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Kamali M, Pegg S, Janos JA, Bobo WV, Brody B, Gao K, Ketter TA, McElroy SL, McInnis MG, Rabideau DJ, Reilly-Harrington NA, Shelton RC, Sylvia LG, Tohen M, Nierenberg A. Illness stage and predominant polarity in bipolar disorder: Correlation with burden of illness and moderation of treatment outcome. J Psychiatr Res 2021; 140:205-213. [PMID: 34118638 PMCID: PMC8319086 DOI: 10.1016/j.jpsychires.2021.05.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/25/2021] [Accepted: 05/29/2021] [Indexed: 11/26/2022]
Abstract
Bipolar disorder often follows a set progression best described in stages where advanced stages are associated with poorer outcomes. Bipolar disorder is also often characterized by a predominance of episode polarity, where some individuals experience more depressive episodes (termed predominant depressive polarity) while others experience more hypo/manic episodes (termed predominant hypo/manic polarity). We examined the associations between staging and predominant polarity with measures of illness burden and treatment outcome utilizing data from a six-month comparative effectiveness trial of lithium and quetiapine in bipolar disorder (Bipolar CHOICE). We used number of self-reported lifetime mood (depressive and hypo/manic) episodes as a proxy for staging and ratio of depressive to manic episodes to define predominant polarity. Polarity and staging were correlated with several measures of burden of illness. Childhood abuse was correlated with more lifetime mood episodes, while more depressive episodes and depressive polarity were correlated with more anxiety disorder comorbidity. Depressive polarity was also correlated with more past trials of psychotropics, particularly antidepressants. However, neither staging nor predominant polarity moderated the randomized treatment effect of lithium vs. quetiapine. Number of depressive episodes in the past year was identified as a potential predictor of overall worse treatment outcome, regardless of medication condition. In conclusion, though staging and predominant episode polarity correlated with several measures of illness burden, they were not associated with differential treatment outcomes. This could be because many of our patients presented for treatment at advanced stages of illness and further highlights the need for early intervention in bipolar disorder.
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Affiliation(s)
- Masoud Kamali
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA, 02114, United States; Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, United States.
| | - Samantha Pegg
- Department of Psychology and Human Development, Vanderbilt University, 230 Appleton Place, Nashville, TN, 37203, United States.
| | - Jessica A. Janos
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, 235 East Cameron Avenue, Chapel Hill, NC 27599, United States
| | - William V. Bobo
- Department of Psychiatry & Psychology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - Benjamin Brody
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68th Street, New York, NY, 10065, United States.
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, 10524 Euclid Avenue, Cleveland, OH, 44106, United States.
| | - Terence A. Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, United States
| | - Susan L. McElroy
- Lindner Center of HOPE, University of Cincinnati Department of Psychiatry and Behavioral Neuroscience, 260 Stetson Street, Cincinnati, OH 45219, United States
| | - Melvin G. McInnis
- Department of Psychiatry, University of Michigan, 4250 Plymouth Road, Ann Arbor, MI 48109, United States
| | - Dustin J. Rabideau
- Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, Suite 560, Boston, MA 02114, United States,Department of Medicine, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States
| | - Noreen A. Reilly-Harrington
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA 02114, United States,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States
| | - Richard C. Shelton
- Department of Psychiatry, University of Alabama at Birmingham School of Medicine, 1720 2nd Avenue S, Birmingham, AL 35294, United States
| | - Louisa G. Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA 02114, United States,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, 2400 Tucker Avenue NE, Albuquerque, NM, 87106, United States.
| | - Andrew Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA, 02114, United States; Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, United States.
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2
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Yaramala SR, McElroy SL, Geske J, Winham S, Gao K, Reilly-Harrington NA, Ketter TA, Deckersbach T, Kinrys G, Kamali M, Sylvia LG, McInnis MG, Friedman ES, Thase ME, Kocsis JH, Tohen M, Calabrese JR, Bowden CL, Shelton RC, Nierenberg AA, Bobo WV. The impact of binge eating behavior on lithium- and quetiapine-associated changes in body weight, body mass index, and waist circumference during 6 months of treatment: Findings from the bipolar CHOICE study. J Affect Disord 2020; 266:772-781. [PMID: 30241956 DOI: 10.1016/j.jad.2018.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/12/2018] [Accepted: 09/11/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Lithium and quetiapine can cause weight gain, but their comparative longer term anthropometric effects are unknown, as are the potential moderating effects of baseline binge-eating (BE) behavior. METHODS We assessed 6 month changes in body weight, body mass index (BMI) and waist circumference in 482 adults with DSM-IV bipolar disorders who participated in a comparative effectiveness study of lithium and quetiapine with evidence-based adjunctive treatment (Bipolar CHOICE). Anthropometric measurements were obtained at baseline, and at 2, 4, 6, 8, 12, 16, 20, and 24 weeks. BE behavior was defined as affirmative responses to MINI items M1 and M3 at baseline. Data were analyzed using a mixed model repeated measures approach, adjusted for baseline values of dependent measures. RESULTS On average, body weight and BMI increased over 6 months with lithium and quetiapine. However, those treated with quetiapine experienced greater increases from baseline in body weight (peak change, + 3.6 lbs. vs. + 1.4 lbs.) and BMI (peak change, + 0.6 kg/m2 vs. + 0.3 kg/m2), starting at 2 weeks (group x time, F8,3052 = 2.9, p = 0.003 for body weight, F8,3052 = 3.0, p = 0.002 for BMI). Significant increases in waist circumference were observed only with quetiapine. The relationship between drug treatment and changes in body weight (group x time x binge eating status, F1,2770 = 2.0, p = 0.002), BMI (F1,2767 = 2.0, p = 0.002), and waist circumference (women only, F25,1621 = 2.9, p < 0.0001) were moderated by BE behavior. The largest increases over 24 weeks in body weight and BMI, and waist circumference in women, occurred for quetiapine-treated patients with baseline binge-eating, relative to quetiapine-treated patients without binge eating and lithium-treated patients with or without baseline binge-eating. LIMITATIONS Bipolar CHOICE was not designed to study anthropometric outcomes. CONCLUSIONS Greater changes in body weight, BMI, and waist circumference occurred with quetiapine- versus lithium-based treatment over 6 months of treatment. The effects of study drugs on these anthropometric measures were moderated by BE behavior at baseline.
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Affiliation(s)
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jennifer Geske
- Department of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN USA
| | - Stacey Winham
- Department of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN USA
| | - Keming Gao
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | | - Machael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, Ithaca, NY, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX
| | - Richard C Shelton
- Department of Psychiatry and Behavioral Neurobiology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA,USA; Harvard Medical School, Boston, MA, USA
| | - William V Bobo
- Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, FL USA.
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Kamali M, Reilly-Harrington NA, Chang WC, McInnis M, McElroy SL, Ketter TA, Shelton RC, Deckersbach T, Tohen M, Kocsis JH, Calabrese JR, Gao K, Thase ME, Bowden CL, Kinrys G, Bobo WV, Brody BD, Sylvia LG, Rabideau DJ, Nierenberg AA. Bipolar depression and suicidal ideation: Moderators and mediators of a complex relationship. J Affect Disord 2019; 259:164-172. [PMID: 31445343 DOI: 10.1016/j.jad.2019.08.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 07/27/2019] [Accepted: 08/17/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Not all patients with bipolar depression have suicidal ideation (SI). This study examines some factors that link bipolar depression to SI. METHODS 482 individuals with bipolar I or II were randomized to either lithium or quetiapine plus adjunctive personalized therapy in a 24 week comparative effectiveness trial. Severity of depression and SI were assessed with the Bipolar Inventory of Symptoms Scale (BISS). We examined potential moderators (age, gender, age of illness onset, bipolar type, comorbid anxiety, substance use, past suicide attempts, childhood abuse and treatment arm) and mediators (severity of anxiety, mania, irritability, impairment in functioning (LIFE-RIFT) and satisfaction and enjoyment of life (Q-LES-Q)) of the effect of depression on SI. Statistical analyses were conducted using generalized estimating equations with repeated measures. RESULTS Bipolar type and past suicide attempts moderated the effect of depression on SI. Life satisfaction mediated the effect of depression and SI. The relationship between anxiety, depression and SI was complex due to the high level of correlation. Treatment with lithium or quetiapine did not moderate the effect of depression on SI. LIMITATIONS Suicide assessment was only done using an item on BISS. Patient population was not specifically chosen for high suicide risk. DISCUSSION Individuals with Bipolar II experienced more SI with lower levels of depression severity. A history of suicide predisposed patients to higher levels of SI given the same severity of depression. Reduced life satisfaction mediates the effect of depression on SI and may be a target for therapeutic interventions.
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Affiliation(s)
- Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States.
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Weilynn C Chang
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati OH and Lindner Center of HOPE, Mason, OH, United States
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, United States
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, United States
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Benjamin D Brody
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Dustin J Rabideau
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, United States
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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4
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Fung VC, Overhage LN, Sylvia LG, Reilly-Harrington NA, Kamali M, Gao K, Shelton RC, Ketter TA, Bobo WV, Thase ME, Calabrese JR, Tohen M, Deckersbach T, Nierenberg AA. Complex polypharmacy in bipolar disorder: Side effect burden, adherence, and response predictors. J Affect Disord 2019; 257:17-22. [PMID: 31299400 PMCID: PMC6711795 DOI: 10.1016/j.jad.2019.06.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/18/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Complex polypharmacy (CP) is common in bipolar disorder (BD). We assessed the associations between CP, adherence, and side effect burden, and patient traits associated with clinical improvement in relationship to CP. METHODS We conducted a secondary analysis of 482 adult BD participants in the Bipolar CHOICE trial. We examined the associations between CP (use of ≥3 BD medications) and non-adherence (missing >30% of BD medication doses in the last 30 days) and side effect burden (Frequency, Intensity and Burden of Side Effects Rating scale) using multivariate models with patient random effects. We used logistic regression to assess the patient traits associated with remission among those with majority CP use (Clinical Global Impression-Severity for BD score ≤2 for 8+ weeks). RESULTS 43% of patients had any CP and 25% had CP for the majority of the study. CP was associated with non-adherence (OR = 2.51, 95% CI [1.81, 3.50]), but not worse side effect burden. Among those with CP, 16% achieved remission; those with non-adherence, comorbid social or generalized anxiety disorder, or BD I vs. II were less likely to achieve remission among those with CP. LIMITATIONS There could be unmeasured confounding between use of CP and side effect burden or adherence. Adherence was measured by self-report, which could be subject to reporting error. CONCLUSIONS BD patients with CP were less likely to adhere to therapy, and those with worse adherence to CP were less likely to clinically respond. Clinicians should assess medication adherence prior to adding another agent to medication regimens.
