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An Update on Bipolar Disorder NARSAD 2008

An Update on Bipolar Disorder NARSAD 2008. Andrew A. Nierenberg, MD Medical Director Harvard Bipolar Clinic and Research Program, Massachusetts General Hospital Director, NIMH Bipolar Trials Network Professor of Psychiatry, Harvard Medical School. Thank you NARSAD. Thilo Deckersbach, PhD

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An Update on Bipolar Disorder NARSAD 2008

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  1. An Update on Bipolar DisorderNARSAD 2008 Andrew A. Nierenberg, MD Medical Director Harvard Bipolar Clinic and Research Program, Massachusetts General Hospital Director, NIMH Bipolar Trials Network Professor of Psychiatry, Harvard Medical School

  2. Thank you NARSAD • Thilo Deckersbach, PhD • Christina Dording, MD • Aude Henin, PhD • Dan Iosifescu, MD • Andrew A. Nierenberg, MD • Michael J. Ostacher, MD, MPH • Janet Witte, MD

  3. Update on Bipolar Disorder • Update on Bipolar basics • STEP-BD • LiTMUS

  4. "Everything was perfect... and then I went insane" Lizzie Simon Time Magazine Aug 11, 2002

  5. Goya Portrait of Don Gaspar Melchor de Jovellanos

  6. Bipolar Disorder • Prevalence: • BPI and II: • 1.1% of the workforce • 2.6% of the general population • Mean age of onset: 17.4 years Kessler et al. Arch Gen Psychiatry. 2005;62:617-627. Kessler et al. Am J Psychiatry. 2006;163:1561-1568.

  7. Bipolar Disorder • Recurrent and chronic disorder • Manic or hypomanic episodes • Major depressive episodes and symptoms • Major burden • Inter-episodic symptoms • Dysfunction: • 65.5 lost days of work per year Kessler et al. Arch Gen Psychiatry. 2005;62:617-627. Kessler et al. Am J Psychiatry. 2006;163:1561-1568.

  8. 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

  9. Collaborative CareandConcordance

  10. Collaborative Care: Integration of Measurement and Management • Shared measurement • Symptoms • Depression • Mania/hypomania • Anxiety • Irritability • Stress, alcohol, weight • Side effects • Functioning Clinical Self-report Form Clinical Monitoring Form Nierenberg AA. J Clin Psychiatry. 2006;67 Suppl 11:3-7. www.manicdepressive.org (see Resources section)

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

  12. Key STEP-BD Baseline Findings

  13. STEP-BD: Bipolar Onset < 13 > 18 13 to 18 Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881

  14. BP I BP II Lifetime Anxiety Comorbidity 60 50 40 30 * * * * 20 * † 10 0 Any Panic±Agor Agor Without Panic SAD OCD PTSD GAD Simon N, et al. Am J Psychiatry. 2004;161:2222-2229.

  15. Key STEP-BD Long-Term Findings

  16. With systematic treatment, 30% of STEP-BD participants achieved recovery and then stayed recovered over 1 year

  17. Anxiety: more difficult to recover from bipolar depressive episode without anxiety with anxiety Otto et al., Br J Psychiatry 2006 Jul;189:20-5.

  18. Anxiety: higher risk of depressive relapse without anxiety with anxiety Otto et al., Br J Psychiatry 2006 Jul;189:20-5.

  19. 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.

  20. No benefit with antidepressants for bipolar depression with manic symptoms Goldberg et al. Am J Psychiatry 2007:164:1348-1355

  21. STEP-BD Randomized Trials

  22. Antidepressants or placebo added to mood stabilizers for bipolar depression % Sachs G et al. N Engl J Med 2007;10.1056/NEJMoa064135

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

  24. Adjunctive Psychosocial Interventions • Collaborative Care Plus • Cognitive-Behavioral Therapy (CBT) • Family-Focused Therapy (FFT) • Interpersonal and Social Rhythm Therapy (IPSRT)

  25. Intensive psychotherapy: remission 110 days earlier 110 Days Miklowitz et al., Arch Gen Psychiatry. 2007 Apr;64(4):419-26.

  26. LiTMUSLithium Moderate Dose Use Study A NIMH Bipolar Trials Network Contract

  27. Problem:Long term outcomes suboptimal for Bipolar DisorderandLithium is under used

  28. Can tolerable doses of lithium added to other medications improve 6 month outcomes?

  29. LiTMUS • Compare strategies of treatment • Optimized treatment with lithium • Optimized treatment without lithium • 6 month outcomes • Open treatment • Blinded outcomes

  30. Update on Bipolar Disorder • Update on Bipolar basics • STEP-BD • LiTMUS

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