Effectiveness evaluation of mood disorder treatment algorithms in Brazilian public healthcare patients

Ana F Lima, Sandro R Miguel, Mírian Cohen, Jacques J Zimmermann, Flávio M Shansis, Luciane N Cruz, Patrícia K Ziegelmann, Carisi A Polanczyk, Marcelo P Fleck, Ana F Lima, Sandro R Miguel, Mírian Cohen, Jacques J Zimmermann, Flávio M Shansis, Luciane N Cruz, Patrícia K Ziegelmann, Carisi A Polanczyk, Marcelo P Fleck

Abstract

Objective: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system.

Methods: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD).

Results: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ∼6 years and the use of mood stabilizers began ∼12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response.

Conclusions: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time.

Clinical trial registration: NCT02901249, NCT02870283, NCT02918097.

Conflict of interest statement

The authors report no conflicts of interest.

Figures

Figure 1. Treatment algorithms. CZ = carbamazepine;…
Figure 1. Treatment algorithms. CZ = carbamazepine; LT = lithium; LSL = lithium serum level; RD = risperidone; VA = valproic acid. * Response was considered a 50% decrease in Hamilton Rating Scale for Depression baseline scores for major depressive disorder and bipolar depressive episodes, and a 50% decrease in Hamilton Scale and Young Mania Rating Scale baseline scores for mixed episode bipolar disorder.
Figure 2. Kaplan-Meier time-event curves (treatment response).
Figure 2. Kaplan-Meier time-event curves (treatment response).
Figure 3. Hamilton Rating Scale for Depression…
Figure 3. Hamilton Rating Scale for Depression (HRSD) and Young Mania Rating Scale (YMRS) mean scores (follow-up).
Figure 4. Kaplan-Meier time-event curves (first asymptomatic…
Figure 4. Kaplan-Meier time-event curves (first asymptomatic measure).
Figure 5. Hamilton Rating Scale for Depression…
Figure 5. Hamilton Rating Scale for Depression (HRSD) and Young Mania Rating Scale (YMRS) mean remission scores (follow-up).

