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Hypomanic symptoms in early pregnancy: prevalence and associated factors. Arch Womens Ment Health 2021; 24:463-471. [PMID: 33094351 DOI: 10.1007/s00737-020-01078-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
Given that the perinatal period is a time of increased risk for pregnant women to manifest mental health problems, the identification of antenatal hypomanic symptoms is particularly important. However, data on antenatal hypomanic symptoms is lacking. The present study was aimed at filling this research gap by investigating the prevalence of hypomanic symptoms, including the "active-elated" and "irritable/risk-taking" sides of hypomanic symptoms at the first trimester, and examining their associations with anxiety and depressive symptoms at the following time points: the first trimester, the second trimester, and up to 6-week postpartum. A prospective longitudinal design with a quantitative approach was adopted. A consecutive sample of 229 pregnant Chinese women in Hong Kong was assessed. Hypomanic symptoms were assessed with the Hypomania Checklist-32 (HCL-32). Of the sample, 43.6% had elevated levels of hypomanic symptoms in the first trimester. Multiple regression analysis showed that after adjusting for potential confounding factors, irritable/risk-taking symptoms were independently associated with higher anxiety symptoms in the first and second trimesters and in the 6-week postpartum period. Primary healthcare practitioners should be made aware of antenatal hypomanic symptoms in pregnant women to facilitate early identification and intervention for anxiety and depression to improve the well-being of both mothers and infants.
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Unrecognized bipolar disorder in patients with depression managed in primary care: A systematic review and meta-analysis. Gen Hosp Psychiatry 2019; 58:71-76. [PMID: 30933689 DOI: 10.1016/j.genhosppsych.2019.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/17/2019] [Accepted: 03/26/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE Bipolar disorder is a common, severe mental health condition and a major financial burden for healthcare systems across the globe. There is some evidence that unrecognized bipolar disorder is prevalent amongst patients with depression in primary care which can lead to non-optimal treatment. However, a systematic synthesis of this literature is lacking. We aimed to determine the percentage of primary care patients who are diagnosed with depression that have unrecognized bipolar disorder. METHODS Medline, Embase, Cochrane and PsycINFO were searched to January 2019. We included quantitative observational studies. Risk of bias was assessed using the Newcastle Ottawa cohort scale. Analyses were performed using random-effects models, heterogeneity was quantified using I2 and formal tests of publication bias were undertaken. RESULTS Ten studies with 3803 participants with depression in primary care were included. The pooled prevalence of bipolar disorder in those with depression was 17% (95% CI = 12 to 22). The prevalence of unrecognized bipolar depression was higher in studies which used questionnaires as assessment tools for bipolar disorder compared to studies which used clinical interviews but this difference was not significant (14%, 95% CI = 8 to 20 versus 22%, 95% CI = 16 to 28, Q = 1.27, p = 0.12). The prevalence of unrecognized bipolar disorder was not significantly affected by study-level variations in the risk of bias and we found no evidence for publication bias. CONCLUSION Over 3 in 20 patients with depression have unrecognized bipolar disorder in primary care which can lead to harmful patient outcomes. Increased awareness of unrecognition of bipolar disorder in primary care patients with depression and efficient assessment strategies in primary care are warranted.
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Dubovsky SL. Applications of calcium channel blockers in psychiatry: pharmacokinetic and pharmacodynamic aspects of treatment of bipolar disorder. Expert Opin Drug Metab Toxicol 2018; 15:35-47. [PMID: 30558453 DOI: 10.1080/17425255.2019.1558206] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Calcium channel blockers (CCBs) comprise a heterogeneous group of medications that reduce calcium influx and attenuate cellular hyperactivity. Evidence of hyperactive intracellular calcium ion signaling in multiple peripheral cells of patients with bipolar disorder, calcium antagonist actions of established mood stabilizers, and a relative dearth of treatments have prompted research into potential uses of CCBs for this common and disabling condition. Areas covered: This review provides a comprehensive overview of intracellular calcium signaling in bipolar disorder, structure and function of calcium channels, pharmacology of CCBs, evidence of efficacy of CCBs in bipolar disorder, clinical applications, and directions for future research. Expert opinion: Despite mixed evidence of efficacy, CCBs are a promising novel approach to a demonstrated cellular abnormality in both poles of bipolar disorder. Potential advantages include low potential for sedation and weight gain, and possible usefulness for pregnant and neurologically impaired patients. Further research should focus on markers of a preferential response, studies in specific bipolar subtypes, development of CCBs acting preferentially in the central nervous system and on calcium channels that are primarily involved in neuronal signaling and plasticity.
