• Mood Disorders Guidelines
• Psychopharmacology

Several organizations have developed guidelines to assist with the treatment of patients with bipolar disorder (eg, The American Psychiatric Association [APA], The Canadian Network for Mood and Anxiety Treatments [CANMAT], The Texas Medical Algorithm Project [TMAP], and the National Institute for Health and Clinical Excellence [NICE]); however, there is not much in the literature about how these guidelines are implemented in clinical practice.

Megan Jo Ehret, PharmD, BCPP, University of Connecticut, Storrs, CT, presented the results of a study that was conducted to identify the demographic and clinical features that are associated with receiving guideline-based pharmacotherapy for bipolar depression in routine clinical care. The study sample comprised 281 inpatients aged 18 to 59 years (73.3% white; 63.7% women) who were discharged from a single facility between January 1, 2005 and December 31, 2007. All patients had a primary clinical diagnosis of bipolar 1 disorder, with the most recent episode being depression. Patients with dementia were excluded. For patients who had more than 1 admission, data from the first admission were used.

Discharge treatment medications were classified by treatment level, based on a consensus of existing guidelines (Table 1).

In this study, most discharged patients were prescribed 2 to 4 medications. Approximately 83% of patients were discharged on mood stabilizers (MSs) (198 with 1 MS, 33 with 2 MSs, and 1 patient with 3 traditional MSs; 49 were discharged without a MS). The most common MSs that were prescribed at discharge were divalproex (∼90 patients) and lithium (∼80 patients). A total of 225 (80%) patients were discharged on antidepressants, the majority of which was a selective serotonin reuptake inhibitor (SSRI). The majority of patients who were discharged on an antipsychotic was prescribed quetiapine (n=∼100 patients); 33 patients were discharged on an atypical antipsychotic without a MS.

Patients with psychotic features were significantly (p<0.001) more likely to be prescribed atypical antipsychotics than those without psychotic features (OR 4.0; 95% CI, 2.0 to 8.3). African-American patients were more likely to receive atypical antipsychotics compared with other races, but the difference was not significant (OR 3.1; 95% CI, 1.0 to 9.2; p=NS). Women were significantly (p=0.004) less likely to receive a MS than men (77.7% vs 91.2%; OR 0.3; 95% CI, 0.2 to 0.7) but were slightly more likely to receive an atypical antipsychotic in the absence of a mood stabilizer (15.6% vs 4.9%; OR 3.6; 95% CI, 1.3 to 9.6; p=NS).

Patients with psychotic features (29.1% vs 12.3% for those without psychotic features; OR 3.5; 95% CI, 1.8 to 7.0) and patients with borderline personality disorder (35.9% vs 12.0%; OR 4.5; 95% CI, 2.2 to 9.0; p<0.001) were significantly (p<0.001) more likely to be discharged with ≥4 psychotropic medications. African-Americans were significantly (p=0.020) less likely to be discharged with ≥4 psychotropic medications (3.0% vs 19.4% for all other races; OR 0.1; 95% CI, 0.01 to 1.0).

“The patients most at risk for not receiving guideline-based treatment in this study,” said Dr. Ehret, “were women and patients with psychotic features or borderline personality disorder.”

The overall results of this study were mixed when compared with other studies that examined concordance with guideline-based therapy, in that the rate of compliance was higher than that seen by Lim and colleagues [Lim PZ et al. Bipolar Disord 2001] but less than what was reported from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BP) trial [Dennehy EB et al. Psychopharmacol Bull 2007]. This may be attributed to differences in study design as well as the population that was studied.

• © 2009 MD Conference Express