1
|
Taylor WD, Ajilore O, Karim HT, Butters MA, Krafty R, Boyd BD, Banihashemi L, Szymkowicz SM, Ryan C, Hassenstab J, Landman BA, Andreescu C. Assessing depression recurrence, cognitive burden, and neurobiological homeostasis in late life: Design and rationale of the REMBRANDT Study. JOURNAL OF MOOD AND ANXIETY DISORDERS 2024; 5:100038. [PMID: 38523701 PMCID: PMC10959248 DOI: 10.1016/j.xjmad.2023.100038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
Background Late-life depression is characterized by disability, cognitive impairment and decline, and a high risk of recurrence following remission. Aside from past psychiatric history, prognostic neurobiological and clinical factors influencing recurrence risk are unclear. Moreover, it is unclear if cognitive impairment predisposes to recurrence, or whether recurrent episodes may accelerate brain aging and cognitive decline. The purpose of the REMBRANDT study (Recurrence markers, cognitive burden, and neurobiological homeostasis in late-life depression) is to better elucidate these relationships and identify phenotypic, cognitive, environmental, and neurobiological factors contributing to and predictive of depression recurrence. Methods Across three sites, REMBRANDT will enroll 300 depressed elders who will receive antidepressant treatment. The goal is to enroll 210 remitted depressed participants and 75 participants with no mental health history into a two-year longitudinal phase focusing on depression recurrence. Participants are evaluated every 2 months with deeper assessments occurring every 8 months, including structural and functional neuroimaging, environmental stress assessments, deep symptom phenotyping, and two weeks of 'burst' ecological momentary assessments to elucidate variability in symptoms and cognitive performance. A broad neuropsychological test battery is completed at the beginning and end of the longitudinal study. Significance REMBRANDT will improve our understanding of how alterations in neural circuits and cognition that persist during remission contribute to depression recurrence vulnerability. It will also elucidate how these processes may contribute to cognitive impairment and decline. This project will obtain deep phenotypic data that will help identify vulnerability and resilience factors that can help stratify individual clinical risk.
Collapse
Affiliation(s)
- Warren D. Taylor
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Health System, Nashville, TN
| | - Olusola Ajilore
- Department of Psychiatry, University of Illinois-Chicago, Chicago, IL
| | - Helmet T. Karim
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Meryl A. Butters
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert Krafty
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA
| | - Brian D. Boyd
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN
| | - Layla Banihashemi
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sarah M. Szymkowicz
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN
| | - Claire Ryan
- Center for Cognitive Medicine, Department of Psychiatry and Behavioral Science, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Hassenstab
- Departments of Neurology and Psychiatry, Washington University in St. Louis, St. Louis, MO
| | - Bennett A. Landman
- Departments of Computer Science, Electrical Engineering, and Biomedical Engineering, Vanderbilt University; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center
| | - Carmen Andreescu
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
2
|
Sylvia LG, Tovey RE, Katz D, Boccagno C, Stromberg AR, Peters AT, Temes CM, Gold AK, Mow J, Puvanich N, Albury EA, Stephan NJ, Faria CM, Nierenberg AA, Kamali MP. A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). J Psychiatr Pract 2023; 29:176-188. [PMID: 37185884 DOI: 10.1097/pra.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned. METHODS We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD. RESULTS By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals. CONCLUSIONS The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care. PUBLIC HEALTH SIGNIFICANCE The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.
