CME credit for this article is now expired. It appears here for your reference.

At the end of this article, readers should be able to:

1. Appreciate and analyze the pharmacodynamic and pharmacokinetic changes that occur as patients age.

2. Develop/modify appropriate treatment strategies for older adults based on pharmacodynamic and pharmacokinetic changes.

3. Assess signs of problems associated with medication pharmacodynamics and pharmacokinetics in older patients.

Heterogeneity is a hallmark of the geriatric population, and nowhere is this as evident as it is in geriatric pharmacotherapy. Variable changes in organ and receptor function with aging make it difficult, in fact, to formulate rules that apply to all patients in the geriatric population. Comorbid disease and coadministered medications, which generally increase with age, add to the complexity.

Certain determinants of drug response in younger patients continue into old age. This is true, for example, of genetic endowment related to cytochrome P-450 (CYP450) metabolizing capacity. Other processes, such as drug absorption and glucuronidation, are little affected by aging. As a general rule, however, all other pharmacological processes change with aging.

Basic pharmacokinetic process: an orally ingested drug passes from the stomach to the proximal small intestine

, an orally ingested drug passes from the stomach to the proximal small intestine, where most absorption takes place. Absorption was once thought to be a simple, passive process, but research over the past few decades has shown that enterocytes lining the intestinal villi express a variety of specific drug transporters to take in drugs and efflux mechanisms to extrude them back into the gut lumen. The enterocytes are thus able to regulate how much drug is passed on to the liver.

Representation of the action of the P-glycoprotein pump

P-glycoproteins (Pgp) that are first encountered in the gut wall act as “pumps” to move absorbed drug back into the gut lumen, where it can be metabolized by resident CYP3A4 enzymes, reabsorbed, or passed along the gut for excretion. The action of the Pgp pump is shown schematically in 

. This pump has a general efflux function in the liver, the brain, the kidneys, and other organs. The Pgp pump has specific drug substrates, inhibitors, and inducers, similar to CYP450 enzymes. Of particular interest to psychiatrists are drugs listed in 

Selected P-glycoprotein (ABCB1) substrates, inhibitors, and inducers

As with CYP450 enzymes, genetic variations that result in expression and activity of the Pgp pump have been identified in the 

 With aging, reduced Pgp pump function at the blood-brain barrier has been demonstrated in vivo.

 This results in a “leakier” blood-brain barrier that is more porous to drugs and toxins.

How quickly a drug is absorbed determines in part how quickly it takes effect. Among the elderly, the rate of absorption may be affected by reduced gastric motility or delayed emptying due to diseases (eg, diabetes) or drugs (eg, antacids). In the absence of significant disease, however, the extent of absorption is little affected in the elderly.

 Drugs that pass from the GI tract to the liver travel by way of the portal circulation. In the liver, the drugs can travel unchanged into the general circulation by way of hepatic veins. Alternatively, drugs can be metabolized in the liver before entering the circulation, via first-pass metabolism. The extent of first-pass metabolism is determined by the activity of enzymes such as CYP450 and uridine 5'-diphosphate-glucu­ronosyltransferase (UGT). Any drug that is conjugated before leaving the liver for the general circulation can be excreted directly by the kidneys. A drug can also be removed by Pgp pump action in the liver, which results in the secretion of substrate drugs and toxins into bile, where they are removed as waste through the GI tract.

Pharmacokinetic processes up to this point are circumvented by intramuscular or intravenous administration of the drug. Avoiding first-pass metabolism renders drugs nearly 100% bioavailable, so that the dose required for the same effect is usually much smaller. Intravenous administration of drugs in geriatric patients should be approached with caution, because dangerous adverse effects can emerge quickly. In addition, intramuscular administration of drugs is not recommended for geriatric patients with small muscle mass, because this leads to erratic absorption and painful injection.

, drugs that pass into the general circulation are distributed to target organs, peripheral storage sites in fat or muscle, the kidneys for elimination, or the liver for metabolism. Distribution to peripheral storage sites is significantly affected by aging, because as lean body mass decreases, there is a relative increase in fat stores. This is true even for thin elderly patients. These changes create a larger volume of distribution for fat-soluble drugs (including most psychotropics) and a smaller volume of distribution for water-soluble drugs, such as lithium.

