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Reddy YJ, Jhanwar V, Nagpal R, Reddy MS, Shah N, Ghorpade S, Kulkarni S. Prescribing practices of Indian psychiatrists in the treatment of bipolar disorder. Aust N Z J Psychiatry 2019; 53:458-469. [PMID: 30727750 DOI: 10.1177/0004867419826718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The treatment of bipolar disorder is challenging because of its clinical complexity and availability of multiple treatment options, none of which are ideal mood stabilizers. This survey studies prescription practices of psychiatrists in India and their adherence to guidelines. METHOD In total, 500 psychiatrists randomly selected from the Indian Psychiatric Society membership directory were administered a face-to-face 22-item questionnaire pertaining to the management of bipolar disorder. RESULTS For acute mania, most practitioners preferred a combination of a mood stabilizer and an atypical antipsychotic to monotherapy. For acute depression, there was a preference for a combination of an antidepressant and a mood stabilizer over other alternatives. Electroconvulsive therapy was preferred in the treatment of severe episodes and to hasten the process of recovery. Approximately, 50% of psychiatrists prescribe maintenance treatment after the first bipolar episode, but maintenance therapy was rarely offered lifelong. While the majority (85%) of psychiatrists acknowledged referring to various clinical guidelines, their ultimate choice of treatment was also significantly determined by personal experience and reference to textbooks. LIMITATIONS The study did not study actual prescriptions. Hence, the responses to queries in the survey are indirect measures from which we have tried to understand the actual practices, and of course, these are susceptible to self-report and social-desirability biases. This was a cross-sectional study; therefore, temporal changes in responses could not be considered. CONCLUSION Overall, Indian psychiatrists seemed to broadly adhere to recommendations of clinical practice guidelines, but with some notable exceptions. The preference for antidepressants in treating depression is contrary to general restraint recommended by most guidelines. Therefore, the efficacy of antidepressants in treating bipolar depression in the context of Indian psychiatrists' practice needs to be studied systematically. Not initiating maintenance treatment early in the course of illness may have serious implications on the long-term outcome of bipolar disorder.
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Affiliation(s)
- Yc Janardhan Reddy
- 1 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Venugopal Jhanwar
- 2 Psychiatry Department, Deva Institute of Healthcare & Research Pvt. Ltd., Varanasi, India
| | | | - M S Reddy
- 4 Asha Bipolar Clinic, Asha Hospital, Hyderabad, India
| | - Nilesh Shah
- 5 Department of Psychiatry, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Sanman Ghorpade
- 6 Medical Affairs, GlaxoSmithKline Pharmaceuticals Ltd, Mumbai, India
| | - Sujay Kulkarni
- 6 Medical Affairs, GlaxoSmithKline Pharmaceuticals Ltd, Mumbai, India
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Renes JW, Regeer EJ, Hoogendoorn AW, Nolen WA, Kupka RW. A nationwide study on concordance with multimodal treatment guidelines in bipolar disorder. Int J Bipolar Disord 2018; 6:22. [PMID: 30341458 PMCID: PMC6195496 DOI: 10.1186/s40345-018-0130-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/17/2018] [Indexed: 12/03/2022] Open
Abstract
Background Most previous studies on concordance with treatment guidelines for bipolar disorder focused on pharmacotherapy. Few studies have included other treatment modalities. Aims To study concordance with the Dutch guideline of various treatment modalities in outpatient treatment settings for patients with bipolar disorder and to identity factors associated with concordance. Methods A nationwide non-interventional study using psychiatrists’ and patients’ surveys. Results 839 patients with bipolar or schizoaffective disorder bipolar type were included. Concordance with the guideline was highest for participation of a psychiatrist in the treatment (98%) and for maintenance pharmacotherapy (96%), but lower for supportive treatment (73.5%), use of an emergency plan (70.6%), psychotherapy (52.2%), group psychoeducation (47.2%), and mood monitoring (47%). Presence of a written treatment plan, a more specialized treatment setting, more years of education, and diagnosis of bipolar I disorder versus bipolar II, bipolar NOS, or schizoaffective disorder were significantly associated with better concordance. Conclusion In contrast to pharmacotherapy, psychosocial treatments are only implemented to a limited extend in everyday clinical practice in bipolar disorder. More effort is needed to implement non-pharmacological guideline recommendations for bipolar disorder.
