Page 48 - e-book CPG - Bipolar Disorder
P. 48
Specific attention is drawn to the role of lithium in preventing suicidal behaviour in BD. A
Specific attention is drawn to the role of lithium in preventing suicidal behaviour in BD. A
30, level I
systematic review of adults with BD showed:
30, level I
systematic review of adults with BD showed:
combination of olanzapine and lithium significantly reduced suicidal item score of HAM-
combination of olanzapine and lithium significantly reduced suicidal item score of HAM-
D vs lithium alone
D vs lithium alone
lithium and valproate were equally effective in reducing suicide ideation among suicidal
lithium and valproate were equally effective in reducing suicide ideation among suicidal
attempters
attempters
no definitive evidence on anti-suicidal effect of lithium
no definitive evidence on anti-suicidal effect of lithium
A meta-analysis of RCTs on adults with mood disorders showed NS difference between lithium
A meta-analysis of RCTs on adults with mood disorders showed NS difference between lithium
and placebo in suicide and non-fatal suicidal behaviour between the groups.
137, level I
The
The
and placebo in suicide and non-fatal suicidal behaviour between the groups.
137, level I
primary papers were of moderate quality based on RoB.
primary papers were of moderate quality based on RoB.
While there is no robust evidence for the anti-suicidal effect of lithium, it remains an
While there is no robust evidence for the anti-suicidal effect of lithium, it remains an
effective treatment option in BD patients with suicidal risk. Its use is guided by individual
effective treatment option in BD patients with suicidal risk. Its use is guided by individual
patient factors (e.g. treatment response, monitoring and risk of lethal overdose).
patient factors (e.g. treatment response, monitoring and risk of lethal overdose).
In a cohort study on patients >10 years of age with BD, ECT reduced suicide risk in depressive
In a cohort study on patients >10 years of age with BD, ECT reduced suicide risk in depressive
state (HR=0.805, 95% CI 0.514 to 0.987) but not in mania or mixed states compared with
state (HR=0.805, 95% CI 0.514 to 0.987) but not in mania or mixed states compared with
138, level II-2
psychopharmacotherapy.
138, level II-2
psychopharmacotherapy.
In a systematic review, a small RCT on the effectiveness of IV ketamine vs placebo in bipolar
In a systematic review, a small RCT on the effectiveness of IV ketamine vs placebo in bipolar
depression found that suicidal ideation scores in MADRS reduced within 40 minutes in
depression found that suicidal ideation scores in MADRS reduced within 40 minutes in
subjects of the ketamine arm (Cohen’s d=0.98, 95% CI 0.64 to 1.33) and remained significant
subjects of the ketamine arm (Cohen’s d=0.98, 95% CI 0.64 to 1.33) and remained significant
139, level I
to Day 3.
139, level I
to Day 3.
Evidence on psychological interventions for suicidal behaviour in BD population is limited.
Evidence on psychological interventions for suicidal behaviour in BD population is limited.
Safety Planning is a personalised and prioritised list of coping strategies and resources to
Safety Planning is a personalised and prioritised list of coping strategies and resources to
reduce suicide risk and improve help-seeking.
reduce suicide risk and improve help-seeking.
Components of Safety Planning include:
140, level III
Components of Safety Planning include:
140, level III
recognising warning signs of impending suicidal crisis
recognising warning signs of impending suicidal crisis
identifying and employing internal coping strategies without needing to contact another
identifying and employing internal coping strategies without needing to contact another
person
person
utilising contacts with people as a means of distraction from suicidal thoughts and urges
utilising contacts with people as a means of distraction from suicidal thoughts and urges
contacting family members or friends who may help to resolve a crisis and with whom
contacting family members or friends who may help to resolve a crisis and with whom
suicidality can be discussed
suicidality can be discussed
contacting mental health professionals or agencies
contacting mental health professionals or agencies
reducing the potential use of lethal means
reducing the potential use of lethal means
A meta-analysis of trials on safety planning interventions (cognitive therapy and CBT for
A meta-analysis of trials on safety planning interventions (cognitive therapy and CBT for
suicide prevention) vs control (TAU or other treatment modalities) among adults with suicidal
suicide prevention) vs control (TAU or other treatment modalities) among adults with suicidal
behaviour (including those with affective disorders) showed mixed results where two RCTs
behaviour (including those with affective disorders) showed mixed results where two RCTs
found significant reduction in suicidal behaviour while another two did not. The overall bias of
found significant reduction in suicidal behaviour while another two did not. The overall bias of
primary papers was considered high based on RoB2.
