NOW Coalition for Bipolar Disorder Practice Tools

Below is a downloadable collection of helpful tools for practitioners treating patients with bipolar disorder.


STABLE Resource Toolkit

Diagnosis and Screening

Treatment

Collaborative Care and Long Term Management

 

STABLE Resource Toolkit

The STAndards for BipoLar Excellence (STABLE) project is a quality improvement initiative designed to advance best practices and quality of care for individuals with bipolar disorder.
www.cqaimh.org/stable

This clinician-led project included the development of 15 evidence-based clinical performance measures and a toolkit with resources related to these performance measures.

The STABLE toolkit is a valuable collection of resources for clinicians in both primary care and psychiatry settings.


Diagnosis and Screening

Dr. Henry A. Nasrallah Webinar: Is It Depression or Bipolar Disorder?
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Dr. Henry A. Nasrallah and Dr. Richard L. Brown Peer-to-Peer Dialogue: Diagnostic Challenges for Patients with Bipolar Disorder
Click Here >>
 
Dr. J. Sloan Manning Standardized Patient Video: Evaluation of a Patient Presenting with Depression and Use of Screening Tools to Evaluate for Mania or Hypomania, Substance Abuse, and Suicide Risk
Click Here >>


Screen for Bipolar Mania and Hypomania Prior to Treatment for Depression
Depressive symptoms are a shared feature of both major depressive disorder and bipolar disorder. Misdiagnosis and inappropriate pharmacotherapy are common in individuals with bipolar disorder. According to some estimates, many patients with bipolar disorder fail to receive an accurate diagnosis for 5 to 10 years following the onset of symptoms.

The routine use of screening tools can help to differentiate bipolar disorder from unipolar depression in clinical practice. The STABLE Resource Toolkit includes several resources for this purpose.

Mood Disorder Questionnaire (MDQ): The MDQ is a self-report instrument that can be easily scored by a health care provider. This is a screening tool only, and for those individuals who screen positive, a comprehensive evaluation for bipolar disorder is warranted.
www.cqaimh.org

Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire. Hirschfeld RM, et al. Am J Psychiatry. 2000;157:1873-1875.
ajp.psychiatryonline.org

The Mood Disorder Questionnaire: A Simple, Patient-Rated Screening Instrument for Bipolar Disorder. Hirschfeld RM. Prim Care Companion J Clin Psychiatry. 2002;4(1):9-11.
ncbi.nlm.nih.gov

World Health Organization Composite International Diagnostic Interview (CIDI 3.0): The CIDI 3.0 is a brief structured interview that is another instrument that can assist clinicians in identifying patients with bipolar disorder.
www.cqaimh.org

Validity of the Assessment of Bipolar Spectrum Disorders in the WHO CIDI 3.0. Kessler RC, et al. J Affect Disord. 2006;96(3):259-269.
www.ncbi.nlm.nih.gov

Interview Questions to Improve Differential Diagnosis of Bipolar Disorder:
www.cqaimh.org

Patient Health Questionnaire (PHQ-9): The PHQ-9 is a depression screening tool based on DSM-IV criteria. This instrument can be used for criteria-based diagnosis of depression and assessment of severity, as well as a tool to monitor and track symptom change over time.
www.cqaimh.org

The PHQ-9: Validity of a Brief Depression Severity Measure. Kroenke K, et al. J Gen Intern Med. 2001;16(9):606-613.
www.ncbi.nlm.nih.gov

Clinicians may wish to screen for additional psychiatric comorbidities such as anxiety. The General Anxiety Disorder-7 (GAD-7) is a brief self-report questionnaire for the assessment of generalized anxiety disorder.
www.phqscreeners.com

A Brief Measure for Assessing Generalized Anxiety Disorder: the GAD-7. Spitzer RL, et al. Arch Intern Med. 2006;166(10):1092-1097.
archinte.ama-assn.org


Suicide Risk Assessment of Patients with Depression or Bipolar Disorder
The risk of suicide is a concern for many patients with mood disorders, particularly for patients with bipolar disorder. Suicide risk assessment should be part of the routine evaluation of patients with depression or bipolar disorder.

The Suicide Behaviors Questionnaire-Revised (SBQ-R) is an instrument for assessing suicidal thoughts and behaviors.
www.cqaimh.org

An additional suicide screening tool is included in the STABLE Resource Toolkit, "Evaluation of Suicide Risk for Clinicians."
www.cqaimh.org

Considerations for suicide risk assessment are summarized in the STABLE Resource Toolkit.
www.cqaimh.org

The American Psychiatric Association Practice Guidelines provide questions that may help during inquiries about suicidal plans and behaviors.
www.psychiatryonline.com


Substance Use Assessment of Patients with Depression or Bipolar Disorder
Comorbid substance use disorders are common in patients with mood disorders and can negatively impact course of illness, treatment outcome, and prognosis. Ongoing assessment for substance use/abuse should be integrated into the routine care of patients with bipolar disorder.

The Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) is a brief instrument that screens for frequency of alcohol consumption, quantity of alcohol consumption, and the quantity of alcohol consumed on one occasion.
www.cqaimh.org

The AUDIT Alcohol Consumption Questions (AUDIT-C): An Effective Brief Screening Test for Problem Drinking. Bush K, et al. Arch Intern Med. 1998;158(16):1789-17G:95.
archinte.ama-assn.org

The full 10-question AUDIT instrument is available from the National Institute on Alcohol and Alcoholism.
www.niaaa.nih.gov

Additional information on AUDIT is available from the World Health Organization.
whqlibdoc.who.int

CAGE-AID (Cut down; people annoy you, feel guilty; need eye-opener-altered to include drugs) is a screening questionnaire that addresses both alcohol and drug use.
www.cqaimh.org

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Treatment

Dr. Caleb M. Adler Webinar: Evidence-Based Management of Patients with Bipolar Disorder
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Dr. Caleb M. Adler Patient Video: How to Tell Your Patient You Believe the Diagnosis is Bipolar Disorder
Click Here >>
 
Dr. Caleb M. Adler Patient Video: Evaluation of a Patient with Bipolar Disorder New to Practice, Currently on Antidepressant Monotherapy
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Evidence-based Treatment Guidelines for the Management of Patients with Bipolar Disorder
Utilize evidence-based treatment guidelines to formulate your treatment approach for your patients with bipolar disorder.

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. Yatham L, et al. Bipolar Disorders. 2009;11:225-255.
www.canmat.org

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2009 on the Treatment of Acute Mania
Grunze H, et al. World J Biol Psychiatry. 2009;10:85-116.
www.wfsbp.org

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression. Grunze H, et al. World J Biol Psychiatry. 2010;11:81-109.
www.wfsbp.org

Using Lithium for the Treatment of Bipolar Disorder–The Basics
Click Here >>


Adjunctive Psychosocial Interventions
Various psychosocial interventions used adjunctively with pharmacotherapy have been shown to improve treatment adherence and reduce relapse/recurrence. Establish mental health referrals and identify local resources to facilitate adjunctive psychosocial interventions for patients with bipolar disorder.

A summary of different psychosocial interventions is available through The National Alliance on Mental Illness (NAMI).
www.nami.org

Mental Health Resources and Services by State
Click Here >>

Selected reading:

    The Role of Psychotherapy in Bipolar Disorder. Lauder SD, et al. Med J Aust. 2010;193:S31-35.
    www.mja.com

    Adjunctive Psychotherapy for Bipolar Disorder: State of the Evidence. Miklowitz DJ. Am J Psychiatry. 2008;165:1408-1419.
    www.ncbi.nlm.nih.gov

    Psychosocial Treatments for Bipolar Depression: A 1-year Randomized Trial from the Systematic Treatment Enhancement Program. Miklowitz D, et al. Arch Gen Psychiatry. 2007;64:419-427.
    archpsyc.ama-assn.org

    A Randomized Trial on the Efficacy of Group Psychoeducation in the Prophylaxis of Recurrences in Bipolar Patients whose Disease is in Remission. Colom F. Arch Gen Psychiatry. 2003;60:402-407.
    archpsyc.ama-assn.org

    Group Psychoeducation for Stabilized Bipolar Disorders: 5-year Outcome of a Randomized Clinical Trial. Colom F, et al. Br J Psychiatry. 2009;194:260-265.
    bjp.rcpsych.org

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Collaborative Care and Long Term Management

Dr. Ronald J. Diamond and Dr. Richard L. Brown Peer-to-Peer Dialogue: Optimizing Patient Engagement in Treatment
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Dr. Ronald J. Diamond and Dr. Layne A. Prest Peer-to-Peer Dialogue: Using Concepts of Chronic Care Management for Patients with Bipolar Disorder
Click Here >>
 
Dr. Ronald J. Diamond Patient Video: Working with Patients to Proactively Identify Problems Before They Get Worse
Click Here >>
 
Dr. Caleb M. Adler Patient Video: How to Tell Your Patient You Believe the Diagnosis is Bipolar Disorder
Click Here >>


The Chronic Care Model and Collaborative Care for the Management of Bipolar Disorder
The features of the chronic care model and collaborative care can be applied to the long-term management of patients with bipolar disorder. The chronic care model involves a planned approach to care including the use of evidence-based guidelines, protocols to support patient involvement, education and self-management, reminder systems to reinforce keeping appointments and use of medication, and continuity of care. Collaborative care not only involves shared disease management between the physician and patient (through shared definition of problems, goal setting, self-management, support services, active and sustained follow-up), but also extends to collaboration among primary care, care managers, and mental health professionals.