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Affiliation(s)
- Joannes W Renes
- Altrecht Institute for Mental Health Care, Utrecht, Nieuwe Houtenseweg 12, 3524 SH, Utrecht, The Netherlands.
| | - Eline J Regeer
- Altrecht Institute for Mental Health Care, Utrecht, Nieuwe Houtenseweg 12, 3524 SH, Utrecht, The Netherlands
| | - Adriaan W Hoogendoorn
- Amsterdam UMC, Vrije Universiteit Amsterdam, Psychiatry, Amsterdam Public Health, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Willem A Nolen
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Ralph W Kupka
- Altrecht Institute for Mental Health Care, Utrecht, Nieuwe Houtenseweg 12, 3524 SH, Utrecht, The Netherlands.,Amsterdam UMC, Vrije Universiteit Amsterdam, Psychiatry, Amsterdam Public Health, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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van Fenema E, Giltay E, van Noorden M, van Hemert A, Zitman F. Assessing adherence to guidelines with administrative data in psychiatric outpatients. J Eval Clin Pract 2017. [PMID: 26223425 DOI: 10.1111/jep.12414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To assess (feasibility) of adherence to treatment guidelines among outpatients with common mental disorders in a routine Dutch clinical outpatient setting for common mental disorders using administrative data. METHODS In a retrospective cohort study, we analysed routinely collected administrative data of 5346 patients, treated for mood, anxiety or somatoform disorders with pharmacotherapy, psychotherapy or a combination of both. Available administrative data allowed assessment of guideline adherence with a disorder-independent set of five quality indicators, assessing psychotherapy, pharmacotherapy, a combination of both and routine outcome measurements (ROM) during diagnostic and therapeutic phases. Associations between the socio-demographic variables age, gender, clinical diagnosis and treatment type on the one hand and non-adherence to guidelines were tested using logistic regression analysis. RESULTS Patients were aged 39.5 years (SD 13.0) on average. The majority of patients were treated with a combination of pharmacotherapy and psychotherapy (50.1%), followed by psychotherapy (44.2%) and pharmacotherapy (5.6%). The majority of patients were suffering from a mood disorder (50.0%), followed by anxiety (43.9%) and somatoform disorders (6.1%). A diagnosis of anxiety or somatoform disorder was associated with higher odds of suboptimal duration [odds ratio (OR): 1.55 and 1.82[ and suboptimal frequency of psychotherapeutic treatment (OR of 0.89 and 0.63), and absence of ROM in the diagnostic phase (ORs 1.31 and 1.36, respectively) compared with depressive disorders. No ROM in the diagnostic phase was also predicted for by increasing age (ORs for the age categories of 56 and older of 1.48). CONCLUSIONS In this proof of principal study, we were able to assess some key indicators assessing adherence to clinical guidelines by using administrative data. Also, we could identify predictors of adherence with simple parameters available in every administrative data. Administrative data could help to monitor and aid guideline adherence in routine care, although quality may vary between settings.
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Affiliation(s)
- Esther van Fenema
- Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Giltay
- Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Albert van Hemert
- Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Frans Zitman
- Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
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Wang Z, Chen J, Zhang C, Gao K, Hong W, Xing M, Wu Z, Yuan C, Huang J, Peng D, Wang Y, Lu W, Yi Z, Yu X, Zhao J, Fang Y. Guidelines concordance of maintenance treatment in euthymic patients with bipolar disorder: Data from the national bipolar mania pathway survey (BIPAS) in mainland China. J Affect Disord 2015; 182:101-5. [PMID: 25983305 DOI: 10.1016/j.jad.2015.04.028] [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: 03/13/2015] [Revised: 04/15/2015] [Accepted: 04/15/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the treatment guidelines of bipolar disorders (BPD) have spread more than a decade, the concordance with evidence-based guidelines was typically low in routine clinical practice. This study is to present the data on the maintenance treatment of BPD in mainland China. METHODS One thousand and twenty-three patients who had experienced a euthymia were eligible for entry into this survey on the maintenance treatment of BPD. Guidelines disconcordance was determined by comparing the medication(s) that patients were prescribed with the recommendations in the guidelines of the Canadian Network for Mood and Anxiety Treatments. RESULTS Three hundred and sixty-four patients (35.6%) had not been prescribed with the maintenance treatment as guidelines recommendations, and 208 patients (20.3%) were prescribed with the antidepressants. A longer duration of BPD, a depressive episode at first onset, and a recent depressive or mixed episode significantly increased the risk for guidelines disconcordance and prescribing antidepressant. In contrast, a hospitalization history due to manic episode was associated with a significant decrease in the risk for guidelines disconcordance and prescribing antidepressant. LIMITATION This study was a cross-sectional and retrospective investigation based on medical records. CONCLUSIONS Considering the potentially hazardous effects of inappropriate treatment, individualized psychoeducational strategies for subjects with BPD are necessary to enhance treatment adherence and close the gap between guidelines and clinical practice in mainland China.
