Bob Post (one of the most eminent psychiatrists of our time) published a passionate article in the March 2018 edition of the Journal of the American Medical Association in support of the importance of specialty care for bipolar disorder.
Of course, we couldn’t agree more. That is one of the reasons we founded the clinic. We saw that specialty care for bipolar disorder or recurrent major depression could achieve much better outcomes. And that has continued to be our experience.
Dr. Post writes that,
“Data from 3 studies suggest that intensive treatment should be started after a first manic episode. Kessing, et al, conducted a randomized clinical trial of 158 patients having a first hospitalization for mania. Compared with patients receiving treatment as usual, those randomized to 2 years of expert treatment in a specialty clinic showed a longer time to rehospitalization, and the between-group differences persisted and increased during the next 6 years … with fewer patients (36.1%) readmitted compared with patients who received treatment as usual (54.7%) and the duration of readmissions was shorter.”
Specialty care for two years was associated with meaningfully better outcomes that persisted for at least six years.
“Kozicky, et al, reported that after a first hospitalization for mania, cognition on a comprehensive battery of tests improved more (returned toward normal) in the 27 patients who experienced no further manic episodes during the next year compared with the 26 who experienced recurrences.”
By preventing recurrences, specialty care can improve cognitive function, with the result that patients may avoid long term disability.
In another trial, Berk, et al, randomized 61 patients who had a first hospitalization for mania to 1 year of treatment with either lithium or the atypical antipsychotic quetiapine (800 mg/d). In mixed-model repeated-measures analyses, lithium was more effective than quetiapine on every outcome measure, including mood, functioning, cognition, and brain imaging alterations with large differences emerging during the second half of the year.”
Lithium is much less likely to be prescribed outside a specialty care setting, despite the strong evidence that lithium is associated with better outcomes.
“What are the consequences of treating a first manic episode without the care, caution,and follow-up that would be used for treating cancer? With inadequate long-term treatment and follow-up of patients with a manic episode, the recurrence of greater numbers of episodes is associated with increasing dysfunction, disability, cognitive dysfunction, treatment resistance, telomere shortening, medical comorbidity, prefrontal cortex deficits, and the risk of receiving a diagnosis of dementia during old age. The accumulation of so many illness-related liabilities would appear to merit the term malignant transformation of bipolar disorder.”
Failure to provide specialty care for bipolar may allow it to transform into a much more malignant illness.
References
Post RM. Preventing the Malignant Transformation of Bipolar Disorder. JAMA. Published online March 05, 2018. doi:10.1001/jama.2018.0322
Kessing LV, Hansen HV, Hvenegaard A, et al; Early Intervention Affective Disorders (EIA) Trial Group. Treatment in a specialised out-patient mood
disorder clinic v standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial. Br J Psychiatry. 2013;202(3):212-219.
Kozicky JM, Torres IJ, Silveira LE, Bond DJ, Lam RW, Yatham LN. Cognitive change in the year after a first manic episode: association between clinical
outcome and cognitive performance early in the course of bipolar I disorder. J Clin Psychiatry. 2014; 75(6):e587-e593.
Berk M, Daglas R, Dandash O, et al. Quetiapine v lithium in the maintenance phase following a first episode of mania: randomised controlled trial. Br J
Psychiatry. 2017;210(6):413-421.
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