Does provider adherence to a treatment guideline change clinical outcomes for patients with bipolar disorder? Results from the Texas Medication Algorithm Project

Background. Despite increasing adoption of clinical practice guidelines in psychiatry, there is little measurement of provider implementation of these recommendations, and the resulting impact on clinical outcomes. The current study describes one effort to measure these relationships in a cohort of public sector out-patients with bipolar disorder.Method. Participants were enrolled in the algorithm intervention of the Texas Medication Algorithm Project (TMAP). Study methods and the adherence scoring algorithm have been described elsewhere. The current paper addresses the relationships between patient characteristics, provider experience with the algorithm, provider adherence, and clinical outcomes. Measurement of provider adherence includes evaluation of visit frequency, medication choice and dosing, and response to patient symptoms. An exploratory composite ‘adherence by visit’ score was developed for these analyses.Results. A total of 1948 visits from 141 subjects were evaluated, and utilized a two-stage declining effects model. Providers with more experience using the algorithm tended to adhere less to treatment recommendations. Few patient factors significantly impacted provider adherence. Increased adherence to algorithm recommendations was associated with larger decreases in overall psychiatric symptoms and depressive symptoms over time, but did not impact either immediate or long-term reductions in manic symptoms.Conclusions. Greater provider adherence to treatment guideline recommendations was associated with greater reductions in depressive symptoms and overall psychiatric symptoms over time. Additional research is needed to refine measurement and to further clarify these relationships.

Download Full-text

Clinical course predicts long-term outcomes in bipolar disorder

Psychological Medicine ◽

10.1017/s0033291718001678 ◽

2018 ◽

Vol 49 (07) ◽

pp. 1109-1117 ◽

Cited By ~ 1

Author(s):

Rudolf Uher ◽

Sanna Pallaskorpi ◽

Kirsi Suominen ◽

Outi Mantere ◽

Barbara Pavlova ◽

...

Keyword(s):

Bipolar Disorder ◽

Depressive Symptoms ◽

Hospital Admissions ◽

Clinical Course ◽

Bipolar Disorders ◽

Long Term Outcomes ◽

Course Characteristics ◽

Manic Symptoms

AbstractBackgroundThe long-term outcomes of bipolar disorder range from lasting remission to chronic course or frequent recurrences requiring admissions. The distinction between bipolar I and II disorders has limited utility in outcome prediction. It is unclear to what extent the clinical course of bipolar disorder predicts long-term outcomes.MethodsA representative sample of 191 individuals diagnosed with bipolar I or II disorder was recruited and followed for up to 5 years using a life-chart method. We previously described the clinical course over the first 18 months with dimensional course characteristics and latent classes. Now we test if these course characteristics predict long-term outcomes, including time ill (time with any mood symptoms) and hospital admissions over a second non-overlapping follow-up period in 111 individuals with available data from both 18 months and 5 years follow-ups.ResultsDimensional course characteristics from the first 18 months prospectively predicted outcomes over the following 3.5 years. The proportion of time depressed, the severity of depressive symptoms and the proportion of time manic predicted more time ill. The proportion of time manic, the severity of manic symptoms and depression-to-mania switching predicted a greater likelihood of hospital admissions. All predictions remained significant after controlling for age, sex and bipolar I v. II disorder.ConclusionsDifferential associations with long-term outcomes suggest that course characteristics may facilitate care planning with greater predictive validity than established types of bipolar disorders. A clinical course dominated by depressive symptoms predicts a greater proportion of time ill. A clinical course characterized by manic episodes predicts hospital admissions.

Download Full-text

Affective Temperaments and Illness Severity in Patients with Bipolar Disorder

Medicina ◽

10.3390/medicina57010054 ◽

2021 ◽

Vol 57 (1) ◽

pp. 54

Author(s):

Mario Luciano ◽

Luca Steardo ◽

Gaia Sampogna ◽

Vito Caivano ◽

Carmen Ciampi ◽

...

Keyword(s):