Collapse
|
3
|
Pogue YZ. Tracking the Medication History of Persons With Serious Mental Disorders. Psychiatr Serv 2023; 74:84-85. [PMID: 35983658 DOI: 10.1176/appi.ps.20220369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
4
|
Köhler-Forsberg O, Sylvia LG, Thase M, Calabrese JR, Tohen M, Bowden CL, McInnis M, Iosifescu DV, Kocsis JH, Friedman ES, Ketter TA, McElroy SL, Shelton RC, Fung V, Ostacher MJ, Nierenberg AA. Lithium plus antipsychotics or anticonvulsants for bipolar disorder: Comparing clinical response and metabolic changes. Aust N Z J Psychiatry 2023; 57:93-103. [PMID: 35164524 DOI: 10.1177/00048674221077619] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Patients with bipolar disorder treated with lithium often require additional antipsychotics or anticonvulsants. However, the comparative effectiveness and safety of these agents as add-on to lithium has not been studied. METHODS This secondary analysis combined two similar 24-week trials on outpatients with bipolar disorder randomized to lithium (target serum level 0.4-0.6 mEq/L). Guideline-based adjunctive antipsychotics (Li+AP) and anticonvulsants (Li+AC) could be used if clinically indicated and was assessed at every study visit. Response was measured on the Clinical Global Impression scale and we performed adjusted mixed effects linear regression analyses. Analysis of variance tests compared metabolic measures including a binary diagnosis of metabolic syndrome before and after 24 weeks of treatment. RESULTS Among 379 outpatients (57% female, mean age 38 years, mean Clinical Global Impression 4.4), users of Li+AP (N = 50, primarily quetiapine and aripiprazole) improved to a similar degree (mean Clinical Global Impression improvement = 1.6, standard deviation = 1.5) as those using lithium-only (i.e. without adjunctive antipsychotics or anticonvulsants, N = 149, mean Clinical Global Impression improvement = 1.7, standard deviation = 1.4) (p = 0.59). Users of Li+AC (N = 107, primarily lamotrigine and valproate, mean Clinical Global Impression improvement = 1.2, standard deviation = 1.3) and users of Li+AP+AC (N = 73, mean Clinical Global Impression improvement = 1.1, standard deviation = 1.3) showed worse response compared to lithium-only users (all p < 0.01). When comparing Li+AP to Li+AC, users of Li+AP improved slightly better on general (p = 0.05) and manic symptoms (p = 0.01), but showed a worse development of glucose, triglycerides, and metabolic syndrome. CONCLUSION Despite treatment-by-indication confounding, these findings are relevant for real-world treatment settings and emphasize the need for randomized trials on this clinically important topic.
Collapse
Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital - Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Dan V Iosifescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Psychiatry, Lindner Center of HOPE, Mason, OH, USA
| | - Richard C Shelton
- Department of Psychiatry, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vicki Fung
- Department of Psychiatry, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Alemi F, Min H, Yousefi M, Becker LK, Hane CA, Nori VS, Crown WH. Procedure for Organizing a Post-FDA-approval Evaluation of Antidepressants. Cureus 2022; 14:e29884. [PMID: 36348913 PMCID: PMC9629984 DOI: 10.7759/cureus.29884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose: The study reports the construction of a cohort used to study the effectiveness of antidepressants. Methods: The cohort includes experiences of 3,678,082 patients with depression in the United States on antidepressants between January 1, 2001, and December 31, 2018. A total of 10,221,145 antidepressant treatment episodes were analyzed. Patients who had no utilization of health services for at least two years, or who had died, were excluded from the analysis. Follow-up was passive, automatic, and collated from fragmented clinical services of diverse providers. Results: The average follow-up was 2.93 years, resulting in 15,096,055 person-years of data. The mean age of the cohort was 46.54 years (standard deviation of 17.48) at first prescription of antidepressant, which was also the enrollment event (16.92% were over 65 years), and most were female (69.36%). In 10,221,145 episodes, within the first 100 days of start of the episode, 4,729,372 (46.3%) continued their treatment, 1,306,338 (12.8%) switched to another medication, 3,586,156 (35.1%) discontinued their medication, and 599,279 (5.9%) augmented their treatment. Conclusions: We present a procedure for constructing a cohort using claims data. A surrogate measure for self-reported symptom remission based on the patterns of use of antidepressants has been proposed to address the absence of outcomes in claims. Future studies can use the procedures described here to organize studies of the comparative effectiveness of antidepressants.