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Affiliation(s)
- Steven L Dubovsky
- a Department of Psychiatry , State University of New York at Buffalo , Buffalo , NY , USA.,b Departments of Psychiatry and Medicine , University of Colorado , Denver , CO , USA
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de Jesus JR, Galazzi RM, de Lima TB, Banzato CEM, de Almeida Lima E Silva LF, de Rosalmeida Dantas C, Gozzo FC, Arruda MAZ. Simplifying the human serum proteome for discriminating patients with bipolar disorder of other psychiatry conditions. Clin Biochem 2017; 50:1118-1125. [PMID: 28662995 DOI: 10.1016/j.clinbiochem.2017.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/22/2017] [Accepted: 06/25/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE An exploratory analysis using proteomic strategies in blood serum of patients with bipolar disorder (BD), and with other psychiatric conditions such as Schizophrenia (SCZ), can provide a better understanding of this disorder, as well as their discrimination based on their proteomic profile. METHODS The proteomic profile of blood serum samples obtained from patients with BD using lithium or other drugs (N=14), healthy controls, including non-family (HCNF; N=3) and family (HCF; N=9), patients with schizophrenia (SCZ; N=23), and patients using lithium for other psychiatric conditions (OD; N=4) were compared. Four methods for simplifying the serum samples proteome were evaluated for both removing the most abundant proteins and for enriching those of lower-abundance: protein depletion with acetonitrile (ACN), dithiothreitol (DTT), sequential depletion using DTT and ACN, and protein equalization using commercial ProteoMiner® kit (PM). For proteomic evaluation, 2-D DIGE and nanoLC-MS/MS analysis were employed. RESULTS PM method was the best strategy for removing proteins of high abundance. Through 2-D DIGE gel image comparison, 37 protein spots were found differentially abundant (p<0.05, Student's t-test), which exhibited ≥2.0-fold change of the average value of normalized spot intensities in the serum of SCZ, BD and OD patients compared to subject controls (HCF and HCNF). From these spots detected, 13 different proteins were identified: ApoA1, ApoE, ApoC3, ApoA4, Samp, SerpinA1, TTR, IgK, Alb, VTN, TR, C4A and C4B. CONCLUSIONS Proteomic analysis allowed the discrimination of patients with BD from patients with other mental disorders, such as SCZ. The findings in this exploratory study may also contribute for better understanding the pathophysiology of these disorders and finding potential serum biomarkers for these conditions.
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Affiliation(s)
- Jemmyson Romário de Jesus
- Spectrometry, Sample Preparation and Mechanization Group - GEPAM, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil; National Institute of Science and Technology for Bioanalytics, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil
| | - Rodrigo Moretto Galazzi
- Spectrometry, Sample Preparation and Mechanization Group - GEPAM, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil; National Institute of Science and Technology for Bioanalytics, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil
| | - Tatiani Brenelli de Lima
- Dalton Mass Spectrometry Group, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil
| | | | | | | | - Fábio Cézar Gozzo
- Dalton Mass Spectrometry Group, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil
| | - Marco Aurélio Zezzi Arruda
- Spectrometry, Sample Preparation and Mechanization Group - GEPAM, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil; National Institute of Science and Technology for Bioanalytics, Institute of Chemistry, University of Campinas - UNICAMP, Campinas, Brazil.
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Aiken CB, Weisler RH, Sachs GS. The Bipolarity Index: a clinician-rated measure of diagnostic confidence. J Affect Disord 2015; 177:59-64. [PMID: 25745836 DOI: 10.1016/j.jad.2015.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 02/05/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND The Bipolarity Index is a clinician-rated scale that rates cardinal features of the disorder across five domains: signs and symptoms, age of onset, course of illness, response to treatment, and family history. We tested the Index in routine clinical practice to identify the optimal cut-off for distinguishing bipolar from non-bipolar disorders. METHOD Sequential patients in a private practice were rated with the Bipolarity Index (n=1903) at intake. Diagnoses were made with the MINI-6.0.0 International Neuropsychiatric Interview according to DSM-IV-TR criteria, except that cases of antidepressant-induced mania and hypomania were included in the bipolar group. A subset completed the self-rated Mood Disorder Questionnaire (MDQ) (n=1620) or Bipolar Spectrum Diagnostic Scale (BSDS) (n=1179). The primary analysis compared Bipolarity Index scores for bipolar vs. non-bipolar patients using receiver operator curves (ROC) to determine the optimal cut-off score. Secondary outcomes repeated this analysis with the MDQ, MDQ-7 (using only the symptomatic items of the MDQ) and BSDS. RESULTS At a cut-off of ≥50, the Bipolarity Index had a high sensitivity (0.91) and specificity (0.90). Optimal cut-offs for self-rated scales were: MDQ: ≥7 (sensitivity 0.74, specificity 0.71); MDQ-7: ≥6 (sensitivity 0.77, specificity 0.77); BSDS: ≥12 (sensitivity 0.71, specificity 0.77). LIMITATIONS The study utilized one rater at a single practice site; the rater was not blinded to the results of the MINI. CONCLUSION The Bipolarity Index can enhance the clinical assessment of mood disorders and, at a score ≥50 has good sensitivity and specificity for identifying bipolar disorders.