 Because the elimination half-life of a drug is directly proportional to its volume of distribution, the practical significance of these changes is that most psychotropics remain in the body longer in geriatric patients.

Another result of the relative increase in body fat with aging is that highly lipophilic drugs, such as diazepam, are rapidly taken up by fat storage sites, so that drug concentration in the blood falls quickly below a minimum effective threshold. With one-time dosing, the duration of effect is short for diazepam. The drug is removed slowly from fat stores, and significant accumulation of the drug can occur with repeated dosing. Moreover, the drug may be released erratically, which can result in changing serum levels over time. For these and other reasons, diazepam is not recommended for the elderly.

On the other hand, the smaller volume of distribution for water-soluble drugs, such as lithium, is associated with a greater amount of drug in the circulation and a correspondingly greater amount available to the brain as the target organ. This is one reason why smaller doses of lithium are used in elderly patients. Drugs that reach the blood-brain barrier gain access to the brain by passive diffusion or by transporters. Those drugs that are substrates for the Pgp pump residing in capillary endothelial cells may be extruded back into the circulation, a process that can be blocked by Pgp pump inhibitors or facilitated by inducers.

 Drug metabolism occurs by phase 1 (oxidation) and/or phase 2 (primarily glucuronidation) processes. The most important drug-metabolizing enzymes are the phase 1 CYP450 enzymes and the phase 2 UGT enzymes. In general, phase 1 oxidation processes are more affected by aging than are UGT processes. Given the choice in treating an elderly patient, a drug metabolized by glucuronidation (also known as “conjugation”) would be preferred to a drug metabolized by those CYP450 enzymes whose activity is reduced with aging. Among benzodiazepines, for example, lorazepam, oxazepam, and temazepam are preferred to other drugs because these drugs are simply conjugated and excreted. Diazepam and chlordiazepoxide-not recommended for the elderly-have several active metabolites, some with long half-lives (eg, desmethyldiazepam).

Clinically relevant CYP450 drug interactions

Three families of CYP enzymes are relevant to psychopharmacology: CYP1, CYP2, and CYP3. Current evidence suggests that within these families, 5 enzymes are primarily responsible for the metabolism of commonly used psychotropics. The activity of each CYP450 enzyme can be reduced by inhibitors or facilitated by inducers. Inhibitory effects are additive when more than one inhibitor is present. For most drugs metabolized by CYP450 enzymes, it is the parent drug that is active, and metabolism results in an inactive or less active metabolite. For certain drugs (eg, codeine, tramadol), the parent drug is a pro-drug with little activity, and metabolism to an active metabolite is necessary for drug effect. In these cases, inducers result in greater drug effect. Clinically relevant substrates, inhibitors, and inducers of CYP450 enzymes are listed in 

Genetic polymorphisms expressed as the absence or changed activity of certain CYP enzymes may result in marked differences in serum levels of psychotropic drugs among individuals administered the same dose. The following are CYP450 metabolizer phenotypes5:

• Poor (slow): little or no enzyme activity, leading to high levels of parent drug

• Intermediate: depending on the specific genotype, activity ranges from slightly more than the poor phenotype to slightly less than the extensive phenotype

• Extensive (average, rapid): normal enzyme activity but can be converted to a poor metabolizer by sufficient CYP enzyme inhibition

• Ultrasensitive (ultrarapid): parent drug is metabolized so rapidly that higher drug doses may be needed; in the case of a pro-drug, toxicity may be seen at usual therapeutic doses

Only 2 of the CYP enzymes important in psychotropic prescribing decline meaningfully with aging: CYP1A2 and CYP3A. Aging also brings a gradual reduction in liver mass, reduced blood flow, and reduced hepatic metabolic rate.

 Among other processes, these changes affect demethylation reactions involved in the conversion of tertiary amines (eg, amitriptyline) to secondary amines (eg, nortriptyline), which may cause the accumulation of more active and more toxic tertiary compounds.

 Most drugs and metabolites are excreted from the body by the kidneys at a rate determined by the glomerular filtration rate (GFR).