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Affiliation(s)
- Vicki C. Fung
- Corresponding Author: Vicki Fung, PhD, , 100 Cambridge St. Suite 1600
- Boston, MA 02108, 617-726-5212 (phone)
- 617-726-4120 (fax)
| | - Lindsay N. Overhage
- Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | | | - Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
| | - Keming Gao
- Adult Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | | | - Terence A. Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA USA
| | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN USA
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine, Philadelphia, PA USA
| | - Joseph R. Calabrese
- Adult Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Mauricio Tohen
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Albuquerque, NM USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA USA
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Behrendt-Møller I, Madsen T, Sørensen HJ, Sylvia L, Friedman ES, Shelton RC, Bowden CL, Calabrese JR, McElroy SL, Ketter TA, Reilly-Harrington NA, Gao K, Thase M, V Bobo W, Tohen M, McInnis M, Kamali M, Kocsis JH, Deckersbach T, Köhler-Forsberg O, Nierenberg AA. Patterns of changes in bipolar depressive symptoms revealed by trajectory analysis among 482 patients with bipolar disorder. Bipolar Disord 2019; 21:350-360. [PMID: 30383333 DOI: 10.1111/bdi.12715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Depressive episodes are often prevalent among patients with bipolar disorder, but little is known regarding the differential patterns of development over time. We aimed to determine and characterize trajectories of depressive symptoms among adults with bipolar disorder during 6 months of systematic treatment. METHODS The pragmatic clinical trial, Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (CHOICE), randomized 482 outpatients with bipolar disorder to lithium or quetiapine. Depressive symptoms were rated at up to 9 visits using the Montgomery-Asberg Depression Rating Scale (MADRS). Growth mixture modeling was utilized to identify trajectories and multinomial regression analysis estimated associations with potential predictors. RESULTS Four distinct trajectories of depressive symptoms were identified. The responding class (60.3%) with a rapid reduction and subsequent low level; the partial-responding class (18.4%) with an initial reduction followed by an increase during the remaining weeks; the fluctuating class (11.6%) with a fluctuation in depressive symptoms; and the non-responding class (9.7%) with sustained moderate-severe depressive symptoms. Bipolar type I predicted membership of the non-responding class and randomization to quetiapine predicted membership of either the responding or the non-responding class. CONCLUSION Approximately 30% experienced a partial or fluctuating course, and almost 10% had a chronic course with moderate-severe depression during 6 months. Patients diagnosed with bipolar type 1 had higher risk of being categorized into a class with a worse outcome. While no differences in average overall outcomes occurred between the lithium and quetiapine groups, trajectory analysis revealed that the lithium group had more variable courses.
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Affiliation(s)
- Ida Behrendt-Møller
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Trine Madsen
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Holger Jelling Sørensen
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Louisa Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Lindner Center of HOPE, Mason, Ohio
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Noreen A Reilly-Harrington
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William V Bobo
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, New Mexico
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Masoud Kamali
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Thilo Deckersbach
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ole Köhler-Forsberg
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark
| | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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6
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Kinrys G, Bowden CL, Nierenberg AA, Hearing CM, Gold AK, Rabideau DJ, Sylvia LG, Gao K, Kamali M, Bobo WV, Tohen M, Deckersbach T, McElroy SL, Ketter TA, Shelton RC, Friedman ES, Calabrese JR, McInnis MG, Kocsis J, Thase ME, Singh V, Reilly-Harrington NA. Comorbid anxiety in bipolar CHOICE: Insights from the bipolar inventory of symptoms scale. J Affect Disord 2019; 246:126-131. [PMID: 30580198 DOI: 10.1016/j.jad.2018.12.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/08/2018] [Accepted: 12/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Approximately 86-89% of patients with BD have a comorbid anxiety disorder associated with poor quality of life and reduced likelihood of recovery from an acute mood episode. The purpose of this study is to assess the prevalence and impact of comorbid anxiety using the Bipolar Inventory of Symptoms Scale (BISS) in patients with BD who participated in a 6-month pragmatic trial. METHODS Participants (N = 482) in the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (CHOICE) study were adults with BD I or II. Anxiety diagnoses were assessed with the MINI. Global illness severity was assessed using the Clinical Global Impression-Bipolar Version. Mood symptoms and anxiety severity were assessed using the BISS. RESULTS 61% of the study sample met criteria for a current anxiety disorder. Patients with a higher BISS anxiety score at baseline had a higher overall BD illness severity, depressive severity, and manic episode severity (p < 0.001). A single cutoff value of BISS anxiety had great sensitivity, yet poor specificity for determining a comorbid anxiety diagnosis. There were no significant differences in outcomes for individuals treated for anxiety disorders with anxiolytics compared with those who were not treated with anxiolytics. LIMITATIONS Sample size limitations prevented an analysis of whether the BISS cutoff score of 10 performed differently across varied anxiety disorders. CONCLUSIONS Given its ability to identify patients with co-occurring anxiety, the BISS anxiety subscale shows clinical utility as a screening measure though its application as a clinical assessment measure may not be advisable.
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Affiliation(s)
- Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Casey M Hearing
- Department of Psychology, The George Washington University, Washington, DC, USA
| | - Alexandra K Gold
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
| | | | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James Kocsis
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, NY, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Bipolar disorder (BD) is a severe, common, and chronic affective disorder. This review highlights the BD and obesity connection and the role of treatments for obesity in this population. RECENT FINDINGS Patients with BD are at a significantly increased risk for obesity, as compared to those without BD, with obesity serving as a proxy for severity and predictor of poorer outcome. BD is characterized by substantial medical burden, with obesity-related conditions contributing to premature mortality. Pharmacotherapy for BD can cause weight gain and may be moderated by binge eating behavior. Bariatric surgery may be the most robust intervention for weight loss in patients with stable BD, but access may be limited. There is a greater need for interventions to prevent weight gain in BD, the development weight-neutral medications for BD, and more research into the role of bariatric surgery for patients with BD.
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Affiliation(s)
- Noreen A Reilly-Harrington
- Massachusetts General Hospital and Harvard Medical School, 50 Staniford Street, 4th Floor, Boston, MA, 02114, USA.
| | - Emily H Feig
- Massachusetts General Hospital and Harvard Medical School, 50 Staniford Street, 4th Floor, Boston, MA, 02114, USA
| | - Jeff C Huffman
- Massachusetts General Hospital and Harvard Medical School, 50 Staniford Street, 4th Floor, Boston, MA, 02114, USA
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Caldieraro MA, Walsh S, Deckersbach T, Bobo WV, Gao K, Ketter TA, Shelton RC, Reilly-Harrington NA, Tohen M, Calabrese JR, Thase ME, Kocsis JH, Sylvia LG, Nierenberg AA. Decreased activation and subsyndromal manic symptoms predict lower remission rates in bipolar depression. Aust N Z J Psychiatry 2018; 52:994-1002. [PMID: 29143534 DOI: 10.1177/0004867417741982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Activation encompasses energy and activity and is a central feature of bipolar disorder. However, the impact of activation on treatment response of bipolar depression requires further exploration. The aims of this study were to assess the association of decreased activation and sustained remission in bipolar depression and test for factors that could affect this association. METHODS We assessed participants with Diagnostic and Statistical Manual of Mental Disorders (4th ed) bipolar depression ( n = 303) included in a comparative effectiveness study of lithium- and quetiapine-based treatments (the Bipolar CHOICE study). Activation was evaluated using items from the Bipolar Inventory of Symptoms Scale. The selection of these items was based on a dimension of energy and interest symptoms associated with poorer treatment response in major depression. RESULTS Decreased activation was associated with lower remission rates in the raw analyses and in a logistic regression model adjusted for baseline severity and subsyndromal manic symptoms (odds ratio = 0.899; p = 0.015). The manic features also predicted lower remission (odds ratio = 0.934; p < 0.001). Remission rates were similar in the two treatment groups. CONCLUSION Decreased activation and subsyndromal manic symptoms predict lower remission rates in bipolar depression. Patients with these features may require specific treatment approaches, but new studies are necessary to identify treatments that could improve outcomes in this population.
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Affiliation(s)
- Marco Antonio Caldieraro
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Samantha Walsh
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Thilo Deckersbach
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,3 Harvard Medical School, Boston, MA, USA
| | - William V Bobo
- 4 Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Keming Gao
- 5 Mood Disorders Program, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Terence A Ketter
- 6 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Noreen A Reilly-Harrington
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,3 Harvard Medical School, Boston, MA, USA
| | - Mauricio Tohen
- 8 Department of Psychiatry and Behavioral Sciences, UNM Health Sciences Center, The University of New Mexico, Albuquerque, NM, USA
| | - Joseph R Calabrese
- 5 Mood Disorders Program, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Michael E Thase
- 9 Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - James H Kocsis
- 10 Department of Psychiatry, Weill Cornell Medical College, Ithaca, NY, USA
| | - Louisa G Sylvia
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,3 Harvard Medical School, Boston, MA, USA
| | - Andrew A Nierenberg
- 1 Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,3 Harvard Medical School, Boston, MA, USA
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9
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Hodgkin D, Stewart MT, Merrick EL, Pogue YZ, Reilly-Harrington NA, Sylvia LG, Deckersbach T, Nierenberg AA. Prevalence and predictors of physician recommendations for medication adjustment in bipolar disorder treatment. J Affect Disord 2018; 238:666-673. [PMID: 29966931 DOI: 10.1016/j.jad.2018.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Successful medication management for bipolar disorder requires clinicians to monitor and adjust regimens as needed, to achieve maximum effectiveness and patient adherence. This study aims to measure the prevalence of indications for medication adjustment at visits for bipolar disorder treatment; the frequency with which physicians recommend medication adjustments; and how strongly the indications predict the adjustments. METHODS Data included 3,094 visits for 457 patients in Bipolar CHOICE, a comparative effectiveness study that compared treatment with lithium versus quetiapine. A set of indications for adjustment was matched to reports of whether the physician recommended a medication adjustment at that visit, and what type. Associations between indication and adjustment were examined using bivariate tests and hierarchical logistic mixed effects models. RESULTS Medication adjustment was recommended at 63% of the visits where one of the indications was present, and at 53% of all visits. In multivariable analyses, adjustment was more likely to be recommended if there was an indication of non-response or side effects, for patients who started on quetiapine rather than lithium, or for patients who were female, married, employed or more educated. LIMITATIONS The study's cross-sectional design implies that observed associations could result from confounding variables. Also, the CHOICE trial placed certain restrictions on physicians' medication choices, although this is not likely to have resulted in major alterations of prescribing patterns. CONCLUSIONS Clinical inertia may help explain the lack of any adjustment recommendation at 37% of the visits where one of the indications was present. Other explanations could also apply, such as watchful waiting.
