Bipolar in Turkey

8/14/2019 Bipolar in Turkey

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duygudurummerkezi

Rasit Tahsin

Drug Administration Patterns:Drug Administration Patterns:BP I outpatients in IstanbulBP I outpatients in Istanbul

E. Timuin Oral, Nesrin Koal, Evrim ErtenE. Timuin Oral, Nesrin Koal, Evrim Ertenzden Arsoy, Aytl Hariri, Erhan Kurtzden Arsoy, Aytl Hariri, Erhan Kurt

Bakirkoy State Hospital for Psychiatric & Neurological Diseases,Bakirkoy State Hospital for Psychiatric & Neurological Diseases,Rasit Tahsin Outpatient Mood Disoders Unit, Istanbul / TurkeyRasit Tahsin Outpatient Mood Disoders Unit, Istanbul / Turkey


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Please change yourPlease change yourdrug, this one can notdrug, this one can not

control your cyclingcontrol your cycling


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Changing face of Psychiatry inChanging face of Psychiatry in

BakrkyBakrky


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4

2

2

Population: 73 000 000 Area: 769 604 sq km Urban pop: 66 %


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Number of physicians: approx.Number of physicians: approx. 100 000100 000Number of hospital beds:Number of hospital beds: 180 797180 797

Total number of psychiatric beds: Total number of psychiatric beds: 6 0006 000

Prevalence of any psychiatric disorderPrevalence of any psychiatric disorder Under age 18:Under age 18: 22.2 %22.2 % Over age 18:Over age 18: 17.2 %17.2 %

Suicide rate:Suicide rate: 3.85 / 100 0003.85 / 100 000

# Psychiatrists:# Psychiatrists: 2 / 100.0002 / 100.000# Child Psychiatrists:# Child Psychiatrists: 0,2 / 100.0000,2 / 100.000# Psychologists:# Psychologists: 4 / 100.0004 / 100.000

# Social workers:# Social workers: 2 / 100.0002 / 100.000# Nurses:# Nurses: 4 / 100.0004 / 100.000

DemographicsDemographics


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Classification SystemClassification System :: DSM (ICD for official use)DSM (ICD for official use)ProblemsProblems ::

Differential Diagnosis (Schizoaffective Disorder)Differential Diagnosis (Schizoaffective Disorder)

Lack of Investigating Hypomania in DepressiveLack of Investigating Hypomania in DepressivePatientsPatients Co-morbidity of endemic thyroid problems inCo-morbidity of endemic thyroid problems in

black sea regionblack sea region

Over crowded wards and lack of qualified staff Over crowded wards and lack of qualified staff Lack of community psychiatry: accumulation of Lack of community psychiatry: accumulation of patients in certain treatment centerspatients in certain treatment centers

Unwillingly hospitalized patients (Stigmatization)Unwillingly hospitalized patients (Stigmatization)

Lack of regulatory criteria (laws?) forLack of regulatory criteria (laws?) forhospitalizationhospitalization

Basic IssuesBasic Issues


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ManiaMania

MSMS (Li, VPA, CBZ)(Li, VPA, CBZ)+ AP+ AP (FGA in acute settings)(FGA in acute settings)40-50 %40-50 % parenteral applicationparenteral application (up to 90 % in first three(up to 90 % in first threedays)days)

ECTECT: 18,6 %: 18,6 %

28,6 % in state hospitals, 8,4 % in university clinics28,6 % in state hospitals, 8,4 % in university clinics ECT is applied in modified form in all through theECT is applied in modified form in all through thecountry since 2005.country since 2005.

