Predictors of Recurrence in Bipolar Disorder: Primary Outcomes From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

Perlis, Roy H.; Ostacher, Michael J.; Patel, Jayendra K.; Marangell, Lauren B.; Zhang, Hongwei; Wisniewski, Stephen R.; Ketter, Terence A.; Miklowitz, David J.; Otto, Michael W.; Gyulai, Laszlo; Reilly-Harrington, Noreen A.; Nierenberg, Andrew A.; Sachs, Gary S.; Thase, Michael E.

doi:10.1176/appi.ajp.163.2.217

Cited by 561 publications

(370 citation statements)

References 31 publications

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“…Risk factors for recurrence include younger age of onset,332 psychotic features,212 rapid cycling,331 more (and more frequent) previous episodes,333 comorbid anxiety,334 and comorbid SUDs 335. Persistent subthreshold symptoms also increase risk for subsequent mood episodes,334, 336, 337 and the presence of residual symptoms should therefore be an indicator of a need for further treatment optimization. Availability of psychosocial support and lower levels of stress are also protective against recurrence 337, 338…”

Section: Maintenance Therapy For Bipolar Disordermentioning

confidence: 99%

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

et al. 2018

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The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third‐ line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment‐emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second‐ line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence‐based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first‐line treatments for acute mania. First‐line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first‐line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

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Section: Maintenance Therapy For Bipolar Disordermentioning

confidence: 99%

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

et al. 2018

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“…Their significance in the course and prognosis of BD is increasingly recognized. The presence of subsyndromal symptoms after resolution of a mood episode has been shown to be a predictor of recurrence in BD patients [16,29,30], and the time to recurrence is 5 times shorter than in fully remitted patients [20]. Moreover, several researchers have found a significant association between the persistence of subsyndromal symptoms and a worse functional outcome [31,32,33].…”

Section: Discussionmentioning

confidence: 99%

“…Some researchers have challenged the present criterion of minimal duration, the core criteria, and the number of signs and symptoms required for the diagnosis of hypomania [42,43,44,45,46]; the notion of a bipolar spectrum points in the same direction [47]. The presence of two or more residual hypomanic symptoms was significantly associated with a shorter time to recurrence of depression or mood elevation [29], a poor response to antidepressants, and a more severe clinical course not only in bipolar [48] but also in recurrent major depressive disorder [49]. Thus, a lower cutoff point for the psychometric diagnosis of hypomanic states could be warranted.…”

Section: Discussionmentioning

confidence: 99%

Syndromal and Subsyndromal Illness Status and Five-Year Morbidity Using Criteria of the International Society for Bipolar Disorders Compared to Alternative Criteria

Dios

Agud²,

Ezquiaga³

et al. 2012

Psychopathology

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Background: Subsyndromal symptoms have been recognized as relevant in the course and outcome of bipolar disorder (BD) patients. Nevertheless, their definition and cutoff points on current depression and mania scales are uncertain. The recently defined International Society for Bipolar Disorders (ISBD) operational criteria for the assessment of the course and outcome of bipolar illness have never been tested until now. Methods: A naturalistic longitudinal follow-up study of up to 5 years included a cohort of 317 DSM-IV-TR BD outpatients. For the first time, we assessed the proportion of visits in different affective states using the ISBD criteria. Secondarily, we compared the results with those obtained applying other cutoff points. Results: Patients were symptomatic in 39.1% (95% CI 35.3–42.9) of the visits. Subsyndromal symptoms, primarily subsyndromal depression, were present in 15.9% of patients (95% CI 13.4–18.4). No significant differences were found between bipolar I patients and bipolar II patients. There were differences in the total percentage of visits in euthymia depending on the cutoff points (p < 0.05). Conclusions: Applying ISBD criteria, bipolar patients have significant clinical morbidity and are often symptomatic, both with threshold symptoms and with subthreshold symptoms, especially with depression. The chosen cutoff points modify the apparent results. Limitations: The cutoff points used have not been validated. Psychopharmacologic treatments were naturalistic.