141, level I
primary papers was considered high based on RoB2. 141, level I
Identifying risk factors for suicide in BD is important.
Identifying risk factors for suicide in BD is important.
Personalised, collaborative management of suicidal behaviour in BD including emerging
Personalised, collaborative management of suicidal behaviour in BD including emerging
treatment options e.g. safety planning is advocated.
CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)
treatment options e.g. safety planning is advocated.
10. IMPLEMENTING THE GUIDELINES
10. IMPLEMENTING THE GUIDELINES
10.1. Facilitating and Limiting Factors
10.1. Facilitating and Limiting Factors
Existing facilitators for the application of the recommendations in the CPG include:
Existing facilitators for the application of the recommendations in the CPG include:
33
33
wide dissemination of the CPG to healthcare providers
Existing facilitators for the application of the recommendations in the CPG include:
wide dissemination of the CPG to healthcare providers
Existing facilitators for the application of the recommendations in the CPG include:
training and updates on the management of BD in relevant scientific and professional
Existing facilitators for the application of the recommendations in the CPG include:
Existing facilitators for the application of the recommendations in the CPG include:
Existing facilitators for the application of the recommendations in the CPG include:
wide dissemination of the CPG to healthcare providers
training and updates on the management of BD in relevant scientific and professional
t
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wide dissemination of the CPG to healthcare providers
training and updates on the management of BD in relevant scientific and professional
meetings, seminars, conferences, etc.
public awareness programmes on the importance of BD e.g. World Bipolar Day, World
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training and updates on the management of BD in relevant scientific and professional al al
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on
training and updates on the management of BD in relevant scientific and professional
public awareness programmes on the
meetings, seminars, conferences, etc. importance of BD e.g. World Bipolar Day, World
m Mental Health Day, Suicide Prevention Day, etc
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meetings, seminars, conferences, etc.
public awareness programmes on the importance of BD e.g. World Bipolar Day, World
Mental Health Day, Suicide Prevention Day, etc
peer support and psychosocial support services by non-governmental organisations and
m
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public awareness programmes on the importance of BD e.g. World Bipolar Day, World d d
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public awareness programmes on the importance of BD e.g. World Bipolar Day, World
peer support and psychosocial support services by non-governmental organisations and
Mental Health Day, Suicide Prevention Day, etc
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Mental Health Day, Suicide Prevention Day, etc
peer support and psychosocial support services by non-governmental organisations and
patient advocates
Existing barriers for application of the recommendations of the CPG are: t al al or g g a a ni ni satio ns a a n n
cho
po
or
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satio
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peer support and psychosocial support services by non-governmental organisations and
Existing barriers for application of the recommendations of the CPG are:
patient advocates
pa limited awareness and knowledge among healthcare providers on BD and its
t
ad
oca
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en
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v
t
t
oca
ad
patient advocates es
en
pa
t
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patient advocates
Existing barriers for application of the recommendations of the CPG are:
limited awareness and knowledge among healthcare providers on BD and its
Existing barriers for application of the recommendations of the CPG are: :
st management
f
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f
pl
ng
x
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t
Existing barriers for application of the recommendations of the CPG areare:
ba
i
C
m
atio
r
t
eco
ers
i
Existing barriers for application of the recommendations of the CPG are:
limited awareness and knowledge among healthcare providers on BD and its
management
lack of awareness of symptoms of BD among families/carers and community
t
on
d
ov
e
d
d
p
r
an
on
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limited awareness and knowledge among healthcare providers on BD and its s
e
r
r
d
p
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t
an
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areness
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s
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B
g
a
areness
al
n
de
limited awareness and knowledge among healthcare providers on BD and its
management
lack of awareness of symptoms of BD among families/carers and community
m variation in treatment practice and preferences due to limited accessibility to resources
m
g
management
an
t
g
an
emen
a
t
a
emen
management
variation in treatment practice and preferences due to limited accessibility to r
lack of awareness of symptoms of BD among families/carers and community esources
s
an
areness
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areness
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f
ack o
lack of awareness of symptoms of BD among families/carers and community
l e.g. medications
f
aw
lack of awareness of symptoms of BD among families/carers and community
variation in treatment practice and preferences due to limited accessibility to resources
e.g. medications
no national clinical registry for BD for planning services
i
variation in treatment practice and preferences due to limited accessibility to resources ces
an
t
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ct
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variation in treatment practice and preferences due to limited accessibility to resources
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no national clinical registry for BD for planning services
e
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no national clinical registry for BD for planning services
10.2. Potential Resource Implications f o o r r pl pl an ni ni n n g g s s er v v i i ces
i
B
i
ni
cal
ni
cal
or
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no national clinical registry for BD for planning services ces
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D
no national clinical registry for BD for planning services
10.2. Potential Resource Implications
10.2. Potential Resource Implications
i
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BD is a complex mental disorder that is challenging to diagnose and treat. Those with BD
10
l
otenti
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R
R
10.2. Potential Resource Implications s
a
otenti
on
ou
on
i
10.2. Potential Resource Implications
BD is a complex mental disorder that is challenging to diagnose and treat. Those with BD
need to be referred to psychiatric services for accurate diagnosis and further management.