Bipolar DepressionBipolar DepressionMSMS (Li, LMT sometimes solely)(Li, LMT sometimes solely) + SSRI+ SSRIECTECT: 1-30 % (differ in clinics): 1-30 % (differ in clinics)

Mixed EpisodeMixed Episode

Generally not seen as it is in the literature, DSM is used forGenerally not seen as it is in the literature, DSM is used forresearch but softer criteria in clinical routineresearch but softer criteria in clinical routine

Treatment Issues Treatment Issues


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Long-termLong-termMSMS (Li / Li+VPA / Li+LMT)(Li / Li+VPA / Li+LMT)after II. episodeafter II. episode (except family hx,(except family hx,severity)severity)SGASGAs rising (FGA is rare, depots are extremely rare)s rising (FGA is rare, depots are extremely rare)

PsychotherapyPsychotherapyNot common, most non-structured training strategiesNot common, most non-structured training strategies

Giving NSI both to patients and relativesGiving NSI both to patients and relatives Giving NSI to patientsGiving NSI to patients Giving NSI to relativesGiving NSI to relatives

Structured psychoeducationStructured psychoeducationStigmaStigma

Better than Western Countries (esp in unchanged social parts)Better than Western Countries (esp in unchanged social parts)Admittance is still low in rural areas.Admittance is still low in rural areas.

Extended families still give support despite higherExtended families still give support despite higherstigmatization.stigmatization.

Treatment Issues Treatment Issues


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The illness must be explained better The illness must be explained better

Restricted number of beds requiresRestricted number of beds requires

outpatient treatment with a closeoutpatient treatment with a closesupervision of the patient and the family:supervision of the patient and the family:Psychoeducation needs attentionPsychoeducation needs attention

Enough attention should be given to theEnough attention should be given to theprophylaxis of the illnessprophylaxis of the illness

What should be done?What should be done?


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duygudurummerkezi

Rasit Tahsin


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Ord. Prof. Dr.Ord. Prof. Dr.

Rait TahsinRait TahsinTusavulTusavul


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BP Treatment Guidelines of PAT BP Treatment Guidelines of PAT

To review the existing literature and knowledgeTo review the existing literature and knowledge

To introduce the opinions of experts and clinicalTo introduce the opinions of experts and clinical

consensus judgements when knowledge is lackingconsensus judgements when knowledge is lackingor not enoughor not enough

To create a setting for discussion and interactionTo create a setting for discussion and interactionof the Turkish psychiatristsof the Turkish psychiatrists

To try to standardize treatment strategiesTo try to standardize treatment strategieswithout recipeswithout recipes

To produce a qualified Turkish referenceTo produce a qualified Turkish reference


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Algorithm for Maintenance TreatmentAlgorithm for Maintenance Treatment

11 stst episodeepisode

Severity of the episodeSeverity of the episode

Quality of lifeQuality of lifePositive family historyPositive family history

The choice of the patientThe choice of the patient

Decision: NODecision: NO

Taper down MS and STOPTaper down MS and STOP

22 ndnd or more episodesor more episodes

Not taking MSNot taking MS Taking MSTaking MS

Start MS (Li)Start MS (Li)

Decision: YESDecision: YES

Cont. MS startCont. MS startacute episodeacute episode

OrOrCont. MSCont. MS

Recurrence orRecurrence orpartial/minimal responsepartial/minimal response

Combine 2 MSsCombine 2 MSs

Full remissionFull remission

DecisionDecision

AlternativesAlternativesContinue treatmentContinue treatment


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Next stepNext step To determineTo determine

the feasibility of the algorithmthe feasibility of the algorithm the effectiveness of the medication algorithmsthe effectiveness of the medication algorithms

the application of the algorithms in differentthe application of the algorithms in differentclinical settingsclinical settings


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Treatment practice guidelinesTreatment practice guidelines

USUS American Psychiatric AssociationAmerican Psychiatric Association Texas Medication Algorithm ProjectTexas Medication Algorithm Project Expert Consensus GuidelinesExpert Consensus Guidelines

EuropeEurope European Algorithm ProjectEuropean Algorithm Project Cochrane Library reviewsCochrane Library reviews British Association of Psychopharmacologist guidelinesBritish Association of Psychopharmacologist guidelines National and local initiatives (Dutch, Turkish etc)National and local initiatives (Dutch, Turkish etc)

WorldwideWorldwide World Federation of Societies of Biological PsychiatryWorld Federation of Societies of Biological Psychiatry


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Europe-USA similarities in BPDEurope-USA similarities in BPD

