Brief Report

Comparing Treatment Outcomes ofBipolar Patients Between PsychiatryResidents and Attending Physicians

Daniel J. Rapport, M.D., Panchajanya Paul, M.D., Angele McGrady, Ph.D.

Dheeraj Kaplish, M.D., Ronald McGinnis, M.D., Kary Whearty, L.S.W.

Objective: The authors sought to compare the outcomes ofpatients treated by psychiatric residents and attending psychiatrists.

Method: Charts of 121 outpatients meeting criteria for bipolarspectrum disorder were analyzed. Residents treated 41, and at-tending physicians 80, of 121 patients. Improvement was definedas at least 12 consecutive months of the following: Remission—euthymic mood; Response—much improved mood, not meetingDSM-IV criteria for mild illness; Relapse—remission or responsefollowed by recurrence. The Active Illness group contained patientswho did not have 12 months of Remission or Response.

Results: The percentage of improved patients was similar be-tween residents (46.3%; 19/41) and attending physicians (42.5%;34/80). There was a significant difference in the number of patientsin the Remission or Response categories between attending physi-cians: (26.5%; 21/80) and residents (12.2%; 5/41).

Conclusion: Similarnumbersof residents’andattendingphysicians’patients achieved improvement for 12 months, but twice the numberof attending physicians’ patients achieved and maintained euthymia.

Academic Psychiatry 2013; 37:329–331

A significant number of patients are treated by over6,000 residents and fellows, working in 184 psychia-

try residency programs in the United States (1). In order tomaintain optimum quality of patient care, the AccreditationCounsel for Graduate Medical Education (ACGME) man-dates that residents must demonstrate clinical care skillswith complicated patients while maintaining compassionand sensitivity to patient needs (2).

Few comparison data on knowledge or patient outcomesbetween resident and attending psychiatrists are available.Tripp and Schwartz (3) found no major differences betweenpsychiatric residents and attending physicians in the types ofpharmacotherapy utilized in treatment. Another study in a psy-chiatric clinic found that residents used a friendlier tone ofvoice than attending psychiatrists and also devoted more timeto data-gathering and patient education (4). Knowledge oftreatment options for geriatric depression in residents and psy-chiatrists was found to be comparable (5), as was the knowl-edge-base of neurology residents and neurologists (6). Theclinical outcomes of bipolar patients treated by residents andattending psychiatrists have not been previously compared.

Method

This was a retrospective chart review conducted in anacademic medical center Adult Psychiatry clinic. The studywas approved by the Institutional Review Board (IRB). TheIRB set the last date for data collection as April 1, 2010. Acomputer query of the clinic’s records identified 271patients billed for treatment of bipolar-spectrum disorderswho had been in the practice for at least 18 months. Chartswere then reviewed independently by a board-certifiedpsychiatrist to confirm the diagnosis of one of the bipolardisorders by use of DSM-IV criteria. Ultimately, 121 chartswere validated, whereas the remainder did not meet criteriaand were not studied further. Subtypes of bipolar disorderwere not specified. Of the 121 patients who met criteria, 37were women, and 84 were men; their average age was 42.8years. Most were Caucasian (115), and the remainder wereAfrican American and Hispanic. Their average age at di-agnosis of bipolar disorder was 24.8 years.

Data from patients’ charts were gathered on baselinemoodinformation from the diagnostic assessment at the first clinicvisit. Data were also collected from each of the patient’s visits

Received December 28, 2011; revised November 20, 2012, February 28,2013; accepted April 2, 2013. From the Dept. of Psychiatry, University ofToledo, Toledo, OH. Send correspondence to Dr. Rapport; e-mail: daniel.rapport@utoledo.edu

Copyright © 2013 Academic Psychiatry

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by two research assistants not involved in patient care. Thenumber of visits was tallied. Five attending psychiatrists andmultiple residents treated patients in this study. Becauseresidents change yearly, patients were treated by more thanone resident; the exact number depended on how long thepatient remained in the practice. All residents received eitherdirect supervision (live) or indirect supervision (later) whencharts were reviewed by the attending psychiatrists. Out-comes were not analyzed by particular physician or resident.Patients’ mood state was evaluated impressionistically,

similar to other clinical assessments in psychiatry. Patientswere assessed clinically with the Clinical Global Impression(CGI) scale of severity, and improvement rating was basedon standard definitions. The majority of patients were inthe depressed or mixed mood state at baseline; none wereeuthymic or manic. Raters noted mood states at each visit,based on patients’ subjective reports and the recorded ob-jective evaluation by the treating physician.Improvement was considered to be a CGI rating of either

1 or 2 for at least 12 consecutive months. The remissioncriterion of 12 months was purposely made more stringentthan the 2 months of “no significant symptoms” defined bythe DSM-IV in order to establish a clinically meaningfultime-frame for patients to stabilize function and to ensurethat patients had established a period of recovery that waslonger than during the natural course of their illness.Improvement was further divided into three categories:Remission (euthymic mood for 12 consecutive months);Response (much improved mood, not meeting DSM-IVcriterion for mild illness for 12 consecutive months); Re-lapse (remission or response but followed by a recurrenceafter a 12-consecutive-month period). Finally, active illnesswas the failure to achieve 12 months of remission or re-sponse. Statistical analyses, including descriptive statistics,and chi-square tests, were conducted with SPSS software.

