Enhancing Multiyear Guideline Concordance for Bipolar Disorder Through Collaborative Care

Harvard University, Cambridge, Massachusetts, United States
American Journal of Psychiatry (Impact Factor: 13.56). 10/2009; 166(11):1244-50. DOI: 10.1176/appi.ajp.2009.09030342
Source: PubMed

ABSTRACT Implementation of evidence-based care for serious mental illnesses such as bipolar disorder has been suboptimal. Improving and sustaining concordance with clinical practice guidelines has been a cornerstone of efforts to enhance evidence-based care and improve outcomes. For bipolar disorder, however, there has been only one regional controlled trial reporting guideline concordance, and no data are available for time periods longer than 1 year. In a multiregion effectiveness trial in veterans with bipolar disorder, the authors assessed the effects of a collaborative care model for this disorder on guideline concordance in care over a 3-year period.
A total of 306 participants with bipolar disorder were randomly assigned at hospital discharge to 3 years of follow-up treatment with a collaborative care model or to usual care. The collaborative care model included provider support through simplified practice guidelines, patient skills management enhancement through group psychoeducation, and facilitated access and continuity via nurse care management. Concordance with guideline-recommended antimanic pharmacotherapy was assessed at baseline and prospectively over six 6-month epochs. Group differences were assessed with generalized estimating equations that controlled for relevant covariates.
The collaborative care model achieved significantly higher rates of guideline-concordant antimanic treatment than usual care over the entire follow-up period. Baseline guideline concordance, but not patient age or bipolar type, was associated with higher concordance.
Multicomponent collaborative care models, which include not only provider support for guideline implementation but also patient self-management skill enhancement and facilitated treatment access and continuity, can improve guideline concordance over the long term, even in severely impaired patients.

