Assessment and management of bipolar disorder: summary of updated NICE guidance
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5673 (Published 25 September 2014) Cite this as: BMJ 2014;349:g5673
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I was very delighted to have read this article which provides a comprehensive, stepwise approach to assessing and managing this frequently encountered, complex and recurrent illness.
The author reminds us of the risk implications associated with Bipolar Affective Disorder, which include physical health insults and co morbidity .
One could not help but appreciate the welcome additions to the management of this disorder, such as a greater emphasis on psychological intervention. These, though evidence based, in reality at not readily accessible, given the rapidly declining availability of these services.
On the other hand, I was disappointed by the absence of ECT as a treatment modality for Bipolar depression. I note that the NICE guidance has continued to include ECT as treatment in mania. Whilst I appreciate the apparent difficulty in providing evidence based information for this treatment modality, it continues to be of superior efficacy in the treatment of depressive illness. This is especially noticeable in individuals who have had previous good response to ECT and also in those who struggle to tolerate untoward effects of pharmacological preparations.
I note that ECT may have been included in NICE Guidance in the past. It is also worth noting , that ECT continues to play a significant role in secondary care. Many of my Consultant colleagues and myself , utilise this treatment to good effect.
It therefore seems farcical to omit this, given the quick response for the client, the minimal side effect profile and the relatively low cost effectiveness of the procedure.
1. NICE, CG 185, sec 1.5.11, Sept 2014
2. NICE, CG 185, 2006
Competing interests: No competing interests
The article by Kendall et al.[1] and the guidance to which it refers[2] come as a disappointment. Though some new recommendations are welcome, such as fostering a collaborative approach with patients and carers, many opportunities have been missed.
First, the issue of diagnosis. ‘This guideline...has been developed to advise on the assessment and management of bipolar disorder... NICE guidance aims to improve standards of care, diminish unacceptable variations in the provision and quality of care across the NHS...The burden of illness is exacerbated by difficulties obtaining an accurate diagnosis and optimal treatment.’[2] It might be inferred that the guideline will advise on which diagnostic criteria are to be preferred. On this the guideline is silent, passing up the opportunity to encourage secondary care clinicians in the UK to use DSM, recommended by other guidelines as the more clear and logical[3]. Colleagues in primary care are advised to ‘ask about periods of overactivity and disinhibited behaviour’ when adults present with depression, and in the article the reader is referred to ‘key symptoms’ and ICD-10. Despite this, the guideline itself refers almost throughout to bipolar I and II, found only in DSM and used in most of the scientific literature on bipolar disorder throughout the world.
The ‘key symptoms’ are described as those of mania and severe depression. In the guideline they are referred to simply as symptoms mania of major depression. The inference might be taken that if one or more of these is absent the patient does not have bipolar disorder. As the guideline observes, mood in hypomania and mania is frequently irritable rather than expansive and grandiose. But overactivity in areas other than talk is probably more important and more easily and reliably recognised than ‘inflated self- esteem’.[4] Fatigue and psychomotor retardation are key symptoms of major depression in both diagnostic systems but not mentioned here, though they may be among the most prominent symptoms of bipolar depression.[5] ‘Profound’ loss of interest in activities, used here to refer to severe depression but in the guideline simply to bipolar depression, is an unnecessary exaggeration of both ICD and DSM criteria. This serves only to further strengthen major obstacles to optimal recognition of bipolar disorder in primary and secondary care, the failure to accept and recognise: irritable mania and hypomania; the importance of hypomania; and of major depression which falls short of the most severe.
Second, the management of bipolar depression in secondary care. The evidence for a heterogeneous group of talking therapies for bipolar disorder is reviewed in the guideline. ‘Most evidence was of low or very low quality’ and ‘the results of the meta-analyses suggest that psychological interventions MAY be associated with symptomatic improvement, reduced relapse, and hospitalisation.’[2] But there is a new recommendation to offer to all those with bipolar depression either a psychological intervention - of whatever type-developed for those with bipolar disorder or one of proven only efficacy in unipolar major depression. The evidence for the effectiveness of talking treatment in unipolar major depression is better than in bipolar depression, so this is extrapolated to bipolar depression, even though the response of these conditions to pharmacological intervention may be very different.[6] This may play to the prevailing public mood but seems to go beyond the evidence.
