Prescribing practices of Indian psychiatrists in the treatment of bipolar disorder

Taiwan consensus on biological treatment of bipolar disorder during the acute, maintenance, and mixed phases: The 2022 update

BACKGROUND

Bipolar disorder is a mood dysregulation characterized by recurrent symptoms and episodes of mania, hypomania, depression, and mixed mood. The complexity of treating patients with bipolar disorder prompted the Taiwanese Society of Biological Psychiatry and Neuropsychopharmacology (TSBPN) to publish the first Taiwan consensus on pharmacological treatment of bipolar disorders in 2012. This paper presents the updated consensus, with changes in diagnostic criteria (i.e., mixed features) and emerging pharmacological evidence published up to April 2022.

METHODS

Our working group systemically reviewed the clinical research evidence and international guidelines and determined the levels of evidence for each pharmacological treatment on the basis of the most recent World Federation of Societies of Biological Psychiatry grading system. Four clinical-specific issues were proposed. The current TSBPN Bipolar Taskforce then discussed research evidence and clinical experience related to each treatment option in terms of efficacy and acceptability and then appraised final recommendation grades through anonymous voting.

RESULTS

In the updated consensus, we include the pharmacological recommendations for bipolar disorder with mixed features considering its high prevalence, the severe clinical prognosis, and the absence of approved medications. Cariprazine, lurasidone, repetitive transcranial magnetic stimulation, and ketamine are incorporated as treatment options. In the maintenance phase, the application of long-acting injectable antipsychotics is emphasized, and the hazards of using antidepressants and conventional antipsychotics are proposed.

CONCLUSIONS

This updated Taiwan consensus on pharmacological treatment for bipolar disorder provides concise evidence-based and empirical recommendations for clinical psychiatric practice. It may facilitate treatment outcome improvement in patients with bipolar disorder.

Management challenges and choices in patients with bipolar disorder: An Egyptian observational study

BACKGROUND

Patients with bipolar disorder (BD) had contributed immensely to high health service utilization. Variation in clinical practices that miss to follow the standard guidelines all with the disorder complexity, deepened the management gap. This study aimed to provide an Egyptian epidemiological database of the ongoing clinical practices that framed different diagnostic and management choices in a sample of patients with bipolar disorder. Highlighting challenges and the need for optimized clinical practices.

METHODS

Over 4 months in 2014, 20 clinicians filled in a designed sheet of their routine healthcare practice with information about; caseload /month, management guidelines knowledge background. Out of 301 patients in acute episode BD, 300 patients aged 20 to 60 years from both sexes, completed their assessment using; (1) a semi-structured interview sheet, (2) Structured Clinical Interview for DSM-IV Axis I (SCID I) for psychiatric diagnoses, (3) Global Assessment of Functioning scale for illness impact.

RESULTS

Psychiatrists received 49.5 ± 37.0 (mean ± SD) patient /month. 95% of them reported positive knowledge background on BD diagnostic guidelines and treatment recommendations (G/R), 89.6% of patients had different initial diagnosis than BD.The most commonly given initial diagnosis was major depressive disorder (33%) followed by brief psychotic disorder(20.7%) and others. The median of time taken from the initial to bipolar diagnosis was 12.3 months. Majority of patients had evident functional impairment. Atypical antipsychotics were mostly used. Drug abuse and obesity were high comorbidities.

CONCLUSION

The evident gap in practice and BD complexity have negative impact on clinical outcomes. Physician's continuous medical education programs and individually tailored standard medical care are recommended for optimized practices.

Pragmatic issues and prescribing patterns in bipolar disorder: A mental health professional's survey

BACKGROUND

There is substantial treatment gap between the suggested guidelines and pragmatic clinical practice for psychotropic usage in bipolar disorder (BD) due to the lack of naturalistic studies and not taking into account the transcultural differences and diverse background. We intend to study this treatment gap and elucidate the preference of psychotropics and prescription patterns, critical clinical issues faced and related pragmatics in BD by conducting the mental health professionals survey.

METHODOLOGY

After focused discussions, Canadian Network for Mood and Anxiety Treatments guidelines being the primary anchor, a 46-item online survey questionnaire was prepared. With 25.4% response rate, 127 psychiatrists were evaluated using Survey Monkey® electronic platform on the demographics, predominant polarity; usage of antipsychotics, antidepressants, and electroconvulsive therapy, psychotropic's preference (monotherapy vs. polytherapy) in the acute and maintenance phase of BD.

RESULTS

Majority of the participants were males (70.9%) and placed in government institute or medical colleges. Majority agreed that child and adolescent and old age bipolar probands are not routinely seen but subthreshold BD cases are frequent; did not prefer mood stabilizer in pregnancy (61.4%) and antidepressants, preferred polytherapy in acute but monotherapy in maintenance phase (after 3^rd episode), seldom preferred ECT as an option (more in suicidality), agreed to a subset of BD being refractory and neuroprogressive.

CONCLUSION

This study elucidates the importance of treatment preferences, prescribing patterns and pragmatic issues faced by the clinicians. These patterns if studied longitudinally in a systematic manner would help in modifying the potential treatment strategies and reduce treatment gap.

Prescription patterns in clinically stable patients with bipolar disorder: Findings from the Bipolar Disorder Course and Outcome from India (BiD-CoIN) study

AIM

To evaluate the prescription pattern of patients with BD, currently in clinical remission. Additional aim of the study was tocompare the prescription pattern across different study centres.

