Clinical features associated with poor pharmacologic adherence in bipolar disorder: results from the STEP-BD study

Real-world effectiveness of long-acting injectable vs. oral antipsychotics in patients with bipolar I disorder: a 1-year retrospective observational study

OBJECTIVE

Long-acting injectable (LAI) antipsychotics are recommended in the treatment non-adherence. Despite the widespread use of LAI antipsychotics, there is limited data on clinical outcomes in bipolar I disorder (BD-I) patients with real-world data. We aimed to compare BD-I patients treated with LAI and oral antipsychotics (OAP) in terms of treatment effectiveness in a 1-year follow-up period.

METHODS

The study was conducted retrospectively with electronic health records of 116 BDI patients. The primary outcomes were whether patients in the LAI group and the OAP group differed in relapse, rehospitalization, emergency room (ER) visits, and all-cause treatment discontinuation at 1-year follow-up after a mania episode. Cox regression modeling was used to predict the recurrence of any mood episode and all-cause treatment discontinuation during follow-up. The secondary outcomes evaluated were the effects of sociodemographic and clinical parameters and concomitant psychotropic medications on the course of the illness and treatment adherence.

RESULTS

Of all 116 patients, 33 (28.4%) were under LAI, and 83 (71.6%) were under OAP treatment. LAI users had a history of more hospitalizations and total mood episodes. Patients in the LAI group had more treatment non-adherence before the index hospitalization. At 1-year follow-up, there was no difference between the groups in terms of any mood relapse, rehospitalization, ER visits, and all-cause treatment discontinuation. As a secondary outcome, lithium users were found to have fewer new episodes and discontinuations of treatments.

CONCLUSIONS

In real-world data, there is no evidence that LAI antipsychotics (compared to OAP) are superior in the maintenance treatment of BD. These results are important in terms of reflecting clinical practices for the treatment of BD-I. These results do not devalue the use of LAI therapy in BD; however, more studies are needed to identify positive predictors for LAI treatments in BD.

Psychiatric disorders among adult deliberate self-harm patients and subsequent risk of dying by suicide, mental and behavioural disorders and other external causes

INTRODUCTION

Deliberate self-harm (DSH) treated in general hospital is a well-established risk factor for suicide and other cause mortality. However, few studies have used population data to investigate the differential impact of specific psychiatric disorders on the risk of subsequent suicide, by sex and age of the patient in the context of previous DSH episodes.

METHOD

All patients aged 18 and older treated for DSH in general hospitals during the period 2008-2018 were identified through national registers. Cox proportional hazards regression was used to ascertain the associated risk of death by suicide, mental and behavioural disorder and other external causes.

RESULTS

The cohort consisted of 39 479 patients of which 878 died by suicide, 461 by mental and behavioural disorders and 1037 by other external causes. Overall, schizophrenia spectrum disorders, affective disorders and personality disorders increased the risk of suicide. Large gender and age differences were identified in the risk of suicide associated with personality disorders and affective disorders. Alcohol use disorders and dementia increased the risk of dying by mental and behavioural disorders and alcohol use disorders and other substance use disorders increased the risk of death by external causes.

CONCLUSION

Schizophrenia spectrum disorders, affective disorders and personality disorders increased the risk of suicide among DSH patients, but the effect varied by gender, age and history of previous DSH. Psychiatric evaluation of all DSH patients and treatment tailored to the patient's specific needs is essential to reduce the risk of premature death.

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.

Anxiety in bipolar disorder: A review of publication trends

BACKGROUND

Although anxiety is highly prevalent in people with bipolar disorders and has deleterious impact on the course of the illness, past reviews have shown that many aspects of the topic remain under-researched. This scoping review aims to provide a comprehensive overview of the literature addressing anxiety in bipolar disorder (A-BD) between 2011 and 2020, assess if the interest in the topic has increased over the period and map the publication trends.

METHODS

Three databases were systematically searched, and all articles were screened at the title/abstract and full text level based on inclusion and exclusion criteria. Of these, 1099 articles were included in the study. The annual number of articles on A-BD published between 2011 and 2020 was calculated and articles addressing it as a primary topic (n = 310) were classified into 4 categories and 11 subcategories to identify gaps in the knowledge.

RESULTS

The results show no clear increase in the number of annual publications during the period and much of the available literature is of a descriptive nature. Less is known about the processes underlying the comorbidity and about treatment approaches.

LIMITATIONS

Given the large scope of the research question, no quality assessment of the evidence was made. Only articles in English or French were considered.

CONCLUSIONS

These results highlight the need to change the focus of research efforts to better understand and address this unique set of conditions in clinical settings.

Effect of long-acting injectable antipsychotics on emergency department visits and hospital admissions in people with bipolar disorder: A retrospective mirror-image analysis from the Northern Milan Area Cohort (NOMIAC) study

BACKGROUND

Mood recurrences in bipolar disorder (BD) are often associated with poor treatment adherence. Despite long-acting injectable antipsychotics (LAIs) may favor treatment compliance, their use in BD is still poorly explored.

METHODS

This mirror-image study investigated the effect of LAIs initiation on the number of emergency department (ED) visits and days of hospitalization, among individuals with BD from the mental health services of a large area of the Metropolitan City of Milan. The mirror periods were 365 days either side of the LAI initiation. Individual medical records were retrospectively reviewed.

RESULTS

Sixty-eight individuals with BD initiating a LAI over the index period were included. We estimated that LAI initiation overall reduced both ED visits (p = 0.002) and days of hospitalization (p < 0.001). This remained true only for those participants who i) continued LAI for the entire 12-month period of observation and ii) were treated with a second-generation antipsychotic LAI. In addition, LAI initiation reduced number of hospitalization days during hypo/manic (p = 0.013), but not depressive (p = 0.641) episodes, as well as compulsory admission days (p = 0.002).

LIMITATIONS

Due to the retrospective design, we could not collect systematic information on symptom severity and reasons of LAI discontinuation. Moreover, the limited sample size did not allow us to estimate effectiveness of single LAI agents.

CONCLUSIONS

Our study provides additional insight on the effectiveness of LAIs in BD, supporting their clinical utility for pragmatic outcomes such as ED visits and hospitalizations. Further longitudinal research is needed to clarify the real-world effectiveness of LAIs for BD clinical management.

Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration

OBJECTIVE

Although long-term benzodiazepine use is not recommended, patients are often prescribed benzodiazepines for &gt;30 days (long-term use). Data from the Veterans Health Administration (VHA) may inform efforts to discontinue such use. This study sought to describe benzodiazepine use and discontinuation among VHA patients and compared patients who continued and discontinued use.

METHODS

The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days.

RESULTS

In FY2019, 3.5% of VHA enrollees were prescribed benzodiazepines for &gt;30 days, which was 72.0% of those prescribed benzodiazepines. One-third of veterans prescribed long-term benzodiazepines discontinued use. Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses. When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder. Continuation was associated with a lower likelihood of sleep and cardiopulmonary disorders and of dementia.

CONCLUSIONS

Higher discontinuation prevalence among patients with substance use disorders, dementia, or cardiopulmonary disorders is encouraging. However, the challenge remains of discontinuing long-term use among patients who are White, older, or diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis. There is a need to identify provider, patient, and contextual factors driving long-term benzodiazepine use in these patient groups to effectively apply evidence-based discontinuation strategies.

