Depression is common, and frequently treated with antipressants (1 in 10 U.S. adults). But bipolar depression, which looks almost identical, can worsen with antidepressants. Yet primary care providers have little time or training for indentifying bipolar depression. Many patients get the wrong treatment, sometimes with terrible results.
PsychEducation.org offers a public-sector, zero-cost solution to this problem. Depressed or anxious patients whose screening questionnaire indicates a possible bipolar disorder need an immediate education about “bipolarity”. They need help understanding that even though they have never had a “manic episode” they can still have version of bipolar disorder. This requires much more psychoeducation than found on basic internet websites such as WebMD. Yet without this education, patients are very likely to reject the idea that they might have a “bipolar disorder”: the diagnosis is frightening; they think it requires having had a manic episode; they’ve not had that; so the diagnosis must be wrong.
PsychEducation.org is the next step after bipolar screening. It explains bipolar variations and their treatment, emphasizing the importance of non-medication approaches as well as medications. It stresses the importance of detailed, referenced information – PsychoEducation – as the starting point for personal management of this common illness.
Research suggests that patients remember no more than 50% of physicians’ advise. Solution: create a readable yet detailed psychoeducation by layering information from basic to extremely detailed. Use 10th grade language but offer more complex information, on separate pages, for those who want more; reference everything.
Thus the site invites patients and families to participate actively in determining their diagnosis and their personalizing their treatment ("shared decision-making"1). Formal bipolar psychoeducation has been shown highly effective in several studies, but is rarely available. Yet the same level of detail is available via PsychEducation.org (indeed far more) -- self-paced, review-able, at no cost, with no additional resources required.
Charge nothing. No advertising. Gather no data on users. Make it inviting, readable, funny at times (so the feedback says…). Over 10 years, learning what patients need, writing about the questions they ask, has led to development of >200 pages.
Access to mental health services is a huge problem. Access to psychiatric services is particularly limited, especially in rural and western states. In this vacuum, the burden of mental health care has fallen on primary care (and jails; a separate, equally regrettable problem). While awaiting broader changes (including more psychiatrists, working in different ways) one solution now is to help primary care providers improve outcomes.
For bipolar disorders, this means effective screening; offloading psychoeducation; and inviting patients and families to become more directly involved in decisions affecting their care. Other mental health professionals, including psychiatrists, have found PsychEducation.org extremely helpful, routinely directing patients there (see Outcomes data). Primary care has proved more difficult to reach, but with more direct efforts (see Use of Award), much more is possible.
Leadership? It wasn't deliberate. Somebody had to do something...
With its innovative approach to Medicaid services, the state of Oregon is often referred to as a “testing ground” for new ideas in healthcare. Use of PsychEducation.org screening and education tools in primary care is supported by a state “Transformation” grant, due for expansion in July 2015. The goal is statewide consideration of this approach. Anything effective in Oregon is likely to receive national scrutiny.
But PsychEducation.org is fully functional now; it does not require further development. Because it costs almost nothing to maintain, there is no risk of “de-funding.” The more broadly the site is used, the more integrated it will become in treatment programs, further guaranteeing its longevity.
Yet there is much more work to do. Diabetic education is paid by insurance. A new diagnosis of bipolar disorder is at least as daunting and alarming as a diagnosis of diabetes. Where is bipolar psychoeducation? PsychEducation.org is a start.
Currently PsychEducation.org is an idea waiting to spread (although it has been read by at least 146,000 people; data below) There are no significant barriers to adoption by other organizations. And the potential target populations? Every patient with depression in every primary care office in the United States (national epidemiologic data suggest that at least 1 in 10, perhaps closer to 1 in 5 such patients have enough bipolarity to guide treatment.2)
Are there comparable programs that agencies and institutions might consider? To my knowledge, there is no analog for PsychEducation.org. HealthWise makes Decision Aids to assist in shared decision-making, but focuses on less complex issues. They also provide the psychoeducation information found on WebMD. But the information on bipolar disorders on WebMD and other such sites is only about 1% of that available on PsychEducation.org. Scaling up is just a matter of spreading the word.
In 10 years, the site has logged 2.3 million page views.
(See Figure 1 in attached: "Application Figures")
85% of visitors do not stay; but 6% read for over an hour.
(See Figure 2)
Thus on average, over 14,000 people per year have read the site long enough to see the intended effects. But do they benefit? In lieu of a costly randomized trial, unsolicited emails are very suggestive (screenshot, Figure 3): in 5 years, 467 users wrote thank yous. Might not sound like much, but please have a look at a random sample of 5 emails, attached. In general, these 400+ emails manifest a level of understanding of bipolar disorder that is precisely what the site is supposed to be providing. As the longer of the 5 examples demonstrate, the site also succeeds in engendering a sense of empowerment and hope. At no cost.