Melissa K. Hasty

Enhancing medication adherence in patients with bipolar disorder

Medication adherence contributes to the efficacy‐effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.

Evidence and implications for early intervention in bipolar disorder

Aims: To review the evidence that supports early intervention in the treatment of bipolar disorder. Background: Bipolar disorder is a pleomorphic condition, with varying manifestations that are determined by a number of complex factors including the “stage” of illness. It is consequently a notoriously difficult illness to diagnose and as a corollary is associated with lengthy delays in recognition and the initiation of suitable treatment. Methods: A literature search was conducted using MEDLINE augmented by a manual search. Results: Emerging neuroimaging data suggests that, in contrast to schizophrenia, where at the time of a first-episode of illness there is already discernible volume loss, in bipolar disorder, gross brain structure is relatively preserved, and it is only with recurrences that there is a sequential, but marked loss of brain volume. Recent evidence suggests that both pharmacotherapy and psychotherapy are more effective if instituted early in the course of bipolar disorder, and that with multiple episodes and disease progression there is a noticeable decline in treatment response. Conclusions: Such data supports the notion of clinical staging, and the tailored implementation of treatments according to the stage of illness. The progressive nature of bipolar disorder further supports the concept that the first episode is a period that requires energetic broad-based treatment, with the hope that this could alter the temporal trajectory of the illness. It also raises hope that prompt treatment may be neuroprotective and that this perhaps attenuates or even prevents the neurostructural and neurocognitive changes seen to emerge with chronicity. This highlights the need for early identification at a population level and the necessity of implementing treatments and services at a stage of the illness where prognosis is optimal.

Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice

While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors, and how these could influence the persons presentation, in addition to attending to personal strengths, may allow the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and potentially provide a better clinical outcome.

Psychological needs of adolescents in the early phase of bipolar disorder: implications for early intervention

Aim: This paper will describe the rationale for, and importance of, psychological interventions for young people early in the course of bipolar disorder.

Can a targeted psychological intervention be effective for young people following a first manic episode? Results from an 18-month pilot study.

Aim: There is a scarce literature describing psychological interventions for a young, first‐episode cohort who have experienced psychotic mania. This study aimed to assess whether a manualized psychological intervention could be effective in reducing symptomatology and relapse, and improve functional outcome in this population.

The therapeutic alliance: is it necessary or sufficient to engender positive outcomes?

There has been considerable interest in the concept of the therapeutic relationship (also described as the therapeutic alliance or treatment alliance) since Freud’s conceptualisation of transference and countertransference early in the 20th century. Part of the reason for this level of interest undoubtedly relates to the therapeutic relationship having been almost universally viewed as one of the most critical constituents of psychoanalytic, cognitive, narrative, solution-focused and schema therapy approaches (2–6). However, the relevance of the therapeutic relationship goes beyond that of psychological interventions and is becoming more widely recognised as important in engagement and retention of people in biological treatments for disorders as diverse as oncology and diabetes (7,8). Compelling evidence is accumulating, which shows that the quality of the therapeutic relationship is a significant predictor of clinical outcome across a number of disorders (9–11). For example, measures of therapeutic alliance, such as the Working Alliance Inventory (12) and the California Psychotherapy Alliance Scale (13), have shown the therapeutic relationship to be a reliable indicator of outcome in depression and affective disorders, with better relationships being correlated with better clinical outcome and reduced likelihood of drop out (10). Blatt et al. (14) analysed data from a large National Institute of Mental Health (NIMH) study on people with depression and concluded, ‘. . . therapeutic gain . . . is significantly influenced by interpersonal dimensions of the treatment process – by patient and therapist capacity to establish a therapeutic relationship’ (p. 1277). Strauss and Johnson (15) found that a strong therapeutic relationship predicted fewer negative attitudes to medication, and led to people with bipolar disorder experiencing less manic symptoms over a 6-month follow-up. In another bipolar disorder sample, people who were more satisfied with their clinicians were found to adapt better to their diagnosis, coped better with symptoms and reported feeling less ashamed or angry than those who were less satisfied with their clinicians (16). Similarly, Frank and Gunderson (17) found that people diagnosed with schizophrenia, who were rated by their clinicians as having good therapeutic alliance, were less likely to drop out of treatment, had better medication adherence and obtained better functional outcomes. Among people attending treatment for substance abuse, the therapeutic alliance has been found to impact significantly on retention, completion of therapy and both clinical and functional outcomes (18). Keeley et al. (19) reported that the therapeutic relationship was also a significant predictor of outcome in obsessive-compulsive disorder, with ratings of the alliance by both patients and therapists being correlated with outcome in the expected direction. Keeley and colleagues suggested that the mechanism for this may be through ‘. . . persuasion and social influence’ (p.125), which impacted on the person’s likelihood to complete tasks that in turn led to behavioural and cognitive changes. Fakhoury et al. (20) found that a strong therapeutic relationship predicted fewer rehospitalisations in people with severe mental health problems and who were new to a clinical service. The alliance therefore is a key clinical component that may modulate treatment outcomes in settings beyond that of formal psychotherapy. In contrast to the studies reported earlier, a critical review by Meier et al. (21) found only a modest relationship between the therapeutic relationship and retention and outcome in people with substance use problems. This led to an editorial by Carroll (22) hypothesising that the importance of the therapeutic relationship may vary across different disorders and possibly across different therapy models. Specifically, Carroll noted that the therapeutic alliance might be particularly challenging when working with people with substance abuse, as the clinician may also be the person who limits the patient’s access to medication. Carroll suggested further that in cognitive-behavioural therapy (CBT), the therapeutic relationship might play less of a role in outcome than for some other models, as there are other significant aspects to CBT including skill acquisition and cognitive change. In contrast, for models that rely more heavily, if not solely, on the therapeutic relationship, if this is not strong, therapy is likely to be ineffective. Carroll concluded, ‘In effect, the presence of at least a minimally positive alliance may be a necessary, but by no means sufficient component of CBT and other effective therapies’ (p.267). Although considerable research has focused on the importance of the therapeutic relationship, debate continues

