|Year : 2022 | Volume
| Issue : 2 | Page : 235-242
Pragmatic issues and prescribing patterns in bipolar disorder: A mental health professional's survey
Shobit Garg1, Nishant Goyal2, Sai Krishna Tikka3, Preeti Mishra1
1 Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
2 Department of Psychiatry, Central Institute of Ranchi, Ranchi, Jharkhand, India
3 Department of Psychiatry, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India
|Date of Submission||31-Jan-2021|
|Date of Acceptance||25-Mar-2021|
|Date of Web Publication||18-Aug-2022|
Dr. Shobit Garg
Department of Psychiatry, Shri Guru Ram Rai Institute of Medical and Health Sciences, Patel Nagar, Dehradun - 248 001, Uttrakhand
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There is substantial treatment gap between the suggested guidelines and pragmatic clinical practice for psychotropic usage in bipolar disorder (BD) due to the lack of naturalistic studies and not taking into account the transcultural differences and diverse background. We intend to study this treatment gap and elucidate the preference of psychotropics and prescription patterns, critical clinical issues faced and related pragmatics in BD by conducting the mental health professionals survey. Methodology: After focused discussions, Canadian Network for Mood and Anxiety Treatments guidelines being the primary anchor, a 46-item online survey questionnaire was prepared. With 25.4% response rate, 127 psychiatrists were evaluated using Survey Monkey® electronic platform on the demographics, predominant polarity; usage of antipsychotics, antidepressants, and electroconvulsive therapy, psychotropic's preference (monotherapy vs. polytherapy) in the acute and maintenance phase of BD. Results: Majority of the participants were males (70.9%) and placed in government institute or medical colleges. Majority agreed that child and adolescent and old age bipolar probands are not routinely seen but subthreshold BD cases are frequent; did not prefer mood stabilizer in pregnancy (61.4%) and antidepressants, preferred polytherapy in acute but monotherapy in maintenance phase (after 3rd episode), seldom preferred ECT as an option (more in suicidality), agreed to a subset of BD being refractory and neuroprogressive. Conclusion: This study elucidates the importance of treatment preferences, prescribing patterns and pragmatic issues faced by the clinicians. These patterns if studied longitudinally in a systematic manner would help in modifying the potential treatment strategies and reduce treatment gap.
Keywords: Bipolar disorder, online, pragmatic, survey, treatment gap
|How to cite this article:|
Garg S, Goyal N, Tikka SK, Mishra P. Pragmatic issues and prescribing patterns in bipolar disorder: A mental health professional's survey. Ind Psychiatry J 2022;31:235-42
The World Mental Health Survey Initiative reported total lifetime prevalence estimates of 2.4% in bipolar disorder (BD) and its subtypes. Without adequate treatment, patients with BD face substantial impairment and disability and have a significant risk of morbidity and mortality. To address this disease burden, several clinical guidelines have been published.,,,, However, as per pharmaco-epidemiology studies, there is this substantial gap between the suggested guidelines and clinical practice for psychotropic usage in BD. In BD, only one quarter of studies have shown to adhere to the guidelines. This treatment gap and poor adherence to guidelines have shown to impact the clinical outcomes in patients with BD., Moreover, as per recent national mental health survey-2016, this treatment gap is even wider, i.e., more than 70% in our country. This could be because of the lack of naturalistic studies not taking into account the transcultural differences and diverse background. The issue is compounded further by the lack of updated clinical practice guidelines till a recent one by Shah et al. In addition, most of studies worldwide have studied prescription patterns from the evaluation of outpatient records, case record file review, and prescription slips.,,, Only few studies have attempted to address the clinical issues such as focusing on psychotropic's preference in bipolar depression, issues of diagnosing BD in child and adolescent population, and barriers to effective management through surveys in BD.,,,,
Therefore, with this background and with intention to study this treatment gap, we aimed to elucidate the preference of psychotropic's and prescription patterns, critical clinical issues faced and related pragmatics in BD by conducting the mental health professional's survey. The ensuing objective of this study was to find out whether these preferences and patterns are similar in clinicians who are involved in private practice in comparison to those who are solely in institutional (or medical college) practice.
| Methodology|| |
The survey evaluated the perception of mental health professionals about the pragmatic issues, their preferences and prescribing patterns in BD. This study received ethical approval from the Institutional Ethics Committee of Central institute of Psychiatry, Ranchi.
