Iain Macmillan

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 targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding 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 these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. 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. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.

Cognitive behaviour therapy for improving social recovery in psychosis: a report from the ISREP MRC Trial Platform study (Improving Social Recovery in Early Psychosis)

BACKGROUND This study reports on a preliminary evaluation of a cognitive behavioural intervention to improve social recovery among young people in the early stages of psychosis showing persistent signs of poor social functioning and unemployment. The study was a single-blind randomized controlled trial (RCT) with two arms, 35 participants receiving cognitive behaviour therapy (CBT) plus treatment as usual (TAU), and 42 participants receiving TAU alone. Participants were assessed at baseline and post-treatment. METHOD Seventy-seven participants were recruited from secondary mental health teams after presenting with a history of unemployment and poor social outcome. The cognitive behavioural intervention was delivered over a 9-month period with a mean of 12 sessions. The primary outcomes were weekly hours spent in constructive economic and structured activity. A range of secondary and tertiary outcomes were also assessed. RESULTS Intention-to-treat analysis on the combined affective and non-affective psychosis sample showed no significant impact of treatment on primary or secondary outcomes. However, analysis of interactions by diagnostic subgroup was significant for secondary symptomatic outcomes on the Positive and Negative Syndrome Scale (PANSS) [F(1, 69)=3.99, p=0.05]. Subsequent exploratory analyses within diagnostic subgroups revealed clinically important and significant improvements in weekly hours in constructive and structured activity and PANSS scores among people with non-affective psychosis. CONCLUSIONS The primary study comparison provided no clear evidence for the benefit of CBT in a combined sample of patients. However, planned analyses with diagnostic subgroups showed important benefits for CBT among people with non-affective psychosis who have social recovery problems. These promising results need to be independently replicated in a larger, multi-centre RCT.

Mood, neuropsychological function and cognitions in premenstrual dysphoric disorder

BACKGROUND Neuropsychological function and cognitive correlates of depression have not previously been examined in a rigorously defined population of patients suffering from premenstrual dysphoric disorder (PMDD). METHOD MOOD, neuropsychological function and cognition were measured in 10 PMDD patients and 10 age-matched controls in both phases of the menstrual cycle in a random order, counter-balanced design. RESULTS The BDI was significantly elevated in the luteal phase of PMDD patients only while other cognitive measures showed no significant differences. Working memory was impaired in the luteal phase of the menstrual cycle with no significant differences between PMDD and control subjects. CONCLUSION Despite the small sample size, these results show that the BDI is sensitive to the mood fluctuations of PMDD patients. An impairment in working memory was also found although this is a general menstrual cycle effect.

Can targeted early intervention improve functional recovery in psychosis? A historical control evaluation of the effectiveness of different models of early intervention service provision in Norfolk 1998-2007.

Aims: This paper assesses the impact of different models of early intervention (EI) service provision on functional recovery and inpatient hospital admission. The study compares the outcome of a comprehensive EI team with a partial model (community mental health team (CMHT) plus specialist support) and traditional care (generic CMHT) over a 10‐year period.

Adolescents and young adults who are not in employment, education, or training

Their problems are more than economic

Social and symptomatic outcomes of first-episode bipolar psychoses in an early intervention service.

Aim:  We aimed to establish the relative proportions of all diagnoses in people aged 14–35 years presenting to an early intervention in psychosis service, and to compare demographic variables, symptoms and outcomes between the bipolar psychoses and other psychoses at 3–6 months and 1 year post referral.

The need for specialist services for serious and recurrent mood disorders.

