Impact of an educational program on the management of bipolar disorder in primary care.
ABSTRACT Government agencies and industry have recently undertaken educational programs for the management of bipolar disorder in primary care, but their medical impact is not well known. Therefore, we conducted a survey among general practitioners to evaluate the impact of the Bipolact Educational Program on the diagnosis and treatment of bipolar disorder.
A total of 45 general practitioners attending the Bipolact Educational Program (trained group) were compared with a control group of 50 untrained general practitioners on their ability to: (i) diagnose bipolar I and II disorders and (ii) treat bipolar disorder patients appropriately.
Trained physicians, but not untrained physicians, showed a significant improvement (p < 0.0001, chi-square test) in the ability to identify patients as having bipolar I (from 10.4% to 28.8%) and bipolar II disorder (from 20.1% to 45.8%). This trend resulted in a strong decrease in nonidentified bipolar disorder patients (from 64.6% to 19.5%). Trained physicians, but not the untrained group, greatly increased the number of prescriptions for mood stabilizers for bipolar disorder patients, from 25.6% to 43.2% (p = 0.0013, chi-square test). Finally, trained physicians reduced the number of antidepressant prescriptions for bipolar disorder patients (the control group also reduced the number of antidepressant prescriptions, suggesting some bias in the survey).
A well-designed education package on diagnosis and management of bipolar disorder greatly increased the likelihood of physicians correctly assigning a subtype, namely bipolar I or bipolar II disorder, to patients already perceived as having some form of bipolar illness, and to prescribing mood stabilizers instead of antidepressants to these patients.
- European Neuropsychopharmacology 03/2001; 11(1):79-88. · 4.60 Impact Factor
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ABSTRACT: According to DSM-IV and ICD-10, hypomania which occurs solely during antidepressant treatment does not belong to the category of bipolar II (BP-II). As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 144 (29.2%) fulfilled the criteria for bipolar II with spontaneous hypomania (BP-II Sp), and 52 (10.5%) had hypomania associated solely with antidepressants (BP-H AA). BP-II Sp group had earlier age at onset, more hypomanic episodes, and higher ratings on cyclothymic and hyperthymic temperaments, and abused alcohol more often. The two groups were indistinguishable on the hypomania checklist score (12.2+/-4.0 vs. 11.4+/-4.4, respectively, P=0.25) and on rates of familial bipolarity (14.1% vs. 11.8%, respectively, P=0.68). But BP-H AA had significantly more family history of suicide, had higher ratings on depressive temperament, with greater chronicity of depression, were more likely to be admitted to the hospital for suicidal depressions, and were more likely to have psychotic features; finally, clinicians were more likely to treat them with ECT, lithium and mood stabilizing anticonvulsants. Naturalistic study, where treatment was uncontrolled. BP-H AA emerges as a disorder with depressive temperamental instability, manifesting hypomania later in life (and, by definition, during pharmacotherapy only). By the standards of clinicians who have taken care of these patients for long periods of time, BP-H AA appears as no less bipolar than those with prototypical BP-II. We submit that familial bipolarity ('genotypic' bipolarity) strongly favors their inclusion within the realm of bipolar II spectrum, as a prognostically less favorable depression-prone phenotype of this disorder, and which is susceptible to destabilization under antidepressant treatment. These considerations argue for revisions of DSM-IV and ICD-10 conventions. BP-HAA may represent a genetically less penetrant expression of BP-II; phenotypically; it might provisionally be categorized as bipolar III.Journal of Affective Disorders 02/2003; 73(1-2):65-74. · 3.30 Impact Factor
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ABSTRACT: The boundaries of bipolarity have been expanding over the past decade. Using a well characterized epidemiologic cohort, in this paper our objectives were: (1). to test the diagnostic criteria of DSM-IV hypomania, (2). to develop and validate criteria for the definition of softer expressions of bipolar-II (BP-II) disorder and hypomania, (3). to demonstrate the prevalence, clinical validity and comorbidity of the entire soft bipolar spectrum. Data on the continuum from normal to pathological mood and overactivity, collected from a 20-year prospective community cohort study of young adults, were used. Clinical validity was analysed by family history, course and clinical characteristics, including the association with depression and substance abuse. (1). Just as euphoria and irritability, symptoms of overactivity should be included in the stem criterion of hypomania; episode length should probably not be a criterion for defining hypomania as long as three of seven signs and symptoms are present, and a change in functioning should remain obligatory for a rigorous diagnosis. (2). Below that threshold, 'hypomanic symptoms only' associated with major or mild depression are important indicators of bipolarity. (3). A broad definition of bipolar-II disorder gives a cumulative prevalence rate of 10.9%, compared to 11.4% for broadly defined major depression. A special group of minor bipolar disorder (prevalence 9.4%) was identified, of whom 2.0% were cyclothymic; pure hypomania occurred in 3.3%. The total prevalence of the soft bipolar spectrum was 23.7%, comparable to that (24.6%) for the entire depressive spectrum (including dysthymia, minor and recurrent brief depression). A national cohort with a larger number of subjects is needed to verify the numerical composition of the softest bipolar subgroups proposed herein. The diagnostic criteria of hypomania need revision. On the basis of its demonstrated clinical validity, a broader concept of soft bipolarity is proposed, of which nearly 11% constitutes the spectrum of bipolar disorders proper, and another 13% probably represent the softest expression of bipolarity intermediate between bipolar disorder and normality.Journal of Affective Disorders 02/2003; 73(1-2):133-46. · 3.30 Impact Factor