The 60-item questionnaire was initially developed based on focused discussions among three mental health professionals (authors) with mean experience of 12 years. Items were framed based on the review of various parameters required for prescribing in cases of BD. The Canadian Network for Mood and Anxiety Treatments guideline was the primary anchor for the content selection for each item. Retrospective prescription surveys were also reviewed and relevant suitable content was drafted into the items.,,,, Certain aspects pertaining to special populations, like treatment options in child and adolescent, old age bipolar, and comorbidities such as substance use disorders were deliberately not included to maintain generalizability of the responders. Item reduction to 46 questions was then made based on expert advice from two mental health professionals having specific expertise in psychopharmacology and BD. Hence, 46 questions online survey was prepared. Survey questions were pertaining to the demographic profile and personal information of the participants. The participants were enquired about the frequency of patients (including new) seen per week, predominant polarity, special populations (pregnancy, children and adolescent, and geriatric), and prescription patterns of antipsychotics and antidepressants in BPD patients. In bipolarity, usage of electroconvulsive therapy (ECT), i.e., its usefulness, preferred indications, and combination with mood stabilizers (MSs) were deliberated in the survey. Psychotropic's preference (monotherapy vs. polytherapy) of the participants was enquired in the acute and maintenance phase in both mania and depression stages of bipolarity. Finally, the burden of treatment resistance in BPD, the reasons behind it and treatment choices including clozapine was enquired.
Survey questionnaire was sent to psychiatrists (those working in general hospital units, medical colleges, institutes, and private practitioner's) across the country in November–December 2018 using Survey Monkey® electronic platform. A computer-generated randomization table was used to select the 500 psychiatrists in the age group of 35–55 years from the directory of the Indian Psychiatric Society. The invitation letter stated that the participation in the survey was voluntary and completion of survey implied their consent to participate. The E-mail link explained the purpose of survey along with an option to “opt out.” Survey was emailed once per week for 6 consecutive weeks. If participants did not comply, mails were resend every week till 6 weeks or till they opted out of survey. Confidentiality and nondisclosure ethical clause was maintained. Of the 500, 17 emails met with failure notice generated by the system (due to wrong E-mail or nonexistent addresses). The responses were divided into two arbitrary groups: Group A (faculty/resident in government or private institutes or medical colleges or hospitals not involved in private practice; n = 56) and Group B (clinicians including faculty in institutes or medical colleges involved in private practice; n = 71). These two groups were compared on the responses for different treatment choices, clinical situations faced and prescribing preferences [Table 1],[Table 2],[Table 3].
|Table 1: Description of special population, bipolar depression and soft bipolarity encountered by mental health professionals (n=127)|
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|Table 2: Description of psychotropic's preferred in acute and maintenance phase in bipolar disorders by mental health professionals (n=127)|
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|Table 3: Description of treatment resistance and usage of electro convulsive therapy in bipolar disorder by mental health professionals (n=127)|
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The data were analyzed using the SPSS software version 21.0 for Windows (SPSS, Chicago, IL, USA). Mean and standard deviation were calculated for the continuous variables and frequencies and percentages were computed for the discontinuous variables. The comparisons were done by using the Chi-square test.
| Results|| |
The survey was emailed to 500 qualified mental health professionals. Of these 17 emails met with failure notice, 55 opted out of the survey. Of the remaining 428, only 147 responded to the survey questionnaire but 20 of them did not fulfill the age criteria. This resulted in actual responders to be 25.4% (n = 127). For few questions, the responses were inadequate or missing but we retained the data to avoid bias. There were no duplicate entries.
Of the 127 participants, majority of physicians' were of male gender (70.9%), are placed in government institute or medical college (48.4%). Average mental health and BD probands examined weekly were reported to be 121.7 (standard deviation [SD] 140.0) and 26.66 (SD 31.82) patients, respectively.