Associations between comorbid anxiety and sleep disturbance in people with bipolar disorder: Findings from actigraphy and subjective sleep measures

BACKGROUND

Studies show that comorbid anxiety disorders are common in people with bipolar disorder. However, little is known about whether this anxiety is associated with sleep disturbance. We investigated, in individuals with bipolar disorder, whether comorbid anxiety disorder is associated with sleep disturbance.

METHODS

Participants were 101 (64% female) currently euthymic individuals with a history of bipolar disorder. Sleep disturbances were assessed using self-report measures of sleep quality (Pittsburgh Sleep Quality Index, PSQI) and six weeks of sleep monitoring using actigraphy. Bipolar disorder and comorbid anxiety diagnoses were assessed using the Mini International Neuropsychiatric Interview. Multiple regression analyses examined associations between comorbid anxiety and sleep disturbance, whilst controlling for confounding covariates known to impact on sleep.

RESULTS

A comorbid anxiety disorder was associated with increased sleep disturbance as measured using the PSQI global score (B = 3.58, 95% CI 1.85-5.32, P < 0.001) but was not associated with sleep metrics (total sleep time, sleep onset latency, sleep efficiency, and wake after sleep onset) derived using actigraphy.

LIMITATIONS

Objective measures of sleep were limited to actigraphy, therefore we were not able to examine differences in sleep neurophysiology.

CONCLUSIONS

Clinicians should be aware that comorbid anxiety may increase the risk of experiencing subjective sleep disturbance in people with bipolar disorder. Research should assess for evidence of comorbid anxiety when examining associations between sleep and bipolar disorder. Future research should explore the mechanisms by which comorbid anxiety may contribute to subjective sleep disturbances in bipolar disorder using neurophysiological measures of sleep (i.e., polysomnography).

Cannabis use and medication nonadherence in bipolar disorder: A nationwide inpatient sample database analysis

BACKGROUND

Medication nonadherence among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cannabis use disorder (CUD) association with medication noncompliance in hospitalized BD patients.

METHODS

Using data on 266,303 BD hospitalizations between 2010 and 2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and CUD. Logistic regression was used to evaluate factors associated with medication noncompliance.

RESULTS

Overall mean age, the prevalence of CUD, and medication nonadherence were 41.58 (± 0.11) years, 15.0% and 16.1%, respectively. There were 56.6% females in the overall population. There was a significant difference in the characteristics of those in the medication nonadherence vs adherence groups, including age, sex, race, comorbid substance use, income, insurance type, hospital region, and hospital teaching status (p < 0.001). After adjusting for other variables using multivariate analysis, there remained a statistically significant association of medication nonadherence in BD hospitalization and CUD (OR 1.42, 95% CI 1.36-1.48).

LIMITATION

Confounding multiple substance use could not be accounted for, and the retrospective nature of the database which includes only inpatients is prone to possible selection and reporting bias.

CONCLUSION

CUD statistically predicts increased rates of medication nonadherence among patients with BD. Given the possible association of CUD with medication nonadherence among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of patients with BD and comorbid CUD.

Which factors delay treatment in bipolar disorder? A nationwide study focussed on duration of untreated illness

AIM

The aim of the present study was to detect factors associated with duration of untreated illness (DUI) in bipolar disorder (BD).

METHOD

A total of 1575 patients were selected for the purposes of the study. Correlation analyses were performed to analyse the relation between DUI and quantitative variables. The length of DUI was compared between groups defined by qualitative variables through one-way analyses of variance or Kruskal-Wallis's tests according to the distribution of the variable. Linear multivariable regressions were used to find the most parsimonious set of variables independently associated with DUI: to this aim, qualitative variables were inserted with the numeric code of their classes by assuming a proportional effect moving from one class to another.

RESULTS

An inverse significant correlation between length of DUI and time between visits in euthymic patients was observed (r = -.52, P < .001). DUI resulted to be longer in patients with: at least one lifetime marriage/partnership (P = .009), a first psychiatric diagnosis of major depressive disorder or substance abuse (P < .001), a depressive polarity of first episode (P < .001), no lifetime psychotic symptoms (P < .001), BD type 2 (P < .001), more lifetime depressive/hypomanic episodes (P < .001), less lifetime manic episodes (P < .001), presence of suicide attempts (P = .004), depressive episodes (P < .001), hypomanic episodes (P = .004), hospitalizations (P = .011) in the last year.

CONCLUSIONS

Different factors resulted to increase the length of DUI in a nationwide sample of bipolar patients. In addition, the DUI was found to show a negative long-term effect in terms of more suicidal behaviour, more probability of hospitalization and depressive/hypomanic episodes.

Relation of medication adherence to cognitive functions in egyptian patients with bipolar I disorder

Nonadherence to medication regimens is frequently reported in bipolar I disorder (BDI) patients. However, little is known about the relationship between cognitive functions and adherence in BDI. To establish possible associations between medication adherence and cognitive function in patients with BDI. A total of 110 inpatients with BDI were subjected to the Structured Clinical Interview for DSM-IV Axis I Disorder, Morisky 8-Item Medication Adherence Scale, Young Mania Rating Scale, Wechsler Adult Intelligence Scale-Revised, Wechsler memory scale (WMS) and Wisconsin card sorting test (WCST). Patients were assessed on admission and followed up 6 months after discharge. Six months after discharge, (58.2%) of patients were nonadherent to their medications. The nonadherent group were younger males with less years of education, with lower mean scores in information orientation and visual memory backward domains of WMS and lower mean scores in perseveration responses, perseveration errors and learning to learn domains of WCST. In logistic regression analysis, younger age and impaired information orientation domain of WMS were putative predictors of nonadherence. Episodic memory and younger age were the strongest patients' related factors associated with nonadherence to medication. These results suggest that rehabilitation of specific cognitive skills may improve adherence in BDI.

A randomized, double-blind, placebo-controlled proof-of-concept study of ondansetron for bipolar and related disorders and alcohol use disorder

Bipolar disorder is associated with high rates of alcohol use disorder. However, little is known about the treatment of this dual diagnosis population. Previous studies suggest that ondansetron decreases alcohol use, particularly in people with specific single nucleotide polymorphism (SNP) alleles. A 12-week, randomized, double-blind, placebo-controlled trial of ondansetron was conducted in 70 outpatients with bipolar spectrum disorders and early onset alcohol use disorder. Outcome measures included alcohol use, assessed with the Timeline Followback method, Penn Alcohol Craving Scale (PACS), Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self-report, and Young Mania Rating Scale. SNPs rs1042173, rs1176713 and rs1150226 were explored as predictors of response. Participants had a mean age of 44.9 ± 9.4 years, were mostly men (60.0%), and African American (51.4%). Mean ondansetron exit dose was 3.23 ± 2.64 mg. No significant between-group differences in alcohol use measures were observed. However, a significant reduction in HRSD scores was observed (p = 0.045). Inclusion of SNPs increased effect sizes for some alcohol-related outcomes and the HRSD. Ondansetron was well tolerated. This proof-of-concept study is the first report on ondansetron in bipolar people with bipolar disorders and alcohol use disorder. Alcohol use did not demonstrate a significant between-group difference. However, the findings suggest that ondansetron may be associated with reduction in depressive symptom severity in persons with bipolar illnesses and alcohol use disorder. A larger trial is needed to examine the effects of ondansetron on bipolar depression.

Antipsychotic medication adherence and preventive diabetes screening in Medicaid enrollees with serious mental illness: an analysis of real-world administrative data

BACKGROUND

There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI).

METHODS

We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models.

RESULTS

Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening).

CONCLUSIONS

The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.

