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Adding a nurse-based intervention programme to usual care improves manic symptoms in people with bipolar disorder
  1. Gary S Sachs, MD
  1. Associate Professor of Psychiatry, Harvard Medical School and Director,
 Bipolar Clinic and Research Program, Massachusetts General Hospital,
 Boston, MA, USA

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 Q Does adding a nurse-based intervention programme to usual care improve the effectiveness of treatment for bipolar disorder?

    METHODS

    Embedded ImageDesign:

    Randomised controlled trial.

    Embedded ImageAllocation:

    Concealed.

    Embedded ImageBlinding:

    Single blinded.

    Embedded ImageFollow up period:

    Twelve months.

    Embedded ImageSetting:

    Four health clinics in the USA; August 1999 to October 2000.

    Embedded ImagePatients:

    441 people treated for bipolar disorder type I or II (DSM-IV) in the previous 12 months. People were excluded if cognitive impairment prevented giving informed consent.

    Embedded ImageIntervention:

    Usual care, or usual care plus a nurse-based intervention programme. The intervention programme consisted of an initial patient assessment and treatment planning session, followed by monthly telephone monitoring of mood symptoms and medication with the support of the treating mental healthcare team, together with a group psycho-educational programme.

    Embedded ImageOutcomes:

    Psychiatric status ratings for mania and depression.

    Embedded ImagePatient follow up:

    94% completed the study.

    MAIN RESULTS

    Usual care with a nursed-based intervention programme reduced manic, but not depressive symptoms, compared with usual care alone, over 12 months (mania scores: p = 0.025; depressive scores: p = 0.82; actual values not stated).

    CONCLUSIONS

    Usual care with a nurse-based intervention programme is more effective than usual care alone for treating bipolar disorder.

    Commentary

    Treatments demonstrated to be efficacious for bipolar disorder in clinical trials deliver disappointing results when applied in general practice. Rather than searching for a more efficacious molecule, Simon et al conducted a well powered randomised controlled trial comparing outcomes over a 12 month period for bipolar patients continuing usual care or adding a multicomponent systematic care management programme coordinated by a specialised nurse.

    The results indicate that tightening up the intervention–measurement–management feedback loop is beneficial. The programme consistently produced a statistically significant reduction in average mania severity scores and a modest reduction in depression over time. Both groups, however, enjoyed rather striking reductions in symptom severity. As the authors point out, this is unlikely to represent regression to the mean, because the sample was not selected for high symptom acuity at study entry. Thus participation in study procedures probably had a salutary effect on the course of bipolar illness. It is plausible that serial independent outcome assessments represent an active intervention-enhancing effectiveness. Benefit might be derived from other study procedures or leakage of improved approaches to usual care.

    The results are consistent with non-specific effects observed in clinical trials1,2 and encourage us to integrate more coordination and measurement into our management of bipolar disorder while we wait for research to clarify the active components. Although a nurse specialist implementing the full systematic care programme might best serve this function, the identification of a care partner, appointment reminders, and quarterly independent assessment might represent a feasible set of core interventions for nearly all mental health settings.

    References

    View Abstract

    Footnotes

    • For correspondence: Dr Gregory Simon, Center for Health Studies, 1730 Minor Avenue, #1600 Seattle, WA 98101, USA; simon.gghc.org

    • Sources of funding: Grant R01 MH59125 from the National Institute of Mental Health.

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