How do I refer a female patient with bipolar disorder and post-traumatic stress disorder (PTSD) to a psychiatrist for further evaluation and management of her condition, including potential lithium-induced thyroid dysfunction?

How to Refer a Patient with Bipolar Disorder and PTSD to Psychiatry

You should directly inform your client that her complex psychiatric needs—including bipolar disorder, PTSD, and potential lithium-induced thyroid dysfunction—require specialized psychiatric care that exceeds the scope of primary care management, and that you are referring her to a psychiatrist who can provide comprehensive medication management and monitoring.

Framework for the Referral Conversation

Opening Statement

• Begin by acknowledging the therapeutic relationship and framing the referral as an enhancement of care rather than abandonment: "I've been working with you on managing your bipolar disorder and PTSD, and I believe you would benefit from specialized psychiatric expertise to optimize your treatment" 1
• Emphasize that this referral reflects the complexity of her conditions, not a failure on her part or yours 1

Specific Clinical Rationale to Communicate

Medication Complexity:

• Explain that lithium therapy requires specialized monitoring including thyroid function, renal function, and lithium levels every 3-6 months, which is best managed by a psychiatrist with expertise in mood stabilizers 1, 2
• Note that 20% of women on long-term lithium develop hypothyroidism, making regular thyroid monitoring essential 3
• Lithium-induced thyroid dysfunction can worsen emotional stability and the clinical course of bipolar disorder, requiring expert management 4

Specialized Psychiatric Needs:

• The combination of bipolar disorder and PTSD requires integrated treatment approaches that psychiatrists are specifically trained to provide 1
• Psychiatrists can offer more frequent medication adjustments and closer monitoring than primary care settings typically allow 1
• The American Academy of Child and Adolescent Psychiatry recommends that complex bipolar disorder cases receive specialized psychiatric care for optimal outcomes 1

Addressing Common Patient Concerns

Continuity of Care:

• Reassure her that you will remain involved in her overall medical care and will coordinate closely with the psychiatrist 5
• Explain that you will continue to monitor her general health, including metabolic parameters if she's on atypical antipsychotics 1
• Provide specific information about how you will communicate with the psychiatrist to ensure seamless care 5

Access and Logistics:

• Offer to help schedule the initial psychiatric appointment and provide all relevant medical records 5
• Discuss potential barriers (insurance, transportation, wait times) and problem-solve together 5
• Provide crisis resources in case symptoms worsen while waiting for the psychiatric appointment 5

Essential Information to Include in the Referral

Clinical Summary for Psychiatrist

• Current medications including lithium dose and most recent lithium level 1, 2
• Baseline thyroid function tests (TSH, free T4) and dates obtained 5, 1
• Baseline renal function (BUN, creatinine, urinalysis) 1, 2
• History of mood episodes, hospitalizations, and treatment responses 1
• PTSD symptoms and triggers 1
• Current mental status and suicide risk assessment 1

Monitoring Parameters to Highlight

• Lithium levels should be checked every 3-6 months along with renal and thyroid function 1, 2
• TSH with option of free T4 should be monitored for hypothyroidism detection 5
• If TSH is elevated (>4.5 mIU/L) or patient develops symptoms, more frequent monitoring is needed 5
• Body mass index, blood pressure, fasting glucose, and lipids if on atypical antipsychotics 1

Common Pitfalls to Avoid

Communication Errors:

• Never frame the referral as "I can't help you anymore"—instead emphasize "I want you to have the best possible care" 1
• Avoid suggesting the referral is due to patient non-compliance or difficulty—focus on clinical complexity 1
• Don't delay the referral while waiting for "one more medication adjustment"—complex cases benefit from early psychiatric involvement 1

Clinical Oversights:

• Ensure thyroid function has been recently checked before the psychiatric appointment, as lithium-induced hypothyroidism affects 20% of women and can develop after 1-9 years of treatment 3
• Verify that the patient has adequate lithium supply and crisis resources during the transition period 1, 2
• Don't discontinue or adjust lithium without psychiatric input, as withdrawal increases relapse risk exceeding 90% 1

Psychoeducation to Provide

• Explain that bipolar disorder is a chronic condition requiring long-term specialized management, with maintenance therapy continuing for at least 12-24 months after stabilization 1, 6
• Discuss the importance of medication adherence, as more than 90% of non-compliant patients relapse versus 37.5% of compliant patients 1
• Emphasize that psychiatrists can offer both medication management and psychosocial interventions (psychoeducation, cognitive-behavioral therapy) that improve outcomes 1
• Normalize the need for specialized care by explaining that complex medical conditions (like diabetes or heart disease) also require specialist management 1