Quality Of Life ◽

Bipolar Disorder ◽

Protective Factor ◽

Psychiatric Symptoms ◽

Control Group ◽

Term Outcome ◽

Long Term Outcome ◽

Affective Temperaments

Background and objectives: Bipolar disorder (BD) is one of the most burdensome psychiatric illnesses, being associated with a negative long-term outcome and the highest suicide rate. Although affective temperaments can impact on BD long-term outcome, their role remains poorly investigated. The aims of the present study are to describe the clinical characteristics of patients with BD more frequently associated with the different affective temperaments and to assess the relation between affective temperaments and severity of clinical picture in a sample of patients with BD. Materials and Methods: A total of 199 patients have been recruited in the outpatients units of two university sites. Patients’ psychiatric symptoms, affective temperaments, and quality of life were investigated through validated assessment instruments. Results: Predominant cyclothymic and irritable temperaments are associated to higher number of relapses, poorer quality of life, higher rates of aggressive behaviors, and suicide attempts. Conversely, the predominant hyperthymic disposition was a protective factor for several outcome measures, including relapse rate, severity of anxiety, depressive and manic symptoms, suicidality, and earlier age at onset. One limitationo of the present study is that the recruitment took place in two university sites; therefore, our findings cannot be fully generalized to the whole community of BD patients. Other limitations are the lack of a control group and the cross-sectional design of the study. Conclusions: The early identification of affective temperaments can help clinicians to identify those BD patients who are more likely to show a poor long-term outcome. An early screening of affective temperaments can be useful to develop targeted integrated pharmacological and psychosocial interventions.

Download Full-text

Carbamazepine-induced delayed-onset agranulocytosis in a case of bipolar disorder with Kikuchi’s disease

BMJ Case Reports ◽

10.1136/bcr-2021-241973 ◽

2021 ◽

Vol 14 (6) ◽

pp. e241973

Author(s):

Cebasta Irudayaraj ◽

Raviteja Innamuri ◽

Dheeraj Kattula

Keyword(s):

Bipolar Disorder ◽

Psychiatric Symptoms ◽

Drug Effects ◽

Significant Loss ◽

Drug Induced ◽

Kikuchi’S Disease ◽

Delayed Onset ◽

Loss Of Weight ◽

Kikuchi's Disease

A 48-year-old man who is a known case of bipolar disorder was maintaining well on a combination of carbamazepine and quetiapine for 3 years until he developed fever, severe leucopenia and lymphadenopathy, along with significant loss of weight and appetite. A thorough investigation revealed Kikuchi’s disease as a likely histological diagnosis. Carbamazepine was discontinued and quetiapine was titrated for the management of psychiatric symptoms. The patient gradually made good recovery following discontinuation of carbamazepine and the diagnosis of drug-induced myelosuppression was retained. Clinicians need to be aware of the adverse effects of medications being used for long-term prophylaxis and other possible conditions that may change the course of drug effects.

Download Full-text

Six-month trajectories of self-reported depressive symptoms in long-term care

International Psychogeriatrics ◽

10.1017/s1041610215001179 ◽

2015 ◽

Vol 28 (1) ◽

pp. 71-81 ◽

Cited By ~ 1

Author(s):

Jane McCusker ◽

Martin G. Cole ◽

Philippe Voyer ◽

Johanne Monette ◽

Nathalie Champoux ◽

...

Keyword(s):

Depressive Symptoms ◽

Long Term Care ◽

Secondary Analysis ◽

Depression Scale ◽

Depression Symptom ◽

Term Care ◽

Symptom Trajectory ◽

Over Time

ABSTRACTBackground:Depression is a common problem in long-term care (LTC) settings. We sought to characterize depression symptom trajectories over six months among older residents, and to identify resident characteristics at baseline that predict symptom trajectory.Methods:This study was a secondary analysis of data from a six-month prospective, observational, and multi-site study. Severity of depressive symptoms was assessed with the 15-item Geriatric Depression Scale (GDS) at baseline and with up to six monthly follow-up assessments. Participants were 130 residents with a Mini-Mental State Examination score of 15 or more at baseline and of at least two of the six monthly follow-up assessments. Individual resident GDS trajectories were grouped using hierarchical clustering. The baseline predictors of a more severe trajectory were identified using the Proportional Odds Model.Results:Three clusters of depression symptom trajectory were found that described “lower,” “intermediate,” and “higher” levels of depressive symptoms over time (mean GDS scores for three clusters at baseline were 2.2, 4.9, and 9.0 respectively). The GDS scores in all groups were generally stable over time. Baseline predictors of a more severe trajectory were as follows: Initial GDS score of 7 or more, female sex, LTC residence for less than 12 months, and corrected visual impairment.Conclusions:The six-month course of depressive symptoms in LTC is generally stable. Most residents who experience a more severe symptom trajectory can be identified at baseline.

Download Full-text

Age-Related Differences in Medication Adherence, Symptoms, and Stigma in Poorly Adherent Adults With Bipolar Disorder

Journal of Geriatric Psychiatry and Neurology ◽

10.1177/0891988719874116 ◽

2019 ◽

Vol 33 (5) ◽

pp. 250-255 ◽

Cited By ~ 1

Author(s):

Stephen Smilowitz ◽

Awais Aftab ◽

Michelle Aebi ◽

Jennifer Levin ◽

Curtis Tatsuoka ◽

...