 For many individuals, this rate falls linearly with aging at a rate of about 1 mL/min/1.73 m2 of body surface area (the average for an adult), starting at around age 20 to 30. Thus, the GFR for such an individual at age 80 years is about half what it was at 30 years.

Drugs cleared solely by renal excretion-lithium and hydroxylated metabolites (eg, hydroxy-bupropion, hydroxy-venlafaxine, hydroxy-nortriptyline, and hydroxy-risperidone)-are most affected by this change in GFR. Reduced clearance of lithium has led to the recommendation that elderly patients be treated with a single nightly dose of short-acting lithium. This schedule allows the serum level to drift downward so that the kidneys have time to recover before the next dose.

Reduced GFR with aging is not a universal phenomenon; some elderly persons show no decline in renal function with aging. Nevertheless, in the elderly with reduced renal function, psychotropics should be used with great caution. The following recommendations apply:

• Beware of coadministration of nephrotoxic drugs (eg, NSAIDs)

• Evaluate renal function to determine dosage

• Do not rely on serum creatinine value to gauge renal function

• Use laboratory-generated report of the GFR or calculate GFR using the Cockroft-Gault equation

 Clearance of a drug from the circulation is a function not only of renal excretion but also of hepatic metabolism. Although oxidative metabolism may be reduced in old age, a more significant factor is decreased hepatic blood flow, which may be as much as 50% decreased.

 This is the primary reason why drug dosing is reduced for hepatically metabolized drugs in elderly patients. The correlation of blood flow reduction with hepatic clearance is a poor one, however, and existing liver function tests are not a good indicator of drug metabolizing capacity.

Clearance is the principal determinant of the plasma concentration of a drug at steady state. The two quantities are related by the following equation:

drug concentration at steady state = dosing rate/clearance

Reduced GFR and reduced hepatic blood flow result in reduced clearance in elderly patients compared with younger patients. This results in increased steady-state drug concentrations, with enhanced main effects and toxic effects. Reduced clearance can be managed with a smaller dose or a longer dosing interval, giving rise to the “start low and go slow” principle of prescribing for a geriatric patient.

Another reason to “go slow” with dosing in elderly patients is because of the time it takes a drug to reach steady state with repeated dosing. Steady state is the point at which the average drug concentration plateaus. Time to steady state is determined by the drug’s half-life:

In general, a drug’s half-life is increased in geriatric patients compared with younger patients, so that it takes longer to reach steady state. Changes in drug dosage are best made when steady state has been achieved, so that main and toxic effects can be observed before the dosage is escalated. The half-life of a drug can also be used to determine the time to washout:

The time to washout can be helpful in determining when a drug is out of the system so that a new medication can be started or withdrawal effects can be expected.

Pharmacodynamic processes are set in motion when the drug reaches the target tissue. Effects can be presynaptic or postsynaptic, or involve enzyme inhibition. Reuptake inhibitors, such as SSRI antidepressants, are examples of drugs that act at presynaptic sites. Acetylcholinesterase inhibitors (donep­ezil, galantamine, and rivastigmine) are examples of enzyme inhibitors.

Most psychotropic drugs act at postsynaptic sites; some also interact with autoreceptors on the presynaptic neuron. In general, the mechanism for these drugs includes drug-receptor binding, signal transduction, and cellular response. Effects are mediated by variables such as receptor density, concentration of the drug at the receptor site, affinity of the drug for the receptor, allosteric modulation of drug binding, intrinsic activity of the drug (the degree to which it influences the receptor to generate a cellular response), the function of second messenger systems, and homeostatic processes that tend to counter drug effects. Different drugs have different effects at the receptor.

Another variable in drug binding that is particularly relevant to drugs such as antidepressants is that of time: acute effects may be different from chronic effects. This occurs because initial pharmacological effects at the receptor induce small changes that over time result in receptor adaptation.

In general, receptors for dopamine, norepinephrine, and serotonin are coupled to G-proteins as second messengers. The mechanisms by which drug-receptor binding ultimately triggers brain effects are complex. Signaling molecules other than G-proteins-Akt, glycogen synthase kinase-3, and Î²-arrestin 2-have been shown in recent years to be involved in the mechanism of action of antidepressants, lithium, and antipsychotics.

