- Email: [email protected]
C.09.02 Understanding patient needs in the acute setting
C.09 Bipolar disorder: the journey from diagnosis to recovery References
[1] Burns, T., 2007 Evolution of outcome measures in schizophrenia. Br J Psychiatry 191, sI-s6 [2] Meltzer, H.Y., Bobo, W.Y., Nuamab, I.E, Lane, R., Hough, D., Kramer, M., Eerdekens, M., 2008 Efficacy and tolerability of oral paliperidone extended-release tablets in the treatment of acute schizophrenia: pooled data from three 6-week, placebo-controlled studies. J Clin Psychiatry 69,817-829 [3] Kahn, R.S., Schulz, S.C., Palazov, Y.D., Reyes, E.B., Brecher, M., Svensson, 0., Andersson, H.M., Meulien, D.; Study 132 Investigators., 2007 Efficacy and tolerability of once-daily extended release quetiapine fumarate in acute schizophrenia: a randomized, double-blind, placebocontrolled study. J Clin Psychiatry 68, 832-842
IC.06.041 Can switching anti psychotics improve patient outcomes? P. Falkai 1 ", 1 University of Gottingen, Department of Psychiatry and Psychotherapy, Gottingen, Germany With a wide range of antipsychotic treatment options available to patients with schizophrenia, it is likely that if a particular antipsychotic is not providing optimal treatment then the prescribing physician will decide to modify, add, or switch medication. Patients with schizophrenia may also discontinue treatment or ask to be switched to other medications [1]. Reasons for switching antipsychotic medication include inadequate efficacy, unacceptable adverse events and partial adherence or non-adherence to medication. An individual treatment approach is required for each patient in order to adjust medications, taking the patient's prior medication history into consideration [1]. Prior to switching treatment to another antipsychotic, an adequate assessment of the first antipsychotic should occur [2]. Newer second-generation antipsychotics (SGAs) may offer improved efficacy and tolerability compared with conventional first-generation antipsychotics (FGAs) hence patients may benefit from switching. Additionally, efficacy and side-effect profiles of SGAs are different and switching between SGAs may also be beneficial [3]. However, potential risks of switching antipsychotics/discontinuing treatment will rapidly include increases in adverse events, withdrawal symptoms and aggravation of psychotic symptoms [2,3]. Therefore, making a decision to switch from a conventional FGA to a newer SGA, or between SGAs, should involve consideration of variables relating to the patient, illness, medication, and the patient's environment [2]. There is evidence to suggest that switching antipsychotic treatment in patients with schizophrenia, utilizing individualized switching strategies that include careful choice of medication, can improve patient outcomes under conditions of routine treatment [2,3].
S711
C.09 Bipolar disorder: the journey from diagnosis to recovery IC.09.011 Optimising outcome in bipolar disorder LN. Ferrier 1 ", 1 Newcastle University, School of Neurology Neurobiology and Psychiatry, Newcastle upon ljme, United Kingdom Bipolar disorder is a lifelong debilitating illness. An international survey was carried out to identify the challenges in understanding, diagnosing and treating bipolar disorder, as well as the difficulties faced by patients, and showed that individuals with bipolar disorder frequently experience stigma, misdiagnosis and diminished quality of life. This presentation will review strategies to improve this situation; for example, regular assessment of patients with depression could help improve diagnosis rates for bipolar disorder, while non-pharmacological adjuncts such as psychoeducation enhance symptomatic and functional outcomes [1]. Achieving optimal clinical outcome in bipolar disorder relies on good adherence to treatment as nonadherence is associated with higher risks of hospitalisation [2]. Aspects associated with treatment adherence may be categorised as patient-, illness- or medication-related. Factors such as comorbid substance abuse, negative attitudes toward medication and complicated medication routines are the primary determinants of adherence to medication in bipolar disorder [2]. Patients often cite side effects of medications, including general physical and cognitive effects, as reasons for their reluctance to take treatment [3]; thus consideration of tolerability profiles is important in improving adherence. Patient denial (especially during mania), reluctance to give up experience of manic episodes and medication expense can also have an effect on adherence to medication. This presentation will review strategies to enhance adherence, including simplifying dosing regimens and novel approaches such as SMS text messaging. Patient surveys provide insight into challenges associated with bipolar disorder; addressing these challenges by using advances in pharmacotherapy, psychotherapy and technology may help optimise clinical outcome. References
[1] Miklowitz, D.l, 2008 Adjunctive psychotherapy for bipolar disorder: state of the evidence. Am J Psychiatry 165, 1408-1419. [2] Sajatovic, M., Ignacio, R.Y., West, lA., Cassidy, K.A., Safavi, R., Kilbourne, A.M., Blow, EC., 2009 Predictors of nonadherence among individuals with bipolar disorder receiving treatment in a community mental health clinic. Compr Psychiatry 50, 100-107. [3] Fleck, D.E., Keck, P.E., Jr., Corey, K.B., Strakowski, S.M., 2005 Factors associated with medication adherence in African American and white patients with bipolar disorder. J Clin Psychiatry 66, 646-652.