Collapse
|
6
|
Alemi F, Min H, Yousefi M, Becker LK, Hane CA, Nori VS, Wojtusiak J. Effectiveness of common antidepressants: a post market release study. EClinicalMedicine 2021; 41:101171. [PMID: 34877511 PMCID: PMC8633963 DOI: 10.1016/j.eclinm.2021.101171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study summarizes the experiences of patients, who have multiple comorbidities, with 15 mono-treated antidepressants. METHODS This is a retrospective, observational, matched case control study. The cohort was organized using claims data available through OptumLabs for depressed patients treated with antidepressants between January 1, 2001 and December 31, 2018. The cohort included patients from all states within United States of America. The analysis focused on 3,678,082 patients with major depression who had 10,221,145 antidepressant treatments. Using the robust, and large predictors of remission, and propensity to prescribe an antidepressant, the study created 16,770 subgroups of patients. The study reports the remission rate for the antidepressants within the subgroups. The overall impact of antidepressant on remission was calculated as the common odds ratio across the strata. FINDINGS The study accurately modelled clinicians' prescription patterns (cross-validated Area under the Receiver Operating Curve, AROC, of 82.0%, varied from 77% to 90%) and patients' remission (cross-validated AROC of 72.0%, varied from 69.5% to 78%). In different strata, contrary to published randomized studies, remission rates differed significantly and antidepressants were not equally effective. For example, in age and gender subgroups, the best antidepressant had an average remission rate of 50.78%, 1.5 times higher than the average antidepressant (30.30% remission rate) and 20 times higher than the worst antidepressant. The Breslow-Day chi-square test for homogeneity showed that across strata a homogenous common odds-ratio did not exist (alpha<0.0001). Therefore, the choice of the optimal antidepressant depended on the strata defined by the patient's medical history. INTERPRETATION Study findings may not be appropriate for specific patients. To help clinicians assess the transferability of study findings to specific patient, the web site http://hi.gmu.edu/ad assesses the patient's medical history, finds similar cases in our data, and recommends an antidepressant based on the experience of remission in our data. Patients can share this site's recommendations with their clinicians, who can then assess the appropriateness of the recommendations. FUNDING This project was funded by the Robert Wood Johnson foundation grant #76786. The development of related web site was supported by grant 247-02-20 from Virginia's Commonwealth Health Research Board.
Collapse
Affiliation(s)
- Farrokh Alemi
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
- OptumLabs Visiting Fellow
| | - Hua Min
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| | - Melanie Yousefi
- School of Nursing, College of Health, George Mason University
| | | | | | | | - Janusz Wojtusiak
- Department of Health Administration and Policy, George Mason University, Fairfax, VA
| |
Collapse
|
7
|
Köhler-Forsberg O, Sloth KH, Sylvia LG, Thase M, Calabrese JR, Tohen M, Bowden CL, McInnis M, Kocsis JH, Friedman ES, Ketter TA, McElroy SL, Shelton RC, Iosifescu DV, Ostacher MJ, Nierenberg AA. Response and remission rates during 24 weeks of mood-stabilizing treatment for bipolar depression depending on early non-response. Psychiatry Res 2021; 305:114194. [PMID: 34500184 DOI: 10.1016/j.psychres.2021.114194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/15/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND We aimed to study the probability of bipolar depression response at 24 weeks given initial non-response. METHODS We combined two multi-site, 24-week trials including similar populations following the same evidence-based guidelines randomizing patients to lithium or quetiapine. Additional mood-stabilizing treatment was possible if clinically indicated. We report cumulative proportions of response (>50% improvement in MADRS) and remission (MADRS<10). RESULTS We included 592 participants with bipolar depression (mean 39 years, 59% female, mean MADRS 25). Among 393 (66%) participants without response after 2 weeks, 46% responded by 24 weeks; for 291 (49%) without response at 4 weeks, 40% responded and 33% remitted by 24 weeks; for 222 (38%) without a response at 6 weeks, 36% responded and 29% remitted by 24 weeks; for 185 (31%) without a response at 8 weeks, 29% responded and 24% remitted by 24 weeks. Rates were similar for participants who had started an additional mood-stabilizing drug during the first 6 or 8 weeks. CONCLUSIONS Among patients with bipolar depression and non-response after 6 weeks treatment, representing an adequate bipolar depression trial, only one-third responded by 24 weeks. These results highlight the need for better treatment alternatives for non-responders to evidence-based treatments for bipolar depression.