BD is a complex mental disorder that is challenging to diagnose and treat. Those with BD
need to be referred to psychiatric services for accurate diagnosis and further management.
B The pharmacological treatment that had been recommended by the CPG is not readily
T
w
t
d
ha
n
s
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B
compl
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g
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m
i
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en
t
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se
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at.
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BD is a complex mental disorder that is challenging to diagnose and treat. Those with BD D
s
no
ag
d
at.
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t
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se
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se
g
t
m
t
t
al
n
e
BD is a complex mental disorder that is challenging to diagnose and treat. Those with BD
need to be referred to psychiatric services for accurate diagnosis and further management.
The pharmacological treatment that had been recommended by the CPG is not readily
ur
f
ed
atr
s
o
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or
m
t
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f
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ac
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t
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r
be
d
m
ne available in some healthcare facilities. The financial burden of psychotropic treatments
no
si
ces
be
serv
c
atr
or
need to be referred to psychiatric services for accurate diagnosis and further management. . .
f
di
a
a
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e
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ed
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curat
chi
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sy
m
f
need to be referred to psychiatric services for accurate diagnosis and further management.
The pharmacological treatment that had been recommended by the CPG is not readily
available in some healthcare facilities. The financial burden of psychotropic treatments
T restricts treatment options and distribution, while a scarcity of clinical psychologists limits
ha
m
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The pharmacological treatment that had been recommended by the CPG is not readily y
di
aco
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ec
s
r
no
t
i
by
m
g
no
be
y
ph
t
m
ar
he
en
The pharmacological treatment that had been recommended by the CPG is not readily
available in some healthcare facilities. The financial burden of psychotropic treatments
restricts treatment options and distribution, while a scarcity of clinical psychologists limits
av access to essential psychosocial interventions. The available psychoeducational materials for
i
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available in some healthcare facilities. The financial burden of psychotropic treatments s
n
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available in some healthcare facilities. The financial burden of psychotropic treatments
restricts treatment options and distribution, while a scarcity of clinical psychologists limits
access to essential psychosocial interventions. The available psychoeducational materials for
rpatients fall short in effectively fostering early help-seeking tendencies and offering
t
t
i
m
m
i
scarci
t
m
cho
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restricts treatment options and distribution, while a scarcity of clinical psychologists limits s
psy
t
i
t
t
t
on
hi
m
t
ct
di
s
r
r
r
restricts treatment options and distribution, while a scarcity of clinical psychologists limits
patients fall short in effectively fostering early help-seeking tendencies and offering
access to essential psychosocial interventions. The available psychoeducational materials for
comprehensive management strategies.
soci
psy
t
r
i
t
l
l
esse
psy
Th
t
l
ss
soci
m
eria
atio
e
av
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on
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acce
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ai
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ai
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a
l
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en
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ab
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ab
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m
cho
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t
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al
nter
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v
i
al
o
i
o
t
nter
o
t
access to essential psychosocial interventions. The available psychoeducational materials for r
av
f
na
access to essential psychosocial interventions. The available psychoeducational materials for
patients fall short in effectively fostering early help-seeking tendencies and offering
comprehensive management strategies.
s
f
an
f
f
l
nci
os
ec
n
y
f
ec
ea
f
os
d
d
see
n
l
t
t
y
f
t
e
ea
e
l
el
n
pa
es
i
k
v
al
r
y
f
el
i
k
y
pa
i
i
t
t
an
f
nci
v
r
i
es
en
l
al
t
en
-
eri
n
en
r
r
t
he
t
f
i
eri
l
g
g
patients fall short in effectively fostering early help-seeking tendencies and offering g g
sho
s
p
sho
n
t
t
p
l
f
t
de
o
n
i
erin
de
o
en
t
i
erin
see
g
g
-
f
he
f
patients fall short in effectively fostering early help-seeking tendencies and offering
comprehensive management strategies.