References
[1] Falkai, P., 2008 Limitations of current therapies: why do patients switch therapies? Eur Neuropsychopharmacol 18 (Suppl 3), S135-139 [2] Buckley, P.E, Correll, C.D., 2008 Strategies for dosing and switching antipsychotics for optimal clinical management. J Clin Psychiatry 69 (Suppl 1), 4-17 [3] Weber, M., Gutierrez, A.M., Mohammadi, M., 2009 The risks and benefits of switching antipsychotics: a case study approach. Perspect Psychiatr Care 45, 54-61
IC.09.021 Understanding patient needs in the acute setting M. Berk 1 ", 1 The University of Melbourne, Department of Clinical & Biomedical Sciences, Geelong, Australia Bipolar disorder is characterised by episodes of depression and mania/hypomania. A key short-term challenge in the management of bipolar disorder is accurate diagnosis of the different phenotypes. Bipolar II disorder is the most prevalent phenotype and is associated with high episode frequency, suicidal behaviour and rapid cycling; however, there is a dearth of information regarding
S712
C.lO Managing life-long treatment in severe psychiatric disorders - clinical experience in the real world
treatment of these patients [1]. Antidepressants are often used as monotherapy for bipolar disorder [2]; however, most do not control manic episodes and may induce manialhypomania. Antipsychotics are effective treatments for bipolar mania and some ofthese agents have demonstrated efficacy in treating depression in patients with bipolar disorder and as maintenance therapy in this patient population. Olanzapine-fluoxetine combination and, to a lesser extent, olanzapine monotherapy significantly improve depressive symptoms. Results from four double-blind, placebo-controlled studies (BOLDER I and II [8-week]; EMBOLDEN I and II [8-weekacutes/26-52-week-continuation phase]) showed that quetiapine monotherapy significantly improved MADRS scores compared with placebo [3]. Currently, data are limited for mood stabilisers, antidepressants and atypical antipsychotics in patients with bipolar II disorder or rapid cycling. Analysis of pooled data from the BOLDERIEMBOLDEN studies showed that improvements in MADRS total scores were significantly greater with quetiapine versus placebo for patients with bipolar I or II depression and in those patients with or without rapid cycling [3]. Similar results have been reported with once-daily, extended release quetiapine fumarate (quetiapine XR). Early, accurate identification of bipolar phenotype and initiation of an appropriate, evidence-based treatment regimen is essential. References [1] Vieta, E., Suppes, T., 2008 Bipolar II disorder: arguments for and against a distinct diagnostic entity. Bipolar Disord 10, 163-178. [2] Baldessarini, R.J., Leahy, L., Arcona, S., Gause, D., Zhang, w., Hennen, J., 2007 Patterns ofpsychotropic drug prescription for U.S. patients with diagnoses of bipolar disorders. Psychiatr Serv 58, 85-91. [3] AstraZeneca Data on file.