Equivalent epidemiological studiesEquivalent epidemiological studies

Equivalent diagnostic studiesEquivalent diagnostic studies

Equivalent perspectives, training of expertsEquivalent perspectives, training of experts

Equivalent care when provided by psychiatricEquivalent care when provided by psychiatricexperts in BP careexperts in BP care


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Main differences inMain differences inEU practice / US algorithmsEU practice / US algorithms

Longer maintenance of antipsychotic(s) aloneLonger maintenance of antipsychotic(s) alone Possibility of two APsPossibility of two APs(one for sedation-conventional?(one for sedation-conventional?

+ one atypical)+ one atypical) No combination of anticonvulsants at this stageNo combination of anticonvulsants at this stage Augmentation with Li in case of non-responseAugmentation with Li in case of non-response

(considered as a starter in resistant patients)(considered as a starter in resistant patients) Progressive administration of Li for maintenanceProgressive administration of Li for maintenance

(prophylaxis) purpose in case of response(prophylaxis) purpose in case of response


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Post RM, et al. J Clin Psychiatry. 2003;64:680-690.Post RM, et al. J Clin Psychiatry. 2003;64:680-690.

Combination TherapyCombination TherapyThe rule, not the exceptionThe rule, not the exception

Total number of medicationsTotal number of medications101099887766554433221100

0.8%0.8%

6.6%6.6%

17.1%17.1%

20.9%20.9%

18.2%18.2%

12.0%12.0%12.0%12.0%

6.6%6.6%

3.1%3.1%

0.8%0.8%1.9%1.9%

N u m

b e r o f

P a t i e n t s

N u m

b e r o f

P a t i e n t s

6060

5050

4040

3030

2020

1010

00


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Combination treatment, rather thanCombination treatment, rather thanmonotherapy, is prevalent in themonotherapy, is prevalent in the

treatment of subjects with bipolartreatment of subjects with bipolardisorder, probably due to the complexdisorder, probably due to the complexand phasic nature of the illness.and phasic nature of the illness.

Levine et al, Bipolar Disord. 2000 Jun;2(2):120-30Levine et al, Bipolar Disord. 2000 Jun;2(2):120-30


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457 BP I457 BP I

LiLi 50%50%VPAVPA 40%40%CBZCBZ 11%11%

1/3 of all receiving APs; 2/3 of them traditional APs1/3 of all receiving APs; 2/3 of them traditional APs

50% were receiving concomitant ADs50% were receiving concomitant ADs

SSRISSRI 50%50%BuproprionBuproprion 25%25%BenzosBenzos 40%40%

MonoMono 18%18%>


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we should strive to achieve rational, yetpragmatic, treatment guidelines &algorithms to minimize the risks,

while maximizing the benefits of thesecombination treatmentsfor patients with BPD

Levine et al, Bipolar Disord. 2000 Jun;2(2):120-30Levine et al, Bipolar Disord. 2000 Jun;2(2):120-30


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Background: Pilot Study for SKBackground: Pilot Study for SKP-TRKP-TRK

AimAim: search for illness characteristics & drug: search for illness characteristics & drugadministration patterns in a naturalistic settingadministration patterns in a naturalistic setting

SiteSite : the greatest & oldest institute of the country / a: the greatest & oldest institute of the country / aspecialized outpatient unit registering MD patientsspecialized outpatient unit registering MD patients

Time spanTime span: starting from the spring of 2003: starting from the spring of 2003

Future PlanFuture Plan: obtained data will shed light on: obtained data will shed light oncolloborative research & will test treatment approach ofcolloborative research & will test treatment approach ofTurkish BP algorithmTurkish BP algorithm


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YAAM BOYUZLEM ZELGES Rasit Tahsin