In line with the key recommendations in this CPG, the following are proposed as clinical audit
a
g
ate
r
e
g
e m
r
comprehensive management strategies.
e
eh
si
a
an
t
si
en
t
en
e m
v
st
m
m
an
st
v
compr
i
.
en
s
.
en
g
compr
i
g
ate
e
e
eh
s
comprehensive management strategies.
In line with the key recommendations in this CPG, the following are proposed as clinical audit
indicators for quality management of BD:
In line with the key recommendations in this CPG, the following are proposed as clinical audit
indicators for quality management of BD:
I
r
t
cal
op
n
w
op
eco
eco
ow
ni
he
i
m
are
ne
i
ose
i
m
i
he
t
i
cal
l
ni
P
n
he
ol
f
ey
s
ey
In line with the key recommendations in this CPG, the following are proposed as clinical audit t t
di
p
di
ne
k
C
w
k
s
ol
r
au
ow
l
n
r
t
i
hi
l
C
p
f
hi
i
l
au
r
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ose
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In line with the key recommendations in this CPG, the following are proposed as clinical audit
indicators for quality management of BD:
Number of patients with bipolar disorder
Percentage of patients with
o
indicators for quality management of BD: : :
i
i
i
t
m
o
en
ua
f
t
cator
ua
q
t
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en
nd
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an
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ag
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m
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f
r
r
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y
t
y
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i
s
indicators for quality management of BD:
Percentage of patients with
Number of patients with bipolar disorder
bipolar disorder not on not on antidepressant monotherapy in a period
Number of patients with bipolar disorder
Percentage of patients with
bipolar disorder not on
Percentage of patients with h h = not on antidepressant monotherapy in a period x 100%
NNumber of patients with bipolar disorder
P antidepressant
bi
i
po
l
sorder
i
t
s
t
l
t
di
w
di
h
s
ercent
w
ar
ercent
bi
h
ar
sorder
po
a
umber
N
P
a
umber
g
e
t
Number of patients with bipolar disorder
g
e
o
i
t
t
en
i
en
pa
f
o
pa
f
i
en
f
i
en
t
i
t
pa
pa
t
f
t
w
w
s
t
i
o
s
t
o
Percentage of patients with
Number of patients with bipolar disorder
Number of patients with bipolar disorder
antidepressant
not on antidepressant monotherapy in a period
bipolar disorder not on
pre in the same period
bi monotherapy
r
i
de
i
de
r
po
bi
no
pe
i
t
i
t
ssan
on
ssan
bipolar disorder not on on = not on antidepressant monotherapy in a period od x 100%
t
l
ar
od
pre
on
other
other
po
y
n a
di
sorder
i
on
i
n a
y
on
sorder
t
no
t
ap
di
pe
t
an
an
t
ap
ar
no
no
m
l
m
on
t
not on antidepressant monotherapy in a period
bipolar disorder not on
Number of patients with bipolar disorder
=
antidepressant
x 100%
monotherapy
in the same period
an (Target of ≥80%)
umber
sorder
t
s
10
i
t
o
pa
l
t
en
en
N
h
i
l
t
po
f
an
sorder
ar
ar
bi
o
t
i
h
t
w
i
f
s
de
x
pressan
0%
=
pressan
t
di
i
10
antidepressant t t = = Number of patients with bipolar disorder x 100% 0%
bi
umber
de
i
w
po
pa
N
x
di
t
=
Number of patients with bipolar disorder
x 100%
antidepressant
(Target of ≥80%)
in the same period
monotherapy
m
m
he
i
on
ap
ap
r
othe
r
r
he
y
r
od
i
e
m
y
i
n t
sa
on
pe
monotherapy in the same period od
e
othe
i
pe
n t
m
sa
in the same period
monotherapy
(Target of ≥80%)
o
≥
r
g
(
t
e
t
o
r
T
≥
f
0
e
g
