An Update on Bipolar Disorder NARSAD 2008
Andrew A. Nierenberg, MDMedical Director
Harvard Bipolar Clinic and Research Program,Massachusetts General Hospital
Director, NIMH Bipolar Trials NetworkProfessor of Psychiatry, Harvard Medical School
Thank you NARSAD
• Thilo Deckersbach, PhD• Christina Dording, MD• Aude Henin, PhD• Dan Iosifescu, MD• Andrew A. Nierenberg, MD• Michael J. Ostacher, MD, MPH• Janet Witte, MD
Update on Bipolar Disorder
• Update on Bipolar basics• STEP-BD• LiTMUS
Lizzie SimonTime Magazine Aug 11, 2002
"Everything was perfect...and then I went insane"
Goya Portrait of Don Gaspar Melchor de Jovellanos
Bipolar Disorder
• Prevalence: – BPI and II:
• 1.1% of the workforce• 2.6% of the general population
• Mean age of onset: 17.4 years
Kessler et al. Arch Gen Psychiatry. 2005;62:617-627.Kessler et al. Am J Psychiatry. 2006;163:1561-1568.
Bipolar Disorder
• Recurrent and chronic disorder– Manic or hypomanic episodes– Major depressive episodes and symptoms
• Major burden– Inter-episodic symptoms
• Dysfunction: – 65.5 lost days of work per year
Kessler et al. Arch Gen Psychiatry. 2005;62:617-627.Kessler et al. Am J Psychiatry. 2006;163:1561-1568.
STEP-BD
• Systematic Treatment Enhancement Program for Bipolar Disorder
• www.stepbd.org• Evidence guided treatment• Specialty bipolar clinics• Integration of measurement and
management• Embedded randomized trials
Collaborative Careand
Concordance
Collaborative Care: Integration of Measurement and Management
• Shared measurement– Symptoms
• Depression• Mania/hypomania• Anxiety• Irritability
– Stress, alcohol, weight– Side effects– Functioning
Nierenberg AA. J Clin Psychiatry. 2006;67 Suppl 11:3-7.www.manicdepressive.org (see Resources section)
Clinical Self-report Form
Clinical Monitoring Form
Collaborative Care: Integration of Measurement and Management
• Mood monitoring• Medication concordance
• Non-concordance open for discussion
• Negotiate– Goals– Medication changes
• Menu of reasonable choices
• Collaborative Care Workbook
Key STEP-BD Baseline Findings
STEP-BD: Bipolar Onset
28%
37%
35%> 18
13 to 18
< 13
Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881
Lifetime Anxiety Comorbidity
Simon N, et al. Am J Psychiatry. 2004;161:2222-2229.
*
0
10
20
30
40
50
60
Any Panic±
Agor
Agor Without
Panic
SAD OCD PTSD GAD
BP I BP II
*
*
* *
†
Key STEP-BD Long-Term Findings
With systematic treatment, 30% of STEP-BD participants
achieved recovery and
then stayed recovered over 1 year
Anxiety: more difficult to recover from bipolar depressive episode
Otto et al., Br J Psychiatry 2006 Jul;189:20-5.
without anxiety
with anxiety
Anxiety: higher risk of depressive relapse
Otto et al., Br J Psychiatry 2006 Jul;189:20-5.
without anxiety
with anxiety
Higher bipolar relapse rate with residual symptoms
Perlis et al., Am J Psychiatry. 2006 Feb;163(2):217-24.
Without residual symptoms
With residual symptoms
Without residual symptoms
With residual symptoms
No benefit with antidepressants for bipolar depression with manic symptoms
Goldberg et al. Am J Psychiatry 2007:164:1348-1355
STEP-BD Randomized Trials
Antidepressants or placebo added to mood stabilizers for bipolar
depression
05
10152025303540
Durable recovery TreatmentEffectiveness
Response
Affective Switch
Sachs G et al. N Engl J Med 2007;10.1056/NEJMoa064135
%
Treatment Resistant Bipolar Depression: Lamotrigine Added Might Help
Nierenberg et al., Am J Psychiatry 2006;163;1-8
Adjunctive Psychosocial Interventions
• Collaborative Care Plus• Cognitive-Behavioral Therapy (CBT)• Family-Focused Therapy (FFT)• Interpersonal and Social Rhythm Therapy
(IPSRT)
Intensive psychotherapy: remission 110 days earlier
110 Days
Miklowitz et al., Arch Gen Psychiatry. 2007 Apr;64(4):419-26.
LiTMUSLithium Moderate Dose Use Study
A NIMH Bipolar Trials Network Contract
Problem:Long term outcomes suboptimal for
Bipolar Disorderand
Lithium is under used
Can tolerable doses of lithium added to other medications improve 6
month outcomes?
LiTMUS
• Compare strategies of treatment– Optimized treatment with lithium– Optimized treatment without lithium
• 6 month outcomes• Open treatment• Blinded outcomes
Update on Bipolar Disorder
• Update on Bipolar basics• STEP-BD• LiTMUS
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