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présentation des améliorations du traitement du TB
 

présentation des améliorations du traitement du TB

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    présentation des améliorations du traitement du TB présentation des améliorations du traitement du TB Presentation Transcript

    • An Update on Bipolar Disorder NARSAD 2008 Andrew A. Nierenberg, MD Medical Director Harvard Bipolar Clinic and Research Program, Massachusetts General Hospital Director, NIMH Bipolar Trials Network Professor of Psychiatry, Harvard Medical School
    • Thank you NARSAD
      • Thilo Deckersbach, PhD
      • Christina Dording, MD
      • Aude Henin, PhD
      • Dan Iosifescu, MD
      • Andrew A. Nierenberg, MD
      • Michael J. Ostacher, MD, MPH
      • Janet Witte, MD
    • Update on Bipolar Disorder
      • Update on Bipolar basics
      • STEP-BD
      • LiTMUS
    • Lizzie Simon Time Magazine Aug 11, 2002 "Everything was perfect... and then I went insane"
    • Goya Portrait of Don Gaspar Melchor de Jovellanos
    • Bipolar Disorder
      • Prevalence:
        • BPI and II:
          • 1.1% of the workforce
          • 2.6% of the general population
      • Mean age of onset: 17.4 years
      Kessler et al. Arch Gen Psychiatry . 2005;62:617-627. Kessler et al. Am J Psychiatry . 2006;163:1561-1568.
    • Bipolar Disorder
      • Recurrent and chronic disorder
        • Manic or hypomanic episodes
        • Major depressive episodes and symptoms
          • Major burden
        • Inter-episodic symptoms
      • Dysfunction:
        • 65.5 lost days of work per year
      Kessler et al. Arch Gen Psychiatry . 2005;62:617-627. Kessler et al. Am J Psychiatry . 2006;163:1561-1568.
    • STEP-BD
      • Systematic Treatment Enhancement Program for Bipolar Disorder
      • www.stepbd.org
      • Evidence guided treatment
      • Specialty bipolar clinics
      • Integration of measurement and management
      • Embedded randomized trials
    • Collaborative Care and Concordance
    •  
    • Collaborative Care: Integration of Measurement and Management
      • Shared measurement
        • Symptoms
          • Depression
          • Mania/hypomania
          • Anxiety
          • Irritability
        • Stress, alcohol, weight
        • Side effects
        • Functioning
      Nierenberg AA. J Clin Psychiatry. 2006;67 Suppl 11:3-7. www.manicdepressive.org (see Resources section) Clinical Self-report Form Clinical Monitoring Form
    • Collaborative Care: Integration of Measurement and Management
      • Mood monitoring
      • Medication concordance
          • Non-concordance open for discussion
      • Negotiate
        • Goals
        • Medication changes
          • Menu of reasonable choices
      • Collaborative Care Workbook
    • Key STEP-BD Baseline Findings
    • STEP-BD: Bipolar Onset > 18 13 to 18 < 13 Perlis RH for the STEP-BD group, Biol Psych 2004;55:875-881
    • Lifetime Anxiety Comorbidity Simon N, et al. Am J Psychiatry . 2004;161:2222-2229. * 0 10 20 30 40 50 60 Any Panic ± Agor Agor Without Panic SAD OCD PTSD GAD * * * * † BP I BP II
    • Key STEP-BD Long-Term Findings
    • With systematic treatment, 30% of STEP-BD participants achieved recovery and then stayed recovered over 1 year
    • Anxiety: more difficult to recover from bipolar depressive episode Otto et al., Br J Psychiatry 2006 Jul;189:20-5. without anxiety with anxiety
    • Anxiety: higher risk of depressive relapse Otto et al., Br J Psychiatry 2006 Jul;189:20-5. without anxiety with anxiety
    • Higher bipolar relapse rate with residual symptoms Perlis et al., Am J Psychiatry. 2006 Feb;163(2):217-24. Without residual symptoms With residual symptoms Without residual symptoms With residual symptoms
    • No benefit with antidepressants for bipolar depression with manic symptoms Goldberg et al. Am J Psychiatry 2007:164:1348-1355
    • STEP-BD Randomized Trials
    • Antidepressants or placebo added to mood stabilizers for bipolar depression Sachs G et al. N Engl J Med 2007;10.1056/NEJMoa064135 %
    • Treatment Resistant Bipolar Depression: Lamotrigine Added Might Help Nierenberg et al., Am J Psychiatry 2006;163;1-8
    • Adjunctive Psychosocial Interventions
      • Collaborative Care Plus
      • Cognitive-Behavioral Therapy (CBT)
      • Family-Focused Therapy (FFT)
      • Interpersonal and Social Rhythm Therapy (IPSRT)
    • Intensive psychotherapy: remission 110 days earlier 110 Days Miklowitz et al., Arch Gen Psychiatry. 2007 Apr;64(4):419-26.
    • LiTMUS Lithium Moderate Dose Use Study A NIMH Bipolar Trials Network Contract
    • Problem: Long term outcomes suboptimal for Bipolar Disorder and Lithium is under used
    • Can tolerable doses of lithium added to other medications improve 6 month outcomes?
    • LiTMUS
      • Compare strategies of treatment
        • Optimized treatment with lithium
        • Optimized treatment without lithium
      • 6 month outcomes
      • Open treatment
      • Blinded outcomes
    • Update on Bipolar Disorder
      • Update on Bipolar basics
      • STEP-BD
      • LiTMUS