Real-World Patterns of Utilization and Costs Associated with Second-Generation Oral Antipsychotic Medication for the Treatment of Bipolar Disorder: A Literature Review

OBJECTIVE

Treatment with second-generation antipsychotics (SGAs) for bipolar disorder, including bipolar I disorder (BD-I), is common. This review evaluated real-world utilization patterns with oral SGAs in the United States (US) for bipolar disorder (and BD-I specifically when reported) and economic burden associated with these patterns.

METHODS

Structured, systematic searches of MEDLINE^®, EMBASE^®, and National Health Service Economic Evaluation Database identified primary research studies (published 2008-2018) describing real-world SGA use in adults with bipolar disorder/BD-I.

RESULTS

Among 769 studies screened, 39 met inclusion criteria. Most studies (72%) were analyses of commercial or Medicare/Medicaid claims databases. Patient-related (eg, demographic, comorbidities) and disease-related (eg, mania, psychosis) factors were associated with prescribed SGA. Suboptimal utilization patterns (ie, nonadherence, nonpersistence, treatment gaps, medication switching, and discontinuation) were common for patients treated with SGAs. Also common were SGAs prescribed with another psychotropic medication and SGA combination treatment (use of ≥2 SGAs concurrently). Suboptimal adherence and SGA combination treatment were both associated with increased health care resource use (HCRU); suboptimal adherence was associated with higher total direct medical and indirect costs.

LIMITATIONS

Different definitions for populations and concepts limited between-study comparisons. Focusing on SGAs limits contextualizing findings within the broader treatment landscape (eg, lithium, anticonvulsants). Given the nature of claims data, prescribing rationale (eg, acute episodes vs maintenance) and factors influencing observed utilization patterns could not be fully derived.

CONCLUSION

Despite increased use of SGAs to treat bipolar disorder over the last decade, reports of suboptimal utilization patterns of SGAs (eg, nonadherence, nonpersistence) were common as was combination treatment. Patterns of SGA use associated with additional HCRU and/or costs were suboptimal adherence and SGA combination treatment; economic consequences associated with other utilization patterns (eg, nonpersistence) were unclear. Strategies to improve SGA treatment continuity, particularly adherence, may improve clinical and economic outcomes among people living with bipolar disorder.

Association between Adherence with an Atypical Antipsychotic and with Other Psychiatric Drugs in Patients with Bipolar Disorder

BACKGROUND

Using U.S. pharmacy and medical claims, medication adherence patterns of patients with serious mental illness suggest that adherence to atypical antipsychotics may be related to adherence to other prescription drugs. This study investigated whether adherence to an atypical antipsychotic was related to adherence to other prescribed psychiatric drugs using self-reported data from patients with bipolar disorder.

METHODS

Daily self-reported medication data were available from 123 patients with a diagnosis of bipolar disorder receiving treatment as usual who took at least 1 atypical antipsychotic over a 12-week period. Patients took a mean of 4.0±1.7 psychiatric drugs including the antipsychotic. The adherence rate for the atypical antipsychotic was compared to that for other psychiatric drugs to determine if the adherence rate for the atypical antipsychotic differed from that of the other psychiatric drug by at least ±10%.

RESULTS

Of the 123 patients, 58 (47.2%) had an adherence rate for the atypical antipsychotic that differed from the adherence rate for at least 1 other psychiatric drug by at least±10%, and 65 (52.8%) patients had no difference in adherence rates. The patients with a difference took a larger total number of psychiatric drugs (p<0.001), had a larger daily pill burden (p=0.020) and a lower adherence rate with the atypical antipsychotic (p=0.007), and were more likely to take an antianxiety drug (p<0.001).

CONCLUSION

Adherence with an atypical antipsychotic was not useful for estimating adherence to other psychiatric drugs in about half of the patients with bipolar disorder.

The Economic Burden of Bipolar Disorder in the United States: A Systematic Literature Review

Bipolar disorder (BD) is a mood disorder with subtypes characterized by episodes of mania, hypomania, and/or depression. BD is associated with substantial economic burden, and the bipolar I disorder (BD-I) subtype is associated with high medical costs. This review further evaluated the economic burden of BD and BD-I in the United States (US), describing health-care resource utilization (HCRU) and sources of direct medical and indirect costs. Data were obtained from systematic searches of MEDLINE^®, EMBASE^®, and National Health Service Economic Evaluation Database. Citations were screened to identify primary research studies (published 2008-2018) on the economic burden of BD/BD-I or its treatment in real-world settings. Reported costs were converted to 2018 US dollars. Of identified abstracts (N=4111), 56 studies were included. The estimated total annual national economic burden of BD/BD-I was more than $195 billion, with approximately 25% attributed to direct medical costs. Individuals with BD/BD-I used health-care services more frequently and had higher direct medical costs than matched individuals without the disease. Drivers of higher direct costs included frequent psychiatric interventions, presence of comorbid medical/psychiatric conditions, and both suboptimal medication adherence and clinical management. Indirect costs (eg, unemployment, lost work productivity for patients/caregivers) accounted for 72-80% of the national economic burden of BD/BD-I. Different definitions for study populations and cost categories limited comparisons of economic outcomes. This review builds on existing literature describing the economic burden of BD and confirmed cost drivers of BD/BD-I. Improved clinical management of BD/BD-I and associated comorbidities, together with better medication adherence, may reduce health-care costs and improve patient outcomes.

Predictive factors of functional outcome in patients with bipolar I disorder: a five-year follow-up

BACKGROUND

Functional impairment is commonly encountered among patients with bipolar disorder (BD) during periods of remission. The distribution of the impairment of the functional outcome is heterogeneous. The objective of this current investigation was to identify neurocognitive and clinical predictors of psychosocial functioning in a sample of patients with BD.

METHODS

Seventy-six patients (59.2% females) and 40 healthy controls (50% females), aged 18 to 55 years, were assessed using a comprehensive neurocognitive battery (six neurocognitive domains), and the Functioning Assessment Short Test (FAST), at baseline and after a 5-year follow-up. Stepwise regression models were used to identify predictor variables related to psychosocial functioning.

RESULTS

The number of hospitalizations during the follow-up, the change occurred in the neurocognitive composite index (NCI change), and NCI at baseline explained 30.8% of the variance of functioning. The number of hospitalizations during the follow-up was the variable that explained a greater percentage of the variance (16.9%). Verbal memory at baseline and the change in sustained attention during the follow-up explained 10% and 5.9% of the variance of the psychosocial functioning, respectively.

LIMITATIONS

The interval of 5 years between the two assessments could be too short to detect a possible progression in functional outcome for the overall sample.

CONCLUSIONS

The clinical course during the follow-up is the factor that has a greater impact on psychosocial functioning in patients with BD. Thus, the interventions aimed to promote prevention of relapses should be considered as essential for avoiding functional impairment in these patients.

Nonadherence in bipolar disorder patients: A 14-year retrospective study

BACKGROUND

Bipolar disorder is a disabling psychiatric disorder. The existing literature suggests about 41% of patients to be nonadherent. Nonadherence leads to relapses, delay in recovery besides higher inpatient care cost as well as higher global cost of the disease. Nonadherence in bipolar affective disorder (BPAD) is a complex phenomenon, its critical determinants are yet to be identified with certainty.

AIMS

This study aims to assess the prevalence of nonadherence in BPAD and to delineate the factors associated with it.

METHODS

Medical records were reviewed in this study from 2005 to 2019 at a medical college in Kerala. Patients who were diagnosed with BPAD according to International Classification of Diseases 10 and who were needing or opting for prophylaxis were included. Patients who were not taking medications for at least 1 week were termed as nonadherent. We included 150 participants in our study.