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Affiliation(s)
- Chris B Aiken
- Mood Treatment Center, 1615 Polo Road, Winston-Salem, NC 27106, USA; Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Richard H Weisler
- University of North Carolina at Chapel Hill, NC, USA; Duke University Medical Center, Durham, NC, USA
| | - Gary S Sachs
- Bipolar Clinic and Research Program at Massachusetts General Hospital, Boston, MA, USA; Therapeutic Area Leader, Bracket, LLC, Wayne, PA, USA
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Inglis AJ, Hippman CL, Carrion PB, Honer WG, Austin JC. Mania and depression in the perinatal period among women with a history of major depressive disorders. Arch Womens Ment Health 2014; 17:137-43. [PMID: 24402681 PMCID: PMC3961475 DOI: 10.1007/s00737-013-0408-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
Abstract
Women with a history of major depressive disorder (MDD) have increased risks for postpartum depression, but less is known about postpartum mania in this population. The objectives of this study were to prospectively determine the frequency with which mania occurs in the postpartum among women who have a history of MDD and to explore temporal relationships between onset of mania/hypomania and depression. We administered the Structured Clinical Interview for DSM IV disorders (SCID) to pregnant women with a self-reported history of MDD to confirm diagnosis and exclude women with any history of mania/hypomania. Participants completed the Edinburgh Postnatal Depression Scale and Altman Self-Rating Mania Scale (ASRM) once during the pregnancy (∼26 weeks) and 1 week, 1 month, and 3 months postpartum. Among women (n = 107) with a SCID-confirmed diagnosis of MDD, 34.6 % (n = 37) experienced mania/hypomania (defined by an ASRM score of ≥6) at ≥1 time point during the postpartum, and for just over half (20/37, 54 %), onset was during the postpartum. The highest frequency of mania/hypomania (26.4 %, n = 26) was at 1 week postpartum. Women who experienced mania/hypomania at 1 week postpartum had significantly more symptoms of mania/hypomania later in the postpartum. A substantive proportion of women with a history of MDD may experience first onset of mania/hypomania symptoms in the early postpartum, others may experience first onset during pregnancy. Taken with other recent data, these findings suggest a possible rationale for screening women with a history of MDD for mania/hypomania during the early postpartum period, but issues with screening instruments are discussed.
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Affiliation(s)
- Angela J Inglis
- Department of Medical Genetics, University of British Columbia, Vancouver
| | - Catriona L Hippman
- Department of Psychiatry, University of British Columbia, Vancouver,Women’s Health Research Institute, BC Women’s Hospital & Health Centre, Vancouver
| | | | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver
| | - Jehannine C Austin
- Department of Medical Genetics, University of British Columbia, Vancouver,Department of Psychiatry, University of British Columbia, Vancouver
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Screening for Bipolar Disorder Symptoms in Depressed Primary Care Attenders: Comparison between Mood Disorder Questionnaire and Hypomania Checklist (HCL-32). PSYCHIATRY JOURNAL 2013; 2013:548349. [PMID: 24236281 PMCID: PMC3820078 DOI: 10.1155/2013/548349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/10/2013] [Accepted: 03/14/2013] [Indexed: 11/17/2022]
Abstract
Objective. To describe the prevalence of patients who screen positive for bipolar disorder (BD) symptoms in primary care comparing two screening instruments: Mood Disorders Questionnaire (MDQ) and Hypomania Checklist (HCL-32). Participants. Adult patients presenting to their primary care practitioners for any cause and reporting current depression symptoms or a depressive episode in the last 6 months. Methods. Subjects completed MDQ and HCL-32, and clinical diagnosis was assessed by a psychiatrist following DSM-IV criteria. Depressive symptoms were evaluated in a subgroup with the Patient Health Questionnaire (PHQ-9). Results. A total of 94 patients were approached to participate and 93 completed the survey. Among these, 8.9% screened positive with MDQ and 43.0% with HCL-32. MDQ positive had more likely features associated with BD: panic disorder and smoking habit (P < .05). The best test accuracy was performed by cut-off 5 for MDQ (sensitivity = .91; specificity = .67) and 15 for HCL-32 (sensitivity = .64; specificity = .57). Higher total score of PHQ-9 was related to higher total scores at the screening tests (P < .001). Conclusion. There is a significant prevalence of bipolar symptoms in primary care depressed patients. MDQ seems to have better accuracy and feasibility than HCL-32, features that fit well in the busy setting of primary care.