Selected reading:

    Improving Chronic Illness Care: Translating Evidence into Action. Wagner E, et al. Health Aff (Millwood). 2001;20(6):64-78.
    content.healthaffairs.org

    Chronic Disease Management: What Will it Take to Improve Care for Chronic Illness? Wagner EH. Eff Clin Pract. 1998;1:2-4.
    www.acponline.org

    Collaborative Care for Bipolar Disorder: Part I. Intervention and Implementation in a Randomized Effectiveness Trial. Bauer M, et al. Psychiatr Serv. 2006;57(7):927-936.
    ps.psychiatryonline.org

    Collaborative Care for Bipolar Disorder: Part II. Impact on Clinical Outcome, Function, and Costs. Bauer M, et al. Psychiatr Serv. 2006;57(7):937-945.
    ps.psychiatryonline.org

    Enhancing Multiyear Guideline Concordance for Bipolar Disorder Through Collaborative Care. Bauer M, et al. Am J Psychiatry. 2009;166(11):1244-1250.
    ajp.psychiatryonline.org

    Long-term Effectiveness and Cost of a Systematic Care Program for Bipolar Disorder. Simon G, et al. Arch Gen Psychiatry. 2006;63:500-508.
    archpsyc.ama-assn.org


Self-management Support for Patients with Bipolar Disorder
An educated, engaged, and activated patient (and family) is an important element of collaborative chronic disease management. Establish self-management support for your patients with bipolar disorder. Disease-specific education and resources for bipolar disorder are available through the following links:

National Institute of Mental Health (NIMH)-Bipolar Disorder (Web site)
www.nimh.nih.gov

NIMH-Bipolar Disorder (PDF)
www.nimh.nih.gov

National Alliance on Mental Illness (NAMI)-Bipolar Disorder
www.nami.org

APA Healthy Minds. Healthy Lives. Bipolar Disorder
www.healthyminds.org

Depression and Bipolar Support Alliance (DBSA)
www.dbsalliance.org

DBSA Chapters/Support Groups
www.dbsalliance.org

DBSA External Referral Services
www.dbsalliance.org

The National Mental Health Consumers' Self-Help Clearinghouse Directory of Consumer-Driven Services
www.cdsdirectory.org

The STABLE Resource Toolkit includes a mood chart for patient self-report. Patient involvement in daily documentation and monitoring can enhance a collaborative therapeutic alliance with clinicians and help patients with early recognition of manic or depressive triggers.
www.cqaimh.org

The Clinical Self-Report Form included in the STABLE Resource toolkit is structured to capture recent symptoms of mood elevation and depression, and can be completed in the waiting room at the time of an appointment.
www.cqaimh.org

The Massachusetts General Hospital Bipolar Clinic & Research Program has information on mood charting as well as treatment contracts.
www.manicdepressive.org


Evidence-based Treatment Guidelines for the Management of Patients with Bipolar Disorder
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. Yatham L, et al. Bipolar Disorders. 2009;11:225-255.
www.canmat.org

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2009 on the Treatment of Acute Mania. Grunze H, et al. World J Biol Psychiatry. 2009;10:85-116.
www.wfsbp.org

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression. Grunze H, et al. World J Biol Psychiatry. 2010;11:81-109.
www.wfsbp.org


Pharmacotherapy-Dependent Safety Considerations and Monitoring
Side effects associated with different therapeutic agents for bipolar disorder can impact treatment adherence and overall outcomes. Educate patients about potential adverse events associated with treatment, and implement routine pharmacotherapy-dependent safety monitoring for all patients with bipolar disorder.

Table of common side effects associated with treatment categories and suggested monitoring
Click Here >>

Texas Medication Algorithm (TMAP) Side-effects Checklists are included in the STABLE Resource Toolkit. These self-report tools can assist patients in monitoring potential side effects associated with treatment.
www.cqaimh.org

The Antipsychotic Side-effect Checklist is another tool included in the STABLE Resource Toolkit for monitoring treatment side effects.
www.cqaimh.org

Metabolic monitoring (such as weight/waist circumference, blood pressure, fasting glucose, and lipid profiles) is recommended for patients being treated with atypical antipsychotics. The STABLE Resource Toolkit includes a metabolic monitoring form that can be used or adapted for this purpose.
www.cqaimh.org

Strategies for Monitoring Outcomes in Patients with Bipolar Disorder. Ketter TA. Prim Care Companion J Clin Psychiatry. 2010;12(Suppl 1):10-16.
www.ncbi.nlm.nih.gov


Monitoring Symptoms/Severity and Level of Functioning
With the chronic, long-term nature of bipolar disorder, routine monitoring of depressive and manic symptoms (and severity) is essential for the assessment of response to treatment and overall patient status. Quality of life indicators (social, occupational, educational, independent living, etc) also reflect patient status and extent of impairment. Establish a system to routinely monitor the symptomatic and functional status of your patients with bipolar disorder.

The STABLE Resource Toolkit includes several tools for monitoring symptoms and functional status:


Additional tools for monitoring symptoms include:

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