Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology.

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. The second version, like the first, is based explicitly on the available evidence and presented, like previous Clinical Practice guidelines, as recommendations to aid clinical decision making for practitioners: they may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed but selective qualitative review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in treatment of episodes, relapse prevention and stopping treatment.

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Bipolar disorder is a common condition diagnosed by the occurrence of pathological mood elevation but most often dominated by dysphoria states. Over the past 10 years, understanding of bipolar disorder and the number of evidence-based treatments have increased dramatically. This article offers strategies for improving diagnostic confidence and simple benchmarks that facilitate integrating principles of evidence-based medicine into the management of patients with bipolar disorder. Simple systematic assessment techniques such as focusing the evaluation to assess the most extreme episode of mood elevation and longitudinal factors such as age of onset and course of illness can avoid errors of omission and raise diagnostic confidence. An iterative measurement-based treatment model that aims to bring patients and their supports into the collaborative care process for progressively better outcomes is recommended.

Despite a marked increase in treatment for bipolar disorder among youths, little is known about their pattern of service use. This article describes mental health service use in the year before and after a new clinical diagnosis of bipolar disorder. Claims were reviewed between April 1, 2004, and March 31, 2005, for 1,274,726 privately insured youths (17 years and younger) who were eligible for services at least one year before and after a service claim; 2,907 youths had new diagnosis of bipolar disorder during this period. Diagnoses of other mental disorders and prescriptions filled for psychotropic drugs were assessed in the year before and after the initial diagnosis of bipolar disorder. The one-year rate of a new diagnosis of bipolar disorder was .23%. During the year before the new diagnosis of bipolar disorder, youths were commonly diagnosed as having depressive disorder (46.5%) or disruptive behavior disorder (36.7%) and had often filled a prescription for an antidepressant (48.5%), stimulant (33.0%), mood stabilizer (31.8%), or antipsychotic (29.1%). Most youths with a new diagnosis of bipolar disorder had only one (28.8%) or two to four (28.7%) insurance claims for bipolar disorder in the year starting with the index diagnosis. The proportion starting mood stabilizers after the index diagnosis was highest for youths with five or more insurance claims for bipolar disorder (42.1%), intermediate for those with two to four claims (24.2%), and lowest for those with one claim (13.8%). Most youths with a new diagnosis of bipolar disorder had recently received treatment for depressive or disruptive behavior disorders, and many had no claims listing a diagnosis of bipolar disorder after the initial diagnosis. The service pattern suggests that a diagnosis of bipolar disorder is often given tentatively to youths treated for mental disorders with overlapping symptom profiles and is subsequently reconsidered.

Treatment Costs Related to Bipolar Disorder and Comorbid Conditions Among Medicaid Patients With Bipolar Disorder

This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution.

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

Management of Psychiatric Disorders during the Perinatal Period.

A number of recent studies have questioned whether, despite modern treatment, the natural course of bipolar illness today still involves multiple relapses and impaired psychosocial functioning. This prospective follow-up study examined longitudinal outcome in a large group of inpatients with affective disorders. Fifty-one bipolar manic patients and 49 unipolar depressed patients were interviewed three times: 1) during hospitalization, 2) approximately 2 years after discharge, and 3) approximately 4.5 years after discharge. Subjects were treated under routine conditions and assessed for global adjustment, rehospitalization, and work and social functioning. Only 41% of the bipolar group had a good overall outcome by the time of the 4.5-year follow-up. The bipolar patients had more severe work impairment than the unipolar group. More than one-half of the bipolar patients were rehospitalized at least once during the 4.5-year follow-up period. Outcome for both diagnostic groups improved significantly over time. Many contemporary bipolar patients demonstrate gradual improvement in the first several years after hospitalization. However, a subgroup approaching 60% still experience poor posthospital adjustment in one or more areas of functioning.