Although elderly patients experience greater drug effects than younger patients, the reason is not always clear. The differences in drug responses can be attributed either to different baselines or to different sensitivities.

 Baseline differences in postural sway (the elderly have more sway than younger patients), for example, might account for the increased risk of falling with benzodiazepine use in the elderly. It may be that for those with a “normal” amount of postural sway (old or young) at baseline, these drugs are safe.

Another factor in differing drug responses among the elderly for certain psychotropic drugs is the reduced function of the Pgp pump with aging. The EC50 of a drug is the (effective) concentration of that drug that yields a half-maximal response. The value of EC50 for any drug is determined systemically, not in the CNS. When the elderly are found to have a lower EC50 than younger patients for a particular psychotropic drug, is that because of increased brain “sensitivity” to the drug or because of a relatively higher concentration of the drug in the CNS?

When increased sensitivity is actually demonstrated, it may be attributed to the fact that the elderly use an ever-greater proportion of reserves (eg, cognitive, motor) as they age, so that fewer reserves are available to offset a perturbation. For example, the elderly are at increased risk for orthostasis as an adverse drug effect.

Drug interactions are more frequent in elderly patients because more medications are taken. In addition, drug interactions may be more serious because of insufficient physiological reserves. When new medications are started or stopped in elderly patients, it is very important to take note of potential interactions with other drugs or foods.

Drug interactions may be pharmacokinetic or pharmacodynamic. Pharmacokinetic interactions may involve any of the phases of drug processing, although the most important and numerous relate to drug metabolism. An example of a drug interaction influencing drug absorption is the effect of an oral antacid on absorption of an antipsychotic or a benzodiazepine. The combination results in a slowing of the rate of absorption, and adverse effects are not seen as quickly. Interactions relating to drug metabolism are mediated largely by CYP450 and UGT enzyme systems. The various actions of the Pgp pump can interact with drug distribution. Introducing a low-sodium diet to a patient receiving lithium results in competition for excretion and may cause lithium levels to rise.

Pharmacodynamic interactions are numerous and involve both receptor binding effects (eg, antipsychotics given with dopamine agonists), complex remote effects (eg, SSRIs inhibiting platelet function when given with warfarin, causing significant bleeding), and additive effects (eg, MAOIs and SSRIs causing serotonin syndrome).

Note: This article was originally published as a CME in the January 2013 issue of 

Portions of it may have since been updated.

Sandra Jacobson, MD, has no disclosures to report.

James M. Ellison, MD, (peer/content reviewer) has disclosed that he received research support from Eli Lilly and Company.

 Toornvliet R, van Berckel BN, Luurtsema G, et al. Effect of age on functional P-glycoprotein in the blood-brain barrier measured by use of (R)-[(11)C]verapamil and positron emission tomography. 

 Bartels AL, Kortekaas R, Bart J, et al. Blood-brain barrier P-glycoprotein function decreases in specific brain regions with aging: a possible role in progressive neurodegeneration. 

Greenblatt DJ, Sellers EM, Shader RI. Drug therapy: drug disposition in old age. 

 Thompson TL 2nd, Moran MG, Nies AS. Drug therapy: psychotropic drug use in the elderly: Part 1. 

Wynn GH, Oesterheld JR, Cozza KL, Armstrong SC. 

Clinical Manual of Drug Interaction Principles for Medical Practice.

 Washington, DC: American Psychiatric Publishing, Inc; 2009.

 Beaulieu JM, Gainetdinov RR, Caron MG. Akt/GSK3 signaling in the action of psychotropic drugs. 

Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. 

Clinical Manual of Geriatric Psychopharmacology.

 Washington, DC: American Psychiatric Publishing, Inc; 2007.

 Oesterheld J. P-glycoprotein (PGP) table-the effect of drugs and foods. 

