Unmet Needs in the Assessment and Management of Bipolar I Depression
Gary S. Sachs, MD
The Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston
Bipolar disorder is a common chronic condition. Although the core feature of bipolar I disorder is at least 1 manic episode, patients usually experience more depression than mood elevation.1 For many patients, depressive episodes are correlated with a poorer quality of life (), but skillful and effective management of bipolar depression can lessen the negative impact and burden of the disorder.
AV 1. Typical Course of Illness for a Patient With Bipolar Disorder (00:26)
Some best practices for bipolar depression include (1) formal assessment of lifetime and current illnesses, (2) individualized chronic care management, and (3) collaborative care that establishes a good therapeutic alliance between the clinician and patient.2 However, implementing these practices is difficult due to the current constraints in clinical practice. One barrier is a lack of time to formally assess patients, which may cause clinicians to rely on impressionistic assessments. Another problem is that most care follows a model appropriate for treating acute rather than chronic conditions. Also, only applying population-based results from studies can undermine the therapeutic alliance with patients, who want personalized care that incorporates the clinician’s experience. The following practical advice will help facilitate the delivery of best practices for patients with bipolar I depression.
Effective management of bipolar I depression begins with a correct diagnosis. To make a formal diagnosis, clinicians should compile a comprehensive patient history of current signs and symptoms, age at onset, course of illness, family history, and previous treatment response.3
Bipolar disorder must be differentiated from other psychiatric illnesses, such as unipolar depression, substance use disorder, schizophrenia, ADHD, and borderline personality disorder. Additionally, patients who have experienced major life events may present with symptoms of mood elevation or depression. Secondary mania and hypomania can also stem from antidepressant medications or medical conditions like stroke or epilepsy. Many conditions often present with bipolar disorder, such as anxiety disorders, substance use disorder, and ADHD.4
After making a definitive diagnosis of bipolar disorder, clinicians should narrow the diagnosis to bipolar I disorder, bipolar II disorder, cyclothymic disorder, or bipolar disorder NOS.5 Because different depression treatments are more effective than others based on the classification, making an accurate diagnosis is critical to disease management.
Saving time with pre-assessments. Traditional office visits limit the amount of time clinicians have to engage the patient, complete an assessment, choose an intervention, and educate the patient. To create more face time, patients can complete a previsit assessment at home either online or on paper before the initial visit (). This work might take the patient 1 to 2 hours, but the clinician can review it in a couple of minutes or less. Collecting basic information before an office visit not only improves efficiency by preparing the clinician to address the patient’s concerns but also is an excellent way to improve diagnostic confidence and facilitate good recordkeeping.
AV 2. Initial and Follow-Up Visits With Pre-Assessment (0:39)
Before each follow-up visit, patients can complete an online pre-assessment or paper versions of forms and rating scales, such as the MADRS, BDI, YMRS, Zung Self-Rating Depression Scale, QIDS-SR, or Q-LES-Q, that track their treatment response (see ). For example, in the STEP-BD trial,6 patients completed a self-report section of The Clinical Monitoring Form in the waiting room. Then, clinicians reviewed this form, rated symptoms, and assigned a clinical status based on DSM-IV criteria, which were used to determine the treatment path. Keeping clinical progress notes and patient self-reports on a single form enabled clinicians to easily incorporate assessment in routine office visits.
Individualized Chronic Care Management
Management of bipolar disorder should follow a chronic care model. Patients need to understand that treatment for bipolar disorder does not follow the acute care model, which aims for cures, but rather aims for improving the rate of wise management decisions. Further, patients want personalized care. They want clinicians to use their clinical expertise to integrate their knowledge of evidence and their knowledge about the patient as a unique individual to guide treatment decisions and create personalized care plans.
During the office visit, clinicians formulate a menu of appropriate interventions based on their knowledge of bipolar depression and the patient’s individual factors and can usually offer patients 2 to 4 treatment options (see ). Individual factors that influence treatment choices include the patient’s course of illness (eg, frequency and number of prior episodes, rapid cycling), current symptoms, comorbid conditions, general medical conditions, adverse effect tolerance, and prior treatment response (ie, effective, ineffective, or intolerable medications given at an adequate dose and duration).
Clinicians should offer proven treatments first. Proven treatments (whether pharmacotherapy or psychotherapy) are those that have shown efficacy in double-blind, placebo-controlled trials with sample sizes that were adequate to detect a meaningful clinical effect. Medications with at least 1 positive trial in treating bipolar depression include quetiapine, olanzapine/fluoxetine combination, lamotrigine, olanzapine, lurasidone, and adjunctive modafinil.7–9 Clinicians should also consider the tolerability profiles of the medications and favor less risky options for individual patients. For example, olanzapine monotherapy is associated with increased weight gain,10 making it less favorable for a patient with metabolic issues.