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    • "Thus the CANMAT and ISBD guideline recommends discontinuing antidepressants 6–8 weeks after full remission of depression (Yatham et al., 2013). And the ISBD task force report suggests that the maintenance treatment with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy (Bauer et al., 2009). The probable factors predicting guidelines disconcordance are mostly consistent with those of prescribing antidepressants, including a longer duration of BPD (4 6 years), a recent depressive or mixed episode, and no hospitalization history due to manic episode, except of a depressive episode at first onset as a specific risk for prescribing antidepressants. "
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    ABSTRACT: Although the treatment guidelines of bipolar disorders (BPD) have spread more than a decade, the concordance with evidence-based guidelines was typically low in routine clinical practice. This study is to present the data on the maintenance treatment of BPD in mainland China. One thousand and twenty-three patients who had experienced a euthymia were eligible for entry into this survey on the maintenance treatment of BPD. Guidelines disconcordance was determined by comparing the medication(s) that patients were prescribed with the recommendations in the guidelines of the Canadian Network for Mood and Anxiety Treatments. Three hundred and sixty-four patients (35.6%) had not been prescribed with the maintenance treatment as guidelines recommendations, and 208 patients (20.3%) were prescribed with the antidepressants. A longer duration of BPD, a depressive episode at first onset, and a recent depressive or mixed episode significantly increased the risk for guidelines disconcordance and prescribing antidepressant. In contrast, a hospitalization history due to manic episode was associated with a significant decrease in the risk for guidelines disconcordance and prescribing antidepressant. This study was a cross-sectional and retrospective investigation based on medical records. Considering the potentially hazardous effects of inappropriate treatment, individualized psychoeducational strategies for subjects with BPD are necessary to enhance treatment adherence and close the gap between guidelines and clinical practice in mainland China. Copyright © 2015 Elsevier B.V. All rights reserved.
    Journal of Affective Disorders 04/2015; 182. DOI:10.1016/j.jad.2015.04.028 · 3.71 Impact Factor
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    • "Several guidelines BDI: 55.6% BDII: 30.7% Smith et al. 2008 [27] In-patients 23 BD Expert consensus panel 52% in naturalistic settings, increased to 75% after intervention Bauer et al. 2009 [28] 306 (87% BDI) Department of Veterans Affairs 50%-60% at index hospitalization in collaborative model; declined to 30%-40% after two years Altinbas et al. 2011 [26] Out-patients 263 depressive episodes in 142 patients (131 BDI) "
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    ABSTRACT: Many new approaches have been adopted for the treatment of bipolar disorder (BD) in the past few years, which strived to produce more positive outcomes. To enhance the quality of care, several guideline recommendations have been developed. For study purposes, we monitored the prescription of psychotropic drugs administered to bipolar patients who had been referred to tertiary care services, and assessed the degree to which treatment met specific guidelines. Between December 2006 and February 2009, we assessed 113 individuals suffering from BD who had been referred to the Royal Ottawa Mental Health Centre (ROMHC) Mood Disorders Program by physicians within the community, mostly general practitioners. The Structured Clinical Interview for DSM-IV-TR was used to assess diagnosis. The prescribed treatment was compared with specific Canadian guidelines (CANMAT, 2009). Univariate analyses and logistic regression were used to assess the contribution of demographic and clinical factors for concordance of treatment with guidelines. Thirty-two subjects had BD type I (BD-I), and 81 subjects had BD type II (BD-II). All subjects with BD-I, and 90% of the BD-II group were given at least one psychotropic treatment. Lithium was more often prescribed for subjects with BD-I (62%) than those with BD-II (19%). Antidepressants were the most frequently prescribed class of psychotropics. Sixty-eight percent of subjects received treatment concordant with guidelines by medication and dose. The presence of a current hypomanic episode was independently associated with poorer concordance to guidelines. In more than half the cases, the inappropriate use of antidepressants was at the origin of the non concordance of treatment with respect to guidelines. Absence of psychotropic treatment in bipolar II patients and inadequate dosage of mood stabilizers were the two other main causes of non concordance with guidelines. The factors related to treatment not concordant with guidelines should be further explored to determine appropriate strategies in implementing the use of guidelines in clinical practice.
    BMC Psychiatry 08/2013; 13(1):211. DOI:10.1186/1471-244X-13-211 · 2.24 Impact Factor
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    • "Other strategies, extending beyond the use of guidelines, therefore need to be examined, especially because the evidence suggests that efforts made to spread good clinical practice invariably result in gains for patients . For example, Bauer et al. (2009) have shown that promoting systematic assessments and offering local support to clinicians working with BD improve patient outcomes . Similar national initiatives are being undertaken, e.g. the French BD network developed by Fondation FondaMental (Henry et al. 2011) and the CIBERSAM in Spain (Vieta 2011). "
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    ABSTRACT: Bipolar disorders rank as one of the most disabling illnesses in working age adults worldwide. Despite this, the quality of care offered to patients with this disorder is suboptimal, largely due to limitations in our understanding of the pathology. Improving this scenario requires the development of a critical mass of expertise and multicentre collaborative projects. Within the framework of the European FP7 programme, we developed a European Network of Bipolar Research Expert Centres (ENBREC) designed specifically to facilitate EU-wide studies. ENBREC provides an integrated support structure facilitating research on disease mechanisms and clinical outcomes across six European countries (France, Germany, Italy, Norway, Spain and the UK). The centres are adopting a standardised clinical assessment that explores multiple aspects of bipolar disorder through a structured evaluation designed to inform clinical decision-making as well as being applicable to research. Reliable, established measures have been prioritised, and instruments have been translated and validated when necessary. An electronic healthcare record and monitoring system (e-ENBREC©) has been developed to collate the data. Protocols to conduct multicentre clinical observational studies and joint studies on cognitive function, biomarkers, genetics, and neuroimaging are in progress; a pilot study has been completed on strategies for routine implementation of psycho-education. The network demonstrates ‘proof of principle’ that expert centres across Europe can collaborate on a wide range of basic science and clinical programmes using shared protocols. This paper is to describe the network and how it aims to improve the quality and effectiveness of research in a neglected priority area.
    04/2013; 1(1). DOI:10.1186/2194-7511-1-2
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