1 / 37

Lessons from STEP-BD for the Treatment of Bipolar Disorder

Lessons from STEP-BD for the Treatment of Bipolar Disorder. Andrew A. Nierenberg, MD Massachusetts General Hospital Harvard Medical School. STEP-BD. Systematic Treatment Enhancement Program for Bipolar Disorder www.stepbd.org Evidence guided treatment Specialty bipolar clinics

thuy
Download Presentation

Lessons from STEP-BD for the Treatment of Bipolar Disorder

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Lessons from STEP-BD for the Treatment of Bipolar Disorder Andrew A. Nierenberg, MD Massachusetts General Hospital Harvard Medical School

  2. STEP-BD • Systematic Treatment Enhancement Program for Bipolar Disorder • www.stepbd.org • Evidence guided treatment • Specialty bipolar clinics • Integration of measurement and management • Embedded randomized trials

  3. Methods • Mini International Neuropsychiatric Interview • Affective Disorders Evaluation Form • Clinical Monitoring form • Self-administered waiting room form • www.manicdepressive.org • Quarterly and yearly evaluations • Participants followed for up to 2 years

  4. Collaborative Care: Integration of Measurement and Management • Shared measurement • Symptoms • Depression • Mania/hypomania • Anxiety • Irritability • Stress, alcohol, smoking, weight • Side effects • Functioning

  5. Collaborative Care: Integration of Measurement and Management • Shared measurement • Mood monitoring • Medication concordance • Non-concordance open for discussion • Negotiate • Goals • Medication changes • Menu of reasonable choices • Collaborative Care Workbook

  6. STEP-BD Baseline Findings

  7. Most Bipolar Patients report onset in childhood or adolescence • Only 35% with onset > 18 • About 65% with onset < 18 • Almost a third with onset < 13 < 13 > 18 13 to 18 Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881

  8. Age of Onset in Bipolar Disorder (STEP-1000) mean age of onset 17.37 (SD 8.67) Perlis RH for the STEP-BD group, Biol Psych 2004

  9. Childhood Onset With Greater Anxiety Comorbid Conditions Onset < 13 N=983 Onset 13 to 18 Onset > 18 Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881

  10. Childhood and Adolescent Onset With Greater Comorbid Substance Abuse/Dependence and ADHD Onset < 13 N=983 Onset 13 to 18 Onset > 18 Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881

  11. Depressive Polarity of First Episode: More lifetime depression Perlis et al., Biological Psychiatry 2005;58:549–553

  12. BP I BP II Lifetime Anxiety Comorbidity in Bipolar Disorder – STEP 500 51% 17% 9% 22% 10% 17% 18% 60 50 40 30 * * * * 20 * † 10 0 Any Panic±Agor Agor Without Panic SAD OCD PTSD GAD *P<0.001; †P<0.005 Agor=agoraphobia; GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; PTSD=posttraumatic stress disorder; SAD=social anxiety disorder. Simon N, et al. Am J Psychiatry. 2004;161:2222-2229.

  13. Anxiety Comorbidity Associated With Reduction in Longest Time Euthymic in Bipolar Disorder in Past 2 Years (N=469) 300 Current Anxiety Disorder 250 Lifetime Anxiety Disorder † 200 ‡ † ‡ § Euthymic, d 150 § * * † * * 100 50 0 No Anxiety PD w/out AGOR GAD OCD Any Anxiety SAD PTSD PD w/ AGOR (n=79, 22) (n=86, 56) (n=49, 26) (n=99, 55) (n 35, 17) (n=81, 37) (n=233, 332) (n=236, 137) ‡ P<0.05; † P<0.01; § P<0.001; * P<0.0001 Simon NM, et al. Am J Psychiatry. 2004;161:2222-2229.

  14. ADHD Comorbidity in Bipolar Adults ADHD Comorbid • Shorter periods of wellness • More likely • BPI • Symptomatic • > lifetime manic episodes • EtOH and drug abuse • Less likely: • Recovered % N = 1000; Nierenberg et al., Biol Psychiatry 2005;57:1467–1473

  15. Comorbid ADHD with more lifetime problems % N = 1000; Nierenberg et al., Biol Psychiatry 2005;57:1467–1473

  16. Prevalence of ADHD with Mood Disorders % With % Without Other Comorbid* Comorbid Conditions Odds Ratio MDD 9.4 3.7 2.7 Dysthymia 22.6 3.7 7.5 Bipolar 21.2 3.5 7.4 Any Mood Disorder 13.1 2.9 5.0 *eg, 21.2% of those with Bipolar Disorder during the previous 12 months have ADHD compared to 3.5% of those without MDD who have ADHD. Kessler RC, et al. Am J Psychiatry. 2006;163:716-723.

  17. Prevalence of Mood Disorders with Adult ADHD % With % Without ADHD* ADHD MDD 18.6 7.8 Dysthymia 12.8 1.9 Bipolar 19.4 3.1 Any Mood Disorder 38.3 5.0 *eg, 19.4% of those with ADHD during the previous 12 months have Bipolar Disorder compared to 3.1% of those without ADHD who have Bipolar Disorder. Kessler RC, et al. Am J Psychiatry. 2006;163:716-723.

