Bipolar units and programmes: are they really needed?

In the era of managed care and cost-effectiveness considerations, some see specialized units and programmes as expensive, sophisticated and elitistic organizations which might not be needed at all in the field of psychiatry, where technology is still a little part of what we do. But what lays behind those considerations is the concept that expertise is not needed in psychiatry, and that everybody can provide psychiatric care because, at the end of the day, what is basically needed is some empathy, compassion, and a minimal knowledge on how to provide some “sedation” to the mentally ill. The reality is that psychiatry is probably the most difficult and clinically sophisticated medical speciality, and that, precisely because of the limited role of technology, expertise is crucial for clinical success. Are specialized units the future of psychiatry? I believe so. Of course, they will have to coexist with generalists, who have the challenging task to know a little of everything, and to deal with the majority of those who seek psychiatric help; but, as it happened with internal medicine or even more recently with neurology, we need superspecialists to deal with the most complex cases, generate high-quality research, and provide education on specific conditions. The patients who do not do well on standard treatment want to find experts in their condition, and this is the spot for specialized clinics and programmes. Specialized units should not be exclusive of the Western world. Their sophistication does not mean that they are necessarily expensive. The main ingredients are striving for excellence, meritocracy, team work, competitive funding, and some intangible joy of living with the privilege to help and learn from our patients. As far as the ingredients are there, this can be done anywhere. I had the privilege to start what is now considered by many not only one of the first specialized health care and research psychiatry programmes in Europe, but also what I like to see as a school of psychiatry, where young doctors, fellows, residents, and medical students receive a sophisticated training in psychopathology, psychopharmacology, and psychotherapy. We used to call this center “the Bipolar Unit”, especially when it started and had only one staff member (a literal “Unit”). With time and a little luck, some Spanish government funding came up, and I was able to hire a psychologist to lead what I wanted to be our first research project, a clinical trial testing the efficacy of psychoeducation for bipolar disorder 1. Subsequently, we got further funding, with special mention of that coming from the Stanley Medical Institute in Bethesda, and we started doing drug clinical trials 2 and research in emerging areas of interest, such as neuropsychology 3, functional outcome 4, and epidemiological studies 5. Right from the beginning, the center had one aim: to generate, teach, and apply knowledge on how to best treat patients with bipolar disorder. It was clear to me then, and still is today, that there is a huge gap between the available scientific evidence and the questions that come up from everyday clinical practice and from the daily contact with patients with bipolar disorder and their caregivers. The center aims to fill that gap as much as possible. Over 700 patients with bipolar disorder attend the programme (mostly as outpatients), and we count on 26 beds for inpatients, which we share with the schizophrenia and depression programmes. About 60% of outpatients come from our designated catchment area, while 40% are sent to us as a reference center for difficult-to-treat cases, including patients with severe rapid cycling, somatic and psychiatric comorbidities, and treatment refractoriness. One unique feature of our department is that programmes take preeminence, and therefore the patients are followed up regardless of the facility which they attend (inpatient unit, outpatient clinic, emergency room). This ensures quality and continuity of care and is particularly helpful for teaching and research. Other features of our programme are the team approach and the open-door policy 6. I believe that specialized programmes such as the Barcelona Bipolar Disorders Programme are truly needed. It is time for evidence-based, but personalized medicine, and for coordinating the efforts of all those who participate in the healing process, from the generalist to the top specialist.