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Affiliation(s)
- Zuowei Wang
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China; Division of Mood Disorders, Hongkou District Mental Health Center of Shanghai, Shanghai 200083, PR China.
| | - Jun Chen
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Chen Zhang
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Keming Gao
- Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Case Medical Center/Case Western Reserve University School of Medicine, Cleveland, OH 44106, United States
| | - Wu Hong
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Mengjuan Xing
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Zhiguo Wu
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Chengmei Yuan
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Jia Huang
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Daihui Peng
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Yong Wang
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Weihong Lu
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Zhenghui Yi
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China
| | - Xin Yu
- Institute of Mental Health, Peking University, Beijing 100191, PR China
| | - Jingping Zhao
- Mental Health Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, PR China
| | - Yiru Fang
- Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, PR China.
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Wang Z, Gao K, Hong W, Xing M, Wu Z, Chen J, Zhang C, Yuan C, Huang J, Peng D, Wang Y, Lu W, Yi Z, Yu X, Zhao J, Fang Y. Guidelines disconcordance in acute bipolar depression: data from the national Bipolar Mania Pathway Survey (BIPAS) in mainland China. PLoS One 2014; 9:e96096. [PMID: 24763748 PMCID: PMC3999095 DOI: 10.1371/journal.pone.0096096] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 04/03/2014] [Indexed: 12/14/2022] Open
Abstract
With the recent attention to the importance of evidence-based medicine in psychiatry, a number of treatment guidelines have been published. This survey investigated prescribing pattern and predictors for guideline disconcordance in the acute treatment of bipolar depression across mainland China. Pharmacological treatments of 1078 patients with bipolar depression were examined. Guidelines disconcordance was determined by comparing the medication(s) patients were prescribed with the recommendation(s) in the guidelines of the Canadian Network for Mood and Anxiety Treatments. Predictors for guidelines discordance were analyzed with logistic regression. Of the 1078 patients, 50.2% patients were treated against treatment guidelines recommendations. The patients who were treated in general hospitals (OR = 1.53, 95% CI 1.18-1.97), with a depressive episode (OR = 1.67, 95% CI 1.27-2.19) and an older age at first onset (OR = 1.62, 95% CI 1.15-2.28) were more likely to receive guideline-disconcordant treatment than their counterparts. In contrast, the patients with current mental comorbidity, an older age at study entry, a longer duration of disease, and more frequent episodes in past year were less likely to receive guideline-disconcordant treatments than their counterparts with an OR of 0.43 (95% CI 0.24-0.77), 0.52 (95CI% 0.36-0.75), 0.48 (95% CI 0.36-0.65), and 0.50 (95% CI 0.38-0.64), respectively. Our finding suggested the disconcordance with treatment guidelines in patients with an acute bipolar depression is common under naturalistic conditions in mainland China, and the predicting factors correlated with guidelines disconcordance include both psychiatrist-specific (clinicians from general hospitals) and patient-specific features (a depressive episode at first onset, no current co-morbidity with mental disorders, a younger age at study entry, an older age at first onset, shorter duration of disease, and non-frequent episodes in past year).