Ic.09.031 The
patient-psychiatrist goal: maintaining stability in bipolar disorder
J. Calabrese 1 ", 1 Case Western Reserve University, School of Medicine, Cleveland, USA Bipolar disorder is a chronic illness characterised by episodes of mania and depression, interspersed by relative euthymia. Further to adequate control of acute symptoms, long-term treatment is required to prevent relapse/recurrence, stabilise mood, and reduce subsyndromal symptoms, suicide risk and cycling frequency. It is essential that the dosing of agents used during the transition from acute to long-term treatment of bipolar disorder is sufficient to prevent both manic and depressive relapse. Treatment regimens for long-term management of bipolar disorder include some antipsychotics and other mood-stabilising agents as monotherapy or combination therapy. For example, based on data from two multicentre, randomised, double-blind, placebo-controlled clinical trials, quetiapine adjunct to lithium or divalproex has been approved in the USA as maintenance treatment for bipolar I disorder. Although the use of combination therapy is efficacious as longterm treatment in bipolar disorder, monotherapy can offer a simplified treatment regimen and may potentially improve adherence. Of the atypical antipsychotics, aripiprazole and olanzapine are approved as monotherapy for maintenance treatment of bipolar disorder, based on recurrence prevention of manic episodes. In addition, evidence supporting the efficacy of long-term quetiapine monotherapy is provided by data from two continuationphase (26-52 weeks) studies, which showed that quetiapine significantly increased time to relapse/recurrence of a mood event compared with placebo and was generally well tolerated [1,2].
In summary, individualised treatment regimens, which consider efficacy and tolerability profiles and the transition from acute to maintenance therapy, could improve long-term outcomes in patients with bipolar disorder. References [1] Young, A.H., McElroy, S., Chang, w., Olausson, B., Paulsson, B., Brecher, M., 2008 A double-blind, placebo-controlled study with acute and continuation phase of quetiapine and lithium in adults with bipolar depression (EMBOLDEN I). Int J Neuropsychopharrnacol 11, 187. [2] McElroy, S., Young, A.H., Carlsson, A., Olausson, B., Nordenhem, A., Paulsson, B., Brecher, M., 2008 A double-blind, placebo-controlled study with acute and continuation phase of quetiapine and paroxetine in adults with bipolar depression (EMBOLDEN II). Bipolar Disord 10, 59.
C.lO Managing life-long treatment in
severe psychiatric disorders clinical experience in the real world IC.1 0.011
Life-long treatment in patients with schizophrenia
F. Cafias1 ", 1 Dr R Lafora Hospital, Department of Psychiatry, Madrid, Spain Schizophrenia is a life-long disease requiring life-long treatment. Ensuring good adherence is a challenge to physicians as treatment goals and medication requirements change throughout the different stages of illness. Poor adherence is common in patients with severe psychiatric illness and can lead to discontinuation of medication, symptom recurrence and rehospitalisation. In the acute phase, use of atypical antipsychotics is standard practice for schizophrenia in adolescents and adults, with oral and intramuscular formulations facilitating individualised approaches. During long-term treatment, symptom improvement needs to be balanced with adverse events, which - if unmanaged - can impact on quality of life and adherence. Atypicals offer advantages over typical agents in the long term, providing effective symptom control with a lower risk of extrapyramidal side-effects. However, individual tolerability profiles vary between atypical antipsychotics and some are associated with a high incidence of metabolic risk factors such as weight gain and dyslipidaernia - adverse events with negative health implications that can impact on patient adherence. Thus, long-term tolerability is a key factor when choosing a treatment. The atypical antipsychotic, aripiprazole, has a favourable metabolic side effect profile, demonstrating minimal weight gain in long-term monotherapy studies [1,2]. Combining aripiprazole and clozapine has also shown significant benefits in terms of weight, body mass index and fasting cholesterol in patients with schizophrenia suboptimally treated with clozapine monotherapy, whilst maintaining efficacy [3]. Consideration of the evolving needs of schizophrenia patients combined with individualised treatment can lead to successful life-long treatment. References [1] McQuade, R.D., Stock E., Marcus, R., et al. A comparison of weight change during treatment with olanzapine or aripiprazole: results from a randomized, double-blind study. J Clin Psychiatry 2004;65(Suppl 18):47-56. [2] Chrzanowski, W.K., Marcus, R.N., Torbeyns, A., Nyilas, M., McQuade, R.D. Effectiveness of long-term aripiprazole therapy in patients with acutely relapsing or chronic, stable schizophrenia: a 52-week,
