By Steve Lewis
BOSTON–Headlines may focus on mental-health issues such as schizophrenia, often related to veteran homelessness or even violent behavior, but bipolar disorder actually is increasing far faster at the VA and can be especially challenging to treat because of the high side-effect profile of the drug commonly used to treat it.
Bipolar disorder “has been an orphan disorder; it’s fallen between the cracks,” said Mark S. Bauer, MD, professor of psychiatry, Harvard Medical School, and associate director, Center for Organization, Leadership and Management Research (COLMR), at the VA Boston Healthcare System.
– Mark S. Bauer, MD. Professor of pschiatry, Harvard Medical School
In research he called “very compelling,” Bauer said prevalence of cases increased from 77,000 to more than 106,000 at the VA between 2002 and 2008 – more than a 37% increase.
“At the same time, there has been a flattening or reduction of the number veterans treated for schizophrenia, from about 86,000 to about 71,000,” he noted.
One of the few occasions when bipolar disorder was in the news lately concerned research on the toxicity of lithium, the treatment of choice for more than 50 years. Research published in the journal The Lancet earlier this year reaffirmed that lithium “is associated with increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism and weight gain.”
The authors also affirmed, however, that lithium should continue to be the first-line treatment for bipolar disorder, despite challenges in managing medication side effects.
“This article was extremely high quality,” Bauer asserts. “What’s important to understand is the reason it was written is that there has been a rebirth in interest in lithium as newer drugs have come to be seen as pretty good alternatives.”
While lithium is an anti-manic medication, so are others such as divalproex, he noted. Yet, there are few alternatives to lithium in treating depression in bipolar patients.
“Probably the strongest data for an anti-depressant effect is with lithium, and there is also a lot of evidence that lithium has a specific anti-suicide effect,” he asserted, adding that, side effects to the contrary, “there are many reasons for providers to increase their use of lithium.”
An article published in 2010 in the Archives of General Psychiatry suggested that the single diagnosis most highly associated with successful suicide is bipolar disorder, “So there is a huge mortality risk, and the number of patients is increasing,” Bauer pointed out.With Increase in Bipolar Patients the VA Tackles Medication Side Effect Issues
The project’s goals include:
- Improved monitoring for and management of physical-health problems among veterans taking atypical antipsychotic medications;
- Improved adherence to guidelines around metabolic monitoring for antipsychotic medication; decreasing the number of veterans who are prescribed antipsychotic medications who are obese; and
- Increasing the use of weight interventions among veterans who are prescribed antipsychotic medications and are obese.
In related work, the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI)’s Mental Health Strategic Plan was issued in December 2011.
“Although we have expectations for screening individuals for cardiovascular risk, we have not yet had official expectations or performance measures around screening seriously mentally ill patients — but we should,” says Bauer. “There are also a series of weight loss and cardiovascular weight loss reduction programs like M.O.V.E., but still very few designed for this special population.”
M.O.V.E. is a national weight management program designed by the VHA National Center for Health Promotion and Disease Prevention, a part of the Office of Patient Care Services. It includes modules on physical activity, eating wisely, screenings and immunizations, smoking cessation and limiting alcohol consumption.
Mental illness can strongly impact how care is provided and whether interventions are affected.
“A lot of times these patients do not show up for the M.O.V.E. program, or they barely participate,” Bauer pointed out. “They are also socially disadvantaged, so it’s harder get there. They take medications that slow their thinking down, so compliance is lower. There are a variety of effects on these folks, which makes you feel like you need specially-designed programs.”
VA currently has effective cardiovascular-risk programs for patients who are not mentally ill and effective self-management programs for patients with bipolar disorder.
“What we need to do is combine them in a creative way to serve the veterans centers’ patient-specific needs of this population,” says Bauer. Those needs include management of mental-health symptoms and cardiovascular risk, such as exercise, smoking cessation, diet and sleep hygiene.
“But we have to deliver these kinds of treatments in such a way that this special population can participate,” he said. “They have a limited attention span, so we need flexible delivery models where they can do their part of the management at home sometime. In addition, some do not do well in groups but others do, so you have to approach this in a more customized way.”
Such a program, he added, would be the “holy grail” of care for these patients. “We have a pretty good idea of what these people need; it’s just a matter of putting it all together,” according to Bauer.
Approach to Side Effects
As with any medication, the potential benefits must be weighed against potential toxicity or side effects. The Lancet article, said Bauer, “reaches very realistic conclusions” – summarizing what had already been known but “in a very elegant manner.”
– Photo Source: North Florida VA Website
“We know two things: We know people with serious mental illness are at higher risk for cardiovascular disease, for diabetes and for early death – as much as 15 to 25 years sooner than those without serious mental illness,” he observed. “Fact No. 2 is that many of the medications we give to treat mental illness can induce diabetes, obesity and cardiovascular risk.”
However, he added, this also is true of the new anti-psychotics. “And it’s an important point the authors make: Lithium can cause modest levels of weight gain, but not as much as the newer drugs like olanzapine,” he explained.
Other side effects are more easily managed, Bauer pointed out. The study authors reported that thyroid disease occurs in 20%-25% of cases but noted that rates of clinical disease are much lower than those of lab abnormalities. “That is easily handled in most cases by giving thyroid hormones,” he said.
A number of projects under way at VA seek to improve management of patients with mental-health issues. One is MIAMI (MIRECC Initiative on Antipsychotic Management Improvement) project, funded by the VA Office of Mental Health Services Initiative. One of the cornerstones of the MIAMI project is 2009 research by VA’s Center for Mental Healthcare and Outcomes Research, which promised development of guidelines to manage antipsychotic metabolic side effects.
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