Improving Outcomes in Bipolar Depression

Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

Jointly sponsored by Educational Review Systems, Inc., and Integritas Communications This activity is supported by an educational grant from Sunovion Pharmaceuticals Inc.

Held in conjunction with the 2014 Pri-Med Regional Conference: Washington, DC

CME/MEDICAL COMMUNICATIONS INQUIRIES info@integritasgrp.com integritasgrp.com

Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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FACULTY Roger S. McIntyre, MD, FRCPC Professor of Psychiatry and Pharmacology University of Toronto Head of Mood Disorders Psychopharmacology Unit University Health Network Toronto, Ontario, Canada

Dr. Roger S. McIntyre is currently a Professor of Psychiatry and Pharmacology at the University of Toronto and Head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto, Canada. Dr. McIntyre completed his medical degree at Dalhousie University, Halifax, Nova Scotia, Canada. He received his Psychiatry residency training and Fellowship in Psychiatric Pharmacology at the University of Toronto.

Dr. McIntyre is involved in multiple research endeavors that primarily aim to characterize the association between mood disorders and medical comorbidity. This research involves elucidating metabolic adverse events associated with the use of psychotropic medications, the impact of medical comorbidity on the course of mood disorders, and the effect of glucose homeostasis on neurocognition.

Dr. McIntyre is extensively involved in medical education. He is a highly sought-after speaker at both national and international meetings. In addition to garnering several teaching awards from the University of Toronto, Department of Psychiatry, he has received the joint Canadian Psychiatric Association (CPA)/ Council of Psychiatric Continuing Education Award for the Most Outstanding Continuing Education Activity in Psychiatry in Canada.

Dr. McIntyre is the co-chair of the Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force on the Treatment of Comorbidity in Adults with Major Depressive Disorder or Bipolar Disorder and a contributor to the CANMAT Guidelines for the Management of Depressive Disorders and Bipolar Disorders. Published extensively in leading peer-reviewed journals and textbooks, Dr. McIntyre is also a reviewer for many journals including The American Journal of Psychiatry, Biological Psychiatry, The Journal of Clinical Psychiatry, and The New England Journal of Medicine.

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EDUCATIONAL OBJECTIVES At the conclusion of this educational activity, participants should be better prepared to: • Discuss epidemiologic and mechanistic relationships between bipolar disorder and cardiometabolic disturbances • Identify patients with bipolar depression based on a comprehensive patient history, key clinical features and risk factors, and the latest diagnostic criteria • Tailor therapeutic regimens for bipolar depression to reflect efficacy, safety, and tolerability of approved agents, common patient comorbidities, and the likelihood of treatment adherence

NEEDS ASSESSMENT AND LEARNER’S GAP Bipolar disorder is a chronic and progressive illness characterized by unpredictable swings between mood poles.1,2 Depressive episodes are associated with especially high medical and psychosocial burdens.3,4 For example, bipolar depression has been tied to markedly impaired work performance, increased cardiovascular risk, and high rates of suicide.5-7 Additionally, diagnostic barriers abound; common comorbidities often muddy patient presentations and misdiagnoses of unipolar depression commonly delay the identification and appropriate treatment of affected individuals.8-10 Once an accurate diagnosis has been established, primary goals for treating bipolar disorder include alleviating acute symptoms quickly, sustaining remission, preventing relapse, and optimizing longterm mental and cardiometabolic health.7,10-12 Yet few treatments for bipolar depression have been highly and consistently effective in clinical trials, and many clinical practice guidelines for bipolar disorder are out-of-date and do not reflect currently available treatments.12,13 Thus, practicing clinicians—and in turn their patients—will benefit from expert recommendations on patient identification, symptom management, and evidence-based management algorithms. During this Interactive Professor™ program, Dr. Roger McIntrye uses interactive video case studies to review practical approaches to the assessment and individualized multimodal treatment of patients with bipolar depression.

In particular, the cases focus on key diagnostic considerations and therapeutic strategies that maximize long-term patient health and promote treatment adherence.

Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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INTENDED AUDIENCE This activity is intended for primary care providers, nurse practitioners, physician assistants, and other health care providers involved in the initial assessment, diagnosis, and ongoing management of patients with bipolar depression.

There are no prerequisites for this educational activity.

ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Educational Review Systems, Inc., and Integritas Communications.

CREDIT DESIGNATION This program has been reviewed and is acceptable for up to 0.5 Prescribed credit hour by The American Academy of Family Physicians.

AAFP Prescribed credit is accepted by the AMA as equivalent to AMA PRA Category 1 Credit™ for the American Medical Association (AMA) Physician’s Recognition Award (PRA). When applying for the AMA PRA, Prescribed hours earned must be reported as Prescribed hours, not as Category 1.

(This statement applies to all Physicians, not just Family Physicians.)

CONFLICT OF INTEREST STATEMENT The Conflict of Interest Disclosure Policy of Educational Review Systems, Inc., requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical, product, or device company. Any presenter whose disclosed relationships prove to create a conflict of interest with regard to his/her contribution to the activity will not be permitted to present.

Educational Review Systems, Inc., also requires that faculty participating in any CME activity and anyone in a position to influence content disclose to the audience when discussing any unlabeled or investigational use of any commercial product, or device, not yet approved for use in the United States.