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Affiliation(s)
- Dominic Hodgkin
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
| | - Maureen T Stewart
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Elizabeth L Merrick
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Ye Zhang Pogue
- Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Harvard Medical School, and Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston, MA, USA
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10
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Caldieraro MA, Dufour S, Sylvia LG, Gao K, Ketter TA, Bobo WV, Walsh S, Janos J, Tohen M, Reilly-Harrington NA, McElroy SL, Shelton RC, Bowden CL, Deckersbach T, Nierenberg AA. Treatment outcomes of acute bipolar depressive episode with psychosis. Depress Anxiety 2018; 35:402-410. [PMID: 29329498 DOI: 10.1002/da.22716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 10/18/2017] [Accepted: 11/13/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The impact of psychosis on the treatment of bipolar depression is remarkably understudied. The primary aim of this study was to compare treatment outcomes of bipolar depressed individuals with and without psychosis. The secondary aim was to compare the effect of lithium and quetiapine, each with adjunctive personalized treatments (APTs), in the psychotic subgroup. METHODS We assessed participants with DSM-IV bipolar depression included in a comparative effectiveness study of lithium and quetiapine with APTs (the Bipolar CHOICE study). Severity was assessed by the Bipolar Inventory of Symptoms Scale (BISS) and by the Clinical Global Impression Scale-Severity-Bipolar Version (CGI-S-BP). Mixed models were used to assess the course of symptom change, and Cox regression survival analysis was used to assess the time to remission. RESULTS Psychotic features were present in 10.6% (n = 32) of the depressed participants (n = 303). Those with psychotic features had higher scores on the BISS before (75.2 ± 17.6 vs. 54.9 ± 16.3; P < .001) and after (37.2 ± 19.7 vs. 26.3 ± 18.0; P = .003) 6-month treatment. The CGI-S-BP yielded similar results. Participants with and without psychosis had similar course of symptom improvement and similar time to remission. There was no significant difference in the treatment outcomes of lithium (n = 11) and quetiapine (n = 21) among the psychotic subgroup. CONCLUSION Bipolar depressive episodes with psychotic features are more severe, and compared to nonpsychotic depressions, present a similar course of improvement. Given the small number of participants presenting psychosis, the lack of statistically significant difference between lithium- and quetiapine-based treatment of psychotic bipolar depressive episodes needs replication in a larger sample.
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Affiliation(s)
- Marco Antonio Caldieraro
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Steven Dufour
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Keming Gao
- Mood Disorders Program, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Samantha Walsh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jessica Janos
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA.,Deparment of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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11
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Tohen M, Gold AK, Sylvia LG, Montana RE, McElroy SL, Thase ME, Rabideau DJ, Nierenberg AA, Reilly-Harrington NA, Friedman ES, Shelton RC, Bowden CL, Singh V, Deckersbach T, Ketter TA, Calabrese JR, Bobo WV, McInnis MG. Corrigendum to bipolar mixed features - Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) study [Journal of Affective Disorders 217 (2017) 183-189]. J Affect Disord 2018; 225:775-777. [PMID: 28826887 DOI: 10.1016/j.jad.2017.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA.
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca E Montana
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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12
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Köhler-Forsberg O, Madsen T, Behrendt-Møller I, Sylvia L, Bowden CL, Gao K, Bobo WV, Trivedi MH, Calabrese JR, Thase M, Shelton RC, McInnis M, Tohen M, Ketter TA, Friedman ES, Deckersbach T, McElroy SL, Reilly-Harrington NA, Nierenberg AA. Trajectories of suicidal ideation over 6 months among 482 outpatients with bipolar disorder. J Affect Disord 2017; 223:146-152. [PMID: 28755622 DOI: 10.1016/j.jad.2017.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Suicidal ideation occurs frequently among individuals with bipolar disorder; however, its course and persistence over time remains unclear. We aimed to investigate 6-months trajectories of suicidal ideation among adults with bipolar disorder. METHODS The Bipolar CHOICE study randomized 482 outpatients with bipolar disorder to 6 months of lithium- or quetiapine-based treatment including other psychotropic medications as clinically indicated. Participants were asked at 9 visits about suicidal ideation using the Concise Health Risk Tracking scale. We performed latent Growth Mixture Modelling analysis to empirically identify trajectories of suicidal ideation. Multinomial logistic regression analyses were applied to estimate associations between trajectories and potential predictors. RESULTS We identified four distinct trajectories. The Moderate-Stable group represented 11.1% and was characterized by constant suicidal ideation. The Moderate-Unstable group included 2.9% with persistent thoughts about suicide with a more fluctuating course. The third (Persistent-low, 20.8%) and fourth group (Persistent-very-low, 65.1%) were characterized by low levels of suicidal ideation. Higher depression scores and previous suicide attempts (non-significant trend) predicted membership of the Moderate-Stable group, whereas randomized treatment did not. LIMITATIONS No specific treatments against suicidal ideation were included and suicidal thoughts may persist for several years. CONCLUSION More than one in ten adult outpatients with bipolar disorder had moderately increased suicidal ideation throughout 6 months of pharmacotherapy. The identified predictors may help clinicians to identify those with additional need for treatment against suicidal thoughts and future studies need to investigate whether targeted treatment (pharmacological and non-pharmacological) may improve the course of persistent suicidal ideation.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark; Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Trine Madsen
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ida Behrendt-Møller
- Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Louisa Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - William V Bobo
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH and Lindner Center of HOPE, Mason, OH, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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13
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Caldieraro MA, Sylvia LG, Dufour S, Walsh S, Janos J, Rabideau DJ, Kamali M, McInnis MG, Bobo WV, Friedman ES, Gao K, Tohen M, Reilly-Harrington NA, Ketter TA, Calabrese JR, McElroy SL, Thase ME, Shelton RC, Bowden CL, Kocsis JH, Deckersbach T, Nierenberg AA. Clinical correlates of acute bipolar depressive episode with psychosis. J Affect Disord 2017; 217:29-33. [PMID: 28365478 DOI: 10.1016/j.jad.2017.03.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/24/2017] [Accepted: 03/05/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Psychotic bipolar depressive episodes remain remarkably understudied despite being common and having a significant impact on bipolar disorder. The aim of this study is to identify the characteristics of depressed bipolar patients with current psychosis compared to those without psychosis. METHODS We used baseline data of a comparative effectiveness study of lithium and quetiapine for bipolar disorder (the Bipolar CHOICE study) to compare demographic, clinical, and functioning variables between those with and without psychotic symptoms. Of the 482 participants, 303 (62.9%) were eligible for the present study by meeting DSM-IV criteria for an acute bipolar depressive episode. Univariate analyses were conducted first, and then included in a model controlling for symptom severity. RESULTS The sample was composed mostly of women (60.7%) and the mean age was 39.5±12.1 years. Psychosis was present in 10.6% (n=32) of the depressed patients. Psychotic patients had less education, lower income, and were more frequently single and unemployed. Psychosis was also associated with a more severe depressive episode, higher suicidality, more comorbid conditions and worse functioning. Most group differences disappeared when controlling for depression severity. LIMITATIONS Only outpatients were included and the presence of psychosis in previous episodes was not assessed. CONCLUSION Psychosis during bipolar depressive episodes is present even in an outpatient sample. Psychotic, depressed patients have worse illness outcomes, but future research is necessary to confirm if these outcomes are only associated with the severity of the disorder or if some of them are independent of it.
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Affiliation(s)
- Marco Antonio Caldieraro
- Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Steven Dufour
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha Walsh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jessica Janos
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Masoud Kamali
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - Keming Gao
- Mood Disorders Program, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA USA
| | - Joseph R Calabrese
- Mood Disorders Program, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, Ithaca, NY, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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14
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Tohen M, Gold AK, Sylvia LG, Montana RE, McElroy SL, Thase ME, Rabideau DJ, Nierenberg AA, Reilly-Harrington NA, Friedman ES, Shelton RC, Bowden CL, Singh V, Deckersbach T, Ketter TA, Calabrese JR, Bobo WV, McInnis MG. Bipolar mixed features - Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) study. J Affect Disord 2017; 217:183-189. [PMID: 28411507 DOI: 10.1016/j.jad.2017.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/09/2017] [Accepted: 03/28/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND DSM-5 changed the criteria from DSM-IV for mixed features in mood disorder episodes to include non-overlapping symptoms of depression and hypomania/mania. It is unknown if, by changing these criteria, the same group would qualify for mixed features. We assessed how those meeting DSM-5 criteria for mixed features compare to those meeting DSM-IV criteria. METHODS We analyzed data from 482 adult bipolar patients in Bipolar CHOICE, a randomized comparative effectiveness trial. Bipolar diagnoses were confirmed through the MINI International Neuropsychiatric Interview (MINI). Presence and severity of mood symptoms were collected with the Bipolar Inventory of Symptoms Scale (BISS) and linked to DSM-5 and DSM-IV mixed features criteria. Baseline demographics and clinical variables were compared between mood episode groups using ANOVA for continuous variables and chi-square tests for categorical variables. RESULTS At baseline, the frequency of DSM-IV mixed episodes diagnoses obtained with the MINI was 17% and with the BISS was 20%. Using DSM-5 criteria, 9% of participants met criteria for hypomania/mania with mixed features and 12% met criteria for a depressive episode with mixed features. Symptom severity was also associated with increased mixed features with a high rate of mixed features in patients with mania/hypomania (63.8%) relative to those with depression (8.0%). LIMITATIONS Data on mixed features were collected at baseline only and thus do not reflect potential patterns in mixed features within this sample across the study duration. CONCLUSIONS The DSM-5 narrower, non-overlapping definition of mixed episodes resulted in fewer patients who met mixed criteria compared to DSM-IV.
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Affiliation(s)
- Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA.
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca E Montana
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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15
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Reilly-Harrington NA, Sylvia LG, Rabideau DJ, Gold AK, Deckersbach T, Bowden CL, Bobo WV, Singh V, Calabrese JR, Shelton RC, Friedman ES, Thase ME, Kamali M, Tohen M, McInnis MG, McElroy SL, Ketter TA, Kocsis JH, Kinrys G, Nierenberg AA. Tracking medication changes to assess outcomes in comparative effectiveness research: A bipolar CHOICE study. J Affect Disord 2016; 205:159-164. [PMID: 27449548 DOI: 10.1016/j.jad.2016.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/23/2016] [Accepted: 07/02/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Comparative effectiveness research uses multiple tools, but lacks outcome measures to assess large electronic medical records and claims data. Aggregate changes in medications in response to clinical need may serve as a surrogate outcome measure. We developed the Medication Recommendation Tracking Form (MRTF) to record the frequency, types, and reasons for medication adjustments in order to calculate Necessary Clinical Adjustments (NCAs), medication adjustments to reduce symptoms, maximize treatment response, or address problematic side effects. METHODS The MRTF was completed at every visit for 482 adult patients in Bipolar CHOICE, a 6-month randomized comparative effectiveness trial. RESULTS Responders had significantly fewer NCAs compared to non-responders. NCAs predicted subsequent response status such that every additional NCA during the previous visit decreased a patient's odds of response by approximately 30%. Patients with more severe symptoms had a greater number of NCAs at the subsequent visit. Patients with a comorbid anxiety disorder demonstrated a significantly higher rate of NCAs per month than those without a comorbid anxiety disorder. Patients with greater frequency, intensity, and interference of side effects had higher rates of NCAs. Participants with fewer NCAs reported a higher quality of life and decreased functional impairment. LIMITATIONS The MRTF has not been examined in community clinic settings and did not predict response more efficiently than the Clinical Global Impression-Bipolar Version (CGI-BP). CONCLUSIONS The MRTF is a feasible proxy of clinical outcome, with implications for clinical training and decision-making. Analyses of big data could use changes in medications as a surrogate outcome measure.