Quetiapine v. lithium in the maintenance phase following a first episode of mania: randomised controlled trial

BackgroundLithium and quetiapine are considered standard maintenance agents for bipolar disorder yet it is unclear how their efficacy compares with each other.AimsTo investigate the differential effect of lithium and quetiapine on symptoms of depression, mania, general functioning, global illness severity and quality of life in patients with recently stabilised first-episode mania.MethodMaintenance trial of patients with first-episode mania stabilised on a combination of lithium and quetiapine, subsequently randomised to lithium or quetiapine monotherapy (up to 800 mg/day) and followed up for 1 year. (Trial registration: Australian and New Zealand Clinical Trials Registry - ACTRN12607000639426.)ResultsIn total, 61 individuals were randomised. Within mixed-model repeated measures analyses, significant omnibus treatment × visit interactions were observed for measures of overall psychopathology, psychotic symptoms and functioning. Planned and post hoc comparisons further demonstrated the superiority of lithium treatment over quetiapine.ConclusionsIn people with first-episode mania treated with a combination of lithium and quetiapine, continuation treatment with lithium rather than quetiapine is superior in terms of mean levels of symptoms during a 1-year evolution.

Bipolar disorder in young people : a psychological intervention manual

Bipolar disorder in young people - Libros de Medicina - Trastorno de la personalidad - 37,74

Olanzapine or chlorpromazine plus lithium in first episode psychotic mania: An 8-week randomised controlled trial

BACKGROUND Treatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments. METHODS Data from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures. RESULTS Ethics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate (P=.032) and earlier occurrence (P=.043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons. CONCLUSIONS Olanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample.

The impact of past direct-personal traumatic events on 12-month outcome in first episode psychotic mania: Trauma and early psychotic mania

Objective: Past traumatic events have been associated with poorer clinical outcomes in people with bipolar disorder. However, the impact of these events in the early stages of the illness remains unclear. The aim of this study was to investigate whether prior traumatic events were related to poorer outcomes 12 months following a first episode of psychotic mania. Methods: Traumatic events were retrospectively evaluated from patient files in a sample of 65 participants who had experienced first episode psychotic mania. Participants were aged between 15 and 28 years and were treated at a specialised early psychosis service. Clinical outcomes were measured by a variety of symptomatic and functioning scales at the 12-month time-point. Results: Direct-personal traumatic experiences prior to the onset of psychotic mania were reported by 48% of the sample. Participants with past direct-personal trauma had significantly higher symptoms of mania (p=0.02), depression (p=0.03) and psychopathology (p=0.01) 12 months following their first episode compared to participants without past direct-personal trauma, with medium to large effects observed. After adjusting for baseline scores, differences in global functioning (as measured by the Global Assessment of Functioning scale) were non-significant (p=0.05); however, participants with past direct-personal trauma had significantly poorer social and occupational functioning (p=0.04) at the 12-month assessment with medium effect. Conclusions: Past direct-personal trauma may predict poorer symptomatic and functional outcomes after first episode psychotic mania. Limitations include that the findings represent individuals treated at a specialist early intervention centre for youth and the retrospective assessment of traumatic events may have been underestimated.