Keyword(s):

Older Adults ◽

Bipolar Disorder ◽

Medication Adherence ◽

Symptom Severity ◽

Psychiatric Symptoms ◽

Significant Finding ◽

Internalized Stigma ◽

Age Related ◽

Severity Scores ◽

Over Time

Objective: We present a secondary analysis of data reporting differences in medication adherence, psychiatric symptom severity, and internalized stigma levels in older (age ≥ 55 years) versus younger (age < 55 years) adults with bipolar disorder (BD) and poor medication adherence. Methods: Data used for this analysis came from 184 participants in a National Institute of Mental Health–funded randomized controlled trial, comparing a customized adherence enhancement (CAE) intervention intended to promote BD medication adherence with a BD-specific educational program (EDU). At screen, study participants were ≥20% nonadherent with BD medications as measured by the Tablets Routine Questionnaire (TRQ). Psychiatric symptoms, functional status, and internalized stigma were measured using validated scales. Results: Older adults had significantly lower anxiety disorder comorbidity ( P < .01 for 1 or more anxiety disorders), depressive symptom severity scores ( P = .011), and self-stigma scores ( P = .001) compared to their younger counterparts. In the analyses evaluating change over time in TRQ between older and younger participants by treatment arm (ie, CAE and EDU), there was a significant finding of interaction between time, age-group, and treatment arm ( P = .007). Conclusions: Older adults may be less anxious and depressed, with less self-stigma, compared to younger people with BD and poor adherence. With respect to medication adherence, older individuals in EDU appear to do less well than younger individuals over time.

Download Full-text

‘Bipolarity’ in bipolar disorder: Distribution of manic and depressive symptoms in a treated population

The British Journal of Psychiatry ◽

10.1192/bjp.187.1.87 ◽

2005 ◽

Vol 187 (1) ◽

pp. 87-88 ◽

Cited By ~ 52

Author(s):

Mark S. Bauer ◽

Gregory E. Simon ◽

Evette Ludman ◽

Jurgen Unützer

Keyword(s):

Bipolar Disorder ◽

Depressive Symptoms ◽

Health Maintenance Organisation ◽

Cross Sectional ◽

Health Maintenance ◽

Manic Symptoms ◽

Clinically Significant ◽

Sectional Analysis ◽

Depressive And Manic Symptoms

SummaryCross-sectional analysis of 441 individuals with bipolar disorder treated at a US health maintenance organisation investigated the distribution of manic and depressive symptoms in that illness. Clinically significant depressive symptoms occurred in 94.1% of those with (hypo)mania, while70.1% inadepressive episode had clinically significant manic symptoms. DSM-unrecognised depression-plus-hypomania was over twice as prevalent as DSM-recognised mixed episodes. Depressive symptoms were unimodally distributed in (hypo)mania. Depressive and manic symptoms were positively, not inversely correlated, and their co-occurrence was associated with worse quality of life. Implications for the DSM and ICD nosological systems are discussed.

Download Full-text

What is the relationship between post-traumatic stress disorder, extreme appraisals of internal state and symptoms in bipolar disorder?

Behavioural and Cognitive Psychotherapy ◽

10.1017/s1352465819000572 ◽

2019 ◽

Vol 48 (1) ◽

pp. 103-115

Author(s):

Laura Frost ◽

Warren Mansell ◽

Filippo Varese ◽

Sara Tai

Keyword(s):

Bipolar Disorder ◽

Depressive Symptoms ◽

Post Traumatic Stress Disorder ◽

Traumatic Stress ◽

Internal State ◽

Cognitive Model ◽

Post Traumatic Stress ◽

Manic Symptoms ◽

Co Morbidity ◽

Post Traumatic

AbstractBackground:It is important to understand the factors associated with more severe mood symptoms in bipolar disorder. The integrative cognitive model of bipolar disorder proposes that extreme appraisals of changes to internal states maintain and exacerbate mood symptoms.Aims:The current study aimed to investigate if post-traumatic stress disorder (PTSD) is related to current depressive and manic bipolar symptoms, and whether this relationship is mediated by appraisals of internal state.Method:Participants with bipolar disorder (n = 82) from a randomized controlled trial of cognitive therapy for bipolar disorder (the TEAMS trial) completed self-reported questionnaires assessing appraisals of internal state, generalized anxiety symptoms, and self-reported and observer-rated depressive and manic symptoms. Clinical interviews assessed PTSD co-morbidity.Results:Participants with bipolar and co-morbid PTSD (n = 27) had higher depressive symptoms and more conflicting appraisals than those without PTSD. Regression analyses found PTSD to be associated with depressive symptoms but not manic symptoms. Conflicting appraisals were found to be associated only with manic symptoms meaning that the planned mediation analysis could not be completed.Conclusions:Findings provide partial support for the integrative cognitive model of bipolar disorder and highlight the need for transdiagnostic treatments in bipolar disorder due to the prevalence and impact of trauma and co-morbidity. Working on trauma experiences in therapy may impact on depressive symptoms for those with bipolar disorder and co-morbid PTSD.