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Affiliation(s)
- Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico, Health Sciences Center, Albuquerque, NM, United States
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, United States; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, NY, United States
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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16
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Reilly-Harrington NA, Shelton RC, Kamali M, Rabideau DJ, Shesler LW, Trivedi MH, McElroy SL, Sylvia LG, Bowden CL, Ketter TA, Calabrese JR, Thase ME, Bobo WV, Deckersbach T, Tohen M, McInnis MG, Kocsis JH, Gold AK, Singh V, Finkelstein DM, Kinrys G, Nierenberg AA. A tool to predict suicidal ideation and behavior in bipolar disorder: The Concise Health Risk Tracking Self-Report. J Affect Disord 2016; 192:212-8. [PMID: 26748736 PMCID: PMC9900871 DOI: 10.1016/j.jad.2015.12.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/11/2015] [Accepted: 12/27/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Few brief, self-report measures exist that can reliably predict adverse suicidality outcomes in patients with BD. This study utilized the Concise Health Risk Tracking Self-Report (CHRT) to assess suicidality in patients with BD and examined its psychometric performance, clinical correlates, and prospective value in predicting adverse events related to suicidality. METHODS The CHRT was administered at baseline and follow-up to 482 adult patients in Bipolar CHOICE, a 6-month randomized comparative effectiveness trial. The Columbia Suicide Severity Rating Scale (CSSRS) was used at baseline to assess lifetime history of suicide attempts and related behaviors. Clinician-rated measures of mood (Bipolar Inventory of Symptoms Scale) and bipolar symptoms (Clinical Global Impressions-Bipolar Version) were conducted at baseline and follow-up. RESULTS The CHRT showed excellent internal consistency and construct validity and was highly correlated with clinician ratings of depression, anxiety, and overall functioning at baseline and throughout the study. Baseline CHRT scores significantly predicted risk of subsequent suicidality-related Serious Adverse Events (sSAEs), after controlling for mood and comorbidity. Specifically, the hazard of a sSAE increased by 76% for every 10-point increase in baseline CHRT score. Past history of suicide attempts and related behaviors, as assessed by the CSSRS, did not predict subsequent sSAEs. LIMITATIONS The CSSRS was used to assess static risk factors in terms of past suicidal behaviors and may have been a more powerful predictor over longer-term follow-up. CONCLUSIONS The CHRT offers a quick and robust self-report tool for assessing suicidal risk and has important implications for future research and clinical practice.
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Affiliation(s)
- Noreen A. Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA,Correspondence to: Massachusetts General Hospital, Department of Psychiatry, Bipolar Clinic & Research Program, 50 Staniford Street, Suite 580, Boston, MA 02114, USA. (N.A. Reilly-Harrington)
| | - Richard C. Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | | - Leah W. Shesler
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Madhukar H. Trivedi
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Susan L. McElroy
- Lindner Center of HOPE, Mason, OH, USA,Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Charles L. Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Terence A. Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R. Calabrese
- Bipolar Disorders Research Center, University Hospital’s Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA
| | - Melvin G. McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James H. Kocsis
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, NY, USA Article history:
| | - Alexandra K. Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | | | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Andrew A. Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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17
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McElroy SL, Kemp DE, Friedman ES, Reilly-Harrington NA, Sylvia LG, Calabrese JR, Rabideau DJ, Ketter TA, Thase ME, Singh V, Tohen M, Bowden CL, Bernstein EE, Brody BD, Deckersbach T, Kocsis JH, Kinrys G, Bobo WV, Kamali M, McInnis MG, Leon AC, Faraone S, Nierenberg AA, Shelton RC. Obesity, but not metabolic syndrome, negatively affects outcome in bipolar disorder. Acta Psychiatr Scand 2016; 133:144-153. [PMID: 26114830 PMCID: PMC4844561 DOI: 10.1111/acps.12460] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Examine the effects of obesity and metabolic syndrome on outcome in bipolar disorder. METHOD The Comparative Effectiveness of a Second Generation Antipsychotic Mood Stabilizer and a Classic Mood Stabilizer for Bipolar Disorder (Bipolar CHOICE) study randomized 482 participants with bipolar disorder in a 6-month trial comparing lithium- and quetiapine-based treatment. Baseline variables were compared between groups with and without obesity, with and without abdominal obesity, and with and without metabolic syndrome respectively. The effects of baseline obesity, abdominal obesity, and metabolic syndrome on outcomes were examined using mixed effects linear regression models. RESULTS At baseline, 44.4% of participants had obesity, 48.0% had abdominal obesity, and 27.3% had metabolic syndrome; neither obesity, nor abdominal obesity, nor metabolic syndrome were associated with increased global severity, mood symptoms, or suicidality, or with poorer functioning or life satisfaction. Treatment groups did not differ on prevalence of obesity, abdominal obesity, or metabolic syndrome. By contrast, among the entire cohort, obesity was associated with less global improvement and less improvement in total mood and depressive symptoms, suicidality, functioning, and life satisfaction after 6 months of treatment. Abdominal obesity was associated with similar findings. Metabolic syndrome had no effect on outcome. CONCLUSION Obesity and abdominal obesity, but not metabolic syndrome, were associated with less improvement after 6 months of lithium- or quetiapine-based treatment.
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Affiliation(s)
- Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH and Lindner Center of HOPE, Mason, OH, USA
| | - David E Kemp
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - Dustin J Rabideau
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Emily E Bernstein
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin D Brody
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Gustavo Kinrys
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Masoud Kamali
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C. Leon
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Stephen Faraone
- Department of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
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18
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Deckersbach T, Nierenberg AA, McInnis MG, Salcedo S, Bernstein EE, Kemp DE, Shelton RC, McElroy SL, Sylvia LG, Kocsis JH, Bobo WV, Friedman ES, Singh V, Tohen M, Bowden CL, Ketter TA, Calabrese JR, Thase ME, Reilly-Harrington NA, Rabideau DJ, Kinrys G, Kamali M. Baseline disability and poor functioning in bipolar disorder predict worse outcomes: results from the Bipolar CHOICE study. J Clin Psychiatry 2016; 77:100-8. [PMID: 26845265 DOI: 10.4088/jcp.14m09210] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 03/13/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine the effects of treatment on functioning impairments and quality of life and assess baseline functioning and employment status as predictors of treatment response in symptomatic individuals from the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (Bipolar CHOICE) study. METHOD Bipolar CHOICE was an 11-site, 6-month randomized effectiveness study comparing lithium to quetiapine, each with adjunctive personalized treatments (APTs). We examined post hoc (1) the effects of treatment on functioning, (2) how changes in functioning differed between treatment responders and nonresponders, and (3) whether functioning and employment status mediated treatment response in 482 participants with DSM-IV-TR bipolar I or II disorder from September 2010 to September 2013. RESULTS Treatment was associated with significant improvements in functioning and quality of life, regardless of treatment group (P values < .0001). Responders showed greater improvements in quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire P values < .05) and functioning (Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool P values < .05) than nonresponders. Unemployed or disabled participants at baseline had significantly greater illness severity at baseline than employed participants (P values < .05). Over the study duration, employed participants reported greater improvements in physical health and quality of life in leisure activities than both unemployed and disabled participants (P values < .05). Individuals who saw greater improvement in functioning and quality of life tended to show greater improvements in depressive and anxiety symptoms (P values ≤ .0001), as well as overall illness severity (P values < .001). Early (8 weeks) and very early (4 weeks) clinical changes in mood symptoms predicted changes in functioning and quality of life at 6 months (P values < .001). CONCLUSIONS Prior disability status was associated with a worse treatment response and prospective illness course. Results implicate functioning and employment status as important markers of illness severity and likelihood of recovery in bipolar disorder, suggesting that interventions that target functional impairment may improve outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier for the Bipolar CHOICE study: NCT01331304.
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Affiliation(s)
- Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, 50 Staniford St, Ste 580, Boston, MA 02114
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19
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Nierenberg AA, McElroy SL, Friedman ES, Ketter TA, Shelton RC, Deckersbach T, McInnis MG, Bowden CL, Tohen M, Kocsis JH, Calabrese JR, Kinrys G, Bobo WV, Singh V, Kamali M, Kemp D, Brody B, Reilly-Harrington NA, Sylvia LG, Shesler LW, Bernstein EE, Schoenfeld D, Rabideau DJ, Leon AC, Faraone S, Thase ME. Bipolar CHOICE (Clinical Health Outcomes Initiative in Comparative Effectiveness): a pragmatic 6-month trial of lithium versus quetiapine for bipolar disorder. J Clin Psychiatry 2016; 77:90-9. [PMID: 26845264 DOI: 10.4088/jcp.14m09349] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 12/19/2014] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bipolar disorder is among the 10 most disabling medical conditions worldwide. While lithium has been used extensively for bipolar disorder since the 1970s, second-generation antipsychotics (SGAs) have supplanted lithium since 1998. To date, no randomized comparative-effectiveness study has compared lithium and any SGA. METHOD Within the duration of the study (September 2010-September 2013), participants with bipolar I or II disorder (DSM-IV-TR) were randomized for 6 months to receive lithium (n = 240) or quetiapine (n = 242). Lithium and quetiapine were combined with other medications for bipolar disorder consistent with typical clinical practice (adjunctive personalized treatment [APT], excluding any SGA for the lithium + APT group and excluding lithium or any other SGA for the quetiapine + APT group). Coprimary outcome measures included Clinical Global Impressions-Efficacy Index (CGI-EI) and necessary clinical adjustments, which measured number of changes in adjunctive personalized treatment. Secondary measures included a full range of symptoms, cardiovascular risk, functioning, quality of life, suicidal ideation and behavior, and adverse events. RESULTS Participants improved across all measures, and over 20% had a sustained response. Primary (CGI-EI, P = .59; necessary clinical adjustments, P = .15) and secondary outcome changes were not statistically significantly different between the 2 groups. For participants with greater manic/hypomanic symptoms, CGI-EI changes were significantly more favorable with quetiapine + APT (P = .02). Among those with anxiety, the lithium + APT group had fewer necessary clinical adjustments per month (P = .02). Lithium was better tolerated than quetiapine in terms of the burden of side effects frequency (P = .05), intensity (P = .01), and impairment (P = .01). CONCLUSIONS Despite adequate power to detect clinically meaningful differences, we found outcomes with lithium + APT and quetiapine + APT were not significantly different across 6 months of treatment for bipolar disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier for the Bipolar CHOICE study: NCT01331304.
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20
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Ostacher MJ, Nierenberg AA, Rabideau D, Reilly-Harrington NA, Sylvia LG, Gold AK, Shesler LW, Ketter TA, Bowden CL, Calabrese JR, Friedman ES, Iosifescu DV, Thase ME, Leon AC, Trivedi MH. A clinical measure of suicidal ideation, suicidal behavior, and associated symptoms in bipolar disorder: Psychometric properties of the Concise Health Risk Tracking Self-Report (CHRT-SR). J Psychiatr Res 2015; 71:126-33. [PMID: 26476489 PMCID: PMC6778403 DOI: 10.1016/j.jpsychires.2015.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 08/11/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE People with bipolar disorder are at high risk of suicide, but no clinically useful scale has been validated in this population. The aim of this study was to evaluate the psychometric properties in bipolar disorder of the 7- and 12-item versions of the Concise Health Risk Tracking Self-Report (CHRT-SR), a scale measuring suicidal ideation, suicidal behavior, and associated symptoms. METHODS The CHRT was administered to 283 symptomatic outpatients with bipolar I or II disorder who were randomized to receive lithium plus optimized personalized treatment (OPT), or OPT without lithium in a six month longitudinal comparative effectiveness trial. Participants were assessed using structured diagnostic interviews, clinician-rated assessments, and self-report questionnaires. RESULTS The internal consistency (Cronbach α) was 0.80 for the 7-item CHRT-SR and 0.90 for the 12-item CHRT-SR with a consistent factor structure, and three independent factors (current suicidal thoughts and plans, hopelessness, and perceived lack of social support) for the 7-item version. CHRT-SR scores are correlated with measures of depression, functioning, and quality of life, but not with mania scores. CONCLUSIONS The 7- and 12-item CHRT-SR both had excellent psychometric properties in a sample of symptomatic subjects with bipolar disorder. The scale is highly correlated with depression, functioning, and quality of life, but not with mania. Future research is needed to determine whether the CHRT-SR will be able to predict suicide attempts in clinical practice.