Results

Table 1 shows the response categories divided by treat-ment provider. Of the 121 patients, 41 were treated by

residents, and 80 were treated by attending physicians. Theaverage length of treatment was 3.7 years for the attendingphysicians’ patients and 3.4 years for the residents’ patients.Overall, 43.8% of patients achieved at least 12 consecutivemonths of improvement, whereas 56.1% did not.The percentage of residents’ patients who improved

(Remission, Response, and Relapse) was 46.3% (19/41).This was slightly greater than that of the attending physi-cians 42.5% (34/80), but this difference was not statisticallysignificant. The mean duration of Remission was 32.2months, and, for the Response group, the average length ofresponse was 25.4 months. The number of visits kept byresidents’ and attending physicians’ patients who improvedor remained in active illness was also compared. In theimproved group (Remission, Response, Relapse) residents’patients had a mean of 30 (SD: 19) visits; attending physi-cians’ patients had 23 (SD: 17) visits. In the active illnessgroup, patients treated by residents completed 28 (SD: 31)visits, and patients treated by attending psychiatrists com-pleted 27 (SD: 35) visits. Neither of the comparisons wassignificantly different by ANOVA.Further comparison of the number of patients in the Re-

mission and Response categories revealed that the attendingpsychiatrists outperformed the residents, with 26.5% (21/80) of the attending physicians’ patients achieving euthy-mia, whereas only 12.2% (5/41) of the residents’ patientsachieved the same outcome. This difference was statisticallysignificant (x2=9.85; p ,0.002).

Discussion

Patients treated by both resident and attending psychia-trists achieved the same degree of improvement initially, buttwice the number of patients seen by attending physiciansremained essentially euthymic, as compared with the resi-dents’ patients. Fewer of the attending physicians’ patientswere likely to relapse after 12 months. This suggests thatresidents can provide quality care comparable to attendingpsychiatrists when they are trained in psychopharmaco-therapeutics and supervised.The second finding, that among the patients who im-

prove, those seen by the attending psychiatrists were morelikely to remain euthymic may be explained by severalfactors. First, the attending is a consistent care-provider,who may have a stronger therapeutic alliance withpatients. Treatment of bipolar disorder requires assess-ment of residual symptoms, knowledge of alternativetreatments, and ability to adjust medications to optimizeresponse while reducing side effects. Second, all of the

TABLE 1. Treatment Outcomes of Patients in the Study

PatientsTreated Remission Response Relapse

ActiveIllness

Total (N=121) 26 12 15 68By resident(N=41)

5 6 8 22

By attending(N=80)

21 6 7 46

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BIPOLAR DISORDER: RESIDENTS AND ATTENDINGS

attending psychiatrists had a minimum of 15 years’ ex-perience and, thus, are more familiar with managing pa-tients in the maintenance phase. However, the number ofpatient visits (intensity of treatment) to residents or attend-ing psychiatrists did not seem to influence outcome. Theseresults may have important implications for resident edu-cation in enhancing outcomes in patients with bipolardisorder. It is suggested that resident training emphasizerigorous evaluation paradigms similar to the STEP-BD (7)and more extensive education treatment algorithms, par-ticularly for patients with bipolar spectrum disorders in themaintenance phase (8).

There are several limitations that affect interpretation ofthis study’s results.We did not separate patient outcomes byindividual providers, by subtype of bipolar disorder, oraccording to supervision style. Biasmay have influenced thedata-gathering and inclusion of patients in specific catego-ries. All of the residents were supervised by attendingpsychiatrists, but sometimes the feedback was direct, and, atother times, the feedback occurred after the encounter. Theresults from the study of a single illness may not be gener-alizable to other disorders. Our sample size was relativelysmall, entirely from an outpatient practice, and from oneclinical practice at an academic institution.

In conclusion, it appears that supervised residents canprovide care comparable to attending psychiatrists in thetreatment of bipolar disorder. Specifically, both groups canobtain an equal percentage of patients who are significantly

better and who achieve a clinically meaningful recovery.However, among the patients who improve the most, thoseseen by the attending psychiatrists were likely to remaineuthymic for a longer period of time.

References

1. American Psychiatric Association: Resident Census: Character-istics andDistribution of PsychiatryResidents in theU.S.A, 2009–2010; Resident Census, 2009–2010; available at www.psych.org

2. ACGMEwebsite; available at http://www.acgme.org/acWebsite/navPages/nav_residents.asp

3. Tripp AC, Schwartz TL: Psychiatric resident and attending di-agnostic and prescribing practices. Acad Psychiatry 2008; 32:214–217

4. Castillo EG, Pincus HA, Wieland M, et al: Communicationprofiles of psychiatric residents and attending physicians inmedication-management appointments: a quantitative pilotstudy. Acad Psychiatry 2012; 36:96–103

5. Baker FM: Attending psychiatrists’ vs. residents’ knowledge ofgeriatric depression. Acad Psychiatry 1993; 17:112–113

6. Davis LE, King MK, Skipper BJ: Education research: assess-ment of neurology resident clinical competencies in the neu-rology clinic. Neurology 2009; 72:e1–e3

7. Sachs GS, Thase ME, Otto MW, et al: Rationale, design, andmethods of the systematic treatment enhancement program forbipolar disorder (STEP-BD). Biol Psychiatry 2003; 53:1028–1042

8. Sachs GS, Nierenberg AA, Calabrese JR, et al: Effectiveness ofadjunctive antidepressant treatment for bipolar depression.N Engl J Med 2007; 356:1711–1722

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