Download Full-text

Long-term outcomes of adolescents with juvenile-onset fibromyalgia into adulthood and impact of depressive symptoms on functioning over time

Pain ◽

10.1097/j.pain.0000000000001415 ◽

2019 ◽

Vol 160 (2) ◽

pp. 433-441 ◽

Cited By ~ 7

Author(s):

Susmita Kashikar-Zuck ◽

Natoshia Cunningham ◽

James Peugh ◽

William R. Black ◽

Sarah Nelson ◽

...

Keyword(s):

Depressive Symptoms ◽

Long Term Outcomes ◽

Juvenile Onset ◽

Over Time

Download Full-text

Predictors of change over time in subjective daytime sleepiness among older adult recipients of long-term services and supports

International Psychogeriatrics ◽

10.1017/s1041610220000782 ◽

2020 ◽

Vol 32 (7) ◽

pp. 849-861

Author(s):

Darina V. Petrovsky ◽

Karen B. Hirschman ◽

Miranda Varrasse McPhillips ◽

Justine S. Sefcik ◽

Alexandra L. Hanlon ◽

...

Keyword(s):

Quality Of Life ◽

Social Support ◽

Older Adults ◽

Depressive Symptoms ◽

Daytime Sleepiness ◽

Daily Living ◽

Services And Supports ◽

Over Time

ABSTRACTObjectives:Daytime sleepiness is associated with multiple negative outcomes in older adults receiving long-term services and supports (LTSS) including reduced cognitive performance, need for greater assistance with activities of daily living and decreased social engagement. The purpose of this study was to identify predictors of change in subjective daytime sleepiness among older adults during their first 2 years of receiving LTSS.Design and Setting:Secondary analysis of data from a prospective longitudinal study of older adults who received LTSS in their homes, assisted living communities or nursing homes interviewed at baseline and every 3 months for 24 months.Participants:470 older adults (60 years and older) newly enrolled in LTSS (mean = 81, SD = 8.7; range 60–98; 71% women).Measurements:Subjective daytime sleepiness was assessed every 3 months through 2 years using the Epworth Sleepiness Scale. Multiple validated measures were used to capture health-related quality of life characteristics of enrollees and their environment, including symptom status (Symptom Bother Scale), cognition (Mini Mental Status Exam), physical function (Basic Activities of Daily Living), physical and mental general health, quality of life (Dementia Quality of Life, D-QoL), depressive symptoms (Geriatric Depression Scale) and social support (Medical Outcomes Survey-Social Support).Results:Longitudinal mixed effects modeling was used to examine the relationship between independent variables and continuous measure of daytime sleepiness. Increased feelings of belonging, subscale of the D-QoL (effect size = −0.006, 95% CI: −0.013 to −0.0001, p = 0.045) and higher number of depressive symptoms (effect size = −0.002, 95% CI: −0.004 to −0.001, p = 0.001) at baseline were associated with slower rates of increase in daytime sleepiness over time.Conclusions:Comprehensive baseline and longitudinal screening for changes in daytime sleepiness along with depression and perceived quality of life should be used to inform interventions aimed at reducing daytime sleepiness among older adults receiving LTSS.

Download Full-text

Stability of Psychiatric Symptoms among Mentally Ill Chemical Abusers in Long-Term Residential Treatment Programs

Journal of Drug Issues ◽

10.1177/002204269702700408 ◽

1997 ◽

Vol 27 (4) ◽

pp. 795-806

Author(s):

Larry Nuttbrock ◽

Michael Rahav ◽

James Rivera ◽

Daisy Ng-Mak ◽

Bert Pepper

Keyword(s):

Depressive Symptoms ◽

Residential Treatment ◽

Mentally Ill ◽

Psychiatric Symptoms ◽

Treatment Programs ◽

Mean Values ◽

Changing Patterns ◽

Chemical Abusers ◽

Anxiety Depression

We examined patterns of changes in psychiatric symptoms among mentally ill chemical abusers (MICAs) in long-term residential treatment. Clients were evaluated with various measures of psychopathology, referred to a therapeutic community (TC) or community residence, and reassessed after 2, 6, and 12 months of treatment with regard to anxiety, depressive symptoms, and psychotic ideation. Reductions in mean values of psychopathology were found only for anxiety and depressive symptoms at the TC during the first 2 months of treatment. However, an examination of changing patterns of symptoms revealed a more complex set of findings. At both programs, a significant number of MICAs showed reductions in psychopathology during treatment, a significant minority exhibited no improvements in psychiatric symptoms, and a few reported new symptoms of anxiety, depression, and psychotic ideation. We conclude that the symptoms of the vast majority of MICAs are highly labile during treatment.

Download Full-text