Third, long-term management. Clinicians are to promote ‘a positive recovery message from the point of diagnosis and throughout care.’ It is unclear what this positive message should be. Though the guideline sets out the often chronic course of bipolar disorder, it fails to take the opportunity to correct the prevalent view that this is an episodic condition. The opportunity to promote the kind of chronic disease management advocated for conditions such as asthma and diabetes[7] is largely missed. Though ‘optimal treatment of bipolar disorder is challenging and requires long-term commitment from health services’ it seems much of this is to be done in primary care. Patients whose symptoms have responded to treatment and remain stable should be offered ‘the option’ of a return to primary care. I suspect this will serve only to encourage the fire-fighting approach to the management of bipolar disorder preferred in current mental health services, where those who are euthymic, if only briefly, are discharged to primary care. There clinicians will ‘engage with and develop an ongoing relationship with (patients), support them to carry out care plans developed in secondary care and achieve their recovery goals.’ This may seem unlikely to some. At the very least expert opinion might have been given on the minimum duration of stability required before discharge from secondary care- say 12 months following resolution of mania?
In this section bipolar disorder is considered as a whole without division into bipolar I and II. There is insufficient emphasis on evaluation of the predominant burden of the disorder, whether (hypo)manic, depressive or both, and tailoring long-term treatment to ameliorate that. Lithium is recommended as first line preventative treatment for all, and if this is ineffective the addition of valproate should be considered. The first may be logical, but many clinicians may think it runs counter to clinical common sense for many if not most patients with bipolar II. The addition of valproate is supported by evidence only in those with bipolar I.[8]
References
1. Kendall T, Morriss R, Mayo-Wilson E, et al. Assessment and management of bipolar disorder: summary of updated NICE guidance. 2014;349:g5673
2. National Institute for Health and Care Excellence. Bipolar Disorder (update): the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. (Clinical Guideline 185.) 2014
3. Goodwin G. Evidence-based guidelines for treating bipolar disorder: revised second edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2009;23:346-88
4. Angst J, Gamma A, Bowden CL, et al. Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients with major depressive episodes in the Bridge Study: validity and comorbidity. Eur Arch Psychiatry Clin Neurosci 2013;263:663-73
5. Goodwin FK, Jamison KR. Manic-depressive Illness: Bipolar Disorders and Recurrent depression. 2nd ed. New York: Oxford University Press, 2007.
6. Pacchiarotti I, Bond DJ, Baldessarini RJ, et al. The International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders. Am J Psychiatry 2013;170:1249-62
7. World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization, 2003.
8. The BALANCE investigators and collaborators. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial. The Lancet 2010;375:385-95
Competing interests: No competing interests
There are some things to applaud about the recently released update of the NICE bipolar guidelines, not least the recognition that the diagnosis has been inappropriately applied to children with behavioural problems. Hopefully this will help curtail the worrying trend of using toxic bipolar drugs in this age group. As usual, however, the Guidelines overlook glaring problems with the evidence base for drug treatment in general, and miss an opportunity to stem the diagnostic creep that has come to the UK and Europe via the United States.
Although NICE does not refer to the inflated prevalence figures suggested by some, the prevalence of classical bipolar disorder (the sort that used to be called ‘manic depression’) is probably more in the region of 1 in 1000 than 1 in 100 (1). But NICE’s concept of bipolar disorder is likely to be stretched well beyond 1% of the population. NICE defines manic and hypomanic episodes as lasting for a minimum of seven and four days respectively (2), but I have never seen anyone with classical bipolar disorder whose mania did not last for several weeks, and sometimes months. The Royal College of Psychiatrists information leaflet on bipolar disorder also specifies that mania lasts for weeks or months (3). As soon as it is suggested that a few days of elevated mood constitutes a manic episode, all sorts of life difficulties can start to be defined as ‘bipolar’ (4).
NICE also fail to mention that research on drug treatment has been conducted almost exclusively in people diagnosed with bipolar 1 disorder. Therefore, quite apart from the questionable validity of concepts like bipolar 2 and ‘rapid cycling’ bipolar disorder, the evidence base cannot be generalised to people with these other diagnoses.