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Affiliation(s)
- Michael J. Ostacher
- VA Palo Alto Health Care System, Palo Alto, CA, USA,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author. VA Palo Alto Health Care System 3801 Miranda Ave, Mail Code 151-T Palo Alto, CA 94304, USA. (M.J. Ostacher)
| | - Andrew A. Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Dustin Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Noreen A. Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Louisa G. Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Alexandra K. Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Leah W. Shesler
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Terence A. Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles L. Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Joseph R. Calabrese
- Bipolar Disorders Research Center, University Hospital’s Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Edward S. Friedman
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dan V. Iosifescu
- Department of Psychiatry, Icahn School of medicine at Mount Sinai, New York, NY, USA
| | - Michael E. Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, USA
| | - Andrew C. Leon
- Biostatistics in Psychiatry & Public Health, Weill Cornell Medical College, New York, NY, USA
| | - Madhukar H. Trivedi
- Department of Psychiatry, The University of Texas Southwestern Medical Center, USA
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21
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Arnold JG, Salcedo S, Ketter TA, Calabrese JR, Rabideau DJ, Nierenberg AA, Bazan M, Leon AC, Friedman ES, Iosifescu D, Sylvia LG, Ostacher M, Thase M, Reilly-Harrington NA, Bowden CL. An exploratory study of responses to low-dose lithium in African Americans and Hispanics. J Affect Disord 2015; 178:224-8. [PMID: 25827507 PMCID: PMC4397978 DOI: 10.1016/j.jad.2015.02.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 02/19/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Few prospective studies examine the impact of ethnicity or race on outcomes with lithium for bipolar disorder. This exploratory study examines differences in lithium response and treatment outcomes in Hispanics, African Americans, and non-Hispanic whites with bipolar disorder in the Lithium Treatment Moderate Dose Use Study (LiTMUS). METHODS LiTMUS was a six-site randomized controlled trial of low-dose lithium added to optimized treatment (OPT; personalized, evidence-based pharmacotherapy) vs. OPT alone in outpatients with bipolar disorder. Of 283 participants, 47 African Americans, 39 Hispanics, and 175 non-Hispanic whites were examined. We predicted minority groups would have more negative medication attitudes and higher attrition rates, but better clinical outcomes. RESULTS African Americans in the lithium group improved more on depression and life functioning compared to whites over the 6 month study. African Americans in the OPT only group had marginal improvement on depression symptoms. For Hispanics, satisfaction with life did not significantly improve in the OPT only group, in contrast to whites and African Americans who improved over time on all measures. Attitudes toward medications did not differ across ethnic/racial groups. CONCLUSIONS African Americans show some greater improvements with lithium than non-Hispanic whites, and Hispanics showed more consistent improvements in the lithium group. The impact of low-dose lithium should be studied in a larger sample as there may be particular benefit for African Americans and Hispanics. Given that the control group (regardless of ethnicity/race) had significant improvements, optimized treatment may be beneficial for any ethnic group.
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Affiliation(s)
| | - Stephanie Salcedo
- Massachusetts General Hospital - Bipolar Clinic and Research Program
| | | | | | | | | | - Melissa Bazan
- University of Texas Health Science Center San Antonio
| | - Andrew C. Leon
- Massachusetts General Hospital - Bipolar Clinic and Research Program
| | | | | | - Louisa G. Sylvia
- Massachusetts General Hospital - Bipolar Clinic and Research Program
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Sylvia LG, Thase ME, Reilly-Harrington NA, Salcedo S, Brody B, Kinrys G, Kemp D, Shelton RC, McElroy SL, Kocsis JH, Bobo WV, Kamali M, McInnis M, Friedman E, Tohen M, Bowden CL, Ketter TA, Singh V, Calabrese J, Nierenberg AA, Rabideau DJ, Elson CM, Deckersbach T. Psychotherapy use in bipolar disorder: Association with functioning and illness severity. Aust N Z J Psychiatry 2015; 49:453-61. [PMID: 25680360 DOI: 10.1177/0004867415569803] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study examines characteristics of individuals with bipolar disorder who sought psychotherapy versus those who did not. METHODS Bipolar CHOICE was an 11-site comparative effectiveness study of lithium versus quetiapine in symptomatic outpatients (N = 482) with bipolar disorder. At baseline, participants' psychotherapy use within the past 3 months, mood, functioning, and overall health were assessed. Logistic regressions were used to test whether psychotherapy users and non-users differed on various demographic and clinical variables at baseline. Mixed-effects regression was used to determine whether psychotherapy groups differed on response to treatment over the 6-month study. Kaplan-Meier plots and log-rank tests were employed to test whether there were any differences in time to recovery (CGI-BP ≤ 2 for at least 8 weeks) between the groups. RESULTS Thirty one percent of participants reported using psychotherapy services. Psychotherapy users reported greater medication side effect burden than non-users and were more likely to have moderate to high suicide risk and at least one anxiety disorder. Participants not utilizing medications or psychotherapy had greater mania symptom severity, were younger, and less educated than medication only users. Medication only users were more likely to be married than the other participants. CONCLUSIONS These data suggest that a minority of individuals with bipolar disorder attend psychotherapy services, and those that do have greater illness burden.
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Affiliation(s)
- Louisa G Sylvia
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | | | | | | | | | - Gustavo Kinrys
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | - David Kemp
- Case Western Reserve University, Cleveland, USA
| | | | - Susan L McElroy
- The Lindner Center of HOPE, Mason, Ohio and University of Cincinnati College of Medicine, Cincinnati, USA
| | | | | | | | | | | | - Mauricio Tohen
- University of New Mexico, Health Sciences Center, Albuquerque, USA
| | | | | | - Vivek Singh
- University of Texas Health Science, San Antonio, USA
| | | | - Andrew A Nierenberg
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
| | | | | | - Thilo Deckersbach
- Massachusetts General Hospital, Boston, USA Harvard Medical School, Boston, USA
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23
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Sylvia LG, Shelton RC, Kemp DE, Bernstein EE, Friedman ES, Brody BD, McElroy SL, Singh V, Tohen M, Bowden CL, Ketter TA, Deckersbach T, Thase ME, Reilly-Harrington NA, Nierenberg AA, Rabideau DJ, Kinrys G, Kocsis JH, Bobo WV, Kamali M, McInnis MG, Calabrese JR. Medical burden in bipolar disorder: findings from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE). Bipolar Disord 2015; 17:212-23. [PMID: 25130321 DOI: 10.1111/bdi.12243] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 04/15/2014] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Individuals with bipolar disorder have high rates of other medical comorbidity, which is associated with higher mortality rates and worse course of illness. The present study examined common predictors of medical comorbidity. METHODS The Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study (Bipolar CHOICE) enrolled 482 participants with bipolar I or bipolar II disorder in a six-month, randomized comparative effectiveness trial. Baseline assessments included current and lifetime DSM-IV-TR diagnoses, demographic information, psychiatric and medical history, severity of psychiatric symptoms, level of functioning, and a fasting blood draw. Medical comorbidities were categorized into two groups: cardiometabolic (e.g., diabetes, hyperlipidemia, and metabolic syndrome) and non-cardiovascular (e.g., seizures, asthma, and cancer). Additionally, we looked at comorbid substance use (e.g., smoking and drug dependence). RESULTS We found that 96.3% of participants had at least one other medical comorbidity. Older age predicted a greater likelihood of having a cardiometabolic condition. Early age of onset of bipolar symptoms was associated with a lower chance of having a cardiometabolic condition, but a greater chance of having other types of medical comorbidity. Additional predictors of other medical comorbidities in bipolar disorder included more time spent depressed, less time spent manic/hypomanic, and longer duration of illness. Medications associated with weight gain were associated with low high-density lipoprotein and abnormal triglycerides. CONCLUSIONS There appears to be a substantial medical burden associated with bipolar disorder, highlighting the need for collaborative care among psychiatric and general medical providers to address both psychiatric and other medical needs concomitantly in this group of patients.
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Affiliation(s)
- Louisa G Sylvia
- Bipolar Clinic and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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24
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Bobo WV, Reilly-Harrington NA, Ketter TA, Brody BD, Kinrys G, Kemp DE, Shelton RC, McElroy SL, Sylvia LG, Kocsis JH, McInnis MG, Friedman ES, Singh V, Tohen M, Bowden CL, Deckersbach T, Calabrese JR, Thase ME, Nierenberg AA, Rabideau DJ, Schoenfeld DA, Faraone SV, Kamali M. Effect of adjunctive benzodiazepines on clinical outcomes in lithium- or quetiapine-treated outpatients with bipolar I or II disorder: results from the Bipolar CHOICE trial. J Affect Disord 2014; 161:30-5. [PMID: 24751304 PMCID: PMC4113323 DOI: 10.1016/j.jad.2014.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 02/28/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the longer-term effects of adjunctive benzodiazepines on symptom response during treatment in patients with bipolar disorders. METHODS The study sample consisted of 482 patients with bipolar I or II disorder enrolled in a 6-month, randomized, multi-site comparison of lithium- and quetiapine-based treatment. Changes in clinical measures (BISS total and subscales, CGI-BP, and CGI-Efficacy Index) were compared between participants who did and did not receive benzodiazepine treatment at baseline or during follow-up. Selected outcomes were also compared between patients who did and did not initiate benzodiazepines during follow-up using stabilized inverse probability weighted analyses. RESULTS Significant improvement in all outcome measures occurred within each benzodiazepine exposure group. Benzodiazepine users (at baseline or during follow-up) experienced significantly less improvement in BISS total, BISS irritability, and CGI-BP scores than did benzodiazepine non-users. There were no significant differences in these measures between patients who did and did not initiate benzodiazepines during follow-up in the weighted analyses. There was no significant effect of benzodiazepine use on any outcome measure in patients with comorbid anxiety or substance use disorders. LIMITATIONS This is a secondary analysis of data from a randomized effectiveness trial that was not designed to address differential treatment response according to benzodiazepine use. CONCLUSIONS Adjunctive benzodiazepines may not significantly affect clinical outcome in lithium- or quetiapine-treated patients with bipolar I or II disorder over 6 months, after controlling for potential confounding factors.
