Setting

This audit will be most suitable for adult and older-adult psychiatry services. Bipolar depression is usually treated within the out-patient department. This audit can be site specific or carried out across a trust.

Background

The depressive episodes in bipolar disorder are debilitating and on the whole they last longer and occur more frequently than manic episodes. The treatment of bipolar depression is controversial and there is evidence that using antidepressants can cause switching and acceleration of cycling. The efficacy of antidepressants in bipolar depression is weak and yet they are widely used.

Standards

The following standards relating to bipolar depression were taken from the guideline on bipolar disorder produced by the National Institute for Health and Clinical Excellence (NICE) (2006):

ᐅ A patient who is prescribed antidepressant medication should also be prescribed an antimanic drug.

ᐅ A selective serotonin reuptake inhibitor (SSRI) should be used instead of a tricyclic antidepressant.

ᐅ Patients should not routinely continue on long-term antidepressant treatment.

ᐅ When initiating antidepressant treatment for patients not on antimanic medication, the risk of switching should be explained.

ᐅ Antidepressants should be avoided for patients with depressive symptoms who:

Method

Data collection

A retrospective case-note analysis was conducted. All patients with a diagnosis of bipolar disorder who had suffered a depressive episode were included. Those with schizoaffective disorder were excluded.

Medical/electronic notes were reviewed to see whether the following had been recorded:

ᐅ the severity of the depression – mild; moderate; severe; with or without psychosis

ᐅ any contraindications to the use of antidepressants – rapid cycling bipolar disorder, recent hypomanic episode or recent mood fluctuations

ᐅ what the baseline medications were (type and dose) and whether these had proved therapeutic/sub-therapeutic

ᐅ the treatment regimen (medication type and dose, therapy, other)

ᐅ whether the patient was on antimanic medication if an antidepressant had been started

ᐅ discussion with the patient of the risk of switching

ᐅ outcome of the treatment regimen (including adverse events such as a manic switch)

ᐅ subsequent treatment regimens (second and third).

Data analysis

Compliance with the above standards was calculated. Demographic data and site-specific data were obtained in order to allow comparisons.