Australian & New Zealand Journal of Psychiatry, 47(9) The WHO predicts that by the year 2030 unipolar depressive disorders will rank as the principal cause of disease burden among high-income countries (Mathers and Loncar, 2006). In Australia, 10% of the total burden of disease in 2003 was accounted for by depression and anxiety in women; double that of men (4.8%). Between 1990 and 2010, depression has jumped from 15th to 11th as a cause of global disability-adjusted life years (DALYs) (Murray et al., 2013). It is highly prevalent, with 6% of the population meeting criteria for depression or dysthymia at any time and 20% of those with major depressive disorder having a prolonged illness course, with symptoms persisting for more than 2 years (Reavley et al., 2011). It is equally highly recurrent, with 30% of individuals experiencing a relapse within 3 months of recovery and 50% experiencing a further episode within 2 years, in the absence of continuation or maintenance treatment (Gordon et al., 2011). Bipolar disorder is frequently under-diagnosed, and is also highly recurrent, costly and disabling; it is one of the most important causes of disability at ages 15 to 44, with 35% of the total cost attributable to hospital care. Suicide rates in bipolar I disorder is elevated to 30 times the general population rate (Malhi and Berk, 2011; Page et al., 2011). Germane to primary care, both depression and bipolar disorders are additionally highly comorbid with a range of mental and medical disorders (Magalhães et al., 2012). Critically, a significant component of the burden of disability of mood disorders is avertable with optimal care, although a large component is not avertable (Andrews et al., 2004). Depression is a predominant cause of work-related disability (both absenteeism and presenteeism), and even sub-threshold depression is a major driver of disability pension awards (Knudsen et al., 2010; McKeith and Scott, 2008). Additionally, the most efficient interventions for depression are highly cost-effective, with each averted DALY costing less than a year of average per capita income (Chisholm, 2005). It has been suggested that the clinical focus on the management of discrete episodes of major depressive disorder and other mood disorders is outdated and that there is a need to treat depression as a ‘life course’ disorder using models of chronic disease management, as promoted for medical problems such as diabetes (Scott, 2006; Wagner et al., 1998). Services oriented to chronic disease management for depression are, however, marked by their paucity. While there are pockets of high-quality care, there are clinically significant obstacles to the delivery of a more uniform highquality model of care for mood disorders. The current funding model, which sees the care of those with a ‘serious mental illness’ as being primarily a state responsibility, leaving the highprevalence disorders in the federal domain has significant and well recognised sequelae for effective continuity of care. It does not support intensive or long-term interventions for those with anxiety or depression by specialised experts in the public system. The additional preoccupation with risk assessment in the triage process, and the reliance on risk assessment within the public services to determine access to care, filters individuals with expressed aggression or suicide into the system, and leaves many with potentially treatable mood disorders outside of the public system unless critical safety issues are present. Most academics are in the public (state) system, which has a primary focus on psychotic disorders rather than mood and anxiety disorders. Indeed, the paucity of expertise in mood and particular anxiety disorders leaves Australia in divergence to most major Western countries. The counterpoint of this anomaly, which is that the ‘high prevalence’ disorders are amongst the greatest contributors to burden of disease in adults, is stark. The federal model of care for mood disorders, with the emphasis on primary care, is appropriate given their frequency; however this leads to a number of service consequences. Funding is focused on primary care, with the GP as the centre of the system. The better access system has clearly had a substantial beneficial The need for specialist services for serious and recurrent mood disorders

A systematic review of the frequency and severity of manic symptoms reported in studies that compare phenomenology across children, adolescents and adults with bipolar disorders

BackgroundIn the last two decades, there has been a significant increase in the diagnosis of Bipolar Disorder (BD) in children. The notion of prepubertal onsets of BD is not without controversy, with researchers debating whether paediatric cases have a distinct symptom profile or follow a different illness trajectory from other forms of BD. The latter issue is difficult to address without long-term prospective follow-up studies. However, in the interim, it is useful to consider the phenomenology observed in groups of cases with different ages of onset and particularly to compare manic symptoms in children diagnosed with BD compared to cases presenting with BD in adolescence and adulthood. This review systematically explores the phenomenology of manic or hypomanic episodes in groups defined by age at onset of BD (children, adolescents and adults; or combined age groups e.g. children and adolescents versus adults).MethodsLiterature reviews of PubMed and Scopus were conducted to identify publications which directly compared the frequency or severity of manic symptoms in individuals with BD presenting with a first episode of mania in childhood, adolescence or adulthood.ResultsOf 304 studies identified, 55 texts warranted detailed review, but only nine studies met eligibility criteria for inclusion. Comparison of manic symptoms across age groups suggested that irritability is a key feature of BD with an onset in childhood, activity is the most prominent in adolescent-onset BD and pressure of speech is more characteristic of adult-onset BD. However, none of the eligible studies made a direct comparison of phenomenology in children versus adults. Assessment procedures varied in quality and undermined the reliability of cross-study comparisons. Other limitations were: the scarcity of comparative studies, the geographic bias (most studies originated in the USA), the failure to fully consider the impact of psychiatric comorbidities on recorded symptoms and methodological heterogeneity.ConclusionsDespite frequent discussion of similarities and differences in phenomenology of mania presenting in different age groups, systematic research is lacking and studies are still required to reliably establish whether the frequency and severity of manic symptoms varies. Such information has implications for clinical practice and the classification of mental disorders.