Flockhart DA. P450 Drug interaction table: abbreviated “clinically relevant” table. 

http://medicine.iupui.edu/clinpharm/ddis/ClinicalTable.aspx

Articles

Effects of Pharmacokinetic and Pharmacodynamic Changes in the Elderly

It is increasingly appreciated that comorbidity in psychiatric illness is an important consideration in clinical practice; it has also become a topic of research interest. Many recent articles highlight the complexity of psychiatric and systemic illness, both in terms of overlapping clinical presentation and in the degrees to which systemic illness and psychiatric illness affect each other. 

(A literature review that offers a sample of these articles can be viewed in the online version of this article here.)

When one speaks of psychiatric comorbidity, 2 constructs come to mind. The first is psychiatric illness that is comorbid with systemic medical illness. Whether the onset of the psychiatric illness is temporally associated with the systemic illness, whether the psychiatric illness comorbidity can be explained by the patient not coping well with the systemic illness, or whether both are referable to a common source is often elusive and ambiguous. What matters is that the patient has 2 (or more) medical problems (that affect different organ systems) that need to be addressed by evidence-based clinical interventions in an integrated approach.

The other “psychiatric comorbidity” refers to more than one psychiatric illness in the same patient. Examples include dementia with episodic delirium, depression with concurrent substance abuse, and personality disorder comorbid with PTSD. Indeed, for some particularly complex psychiatric patients, one may speak of “trimorbidity” (eg, mood disorder, personality disorder, and substance abuse), even in the absence of significant systemic illness. Of course, physicians are quite familiar with patients who are “multiply comorbid” on 2 dimensions (ie, 2 or more chronic systemic illnesses and 2 or more psychiatric illnesses) simultaneously.

The semantics of all of this can be daunting and less than precise. What is important, for psychiatrists and other specialty physicians, is to be vigilant for comorbidity within the category of psychiatric illness and to look for psychiatric and systemic comorbidity simultaneously. Care for these various conditions should be integrated and balanced, so that various medical interventions do not work at cross purposes. Comorbidity can serve as the illnesses’ “substrate” that encourages the patient’s various specialty physicians to thoughtfully collaborate and complement their respective interventions.

The authors of this Special Report-which will appear in this issue and also in February and which can now be read online at www.psychiatrictimes.com-have chosen a compelling series of topics. In her article, 

, addresses the psychiat-ric comorbidity of painful and life-limiting illnesses. She emphasizes that these systemic conditions both mimic primary psychiatric illnesses and are frequently comorbid with them. The inclusion of the Fukuda and Canadian criteria is a timely addition. Dr Stein specifies which symptoms of myalgic encephalomyelitis and fibromyalgia overlap with psychiatric illness and which do not, adding diagnostic and attributional specificity. She suggests that conventional psychiatric interventions such as psychotropic medication and psychotherapy may be indicated for the “non-psychiatric” systemic illnesses as well as for their comorbid psychiatric conditions. The specification of cognitive-behavioral therapy as the chosen psychotherapy model for pain conditions is especially important.

, describe the synergistic and often “reciprocal” relationship between depression and diabetes. Because these two illnesses are, independent of each other, major public health problems worldwide, thoughtful management of their commonly overlapping presentations is especially crucial for patient outcomes. The authors describe the pervasive effects diabetes and depression each have on the other. Their guidance on attributional interpretation of symptoms is particularly helpful.

, straddles the neuropsychiatric borderland in his article. It is often best to think of many CNS phenomena as neither exclusively psychiatric nor exclusively neurological, but as both. He provides concise and clinically utilitarian descriptions of the various movement disorders encountered in psychiatric practice and offers useful management approaches.

Todd Smitherman, PhD, Donald B. Penzien, PhD, and Jeanetta C. Rains, PhD

, review a common clinical relationship between migraine and psychiatric illness. Because psychiatric comorbidity is both common and complicating, physicians are reminded to consider migraine and its psychiatric comorbidity in an integrated fashion. Both psychopharmacological and nonpsychopharmacological treatment should be actively considered.

, describe the complex and often multiple psychiatric comorbidities that affect patients with borderline personality disorder, one of the more complex and common patient presentations in clinical practice. The authors remind us that simultaneous attention to these comorbidities is crucial in the clinical management and treatment outcomes for these patients.