Collapse
Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit & Department of Affective Disorders, Aarhus University Hospital Psychiatry, Denmark, Europe; Department of Clinical Medicine, Aarhus University, Denmark, Europe; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Kirstine H Sloth
- Psychosis Research Unit & Department of Affective Disorders, Aarhus University Hospital Psychiatry, Denmark, Europe; Department of Clinical Medicine, Aarhus University, Denmark, Europe
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Palestine, United States
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, United States
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH and Lindner Center of HOPE, Mason, OH, United States
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Dan V Iosifescu
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| |
Collapse
|
8
|
Köhler-Forsberg O, Sylvia LG, Fung V, Overhage L, Thase M, Calabrese JR, Deckersbach T, Tohen M, Bowden CL, McInnis M, Kocsis JH, Friedman ES, Ketter TA, McElroy SL, Shelton RC, Ostacher MJ, Iosifescu DV, Nierenberg AA. Adjunctive antidepressant treatment among 763 outpatients with bipolar disorder: Findings from the Bipolar CHOICE and LiTMUS trials. Depress Anxiety 2021; 38:114-123. [PMID: 32598093 DOI: 10.1002/da.23069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/12/2020] [Accepted: 06/03/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Adjunctive antidepressants are frequently used for bipolar depression but their clinical efficacy has been studied in few trials and little is known about how co-occurring manic symptoms affect treatment response. METHODS Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (N = 482) and Lithium Treatment Moderate-Dose Use Study (N = 281) were similar comparative effectiveness trials on outpatients with bipolar disorder comparing four different randomized treatment arms with adjunctive personalized guideline-based treatment for 24 weeks. Adjunctive antidepressant treatment could be used if clinically indicated and was assessed at every study visit. Adjusted mixed effects linear regression analyses compared users of antidepressants to nonusers overall and in different subcohorts. RESULTS Of the 763 patients, 282 (37.0%) used antidepressant drugs during the study. Antidepressant users had less improvement compared to nonusers on the Clinical Global Impression Scale for Bipolar Disorder and on measures of depression. This was particularly true among patients with co-occurring manic symptoms. Exclusion of individuals begun on antidepressants late in the study (potentially due to overall worse response) resulted in no differences between users and nonusers. We found no differences in treatment effects on mania scales. CONCLUSIONS In this large cohort of outpatients with bipolar disorder, clinically indicated and guideline-based adjunctive antidepressant treatment was not associated with lower depressive symptoms or higher mania symptoms. The treatment-by-indication confounding due to the nonrandomized design of the trials complicates causal interpretations, but no analyses indicated better treatment effects of adjunctive antidepressants.
Collapse
Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit and the Department of Affective Disorders, Aarhus University Psychiatry Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Louisa G Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Vicki Fung
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Lindsay Overhage
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
| | - Thilo Deckersbach
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry, Lindner Center of HOPE, Mason, Ohio
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Dan V Iosifescu
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
9
|
Fung VC, Overhage LN, Sylvia LG, Reilly-Harrington NA, Kamali M, Gao K, Shelton RC, Ketter TA, Bobo WV, Thase ME, Calabrese JR, Tohen M, Deckersbach T, Nierenberg AA. Complex polypharmacy in bipolar disorder: Side effect burden, adherence, and response predictors. J Affect Disord 2019; 257:17-22. [PMID: 31299400 PMCID: PMC6711795 DOI: 10.1016/j.jad.2019.06.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/18/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Complex polypharmacy (CP) is common in bipolar disorder (BD). We assessed the associations between CP, adherence, and side effect burden, and patient traits associated with clinical improvement in relationship to CP. METHODS We conducted a secondary analysis of 482 adult BD participants in the Bipolar CHOICE trial. We examined the associations between CP (use of ≥3 BD medications) and non-adherence (missing >30% of BD medication doses in the last 30 days) and side effect burden (Frequency, Intensity and Burden of Side Effects Rating scale) using multivariate models with patient random effects. We used logistic regression to assess the patient traits associated with remission among those with majority CP use (Clinical Global Impression-Severity for BD score ≤2 for 8+ weeks). RESULTS 43% of patients had any CP and 25% had CP for the majority of the study. CP was associated with non-adherence (OR = 2.51, 95% CI [1.81, 3.50]), but not worse side effect burden. Among those with CP, 16% achieved remission; those with non-adherence, comorbid social or generalized anxiety disorder, or BD I vs. II were less likely to achieve remission among those with CP. LIMITATIONS There could be unmeasured confounding between use of CP and side effect burden or adherence. Adherence was measured by self-report, which could be subject to reporting error. CONCLUSIONS BD patients with CP were less likely to adhere to therapy, and those with worse adherence to CP were less likely to clinically respond. Clinicians should assess medication adherence prior to adding another agent to medication regimens.
