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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

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Lessons from STEP-BD for the Treatment of Bipolar Disorder

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  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

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