CURRENT CHALLENGES IN BIPOLAR DISORDER London Division 27 October 2014 Dr Matthew Taylor Institute of Psychiatry, Psychology & Neuroscience Bipolar Disorder prevalence estimate 0.9% i.e. 3 million people across Europe Spectrum of mood disorders ‘bipolar spectrum’ Hypomania Mania Depression Recurrent depressive disorder Bipolar II Bipolar I Clare Dolman http://www.bipolaruk.org.uk/ Psychiatrist’s Perspective Delayed Diagnosis anxiety often precedes mood Sx Substance use disorders after onset mood Sx Delays in current care First symptoms Age (yr): 17.5 First episode 21.2 First treatment sought 24 Bipolar diagnosis 30 Participants in Bipolar Comprehensive Outcomes Study (n=240) Berk et al. (2007) Journal of Affective Disorders 103:181-186 Recurrence rates and number of episodes Denmark: all admissions 1971-1993 n~3000 Adapted from Kessing et al. British Journal of Psychiatry 1998:172:23-28 SLaM cohort pseudonymised electronic health records Cohort of 1,440 patients: (i) Age: 16 – 65 years (ii) First referral to SLaM between 01/01/2007 and 31/05/2012 (iii) Subsequent diagnosis of bipolar disorder Prior personality disorder 65 0.322 1.24 0.81 Time to diagnosis from presentation to SLaM • HR >1 implies variable is associated with greater delay to diagnosis of bipolar disorder 1.89 • Cox regression model adjusted for age, gender, ethnicity, employment status and accommodation status Figure 1 Diagnosis on presentation (secondary care) Unipolar depression 228(16%) With psychosis (44; 3%) Non-affective psychosis Anxiety disorder Substance disorder Personality disorder 227 (16%) 87 (6%) 87 (6%) 65 (5%) Is there a role for self-report screening instruments? MDQ (Mood Disorder Questionnaire) Includes 13-item yes/no. HCL-32 (Hypomania Checklist) Includes 32-item yes/no. Shorter versions in development BSDS (Bipolar Spectrum Diagnostic Scale) Rating how well a descriptive paragraph fits Hirschfeld, R. M., et al. American Journal of Psychiatry, 2000;157, 1873–1875 Angst, J., et al. Journal of Affective Disorders, 2005;88, 217–233. Ghaemi, S. N. et al. Journal of Affective Disorders, 2005;84, 273–277 Recognition of bipolar disorder Primary care patients with working diagnosis of unipolar depression Screening instruments (HCL-32 & BSDS) High score Low score Shortage of Interventions Poor access to effective interventions I n the subgroups with depressive (n = 298) or hypomania or failure to co hypomanic ﬁrst episodes (n = 50), it is notable implications of such a presenta that these occur earlier than mania, and suicide women are more likely to seek attempts typically occur prior to the introduction healthcare services (29–31), w of any form of treatment. The longest DUB was in wait 2 years longer than men those presenting with hypomania (median, scribed a mood stabilizer, sugg 14.5 years) rather than depression (median DUB ment in this gender bias over Franceof(Drancourt et al. 2013) 13 years) or mania (median DUB of 8 years). 32). When diagnostic subtype into account, We demonstrated that onset Median four years fromwas firsttaken admission to ‘mood stabiliser’ (n=501) the median DUB in BD-I I cases presenting with niﬁcantly inﬂuenced the DUB. • [atypical antipsychotic, lithium, anticonvulsant] depression was about 14 years compared with £21 years) is associated with a about 11 years for BD-I cases (data available on represents the most replicated request) (Fig. 3). ture (9, 10, 12, 15, 31, 33–35 Time to appropriate treatment Fig. 2. K ey clin age in years ± tion of Untreat (DUB) for all s Time to treatment initiation Time to atypical antipsychotic, lithium, or anticonvulsant Median 35 days (IQR 6 to 140) Time from presentation to secondary care services Time to treatment initiation - SLaM Time to atypical antipsychotic, lithium, or anticonvulsant Median -3 days (IQR -64 to 0) Neglect in service development Bipolar Disorder Mood monitoring Facilitate self-management Improved communication Improvements in engagement, treatment adherence