Collapse
Affiliation(s)
- Vicki C. Fung
- Corresponding Author: Vicki Fung, PhD, , 100 Cambridge St. Suite 1600
- Boston, MA 02108, 617-726-5212 (phone)
- 617-726-4120 (fax)
| | - Lindsay N. Overhage
- Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | | | - Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | - Keming Gao
- Adult Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | | | - Terence A. Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA USA
| | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN USA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, Philadelphia, PA USA
| | - Joseph R. Calabrese
- Adult Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Mauricio Tohen
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Albuquerque, NM USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | | |
Collapse
|
10
|
Hodgkin D, Stewart MT, Merrick EL, Pogue YZ, Reilly-Harrington NA, Sylvia LG, Deckersbach T, Nierenberg AA. Prevalence and predictors of physician recommendations for medication adjustment in bipolar disorder treatment. J Affect Disord 2018; 238:666-673. [PMID: 29966931 DOI: 10.1016/j.jad.2018.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Successful medication management for bipolar disorder requires clinicians to monitor and adjust regimens as needed, to achieve maximum effectiveness and patient adherence. This study aims to measure the prevalence of indications for medication adjustment at visits for bipolar disorder treatment; the frequency with which physicians recommend medication adjustments; and how strongly the indications predict the adjustments. METHODS Data included 3,094 visits for 457 patients in Bipolar CHOICE, a comparative effectiveness study that compared treatment with lithium versus quetiapine. A set of indications for adjustment was matched to reports of whether the physician recommended a medication adjustment at that visit, and what type. Associations between indication and adjustment were examined using bivariate tests and hierarchical logistic mixed effects models. RESULTS Medication adjustment was recommended at 63% of the visits where one of the indications was present, and at 53% of all visits. In multivariable analyses, adjustment was more likely to be recommended if there was an indication of non-response or side effects, for patients who started on quetiapine rather than lithium, or for patients who were female, married, employed or more educated. LIMITATIONS The study's cross-sectional design implies that observed associations could result from confounding variables. Also, the CHOICE trial placed certain restrictions on physicians' medication choices, although this is not likely to have resulted in major alterations of prescribing patterns. CONCLUSIONS Clinical inertia may help explain the lack of any adjustment recommendation at 37% of the visits where one of the indications was present. Other explanations could also apply, such as watchful waiting.