The collaborative care model fosters communication and shared decision-making between the physician and the patient. To build the therapeutic alliance, clinicians should discuss treatment goals and expectations with patients, educate them about viable treatment options, and negotiate as necessary to build concordance and promote adherence. Patients are encouraged to select a treatment regimen based on their personal preference. Involving care partners is also a key element of collaborative care. These external supports provide collateral information and help the patient stay on track with the treatment plan.
AV 3. Tracking Illness Course and Treatment Response Using Measurement-Based Scales (0:22)
Throughout bipolar depression management, formal measures (rating scales) are recommended for clinicians to systematically monitor patients’ response to each intervention and adjust care to prevent relapse. Administering a formal scale in pre-assessment allows clinicians to calculate the percentage of improvement (or worsening) the patient has experienced with the current treatment (). This is beneficial because several studies show that when patients have had less than 20% improvement after the first 2 or 3 weeks of treatment, they are unlikely to achieve response or remission.11 At that point, it is useful for the clinician to share the measurement data and results with the patient and discuss modifying the treatment plan, such as optimizing the dosage or switching medications, which will increase the patient’s understanding of treatment strategies. Clinicians should also be aware that many studies find discontinuing an effective treatment is associated with a high relapse rate.12
Bipolar depression causes considerable patient distress and poses unique challenges to effective management. The first step is making a correct diagnosis using a full formal diagnostic assessment to rule out other causes of depressive symptoms. By shifting the collection of patient data to a pre-assessment before office visits, clinicians free up valuable face time to engage with patients. The second step is implementing a chronic care model that offers patients an individualized menu of reasonable choices from proven treatments. And finally, collaborating with patients encourages them to be active decision makers in conjunction with the expertise offered by the clinician. Clinicians then track each intervention’s effectiveness and tolerability using pre-assessment tools completed by the patient before each visit. Together, clinicians and patients, along with care partners, can choose individualized regimens to encourage patient adherence, help patients achieve remission, and restore patients to previous levels of functioning.
- Complete a differential diagnosis of bipolar disorder, make a definitive diagnosis, and narrow the diagnosis to the correct classification
- Review pre-assessment results before patient office visits to save time
- Educate patients and involve care partners to choose a treatment from a menu of proven choices
- Use systematic measurements to determine the effectiveness of each intervention and modify the treatment plan when necessary
lamotrigine (Lamictal and others), lurasidone (Latuda), modafinil (Provigil), olanzapine (Zyprexa and others), olanzapine/fluoxetine combination (Symbyax and others), quetiapine (Seroquel and others)
ADHD = attention-deficit/hyperactivity disorder, BDI = Beck Depression Inventory, MADRS = Montgomery-Asberg Depression Rating Scale, MDQ = Mood Disorder Questionnaire, NOS = not otherwise specified, QIDS-SR = Quick Inventory of Depressive Symptomatology–Self Report, Q-LES-Q = Quality of Life Enjoyment and Satisfaction Questionnaire, STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder, YMRS = Young Mania Rating Scale
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- Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530–537. PubMed
- American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder. 2nd ed. http://psychiatryonline.org/content.aspx?bookid=28§ionid=1669577#50051. 2002. Accessed March 21, 2013.
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- Sachs GS, Thase ME, Otto MW, et al. Rationale, design, and methods of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Biol Psychiatry. 2003;53(11):1028–1042. PubMed
- Kemp DE, Muzina DJ, McIntyre RS, et al. Bipolar depression: trial-based insights to guide patient care. Dialogues Clin Neurosci. 2008;10(2):181–192. PubMed
- Loebel A, Cucchiaro J, Silva R, et al. Lurasidone monotherapy for the treatment of bipolar I depression: results of a 6-week, double-blind, placebo-controlled study [abstract NR3-72]. In: New Research Abstract Book of the 165th Annual Meeting of the American Psychiatric Association; May 5–9, 2012; Philadelphia, PA.
- Frye MA, Grunze H, Suppes T, et al. A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression. Am J Psychiatry. 2007;164(8):1242–1249. PubMed
- Suppes T, Dennehy EB, Hirschfeld RMA, et al, for the Texas Consensus Conference Panel on Medication Treatment of Bipolar Disorder. The Texas Implementation of Medication Algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66(7):870–886. Full Text
- Kemp DE, Calabrese JR, Eudicone JM, et al. Predictive value of early improvement in bipolar depression trials: a post-hoc pooled analysis of two 8-week aripiprazole studies. Psychopharmacol Bull. 2010;43(2):5–27. PubMed
- Altshuler L, Suppes T, Black D, et al. Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up. Am J Psychiatry. 2003;160(7):1252–1262. PubMed