Treatment
Traditionally, treatment for manic–depressive disorder has been
categorized as acute versus prophylaxis, or maintenance; that is, treatment
geared toward resolution of a specific episode versus continued treatment to
prevent further symptoms. Treat-ment can also be considered along several other
lines. In gen-eral, more structured treatment settings, such as full or partial
hospitalization, are indicated if patients are likely to endanger self or
others, if manic–depressive disorder is complicated by other medical or
psychiatric illnesses that make ambulatory management particularly dangerous,
or if more aggressive management is desired than is easily available on an
ambula-tory basis (e.g., intensive psychosocial intervention or rapid dosage
titration of psychotropic agents). In addition, social fac-tors play an
important role in the decision to hospitalize in the real world of clinical
psychiatry. Such reasons may include lack of social support to ensure
medication compliance during acute illness, social stresses aggravating
symptoms and making treat-ment compliance difficult (e.g., manipulative or
hostile living situation), or lack of transportation to accommodate frequent
ambulatory appointments during acute illness. Unfortunately, it is sometimes
the case, although less frequent in this era of managed care, that a person’s
insurance plan covers inpatient but not ambulatory mental health treatment,
forcing expensive inpatient care when less costly, time-limited, intensive
ambula-tory care would suffice.
Finally, treatment can be categorized according to its goals. Treatment
can be focused on improving clinical outcome (episodes and symptoms) or
functional outcome (social and oc-cupational function and health-related
quality of life). Although this categorization appears straightforward,
clinical practice reveals many subtleties. For instance, it is erroneous to
assume that clinical outcome is the domain of pharmacotherapy and that
functional outcome is the domain of psychotherapy. In actual-ity, most psychotherapies
by design focus on improving symp-toms. Likewise, pharmacotherapeutic
stabilization of symptoms clearly contributes to improved role function.
Further, treatments that improve one domain may cause decrements in another.
For instance, effective maintenance treatment with lithium may come at the cost
of hand tremor, which interfere with work function and causes embarrassment in
social situations. Compassionate psych-oeducation and alliance building are
integral goals of each form of treatment. In analogy to infectious disease
treatment, attention to such host factors can often make the difference between
suc-cess and failure of treatment.
Great optimism justifiably accompanied the introduction of lith-ium in
the 1960s, with the drug projected to save society millions of dollars in
direct and indirect treatment costs. However, there are reasons to be concerned
that lithium has made much less of an impact than originally projected, and
there is clear evidence that manic–depressive disorder remains a major health
concern, even with the addition of anticonvulsants to our armamentarium. For
example, readmission rates for manic–depressive disorder may be as high as 90%
during 2-year follow-up, with no differ-ence between lithium-treated and
nontreated patients (Markar and Mandar, 1989). Overall, the impact of lithium
“under ordi-nary clinical conditions” appears to be much less than would be
expected from results of randomized clinical trials.
How can these data be reconciled with early estimates projecting
dramatic decreases in treatment costs due to the intro-duction of lithium?
Presumably, the medications themselves do not differ between controlled
clinical trials and general clinical practice. If anything, the diffusion over
time of the new phar-macological technology into general clinical practice
might be expected to lead to further gains in illness management beyond those
initially seen. The use of several anticonvulsants such as carbamazepine,
valproic acid and lamotrigine in the treatment of manic–depressive disorder
holds promise for further improve-ment in outcome. For instance, these drugs
may have efficacy in controlled
clinical trials, but concerns regarding the effective-ness of lithium in clinical practice also apply to the
use of these anticonvulsants.
What, then, are the sources of this efficacy–effectiveness
gap in the treatment of
manic–depressive disorder? It is likely that
the gap is in part due to the exclusion of “complicated” manic–depressive
patients from clinical trials (e.g., those with substance abuse, personality
disorders, or medical problems, and those unwilling to risk exposure to
placebo. Although such ex-clusions are appropriate for establishing the
efficacy of potential treatments, the exclusivity of structured clinical trials
limits their relevance in the general clinical setting. Another likely
contribu-tor to the efficacy–effectiveness gap is variation in provider
at-tributes such as attitudes and capabilities. For instance, it is well established
that even at academic medical centers, the intensity of medication treatment
for mood disorders is much less than that which experts consider optimal. It is
possible, then, that sup-porting providers with specific data regarding
treatment options will aid in decreasing the efficacy–effectiveness gap. With
this in mind, several organizations have developed clinical practice guideline
to assist providers. Finally, the organization and orietn-tation of care giving
systemes may not be optimally supportive.
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