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Research and Audit Table 5 shows how the GPs and MHNPs combined diagnoses (BPD or another condition) performed against the psychiatrists final diagnosis, which is used as the gold standard in this study. Thirty-three patients were seen by both the psychiatrist and their GP. Of the 7 patients diagnosed with BPD by the psychiatrist 5 were correctly identified by their GP whilst 2 received another diagnosis. However in 4 patients where the psychiatrist diagnosed another condition the GP suggested a diagnosis of BPD. The corresponding sensitivity and specificity of the GPs diagnoses were 71.4% and 84.6%. The PPV for the GPs diagnoses was 55.6% while the NPV was 91.7%. However the LR+ and LR- were 4.75 and 0.34 respectively which are outside of the limits of a good diagnostic test. (Please refer to Fields A, 2009 for a detailed explanation of these terms.) Twenty patients were seen by a MHNP before seeing the psychiatrist. The MHNP correctly picked up BPD in 2 of the 4 cases diagnosed with BPD by the psychiatrist. However in 6 out of 16 cases the MHNP diagnosed BPD whilst the psychiatrist diagnosed another condition. The sensitivity, specificity, PPV and NPV for the MHNPs diagnoses were 50%, 62.5%, 25% and 80% respectively. Again the LR+ and LR- which are 1.35 and 0.8 respectively fall outside of the limits of an acceptable diagnostic test. Discussion There is a growing body of evidence showing the importance of correctly identifying and treating sufferers of BPD to improve their quality of life, preserve their social and occupational functioning and to lessen the financial burden of healthcare costs related to the mismanagement of this important condition. Equally, the fact that there is often a delay of several years before this condition is correctly identified, highlights the importance of vigilantly screening for BPD, especially in the primary care setting. Our first aim was to establish the frequency with which our primary care practitioners screened for BPD. In this sample of patients presenting with affective symptoms, only 21.1% of those referred by their GP showed any evidence that they had been screened for BPD. Although this figure rose to 38.9% for MHNPs, this still represents a rather low proportion of screening for patients who are within the at risk category. This is especially important as tools such as the MDQ are available, short, and easy to use, and could easily be administered in the context of a primary care assessment. A potential downfall of this study design is that it relied on evidence from the referral letter that the clinician had screened for BPD and therefore it is possible that where a patient screened negative, it was not mentioned in the referral letter. However, a good referral should mention both positive and salient negative findings and routine use of the MDQ could circumnavigate this issue. Secondly, we aimed to establish whether screening for BPD increases the likelihood of correctly identifying the signs and symptoms of this disorder. In our study both GPs and MHNPs almost exclusively (with the exception of one patient in each case) only proposed a diagnosis of BPD when there was evidence that they had screened for hypomania. These highly significant results show that it was highly unlikely that clinicians would propose a diagnosis of BPD when they had not screened for the condition. These results emphasize the great importance of consistent screening. Our third question looks at the accuracy with which GPs and MHNPs were able to rule in or rule out BPD in their patients. As previously mentioned, a good screening tool should have both good sensitivity (low false negatives) and good specificity (low false positives). We also looked at PPV and NPV as well as LR+ and LR- as these give additional information about the quality of a screening test. 14 Surrey and Borders Online Journal www.sabp.nhs.uk/journal
In our sample the GPs screening method was very effective at ruling out BPD, but was less accurate when it came to ruling the condition in. The MHNPs’ method was also ineffective at ruling in BPD and although it was slightly better at ruling out this condition, only the NPV was above the cut off value. However for both groups of practitioners the LR+ and LR- of their methods, which reflects the value of a positive or negative test result, was well below the accepted cut off range. This suggests that the methods used by the primary care practitioners in our study had little value in correctly identifying the presence or absence of BPD. There are, however, some limitations to our study. We should note that this study encompassed relatively small numbers and this makes it difficult to make predictions about how these methods would perform in a larger population. In this study neither the GPs nor the MHNPs used a standardized screening tool; instead we were examining the validity of the methods they are already using. Although our results suggest that the GPs methods were slightly more effective than the MHNPs’ methods, it is also possible that the cases seen by the MHNPs were more complex and displayed a less clear cut presentation. Another limitation of the study is that the psychiatrist’s diagnosis may not represent an accurate gold standard, particularly in patients suffering a first episode of affective illness. In summary, the results of our study show that within the primary care setting in our catchment area screening for BPD is currently unacceptably low. Also it clearly shows that screening for BPD greatly enhances the chances of recognising this condition and that current screening methods used by primary care practitioners could be improved. Recommendations 1. Increase awareness of BPD and the importance of screening within our primary care setting. This could be achieved by doing a presentation for GPs and MHNPs regarding the findings of our study. 2. Role out the use of the MDQ as a standard screening tool to be administered to all patients in primary care presenting with an affective episode. 3. Improve communication between primary and secondary care practitioners. This could be through informal discussions or telephone advice. 4. Re-audit in 12 months to see the change in practice. References • Angst J. The emerging epidemiology of hypomania and bipolar II disorder. Journal of Affective Disorders, 1998; 50: 143-51. • Bauer MS, McBride L, Williford WO et al. Collaborative Care for Bipolar Disorder: Part II. Impact on Clinical Outcome, Function, and Costs. Psychiatric Services, July 2006; 57:937- 945. • Brickman, Andrew L, LoPiccolo et al. Screening for bipolar disorder. Psychiatric Services, March 2002; 53/3(349): 1075- 2730. • Corona, Rodrigo, Berlanga et al. Detection of bipolar disorder with a clinical screening questionnaire: The Spanish version of the Mood Disorder Questionnaire. Salud Mental, March 2007; 30(2): 50-57. • Das Gupta R, Guest JF. Annual cost of bipolar disorder to UK society. British Journal of Psychiatry, 2002; 180: 227-33. Research and Audit Surrey and Borders Online Journal www.sabp.nhs.uk/journal 15
Page 1 and 2: Issue 1 Summer 2010 Surrey and Bord
Page 3 and 4: Do you ever wonder why you agree to
Page 5 and 6: We are not so aware of the hidden f
Page 7 and 8: esorting too soon to complex statis
Page 9 and 10: Bipolar Disorder: how effective is
Page 11 and 12: Research Method The study was condu
Page 13: Screened for Hypomania Yes No Total
Page 17 and 18: Audit of risk assessment documentat
Page 19 and 20: Fig. 2 Re-audit May 2009 - distribu
Page 21 and 22: An evolving service - results of a
Page 23 and 24: having clinical responsibility for
Page 25 and 26: school exposure to psychiatry as an
Page 27 and 28: The measures outlined above will ho
Page 29 and 30: Interview with Fiona Edwards, Chief
Page 31 and 32: Q. Very topical to that is the appo

Here - Surrey and Borders Partnership NHS Foundation Trust

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