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Affiliation(s)
- William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA,Correspondence to: William V. Bobo, MD, MPH, 200 First Street SW, Generose 2A, Rochester, MN 55904, , Telephone: 507-255-9412
| | | | | | - Benjamin D. Brody
- Weill Cornell Medical College of Cornell University, New York, NY, USA
| | | | - David E. Kemp
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Richard C. Shelton
- University of Alabama-Birmingham School of Medicine, Birmingham, AL, USA
| | - Susan L. McElroy
- Lindner Center for HOPE, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - James H. Kocsis
- Weill Cornell Medical College of Cornell University, New York, NY, USA
| | | | | | - Vivek Singh
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Mauricio Tohen
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Charles L. Bowden
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | | | - Michael E. Thase
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | - Stephen V. Faraone
- Upstate Medical University, State University of New York, Syracuse, NY, USA
| | - Masoud Kamali
- University of Michigan School of Medicine, Ann Arbor, MI, USA
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Sylvia LG, Reilly-Harrington NA, Leon AC, Kansky CI, Calabrese JR, Bowden CL, Ketter TA, Friedman ES, Iosifescu DV, Thase ME, Ostacher MJ, Keyes M, Rabideau D, Nierenberg AA. Medication adherence in a comparative effectiveness trial for bipolar disorder. Acta Psychiatr Scand 2014; 129:359-65. [PMID: 24117232 PMCID: PMC3975824 DOI: 10.1111/acps.12202] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2013] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Louisa G. Sylvia
- Massachusetts General Hospital, Boston, MA USA,Corresponding author: Louisa G. Sylvia, PhD, 50 Staniford St, Suite 580, Boston, MA, , Phone: 617-643-4804, Fax: 617-643-6768
| | | | | | | | | | | | | | | | | | | | | | | | - Dustin Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA
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26
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Nierenberg AA, Sylvia LG, Leon AC, Reilly-Harrington NA, Shesler LW, McElroy SL, Friedman ES, Thase ME, Shelton RC, Bowden CL, Tohen M, Singh V, Deckersbach T, Ketter TA, Kocsis JH, McInnis MG, Schoenfeld D, Bobo WV, Calabrese JR. Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE): a pragmatic trial of complex treatment for a complex disorder. Clin Trials 2014; 11:114-27. [PMID: 24346608 PMCID: PMC4495881 DOI: 10.1177/1740774513512184] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Classic and second-generation antipsychotic mood stabilizers are recommended for treatment of bipolar disorder, yet there are no randomized comparative effectiveness studies that have examined the 'real-world' advantages and disadvantages of these medications. PURPOSE We describe the strategic decisions in the design of the Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE). This article outlines the key issues and solutions the investigators faced in designing a clinical trial that would maximize generalizability and inform real-world clinical treatment of bipolar disorder. METHODS Bipolar CHOICE was a 6-month, multi-site, prospective, randomized clinical trial of outpatients with bipolar disorder. This study compares the effectiveness of quetiapine versus lithium, each with adjunctive personalized treatments (APTs). The co-primary outcomes selected are the overall benefits and harms of the study medications (as measured by the Clinical Global Impression-Efficacy Index) and the Necessary Clinical Adjustments (a measure of the number of medication changes). Secondary outcomes are continuous measures of mood, the Framingham General Cardiovascular Risk Score, and the Longitudinal Interval Follow up Evaluation Range of Impaired Functioning Tool (LIFE-RIFT). RESULTS The final study design consisted of a single-blind, randomized comparative effectiveness trial of quetiapine versus lithium, plus APT, across 10 sites. Other important study considerations included limited exclusion criteria to maximize generalizability, flexible dosing of APT medications to mimic real-world treatment, and an intent-to-treat analysis plan. In all, 482 participants were randomized to the study, and 364 completed the study. LIMITATIONS The potential limitations of the study include the heterogeneity of APT, selection of study medications, lack of a placebo-control group, and participants' ability to pay for study medications. CONCLUSION We expect that this study will inform our understanding of the benefits and harms of lithium, a classic mood stabilizer, compared to quetiapine, a second-generation antipsychotic with broad-spectrum activity in bipolar disorder, and will provide an example of a well-designed and well-conducted randomized comparative effectiveness clinical trial.
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Kemp DE, Sylvia LG, Calabrese JR, Nierenberg AA, Thase ME, Reilly-Harrington NA, Ostacher MJ, Leon AC, Ketter TA, Friedman ES, Bowden CL, Pencina M, Iosifescu DV. General medical burden in bipolar disorder: findings from the LiTMUS comparative effectiveness trial. Acta Psychiatr Scand 2014; 129:24-34. [PMID: 23465084 PMCID: PMC3789858 DOI: 10.1111/acps.12101] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study examined general medical illnesses and their association with clinical features of bipolar disorder. METHOD Data were cross-sectional and derived from the Lithium Treatment - Moderate Dose Use Study (LiTMUS), which randomized symptomatic adults (n = 264 with available medical comorbidity scores) with bipolar disorder to moderate doses of lithium plus optimized treatment (OPT) or to OPT alone. Clinically significant high and low medical comorbidity burden were defined as a Cumulative Illness Rating Scale (CIRS) score ≥4 and <4 respectively. RESULTS The baseline prevalence of significant medical comorbidity was 53% (n = 139). Patients with high medical burden were more likely to present in a major depressive episode (P = .04), meet criteria for obsessive-compulsive disorder (P = .02), and experience a greater number of lifetime mood episodes (P = 0.02). They were also more likely to be prescribed a greater number of psychotropic medications (P = .002). Sixty-nine per cent of the sample was overweight or obese as defined by body mass index (BMI), with African Americans representing the racial group with the highest proportion of stage II obesity (BMI ≥35; 31%, n = 14). CONCLUSION The burden of comorbid medical illnesses was high in this generalizable sample of treatment-seeking patients and appears associated with worsened course of illness and psychotropic medication patterns.
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Affiliation(s)
- David E. Kemp
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
| | | | - Joseph R. Calabrese
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH USA
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28
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Friedman ES, Calabrese JR, Ketter TA, Leon AC, Thase ME, Bowden CL, Sylvia LG, Ostracher MJ, Severe J, Iosifescu DV, Nierenberg AA, Reilly-Harrington NA. Using comparative effectiveness design to improve the generalizability of bipolar treatment trials data: contrasting LiTMUS baseline data with pre-existing placebo controlled trials. J Affect Disord 2014; 152-154:97-104. [PMID: 23845385 DOI: 10.1016/j.jad.2013.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/11/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Efficacy-based double-blind placebo controlled trials were conducted to establish efficacy and safety for FDA approval. Such designs allowed and encouraged the use of exclusion criteria to improve assay sensitivity and internal validity. The LiTMUS trial increased the representation of real-world individuals with bipolar disorder despite the acknowledgment that this compromises assay sensitivity. METHOD To maximize generalizability, LiTMUS used broad inclusion and narrow exclusion criteria: participants experiencing mood symptoms of sufficient intensity (at least with a CGI-BP ≥ 3) that would warrant a change in treatment, and that lithium treatment would be a reasonable therapeutic option if they were randomized to it. At baseline demographic, illness, clinical, and treatment characteristics were collected. The LiTMUS study design and baseline sociodemographic data were compared to previous efficacy studies. RESULTS As compared to the previous bipolar disorder efficacy studies, LiTMUS participants were of similar age, gender, weight and illness severity; however LiTMUS participants were more racially and ethnically representative of the general population, had a greater number of mood episodes in the past 12 months, more Axis I/II comorbidity, a greater number of prior suicide attempts, and higher functional capacity. CONCLUSIONS LiTMUS was a comparative effectiveness trial that had broad inclusion and minimal exclusion criteria that produced a more representative sample comprised of real-world participants. This design enables the results of the LiTMUS study to be a more representative of real world pharmacotherapuetic outcomes. LIMITATIONS Limitations include possible selection bias, paucity of sociodemographic data in efficacy trials, and lack of a placebo.
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Affiliation(s)
- E S Friedman
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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29
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Sylvia LG, Friedman ES, Kocsis JH, Bernstein EE, Brody BD, Kinrys G, Kemp DE, Shelton RC, McElroy SL, Bobo WV, Kamali M, McInnis MG, Tohen M, Bowden CL, Ketter TA, Deckersbach T, Calabrese JR, Thase ME, Reilly-Harrington NA, Singh V, Rabideau DJ, Nierenberg AA. Association of exercise with quality of life and mood symptoms in a comparative effectiveness study of bipolar disorder. J Affect Disord 2013; 151:722-727. [PMID: 23993440 DOI: 10.1016/j.jad.2013.07.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Individuals with bipolar disorder lead a sedentary lifestyle associated with worse course of illness and recurrence of symptoms. Identifying potentially modifiable predictors of exercise frequency could lead to interventions with powerful consequences on the course of illness and overall health. METHODS The present study examines baseline reports of exercise frequency of bipolar patients in a multi-site comparative effectiveness study of a second generation antipsychotic (quetiapine) versus a classic mood stabilizer (lithium). Demographics, quality of life, functioning, and mood symptoms were assessed. RESULTS Approximately 40% of participants reported not exercising regularly (at least once per week). Less frequent weekly exercise was associated with higher BMI, more time depressed, more depressive symptoms, and lower quality of life and functioning. In contrast, more frequent exercise was associated with experiencing more mania in the past year and more current manic symptoms. LIMITATIONS Exercise frequency was measured by self-report and details of the exercise were not collected. Analyses rely on baseline data, allowing only for association analyses. Directionality and predictive validity cannot be determined. Data were collected in the context of a clinical trial and thus, it is possible that the generalizability of the findings could be limited. CONCLUSION There appears to be a mood-specific relationship between exercise frequency and polarity such that depression is associated with less exercise and mania with more exercise in individuals with bipolar disorder. This suggests that increasing or decreasing exercise could be a targeted intervention for patients with depressive or mood elevation symptoms, respectively.
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Affiliation(s)
| | | | - James H Kocsis
- Weill Cornell Medical College of Cornell University, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michael E Thase
- Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Vivek Singh
- University of Texas Health Science Center at San Antonio, USA
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Reilly-Harrington NA, Sylvia LG, Leon AC, Shesler LW, Ketter TA, Bowden CL, Calabrese JR, Friedman ES, Ostacher MJ, Iosifescu DV, Rabideau DJ, Thase ME, Nierenberg AA. The Medication Recommendation Tracking Form: a novel tool for tracking changes in prescribed medication, clinical decision making, and use in comparative effectiveness research. J Psychiatr Res 2013; 47:1686-93. [PMID: 23911057 DOI: 10.1016/j.jpsychires.2013.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 06/12/2013] [Accepted: 07/03/2013] [Indexed: 10/26/2022]
Abstract
This paper describes the development and use of the Medication Recommendation Tracking Form (MRTF), a novel method for capturing physician prescribing behavior and clinical decision making. The Bipolar Trials Network developed and implemented the MRTF in a comparative effectiveness study for bipolar disorder (LiTMUS). The MRTF was used to assess the frequency, types, and reasons for medication adjustments. Changes in treatment were operationalized by the metric Necessary Clinical Adjustments (NCA), defined as medication adjustments to reduce symptoms, optimize treatment response and functioning, or to address intolerable side effects. Randomized treatment groups did not differ in rates of NCAs, however, responders had significantly fewer NCAs than non-responders. Patients who had more NCAs during their previous visit had significantly lower odds of responding at the current visit. For each one-unit increase in previous CGI-BP depression score and CGI-BP overall severity score, patients had an increased NCA rate of 13% and 15%, respectively at the present visit. Ten-unit increases in previous Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) scores resulted in an 18% and 14% increase in rates of NCAs, respectively. Patients with fewer NCAs had increased quality of life and decreased functional impairment. The MRTF standardizes the reporting and rationale for medication adjustments and provides an innovative metric for clinical effectiveness. As the first tool in psychiatry to track the types and reasons for medication changes, it has important implications for training new clinicians and examining clinical decision making. (ClinicalTrials.gov number NCT00667745).