Collapse
Affiliation(s)
- Dominic Hodgkin
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
| | - Maureen T Stewart
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Elizabeth L Merrick
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Ye Zhang Pogue
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
11
|
Sleep disturbance may impact treatment outcome in bipolar disorder: A preliminary investigation in the context of a large comparative effectiveness trial. J Affect Disord 2018; 225:563-568. [PMID: 28881294 DOI: 10.1016/j.jad.2017.08.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/25/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bipolar patients experience sleep disturbances during and between mood episodes. Yet the impact of sleep on treatment with different medications has not been fully explored. The purpose of this paper is to explore the potential impact of poor sleep at baseline on outcomes in a randomized effectiveness trial of quetiapine and lithium. METHODS The Bipolar CHOICE study was a 6-month, parallel group, multisite randomized controlled trial. Participants with bipolar disorder (N = 482; 59% female and age 18-70 years) received quetiapine or lithium. Patients were allowed to also receive adjunctive personalized treatments, which were guideline-informed, empirically-based medications added to treatment as needed. Medication changes were recorded as necessary clinical adjustments (NCA). Fisher's exact tests, mixed-regression models, and Mann-Whitney U tests were used to assess demographic and clinical characteristics as well as whether sleep disturbance would predict outcomes. RESULTS 63% of patients had baseline sleep disturbance. Individuals with sleep disturbance had worse bipolar illness severity, greater severity of depression, mania, anxiety, irritability, and psychosis, were less likely to have sustained response (17% vs. 29%; adjusted RR: 0.55, 95% CI: 0.38-0.78, p = 0.0006) and had more NCAs (median 0.71 vs. 0.59, p = 0.03). LIMITATIONS Our findings were limited by how we defined sleep disturbance, and by how severity of sleep disturbance was assessed with one item with a non-sleep specific measure. CONCLUSIONS Baseline sleep disturbance was associated with more severe bipolar symptoms and worse 6-month outcomes. Further research is warranted on improving sleep in bipolar disorder, especially the role of psychosocial interventions.
Collapse
|
12
|
Köhler-Forsberg O, Sylvia L, Thase M, Calabrese JR, Deckersbach T, Tohen M, Bowden CL, McInnis M, Kocsis JH, Friedman ES, Ketter TA, McElroy S, Shelton RC, Nierenberg AA. Nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol do not affect 6-month mood-stabilizing treatment outcome among 482 patients with bipolar disorder. Depress Anxiety 2017; 34:281-290. [PMID: 28135023 DOI: 10.1002/da.22601] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/11/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Many mood disorder patients need analgesics due to increased pain sensitivity. Recent studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) may inhibit antidepressant treatment, which requires replication before clinical recommendations. METHODS The Clinical and Health Outcomes Initiatives in Comparative Effectiveness for Bipolar Disorder Study randomized participants to 6 months lithium or quetiapine treatment. Use of NSAIDs and paracetamol was assessed throughout the study period and psychopathology measured with the Clinical Global Impression Scale for Bipolar Disorder (CGI-BP) and Bipolar Inventory of Symptoms Scale (BISS). The effects of NSAIDs and paracetamol on treatment outcome were examined using mixed effects linear regression adjusted for age, gender, body mass index, smoking status, exercise, and somatic diseases. RESULTS Among 482 participants, 177 (36.7%) used NSAIDs and/or paracetamol during the study. NSAID and paracetamol users did not differ from nonusers with respect to treatment outcome with lithium or quetiapine at any time point during 6 months treatment on the overall CGI-BP (β = 0.001 (95% CI = -0.01 to -0.01), P = .87), the BISS (β = 0.01 (95% CI = -0.17 to 0.15), P = .91), nor the CGI-BP subscales for depression or mania. Users of NSAIDs only (n = 76), paracetamol only (n = 62), and users of both NSAIDs and paracetamol (n = 39) showed no statistical difference compared to nonusers (all P > .3). CONCLUSIONS This is the first trial to show that use of NSAIDs and paracetamol, alone or in combination, does not affect lithium- or quetiapine-based bipolar disorder mood-stabilizing treatment outcomes. Prior studies have suggested that NSAIDs may inhibit antidepressant treatment, whereas our results support findings indicating no detrimental effects of NSAIDs or paracetamol on affective disorder treatment.