METHODOLOGY

Prescription of 773 patients, currently in clinical remission, recruited from the outpatient setting of 14 General Hospital Tertiary Care Units of tertiary care centres in the country were evaluated.

RESULTS

Almost all (98.1 %) participants were on medications at the time of assessment. In terms of conventional mood stabilizers, those receiving valproate (44.2 %), out-numbered those receiving lithium (38.9 %). A small proportion (7.4 %) was receiving a combination of both valproate and lithium. About two-third (62.5 %) were receiving at least one antipsychotic medication, with olanzapine (31.7 %) being the most commonly prescribed antipsychotic, followed by quetiapine (11.1 %), and risperidone (9.6 %). About one-third (34.4 %) of the participants were receiving antidepressants, with sertraline (22.6 %) forming bulk of the prescription. Less than half (43.9 %) of the participants were also receiving a benzodiazepine medication at the time of assessment, with chlordiazepoxide (18 %) being the most common agent, followed by clonazepam (14.5 %). There was variation in the prescription patterns across different centres, in terms of monotherapy, polypharmacy, use of preferred conventional mood stabilizers, use of various antipsychotics and antidepressants.

CONCLUSION

Besides conventional mood stabilizers, about two-third of patients with bipolar disorder received concomitant antipsychotics, one-third received concomitant antidepressants and less than half received benzodiazepines.

Bipolar Disorder Course and Outcome Study from India (BiD-CoIN study): Sample Description & Methods

OBJECTIVES

This multicentric study from India aimed to evaluate the long term course and outcome of bipolar disorder (BD).

METHOD

Seven hundred and seventy-three participants diagnosed with BD, attending 14 outpatient clinic centers across the country, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the long term course of BD.

RESULTS

The mean age of onset of the first episode of illness of the study sample was 26.3 (8.54) years, and mean duration of illness at the time of assessment was 233.05 (94.55) months. In terms of the total number of lifetime episodes, the mean number of manic episodes (mean: 3.68; SD: 4.75) exceeded the mean number of depressive episodes (mean: 3.36; SD: 5.51). The mean numbers of total lifetime episodes were 8.58 (10.6%). When the number of episodes per year was computed, the mean number of manic episodes per year exceeded that of the mean number of depressive episodes. Compared to females, a higher proportion of males had a history of comorbid substance dependence.

LIMITATIONS

The course was assessed retrospectively and the study was limited to participants attending the outpatient clinics.

CONCLUSIONS

The course of BD in India differs from that described from developed countries in the form of a number of manic episodes exceeding the depressive episodes.

A Retrospective Study of the Effects of Psychotropic Drugs on Neuroendocrine Hormones in Patients with Bipolar Disorder

BACKGROUND

Bipolar disorder (BD) is predominantly treated with medication, and previous studies have shown that psychotropic drugs have an effect on the neuroendocrine system. And the objectives of this study were: 1) to assess changes in neuroendocrine hormones of HPA axis and HPT axis in patients with BD after psychotropic drug treatment; 2) to determine differences in the above neuroendocrine hormones between psychotropic drug monotherapy and polytherapy treated patients.

METHODS

This study was a retrospective study that included 188 subjects.

RESULTS

After psychotropic drugs treatment, TSH levels increased significantly from baseline (p<0.001) and FT3, TT3, FT4, TT4, ACTH and CORT levels decreased significantly from baseline (p<0.001, p<0.001, p<0.001, p=0.007, p=0.039, p=0.031). There was no significant difference in hormonal changes between the monotherapy group and the polytherapy group, even though the polytherapy group was further divided into 4 subgroups. And there was no correlation between changes in hormones and treatment duration.

CONCLUSION

Although the incidence of significant HPT axis and HPA axis dysfunction after psychotropic drug treatment is low in patients with BD who have normal baseline neuroendocrine hormone levels, psychotropic drug treatment does suppress HPT axis and HPA axis function irrespective of the use of psychotropic drugs alone or in combination, and duration of psychotropic drug treatment. Therefore, even patients with BD who have normal baseline levels of neuroendocrine hormones should have their neuroendocrine hormone levels regularly monitored after psychotropic drug medication. But, the interval of monitoring can be slightly longer, which can be once every six months after taking psychotropic drugs.

Pharmacotherapeutic interventions for bipolar disorder type II: addressing multiple symptoms and approaches with a particular emphasis on strategies in lower and middle-income countries

Introduction: Appropriately managing mental disorders is a growing priority across countries in view of the impact on morbidity and mortality. This includes patients with bipolar disorders (BD). Management of BD is a concern as this is a complex disease with often misdiagnosis, which is a major issue in lower and middle-income countries (LMICs) with typically a limited number of trained personnel and resources. This needs to be addressed.Areas covered: Medicines are the cornerstone of managing patients with Bipolar II across countries including LMICs. The choice of medicines, especially antipsychotics, is important in LMICs with high rates of diabetes and HIV. However, care is currently compromised in LMICs by issues such as the stigma, cultural beliefs, a limited number of trained professionals and high patient co-payments.Expert opinion: Encouragingly, some LMICs have introduced guidelines for patients with BD; however, this is very variable. Strategies for the future include addressing the lack of national guidelines for patients with BD, improving resources for mental disorders including personnel, improving medicine availability and patients' rights, and monitoring prescribing against agreed guidelines. A number of strategies have been identified to improve the treatment of patients with Bipolar II in LMICs, and will be followed up.