[1] Burns, T., 2007 Evolution of outcome measures in schizophrenia. Br J Psychiatry 191, sI-s6 [2] Meltzer, H.Y., Bobo, W.Y., Nuamab, I.E, Lane, R., Hough, D., Kramer, M., Eerdekens, M., 2008 Efficacy and tolerability of oral paliperidone extended-release tablets in the treatment of acute schizophrenia: pooled data from three 6-week, placebo-controlled studies. J Clin Psychiatry 69,817-829 [3] Kahn, R.S., Schulz, S.C., Palazov, Y.D., Reyes, E.B., Brecher, M., Svensson, 0., Andersson, H.M., Meulien, D.; Study 132 Investigators., 2007 Efficacy and tolerability of once-daily extended release quetiapine fumarate in acute schizophrenia: a randomized, double-blind, placebocontrolled study. J Clin Psychiatry 68, 832-842
IC.06.041 Can switching anti psychotics improve patient outcomes? P. Falkai 1 ", 1 University of Gottingen, Department of Psychiatry and Psychotherapy, Gottingen, Germany With a wide range of antipsychotic treatment options available to patients with schizophrenia, it is likely that if a particular antipsychotic is not providing optimal treatment then the prescribing physician will decide to modify, add, or switch medication. Patients with schizophrenia may also discontinue treatment or ask to be switched to other medications [1]. Reasons for switching antipsychotic medication include inadequate efficacy, unacceptable adverse events and partial adherence or non-adherence to medication. An individual treatment approach is required for each patient in order to adjust medications, taking the patient's prior medication history into consideration [1]. Prior to switching treatment to another antipsychotic, an adequate assessment of the first antipsychotic should occur [2]. Newer second-generation antipsychotics (SGAs) may offer improved efficacy and tolerability compared with conventional first-generation antipsychotics (FGAs) hence patients may benefit from switching. Additionally, efficacy and side-effect profiles of SGAs are different and switching between SGAs may also be beneficial [3]. However, potential risks of switching antipsychotics/discontinuing treatment will rapidly include increases in adverse events, withdrawal symptoms and aggravation of psychotic symptoms [2,3]. Therefore, making a decision to switch from a conventional FGA to a newer SGA, or between SGAs, should involve consideration of variables relating to the patient, illness, medication, and the patient's environment [2]. There is evidence to suggest that switching antipsychotic treatment in patients with schizophrenia, utilizing individualized switching strategies that include careful choice of medication, can improve patient outcomes under conditions of routine treatment [2,3].
S711
C.09 Bipolar disorder: the journey from diagnosis to recovery IC.09.011 Optimising outcome in bipolar disorder LN. Ferrier 1 ", 1 Newcastle University, School of Neurology Neurobiology and Psychiatry, Newcastle upon ljme, United Kingdom Bipolar disorder is a lifelong debilitating illness. An international survey was carried out to identify the challenges in understanding, diagnosing and treating bipolar disorder, as well as the difficulties faced by patients, and showed that individuals with bipolar disorder frequently experience stigma, misdiagnosis and diminished quality of life. This presentation will review strategies to improve this situation; for example, regular assessment of patients with depression could help improve diagnosis rates for bipolar disorder, while non-pharmacological adjuncts such as psychoeducation enhance symptomatic and functional outcomes [1]. Achieving optimal clinical outcome in bipolar disorder relies on good adherence to treatment as nonadherence is associated with higher risks of hospitalisation [2]. Aspects associated with treatment adherence may be categorised as patient-, illness- or medication-related. Factors such as comorbid substance abuse, negative attitudes toward medication and complicated medication routines are the primary determinants of adherence to medication in bipolar disorder [2]. Patients often cite side effects of medications, including general physical and cognitive effects, as reasons for their reluctance to take treatment [3]; thus consideration of tolerability profiles is important in improving adherence. Patient denial (especially during mania), reluctance to give up experience of manic episodes and medication expense can also have an effect on adherence to medication. This presentation will review strategies to enhance adherence, including simplifying dosing regimens and novel approaches such as SMS text messaging. Patient surveys provide insight into challenges associated with bipolar disorder; addressing these challenges by using advances in pharmacotherapy, psychotherapy and technology may help optimise clinical outcome. References
[1] Miklowitz, D.l, 2008 Adjunctive psychotherapy for bipolar disorder: state of the evidence. Am J Psychiatry 165, 1408-1419. [2] Sajatovic, M., Ignacio, R.Y., West, lA., Cassidy, K.A., Safavi, R., Kilbourne, A.M., Blow, EC., 2009 Predictors of nonadherence among individuals with bipolar disorder receiving treatment in a community mental health clinic. Compr Psychiatry 50, 100-107. [3] Fleck, D.E., Keck, P.E., Jr., Corey, K.B., Strakowski, S.M., 2005 Factors associated with medication adherence in African American and white patients with bipolar disorder. J Clin Psychiatry 66, 646-652.
