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Bipolar Disorder: Individualizing Treatment to Improve Patient Outcomes, Part 2

neuroscienceCME Journal Club

Premiere Date: Tuesday, December 2, 2008

This activity offers CE credit for:

  1. Physicians (ACCME/AMA PRA Category 1)
  2. Nurses (CNE)
  3. Pharmacists (ACPE)
  4. Psychologists (APA)
  5. Social Workers (NASW)
  6. Certified Case Managers (CCMC)

All other clinicians will receive a Certificate of Attendance stating this activity was certified for AMA PRA Category 1 Credit™

Credit Expiration Date:
Wednesday, December 2, 2009
Note: Credit Is No Longer Available


Roger S. McIntyre, MD, FRCPCRoger S. McIntyre, MD, FRCPC 
University of Toronto
University Health Network
Toronto, ON
Chairman and Executive Director, Brain and Cognition, Depression and Bipolar Support Alliance (DBSA)
Chicago, IL
Clinical Professor, Department of Psychiatry and Neurosciences
University of California School of Medicine
Riverside, CA

Trisha Suppes, MD, PhDTrisha Suppes, MD, PhD (Faculty)
Professor, Department of Psychiatry and Behavioral Science
Stanford University School of Medicine
War Related Illness and Injury Study Center
VA Palo Alto Health Care System
Stanford, CA

Statement of Need

Bipolar disorder (BPD) is a chronic condition characterized by fluctuating episodes of manic, or mixed symptoms, and depression. A recent estimate of the annual prevalence of BPD in the US is 2.6%.(1) BPD ranked as the 6th leading cause of disability worldwide in 1990.(2) Despite the dominance of depressive symptoms and episodes over the course of both bipolar I and II disorder, and the more frequent functional impairment associated with bipolar depression, there has been a disproportionate lack of attention to establishing effective treatment and management of bipolar depression. Researchers continue to explore the best possible treatments for these patients, as well as the potential role of proteins such as brain-derived neurotrophic factor (BDNF) in predicting the onset and treatment of bipolar disorder. In this evidence-based neuroscienceCME Journal Club activity, experts will review the latest clinical literature in the field of bipolar disorder and translate this information into improved clinical outcomes for patients with BPD.

  1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617-627.
  2. Murray C, Lopez A, eds. The Global Burden of Disease. Cambridge, MA: Harvard University Press; 1996.

Featured Article: Vieta E, Suppes T, Eggens I, Persson I, Paulsson B, Brecher M. Efficacy and safety of quetiapine in combination with lithium or divalproex for maintenance of patients with bipolar I disorder (international trial 126). J Affect Disord 2008;109:251-263.
View Abstract

Summary: The efficacy and safety of quetiapine was compared in combination with the common mood stabilizers, lithium or divalproex, to placebo for the prevention of recurrent mood events in patients with bipolar I disorder, whose most recent episode was mania, depression, or mixed. A total of 1461 patients were enrolled in the pre-randomization phase of the trial and 706 patients were randomized to double-blind treatment. During the prerandomization phase, patients received open-label quetiapine (400-800 mg/day, flexible, divided dose) plus lithium/divalproex for up to 36 weeks. Patients needed to reach clinical stability for 12 weeks during this phase at which point, they were randomized to double-blind treatment to receive quetiapine (400-800 mg/day) plus lithium or divalproex, or placebo plus lithium or divalproex for up to 104 weeks. The primary endpoint was time to recurrence of any mood event. Treatment with quetiapine in combination with either mood stabilizer, significantly increased time to recurrence of any mood event. Hazard rations for mood events in the combination groups were .28 for a mood event, .30 for a mania event, and .36 for depressive event; corresponding to risk reduction of 73%, 70%, and 74% respectively. During the randomization phase, the most common adverse events occurring in ≥5% in the quetiapine plus lithium/divalproex group were somnolence, nasopharyngitis, and headache. Insomnia was more common in the placebo plus lithium/divalproex group, during the randomization phase there was an increase in weight of .5 kg in the quetiapine group compared to a reduction of 1.9 kg in the placebo group. The majority of weight gain occurred during the open phase treatment (2.9 kg), with a small amount of additional gain for those patients randomized to combination therapy and some loss for those randomized to monotherapy. The authors concluded that maintenance treatment for patients with bipolar I disorder with quetiapine in combination with lithium/divalproex significantly increased time to recurrence of any event (mania, depression, or mixed) irrespective of the polarity of the index episode compared with placebo plus monotherapy therapy. Long-term treatment with quetiapine with lithium/divalproex was overall well tolerated and can be an effective long-term treatment option for bipolar I disorder.

