Danielle Adams

Clinical practice recommendations for bipolar disorder

Objective:  To provide clinically relevant evidence‐based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision‐making.

Clinical practice recommendations for depression

Objective:  To provide clinically relevant evidence‐based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

The management of individuals with bipolar disorder : a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.

Medicating mood with maintenance in mind: bipolar depression pharmacotherapy

OBJECTIVES Bipolar depression is a core feature of bipolar disorder, a phase in which many patients spend the majority of time and one that confers a significant degree of burden and risk. The purpose of this paper is to briefly review the evidence base for the pharmacotherapy of bipolar depression and to discuss the recommendations for its optimal management. METHODS A detailed literature review was undertaken with a particular emphasis on pharmacological treatment strategies for bipolar depression across the acute and maintenance phases of the illness. Electronic library and Web-based searches were performed using recognised tools (MEDLINE, PubMED, EMBASE and PsychINFO) to identify the pertinent literature. A summary of the evidence base is outlined and then distilled into broad clinical recommendations to guide the pharmacological management of bipolar depression. RESULTS Partitioning treatment into acute and maintenance therapy is difficult based on the paucity of current evidence. The evidence from treatment trials favours the use of lithium and lamotrigine as first-line treatment in preference to valproate, and indicates that, for acute episodes, quetiapine and olanzapine have perhaps achieved equivalence at least in terms of efficacy. However, the effectiveness of the atypical antipsychotics in maintenance therapy is constrained by the potential for significant side effects of individual agents and the lack of both long-term research data and clinical experience in treating bipolar disorder as compared to other agents. Conversely, lithium and the anticonvulsants are generally slower to effect symptomatic change, and this limits their usefulness. CONCLUSIONS There has been a tendency for research trials of bipolar depression to differentiate the illness cross-sectionally into the acute and maintenance phases of bipolar depression; however, in clinical terms, bipolar depression invariably follows a longitudinal course in which the phases of illness are inextricably linked, and useful acute treatments are typically continued in maintenance. Therefore, when medicating mood in acute bipolar depression it is imperative to keep maintenance in mind as it is this aspect of treatment that determines long-term success.

Is Lithium in a Class of Its Own? A Brief Profile of Its Clinical Use

Lithium is a unique and effective psychotropic agent with a long-standing history of clinical use yet it is increasingly overlooked in lieu of newer agents. The purpose of the present paper was to succinctly review the therapeutic profile of lithium particularly with respect to the treatment of mood disorders and consider its unique properties and clinical utility. A comprehensive literature review pertaining to lithium was undertaken using electronic database search engines to identify relevant clinical trials, meta-analyses and Cochrane reviews. In addition articles and book chapters known to the authors were carefully reviewed, and the authors appraised published guidelines. The evidence from these sources was rated using National Health and Medical Research Council evidence levels and synthesized according to phenotype and mood states. In addition, the authors have drawn upon published guidelines and their own clinical experience. Lithium has specificity for mood disorders with proven efficacy in the treatment of both unipolar depression and bipolar disorder. The recommendations are based predominantly on Level I evidence, but its clinical use has to be tempered against potential side-effects and the need for ongoing monitoring. In practice, lithium should be considered a first-line option in bipolar disorder, especially in prophylaxis and when onset of action is not an imperative. Lithium has been in use in modern medicine for 60 years and as such has been tried and tested across the full range of mood disorders. Arguably, lithium is the only true mood stabilizer and because of its unique properties is in a class of its own.

Are guidelines in need of CPR? The development of clinical practice recommendations (CPR).

In psychiatry, there is a considerable time-lag between the identification of evidence-based practices and their application in clinical settings (1). One approach to this problem has been to develop clinical practice guidelines for distribution and implementation either through professional bodies or health services. However, it has gradually become apparent that simply disseminating knowledge does not ensure its clinical uptake (2). One reason for this is that clinicians draw upon a variety of sources of evidence, of which guidelines are only one component (3). Recent research has shown that to enhance compliance with clinical guidelines it is important to use a multifaceted approach that incorporates a number of interactive strategies (4), such as feedback and audit. These activities are effective in improving patient outcome because they alter physician decision-making and clinical judgment (5). Interestingly, the manner in which physicians evaluate decisions and make sense of different types of evidence has been described using the concept of mindlines (6). The latter are essentially internalised guidelines that are the product of personal experience. Mindlines are determined largely through learning from interactions with peers and patients, as opposed to drawing on research findings and evidence, and can perhaps explain why guidelines often fail to be implemented.