References
[1] Falkai, P., 2008 Limitations of current therapies: why do patients switch therapies? Eur Neuropsychopharmacol 18 (Suppl 3), S135-139 [2] Buckley, P.E, Correll, C.D., 2008 Strategies for dosing and switching antipsychotics for optimal clinical management. J Clin Psychiatry 69 (Suppl 1), 4-17 [3] Weber, M., Gutierrez, A.M., Mohammadi, M., 2009 The risks and benefits of switching antipsychotics: a case study approach. Perspect Psychiatr Care 45, 54-61
IC.09.021 Understanding patient needs in the acute setting M. Berk 1 ", 1 The University of Melbourne, Department of Clinical & Biomedical Sciences, Geelong, Australia Bipolar disorder is characterised by episodes of depression and mania/hypomania. A key short-term challenge in the management of bipolar disorder is accurate diagnosis of the different phenotypes. Bipolar II disorder is the most prevalent phenotype and is associated with high episode frequency, suicidal behaviour and rapid cycling; however, there is a dearth of information regarding
S712
C.lO Managing life-long treatment in severe psychiatric disorders - clinical experience in the real world
treatment of these patients [1]. Antidepressants are often used as monotherapy for bipolar disorder [2]; however, most do not control manic episodes and may induce manialhypomania. Antipsychotics are effective treatments for bipolar mania and some ofthese agents have demonstrated efficacy in treating depression in patients with bipolar disorder and as maintenance therapy in this patient population. Olanzapine-fluoxetine combination and, to a lesser extent, olanzapine monotherapy significantly improve depressive symptoms. Results from four double-blind, placebo-controlled studies (BOLDER I and II [8-week]; EMBOLDEN I and II [8-weekacutes/26-52-week-continuation phase]) showed that quetiapine monotherapy significantly improved MADRS scores compared with placebo [3]. Currently, data are limited for mood stabilisers, antidepressants and atypical antipsychotics in patients with bipolar II disorder or rapid cycling. Analysis of pooled data from the BOLDERIEMBOLDEN studies showed that improvements in MADRS total scores were significantly greater with quetiapine versus placebo for patients with bipolar I or II depression and in those patients with or without rapid cycling [3]. Similar results have been reported with once-daily, extended release quetiapine fumarate (quetiapine XR). Early, accurate identification of bipolar phenotype and initiation of an appropriate, evidence-based treatment regimen is essential. References [1] Vieta, E., Suppes, T., 2008 Bipolar II disorder: arguments for and against a distinct diagnostic entity. Bipolar Disord 10, 163-178. [2] Baldessarini, R.J., Leahy, L., Arcona, S., Gause, D., Zhang, w., Hennen, J., 2007 Patterns ofpsychotropic drug prescription for U.S. patients with diagnoses of bipolar disorders. Psychiatr Serv 58, 85-91. [3] AstraZeneca Data on file.