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TEDAV

iddetli

IlmlOrtaHafif

iddetliOrta

Hafif

iddetliOrtaiddetli

IlmlOrta

M A N

D E P R E S Y O N

E t k i

D e r e c e s

i

Y a a m

O l a y

Y O R U M

EKT

Anksiyolitik

Li

Antidepresan

Antipsikotik

VPA

CBZ

~

+=

YILYA

25

1980 1990 1999 2000 20031977 2001

Li X *************

EKT

duygudurummerkezi

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+4

1994

Annesininlm

Eininlm

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2002

+4

EKT . EKT .VPA


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PopulationPopulation

241 BP Type I patients out of 266241 BP Type I patients out of 266registered in 8 monthsregistered in 8 months

Registered & evaluated with a structuredRegistered & evaluated with a structuredfollow-up form, developed & computerizedfollow-up form, developed & computerizedby the Mood Disorders Section of Turkishby the Mood Disorders Section of Turkish

Psychiatric Association for the databasePsychiatric Association for the databaseproject to be used country-wide (SKproject to be used country-wide (SKP-P-TRK)TRK)


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PatientsPatients

BP Type I patients registered onlyBP Type I patients registered only

BP : 203 UPM : 38BP : 203 UPM : 38 (UPM min 4 episodes and min 5 years)(UPM min 4 episodes and min 5 years) Genetic loadGenetic load

MD amongst first degree relatives 51.3%MD amongst first degree relatives 51.3%

MD amongst second degree relatives 45%MD amongst second degree relatives 45%


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DemographicsDemographics SexSex

61.4 % male61.4 % male 38.6 % female38.6 % female

Mean ageMean age 35.61 10.7 (16-67)35.61 10.7 (16-67)

Marital statusMarital status single 33.2 %single 33.2 % married 51.5 %married 51.5 % divorced or separated 15.4 %divorced or separated 15.4 %

marriage & divorce F>Mmarriage & divorce F>M


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AgeAge67676161

57575353

50504747

44444141

38383535

32322929

26262323

20201616

1414

1212

1010

88

66

44

22

00

N u m

b e r o

f p a

t i e n t s

N u m

b e r o

f p a

t i e n t s


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Social & economic statusSocial & economic status

99 (42%) are housewifes 55 (22.8%) unemployed(45 % because of illness) 20 (8.2 %) retired

67 (27.8 %) are employed or students

DemographicsDemographics


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BPD & psychosocial impairmentBPD & psychosocial impairment

Work / schoolWork / school Social / leisure lifeSocial / leisure life Family lifeFamily life > >

8 S h e e h a m

D i s a b

i l i t y

S c a

l e

8 S h e e

h a m

D i s a b i l i t y

S c a

l e ( % ) ( % )

p


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Illness characteristicsIllness characteristics

The first episode of the illnessThe first episode of the illness ManiaMania 54.9 %54.9 % DepressionDepression 38 %38 % MixedMixed 1.7 %1.7 % HypomaniaHypomania 1.6 %1.6 % DysthymiaDysthymia 0.4 %0.4 %

UnidentifiedUnidentified 3.8 %3.8 % Mean age of onset 22.53 7.42 (10-58)Mean age of onset 22.53 7.42 (10-58)

Duration of illness 12.83 9.52 (0-52)Duration of illness 12.83 9.52 (0-52)


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Duration of illnessDuration of illness

51514444

41413838

36363434

32323030

28282626

24242222

20201818

16161414

12121010

4040

3030

2020

1010

00


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Treatment of BP Mania inTreatment of BP Mania inAcute-Maintenance/Prevention PeriodsAcute-Maintenance/Prevention Periods

in an Inpatient Unitin an Inpatient UnitAcute PeriodAcute Period

Rezistance =Rezistance = im APs / EKT im APs / EKT DangerousnessDangerousness

Cooperation =Cooperation = Li (and/or VPA) + APLi (and/or VPA) + AP

MaintenanceMaintenance Li and/or VPALi and/or VPA

PreventionPrevention Li and/or VPA / Other MSLi and/or VPA / Other MS


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Prescribed Mood StabilizersPrescribed Mood Stabilizers