Of the total, 42% of responders estimated that they examine an average of more than 5 BD probands (old & new) on the daily basis. In turn 86.5% of participants estimated that the new BD probands seen on the average daily basis is less than 5. Furthermore, most common mood states encountered in new patients were mania (36.9%) and depression (30.4), respectively [Table 4].
|Table 4: Description of demographics of mental health professionals and pattern of patients seen (n=127)|
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Special population, soft bipolarity and bipolar depression
Around 49% and 55% of the participants agreed (in a Likert scale) that child and adolescent and old age BD (OABD) probands are encountered not routinely in clinical practice. Majority agreed that they encounter soft bipolarity in practice (84% of participants) but do not often encounter it along with disruptive mood dysregulation. [Table 1] shows that the proportion of female BD population encountered by the majority is between 25% to 50% of the total BD probands seen in clinical practice. Regarding the use of MS during pregnancy most of the participants expressed nonpreference (61.4%) with inter-agreement of both the groups A and B (χ2 (1, 127) = 0.081, P = 0.775). If at all needed, the most preferred chosen MS in pregnancy was lamotrigine (67.5% of responders) [Table 1].
Around 46% of mental health professionals agreed that they encounter bipolar depression in around one quarter of the total BD probands in clinical practice. Of note, the clinicians involved in private practice (Group B) preferred antidepressants in BD significantly more than those who are not (χ2 (3, 127) = 8.798, P < 0.05). Similarly, both the groups (A and B) differed on the extent of usage of antipsychotics in the management of BD (χ2 (3, 127) = 12.49, P < 0.01) [Table 1].
Psychotropic's preferred in acute and maintenance phase in bipolar disorders
Psychotropic's preference (monotherapy vs. polytherapy) of the participants was enquired in the acute and maintenance phase in both mania and depression stages of bipolarity in line with CANMAT recommendations of Yatham and colleagues (2017) [Table 2].
Polytherapy was the preferred treatment option in the acute stages of mania (>79%) and depression (>60%) of the participants. However, in maintenance phase, monotherapy (MS) was preferred by the participants (around 50%) across both the stages. Maintenance life-long therapy was pursued by the 78.7% of participants but majority preferred to initiate it only after the 3rd episode. Around 85% of total participants chose selective serotonin reuptake inhibitors (SSRIs) to be initiated among antidepressant if at all considered. Clinicians in private practice (group B) preferred other antidepressant classes than those who are in institutional practice (χ2 (4, 127) = 9.67, P < 0.01) like serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressant. Majority of the psychiatrist encountered rapid cycling phenomenon in <1/10th of BD probands. Sodium valproate was the preferred drug for in rapid cycling [Table 2]. When given choices as to which agent (lithium, lamotrigine, aripiprazole, and quetiapine) lacks the efficacy in acute or maintenance phase of bipolar depression, majority (56%) chose aripiprazole. Apart from conventional psychotropic's usage, around 80% of participants agreed that holistic approach of psycho-education and sideeffect surveillance would be critical in improving quality of life (QoL) in BD probands.
Electroconvulsive therapy and treatment resistance in bipolar disorder
Only 12% of the participants agreed (in a Likert scale) that BD probands required routine ECT in clinical practice. There was disagreement between the two groups for ECT usage though (χ2 (4, 127) = 11.821, P < 0.05). The most common indication for ECT in BD reported is suicidality by all participants (>55%). This common indication was more commonly preferred by Group B participants than Group A. Notion of nonsafety of ECT and lithium combination was supported by the participants (>54%).
Resistance in bipolarity was encountered by 87.4% of clinicians. However, the fraction of total patients with treatment resistance is <10% of whole BD population in clinical practice as per the majority. Regarding clozapine usage in BD, more than 70% of participants agreed. However, 35% of Group B participants preferred not to use it in comparison to 16% from group A (χ2 (1, 127) = 4.988, P < 0.05). Furthermore, majority of clinicians preferred clozapine in the acute and maintenance phase of Bipolar mania [Table 3]. Around 80% of total participants were in agreement that BD is a neuroprogressive illness.
| Discussion|| |
The aim of the present study was to investigate the preference of psychotropics and prescription patterns, critical clinical issues faced and related pragmatics by psychiatrists in BD. The ensuing objective of this study was to compare these patterns in clinicians involved in private practice in comparison to those who are solely in institutional (or medical college) practice. To our knowledge, this is one of the comprehensive surveys from this region elucidating psychotropic's prescription patterns and choices and critical clinical issues faced by the mental health professional in BD.
