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Bucket Two: the Challenge of PTSD and Bipolarity in Primary Care

Posted By Jim Phelps, Friday, February 19, 2016

“The difficult we do immediately. The impossible takes a little longer.” 
(motto of the WWII Army Corp of Engineers)


Consider three primary care buckets, for simplicity:  in the first bucket, you’ll find patients with the many forms of depression and anxiety that can benefit significantly from the brief interventions commonly provided by Behavioral Health Consultants. 

In the third bucket, you’ll find those who clearly need specialty mental health services: psychosis, significant borderlinity, complex or treatment-resistant substance use, and complex medication regimens. Left over is a large group of patients our behavioral team has lumped in “Bucket Two”.  These are folks whose depression and anxiety is complex, or not responding to the interventions of Bucket One, but who are unable or not inclined to go see a mental health specialist. 

Bucket Two includes a mix of difficult-to-treat depression, anxiety, and bipolarity.  And, as CFHA providers well know, trauma histories in this group are extremely common. Patients in this bucket represent the majority of patients referred to our Primary Care Psychiatric Consultation (PCPC) program. Their diagnoses include substance use, GAD, borderlinity, ADHD – but most common of all are PTSD and bipolar disorders.  Unfortunately, these are difficult to treat in primary care: their complexity level is often very high (e.g. prior therapies, prior medications, co-morbid mental health conditions, and co-morbid general medical problems), potentially swamping busy behaviorist and primary care providers; and with their trauma histories, they often do not respond fully to brief interventions.

The Collaborative Care model for psychiatric consultation has demonstrated efficacy in patients with Major Depression, and is sometimes promoted over other models on this basis. But it has less evidence for efficacy for PTSD (e.g. the recent negative trial by Meredith et al, 2016) and bipolar disorders (e.g. Cerimele et al, 2014).  However, the news for Bucket Two is not all bad.  A recent randomized trial in the Netherlands showed that a collaborative care approach to bipolar disorders reduced the frequency and severity of depression symptoms relative to treatment-as-usual (van der Voort et al, 2016). And a Behavioral Integration program for small and solo primary care practices, being studied in a randomized trial (sponsored by a large insurance company!), utilizes an intervention designed to treat both unipolar and bipolar depression (Kilbourne et al, 2014).

Consider a review from Dr. Kilbourne’s group, on integrating bipolar disorder management in primary care (2012). In it she and her colleagues emphasize the unrecognized burden of bipolar disorder in primary care (“the de facto site of care for persons with bipolar disorder”) , noting:

Subthreshold bipolar diagnoses, such as bipolar disorder not otherwise specified and cyclothymia, are not only prevalent and clinically significant but also go largely untreated in primary care. In a nationally representative sample of U.S. adults diagnosed with depression, 40% of participants also had a history of subthreshold bipolar manic symptoms…  Notably, the role impairment associated with these subthreshold disorders is similar to that of bipolar I disorder and present with significant psychiatric comorbidity and symptom severity predisposing them to an increased risk for suicide and general medical conditions.

That’s Bucket Two – or rather, a portion of it.  As noted, the other common diagnosis in there is PTSD, which is similarly role-impairing and similarly likely to present with comorbidities, psychiatric and medical. 

Suffice to say that if your program is having difficulty managing the folks in Bucket Two, so are we: they need more than can be provided in Bucket One, the main territory of the primary care behaviorist, but either can’t or won’t access specialty mental health (in our case, access is a huge problem: our psychiatry residency program is just about the only place in a large catchment area that will take patients with Medicare, for example, so we have a chronic long wait list).  In a later post I will return to describe a program for the bipolar disorders in Bucket Two. Hopefully, between us all here in CFHA, the PTSD will take “just a little longer”. 


James Phelps, M.D., Staff Psychiatrist at Samaritan Mental Health, has specialized in bipolar spectrum variations for over 15 years.  He has authored multiple peer-reviewed articles on mood disorders, and serves as Bipolar section editor for Psychiatric Times.  His no-profit website,, focuses on complex bipolar variations; it has received over a million visitors.  He accepts no honoraria from pharmaceutical companies, but does receive royalties from McGraw-Hill and W.W. Norton for books on the bipolar spectrum. His new book from Norton, A Spectrum Approach to Mood Disorders, will be out in June 2016.

Dr. Phelps received his M.D. from Case Western Reserve University, and completed his residency in psychiatry and a fellowship in medical education at the University of New Mexico. Current grant funding focuses on primary care psychiatric consultation.

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