A Community Mental Health Service Delivery Model: Integrating the Evidence Base Within Existing Clinical Models

Objectives: A model of care for community mental health services was developed by reviewing the available literature, surveying ‘best practice’ and evaluating the performance of existing services in a metropolitan area mental health service servicing a population of approximately 1.1 million people. Methods: A review of relevant academic literature and recognized ‘good practice’ service delivery models was undertaken in conjunction with a review of local activity data and consultation with key stakeholders (not addressed in this paper). A model was developed identifying the core functions of community mental health service delivery. Results: The components of a comprehensive, integrated model of community mental health service (CMHS) are outlined. The essential components of a comprehensive, integrated model of CMHSs include: acute and emergency response, community continuing care services, assertive rehabilitation teams, partnerships with general practitioners and other human services agencies. Conclusions: We propose a comprehensive integrated model of community mental health service. Clarity of role, required outputs and expected outcomes will assist the development of effective and appropriate community mental health services. Outreach to the community is a key success factor for these services and their associated inpatient services. Gap analysis can assist in the planning and costing of community mental health services.

Clozapine and cardiometabolic health in chronic schizophrenia: correlations and consequences in a clinical context.

Objective: The aim of this study was to identify the prevalence of metabolic syndrome and its putative precursors in a naturalistic study of non-acute inpatients at a psychiatric hospital. Method: Anthropometric and biochemical data collected from the hospitals annual cardiometabolic survey, along with information about prescribed medications, were used to assess the prevalence and predictors of physical health problems in patients with schizophrenia. Results: Of the 167 patients included in the survey, 52.4% met criteria for metabolic syndrome. A shorter duration of hospital admission and clozapine use were significant predictors of metabolic syndrome. Age, gender, duration of admission and clozapine use were all predictors of individual cardiometabolic risk factors. Conclusions: The findings from this naturalistic study reinforce the high prevalence of physical health problems in patients with schizophrenia and the important influence that psychiatric treatments can have on physical health. The impact of clozapine on cardiometabolic health appears to occur early in the course of treatment and emphasizes the need for proactive monitoring and interventions from the outset of management.

Time to 'get real': preliminary insights into the long-term management of schizophrenia

Objective: A brief file and medication chart review was undertaken to examine the ‘real world’ treatment of schizophrenia, with a particular focus on long-term treatment strategies that extend beyond existing evidence-based guidelines. Method: Treatment strategies were identified through an audit of patient files and their medication charts for patients admitted 2–5 years in a non-acute psychiatric hospital. Results: Twenty-nine file reviews and 20 medication chart audits were conducted. High levels of diagnostic heterogeneity were identified with the presence of psychosis and mood-related diagnoses (primarily schizophrenia and schizoaffective disorder) and high rates of comorbidity (86%). Functional impairment, poor insight and high levels of risk were present in most patients. Treatments largely consisted of combination strategies with 75% of patients prescribed two or more antipsychotics and an average of 3.4 psychotropic medications in total. While clozapine was commonly prescribed (65%), this was often in combination with, on average, two other psychotropic agents. Conclusions: Notwithstanding the limited sample, these findings provide a valuable glimpse into the management strategies employed in the long-term management of schizophrenia. Evidence-based guidelines are largely of limited value for this cohort that often has complex presentations and further research is urgently needed to provide guidance into management strategies that extend beyond 5 years, with particular emphasis on the utility of medication combinations.

Comment: clinical practice guidelines – guiding or goading?

J ust as the real estate mantra assigns priority to ‘location, location, location’, the guideline equivalent should perhaps emphasize ‘implementation, implementation, implementation’. Sadly, since publication of the College CPGs, the chant of ‘effective implementation’ has gradually become quieter and is ‘effectively’ silenced. The wish for widespread uptake of CPGs and assimilation into routine clinical practice, though well intentioned, has largely gone unfulfilled. Rosenman et al. aptly describe the limitations of the College guidelines that have likely contributed to their apparent lack of impact. Their article details the issues that clinicians of all persuasion have identified as possible barriers to the use of guidelines and while many of the points raised by the authors are valid, there are a number of issues that warrant further discussion.