The most common mood state in new BD probands was reported to be mania and then depression in our study. This could be due to more acute onset of dysfunction associated with manic states and underreporting of depressive episodes. Extreme of age BD cases were encountered infrequently. This finding is supported by few surveys. In contrast, subthreshold BD cases which were routinely encountered in outpatient settings as per our sample survey. The World Mental Health Survey Initiative has also reported that subthreshold BD is the most common prevalent condition among various BDs. With regard to usage of MS during pregnancy most participants deferred but considered lamotrigine to be safer. The same could be due to the majority of the MS stabilizers have a pregnancy C category of classification for teratogenicity.
As per our study, psychiatrists encounter bipolar depression in one quarter of total BP probands. This matches the disease prevalence of BDII which is less than one fourth of the total BD disease burden. Only less than 10% of total BD probands required antidepressants as per our survey. This trend resembles the recommendation that only a subset of patients (~ 15%) with bipolar depression requires antidepressants (SSRIs/bupropion). Private clinic based and institute (or medical college) based clinicians preferred antidepressants (SSRI was most preferred) and antipsychotics, respectively, in BD.
Polytherapy was the preferred treatment options selected in the acute phase of BD either mania or depression. As per the recent CANMAT guidelines, in acute mania either monotherapy or polytherapy can be preferred depending on the rapidity of response required, severity of index episode and patient choices. Whereas in acute depression, monotherapy (quetiapine, lithium, lamotrigine, and lurasidone) is preferred as per CANMAT and polytherapy (combination) is considered only in the presence of breakthrough episode or nonresponse to monotherapy. Regarding prophylaxis, our survey bases consensus was that the 3rd episode distinguishes the time to start lifelong treatment similar to other survey. This is in accordance to the World Federation of Societies of Biological Psychiatry (WSFBS) guidelines. Rather, other less conservative guidelines such as European and North American prefers lifelong earlier than 3rd episode., Majority of other survey participants chose monotherapy as prophylaxis in BD as per recommendations., Indian psychiatrist's nonpreference for earlier prophylaxis (1st and 2nd mood episode) could be the result of amalgam of factors like negative attitudes toward medications, varying illness course, poor tolerability/adherence, and low acceptance rates.
Regarding rapid cycling, valproate was still preferred as per popular notion but is not evidenced based as per the recent guidelines. Survey participants preferred ECT only as a seldom treatment option in BD. This is supported by guidelines as ECT is being recommended as 2nd line treatment option. The most common indication for ECT in our survey was suicidality more preferred by clinicians involved in private practice. This could be explained due to the lack of infrastructure (e.g., limited beds), shortened hospital stay to cut the costs, and expectation of a quick recovery by families.
Major proportion of participants (>80%) agreed that BD subset is neuroprogressive, refractory to treat and would require psychoeducation and side effects monitoring (for compliance) to improve Qol. A UK − US survey establishes the role of psychoeducation and long-term monitoring to healthy outcomes in BD. Clozapine is viewed as a viable option in BD preferably by clinicians involved in institutional (or medical college) and in manic stage (acute or maintenance). Suppes et al. have shown that clozapine use in BD reduces the mood symptoms and total medication use in treatment-resistant patients.
The findings of this study are to be considered in the context of certain limitations. First, responses to survey queries by the participants are indirect measures to assess pragmatic practices. Furthermore, these responses could have self report bias. Second, the categorization of centers into two groups was arbitrary and is not proxy for the different schools of practices. Third, preference for individual drugs (among second-generation antipsychotics) was not elicited by our survey. Finally, this is a cross-sectional study with limited sample size. Hence, options assessing longitudinal treatment views could not be ascertained and limits the generalizability of the findings.
| Conclusion|| |
This survey establishes the importance of elucidating the treatment preferences (phase and stage), prescribing patterns and pragmatic issues faced by the clinicians. These patterns if studied longitudinally in a systematic manner would help in modifying the potential treatment strategies to be more effective and reduce treatment gap.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]