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FACULTY AND PLANNING COMMITTEE DISCLOSURES Roger S. McIntyre, MD, FRCPC Grant/Research Support — AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Lundbeck, National Alliance for Research on Schizophrenia and Depression (NARSAD), National Institutes of Mental Health, Pfizer Inc., Shire Plc, Stanley Medical Research Institute; Advisory Boards — AstraZeneca, Bristol-Myers Squibb and Company, Eli Lilly and Company, France Foundation, GlaxoSmithKline, Janssen Pharmaceuticals, Inc., Lundbeck, Merck & Co., Inc, Organon, Pfizer Inc., Shire Plc; Speakers Bureau — AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Lundbeck, Merck & Co., Inc., Pfizer Inc. Jim Kappler, PhD, of Integritas Communications, has no relevant financial relationships to disclose.

REFERENCES 1. Goldstein BI, Shamseddeen W, Axelson DA, et al. J Am Acad Child Adolesc Psychiatry.

2010;49(4):388-396.

2. Fiedorowicz JG, Endicott J, Leon AC, et al. Am J Psychiatry. 2011;168(1):40-48.

3. Rosa AR, Reinares M, Michalak EE, et al. Value Health. 2010;13(8):984-988.

4. Judd LL, Akiskal HS, Schettler PJ, et al. Arch Gen Psychiatry. 2002;59(6):530-537.

5. Morgan VA, Mitchell PB, Jablensky AV. Bipolar Disord. 2005;7(4):326-337.

6. Cousins DA, Young AH. Int J Neuropsychopharmacol. 2007;10(3):411-431.

7. Slomka JM, Piette JD, Post EP, et al. J Affect Disord. 2012;138(3):405-408.

8. Ramsley SE. J Am Acad Nurse Pract. 2007;19(4):172-178.

9. Berk M, Berk L, Moss K, Dodd S, Malhi GS. Med J Aust. 2006;184(9):459-462.

10. McIntyre RS, Rosenbluth M, Ramasubbu R, et al. Ann Clin Psychiatry. 2012;24(2):163-169.

11. McIntyre RS. J Clin Psychiatry. 2009;70(6):e17.

12. Belmaker RH. Am J Psychiatry. 2014;171(2):131-133.

13. Kohler S, Gaus S, Bschor T. Pharmacopsychiatry. 2014;47(2):53-59.

Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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Improving Outcomes in Bipolar Depression Overcoming Diagnostic Challenges, Targeting Remission, and Optimizing Cardiometabolic Health

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TOOLS Depression and Bipolar Support Alliance The Depression and Bipolar Support Alliance (DBSA) Web site offers information, education, and support for individuals suffering from bipolar depression. Tools such as the mental health screening center helps patients track and assess their symptoms. The Web site also offers a mood calendar that helps patients document their moods and may be of use to both patient and clinician when monitoring treatment efficacy. http://www.dbsalliance.org

Mood Disorder Questionnaire The questionnaire was developed to address a critical need for timely and accurate diagnosis of bipolar disorder.

A screening score of 7 or more items across 3 criteria yields a positive screen for bipolar disorder. It has very good sensitivity and specificity.

Hirschfeld RM, et al. Am J Psychiatry. 2000;157:1873-1875.

Bipolar Depression Rating Scale The Bipolar Depression Rating Scale is designed to measure the severity of current depressive symptoms in bipolar depression. The scale contains 20 questions for a maximum score of 60. Higher scores indicate greater severity.

Berk M, et al. Bipolar Disord. 2007;9:571-579.

GUIDELINES Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) 2013 version of the American Psychological Association’s diagnostic guidelines include the bipolar disorder spectrum.

American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013: Arlington, VA, American Psychiatric Publishing.

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VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults Guideline statements on the step-by-step process of clinical decision-making and intervention in the diagnosis and management of bipolar disorder. Contains best practice recommendations on general care and treatment, as well as specific recommendations for an older patient population.

VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults. 2010: Washington, DC, Department of Veterans Affairs, Department of Defense.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) Collaborative Update of CANMAT Guidelines for the Management of Patients With Bipolar Disorder: Update 2013 The CANMAT-ISBD guidelines include instructions for the diagnosis, treatment, and management of bipolar disorder. The 2013 update contains new evidence for pharmacological treatments of bipolar depression as well as specific recommendations for bipolar II management.

Yatham LN, et al. Bipolar Disord. 2013:15:1-44.

SUGGESTED READING Treatment options for acute depression in bipolar disorder.

Bauer M, et al. Bipolar Dis. 2012;14:37-50.

Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder.

Fiedorowicz JG, et al. Am J Psychiatry. 2011;168:40-48.

Clinical differences between bipolar and unipolar depression.

Forty L, et al. Br J Psychiatry. 2008;19:388-389.

Clinical practice. Bipolar disorder—a focus on depression.

Frye MA. N Engl J Med. 2011;364:51-59.

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Acute and maintenance treatments for bipolar depression.

Ketter TA. J Clin Psychiatry. 2014;75:e10.

Strategies for monitoring outcomes in patients with bipolar disorder.

Ketter TA. Prim Care Companion J Clin Psychiatry. 2010;12:10-16.

Clinical practice recommendations for bipolar disorder.

Malhi GS, et al. Acta Psychiatr Scand. 2009;119:27-46.

Metabolic syndrome in bipolar disorder: a review with a focus on bipolar depression.

McElroy SL, Keck PE. J Clin Psychiatry. 2014;75:46-61.

Medical comorbidity in bipolar disorder: implications for functional outcomes and health service utilization.

McIntyre RS, et al. Psychiatr Serv. 2006;57:1140-1144.

The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders.

Pacchiarotti I, et al. Am J Psychiatry. 2013;170:1249-1262.

The neurobiology of the switch process in bipolar disorder: a review.

Salvadore G, et al. J Clin Psychiatry. 2010;71:1488-1501.

An update on antidepressant use in bipolar depression.

Sidor MM, MacQueen GM. Curr Psychiatry Rep. 2012;14:696-704.

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