Ic.09.031 The
patient-psychiatrist goal: maintaining stability in bipolar disorder
J. Calabrese 1 ", 1 Case Western Reserve University, School of Medicine, Cleveland, USA Bipolar disorder is a chronic illness characterised by episodes of mania and depression, interspersed by relative euthymia. Further to adequate control of acute symptoms, long-term treatment is required to prevent relapse/recurrence, stabilise mood, and reduce subsyndromal symptoms, suicide risk and cycling frequency. It is essential that the dosing of agents used during the transition from acute to long-term treatment of bipolar disorder is sufficient to prevent both manic and depressive relapse. Treatment regimens for long-term management of bipolar disorder include some antipsychotics and other mood-stabilising agents as monotherapy or combination therapy. For example, based on data from two multicentre, randomised, double-blind, placebo-controlled clinical trials, quetiapine adjunct to lithium or divalproex has been approved in the USA as maintenance treatment for bipolar I disorder. Although the use of combination therapy is efficacious as longterm treatment in bipolar disorder, monotherapy can offer a simplified treatment regimen and may potentially improve adherence. Of the atypical antipsychotics, aripiprazole and olanzapine are approved as monotherapy for maintenance treatment of bipolar disorder, based on recurrence prevention of manic episodes. In addition, evidence supporting the efficacy of long-term quetiapine monotherapy is provided by data from two continuationphase (26-52 weeks) studies, which showed that quetiapine significantly increased time to relapse/recurrence of a mood event compared with placebo and was generally well tolerated [1,2].
In summary, individualised treatment regimens, which consider efficacy and tolerability profiles and the transition from acute to maintenance therapy, could improve long-term outcomes in patients with bipolar disorder. References [1] Young, A.H., McElroy, S., Chang, w., Olausson, B., Paulsson, B., Brecher, M., 2008 A double-blind, placebo-controlled study with acute and continuation phase of quetiapine and lithium in adults with bipolar depression (EMBOLDEN I). Int J Neuropsychopharrnacol 11, 187. [2] McElroy, S., Young, A.H., Carlsson, A., Olausson, B., Nordenhem, A., Paulsson, B., Brecher, M., 2008 A double-blind, placebo-controlled study with acute and continuation phase of quetiapine and paroxetine in adults with bipolar depression (EMBOLDEN II). Bipolar Disord 10, 59.
C.lO Managing life-long treatment in
severe psychiatric disorders clinical experience in the real world IC.1 0.011
Life-long treatment in patients with schizophrenia
F. Cafias1 ", 1 Dr R Lafora Hospital, Department of Psychiatry, Madrid, Spain Schizophrenia is a life-long disease requiring life-long treatment. Ensuring good adherence is a challenge to physicians as treatment goals and medication requirements change throughout the different stages of illness. Poor adherence is common in patients with severe psychiatric illness and can lead to discontinuation of medication, symptom recurrence and rehospitalisation. In the acute phase, use of atypical antipsychotics is standard practice for schizophrenia in adolescents and adults, with oral and intramuscular formulations facilitating individualised approaches. During long-term treatment, symptom improvement needs to be balanced with adverse events, which - if unmanaged - can impact on quality of life and adherence. Atypicals offer advantages over typical agents in the long term, providing effective symptom control with a lower risk of extrapyramidal side-effects. However, individual tolerability profiles vary between atypical antipsychotics and some are associated with a high incidence of metabolic risk factors such as weight gain and dyslipidaernia - adverse events with negative health implications that can impact on patient adherence. Thus, long-term tolerability is a key factor when choosing a treatment. The atypical antipsychotic, aripiprazole, has a favourable metabolic side effect profile, demonstrating minimal weight gain in long-term monotherapy studies [1,2]. Combining aripiprazole and clozapine has also shown significant benefits in terms of weight, body mass index and fasting cholesterol in patients with schizophrenia suboptimally treated with clozapine monotherapy, whilst maintaining efficacy [3]. Consideration of the evolving needs of schizophrenia patients combined with individualised treatment can lead to successful life-long treatment. References [1] McQuade, R.D., Stock E., Marcus, R., et al. A comparison of weight change during treatment with olanzapine or aripiprazole: results from a randomized, double-blind study. J Clin Psychiatry 2004;65(Suppl 18):47-56. [2] Chrzanowski, W.K., Marcus, R.N., Torbeyns, A., Nyilas, M., McQuade, R.D. Effectiveness of long-term aripiprazole therapy in patients with acutely relapsing or chronic, stable schizophrenia: a 52-week,