Activity Goal

Incorporate the latest evidence-based literature to develop strategies for early detection, intervention, and long-term maintenance of patients with bipolar depression.

Learning Objectives

At the end of this CE activity, participants should be able to:

  • Compare the use of atypical antipsychotics in combination with mood stabilizers versus mood stabilizers plus placebo in patients with bipolar I disorder.

Target Audience

Physicians, physician assistants, nurse practitioners, nurses, psychologists, social workers, certified case managers, pharmacists, and other healthcare professionals with an interest in mental health.

Credit Information

CME Credit (Physicians):
CME Outfitters, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CME Outfitters, LLC, designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CNE Credit (Nurses):
CME Outfitters, LLC, is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

It has been assigned code 6WASUP-PRV-0647. 1.0 contact hours will be awarded for each part upon successful completion.
Note to Nurse Practitioners: The content of this CNE activity pertains to Pharmacology.

CEP Credit (Psychologists):
CME Outfitters is approved by the American Psychological Association to sponsor continuing education for psychologists. CME Outfitters maintains responsibility for this program and its content. (1.0 CE credits)

NASW Credit (Social Workers):
This program was approved by the National Association of Social Workers (provider #886407722) for 1 continuing education contact hour.

CCMC Credit (Certified Case Managers):
This program has been approved for 1 hour by the Commission for Case Manager Certification (CCMC).

CPE Credit (Pharmacists):
ACPE CME Outfitters, LLC, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 1.0 contact hours (0.1 CEUs)
Universal Program Number: 376-000-08-024-L01-P (live presentation) 376-000-08-024-H01-P (recorded programs)

Post-tests, credit request forms, and activity evaluations can be completed online at (click on the Testing/Certification link under the Activities tab - requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required).

(NOTE: Additional time for completing the post-test and evaluation will be added to this 45-minute presentation to equal 1.0 CE credit)

Roger S. McIntyre, MD, FRCPC, Guest Host
Dr. McIntyre is currently an Associate Professor of Psychiatry and Pharmacology at the University of Toronto and Head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto, Canada.

Dr. McIntyre is involved in multiple research endeavours which primarily aim to characterize the association between mood disorders and medical comorbidity. This research involves elucidating metabolic adverse events associated with the use of psychotropic medications, the impact of medical comorbidity on the course of mood disorders, and the effect of glucose homeostasis on neurocognition.

Dr. McIntyre is extensively involved in medical education. He is a highly sought-after speaker at both national and international meetings. He has received several teaching awards from the University of Toronto, Department of Psychiatry and has been a recipient of the joint Canadian Psychiatric Association (CPA) / Council of Psychiatric Continuing Education Award for the Most Outstanding Continuing Education Activity in Psychiatry in Canada.

Dr. McIntyre is a contributor to the CPA guidelines for the treatment of depressive disorders and the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of bipolar disorder. Dr. McIntyre has published extensively in leading peer-reviewed journals and textbooks. Dr. McIntyre is also a reviewer for many journals including the American Journal of Psychiatry, Biological Psychiatry, Journal of Clinical Psychiatry and The New England Journal of Medicine, and serves as a grant reviewer for the National Institute of Mental Health.

