Thanks for this really thorough and insightful proposal. I’m sympathetic with your sense of the scope of the problem. My readings suggest that the total burden of bipolar disorders is around 9 million DALYs per year, so the proposal that BSD misdiagnosed as depression is around 3 million DALYs per year seems plausible. So it’s a major problem. I have some questions about implementation, especially outside of developed countries:
• My primary concern is that this is one of a family of problems arising from a lack of psychiatrists, even in developed countries. A lot of your proposal aims at improving the psychiatric expertise/education of GP’s, but even your positive proposal includes a referral to a psychiatrist. My thought is that this might be workable in the UK, but it would be unworkable at the global level where the availability of psychiatrists is even lower. You address this in your proposal about “offshoring,” but of course that just defers the problem (if the UK offshores to Poland, who does Poland offshore to, etc.).
I wonder whether resources might be better invested in a trans-diagnostic approach, which increases training and licensing for mid-level psychiatric experts (these are psychiatric NP’s in the US system). This would potentially address the variety of psychiatric conditions that are not ideally treated in primary care, especially with an eye towards the global level.
• It bears noting that (as I understand it) this is ultimately a problem for pharmeceutical approaches. The standard medications for unipolar depression don’t work for BSD, so misdiagnosis leads to mistreatment. But (to my knowledge) depression is responsive to CBT/ACT whether or not it is unipolar or bipolar. So, for non-pharmeceutical approaches to depression, the question of misdiagnosis is less significant. Given the effectiveness of those treatment (and their low-cost and scalability), shouldn’t thinking about BSD lead us to allocate a greater percentage of resources to non-pharmaceutical approaches to depression?
Thanks again for this illuminating post, I hope these preliminary reactions are useful.
Thank you for your comment, you make some really good points!
When it comes to the lack of psychiatrists: I agree it’s a very difficult issue and I’m not trying to solve it here, but rather sidestep it. I do include a psychiatrist referral in my proposal, but I completely understand that the best one could hope for there is helping the patient see an overworked NHS psychiatrist e.g. in a year rather than two years. The main element of my proposal is having the GP be able to directly prescribe bipolar-appropriate medication, without necessitating the involvment of a psychiatrist. This is what already happens with unipolar depression and antidepressants, and the fact that it’s possible in primary care averts a massive amount of suffering and lessens the load on the secondary care psychiatric system.
I haven’t thought about including NPs in my analaysis, thanks for pointing out this possibility. As far as I understand, in the UK they mostly work in mental health institutions, so a BSD patient would be unlikely to encounter them unless they make a suicide attempt. I need to look into how it works in other countries.
It’s really difficult to determine how effective therapy is compared to medications; I’d love to see a large clinical trial comparing BSD patients’ outcomes on placebo, lamotrigine, SSRIs, a few other medications, therapies like CBT or IPSRT, following the cohort for a good few years, studying whether people who didn’t improve on one type of treatment improve on another etc. I don’t think we’ll ever get such comprehensive data; we’re stumbling in the dark and it’s quite frustrating.
I definitely agree that many depressions, unipolar or bipolar, improve on CBT, but I’m quite sure there is a percentage of patients with BSD (or depression, for that matter), where the problem is almost purely physiological (some kind of chemical imbalance in the brain) rather than psychological—so relying solely on therapy would be like trying to therapise away cancer or diabetes. How big is this percentage, and how does it compare to BSD cases amenable to therapy? We don’t have enough data to say.
I also think that pursuing non-pharmaceutical approaches to depression is somewhat less neglected than advocating for improving access to medication, including in EA circles, hence my focus on the latter.
Thanks for this really thorough and insightful proposal. I’m sympathetic with your sense of the scope of the problem. My readings suggest that the total burden of bipolar disorders is around 9 million DALYs per year, so the proposal that BSD misdiagnosed as depression is around 3 million DALYs per year seems plausible. So it’s a major problem. I have some questions about implementation, especially outside of developed countries:
• My primary concern is that this is one of a family of problems arising from a lack of psychiatrists, even in developed countries. A lot of your proposal aims at improving the psychiatric expertise/education of GP’s, but even your positive proposal includes a referral to a psychiatrist. My thought is that this might be workable in the UK, but it would be unworkable at the global level where the availability of psychiatrists is even lower. You address this in your proposal about “offshoring,” but of course that just defers the problem (if the UK offshores to Poland, who does Poland offshore to, etc.).
I wonder whether resources might be better invested in a trans-diagnostic approach, which increases training and licensing for mid-level psychiatric experts (these are psychiatric NP’s in the US system). This would potentially address the variety of psychiatric conditions that are not ideally treated in primary care, especially with an eye towards the global level.
• It bears noting that (as I understand it) this is ultimately a problem for pharmeceutical approaches. The standard medications for unipolar depression don’t work for BSD, so misdiagnosis leads to mistreatment. But (to my knowledge) depression is responsive to CBT/ACT whether or not it is unipolar or bipolar. So, for non-pharmeceutical approaches to depression, the question of misdiagnosis is less significant. Given the effectiveness of those treatment (and their low-cost and scalability), shouldn’t thinking about BSD lead us to allocate a greater percentage of resources to non-pharmaceutical approaches to depression?
Thanks again for this illuminating post, I hope these preliminary reactions are useful.
Thank you for your comment, you make some really good points!
When it comes to the lack of psychiatrists: I agree it’s a very difficult issue and I’m not trying to solve it here, but rather sidestep it. I do include a psychiatrist referral in my proposal, but I completely understand that the best one could hope for there is helping the patient see an overworked NHS psychiatrist e.g. in a year rather than two years. The main element of my proposal is having the GP be able to directly prescribe bipolar-appropriate medication, without necessitating the involvment of a psychiatrist. This is what already happens with unipolar depression and antidepressants, and the fact that it’s possible in primary care averts a massive amount of suffering and lessens the load on the secondary care psychiatric system.
I haven’t thought about including NPs in my analaysis, thanks for pointing out this possibility. As far as I understand, in the UK they mostly work in mental health institutions, so a BSD patient would be unlikely to encounter them unless they make a suicide attempt. I need to look into how it works in other countries.
It’s really difficult to determine how effective therapy is compared to medications; I’d love to see a large clinical trial comparing BSD patients’ outcomes on placebo, lamotrigine, SSRIs, a few other medications, therapies like CBT or IPSRT, following the cohort for a good few years, studying whether people who didn’t improve on one type of treatment improve on another etc. I don’t think we’ll ever get such comprehensive data; we’re stumbling in the dark and it’s quite frustrating.
I definitely agree that many depressions, unipolar or bipolar, improve on CBT, but I’m quite sure there is a percentage of patients with BSD (or depression, for that matter), where the problem is almost purely physiological (some kind of chemical imbalance in the brain) rather than psychological—so relying solely on therapy would be like trying to therapise away cancer or diabetes. How big is this percentage, and how does it compare to BSD cases amenable to therapy? We don’t have enough data to say.
I also think that pursuing non-pharmaceutical approaches to depression is somewhat less neglected than advocating for improving access to medication, including in EA circles, hence my focus on the latter.