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Affiliation(s)
- Zuowei Wang
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Division of Mood Disorders, Hongkou District Mental Health Center of Shanghai, Shanghai, China
| | - Keming Gao
- Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Case Medical Center/Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Wu Hong
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengjuan Xing
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhiguo Wu
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Chen
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Zhang
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengmei Yuan
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Huang
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Daihui Peng
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong Wang
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihong Lu
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhenghui Yi
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Yu
- Institute of Mental Health, Peking University, Beijing, China
| | - Jingping Zhao
- Mental Health Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yiru Fang
- Division of Mood Disorders, Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Paton C, Adroer R, Barnes TRE. Monitoring lithium therapy: the impact of a quality improvement programme in the UK. Bipolar Disord 2013; 15:865-75. [PMID: 24119180 DOI: 10.1111/bdi.12128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The study was designed to test an audit-based quality improvement programme (QIP) addressing lithium prescribing and monitoring in UK mental health services. METHODS A baseline clinical audit was conducted against the following standards: (i) measurement of renal and thyroid function before initiating treatment with lithium and (ii) recommended monitoring of serum lithium and renal and thyroid function during maintenance treatment. A re-audit was conducted at 18 months and a supplementary audit at three years. RESULTS Data were submitted for patients at baseline (n = 3,373), re-audit (n = 3,647), and supplementary audit (n = 5,683), 57% of whom had bipolar disorder. The baseline findings prompted a patient safety alert issued by the National Patient Safety Agency. By supplementary audit, the proportion of patients having four serum lithium tests over the previous year had increased from 30% at baseline to 48%, and the respective proportions that had two tests of renal function from 55% to 70% and thyroid function from 49% to 66%. Elderly patients and those prescribed a drug known to interact with lithium were not more likely to be monitored in line with the audit standards. Between baseline and supplementary audit, the proportion of patients with a diagnosis of bipolar disorder prescribed an antidepressant increased from 36% to 41%. CONCLUSIONS Improvements in biochemical monitoring of lithium treatment were achieved over time with participation in a QIP that included benchmarking of performance against clinical standards and customized change interventions. Nevertheless, gaps remain between the standard and current practice. Antidepressants are frequently prescribed in patients with bipolar disorder despite a paucity of evidence supporting their efficacy.
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Affiliation(s)
- Carol Paton
- Division of Brain Sciences, Department of Medicine, Centre for Mental Health, Imperial College, London, UK; Prescribing Observatory for Mental Health, Royal College of Psychiatrists' Centre for Quality Improvement, London, UK
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Paterniti S, Bisserbe JC. Pharmacotherapy for bipolar disorder and concordance with treatment guidelines: survey of a general population sample referred to a tertiary care service. BMC Psychiatry 2013; 13:211. [PMID: 23941445 PMCID: PMC3751340 DOI: 10.1186/1471-244x-13-211] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 08/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many new approaches have been adopted for the treatment of bipolar disorder (BD) in the past few years, which strived to produce more positive outcomes. To enhance the quality of care, several guideline recommendations have been developed. For study purposes, we monitored the prescription of psychotropic drugs administered to bipolar patients who had been referred to tertiary care services, and assessed the degree to which treatment met specific guidelines. METHODS Between December 2006 and February 2009, we assessed 113 individuals suffering from BD who had been referred to the Royal Ottawa Mental Health Centre (ROMHC) Mood Disorders Program by physicians within the community, mostly general practitioners. The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis. The prescribed treatment was compared with specific Canadian guidelines (CANMAT, 2009). Univariate analyses and logistic regression were used to assess the contribution of demographic and clinical factors for concordance of treatment with guidelines. RESULTS Thirty-two subjects had BD type I (BD-I), and 81 subjects had BD type II (BD-II). All subjects with BD-I, and 90% of the BD-II group were given at least one psychotropic treatment. Lithium was more often prescribed for subjects with BD-I (62%) than those with BD-II (19%). Antidepressants were the most frequently prescribed class of psychotropics. Sixty-eight percent of subjects received treatment concordant with guidelines by medication and dose. The presence of a current hypomanic episode was independently associated with poorer concordance to guidelines. In more than half the cases, the inappropriate use of antidepressants was at the origin of the non concordance of treatment with respect to guidelines. Absence of psychotropic treatment in bipolar II patients and inadequate dosage of mood stabilizers were the two other main causes of non concordance with guidelines. CONCLUSIONS The factors related to treatment not concordant with guidelines should be further explored to determine appropriate strategies in implementing the use of guidelines in clinical practice.
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Assessing adherence to guidelines for common mental disorders in routine clinical practice. Int J Qual Health Care 2011; 24:72-9. [DOI: 10.1093/intqhc/mzr076] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The treatment modalities of bipolar disorder and adherence to international guidelines recommendations in France were investigated. We conducted an observational survey among 210 French psychiatrists concerning their prescribing practice in bipolar disorder, and whether they use guidelines or not. Simple mania is mainly treated with valproate, whereas second-generation antipsychotics are preferred for delusional mania. Lithium is mostly used as second-line treatment by "young psychiatrists." Personal experience appears in the foreground (41% of psychiatrists) in the choice of therapy. Young psychiatrists refer more to guidelines (32% of responders) as compared with other psychiatrists. The main reason for the lack of use of guidelines is because they refer mostly to an Anglo-Saxon medical practice, which is considered different from the French practice. Guidelines for treatment of bipolar disorder are not frequently used. French psychiatrists' age and practice type are the most important variables correlated to the level of use of guidelines.
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