Dr. McIntyre completed his medical degree at Dalhousie University. He received his Psychiatry residency training and Fellowship in Psychiatric Pharmacology at the University of Toronto.

Trisha Suppes, MD, PhD
Trisha Suppes, MD, PhD, is Professor of Psychiatry and Behavioral Science at Stanford University School of Medicine and the VA Palo Alto Health Care System in Palo Alto, California. Additionally, she serves as the Director of the Bipolar Disorders Research Program at the VA Palo Alto Health Care System. Her areas of expertise and research include long-term treatment strategies for bipolar disorder, treatment for bipolar II disorder, use of treatment algorithms, and treatment of bipolar depression.

Dr. Suppes is the principal investigator on two NIMH sponsored R01s. She currently serves as an associate editor on the American Journal of Psychiatry Editorial Board and as a member of the Board of Councilors for the International Society for Bipolar Disorders. Dr. Suppes is a member of the American Psychiatric Association (APA) Work Group for the Practice Guidelines for Bipolar Disorder APA Diagnostic and Statistical Manual for Mental Disorders V. She also serves as a member of the Scientific Advisory Board of the Depression and Bipolar Support Alliance. She has authored or co-authored over 170 peer-reviewed articles.

Before moving to Stanford in June 2008, Dr. Suppes was the Director of the Bipolar Disorders Research Program at UT Southwestern Medical Center at Dallas. Dr. Suppes earned her BA in human biology at Stanford University in Stanford, California, her PhD in anatomy/physiology at the University of California at Los Angeles, and her MD at Dartmouth Medical School in Hanover, New Hampshire. After graduating, she completed her residency in adult psychiatry at McLean Hospital in Belmont, Massachusetts. Her postdoctoral fellowship in neurology was conducted at Stanford University School of Medicine, and her clinical fellowship in psychiatry was conducted at McLean Hospital at the Harvard Medical School in Boston, Massachusetts. She also completed a fellowship in neuroscience at Harvard Medical School.

Disclosure Declaration

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all its CE activities. Faculty must disclose to the participants any significant relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer review process. The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Dr. McIntyre has disclosed that he receives grants/research support from Eli Lilly and Company, the National Alliance for Research on Schizophrenia and Depression (NARSAD) and the Stanley Medical Research Institute. He serves on the advisory boards of AstraZeneca Pharmaceuticals LP, Biovail Pharmaceuticals, Inc., Bristol-Myers Squibb Company, Eli Lilly and Company, The France Foundation, GlaxoSmithKline, H. Lundbeck A/S, Janssen-Ortho Inc., Organon Pharmaceuticals USA Inc., Pfizer Inc., Shire Pharmaceuticals, Solvay Pharmaceuticals, Inc., and Wyeth Pharmaceuticals. He serves on the speakers bureaus of AstraZeneca Pharmaceuticals LP, Biovail Pharmaceuticals, Inc., Bristol-Myers Squibb Company, Eli Lilly and Company, The France Foundation, GlaxoSmithKline, H. Lundbeck A/S, Janssen-Ortho Inc., Organon Pharmaceuticals USA Inc., Pfizer Inc., Shire Pharmaceuticals, Solvay Pharmaceuticals, Inc., and Wyeth Pharmaceuticals.

Dr. Suppes has disclosed that she receives grants/research support from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, GlaxoSmithKline, JDS Pharmaceuticals, National Institute of Mental Health, Novartis Pharmaceuticals Corporation, Pfizer Inc., and The Stanley Medical Research Institute. She serves as a consultant to and on the speakers bureau of Orexigen Therapeutics. She receives royalties from Compact Clinicals.

Unlabeled Use Disclosure

Faculty of this CE activity may include discussions of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices.

CME Outfitters, LLC, the faculty, and AstraZeneca Pharmaceuticals do not endorse the use of any product outside of the FDA labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Questions about this activity? Call us at 877.CME.PROS (877.263.7767).


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