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Affiliation(s)
- Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 580, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Sylvia LG, Iosifescu D, Friedman ES, Bernstein EE, Bowden CL, Ketter TA, Reilly-Harrington NA, Leon AC, Calabrese JR, Ostacher MJ, Rabideau DJ, Thase ME, Nierenberg AA. Use of treatment services in a comparative effectiveness study of bipolar disorder. Psychiatr Serv 2013; 64:1119-26. [PMID: 23945956 DOI: 10.1176/appi.ps.201200479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Bipolar disorder is a severe, chronic mental illness with a high incidence of medical and psychological comorbidities that make treatment and prevention of future episodes challenging. This study investigated the use of services among outpatients with bipolar disorder to further understanding of how to maximize and optimize personalization and accessibility of services for this difficult-to-treat population. METHODS The Lithium Treatment-Moderate Dose Use Study (LiTMUS) was a six-month multisite, comparative effectiveness trial that randomly assigned 283 individuals to receive lithium plus optimized care-defined as personalized, guideline-informed care-or optimized care without lithium. Relationships between treatment service utilization, captured by the Cornell Service Index, and demographic and illness characteristics were examined with generalized linear marginal models. RESULTS Analyses with complete data (week 12, N=246; week 24, N=236) showed that increased service utilization was related to more severe bipolar disorder symptoms, physical side effects, and psychiatric and general medical comorbidities. Middle-aged individuals and those living in the United States longer tended to use more services than younger individuals or recent immigrants, respectively. CONCLUSIONS These data suggest that not all individuals with bipolar disorder seek treatment services at the same rate. Instead, specific clinical or demographic features may affect the degree to which one seeks treatment, conveying clinical and public health implications and highlighting the need for specific approaches to correct such discrepancies. Future research is needed to elucidate potential moderators of service utilization in bipolar disorder to ensure that those most in need of additional services utilize them.
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Sylvia LG, Reilly-Harrington NA, Leon AC, Kansky CI, Ketter TA, Calabrese JR, Thase ME, Bowden CL, Friedman ES, Ostacher MJ, Iosifescu DV, Severe J, Keyes M, Nierenberg AA. Methods to limit attrition in longitudinal comparative effectiveness trials: lessons from the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder. Clin Trials 2011; 9:94-101. [PMID: 22076437 DOI: 10.1177/1740774511427324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High attrition rates, which occur frequently in longitudinal clinical trials of interventions for bipolar disorder, limit the interpretation of results. PURPOSE The aim of this article is to present design approaches that limited attrition in the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder. METHODS LiTMUS was a 6-month randomized, longitudinal multisite comparative effectiveness trial that enrolled bipolar participants who were at least mildly ill. Participants were randomized to either low to moderate doses of lithium or no lithium; other treatments needed for mood stabilization were administered in a guideline-informed, empirically supported, and personalized fashion to participants in both treatment arms. RESULTS Components of the study design that may have contributed to low attrition (16%) among 283 participants randomized included the use of (1) an intent-to-treat design, (2) a randomized adjunctive single-blind design, (3) participant reimbursement, (4) assessment of intent to attend the next study visit (included a discussion of attendance obstacles when intention was low), (5) quality care with limited participant burden, and (6) target windows for study visits. LIMITATIONS The relationships between attrition and effectiveness and tolerability of treatment have not been analyzed yet. CONCLUSIONS These components of the LiTMUS design may have limited attrition and may inform the design of future randomized comparative effectiveness trials among similar patients and those from other difficult-to-follow populations.
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Bowden CL, Perlis RH, Thase ME, Ketter TA, Ostacher MM, Calabrese JR, Reilly-Harrington NA, Gonzalez JM, Singh V, Nierenberg AA, Sachs GS. Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD). CNS Neurosci Ther 2011; 18:243-9. [PMID: 22070541 DOI: 10.1111/j.1755-5949.2011.00257.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) was funded as part of a National Institute of Mental Health initiative to develop effectiveness information about treatments, illness course, and assessment strategies for severe mental disorders. STEP-BD studies were planned to be generalizable both to the research knowledge base for bipolar disorder and to clinical care of bipolar patients. Several novel methodologies were developed to aid in illness characterization, and were combined with existing scales on function, quality of life, illness burden, adherence, adverse effects, and temperament to yield a comprehensive data set. The methods integrated naturalistic treatment and randomized clinical trials, which a portion of STEP-BD participants participated. All investigators and other researchers in this multisite program were trained in a collaborative care model with the objective of retaining a high percentage of enrollees for several years. Articles from STEP-BD have yielded evidence on risk factors impacting outcomes, suicidality, functional status, recovery, relapse, and caretaker burden. The findings from these studies brought into question the widely practiced use of antidepressants in bipolar depression as well as substantiated the poorly responsive course of bipolar depression despite use of combination strategies. In particular, large studies on the characteristics and course of bipolar depression (the more pervasive pole of the illness), and the outcomes of treatments concluded that adjunctive psychosocial treatments but not adjunctive antidepressants yielded outcomes superior to those achieved with mood stabilizers alone. The majority of patients with bipolar depression concurrently had clinically significant manic symptoms. Anxiety, smoking, and early age of bipolar onset were each associated with increased illness burden. STEP-BD has established procedures that are relevant to future collaborative research programs aimed at the systematic study of the complex, intrinsically important elements of bipolar disorders.
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Affiliation(s)
- C L Bowden
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Abstract
OBJECTIVES The Interactive Computer Interview for Mania (ICI-M) is a computer-administered interview that presents probes to assess symptom severity and utilizes a scoring algorithm to select follow-up questions and rate subject responses in accordance with rating scale anchor points. The current study examines the acceptability, feasibility, and reliability of the ICI-M as a potential method for evaluating the performance of human raters. METHODS Participants with a diagnosis of bipolar I or II disorder completed both a live interview of the Young Mania Rating Scale with a human rater (LR) and the ICI-M. A panel of three expert raters reviewed each videotaped LR and assigned a consensus rating (CR). Participants completed a modified version of the Client Satisfaction Questionnaire to assess each method. RESULTS Intraclass correlation coefficients were 0.91 between the ICI-M and CR and 0.97 between the LR and CR (n = 100), providing empirical support for the inter-rater reliability of each approach. Coefficient alphas indicated comparable internal consistency reliability: ICI-M = 0.82, LR = 0.83, and CR = 0.84. The ICI-M was significantly more sensitive in detecting symptomatology than the LR (p < 0.001) and the CR (p < 0.001), and resulted in significantly higher ratings than CR on mood, speech, psychotic content, and disruptive-aggressive behavior. While participants endorsed significantly higher overall satisfaction with LR, no significant differences emerged between ICI-M and LR regarding willingness to participate again or ability to understand the questions. CONCLUSIONS The ICI-M is a well-accepted and reliable method for assessing manic symptoms. The ICI-M is a tool with adequate sensitivity to elicit symptoms and rate severity and is recommended as a tool to monitor and improve rater performance, not as a replacement of a human rater.
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Affiliation(s)
| | | | - Andrew C Leon
- Weill Medical College of Cornell University, New York, NY, USA
| | - Louisa Sylvia
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Roy Perlis
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Gary S Sachs
- Concordant Rater Systems, Boston, MA,Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Nierenberg AA, Sylvia LG, Leon AC, Reilly-Harrington NA, Ketter TA, Calabrese JR, Thase ME, Bowden CL, Friedman ES, Ostacher MJ, Novak L, Iosifescu DV. Lithium treatment -- moderate dose use study (LiTMUS) for bipolar disorder: rationale and design. Clin Trials 2009; 6:637-48. [PMID: 19933719 DOI: 10.1177/1740774509347399] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent data indicate that lithium use for bipolar disorder has declined over the last decade and that lithium largely has been replaced with alternate, commercially promoted medications that may or may not result in better outcomes. PURPOSE This article describes the rationale and study design of LiTMUS, a multi-site, prospective, randomized clinical trial of outpatients with bipolar disorder. LiTMUS seeks to address whether initiating therapy at lower doses of lithium as part of optimized treatment (OPT, guideline-informed, evidence-based, and personalized pharmacotherapy) improves outcomes and decreases the need for other medication changes across 6 months of therapy. METHODS LiTMUS will randomize 284 adults with bipolar disorder (Type I or II) across 6 study sites. The co-primary outcomes are overall illness severity on clinical global improvement scale for bipolar disorder and a novel measure, necessary clinical adjustments. This metric provides a composite that reflects both clinical response and tolerability. Other relevant outcomes include full symptomatic recovery, quality of life, suicidal behaviors, and moderators of suicidality. RESULTS As of August 28th, 2009, we have consented 338 patients and randomized 281 for this study. LIMITATIONS The potential limitations of the study include an arbitrary definition of 'low, but effective' doses of lithium, lack of a placebo-controlled group, open treatment, and use of a new outcome measure (i.e., necessary clinical adjustments). CONCLUSION We expect that this study will inform our understanding of the effectiveness of low to moderate doses of lithium therapy for individuals with bipolar disorder.
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Affiliation(s)
- Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, USA.
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Reilly-Harrington NA, Miklowitz DJ, Otto MW, Frank E, Wisniewski SR, Thase ME, Sachs GS. Dysfunctional Attitudes, Attributional Styles, and Phase of Illness in Bipolar Disorder. Cogn Ther Res 2008. [DOI: 10.1007/s10608-008-9218-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reilly-Harrington NA, Deckersbach T, Knauz R, Wu Y, Tran T, Eidelman P, Lund HG, Sachs G, Nierenberg AA. Cognitive behavioral therapy for rapid-cycling bipolar disorder: a pilot study. J Psychiatr Pract 2007; 13:291-7. [PMID: 17890977 DOI: 10.1097/01.pra.0000290667.02484.3d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bipolar disorder is characterized by depressive and/or manic episodes that interfere with daily functioning. Between 10%-24% of bipolar patients experience a rapid-cycling course, with 4 or more mood episodes occurring per year. Characterized by nonresponse to standard mood stabilizing medications, patients with rapid-cycling bipolar disorder are particularly in need of effective, adjunctive treatments. Adjunctive cognitive-behavioral therapy (CBT) has been shown to improve adherence to medication and reduce relapse rates in patients with bipolar disorder. However, no published trials to date have examined the application of CBT to the treatment of patients with a rapid-cycling course of illness, with only a single case study published in the literature. We recently developed a CBT protocol that addresses the specific needs of bipolar patients with rapid cycling. The present study was designed to investigate outcomes with this CBT protocol. Study participants were 10 patients with rapid-cycling bipolar disorder, 6 of whom completed the study. Completers showed significant decreases in depressive mood, and improvements remained stable during the 2-month follow-up. This suggests that CBT for rapid cycling may have beneficial effects.