References

    1. Parker G, McCraw S, Hadzi-Pavlovic D, Fletcher K. Costs of the principal mood disorders: a study of comparative direct and indirect costs incurred by those with bipolar I, bipolar II and unipolar disorders. J Affect Disord. 2013;149:46–55.
    1. Ekman M, Granstrom O, Omerov S, Jacob J, Landen M. The societal cost of bipolar disorder in Sweden. Soc Psychiatry Psychiatr Epidemiol. 2013;48:1601–10.
    1. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163–96.
    1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:593–602.
    1. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68:241–51.
    1. Dell'Aglio JC, Jr, Basso LA, Argimon II, Arteche A. Systematic review of the prevalence of bipolar disorder and bipolar spectrum disorders in population-based studies. Trends Psychiatry Psychother. 2013;35:99–105.
    1. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo 2010 [Internet]. 2010 [cited 2015 Feb 12].
    1. Brasil, Ministério da Saúde, Departamento de Informática do SUS (DATASUS). Informações de Saúde (TABNET) [Internet]. 2009 [cited 2015 May 29].
    1. Banta D, Almeida RT. The development of health technology assessment in Brazil. Int J Technol Assess Health Care. 2009;25:255–9.
    1. Brasil, Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas, Coordenação Geral de Saúde Mental, Álcool e Outras Drogas Saúde mental em dados 8 [Internet]. 2011 [cited 2015 May 29].
    1. Brasil, Ministério da Saúde (MS). Consulta pública n° 24, de 16 de dezembro de 2014 [Internet]. 2014 [cited 2015 May 29].
    1. Goncalves DA, Mari Jde J, Bower P, Gask L, Dowrick C, Tofoli LF, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saude Publica. 2014;30:623–32.
    1. Castelo MS, Hyphantis TN, Macedo DS, Lemos GO, Machado YO, Kapczinski F, et al. Screening for bipolar disorder in the primary care: a Brazilian survey. J Affect Disord. 2012;143:118–24.
    1. Mateus MD, Mari JJ, Delgado PG, Almeida-Filho N, Barrett T, Gerolin J, et al. The mental health system in Brazil: policies and future challenges. Int J Ment Health Syst. 2008;2:12–12.
    1. Santos IS, Tavares BF, Munhoz TN, Almeida LS, Silva NT, Tams BD, et al. [Sensitivity and specificity of the Patient Health Questionnaire-9 (PHQ-9) among adults from the general population]. Cad Saude Publica. 2013;29:1533–43.
    1. Soares OT, Moreno DH, Moura EC, Angst J, Moreno RA. Reliability and validity of a Brazilian version of the Hypomania Checklist (HCL-32) compared to the Mood Disorder Questionnaire (MDQ) Rev Bras Psiquiatr. 2010;32:416–23.
    1. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.
    1. Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr. 2000;22:106–15.
    1. Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de classificação econômica Brasil [Internet]. 2009 [cited 2015 May 29].
    1. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967;6:278–96.
    1. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429–35.
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Arlington: American Psychiatric Publishing; 2000.
    1. Trivedi MH, Rush AJ, Wisniewski SR, Nierenberg AA, Warden D, Ritz L, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28–40.
    1. Yatham LN, Kennedy SH, Schaffer A, Parikh SV, Beaulieu S, O'Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. Bipolar Disord. 2009;11:225–55.
    1. Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS, Milev R, Ramasubbu R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord. 2009;117:S26–43.
    1. Goldberg JF, Perlis RH, Ghaemi SN, Calabrese JR, Bowden CL, Wisniewski S, et al. Adjunctive antidepressant use and symptomatic recovery among bipolar depressed patients with concomitant manic symptoms: findings from the STEP-BD. Am J Psychiatry. 2007;164:1348–55.
    1. Andrade LH, Wang YP, Andreoni S, Silveira CM, Alexandrino-Silva C, Siu ER, et al. Mental disorders in megacities: findings from the Sao Paulo megacity mental health survey, Brazil. PloS One. 2012;7:e31879.
    1. Leucht C, Huhn M, Leucht S. Amitriptyline versus placebo for major depressive disorder. Cochrane Database Syst Rev. 2012;12:CD009138.
    1. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care . national institute for health and clinical excellence. Leicester: Guidance; 2006.
    1. Geddes JR, Miklowitz DJ. Treatment of bipolar disorder. Lancet. 2013;381:1672–82.
    1. Brown KM, Tracy DK. Lithium: the pharmacodynamic actions of the amazing ion. Ther Adv Psychopharmacol. 2013;3:163–76.
    1. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ. 2013;346:f3646.
    1. Rapoport SI, Basselin M, Kim HW, Rao JS. Bipolar disorder and mechanisms of action of mood stabilizers. Brain Res Rev. 2009;61:185–209.
    1. Post RM, Ketter TA, Uhde T, Ballenger JC. Thirty years of clinical experience with carbamazepine in the treatment of bipolar illness: principles and practice. CNS Drugs. 2007;21:47–71.
    1. Gijsman HJ, Geddes JR, Rendell JM, Nolen WA, Goodwin GM. Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. Am J Psychiatry. 2004;161:1537–47.
    1. Sidor MM, Macqueen GM. Antidepressants for the acute treatment of bipolar depression: a systematic review and meta-analysis. J Clin Psychiatry. 2011;72:156–67.
    1. Suppes T, Dennehy EB, Hirschfeld RM, Altshuler LL, Bowden CL, Calabrese JR, et al. The Texas implementation of medication algorithms: update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66:870–86.
    1. McElroy SL, Weisler RH, Chang W, Olausson B, Paulsson B, Brecher M, et al. A double-blind, placebo-controlled study of quetiapine and paroxetine as monotherapy in adults with bipolar depression (EMBOLDEN II) J Clin Psychiatry. 2010;71:163–74.
    1. Tundo A, Calabrese JR, Proietti L, de Filippis R. Short-term antidepressant treatment of bipolar depression: are ISBD recommendations useful in clinical practice? J Affect Disord. 2015;171:155–60.
    1. Pacchiarotti I, Bond DJ, Baldessarini RJ, Nolen WA, Grunze H, Licht RW, et al. The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. Am J Psychiatry. 2013;170:1249–62.

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