OBJECTIVE: This study estimated changes during the 1990s in the quality of usual-care treatment among persons diagnosed as having bipolar I disorder in a privately insured population. METHODS: Retrospective private insurance administrative data were analyzed for enrollees aged 18 to 64 who were diagnosed as having bipolar I disorder during 1991 (431 person-years), 1994 (598 person-years), and 1999 (600 person-years). Medication and psychotherapy quality indicators were derived from bipolar disorder expert guidelines published in 1994, which were consistent with guidelines published until year 2002. RESULTS: The unadjusted prevalence of receiving any lithium, valproate, or carbamazepine improved over the study period (68 percent in 1991, 64 percent in 1994, and 77 percent in 1999), whereas, compared with 1991, receiving any antidepressant in the absence of lithium, valproate, or carbamazepine increased in 1994 and then declined in 1999 (13 percent in 1991, 23 percent in 1994, and 14 percent in 1999). The unadjusted prevalence of receiving any psychotherapy declined steadily and sharply (94 percent in 1991, 89 percent in 1994, and 69 percent in 1999). The unadjusted prevalence of receiving any lithium, valproate, or carbamazepine and therapy together declined over time (65 percent in 1991, 58 percent in 1994, and 54 percent in 1999). After the analyses adjusted for patient characteristics, these changes were significant from p<.01 to p<.001. CONCLUSIONS: The prevalence of receiving the pharmacotherapy recommended in the guidelines improved after guideline publication in 1994, whereas other quality measures that included receiving psychotherapy declined throughout the study period. These results suggest different psychotherapeutic modalities are under differing constraints under managed care, constraints that overpower consensus in the literature of quality practice. Policy makers should measure a variety of key therapeutic modalities when measuring quality in order to capture these differences.

WHAT IS ALREADY KNOWN ON THE SUBJECT?: Understanding the need for psychoeducation and management strategies in relapse prevention, for individuals with schizophrenia or bipolar disorder. Interventions for individuals with severe mental illness, especially schizophrenia, often requires support from family or social network to successfully improve mental stability in the life of the mentally ill. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no previous review has provided an overview of state of the art intervention elements currently used in ambulant mental health care interventions and how these elements are combined in interventions tailored to individuals with schizophrenia or bipolar disorder. Moreover, this systematic review indicates the effect of the different intervention elements. This review reveals an apparent gab in knowledge regarding patient perceptions of and need for individualized relapse prevention interventions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The review is a relevant tool for stakeholders and practitioners in community mental health service when planning future interventions. Considering the specific needs for intervention complexity of the target group is likely to improve not only treatment outcome, but also patient satisfaction and treatment adherence. ABSTRACT: Introduction In recent years, there has been a development in ambulant mental health care towards a more preventive approach, resulting in relapse prevention interventions. Interventions may be patient tailored, to a greater or lesser extent, in relation to the treatment elements included. Aim To create an overview of non-pharmacological intervention elements described in relapse prevention interventions for patients with schizophrenia or bipolar disorder based on a systematic review. Method Six scientific databases were systematically searched. The search strategy, identification and selection of literature complied with the PRISMA statement. Results Of 7.429 studies screened, 25 were included for analysis. Six treatment elements were identified: Pharmacological treatment, personalized action plan, patient education, patient skills, treatment adherence and family involvement. Discussion The varying degree of complexity of the interventions indicates that patients with bipolar disorder and schizophrenia have, respectively, different treatment needs. Patients with schizophrenia seem to benefit more from interventions that include support from social network or family than patients with bipolar disorder. More qualitative studies clarifying the patient's perspective on tailored relapse prevention are indicated. Implications for practice Optimally tailoring relapse prevention for patients with schizophrenia and bipolar disorder will improve treatment outcome, and probably also treatment satisfaction and adherence.

Few data exist on the cost and quality effects of increased use of prior-authorization policies to control psychoactive drug spending among persons with serious mental illness. This study examined the impact of a prior-authorization policy in Maine on second-generation antipsychotic and anticonvulsant utilization, discontinuations in therapy, and pharmacy costs among Medicaid beneficiaries with bipolar disorder. Using Medicaid and Medicare utilization data for 2001-2004, the authors identified 5,336 patients with bipolar disorder in Maine (study state) and 1,376 in New Hampshire (comparison state). With an interrupted time-series and comparison group design, longitudinal changes were measured in second-generation antipsychotic and anticonvulsant use; survival analysis was used to examine treatment discontinuations and rates of switching medications. The prior-authorization policy resulted in an 8-percentage point reduction in the prevalence of use of nonpreferred second-generation antipsychotic and anticonvulsant medications (those requiring prior authorization) but did not increase use of preferred agents (no prior authorization) or rates of switching. The prior-authorization policy reduced total pharmacy reimbursements for bipolar disorder by $27 per patient during the eight-month policy period. However, the hazard rate of treatment discontinuation (all bipolar drugs) while the policy was in effect was 2.28 (95% confidence interval=1.36-4.33) higher than during the prepolicy period, with adjustment for trends in the comparison state. The small reduction in pharmacy spending for bipolar treatment after the policy was implemented may have resulted from higher rates of medication discontinuation rather than switching. The findings indicate that the prior-authorization policy in Maine may have increased patient risk without appreciable cost savings to the state.

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

Improving Medical and Psychiatric Outcomes Among Individuals With Bipolar Disorder: A Randomized Controlled Trial