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Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, Kogan JN, Sachs GS, Thase ME, Calabrese JR, Marangell LB, Ostacher MJ, Patel J, Thomas MR, Araga M, Gonzalez JM, Wisniewski SR. Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry 2007; 164:1340-7. [PMID: 17728418 PMCID: PMC3579578 DOI: 10.1176/appi.ajp.2007.07020311] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Psychosocial interventions are effective adjuncts to pharmacotherapy in delaying recurrences of bipolar disorder; however, to date their effects on life functioning have been given little attention. In a randomized trial, the authors examined the impact of intensive psychosocial treatment plus pharmacotherapy on the functional outcomes of patients with bipolar disorder over the 9 months following a depressive episode. METHOD Participants were 152 depressed outpatients with bipolar I or bipolar II disorder in the multisite Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. All patients received pharmacotherapy. Eighty-four patients were randomly assigned to intensive psychosocial intervention (30 sessions over 9 months of interpersonal and social rhythm therapy, cognitive behavior therapy [CBT], or family-focused therapy), and 68 patients were randomly assigned to collaborative care (a 3-session psychoeducational treatment). Independent evaluators rated the four subscales of the Longitudinal Interval Follow-Up Evaluation-Range of Impaired Functioning Tool (LIFE-RIFT) (relationships, satisfaction with activities, work/role functioning, and recreational activities) through structured interviews given at baseline and every 3 months over a 9-month period. RESULTS Patients in intensive psychotherapy had better total functioning, relationship functioning, and life satisfaction scores over 9 months than patients in collaborative care, even after pretreatment functioning and concurrent depression scores were covaried. No effects of psychosocial intervention were observed on work/role functioning or recreation scores during this 9-month period. CONCLUSIONS Intensive psychosocial treatment enhances relationship functioning and life satisfaction among patients with bipolar disorder. Alternate interventions focused on the specific cognitive deficits of individuals with bipolar disorder may be necessary to enhance vocational functioning after a depressive episode.
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Affiliation(s)
- David J Miklowitz
- Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
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Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, Wisniewski SR, Kogan JN, Nierenberg AA, Calabrese JR, Marangell LB, Gyulai L, Araga M, Gonzalez JM, Shirley ER, Thase ME, Sachs GS. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry 2007; 64:419-26. [PMID: 17404119 PMCID: PMC3579612 DOI: 10.1001/archpsyc.64.4.419] [Citation(s) in RCA: 283] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder. OBJECTIVE To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression. DESIGN Randomized controlled trial. SETTING Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention. INTERVENTIONS Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. MAIN OUTCOME MEASURES Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months. RESULTS All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies. CONCLUSIONS Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00012558.
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Affiliation(s)
- David J Miklowitz
- Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
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Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME. Predictors of Recurrence in Bipolar Disorder: Primary Outcomes From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). FOC 2006. [DOI: 10.1176/foc.4.4.553] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Miklowitz DJ, Otto MW, Wisniewski SR, Araga M, Frank E, Reilly-Harrington NA, Lembke A, Sachs GS. Psychotherapy, symptom outcomes, and role functioning over one year among patients with bipolar disorder. Psychiatr Serv 2006; 57:959-65. [PMID: 16816280 DOI: 10.1176/ps.2006.57.7.959] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Randomized trials indicate that psychosocial interventions effective adjuncts to pharmacotherapy in bipolar disorder (1,2). A one-year naturalistic-prospective design was used to examine the association between psychotherapy use and the symptomatic and functional outcomes of patients with bipolar disorder. METHODS Patients with bipolar disorder in a depressed phase (N=248) were drawn from the first 1,000 enrollees (November 1999 to April 2002) in the Systematic Treatment Enhancement Program (STEP-BD), a study of patients with bipolar disorder receiving best-practice pharmacotherapy. Patients were seen clinics and interviewed every three months over one year regarding of psychotherapy services, symptoms, and role functioning. Mixed-effects regression models were used to examine whether the amount of psychotherapy the patients received during each three-month interval was associated with symptomatic or psychosocial functioning during the same or a subsequent three-month interval. RESULTS During the study year, percent of the patients had at least one psychotherapy session. Among patients who began an interval with severe depressive symptoms or low functioning, having more frequent sessions of psychotherapy was associated with less severe mood symptoms and better functioning in the same or a subsequent study interval. In contrast, among patients who began interval with less severe depressive symptoms or higher functioning, fewer psychotherapy sessions were associated with less severe depressive symptoms and greater functioning in the same or a subsequent interval. CONCLUSIONS Intensive psychotherapy may be most applicable to severely ill patients with bipolar disorder, whereas briefer treatments may be adequate for less severely ill patients.
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Affiliation(s)
- David J Miklowitz
- Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
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Otto MW, Simon NM, Wisniewski SR, Miklowitz DJ, Kogan JN, Reilly-Harrington NA, Frank E, Nierenberg AA, Marangell LB, Sagduyu K, Weiss RD, Miyahara S, Thas ME, Sachs GS, Pollack MH. Prospective 12-month course of bipolar disorder in out-patients with and without comorbid anxiety disorders. Br J Psychiatry 2006; 189:20-5. [PMID: 16816301 DOI: 10.1192/bjp.bp.104.007773] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The impact of anxiety disorders has not been well delineated in prospective studies of bipolar disorder. AIMS To examine the association between anxiety and course of bipolar disorder, as defined by mood episodes, quality of life and role functioning. METHOD A thousand thousand out-patients with bipolar disorder were followed prospectively for 1 year. RESULTS A current comorbid anxiety disorder (present in 31.9% of participants) was associated with fewer days well, a lower likelihood of timely recovery from depression, risk of earlier relapse, lower quality of life and diminished role function over I year of prospective study. The negative impact was greater with multiple anxiety disorders. CONCLUSIONS Anxiety disorders, including those present during relative euthymia, predicted a poorer bipolar course. The detrimental effects of anxiety were not simply a feature of mood state. Treatment studies targeting anxiety disorders will help to clarify the nature of the impact of anxiety on bipolar course.
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Affiliation(s)
- M W Otto
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME. Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry 2006; 163:217-24. [PMID: 16449474 DOI: 10.1176/appi.ajp.163.2.217] [Citation(s) in RCA: 426] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Little is known about clinical features associated with the risk of recurrence in patients with bipolar disorder receiving treatment according to contemporary practice guidelines. The authors looked for the features associated with risk of recurrence. METHOD The authors examined prospective data from a cohort of patients with bipolar disorder participating in the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study for up to 24 months. For those who were symptomatic at study entry but subsequently achieved recovery, time to recurrence of mania, hypomania, mixed state, or a depressive episode was examined with Cox regression. RESULTS Of 1,469 participants symptomatic at study entry, 858 (58.4%) subsequently achieved recovery. During up to 2 years of follow-up, 416 (48.5%) of these individuals experienced recurrences, with more than twice as many developing depressive episodes (298, 34.7%) as those who developed manic, hypomanic, or mixed episodes (118, 13.8%). The time until 25% of the individuals experienced a depressive episode was 21.4 weeks and until 25% experienced a manic/hypomanic/mixed episode was 85.0 weeks. Residual depressive or manic symptoms at recovery and proportion of days depressed or anxious in the preceding year were significantly associated with shorter time to depressive recurrence. Residual manic symptoms at recovery and proportion of days of elevated mood in the preceding year were significantly associated with shorter time to manic, hypomanic, or mixed episode recurrence. CONCLUSIONS Recurrence was frequent and associated with the presence of residual mood symptoms at initial recovery. Targeting residual symptoms in maintenance treatment may represent an opportunity to reduce risk of recurrence.
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Affiliation(s)
- Roy H Perlis
- Bipolar Clinical and Research Program, Massachusetts General Hospital, ACC 812, 15 Parkman Street, Boston, MA 02114, USA.
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Wilhelm S, Steketee G, Reilly-Harrington NA, Deckersbach T, Buhlmann U, Baer L. Effectiveness of Cognitive Therapy for Obsessive-Compulsive Disorder: An Open Trial. J Cogn Psychother 2005. [DOI: 10.1891/jcop.19.2.173.66792] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study examined the effectiveness of a new type of purely Beckian cognitive treatment for Obsessive-Compulsive Disorder (OCD). The manualized treatment used a flexible format permitting therapists to choose among several modules developed to address specific OCD belief domains identified by the Obsessive-Compulsive Cognition Working Group (1997). Fifteen participants diagnosed with OCD were treated individually for 14 weekly sessions. Ten participants had never received behavior therapy, and 5 participants had failed to benefit from exposure and response prevention (ERP) in the past. Participants improved with respect to their depressive and obsessive-compulsive symptoms over the course of the treatment. However, those who had never received ERP improved more than those who had failed to benefit from prior ERP. Implications of the study are discussed.
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Henin A, Otto MW, Reilly-Harrington NA. Introducing flexibility in manualized treatments: Application of recommended strategies to the cognitive-behavioral treatment of bipolar disorder. Cognitive and Behavioral Practice 2001. [DOI: 10.1016/s1077-7229(01)80004-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Reilly-Harrington NA, Alloy LB, Fresco DM, Whitehouse WG. Cognitive styles and life events interact to predict bipolar and unipolar symptomatology. J Abnorm Psychol 2000. [PMID: 10609421 DOI: 10.1037//0021-843x.108.4.567] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the interaction of cognitive style (as assessed self-report and information-processing battery) and stressful life events in predicting the clinician-rated depressive and manic symptomatology of participants with Research Diagnostic Criteria lifetime diagnoses of bipolar disorder (n = 49), unipolar depression (n = 97), or no lifetime diagnosis (n = 23). Bipolar and unipolar participants' attributional styles, dysfunctional attitudes, and negative self-referent information processing as assessed at Time 1 interacted significantly with the number of negative life events that occurred between Times 1 and 2 to predict increases in depressive symptoms from Time 1 to Time 2. Within the bipolar group, participants' Time 1 attributional styles and dysfunctional attitudes interacted significantly, and their self-referent information processing interacted marginally, with intervening life events to predict increases in manic symptoms from Time 1 to Time 2. These findings provide support for the applicability of cognitive vulnerability-stress theories of depression to bipolar spectrum disorders.
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Affiliation(s)
- N A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Reilly-Harrington NA, Alloy LB, Fresco DM, Whitehouse WG. Cognitive styles and life events interact to predict bipolar and unipolar symptomatology. J Abnorm Psychol 1999; 108:567-78. [PMID: 10609421 DOI: 10.1037/0021-843x.108.4.567] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the interaction of cognitive style (as assessed self-report and information-processing battery) and stressful life events in predicting the clinician-rated depressive and manic symptomatology of participants with Research Diagnostic Criteria lifetime diagnoses of bipolar disorder (n = 49), unipolar depression (n = 97), or no lifetime diagnosis (n = 23). Bipolar and unipolar participants' attributional styles, dysfunctional attitudes, and negative self-referent information processing as assessed at Time 1 interacted significantly with the number of negative life events that occurred between Times 1 and 2 to predict increases in depressive symptoms from Time 1 to Time 2. Within the bipolar group, participants' Time 1 attributional styles and dysfunctional attitudes interacted significantly, and their self-referent information processing interacted marginally, with intervening life events to predict increases in manic symptoms from Time 1 to Time 2. These findings provide support for the applicability of cognitive vulnerability-stress theories of depression to bipolar spectrum disorders.
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Affiliation(s)
- N A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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