Measure:

Bipolar Disorder: Use of mood stabilizing or antimanic agent in BD I with depression

Summary:

This measure assesses the percentage of patients with Bipolar I Disorder with depressive symptoms and behaviors who have evidence of use of a mood stabilizing or antimanic agent during the first 12 weeks of pharmacotherapy treatment. 

Clinical Rationale:

Goals of Acute Treatment: Bipolar Disorder Depressive Episodes

• Remission of symptoms with a full return to usual levels of psychosocial functioning (1)
• Avoid mood destabilization and precipitating a manic or hypomanic episode (1,2)

Initial Treatment Considerations

• Treatment selection is dependent on illness severity, associated clinical features and patient preference (1)
• Treatment choice should also consider patient history, potential side effects and individual therapeutic response to specific pharmacotherapy agents (2)

Initial Treatment Recommendations

• Refer to published guidelines for 1st stage, 2nd stage, etc. detailed recommendations (1,2,3)
• Guidelines suggest lithium or lamotrigine alone or in combination with an atypical antipsychotic or lithium or lamotrigine alone or in combination, simultaneously, with an antidepressant (1,2,3)
• Stage 3, Stage 4, and for TIMA- Stage 5, guideline recommendations include the use of additional antimanic and antipsychotic agents, significantly expanding the selection options 
• The use of antidepressants even in combination with a mood stabilizing or antimanic agent has been associated with some controversy over their liability to induce a mood switch. (2,3)
• Typical antipsychotics have been associated with significant acute neurologic side effect risks (extrapyradmidal) and long-term risk of tardive dyskinesia (1,2,3)

Denominator Population:

Patients with Bipolar I Disorder with symptoms or episodes that involve depression

Data Sources:

• Administrative data
• Medical Record

Numerator Population:

Patients with evidence of use of a mood-stabilizing or antimanic agent during the first 12 weeks of  pharmacotherapy treatment

Data Source:

• Medical Record
• If available, administrative data that indicates specific pharmacotherapy

Initial Case-finding Guidance:

Patients with diagnosis of Bipolar I Disorder, with depression
ICD9CM or DSM IV TR:  296.5x

Specialty-specific Measure:

This measure is recommended by the STABLE National Coordinating Council as a specialty-specific measure for psychiatry as the denominator requires documentation of diagnostic information indicating  Bipolar Disorder I and the specific symptoms, behaviors, or episodes that are being addressed.

References:

1. Practice Guideline for the Treatment of Patients with Bipolar Disorder (2002 Revision); American Psychiatric Association; Am J Psychiatry 159:4, April 2002 Supplement ;   Also, Guideline Watch (2006) Update, Hirschfeld RM, American Psychiatric Association, 2006
2. Suppes T, Dennehy E, Hirschfeld R, Altshuler L, Bowden D, Calabrese J, Ketter T, Sachs G, Swann A, The Texas Implementation of Medication Algorithms: Update to the Algorithms for Treatment of Bipolar I Disorder, J Clin Psychiatry 2005; 66:870-886
3. Keck PE, Perlis R, Otto M, Carpenter, Ross R, Docherty J, Treatment of Bipolar Disorder 2004; The Expert Consensus Guideline Series, Postgraduate Medicine – A Special Report, December 2004