RESULTS

To test the statistical significance of the association of categorical variables between H/O of adherence and nonadherence, Chi-square test was used. In the sample, 82.7% had at least 1 week of history of noncompliance in the past. The most common reason was poor understanding of illness by the family (56%) followed by a negative aspect of the patient toward the drug (20%).

CONCLUSION

Therefore, this study concludes that though majority of the patients have a history of nonadherence of at least 1 week on long-term follow-up, it was seen that majority of the patients were more than 80% adherent to medications.

Paliperidone LAI and Aripiprazole LAI Plasma Level Monitoring in the Prophylaxis of Bipolar Disorder Type I with Manic Predominance

Introduction The objective of this study was the evaluation of utility of plasma level monitoring in the clinical stabilizing efficacy and tolerability of paliperidone palmitate (PP) vs. aripiprazole monohydrate (AM) in bipolar disorder I (BD I) with manic predominance.

Methods Fifty-six outpatients of both sexes, age ranging from 18 to 65 years, affected by BD I with manic predominance, orally treated and stabilized after acute episode for at least 2 weeks with paliperidone or aripiprazole (n=31, paliperidone; n=25, aripiprazole) underwent a prospective observational study of switching to the corresponding long-acting injection (LAI) on the basis of clinical evaluation. The efficacy and tolerability of the 2 treatments were assessed by BPRS, PANSS, HAMD21, and MRS rating scales and a check list every month for 12 months. Drug plasma levels determinations (PLs) were performed at the same times.

Results A good clinical stability and tolerability of both drugs were reported. Lower mean PLs of PP showed a positive effect on depressive symptoms. AM PLs variability was associated with greater instability of manic symptoms whereas intermediate PLs seem to have more influence on depressive symptomatology.

Discussion PLs drug monitoring has been proven to be useful, and further investigations to identify optimal therapeutic ranges for LAI formulations are needed.

A Prospective Comparison of Bipolar I and II Subjects With and Without Comorbid Alcohol Dependence From the COGA Dataset

Objective: Comorbidity of alcohol use disorders in bipolar subjects is high as indicated by epidemiological and clinical studies. Though a more severe course of bipolar disorder in subjects with comorbid alcohol dependence has been reported, fewer studies considered the longitudinal course of alcohol dependence in bipolar subjects and the prospective course of comorbid bipolar II subjects. Beside baseline analysis, longitudinal data of the COGA (Collaborative Study on Genetics in Alcoholism) were used to evaluate the course of bipolar I and II disordered subjects with and without comorbid alcohol dependence over more than 5 years of follow-up. Methods: Characteristics of bipolar disorder, alcohol dependence and comorbid psychiatric disorders were assessed using semi-structured interviews (SSAGA) at baseline and at a 5-year follow-up. Two hundred twenty-eight bipolar I and II patients were subdivided into groups with and without comorbid alcohol dependence. Results: Of the 152 bipolar I and 76 bipolar II patients, 172 (75, 4%) had a comorbid diagnosis of alcohol dependence. Bipolar I patients with alcohol dependence, in particular women, had a more severe course of bipolar disorder, worse social functioning and more suicidal behavior than all other groups of subjects during the 5-year follow-up. In contrast, alcohol dependence improved significantly in both comorbid bipolar I and II individuals during this time. Conclusions: A 5-year prospective evaluation of bipolar patients with and without alcohol dependence confirmed previous investigations suggesting a more severe course of bipolar disorder in comorbid bipolar I individuals, whereas bipolar II individuals were less severely impaired by comorbid alcohol use disorder. While severity of alcohol dependence improved during this time in comorbid alcohol-dependent bipolar I patients, the unfavorable outcome for these individuals might be due to the higher comorbidity with personality and other substance use disorders which, together with alcohol dependence, eventually lead to poorer symptomatic and functional clinical outcomes.

Case Report: Paliperidone Palmitate in the Management of Bipolar I Disorder With Non-compliance

Background: Medication non-adherence is prevalent in patients with bipolar disorder (BD). Long-acting injectable antipsychotics (LAIAs) are widely used to improve compliance with treatment. This study aimed to illustrate the effectiveness, compliance, and safety profile of once-monthly paliperidone palmitate (PP1M), a novel therapeutic LAIA, in the management of bipolar I disorder (BDI). Method: A prospective follow-up was arranged to 11 BDI patients who were prescribed PP1M as monotherapy or adjunctive treatment. Severity of symptoms, disturbing behavior, status of employment, 17-item Hamilton Depression Rating Scale (HAMD-17), and Young Mania Rating Scale (YMRS) were evaluated at the baseline and the endpoint of follow-up. Clinical Global Impression-Bipolar Disorder-Severity of Illness Scale (CGI-BP) and Treatment Emergent Symptom Scale (TESS) were measured at each injection of PP1M. Compliance, relapse or switch, and new hospitalization were monitored through the period of follow-up. Results: The median duration of treatment was 14 months, ranging from 5 to 22 months. The scores (mean ± standard deviation) of HAMD-17, YMRS, and CGI-BP generally decreased from the baseline (16.1 ± 10.3, 30.9 ± 12.6, 5.3 ± 0.7) to the endpoint (7.4 ± 5.7, 3.7 ± 3.2, 2.3 ± 0.7). No disturbing behavior was detected at the endpoint. Neither new hospitalization nor manic/mixed episode occurred during treatment, whereas mild to moderate depressive episodes were reported in three cases. The status of employment of 10 participants (90.9%) was improved, and no new safety concern was detected. Conclusion: PP1M might offer a new valid treatment option in the long-term management of BDI, especially for those with poor compliance with oral medication. However, more studies are needed to further justify such role.

Self-reported medication adherence and its correlates in a lithium-maintained cohort with bipolar disorder at a tertiary care centre in India

BACKGROUND

Lithium remains a cornerstone of prophylaxis in bipolar disorder (BD), but adherence continues to be a major clinical challenge and merits a closer attention. There is scant literature available in Indian as well as Asian context.

METHODS

This study was conducted at Department of Psychiatry, AIIMS, New Delhi with an aim to assess the self-reported medication adherence and its correlates among a naturalistic, lithium-maintained cohort (n = 76) with bipolar disorder. Subjects were included if they were on lithium therapy ≥1 year, met DSM-5 diagnosis of bipolar disorder and were in clinical remission (≥1 month). Besides sociodemographic and clinical performa, participants were assessed on medication adherence rating scale (MARS), lithium questionnaire for knowledge and lithium attitude questionnaire (LAQ).

RESULTS

Mean age was 35.7 ± 10.6 years (males: 59.2%); median duration of illness and lithium therapy was 84 months and 24.5 months, respectively. Mean MARS score was 6.95 ± 2.81. Regression analysis (with MARS total as dependent variable) found LAQ score to be the single most significant predictor variable (β=-0.681, p < 0.0001), explaining over 75% of the total variance. In regression model with MARS factor-1 score as dependent variable, the 'LAQ score' (β=-0.601, p < 0.0001) and 'being accompanied by family during psychiatric visits (always/mostly) in the past year' (β = 0.193, p = 0.010) emerged as significant predictor variables.

CONCLUSION

Adherence in lithium-maintained treatment-seeking cohort of patients with BD remains far from ideal as observed in this naturalistic setting. Lithium-related attitudes and being accompanied by family during psychiatric visits were found to be significant predictors for adherence.