(Target of ≥80%) ) Number of patients with bipolar disorder on
a
8
%
0
a
8
f
)
(
%
Percentage of patients with
T
(Target of ≥80%)
Number of patients with bipolar disorder on
Percentage of patients with
bipolar disorder on lithium lithium monitoring every six months within a period
bipolar disorder on lithium
Percentage of patients with
Number of patients with bipolar disorder on od
Percentage of patients with h = lithium monitoring every six months within a peri x 100%
P monitoring every six
N Total number of patients with bipolar disorde
Number of patients with bipolar disorder on r
ar
l
ercent
g
i
umber
s
p
p
di
sorder
sorder
a
t
umber
ercent
g
N
a
a
f
a
di
n
w
p
w
po
s
a
s
f
i
i
po
s
t
o
w
p
h
ie
n
i
t
h
t
ie
ie
n
w
P
t
t
bi
t
t
bi
o
a
t
o
t
e
ie
f
n
e
t
o
t
ar
l
on
on
h
f
Number of patients with bipolar disorder on
Percentage of patients with
bipolar disorder on lithium
lithium monitoring every six months within a period
monitoring every six
Total number of patients with bipolar disorder
bi months
hi
l
i
i
po
n a
i
t
t
i
i
i
sorder
t
i
l
um
ar
l
l
t
r
u
on
od
l
sorder
r
u
hi
m
hi
on
po
t
um
pe
hi
t
hi
hi
n a
pe
i
n
r
i
t
x
on
bipolar disorder on lithium m = lithium monitoring every six months within a period od x 100%
di
g
g
t
ery
t
n
i
on
di
l
si
i
ev
on
hs w
on
o
hs w
ev
m on lithium within the same period
ery
m
o
bi
m
m
si
ar
r
i
t
x
lithium monitoring every six months within a period
bipolar disorder on lithium
x 100%
Total number of patients with bipolar disorder
monitoring every six
months
=
on lithium within the same period
m (Target of ≥80%)
sorde
o
p
on
u
r
orin
s
x
m
10
i
t
sorde
i
i
t
s
t
w
r
f
r
x
g ev
t
s
m
s
h bi
m
f
t
a
ie
monitoring every six x = = Total number of patients with bipolar disorder x 100% 0%
e
l
t
p
o
ie
t
n
n
o
t
o
e
b
po
0%
l
l
a
ar
i
t
i
orin
ar
t
on
ery
a
l
a
po
r
T
10
di
b
w
ery
=
n
g ev
di
u
T
n
i
h bi
x
=
x 100%
Total number of patients with bipolar disorder
monitoring every six
on lithium within the same period
months of ≥80%)
(Target
hs
t
m
months hs on lithium within the same period od
on
on
m
t
he
i
l
t
t
i
n t
i
e per
i
hi
t
on
od
i
t
sam
i
hi
w
n t
sam
l
hi
he
um
um
w
on
hi
e per
months
(Target of ≥80%)
Implementation strategies will be developed following the approval of the CPG by MoH which
(
≥
8
8
f
t
r
g
0
r
t
a
0
)
e
f
g
(
%
e
≥
o
%
T
T
a
o
(Target of ≥80%) ) on lithium within the same period
(Target of ≥80%)
Implementation strategies will be developed following the approval of the CPG by MoH which
include a Quick Reference and a Training Module.
Implementation strategies will be developed following the approval of the CPG by MoH which
include a Quick Reference and a Training Module.
I
oH
ap
t
ch
i
i
i
emen
st
i
ate
i
w
on
w
emen
i
prov
ng
prov
i
h
oH
ap
st
on
g
g
r
ng
h
r
ate
e
al
de
G
G
t
m
e
P
P
de
f
a
t
al
by
ol
ol
f
e
b
b
Implementation strategies will be developed following the approval of the CPG by MoH which ch
o
he
t
f
ed
f
t
he
he
op
t
op
pl
v
el
C
C
v
pl
el
t
o
ed
he
l
s
i
l
M
M
i
w
w
l
I
a
t
s
ow
e
l
by
l
i
ow
m
l
Implementation strategies will be developed following the approval of the CPG by MoH which
include a Quick Reference and a Training Module.
R
M
r
ui
en
ai
ncl
a
ai
c
r
k
ul
ce and
en
n
g
ui
g
ni
ce and
n
i
k
ni
a
R
f
i
c
od
ud
ul
T
Q
e
e
f
include a Quick Reference and a Training Module. e.
e
a
e
a
od
r
e
r
ud
e
e.
ncl
Q
T
M
include a Quick Reference and a Training Module.
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3
3
4
34
