This audit is of relevance to all psychiatrists in Scotland who are involved in treating patients with bipolar disorder.
The guideline on bipolar affective disorder produced by the Scottish Intercollegiate Guidelines Network (SIGN) was last updated in July 2005 and is based on a critical appraisal of primary research evidence. The guideline separately considers treatment for mania, depression, relapse prevention, psychosocial interventions, comorbid substance misuse, reproductive health and suicide prevention.
The SIGN standards used for this audit include the following.
ᐅ In the acute treatment of mania:
▹ antipsychotics, semisodium valproate or lithium should be used
▹ antidepressant drug treatment should be reduced and discontinued.
ᐅ In the acute treatment of depression, an antidepressant with an antimanic drug or lamotrigine should be given.
ᐅ Intramuscular injection of antipsychotics and/or benzodiazepines should be used in emergencies for rapid tranquillisation.
ᐅ Evidence-based psychosocial interventions (e.g. cognitive–behavioural therapy, behavioural family therapy) should be available and arranged for a patient when indicated.
ᐅ Where coexisting substance misuse or alcohol problems exist, patients may be usefully managed under the care programme approach (CPA).
ᐅ In relation to suicide prevention, acute and maintenance treatment with lithium should be optimised (blood lithium level and adjustment of dose to therapeutic level).
The case notes of all patients discharged from hospital with a diagnosis of bipolar disorder over a specified period were reviewed. A standardised form was used to collect anonymised data on age, gender, diagnosis, treatment for mania, treatment for depression, medication used in rapid tranquillisation, documented need for psychosocial interventions and their availability, assessment and treatment of drug or alcohol misuse (including use of CPA) and optimisation of lithium treatment.
For patients with mania or depression, or those requiring rapid tranquillisation, the percentages were recorded of who were treated pharmacologically in accordance with the guideline. The proportion of patients who were referred for psychosocial interventions was also noted. Account was taken of which psychosocial interventions were available in each locality as this restricted the ability to arrange such interventions. The proportion of case notes which document the presence or otherwise of alcohol/drug misuse was noted along with the percentage of such patients on the CPA.