Long-acting injectable antipsychotics (LAIs) for maintenance treatment of bipolar and schizoaffective disorders: A systematic review

Long-Acting Injectable Antipsychotics (LAIs) are used to overcome non-compliance in psychoses, mainly schizophrenia spectrum disorders. We aimed to summarize available evidence of studies comparing the efficacy of LAIs to placebo or oral medications for Bipolar Disorder (BD) and/or Schizoaffective Disorder (SAD). We searched six databases from inception to 28-March-2018, using the strategy: long-acting antipsychotics AND (bipolar disorder OR schizoaffective disorder OR mania OR manic OR bipolar depression). We included peer-reviewed double-blind comparisons of LAIs for any clinical outcome occurrence in BD, or open mirror studies with same prospective as retrospective assessment periods. We excluded studies reporting on mixed schizophrenia/SAD populations without reporting results separately. The pooled records amounted to 642. After duplicate removal and inclusion/exclusion criteria application, we included 15 studies, 6 double-blind and 9 open, 13 assessing BD and 2 SAD. Depot neuroleptics prevented manic, but not depressive recurrences and may worsen depressive symptoms. Risperidone long-acting injectable was found to be effective in protecting from any mood/manic symptom compared to placebo, but not from depressive recurrences. Add-on or monotherapy paliperidone palmitate in SAD patients protected from psychotic, depressive, and manic symptoms. In patients with BD-I with a manic episode at study enrolment, aripiprazole monohydrate significantly delayed time to recurrence of manic episodes without inducing depressive episodes. LAIs are effective and well-tolerated maintenance treatments for BD and SAD. They showed better efficacy in preventing mania than depression. LAIs may be first-line for BD-I and SAD patients with a manic predominant polarity and with non-adherence problems.

Medication nonadherence in bipolar disorder: a narrative review

A number of effective maintenance medication options exist for bipolar disorder (BD) and these are regarded as the foundation of long-term treatment in BD. However, nonadherence to medication is common in BD. For example, a large data base study in the United States of America (USA) showed that approximately half of patients with BD were nonadherent with lithium and maintenance medications over a 12 month period. Such nonadherence carries a high risk of relapse due to the recurrent nature of the illness and the fact that abrupt cessation of treatment, particularly lithium, may cause rebound depression and mania. Indeed, medication nonadherence in BD is associated with significantly increased risks of relapse, recurrence, hospitalization and suicide attempts and a decreased likelihood of achieving remission and recovery, as well as with higher overall treatment costs. Factors associated with nonadherence include adverse effects of medication, complex medication regimens, negative patient attitudes to medication, poor insight, rapid-cycling BD, comorbid substance misuse and a poor therapeutic alliance. Clinicians should routinely enquire about nonadherence in a nonjudgmental fashion. Potential steps to improve adherence include simple pragmatic strategies related to prescribing including shared decision-making, psychoeducation with a clear focus on adherence, reminders (traditional and digital), potentially using a depot rather than an oral antipsychotic, managing comorbid substance misuse and improving therapeutic alliance. Financial incentives have been shown to improve adherence to depot antipsychotics, but this approach raises ethical issues and its long-term effectiveness is unknown. Often a combination of approaches will be required. The strategies that are adopted need to be patient specific, reflecting that nonadherence has no single cause, and chosen by the patient and clinician working together.

Treatment of anxiety disorders in patients with comorbid bipolar disorder

Anxiety disorders are the most prevalent comorbid diagnoses in patients with bipolar disorder (BD). A comorbid anxiety diagnosis can significantly impact the severity of bipolar symptoms, increase the risk of suicidality, and decrease psychosocial functioning and quality of life. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force published recommendations for treatment in 2012 suggesting that specific anticonvulsant mood stabilizers and second-generation antipsychotics are the medications of choice to treat these comorbidities. Serotonergic antidepressant medications are first-line medications for the treatment of most anxiety disorders; however, this can be problematic for a patient with BD. Antidepressant use in BD has been associated with a risk of manic switch as well as potential destabilization of mood. Mood stabilizer therapy should be established for patients with comorbid BD and an anxiety disorder before other medications are added to address the anxiety disorder. While benzodiazepine medications are recommended as third-line therapy in the CANMAT task force recommendations, their use should be avoided in patients with comorbid BD, posttraumatic stress disorder, and substance use disorders. The use of benzodiazepines should in general be avoided for all patients if possible, based upon current clinical research. Interpersonal, cognitive behavioral, and relaxation therapy are effective for the treatment of anxiety symptoms, especially emotional experiences, in patients who are euthymic.

Identifying clinical net benefit of psychotropic medication use with latent variable techniques: Evidence from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

BACKGROUND

Poor medication adherence is common among individuals with Bipolar Disorder (BD). Understanding the sources of heterogeneity in clinical net benefit (CNB) and how it is related to psychotropic medications can provide new insight into ways to improve adherence.

METHODS

Data come from the baseline assessments of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Latent class analysis identified groups of CNB, and validity of this construct was assessed using the SF-36. Adherence was defined as taking 75% or more of medications as prescribed. Associations between CNB and adherence were tested using multiple logistic regression adjusting for sociodemographic characteristics.

RESULTS

Five classes of CNB were identified: High (24%), Moderately high (12%), Moderate (26%), Moderately low (27%) and Low (12%). Adherence to psychotropic medications did not differ across classes (71% to 75%, χ²= 3.43, p = 0.488). Medication regimens differed by class: 57% of the High CNB were taking ≤2 medications, whereas 49% of the Low CNB were taking ≥4. CNB classes had good concordance with the SF-36.

LIMITATIONS

Missing data limited measures used to define CNB. Participants' perceptions of their illness and treatment were not assessed.

CONCLUSIONS

This novel operationalization of CNB has construct validity as indicated by the SF-36. Although CNB and polypharmacy regimens are heterogeneous in this sample, adherence is similar across CNB. Studying adherent individuals, despite suboptimal CNB, may provide novel insights into aspects influencing adherence.

A Cross-sectional Analysis of Patterns and Predictors of Medication Adherence in Bipolar Disorder: Single Center Experience from South India

Objective

Our objective was to determine patterns and predictors of medication adherence in bipolar disorder.

Methods

Between August 2015 and December 2016, we recruited 160 patients with a diagnosis of bipolar disorder as per International Classification of Diseases-10: Clinical Descriptions and Diagnostic Guidelines. The diagnosis was further confirmed by using the MINI International Neuropsychiatric Inventory. All of them were currently in remission (confirmed by standard measures) and on stable dosing of medication for at least a year. Medication adherence was assessed using Tamil validated version of Morisky Medication Adherence Scale. Patients were dichotomized into low adherence (<6) and high adherence (≥6) groups and compared on various socio-demographic and clinical variables.

Results

Majority of the sample (n=97, 60.6%) demonstrated low adherence to treatment regimen. Being employed and having spent greater number of days in hospital were predictive of higher medication adherence (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.019-7.585; and OR 1.02, 95% CI 1.003-1.037, respectively). Fewer number of lifetime depressive episodes and positive drug attitudes demonstrated trend level positive association with high medication adherence.

Conclusion

Non-adherence to prescribed medications is a common problem in bipolar disorder. Interventions targeting vocation, medication focused psychoeducation and promotion of positive drug attitudes are likely to enhance medication adherence in this group.

