Review articleEarly intervention for bipolar disorder – Do current treatment guidelines provide recommendations for the early stages of the disorder?
Introduction
Bipolar disorder (BD) is the fourth most significant contributor to disability amongst adolescents and young adults (Gore et al., 2011) and has one of the highest rates of suicide amongst mental disorders (Chesney et al., 2014). Most adults with BD experience the onset of mood symptoms before their 20s (Geoffroy et al., 2013). While earlier diagnosis and rapid implementation of effective evidence-based treatment can improve outcomes for those with BD (Kessing et al., 2014), there is typically a significant delay of 5–10 years between symptom onset and diagnosis (Baldessarini et al., 2003, Post et al., 2010).
Earlier diagnosis and interventions (termed early intervention or EI) refer to strategies to allow prompt and timely access to care, with appropriate and comprehensive interventions that are tailored to the ‘stage’ of disorder (Vieta et al., 2018). Staging models have helped articulate the imperative for EI by combining characteristics such as severity and time course of symptoms and level of functioning in profiling individuals with BD (Berk et al., 2007a, b). Although staging models are a fairly new conceptualization, they can help clinicians to focus on the needs of persons with BD at different ‘disorder stages’ and potentially personalise treatment approaches. Staging models conceptualise interventions in earlier stages as preventing illness progression (Berk et al., 2011) and as minimising functional and cognitive impairment, thereby limiting illness-related disability (Berk et al., 2007a, McGorry et al., 2006). Although direct evidence for prevention of illness progression is limited, there is already evidence that interventions in earlier illness stages may be more effective than those in later illness stages (Joyce et al., 2016). Those with fewer lifetime episodes show greater treatment improvement with Cognitive Behavioural Therapy (CBT) (Scott et al., 2006) and psychoeducation (Colom et al., 2010b).
Although there are several definitions on defining stages for BD, we considered early stage BD to be those in the first few episodes of BD as recommended by the International Society of Bipolar Disorders (ISBD) Staging Task Force (Kapczinski et al., 2014). This taskforce considers early stages as those “at the first or the first few episodes and are in aggregate associated with better functioning after recovery”. and corresponds to Stage 2 disorder as outlined by Berk et al. (2007a) and Cosci and Fava (2013). Thus, we included those in the early course of BD, after their onset of clear mania or hypomania that define BD I or II. This should be contrasted with the earlier stages of BD described by Duffy (2014) and Post (2010) which include subthreshold states, a vulnerability for the disorders, internalising disorders and anxiety symptoms as being in the earlier illness stages. However, these syndromes would be better categorised as prodromes, precursor syndromes or states (Eaton et al., 1995) rather than the more accepted ISBD consensus definition of early stage BD.
Among those in an earlier illness course, interventions have had limited and sporadic uptake, especially in comparison to services for those with early psychosis (though the latter often include a proportion of people with bipolar psychosis). Persons with early stage BD receive treatment from a variety of clinical services (e.g., EI services, community mental health teams, youth services), none of which are specialists in bipolar care, thus treatments vary greatly. Although there is promising data that specialised mood disorder services have better treatment outcomes (Kessing et al., 2013), it is highly likely that generalist clinicians are likely to provide interventions for those in earlier stages of BD in most parts of the world. These clinicians need access to high quality clinical guidance to support the care of those with early stage BD.
While there are several clinical guidelines with regards to the care for persons with BD (Goodwin et al., 2016, Grunze et al., 2009,Grunze et al., 2010, Grunze et al., 2013b, Yatham et al., 2018), few relate to early stage disorder (or early in the course of the disorder). These guidelines typically categorise treatments based on acute (manic, depressive, mixed episodes) or maintenance phases, and interventions for children and adolescents may receive a separate mention (Goodwin et al., 2016, Grunze et al., 2009, Grunze et al., 2010, Grunze et al., 2013b, Yatham et al., 2018). However, those in early course of the disorder (early stage) are rarely considered. The guidelines relating to adolescents may be relevant to those in early stage disorder, as the categories are overlapping, given that the peak age of onset of the disorder is in the late teens (Lin et al., 2006). However, as a substantial proportion of those with BD will have an onset in adulthood (Geoffroy et al., 2013), there is a need for a focus on early stage or course of the disorder rather than a focus on age of the affected individuals alone.
Therefore, clinicians currently have limited guidance in providing care for clients with early stage BD despite their clinical needs and outcomes being different to those with established illness. Consequently, it is important to review and compile recommendations from current guidelines that are specific to those with early stage BD. A set of such recommendations could also identify gaps in current evidence and develop a roadmap for future research which could in-turn generate future evidence-informed guidelines. Thus, we aimed to scope the literature and summarise the recommendations from clinical guidelines pertaining to treatment for early stage with a secondary focus on adolescents with BD.
Section snippets
Methods
We conducted a comprehensive scoping review for clinical guidelines describing treatment for those with BD, mania or affective psychoses.
Results
The keywords search of the electronic databases yielded 823 potentially eligible articles, of which 30 articles met the final criteria for inclusion. This included two guidelines (the National Institute of Health and Care Excellence guideline for Bipolar Disorder - Guideline 185 (NICE) (National Collaborating Centre for Mental Health (UK), 2014) and Australian Clinical Guidelines for Early Psychosis (ACGEP) (Early Psychosis Guidelines Writing Group and EPPIC National Support Program, 2016)),
Discussion
In our review of the international and national guidelines on BD published in the last decade, we identified a relative lack of recommendations for early stage disorder. Among the fourteen guidelines, half did not have any specific recommendations for the early stages of BD. This indicates a clear evidence gap in the literature which is likely to be preventing optimal care of people with early stage BD. This stands in comparison to the focus on, and positive outcomes from 20 years of early
CRediT authorship contribution statement
Chia Ming Fang: Data curation, Writing - original draft. Sue Cotton: Conceptualization, Data curation, Writing - original draft. Kate Filia: Data curation, Writing - original draft. Mark Phelan: Writing - review & editing, Writing - original draft. Philippe Conus: Writing - review & editing, Writing - original draft. Sameer Jauhar: Writing - review & editing, Writing - original draft. Steven Marwaha: Writing - review & editing, Writing - original draft. Patrick D McGorry: Writing - review &
Declaration of Competing Interest
MFC, SC, KF, MP, PC, SJ, SM, CD and AR have no conflicts to declare.
Role of funding source
PM has received grant funding from the Colonial Foundation, the National Health and Medical Research Council of Australia, NARSAD, the Stanley Foundation, NIH, and the Australian and Victorian Governments. He has also received past unrestricted grant funding from Janssen-Cilag, Astra Zeneca, Bristol-Meyers Squibb, Eli Lilly, Novartis, and Pfizer, and honoraria for consultancy and teaching from Janssen-Cilag, Eli Lilly, Pfizer, Astra Zeneca, Roche, Bristol-Meyers Squibb, and Lundbeck. He is a
Acknowledgements
PM, SC, MB, CD and AR are supported by Australian NHMRC Fellowships.
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