It is welcome that NICE highlight the option of psychological treatment in some situations, but the Guideline recommendations on drug treatment still fail to acknowledge the serious methodological problems of drug trials in bipolar disorder. Having previously promoted the use of atypical antipsychotics, NICE now strongly emphasises the role of lithium, stressing that it has the strongest evidence base. It has been recognised for decades now, however, that the evidence for lithium is fatally flawed by the fact that you are more likely to have a relapse of your bipolar disorder after stopping lithium treatment than you were before you started it (5). Thus all the placebo controlled trials of long-term lithium treatment are confounded by lithium-discontinuation induced relapse in the placebo group.
Lithium therapy was described by a psychiatrist in the 1960s as ‘the treatment of manic patients by lithium poisoning’ (6). As well as acute toxicity, long-term use frequently impairs the thyroid gland and inevitably damages the kidneys to a greater or lesser extent. Lithium’s brain-dampening effects are usually experienced as unpleasant, and there are safer sedatives if this is the desired effect.
Comparing relapse rates in recent trials and follow-up studies with those found in the first half of the 20th century suggests that modern drug treatment such as lithium and antipsychotics has not improved the prognosis of manic depression or bipolar disorder, and may even have made it worse (7).
NICE missed its opportunity to take a more critical view of the evidence, and stem the diagnostic creep that is spreading drugs that are certainly toxic and probably ineffective to ever greater sections of the population.
References:
(1) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.
(2) National Institute for Health and Care Excellence. Bipolar Disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. NICE clinical guideline 185. London: National Institute of Health and Care Excellence; 2014.
(3) Royal College of Psychiatrists. Information leaflet on Bipolar Disorder. 2013 http://www.rcpsych.ac.uk/expertadvice/problems/bipolardisorder/bipolardi...
(4) Moncrieff J. The medicalization of "ups and downs": The marketing of the new bipolar disorder. Transcult Psychiatry 2014; 51: 581-598 http://tps.sagepub.com/content/51/4/581.full.pdf+html
(5) Suppes T, Baldessarini RJ, Faedda GL, Tohen M. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991; 48(12):1082-8.
(6) Wikler A. The Relation of Psychiatry to Pharmacology. Baltimore: Williams & Wilkins Co; 1957.
(7) Moncrieff J. The Bitterest Pills: the troubling story of antipsychotic drugs. 2013. London: Palgrave Macmillan.
Competing interests: No competing interests
In summarising the NICE guidelines for bipolar disorder Kendell et al. [1] mentioned that people whose symptoms have responded effectively to treatment and who remain stable should be offered the option to return to primary care for further management. However, the summary and the full guidelines are less clear when people with bipolar disorder are still entitled to secondary care, if they prefer this.
Without clear guidelines, they might well be forced to go back to primary care at a time when most mental health services have to reduce costs. Something similar might happen here, as happened with gate keeping by home treatment teams in England and Wales, whereby people with a psychotic relapse cannot be admitted, if the home treatment team does not agree, even if they and their carers prefer this [2].
It is a commendable that the new guidelines discuss the option of transfer back to primary care, but it is a pity that the guidelines do not clearly distinguish when people should be treated in primary care, when in secondary care and when they should be offered a choice.
References
1. Kendall, T., Morriss, R., Mayo-Wilson, E., & Marcus, E. (2014). Assessment and management of bipolar disorder: summary of updated NICE guidance. BMJ, 349(sep25 5), g5673–g5673. doi:10.1136/bmj.g5673
2. Hubbeling, D. (2012). Gate-keeping or free choice in crisis resolution and home treatment teams. Clinical Ethics, 7, 111–115.
Competing interests: No competing interests
Re: Assessment and management of bipolar disorder: summary of updated NICE guidance
A recent systematic review and meta-analysis of relative clinical trials concluded that administration of divalproex (valproic acid) in patients with bipolar disorder did not reduce the incidence rates of suicide attempts or completed suicides.
Reference
https://www.ncbi.nlm.nih.gov/pubmed/30699864/
Competing interests: No competing interests