• Psychopharmacology Guidelines

Although algorithmic approaches to the pharmacological treatment of general medical conditions are not new, very little data has been gathered on the use of this approach in psychiatric conditions. At this years APA meeting, Thomas Smith, MD, Columbia University, presented data evaluating physician adherence to treatment guidelines for the pharmacological management of bipolar disorder, before and after a training program geared towards increasing compliance to those guidelines. Evidence suggests that the pharmacological treatment of bipolar disorder is highly variable, based on individual psychiatrists' predilections for certain medications, often yielding poor outcomes.

Smith notes, “Our goal was to use a combination of didactic training and individualized feedback with data to effect change in practice patterns.” In Phase 1 of this study, clinical raters evaluated the medical records of 23 bipolar patients who had resided, at one point in time, in an acute psychiatric inpatient unit. These patients were treated by 4 psychiatrists. In order to complete a reliable and valid assessment, a rating tool was developed that would assess which medication was chosen for the treatment of bipolar disorder. Medications were either rated as either “First-” or “Second-line” options based on the Expert Consensus Treatment Guidelines for Bipolar Disorder (Keck, PE, Perlis, RH, Otto, MW, Carpenter, D, Ross, R, Doherty, JP. Postgrad Med Special Report 2004, Dec: 1–120).

At the initial rating, approximately 52% of the cases reviewed showed that the clinician followed the guidelines for the treatment of bipolar disorder. Under the sub-category of “bipolar-depressed”, adherence rates dropped to approximately 39%. No statistical comparison was reported. It was suggested that these adherence rate differences are indicative of the difficult nature of treating bipolar-depressed patients with pharmacological agents (Sach S, Koslow CL, Ghaemi SN. Bipolar Disord 2000. 2:256–60).

Following the evaluation of pharmacological management of bipolar disorder in these records, training on the guidelines, set forth by the above mentioned treatment guidelines, was provided to a subset of the psychiatrists from the initial sample. The training included discussion-based groups as well as a review of specific cases with the psychiatrist of record.

After this training was completed, 6 months were allowed to pass before 16 new cases were evaluated for adherence rates to the Expert Consensus Treatment Guidelines for Bipolar Disorder (2004). At this time, adherence rates for the general bipolar population rose to approximately 63% (constituting an 11% increase). For the subgroup of bipolar-depressed patients, adherence rate increased to 73% (constituting a 34% increase).

Dr. Smith concluded, “These preliminary results indicate that a published treatment guideline can be used to develop an assessment tool, and that a focused intervention involving a combination of didactic training and individual provider feedback can improve guideline adherence in the treatment of acutely ill bipolar patients.” For a review of a similar program, see Dennehy et al. Psychol Med 2005;35:1695–706).

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