  18. 52% No SUD Most bipolar patients with lifetime comorbid substance use disorder recover from SUD • 36% + 12% = 48% of bipolar patients • have lifetime SUD. • 36%/48% (3/4) of those with lifetime comorbid SUD recover from SUD 12% Current SUD 36% Past SUD 48% lifetime SUD Weiss RD, Ostacher M, et.al. Recovery from Substance Use in Bipolar Disorder: Does it Matter J Clin Psychiatry. 2005; J Clin Psych. 2005; 66:730-735.

  19. STEP-BD Results:Observational Prospective Findings

  20. Higher bipolar relapse rate with residual symptoms Without residual symptoms Without residual symptoms With residual symptoms With residual symptoms Perlis et al., Am J Psychiatry. 2006 Feb;163(2):217-24.

  21. Less than 1/3 of symptomatic bipolar patients reach recovery and remain well over 2 years in STEP-BD • Achieved recovery 58.5% • (< 2 mood symptoms for at least 8 weeks) • Relapse into depression 34.7% • Relapse into mood elevation 13.8% • Total relapse rate 48.5% • Total that stayed recovered over 2 years (100%-48.5%) 51.5% • Total who recovered and remained free of depressive and mood elevation recurrences over 2 years (51.5% out of 58.5% who achieved remission) 30.1% N=1469 who entered symptomatic Perlis et al., Am J Psychiatry. 2006 Feb;163(2):217-24.

  22. Anxiety comorbid conditions with lower probability of recovery from bipolar depression in STEP-BD without anxiety N=248 Overall recovery rate = 80.7% Overall Hazard Ratio (HR)= 0.661 (Chi sq=5.41, P=0.020) HR=0.452 for social anxiety disorder with anxiety Otto et al., Br J Psychiatry 2006 Jul;189:20-5.

  23. Anxiety comorbid conditions with higher risk of relapse in bipolar disorder in STEP-BD N=489 Overall relapse rate = 41.4% Overall Hazard Ratio (HR)= 1.764 ( 2=10.9, P=0.001) HR=1.55 for one disorder HR=2.17 for two or more disorders HR=2.07 for social anxiety disorder HR=2.45 for PTSD without anxiety with anxiety Otto et al., Br J Psychiatry 2006 Jul;189:20-5.

  24. Embedded Randomized Trials

  25. No Advantage or Disadvantage to Adding AD to Mood Stabilizers for Bipolar Depression Sachs G et al. N Engl J Med 2007;10.1056/NEJMoa064135

  26. Adjunctive Psychosocial Interventions with Empirical Support for Adult Bipolar Disorder • Cognitive-Behavioral Therapy (CBT) • Family-Focused Therapy (FFT) • Interpersonal and Social Rhythm Therapy (IPSRT) • Collaborative Care Plus

  27. Intensive psychosocial interventions for bipolar depression better than collaborative care 1-year recovery rate for intensive group, 105/163 [64.4%]; for CC, 67/130 [51.5%]; log-rank 2(1) = 6.20, p = 0.013; hazard ratio (HR) = 1.47; 95% CI = 1.08-2.00 Miklowitz et al., Arch Gen Psychiatry, in press

  28. Treatment Resistant Bipolar Depression: Lamotrigine Added Might Help Nierenberg et al., Am J Psychiatry 2006;163;1-8

  29. Valproate Associated Polycsytic Ovarian Syndrome (PCOS) • PCOS • Menstrual cycle irregularities • < or = 9 cycles per year • Hyperandrogenism • Hirsuitism • Acne • Male pattern alopecia • Elevated serum androgens • Obesity, insulin resistance, polycystic ovarian morphology

  30. New Onset Oligoamenorrhea with Hyperandrogenism with Valproate with new onset PCOS % 2/44 9/86 Median time to onset = 3 months Joffe et al. Valproate is associated with new-onset oligoamenorrhea with hyper- Androgenism in women with bipolar disorder. Biol Psych 2006;59:1078-1086

  31. Questions that remain after STEP-BD • What are the best acute and long-term treatments for bipolar depression? • What are the best treatments to prevent mood episodes and restore functioning in generalizable populations?

  32. Questions that remain after STEP-BD • What are the best treatments for comorbid conditions (anxiety, substance abuse, ADHD)? • Substance use disorders are untreated • What can decrease medical morbidity and overall mortality, including suicide?

  33. Questions that remain after STEP-BD • What biomarkers can be used to personalize acute and long-term treatment? • Molecular • Genetic • Imaging • Cognitive assessments • Other biomarkers

  34. What are the best treatments of bipolar depression? • Novel therapeutic interventions • Do patients with BPII depression need mood stabilizers? • After recovery from bipolar depression, what treatments promote long-term functioning and prevent relapse?

  35. What are the best treatments for comorbid conditions and symptoms? • Anxiety • Pharmacologic • Psychotherapeutic • Substance abuse • Unique challenge of difficult to treat patients • ADHD • Benefits and risks of psychostimulants • Cognitive dysfunction • Medical burdens

  36. What is the best treatment for bipolar disorder with comorbid anxiety? • Anxiety comorbidity • 51% of STEP-BD cohort • associated with poorer outcomes • No evidence-based treatment options • Antidepressants can exacerbate disease course • Benzodiazepines of concern due to high comorbid substance abuse rates in BP • No studies of psychotherapies for comorbid anxiety • Novel psychosocial interventions needed

  37. The sun and moon allude to the cyclical nature of bipolar disorder and the mission of the BTN: enduring commitment to clinical research on behalf of patients with bipolar disorder and their families. Designed by Gianna Marzilli Ericson

More Related