These articles illustrate the variety and complexity of problems associated with comorbidity in psychiatric disorder. We hope that physicians who daily face the challenges of often multiple psychiatric illnesses in patients with significant comorbidity will find these articles useful.

 These articles illustrate the variety and complexity of problems associated with comorbidity in psychiatric disorder.

Introduction: The Integrated Approach to Addressing Comorbidities-Part 1

How people manage their chronic condition when not under direct medical supervision makes a difference in their quality of life, their health, and their utilization of the health care system-and such self-management can be both time-consuming and complex. While health care providers routinely educate patients about understanding medical conditions, diagnoses, and treatment options, self-management is defined as the tasks that individuals must undertake to live well with 1 or more chronic conditions.

 These tasks include having the confidence to deal with the medical and emotional management of their condition.

Self-management programs are an effective complement to the work provided by clinicians. While variation exists regarding the implementation of self-management programs in terms of program location, staffing, and the extent of personal interaction between self-management coaches and patients, the overall objective of self-management programs is to change behavior.

These changes allow patients to effectively cope with their chronic conditions-many of which can be progressive and debilitating-by learning healthier ways to live, gaining confidence and motivation to manage their health, and feeling more positive about their lives.

Making behavior changes is difficult, and the changes are often hard to maintain. For behavior change to occur, patient education alone is not sufficient. Having the confidence to make the change is critical. This confidence can be translated to self-efficacy-the belief that one is capable of attaining certain goals.

Self-efficacy can be enhanced through specific self-management tools and techniques, such as skills mastery through the achievement of action plans; modeling, which allows self-management program participants to see people like themselves helping others and being successful; reinterpretation of beliefs; and social persuasion. All self-management programs are built on 3 important underlying skills: action planning, problem solving, and decision making. Evidence-based self-management programs stress that for action plans to be effective, they must

• Reflect what the patient really wants to do

• Be specific about what is to be accomplished, how much, how often, when, and where

• Be realistic in what can be achieved successfully

• Incorporate problem-solving and decision-making techniques that allow for adjustments when issues arise that might interfere with the action plan

The Chronic Disease Self-Management Program (CDSMP) is the most extensively tested peer-led self-management program designed to address the needs of persons who have a wide range of chronic medical conditions, such as diabetes mellitus, arthritis, chronic pain, and HIV infection.

As with all self-management programs, the CDSMP enhances regular treatment and disease-specific education. The program consists of 6 structured small-group sessions that focus on a set of self-management tasks that have been found to be common across chronic conditions, including becoming a better self-manager, increasing healthy behaviors, and using the health care system effectively.

The elements of the intervention, grounded in self-efficacy theory, include regular action planning and feedback, modeling of behaviors and problem solving, reinterpretation of symptoms, and self-tailoring (ie, making your own plans based on what you have learned), so choices are based on the preferences and voice of the patient 

Efforts to improve the treatment of more common mental health conditions, such as depression, often incorporate elements of the chronic illness care model that support the improvement in self-efficacy.

 By implementing behavioral changes, the patient is better prepared for crises and relapse prevention. Allowing mental health patients to assume a greater role in decision making and self-management is a main theme described by proponents of recovery.

The recovery model is based on understanding personal meaning; attending to personal experiences, contexts, and meanings; building better patient-clinician partnerships; and creating integrated, self-management support structures. Both recovery and self-management stress wellness by removing the blame for the disease or condition from the patient and empowering him or her to take control of his or her life and health. In fact, self-management of psychiatric illnesses has become a central tenet of patient-directed mental health treatment.

One of the most widely circulat-ed programs that expands mental health recovery and consumer movements to include self-management is the Wellness Recovery Action Plan (WRAP).

 WRAP is patient-directed and centers on identifying internal and external resources for facilitating recovery. Using presentations, demonstrations, interactive discussions, and related activities, WRAP facilitators teach participants that to successfully recover from mental illness, they must be determined to get better, manage illness, take action, face problems, and make choices. WRAP facilitators assist participants in creating a personal “Wellness Toolbox” that consists of simple and easily accessible strategies, such as healthy diet, exercise, sleep, and meeting life and vocational goals, in addition to the identification of “early warning signs” and how to effectively manage a crisis situation.