No Li/ACNo Li/AC 1313 5,5 %5,5 %LiLi 125125 52,752,7 %%VPAVPA 3030 12,712,7 %%CBZCBZ 55 2,12,1 %%Li+VPALi+VPA 5858 24,524,5 %%Li+CBZLi+CBZ 11 0,40,4 %%VPA+CBZVPA+CBZ 11 0,40,4 %%VPA+LamVPA+Lam 11 0,40,4 %%Li+LamLi+Lam 33 1,31,3 %%


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Proportions of MS drugs in the U.S. (2001)Proportions of MS drugs in the U.S. (2001)

DivalproateDivalproate 33.4%33.4% OlanzapineOlanzapine 16.1%16.1%

RisperidoneRisperidone 11.3%11.3% GabapentinGabapentin 11.1%11.1% LithiumLithium 8.8%8.8% QuetiapineQuetiapine 8.5%8.5% LamotrigineLamotrigine 3.6%3.6% TopiramateTopiramate 3.6%3.6% CarbamazepineCarbamazepine 3.6%3.6%


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LiLi

VPAVPACBZCBZ

Kings of PreventonKings of Preventon

Prescribed AntipsychoticsPrescribed Antipsychotics


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Prescribed AntipsychoticsPrescribed Antipsychotics

No APNo AP 125125 52,752,7ChlorpromazineChlorpromazine 4040 16,916,9TioridazineTioridazine 33 1,31,3

ZuclopenthixolZuclopenthixol 22 0,80,8HaloperidoleHaloperidole 22 0,80,8ClozapinClozapin 44 1,71,7

OlanzapineOlanzapine 3030 12,712,7RisperidoneRisperidone 1010 4,24,2QuetiapineQuetiapine 33 1,31,3SulpirideSulpiride 1717 7,27,2Amisul irideAmisul iride 11 0 40 4

fP i i f N l & C i l


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7676 7676 7171 67676363 6262

1515 19192525 2828

3333 3535

0010102020303040405050606070708080

ConventionalConventional NovelNovel

19971997 19981998 19991999 20002000 20012001 20022002

Prescription of Novel & ConventionalPrescription of Novel & ConventionalAntipsychotics in TurkeyAntipsychotics in Turkey


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Novel AntipsychoticsNovel Antipsychotics

0022

44

66

881010

1212

1414

16161818

19971997 19981998 19991999 20002000 20012001 20022002

ClozapineClozapine SulprideSulpride RisperidoneRisperidone OlanzapineOlanzapine QuetiapineQuetiapine

114 (47 3 %) patients are not using APs or ADs and


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114 (47,3 %) patients are not using APs or ADs andonly followed by MSs.

Of these patients who are receiving only MS

No drug 6 5,3Li mono 71 62,3VPA mono 9 7,9Li+VPA 27 23,7Li+Cbz 1 0,9

80 of them (70,2%) are on monotherapy witheither Li or VPA and 28 24,6 % on Li + VPA

M d St biliMood Stabilizers


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Mood StabilizersMood StabilizersNo MSNo MS 1313 5,5 %5,5 %

Mono-MSMono-MS 160160 67,567,5 %%Double-MSDouble-MS 6464 2727 %%

AntidepressantsAntidepressants

No ADNo AD 222222 93,793,7 %%SSRISSRI 1010 4,24,2 %%SNRI-NaSSASNRI-NaSSA 55 2,12,1 %%

AntipsychoticsAntipsychotics No APNo AP 125125 52,752,7 %%Novel APNovel AP 3434 14,414,4 %%ConventionalConventional 4747 19,819,8 %%


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VPAVPA Li-APLi-AP


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ConclusionConclusion

1/3 of the patients are on monotherapy.1/3 of the patients are on monotherapy.

MS alone are not found satisfactory by theMS alone are not found satisfactory by thepsychiatrists as monotherapeutic agentspsychiatrists as monotherapeutic agents

The application of guidelines and a structeredThe application of guidelines and a structeredfollow-up method, in a specialized setting mayfollow-up method, in a specialized setting maybe helpful to reduce the number of combinationbe helpful to reduce the number of combinationtreatments and risks for relapse.treatments and risks for relapse.


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The( Happy?)End


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The (Happy?)End

Documents

Bipolar in Turkey