Associations of Comorbid Anxiety With Medication Adherence and Psychiatric Symptomatology in a Population of Nonadherent Bipolar Disorder Subjects

This analysis was conducted on baseline data from 178 nonadherent bipolar disorder subjects in a randomized controlled trial. Medication adherence was measured with Tablets Routine Questionnaire as percentage of days with missed doses. Inclusion criteria required at least 20% nonadherence. Medication adherence, symptomatology, and functioning in individuals with and without a comorbid anxiety disorder were compared. There were 78.9% of subjects who had at least one or more current anxiety disorder, with the most common being posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. The percentage of days with missed doses over the past month was significantly lower in those with anxiety disorders compared with those without (40.1% vs 50.5%, p = 0.03). Those with comorbid anxiety disorders and those with greater number of anxiety disorder diagnoses had significantly worse mean scores on the Montgomery-Åsberg Depression Rating Scale, Brief Psychiatric Rating Scale, Clinical Global Impression-Bipolar Version, and Global Assessment of Functioning.

Symptoms and functioning with aripiprazole once-monthly injection as maintenance treatment for bipolar I disorder

BACKGROUND

Effects of maintenance treatment with aripiprazole once-monthly 400mg (AOM 400) on symptoms and functioning were assessed in adults with bipolar I disorder (BP-I) after a manic episode.

METHODS

Patients were stabilized on oral aripiprazole, cross-titrated to AOM 400, then randomized in a 52-week, double-blind, placebo-controlled, withdrawal phase. Prespecified secondary outcomes are reported: time to hospitalization for mood episode, Young Mania Rating Scale (YMRS), Montgomery-Åsberg Depression Rating Scale (MADRS), Clinical Global Impression-Bipolar scale, Functioning Assessment Short Test (FAST), and Brief Quality of Life in Bipolar Disorder questionnaire. Time to hospitalization for mood episode was analyzed using log-rank test and changes from baseline using mixed model for repeated measures or analysis of covariance.

RESULTS

AOM 400 significantly increased time to hospitalization for any mood episode versus placebo (P=0.0002). YMRS total scores decreased with oral aripiprazole; improvements were maintained with AOM 400. After randomization, YMRS scores changed little with AOM 400 but worsened with placebo (P=0.0016), and MADRS scores, already low at trial initiation, did not differ between groups. FAST score improvements were maintained with AOM 400 but not placebo (P=0.0287).

LIMITATIONS

Results are generalizable to patients with BP-I stabilized on aripiprazole following a manic episode.

CONCLUSIONS

Patients with BP-I experiencing an acute manic episode exhibited symptomatic and functional improvements during stabilization with oral aripiprazole and AOM 400 that were maintained with continued AOM 400 treatment but not placebo. AOM 400 is the first once-monthly long-acting injectable antipsychotic to demonstrate efficacy in maintenance treatment of the manic phase of BP-I.

An overview of pharmacotherapy for bipolar I disorder

INTRODUCTION

Bipolar I disorder (BD I) is complex with a chronic course that significantly impacts a sufferer's quality of life. As of right now, there are many available treatments that aim to rapidly treat manic or depressive episodes and stabilize mood. The purpose of this report is to provide an up-to-date comprehensive review of the available evidence-based trials of pharmacotherapy for the treatment of BD I.

AREAS COVERED

This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of current pharmacotherapy in adults with BD I from phase III to clinical practice. Monotherapy and combination therapy for acute and long-term treatment were reviewed for this purpose.

EXPERT OPINION

There are many treatments available for BD mania; however, the depressive and stabilization phases of the illness remain a clinical challenge. Unfortunately, randomized controlled trials do not represent 'real world' patients, as their strict inclusion and exclusion criteria do not allow for different features sometimes present in patients to be considered. Research efforts must also focus on treating cognitive deficits, which adds to lower functional outcome. The authors believe that there is dire need for new, more targeted treatments in BD I, with a critical view of the side effects.

Systematic literature review on patterns of pharmacological treatment and adherence among patients with bipolar disorder type I in the USA

BACKGROUND

Bipolar disorder type I (BD-I) is a chronic condition characterized by mania episodes followed by syndromic recovery periods, usually permeated by depressive symptoma-tology and recurring acute manic episodes. It requires long-term pharmacological treatment; thus, it is critical to understand the patterns of drug therapy use and medication compliance to better plan health care policies and needs. This systematic literature review aims to study these data among patients with BD-I in the USA, focusing on medications to treat mania.

METHODS

Articles published in the last 10 years to October 2016 were searched on MEDLINE and Embase. Studies on patterns of drug therapy, concordance of prescription with clinical practice guidelines, and adherence and persistence with pharmacological treatments for BD-I in the USA under observational conditions, with focus on treatments for mania, were selected.

RESULTS

Treatment prevalence for BD-I is low in the USA, with the most current study showing a 46% 12-month rate. There is a lack of studies addressing the use of long-acting injectable (LAI) antipsychotics. Second-generation antipsychotics (SGAs) have been used by nearly all patients receiving oral antipsychotics since the 2000s. However, 30%-60% of individuals with BD do not receive appropriate treatment, and adherence to oral therapies is poor, with medication possession ratios ≥80% seen in only approximately 60% of patients. For persistence rates, results suggest that treatment duration is short for a condition with recommendation for at least 6 months of maintenance therapy. Literature indicates that LAI SGAs may be related to better adherence and persistence.

CONCLUSION

There is a need for studies addressing specifically patterns of therapy and adherence to pharmacological treatment in BD-I patients in the USA to better understand the value of current standards, and an urgent need to improve the rates of adherence and persistence to BD-I pharmacotherapy and to increase the understanding of LAI SGAs' potential to address this issue.

Neuropsychological functioning, age, and medication adherence in bipolar disorder

Objectives

Poor adherence to medication is frequent in bipolar disorder (BD) and has been associated with several factors. To date, the relationship between low adherence and neuropsychological functioning in BD is still unclear. As age and neuropsychological functioning might have opposing influences on adherence, our aim was to investigate this link with a particular focus on the effect of age.

Methods

In a cross-sectional study, we included 353 patients divided into two age-groups (16–46; 47–71) from a French cohort diagnosed with BD (type I, II, NOS) and strictly euthymic. All patients had a standardized clinical and neuropsychological assessment and were categorized as high (n = 186) or low (n = 167) adherent based on their score from the Medication Adherence Rating Scale. Clinical information was collected based on a standardized interview and clinical validated scales. Neuropsychological performances were evaluated with an established standardized neuropsychological battery for bipolar disorder patients. After univariate analysis, neuropsychological and clinical predictors of low adherence were included in two age-specific stepwise multiple logistic regressions.

Results

A smaller number of hospitalizations (OR = 0.846, p = 0.012), a shorter illness duration (OR = 0.937, p = 0.003) and higher adverse effects (OR = 1.082, p<0.001) were associated with a greater risk of low adherence in the younger patients. In the older patients, low adherence was also predicted by a smaller number of hospitalizations (OR = 0.727, p = 0.008) and higher adverse effects (OR = 1.124, p = 0.005). Interestingly poor inhibition performance was also a significant predictor of low adherence in older patients (OR = 0.924, p = 0.030).

Conclusions

We found an age-specific relationship between cognitive functioning and adherence in patients with BD. Poor inhibition performances predicted low adherence in older patients only. Our results highlight the need to provide age-adapted therapeutic interventions to improve adherence in patients with BD.

Medication non-adherence in bipolar disorder: Review of rates, demographic and clinical predictors

AIM

To conduct a systematic search for all studies examining rates and demographic and illness-related determinants of medication non-adherence in bipolar disorder (BD).

