Individuals with bipolar disorder (BD) or posttraumatic stress disorder (PTSD) often present for treatment in primary care settings, particularly in safety net primary care clinics where there is a high prevalence of both disorders, explains Joseph M. Cerimele, MD, MPH. “Clinicians and clinic systems are starting to use screening instruments to identify individuals with these disorders,” Dr. Cerimele said. “[For a study published in General Hospital Psychiatry,] we observed patients with positive and negative screening results on commonly used instruments and compared those with psychiatrist-determined clinical diagnoses. This is critical because clinicians want to know common diagnoses associated with positive screening results, since treatments can differ based on diagnosis.”
Such individuals, Dr. Cerimele and colleagues note, are at risk of receiving lower-quality care in primary care than in mental health specialty care, partly due to problems with detection of PTSD and BD. “Most individuals screening positive for PTSD and/or BD have had two or more psychiatric diagnoses,” says Dr. Cerimele. “In addition, misclassification exists for both the PTSD Checklist (PCL-6) and Composite International Diagnostic Interview 3.0 (CIDI).”
Screening Tests, Assessment Surveys & Psychiatric Consults
For their study, Dr. Cerimele and colleagues aimed to describe clinical diagnoses from telepsychiatrist consultation in safety net primary care settings for adult patients screening positive for BD, PTSD, or both. Patients participated in the Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT), a randomized, pragmatic, comparative effectiveness study conducted in 12 Federally Qualified Health Centers (FQHCs) in three states. FQHCs are safety-net primary care clinics that provide care to 26 million individuals. Almost one-half (44%) of FQHC patients live in rural areas, 90% live in poverty, and 59% identify as racial and/or ethnic minorities.
Patients were administered the PCL-6 and the CIDI for BD. Positive screening result definitions were a PCL-6 score of 14 or greater and CIDI positive stem question responses and score of 8 or greater. Patient characteristics were assessed by survey. Psychiatrists consulted in primary care via telehealth and recorded clinical diagnoses.
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 BD diagnosis occurring more often in those screening CIDI positive compared with negative (42% vs 15%). Positive predictive values were 64.9% for PCL-6 and 43.8% for CIDI.
Positive Results “Shifted the Distribution” of Diagnoses
“We found that a positive result on the BD screening measure ‘shifted the distribution’ of mood disorder diagnoses,” Dr. Cerimele says. “In patients screening negative on the CIDI instrument, the ratio of major depression to BD diagnoses was about 4:1. In those screening positive, the ratio was about 1:1. Therefore, some patients with negative screening results were still diagnosed with BD, and many patients screening positive were not diagnosed with BD, but the shift in distribution is informative.”
Consultation with a psychiatrist early in treatment for individuals screening positive on the PCL-6 and/or CIDI could help clarify diagnoses and improve treatment planning, Dr. Cerimele notes.
The study team would like to see future research include the evaluation of clinical characteristics of individuals diagnosed with BD who screened negative on the CIDI measure, those diagnosed with PTSD who screened negative on the PCL-6, prospective observation of diagnoses beyond initial consultation, and strategies to improve accurate diagnosis for individuals screening positive. “Another potential next step would be to observe any changes in diagnoses over time,” adds Dr. Cerimele.