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Homish GG, Marshall D, Dubovsky SL, Leonard K. Predictors of later bipolar disorder in patients with subthreshold symptoms. J Affect Disord 2013; 144:129-33. [PMID: 22842021 DOI: 10.1016/j.jad.2012.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 06/13/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The clinical significance of subthreshold bipolar disorder (SBD), which is characterized by an insufficient number or severity of hypomanic symptoms to qualify for a formal bipolar disorder diagnosis, remains to be determined. METHODS We examined the outcomes three years later (2004-2005; Wave 2) of 40,512 civilian, non-institutionalized subjects who endorsed elation and/or irritability but did not meet full criteria for lifetime mania or hypomania in 2001-2002 (Wave 1). RESULTS The likelihood of developing a clear episode of mania or hypomania by Wave 2 was significantly increased in subjects with elation or only irritability at Wave 1 compared with subjects who did not endorse either (OR 2.8, p<0.01 for each). Endorsement of both symptoms at Wave 1 increased the likelihood of a new episode of mania or hypomania 4.6 times, which was significantly higher than for those with only elation or irritability (p<.05 for each). LIMITATIONS SBD was not limited to depression, reducing comparability to previous studies. Despite the large sample size, there were not enough subjects to determine the impact of different numbers and types of additional symptoms on bipolar outcome. Although the majority of subjects were followed between the two Waves, the total duration of follow-up was probably too short to determine the long-term conversion rate to mania or hypomania. CONCLUSIONS Elation and/or irritability, especially if accompanied by trouble concentrating, racing thoughts or hyperactivity, may represent a prodrome of formal bipolar disorder that indicate close follow-up and cautious use of antidepressants.
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Affiliation(s)
- Gregory G Homish
- Department of Community Health and Health Behavior; University at Buffalo, 462 Grider St, Room 1182, Buffalo, NY 14215, USA
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Dubovsky SL. Pharmacokinetic evaluation of olanzapine + fluoxetine for the treatment of bipolar depression. Expert Opin Drug Metab Toxicol 2013; 9:207-14. [PMID: 23294052 DOI: 10.1517/17425255.2013.761206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION A proprietary combination of the atypical antipsychotic drug olanzapine and the serotonin reuptake inhibitor fluoxetine (OFC, Symbyax) was approved for the treatment of bipolar depression based on a double-blind, placebo-controlled comparison of olanzapine, OFC, and placebo. AREAS COVERED This review considers published controlled and uncontrolled studies of the efficacy, pharmacodynamics, pharmacokinetics, interactions, and adverse effects of OFC. Beyond previously reviewed efficacy studies, an open-label 7-week study of 161 bipolar depressed patients (93% bipolar I), and an 8-week double-blind study of 833 bipolar I depressed patients with an open-label extension were identified. The structure and limitations of clinical trials of OFC are critically addressed. EXPERT OPINION OFC trades simplicity of administration for loss of flexibility of dosing and lack of a generic preparation, both of which are available for olanzapine and fluoxetine separately. Clinical trials are limited by short-term follow-up, exclusive use of symptom rating scale scores, limitation of subjects to those with depression that is not overly complex or comorbid, lack of consideration of subsyndromal hypomania and mood cycling, and high dropout rates. In the absence of comparisons to mood stabilizers combined with each other and/or antidepressants, the role of OFC in the treatment of bipolar depression remains unclear.
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Affiliation(s)
- Steven L Dubovsky
- Department of Psychiatry, State University of New York at Buffalo, 462 Grider St, Buffalo, NY 14215, USA.
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Warren CG, Dubovsky SL. New approaches for the management of bipolar disorder: role of sublingual asenapine in the treatment of mania. Neuropsychiatr Dis Treat 2013; 9:753-8. [PMID: 23785236 PMCID: PMC3682805 DOI: 10.2147/ndt.s16078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Indexed: 12/02/2022] Open
Abstract
Bipolar disorder is a prevalent disorder that tends to become progressive without treatment and with inadequate treatment. Second generation (atypical) antipsychotic drugs have increasingly been used as adjunctive treatment or monotherapy for mania, but they have the potential for significant adverse effects and their role in maintenance treatment remains unclear. Asenapine is a new atypical antipsychotic medication formulated in a sublingual preparation that has been studied for mania but not maintenance therapy. Evidence indicating efficacy, adverse effects, and potential benefits and drawbacks of using asenapine in the treatment of bipolar disorder based on currently available published data are summarized.
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Affiliation(s)
- Calvert G Warren
- Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA
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Kilbourne AM, Goodrich DE, O’Donnell AN, Miller CJ. Integrating bipolar disorder management in primary care. Curr Psychiatry Rep 2012; 14:687-95. [PMID: 23001382 PMCID: PMC3492519 DOI: 10.1007/s11920-012-0325-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care.
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Affiliation(s)
- Amy M. Kilbourne
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - David E. Goodrich
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | | | - Christopher J. Miller
- Center for Organization, Leadership, & Management Research, VA Boston Healthcare System, Boston, MA
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