METHODS

A comprehensive literature search was undertaken of six English-language databases to identify published articles on medication non-adherence in BD from inception till December 2016. Any article, either a review or an original-research article was examined for its relevance to the subject. All such articles were manually searched to locate any further articles containing relevant information. Studies were included only if they had adequately described the patient sample, assessment methods and statistical procedures, presented their results systematically and their conclusions were congruent with the results.

RESULTS

The initial search yielded 249 articles on the subject; of these 198 articles were included. Of the 162 original-research studies, 132 had provided information on rates of medication non-adherence in BD. There was a wide variation in rates ranging from universal adherence (100%) to almost universal non-adherence (96%); this discrepancy was more due to methodological differences than true variations in rates. Notwithstanding the significant discrepancies in methodology, based on these 132 studies mean rates of 41.5%-43% and median rates of 40%-41% were obtained for medication non-adherence in BD. Rates of adherence with mood stabilizers were significantly lower than those for antipsychotics, or for medications of all classes. None of the demographic attributes were unequivocally linked to medication non-adherence in BD. Similarly, medication-related variables such as type of medications, doses, treatment regimens and side effects did not demonstrate consistent associations with non-adherence. Among clinical characteristics the presence of comorbid substance use disorder and absence of insight were the only two factors clearly linked to non-adherence in BD.

CONCLUSION

Medication non-adherence is prevalent in about a third to half of patients with BD. Demographic, illness and treatment related factors do not predict non-adherence with certainty.

Assessing adherence to guidelines with administrative data in psychiatric outpatients

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.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

Threat sensitivity in bipolar disorder

Life stress is a major predictor of the course of bipolar disorder. Few studies have used laboratory paradigms to examine stress reactivity in bipolar disorder, and none have assessed autonomic reactivity to laboratory stressors. In the present investigation we sought to address this gap in the literature. Participants, 27 diagnosed with bipolar I disorder and 24 controls with no history of mood disorder, were asked to complete a complex working memory task presented as "a test of general intelligence." Self-reported emotions were assessed at baseline and after participants were given task instructions; autonomic physiology was assessed at baseline and continuously during the stressor task. Compared to controls, individuals with bipolar disorder reported greater increases in pretask anxiety from baseline and showed greater cardiovascular threat reactivity during the task. Group differences in cardiovascular threat reactivity were significantly correlated with comorbid anxiety in the bipolar group. Our results suggest that a multimethod approach to assessing stress reactivity-including the use of physiological parameters that differentiate between maladaptive and adaptive profiles of stress responding-can yield valuable information regarding stress sensitivity and its associations with negative affectivity in bipolar disorder. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis

BACKGROUND

Comorbidity between substance use disorders (SUDs) and bipolar disorder (BD) is highly prevalent to the extent it may almost be regarded the norm. This systematic review and meta-analysis aimed to estimate the prevalence rates of SUDs in treatment seeking patients diagnosed with BD in both inpatient and outpatient settings.

METHODS

A comprehensive literature search of Medline, EMBASE, psychINFO and CINAHL databases was conducted from 1990 to 2015. Prevalence of co-morbid SUDs and BD were extracted and odds ratios (ORs) were calculated using random effects meta-analysis.

RESULTS

There were 151 articles identified by electronic searches that yielded 22 large, multi-site studies and 56 individual studies describing comorbid rates of SUDs amongst community dwelling, BD inpatients or outpatients. The SUDs with the highest prevalence in BD were alcohol use (42%) followed by cannabis use (20%) and other illicit drug use (17%). Meta-analysis showed males had higher lifetime risks of SUDs compared to females. BD and comorbid SUDS were associated with earlier age of onset and slightly more hospitalisations than non-users.

LIMITATIONS

The results do not take into account the possibility that individuals may have more than one comorbid disorder, such as having more than one SUD, anxiety disorder, or other combination. Some of the meta-analyses were based on relatively few studies with high rates of heterogeneity. Most included studies were cross-sectional and therefore causality cannot be inferred.

CONCLUSIONS

This systematic review shows comorbidity between SUDs and bipolar illness is highly prevalent in hospital and community-based samples. The prevalence of SUDs was similar in patients with bipolar I and bipolar II disorders. This study adds to the literature demonstrating that SUDs are common in BD and reinforces the need to provide better interventions and properly conducted treatment trials to reduce the burden conferred by comorbid SUD and BD.

Medication Adherence in Patients with Bipolar Disorder: A Comprehensive Review

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

Long-Acting Injectable Antipsychotics for Prevention of Relapse in Bipolar Disorder: A Systematic Review and Meta-Analyses of Randomized Controlled Trials

BACKGROUND

This meta-analysis of randomized controlled trials aimed to examine the advantages of long-acting injectable antipsychotics over placebo or oral medications regarding efficacy and safety for patients with bipolar disorder.

METHODS

Two categorical meta-analyses of randomized controlled trials were performed to compare study-defined relapse rate (primary), discontinuation rates, and individual adverse events: (1) risperidone-long-acting injectable vs placebo, and (2) long-acting injectable antipsychotics vs oral medications.

RESULTS

We identified 7 randomized controlled trials (n=1016; long-acting injectable antipsychotics [flupenthixol (1 randomized controlled trial) and risperidone (6 randomized controlled trials)=449]; oral medications [mood stabilizers, antidepressants, antipsychotic, or any combination of these agents=283]; and placebo=284). Risperidone-long-acting injectable antipsychotic was superior to placebo for study-defined relapse rate (risk ratio=0.63, P<.0001), relapse of manic symptoms (risk ratio=0.42, P<.00001), and all-cause discontinuation (risk ratio=0.75, P=.007). Risperidone-long-acting injectable was associated with higher incidence of prolactin-related adverse events (risk ratio=4.82, P=.001) and weight gain (risk ratio=3.80, P<.0001) than placebo. The pooled long-acting injectable antipsychotics did not outperform oral medications regarding primary outcome but with significant heterogeneity (I2=74%). Sensitivity analysis, including only studies with rapid cycling or high frequency of relapse patients, revealed that long-acting injectable antipsychotics were superior compared to oral medications (I2=0%, RR=0.58, P=.0004). However, the comparators in this sensitivity analysis did not include second-generation antipsychotic monotherapy. In sensitivity analysis, including only studies with second-generation antipsychotic monotherapy as the comparator, long-acting injectable antipsychotics did not outperform second-generation antipsychotic monotherapy. Risperidone-long-acting injectable was also associated with higher incidence of prolactin-related adverse events than oral medications (RR=2.66, P=.03).

CONCLUSIONS

Long-acting injectable antipsychotics appear beneficial for relapse prevention in patients with rapid cycling. Furthermore, randomized controlled trials comparing long-acting injectable antipsychotics and oral second-generation antipsychotic using larger samples of rapid cycling patients are warranted.