Collapse
Affiliation(s)
| | - Louisa Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH.,Lindner Center of HOPE, Mason, OH, USA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
13
|
Reilly-Harrington NA, Sylvia LG, Rabideau DJ, Gold AK, Deckersbach T, Bowden CL, Bobo WV, Singh V, Calabrese JR, Shelton RC, Friedman ES, Thase ME, Kamali M, Tohen M, McInnis MG, McElroy SL, Ketter TA, Kocsis JH, Kinrys G, Nierenberg AA. Tracking medication changes to assess outcomes in comparative effectiveness research: A bipolar CHOICE study. J Affect Disord 2016; 205:159-164. [PMID: 27449548 DOI: 10.1016/j.jad.2016.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/23/2016] [Accepted: 07/02/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Comparative effectiveness research uses multiple tools, but lacks outcome measures to assess large electronic medical records and claims data. Aggregate changes in medications in response to clinical need may serve as a surrogate outcome measure. We developed the Medication Recommendation Tracking Form (MRTF) to record the frequency, types, and reasons for medication adjustments in order to calculate Necessary Clinical Adjustments (NCAs), medication adjustments to reduce symptoms, maximize treatment response, or address problematic side effects. METHODS The MRTF was completed at every visit for 482 adult patients in Bipolar CHOICE, a 6-month randomized comparative effectiveness trial. RESULTS Responders had significantly fewer NCAs compared to non-responders. NCAs predicted subsequent response status such that every additional NCA during the previous visit decreased a patient's odds of response by approximately 30%. Patients with more severe symptoms had a greater number of NCAs at the subsequent visit. Patients with a comorbid anxiety disorder demonstrated a significantly higher rate of NCAs per month than those without a comorbid anxiety disorder. Patients with greater frequency, intensity, and interference of side effects had higher rates of NCAs. Participants with fewer NCAs reported a higher quality of life and decreased functional impairment. LIMITATIONS The MRTF has not been examined in community clinic settings and did not predict response more efficiently than the Clinical Global Impression-Bipolar Version (CGI-BP). CONCLUSIONS The MRTF is a feasible proxy of clinical outcome, with implications for clinical training and decision-making. Analyses of big data could use changes in medications as a surrogate outcome measure.
Collapse
Affiliation(s)
- Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico, Health Sciences Center, Albuquerque, NM, United States
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, United States; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, NY, United States
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| |
Collapse
|
14
|
Sylvia LG, Thase ME, Reilly-Harrington NA, Salcedo S, Brody B, Kinrys G, Kemp D, Shelton RC, McElroy SL, Kocsis JH, Bobo WV, Kamali M, McInnis M, Friedman E, Tohen M, Bowden CL, Ketter TA, Singh V, Calabrese J, Nierenberg AA, Rabideau DJ, Elson CM, Deckersbach T. Psychotherapy use in bipolar disorder: Association with functioning and illness severity. Aust N Z J Psychiatry 2015; 49:453-61. [PMID: 25680360 DOI: 10.1177/0004867415569803] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study examines characteristics of individuals with bipolar disorder who sought psychotherapy versus those who did not. METHODS Bipolar CHOICE was an 11-site comparative effectiveness study of lithium versus quetiapine in symptomatic outpatients (N = 482) with bipolar disorder. At baseline, participants' psychotherapy use within the past 3 months, mood, functioning, and overall health were assessed. Logistic regressions were used to test whether psychotherapy users and non-users differed on various demographic and clinical variables at baseline. Mixed-effects regression was used to determine whether psychotherapy groups differed on response to treatment over the 6-month study. Kaplan-Meier plots and log-rank tests were employed to test whether there were any differences in time to recovery (CGI-BP ≤ 2 for at least 8 weeks) between the groups. RESULTS Thirty one percent of participants reported using psychotherapy services. Psychotherapy users reported greater medication side effect burden than non-users and were more likely to have moderate to high suicide risk and at least one anxiety disorder. Participants not utilizing medications or psychotherapy had greater mania symptom severity, were younger, and less educated than medication only users. Medication only users were more likely to be married than the other participants. CONCLUSIONS These data suggest that a minority of individuals with bipolar disorder attend psychotherapy services, and those that do have greater illness burden.
Collapse
Affiliation(s)
- Louisa G Sylvia
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | | | | | | | | | - Gustavo Kinrys
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | - David Kemp
- Case Western Reserve University, Cleveland, USA
| | | | - Susan L McElroy
- The Lindner Center of HOPE, Mason, Ohio and University of Cincinnati College of Medicine, Cincinnati, USA
| | | | | | | | | | | | - Mauricio Tohen
- University of New Mexico, Health Sciences Center, Albuquerque, USA
| | | | | | - Vivek Singh
- University of Texas Health Science, San Antonio, USA
| | | | - Andrew A Nierenberg
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | | | | | - Thilo Deckersbach
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| |
Collapse
|