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“…These minimisation variables were selected as there is preliminary evidence that clinical outcomes are better in BD for individuals with fewer episodes 43 and with less severe mood problems at inception (although this research is clearest with respect to symptoms of depression, the high rates of manic symptoms found in individuals in depressed states indicates the importance of allowing for both affective poles 326,327 ). Participants were randomised to receive RfCBT plus TAU or TAU alone.…”

Section: Methodsmentioning

confidence: 99%

Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder: a mixed-methods approach

Morrison

Law

Barrowclough

et al. 2016

Programme Grants Appl Res

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BackgroundRecovery in mental health is a relatively new concept, but it is becoming more accepted that people can recover from psychosis. Recovery-orientated services are recommended for adult mental health, but with little evidence base to support this.ObjectivesTo facilitate understanding and promotion of recovery in psychosis and bipolar disorder (BD), in a manner that is empowering and acceptable to service users.MethodThere were six linked projects using qualitative and quantitative methodologies: (1) developing and piloting a service user-defined measure of recovery; (2) a Delphi study to determine levels of consensus around the concept of recovery; (3) examination of the psychological factors associated with recovery and how these fluctuate over time; (4) development and evaluation of cognitive–behavioural approaches to guided self-help including a patient preference trial (PPT); (5) development and evaluation of cognitive–behavioural therapy (CBT) for understanding and preventing suicide in psychosis including a randomised controlled trial (RCT); and (6) development and evaluation of a cognitive–behavioural approach to recovery in recent onset BD, including a RCT of recovery-focused cognitive–behavioural therapy (RfCBT). Service user involvement was central to the programme.ResultsMeasurement of service user-defined recovery from psychosis (using the Subjective Experience of Psychosis Scale) and BD (using the Bipolar Recovery Questionnaire) was shown to be feasible and valid. The consensus study revealed a high level of agreement among service users for defining recovery, factors that help or hinder recovery and items which demonstrate recovery. Negative emotions, self-esteem and hope predicted recovery judgements, both cross-sectionally and longitudinally, whereas positive symptoms had an indirect effect. In the PPT, 89 participants entered the study, three were randomised, 57 were retained in the trial until 15-month follow-up (64%). At follow-up there was no overall treatment effect on the primary outcome (Questionnaire about the Process of Recovery total;p = 0.82). In the suicide prevention RCT, 49 were randomised and 35 were retained at 6-month follow-up (71%). There were significant improvements in suicidal ideation [Adult Suicidal Ideation Questionnaire; treatment effect = –12.3, 95% confidence interval (CI) –24.3 to –0.14], Suicide Probability Scale (SPS; treatment effect = –7.0, 95% CI –15.5 to 0) and hopelessness (subscale of the SPS; treatment effect = –3.8, 95% CI –7.3 to –0.5) at follow-up. In the RCT for BD, 67 participants were randomised and 45 were retained at the 12-month follow-up (67%). Recovery score significantly improved in comparison with treatment as usual (TAU) at follow-up (310.87, 95% CI 75.00 to 546.74). At 15-month follow-up, 32 participants had experienced a relapse of either depression or mania (20 TAU vs. 12 RfCBT). The difference in time to recurrence was significant (estimated hazard ratio 0.38, 95% CI 0.18 to 0.78;p < 0.006).ConclusionsThis research programme has improved our understanding of recovery in psychosis and BD. Key findings indicate that measurement of recovery is feasible and valid. It would be feasible to scale up the RCTs to assess effectiveness of our therapeutic approaches in larger full trials, and two of the studies (CBT for suicide prevention in psychosis and recovery in BD) found significant benefits on their primary outcomes despite limited statistical power, suggesting definitive trials are warranted.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Predictors of Recurrence in Bipolar Disorder: Primary Outcomes From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

Abstract: Recurrence was frequent and associated with the presence of residual mood symptoms at initial recovery. Targeting residual symptoms in maintenance treatment may represent an opportunity to reduce risk of recurrence.

Cited by 561 publications

References 31 publications

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Syndromal and Subsyndromal Illness Status and Five-Year Morbidity Using Criteria of the International Society for Bipolar Disorders Compared to Alternative Criteria

Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder: a mixed-methods approach

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