Adherence to Antipsychotic Medication in Bipolar Disorder and Schizophrenic Patients: A Systematic Review

Antipsychotics are the drugs prescribed to treat psychotic disorders; however, patients often fail to adhere to their treatment, and this has a severe negative effect on prognosis in these kinds of illnesses. Among the wide range of risk factors for treatment nonadherence, this systematic review covers those that are most important from the point of view of clinicians and patients and proposes guidelines for addressing them. Analyzing 38 studies conducted in a total of 51,796 patients, including patients with schizophrenia spectrum disorders and bipolar disorder, we found that younger age, substance abuse, poor insight, cognitive impairments, low level of education, minority ethnicity, poor therapeutic alliance, experience of barriers to care, high intensity of delusional symptoms and suspiciousness, and low socioeconomic status are the main risk factors for medication nonadherence in both types of disorder. In the future, prospective studies should be conducted on the use of personalized patient-tailored treatments, taking into account risk factors that may affect each individual, to assess the ability of such approaches to improve adherence and hence prognosis in these patients.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Illness perception of dropout patients followed up at bipolar outpatient clinic, Turkey

Dropout is a common problem in the treatment of psychiatric illnesses including bipolar disorders (BD). The aim of the present study is to investigate illness perceptions of dropout patients with BD. A cross sectional study was done on the participants who attended the Mood Disorder Outpatient Clinic at least 3 times from January 2003 through June 2008, and then failed to attend clinic till to the last one year, 2009, determined as dropout. Thirty-nine dropout patients and 39 attendent patients with BD were recruited for this study. A sociodemographic form and brief illness perception questionnaire were used to capture data. The main reasons of patients with BD for dropout were difficulties of transport (31%), to visit another doctor (26%), giving up drugs (13%) and low education level (59%) is significant for dropout patients. The dropout patients reported that their illness did not critically influence their lives, their treatment had failed to control their illnesses, they had no symptoms, and that their illness did not emotionally affect them. In conclusion, the nonattendance of patients with serious mental illness can result in non-compliance of therapeutic drug regimens, and a recurrence of the appearance symptoms. The perception of illness in dropout patients with BD may be important for understanding and preventing nonattendance.

Interpersonal Psychotherapy and Cognitive-Behavioral Therapy as an Integrated Treatment Approach for Co-Occurring Bipolar I and Social Anxiety Disorder

Social anxiety disorder (SAD) is frequently comorbid with bipolar disorder (BD), yet frontline pharmacological interventions for SAD are often contraindicated for individuals with BD. We present a case report of a 29-year-old male with Bipolar I Disorder who received cognitive-behavioral therapy (CBT) for SAD, followed by CBT and interpersonal therapy (IPT) for SAD. The patient completed standardized self-report measures of social anxiety and depressive symptoms throughout treatment and at 1-month and 3-month follow-ups. The greatest social anxiety symptom improvement occurred during the CBT phase, and the patient experienced small but additional benefit with the incorporation of IPT techniques. Although not a direct target of treatment, the patient’s depressive symptoms remained subthreshold throughout treatment. Finally, the patient reported significantly higher quality of life at 1-month and 3-month follow-ups, compared with a reference group of BD outpatients. Findings offer preliminary support for the integration of CBT and IPT in treating comorbid SAD among individuals with BD. Clinical implications and suggestions for future research are discussed.

Predictors for initiation of pharmacological prophylaxis in patients with newly diagnosed bipolar disorder--A nationwide cohort study

BACKGROUND

Treatment guidelines state that all patients with bipolar disorder should use pharmacological prophylaxis; however the actual use of prophylactic drugs after bipolar disorder diagnosis is unknown. Our aim was to assess the use of, and predictors for, pharmacoprophylaxis in newly diagnosed bipolar disorder patients.

METHODS

Data from three Swedish nationwide registers were obtained. We identified patients aged 18-75 with a first time diagnosis of bipolar disorder between 2006 and 2012 (n=31,770) and reviewed subsequent mood-stabilizer and antipsychotic prescription fills. In multivariable Cox regression models, we studied demographic and illness related factors as predictors of prescription fills after diagnosis.

RESULTS

In total, 72.2% (95% confidence interval [CI] 71.7-72.7%) of the patients filled a prescription of a prophylactic drug within 3 months after diagnosis. Pharmacological prophylaxis was mainly associated with a longer duration of hospitalization at bipolar disorder diagnosis (adjusted hazard ratio [AHR] 2.18; CI 2.02-2.35 for a hospitalization of ≥28 days compared to <7 days) and previous use of any mood-stabilizer or antipsychotic (inpatients: AHR 1.24; CI 1.17-1.31 and outpatients: AHR 1.78; CI 1.73-1.84).

LIMITATIONS

We had no information on drug prescriptions that were never filled.

CONCLUSIONS

The proportion of newly diagnosed bipolar disorder patients without pharmacological prophylaxis is substantial. Patients who are naïve to mood-stabilizers and antipsychotics and are hospitalized for a brief period at diagnosis are the ones least likely to initiate pharmacoprophylaxis, suggesting that this group deserves attention in order to improve the long term prognosis.

Role of adverse effects in medication nonadherence in bipolar disorder

Nonadherence to medications is common and associated with poor or limited clinical outcomes in the treatment of bipolar disorder. A review of the literature discloses that adverse effects are one of the commonly reported reasons for nonadherence to mood stabilizers by patients with bipolar disorder. Nevertheless, other than such broad summaries, relatively little attention has been given to the role of adverse effects in relation to nonadherence. This review article is the first to consolidate the available data on this topic. Weight gain, perceived cognitive impairment, tremors, and sedation are the adverse effects most likely to lead to nonadherence. Further research is needed to anticipate, identify, manage, and potentially minimize the impact of adverse effects.

Illness-course modulates suicidality-related prefrontal gray matter reduction in women with bipolar disorder

OBJECTIVE

Explore interrelationships between suicide attempt history (Objective 1) or suicide attempt severity (Objective 2) with prefrontal cortex gray matter (PFCGM ) volume and illness-course in patients with bipolar disorder (BD).

METHOD

Ninety-three women with BD-I or -II diagnosis (51 with and 42 without suicide attempt history) underwent structural MRI and filled out questionnaires. Measured were GM volumes of 11 PFC regions, BD illness-course, and attempt history and severity. Effects were examined with repeated measures GLM or logit analyses.

RESULTS

Objective 1: Attempt history was associated with increased trait impulsivity and aggression, and higher prevalence of BD-I, past drug use disorder, and past psychiatric hospitalization. PFCGM volume was lower in patients with than without attempt history in those with past psychiatric hospitalization. PFCGM volume was higher in patients with than without attempt history in those without hospitalization. Higher trait aggression predicted attempt history. Objective 2: Increased frontal pole volume and younger age at first hospitalization predicted many suicide attempts.

CONCLUSION

Attempt history in patients with BD related to PFCGM volume reduction or increase. Volume modulation by psychiatric hospitalization could reflect effects of illness-course or care. Attempt severity was not related to volume reduction. Research on suicidality-brain relationships should include illness-course and attempt severity measures.

Medication adherence in a comparative effectiveness trial for bipolar disorder

OBJECTIVE

Psychopharmacology remains the foundation of treatment for bipolar disorder, but medication adherence in this population is low (range 20-64%). We examined medication adherence in a multisite, comparative effectiveness study of lithium.

METHOD

The Lithium Moderate Dose Use Study (LiTMUS) was a 6-month, six-site, randomized effectiveness trial of adjunctive moderate dose lithium therapy compared with optimized treatment in adult out-patients with bipolar I or II disorder (N=283). Medication adherence was measured at each study visit with the Tablet Routine Questionnaire.

RESULTS

We found that 4.50% of participants reported missing at least 30% of their medications in the past week at baseline and non-adherence remained low throughout the trial (<7%). Poor medication adherence was associated with more manic symptoms and side-effects as well as lower lithium serum levels at mid- and post-treatment, but not with poor quality of life, overall severity of illness, or depressive symptoms.

CONCLUSION

Participants in LiTMUS were highly adherent with taking their medications. The lack of association with possible predictors of adherence, such as depression and quality of life, could be explained by the limited variance or other factors as well as by not using an objective measure of adherence.