There is a limited amount of good quality research being published about bipolar disorder, particularly investigating the early stages. Bipolar is associated with a high risk of relapse and this risk of relapse increases with the number of previous episodes.

Observational studies suggest that early intervention may improve both course and outcome, but currently progression of bipolar is not prevented in clinical practice. This might be because people with bipolar sometimes don’t get the medication and talking treatments they need early enough, or that they stop taking their mood stabilisers too soon.

It has been claimed that specialised bipolar disorder units and programmes are needed to improve outcomes and advance research in bipolar disorder. The main advantage of these clinics is that a specialist multi-disciplinary team of professionals can offer a focused treatment programme combining updated evidence-based drug treatment with group psychological interventions such as group psycho-education.

A recent study in the British Journal of Psychiatry concludes that treatment in a specialised mood disorder clinic early in the course of bipolar disorder substantially reduces readmission to a psychiatric hospital and increases satisfaction with care.

Methods

The trial took place in Denmark and 158 patients were involved in the study.

Inclusion criteria: patients discharged from their first, second or third hospital admission from an in-patient psychiatric ward, with an ICD-10 diagnosis of single manic episode or bipolar disorder. Co-morbidity with alcohol or substance misuse and other psychiatric disorders were allowed.

Exclusion criteria: patients with moderate or severe dementia, with a poor understanding of Danish, under any kind of commitment (e.g. compulsory hospitalisation or treatment) or without informed consent.

Patients were randomised to the mood disorder clinic group or to standard care. The study was not blind as it was not possible to mask the identity of patients.

Specialised out-patient mood disorder clinic: The clinic offers combined treatment with evidence based drug treatment and group sessions to learn about their illness. The staff consisted of full-time specialists in psychiatry, psychologists, nurses and a social worker with specific clinical experience and knowledge about the diagnosis and treatment of bipolar disorder.

Control group: Standard care in an out-patient mental health service e.g. treatment with a GP, a private psychiatrist, at the local community mental health centre or local psychiatrist associated with the discharging ward.

The primary outcome measure was first readmission to the psychiatric ward after discharge. Questionnaires were also mailed to participants one and two years after discharge – these included the Major Depression Inventory and satisfaction with care.

Results

A log-rank test was used to analyse the results.

When compared with standard care:

• Readmission to a psychiatric hospital following care in a specialised out-patient mood disorder clinic substantially reduced readmission to a psychiatric hospital (HR = 0.60, 95% CI 0.37-0.98, P = 0.043)
• Satisfaction with treatment was significantly higher for those treated in the specialised out-patient mood disorder clinic (P = 0.01)

Conclusions

The authors found that:

Out-patient treatment in the mood disorder clinic resulted in a 40% reduction in risk of readmission to hospital, which represents a substantial decrease. Patients in the mood disorder clinic group more often used a mood stabilizer or an antipsychotic, and satisfaction with treatment was more prevalent than among patients who received standard care.

There were some key differences between treatment in the control group and those seen at the mood disorder clinic. The drug and talking therapies offered in the control group were more likely to be based on the preferences of the individual physician than on national or international guidelines and patients were not offered group or individual therapy to learn about their illness. Contact with family was also provided more infrequently compared with the mood disorder clinic.

This study highlights the importance of early intervention in bipolar disorder and the need to use evidence-based treatments to improve the long-term course of illness. Future research should consider which components of care are important in preventing future readmission.

Link

Kessing LV, Hansen HV, Hvenegaard A, Christensen EM, Dam H, Gluud C, Wetterslev J; Early Intervention Affective Disorders (EIA) Trial Group. Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial. Br J Psychiatry. 2013 Mar;202:212-9. doi: 10.1192/bjp.bp.112.113548. Epub 2013 Jan 24. [PubMed abstract]