What works for bipolar disorder and how should this be delivered in practice?

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1 What works for bipolar disorder and how should this be delivered in practice? Daniel Smith W4 Improving the diagnosis and management of bipolar disorder: screening, integrated care pathways and specialised clinics

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4 What works for bipolar disorder: 1. Early and accurate diagnosis 2. Expert pharmacotherapy 3. Psychoeducation and self-management

5 What works for bipolar disorder: 1. Early and accurate diagnosis 2. Expert pharmacotherapy 3. Psychoeducation and self-management

6 Ewald Hecker (1882) Virtually all of the patients presented with a depressive state. The state of excitation had escaped the attention of the patient s doctor, his family and friends, and the patient. The patients only became aware of it when I described the characteristics of this state to them and, having up until that moment considered them as their healthiest periods, were forced to recognise that they were ill during these periods also.

7 Bipolar Comprehensive Outcomes Study (Berk et al, 2007) N=216 patients First experience of any symptoms First major depressive episode First manic episode BIPOLAR DIAGNOSIS 5 YEARS Age YEARS First experience of depressive symptoms First seeks medical treatment

8 Angst et al, Archives of General Psychiatry, Aug 2011 Global study, 18 countries: 5635 adults with an ongoing major depressive episode assessed 16.0% (almost 1 in 6) had undiagnosed DSM-IV bipolar disorder 47.0% had broadly-defined bipolar disorder, associated with: Family history of mania Multiple past mood episodes Manic states during antidepressant therapy Current mixed mood symptoms Comorbid substance use disorder.

9 Why is early diagnosis difficult? Patients tend only to seek help when depressed Patient insight into previous manic symptoms is often impaired Doctors (GPs) are (understandably) depression-centric in their assessments A corroborative history is often not obtained Drug and alcohol use in younger patients clouds the picture

10 Why is early diagnosis important? Earlier diagnosis should improve prognosis Considerable uncertainty about the benefits and risks of antidepressants for bipolar depression Addressing comorbidities, eg, anxiety, alcohol misuse Addressing physical health problems at the bginning of treatment, eg, obesity, diabetes and cardiovascular risk

11 Clinical features suggestive of Bipolar Depression Bipolar depression Unipolar depression Substance abuse Family history Seasonality Onset before age Postpartum onset Psychotic depression <age Atypical features ++ + Rapid on/off pattern Recurrent MDE s ++ + Antidepressant associated mania or hypomania Brief episodes of depression (< 3 months) Antidepressant wear-off Mixed depression (manic features during episode) ++ --

12 Bipolar versus Borderline: Clear history of mania or hypomania, lasting at least a week Bipolar Yes Borderline No

13 Bipolar versus Borderline: Clear history of mania or hypomania, lasting at least a week Bipolar Yes Borderline No Strong family history of psychosis or mood disorder Yes No

14 Bipolar versus Borderline: Clear history of mania or hypomania, lasting at least a week Bipolar Yes Borderline No Strong family history of psychosis or mood disorder Yes No Fulfills ICD-10 general criteria for personality disorder No Yes

15 ICD-10 general criteria for personality disorder 1. Enduring patterns of inner experience and behaviour which deviate markedly from the accepted cultural range or norm 2. Behaviour that is inflexible and maladaptive across a broad range of personal and social situations 3. Personal distress attributable to the behaviour 4. The deviation is stable and of long duration, with onset in late childhood or adolescence 5. The deviation is not better explained by other mental disorders 6. Organic brain disease has been excluded

16 Bipolar versus Borderline: Clear history of mania or hypomania, lasting at least a week Bipolar Yes Borderline No Strong family history of psychosis or mood disorder Yes No Fulfills ICD-10 general criteria for personality disorder No Yes Emotionally unstable personality features No Yes

17 Borderline personality features: 1. Disturbances in and uncertainty about self-image and internal preferences 2. Liability to become involved in intense and unstable relationships, often leading to emotional crises 3. Excessive efforts to avoid abandonment 4. Recurrent threats or acts of self-harm 5. Chronic feelings of emptiness

18 Bipolar versus Borderline: Clear history of mania or hypomania, lasting at least a week Bipolar Yes Borderline No Strong family history of psychosis or mood disorder Yes No Fulfills ICD-10 general criteria for personality disorder No Yes Emotionally unstable personality features No Yes Episodic course Yes No

