well as the risk of patients running into mixed affective or rapid cycling states. Furthermore, there is strong evidence indicating the clinical effectiveness of collaborative care, with regard to short and long-term depression outcomes2 as well as cost savings3 for major episodes of depression. However, further randomised controlled trials in a UK setting would be needed to ratify the utility of adopting a collaborative care approach to depression and bipolar II disorder in the NHS.
- © British Journal of General Practice, January 2011
