Bipolar

Recurrence rates for bipolar disorder are high even with ongoing therapy. One study found a 73% relapse rate at 5 years, and two thirds of the patients had multiple relapses.11 Other estimates place the relapse rate at about 90%, with nearly half of the relapses occurring within 2 years.12 - See more at: http://www.ajmc.com/publications/supplement/2005/2005-06-vol11-n3Suppl/Jun05-2075pS80S84/#sthash.Ui3ebI5P.dpuf Patients with bipolar disorder have a higher risk of suicide than patients with any other psychiatric or medical illness.33 According to one study, the odds ratio for suicide attempts in bipolar disorder was 6.2, which was higher than any other axis I psychiatric disorder, including depression.34 Another study showed that patients with bipolar disorder had a higher lifetime history of suicide attempt than patients with any other psychiatric disorder.35 Rates of suicidal ideation and attempts range between 35% and 50%.28,33,36 The Stanley Center Bipolar Disorder Registry reported that 50% of patients enrolled had attempted suicide, and 35% of the attempts resulted in hospitalization.28 The rate of completed suicide is approximately 20% - See more at: http://www.ajmc.com/publications/supplement/2005/2005-06-vol11-n3suppl/jun05-2075ps80s84/2#sthash.J0hNSSBP.dpuf
Sajatovic M, Blow F, Ignacio RV, Kales HC. New onset bipolar disorder in later life. Am J Geriatr Psychiatry. 2005;13:282-289.
Recurrence rates are high at around 50% at one year and 70% at four years

Relapse and impairment in bipolar disorder.

Gitlin MJ, Swendsen J, Heller TL, Hammen C.
Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry. 1995;152:1635-1640.

Source
Department of Psychiatry, University of California, Los Angeles 90024-6968, USA.

Abstract
OBJECTIVE: The purpose of this study was to evaluate the outcome of bipolar disorder in the context of maintenance pharmacotherapy. METHOD: Eighty-two bipolar outpatients were followed prospectively for a mean of 4.3 years (minimum of 2 years); symptom rating and psychosocial outcome scales were used, and pharmacotherapy was rated on a 5-point scale. RESULTS: Despite continual maintenance treatment, survival analysis indicated a 5-year risk of relapse into mania or depression of 73%. Of those who relapsed, two-thirds had multiple relapses. Relapse could not be attributed to inadequate medication. Even for those who did not relapse, considerable affective morbidity was observed. A measure of cumulative affective morbidity appeared to be a more sensitive correlate of psychosocial functioning than was the number of relapses. Poor psychosocial outcome paralleled poor syndromal course. Poor psychosocial functioning, especially occupational disruption, predicted a shorter time to relapse. Depressions were most strongly related to social and family dysfunction. CONCLUSIONS:

Even aggressive pharmacological maintenance treatment does not prevent relatively poor outcome in a significant number of bipolar patients.

Family and Psychosocial Issues

Psychosocial stress is known to trigger manic and depressive symptoms. Although there are limited and heterogeneous data to support family interventions for bipolar disorders,55 patients who have social support in recognizing early warning signs of recurrence appear to have less risk of recurrence and hospitalization and have better functioning.33 Patients who receive intensive psychotherapy 7 or group therapy 31 have fewer relapses and longer periods of relative wellness compared with patients who receive brief therapy. Patients with frequent episodes of mania may benefit from strategies that emphasize medication adherence, whereas those with more depressive symptoms benefit from treatments focused on coping strategies and cognitive behavior therapy.56 Patients, families, and caregivers should establish a plan for addressing suicidal and homicidal ideation quickly if they become apparent.

Bipolar Disorders: A Review

AMY L. PRICE, MD, Eastern Virginia Medical School, Norfolk, Virginia GABRIELLE R. MARZANI-NISSEN, MD, University of Virginia School of Medicine, Charlottesville, Virginia Am Fam Physician. 2012 Mar 1;85(5):483-493.

Psikotik akut

Box 6 shows possible outcomes of standard care, on the basis of two reviews.7 20 Between 30% and 60% of patients with a first episode of psychosis receiving interventions from UK community mental health teams had a good outcome at three years.12 Among those patients who do not respond to treatment initially, 16% have a good recovery at 15 years.7 These patients, who have a complex long term illness and a high risk of relapse, are best managed in specialist settings. Early intervention teams provide phase specific treatments, integrated case management, and cognitive behaviour therapy interventions.13 A randomised clinical trial has shown the value of integrated care in patients with a first episode of psychosis.21 Patterns of symptoms change over time and a modular form of cognitive behaviour therapy meets people's needs most effectively. Early intervention teams reduce the duration of untreated psychosis.13 22 Despite early misgivings among researchers, duration of untreated psychosis is a remediable, independent predictor of worse outcome.w35 Social functioning and vocational outcomes at 18 months are significantly improved by early intervention teams.23 Excess deaths including suicide are seen in all patients with a first episode of psychosis,7 but a fall in suicide rates in people with schizophrenia has been attributed to reduced access to lethal methods and better treatment (from early intervention teams).24 The evidence supporting early intervention teams is better than that justifying the current practice of standard care.w36 One key research question remains: Do specialised early intervention teams offer improvements in outcome over and above those provided by phase-specific interventions alone?w36
Box 6 Relapse and recovery after a psychotic episode

Relapse at one year20

Antipsychotic drug treatment but no psychosocial interventions

40% of all patients; 62% if in a stressful environment 27% of patients with a first episode of psychosis; 48% of patients with five or more previous episodes

Placebo treatment and no psychosocial interventions

61% of patients with a first episode of psychosis; 87% of patients with five or more previous episodes

Antipsychotic drug treatment and psychosocial intervention(s)

19% with family education; 20% after social skills training; 0% with both interventions; 38% for controls (antipsychotic drug treatment alone). A total of 103 patients from stressful environments were studied

Recovery (defined as global assessment of function >60) at 15-25 years' follow-up7

37.8% of patients with schizophrenia 54.8% of patients with other psychoses

After recovery (full or partial), a single antipsychotic drug is given prophylactically, usually at a lower dose than that needed for treating acute illness (table 22).). Treatment of a first episode is recommended for one year, followed by gradual cessation in asymptomatic patients at low risk. Risk of relapse is indicated by residual disability, family history of psychosis, or current substance misuse. Patients at risk and those with multiple psychotic episodes require longer prophylaxis. Patients with a history of violence need more intensive case management to reduce risk, and this may include prolonged medication under supervision. Given the high personal and health service costs of relapse, decisions about discontinuation and prophylaxis should be agreed with early intervention teams. Several early models for intervention teams have been described, with varying resource implications.25 The subject of treatment resistant psychosis has been discussed by others.10 26 Multiple coordinated interventions at adequate doses with verified adherence, including clozapine as a third line drug, must be applied before treatment failure is confirmed.
BMJ. 2007 March 31; 334(7595): 686692.

doi: 10.1136/bmj.39148.668160.80

CID: PMC1839209

Peter Byrne, consultant psychiatrist