19 What works for bipolar disorder: 1. Early and accurate diagnosis 2. Expert pharmacotherapy 3. Psychoeducation and self-management

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21 Reasons why bipolar disorder requires expert prescribing: 1. Complex disorder dominated by depression, not mania 2. Full inter-episode recovery does not occur for many patients 3. Risk of suicide is at least 8%; premature mortality of years 4. Multiple comorbidities are the norm (eg, anxiety disorders, alcohol misuse, obesity and cardiovascular disease) 5. Patients will tend to self-medicate and titrate their medication

22 Some more reasons why bipolar disorder requires expert prescribing: 6. Special considerations for lithium and valproate 7. Combination mood stabilisers are often required (and may be desirable) but require expert supervision 8. Antidepressants are (probably) overused and may be unhelpful 9. As prescribers we need to address potential adverse health outcomes of psychotropic medications

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24 What works for bipolar disorder: 1. Early and accurate diagnosis 2. Expert pharmacotherapy 3. Psychoeducation and self-management

25 Barcelona Group Psychoeducation Programme

26 Colom et al. Arch Gen Psychiatry. 2003;60:

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28 Developing and testing psychoeducational interventions in Cardiff:

29 Module: Introduction to group psychoeducation What is bipolar disorder? What causes bipolar disorder? Lifestyle Monitoring mood and identifying triggers Early warning signature Medication Psychological approaches 2 facilitators 10 sessions Each session 2 hours: Information Exercises Discussion Partners, families and carers Bringing it all together

30 Eight online modules lasting 30 mins each: 1. What is bipolar disorder? 2. What causes bipolar disorder? 3. Role of medication 4. Role of lifestyle changes 5. Relapse prevention and early intervention 6. Psychological approaches 7. Women and bipolar disorder 8. Advice for family and carers Secure discussion forum for users to share thoughts, experiences and advice with each other.

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32 Assessed for eligibility N=80 Excluded (not euthymic) N=30 Randomised N=50 Intervention group N=24 Treatment as usual N=26 Lost to follow-up N=7 Lost to follow-up N=6 Analysed N=17 Analysed N=20 Smith et al (2011) Bipolar Disorders, 13,

33 Patient compliance with the programme Smith et al (2011) Bipolar Disorders, 13,

34 Treatment group (N=17) Control group (N=20) P value Primary Outcome: WHOQOL-Bref total, mean (SD) (52.7) (63.2) 0.27 Physical, mean (SD) 62.3 (19.0) 62.6 (16.5) 0.56 Psychological, mean (SD) 60.8 (17.8) 56.9 (16.4) 0.05 Social relationships, mean (SD) 55.5 (20.9) 62.7 (25.4) 0.93 Environment, mean (SD) 78.1 (14.9) 77.0 (19.8) 0.19 Smith et al (2011) Bipolar Disorders, 13,

35 Web-based psychoeducation for bipolar disorder: qualitative study of feasibility, acceptability and impact Poole et al, BMC Psychiatry, FEASIBILITY Accessibility and flexibility The effect of illness on engagement with the programme The importance of accessing the programme in a private environment ACCEPTABILITY Clarity and quality of content but lack of activity on the forum Presentation of lithium within the medication module Internet-based psychoeducation lacks the sociability of group-based learning Internet-based psychoeducation may be more acceptable than group-based psychoeducation for those newly diagnosed IMPACT Minimal contribution to existing knowledge for those with a long-standing diagnosis Potential greater impact for those with a recent diagnosis Greater knowledge of bipolar disorder Improved self-awareness Behaviour change as a result of the programme Change in attitudes towards medication Facilitation of greater understanding and support from others

36 Now free access:

37 Summary: 1. Early and accurate diagnosis 2. Expert pharmacotherapy 3. Psychoeducation and self-management

B i p o l a r D i s o r d e r

B i p o l a r D i s o r d e r B i p o l a r D i s o r d e r Professor Ian Jones Director National Centre for Mental Health www.ncmh.info @ncmh_wales /WalesMentalHealth 029 2074 4392 info@ncmh.info Robert Schumann 1810-1856 Schumann's

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