Over the past several years, a number of other well-established, peer-led mental health recovery programs have incorporated self-management concepts. In the mid-1990s, Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES)

 began to involve peers in teaching courses on recovery and in facilitating ongoing support groups promoting overall wellness.

Similarly, the National Alliance on Mental Illness (NAMI) Peer-to-Peer program

 uses peers to assist persons with mental illness to establish and maintain their recovery through a unique, experimental consumer education and learning program (NAMI 2005). The Vet-to-Vet Peer Support program

 and the Massachusetts Peer Educators Project stress that meetings should encourage, validate, and support recovery in an ongoing fashion.

To help individuals gain the skills needed to lead more peaceful and productive lives, Abraham Low Self-Help Systems (the result of a merger of Recovery International and the Abraham Low Institute) also provide a safe place to talk about life’s struggles with others who have had similar experiences.

As with medical self-management interventions, peer-led mental health programs use the power and influence of peer networks to model physical and social functioning and further build self-efficacy. Peer-led self-management programs are increasingly becoming part of mainstream care delivery in the public mental health system. More than half of state Medicaid programs reimburse peers who provide these evidence-based services. In the context of peer support, self-management allows mental health consumers to become active participants in their health care, leading them to an overall sense of well-being despite their illnesses.

Medical disease self-management among persons with serious mental illness

Research shows that persons with serious mental illness are at elevated risk for a wide range of chronic medical conditions that contribute to increased morbidity and premature death.

Compared with the general population, persons with serious mental illness die about 25% earlier. More specifically, 60% of premature deaths in persons with schizophrenia are due to medical conditions, such as cardiovascular, pulmonary, and infectious diseases.

Modifiable risk factors, such as physical inactivity, poor diet, smoking and other drug use, problems with medication adherence, and limited health literacy, increase the incidence of illness. At the same time, individuals with serious mental illness face a series of barriers to effectively manage their illness and access appropriate health care. Persons with serious mental illness experience greater social challenges that include unemployment, homelessness, incarcerations, victimization/trauma, poverty, and social exclusion. Consequently, it is particularly important for these persons to acquire the skills to self-manage both their chronic medical conditions and their mental illness.

The Health and Recovery Peer (HARP) program is an adaptation of the CDSMP. It is the first fully peer-led program specifically designed to be delivered by, and to, mental health consumers.

To adapt the CDSMP for mental health consumers, modifications that address potential gaps in health literacy and cognitive limitations were made, and peer coaching sessions were added to personalize the program and reinforce each group session. Materials emphasizing the connection between the mind and body, the importance of coordinating information and medications between primary care providers and mental health clinicians, and the need to consider a mental health advanced directive were also added. The diet and exercise sections were adapted to address high rates of poverty and social disadvantage in this population, and interactive cooking and exercise classes were added.

In a pilot trial, participants in the HARP program showed significant improvement in patient activation (a measure of an individual’s self-management capacity) and in using primary care medical services.

 These benefits appeared greatest in populations with financial and social disadvantage. A multisite, randomized trial of the intervention is now under way in Georgia.

The role of mental health providers in promoting self-management

Interactions with patients should be structured to identify problems from a patient perspective and to design real-life solutions through goal setting, problem solving, action plans, and regular feedback. Sharing responsibilities with patients and emphasizing the vital role patients play in improving health-related habits and self-managing their health conditions are key, regardless of diagnoses. One study found that 4 months after participating in the CDSMP, patients with diabetes mellitus showed significant improvements in eating breakfast, mental stress, aerobic activities, shortness of breath, and pain.

 These improvements continued after 1 year and resulted in increased physician utilization and decreased hospitalizations.

Over the past 20 years, self-management programs have yielded significant, measurable improvements in long-term health benefits, patient outcomes, quality of life, and utilization of health care resources for patients with many different chronic conditions, including diabetes mellitus, heart disease, lung disease, HIV infection, arthritis, autoimmune disorders, and mental illness. These programs have targeted a variety of populations in the United States and abroad.

Self-management support assists patients as they take greater ownership of their care: patients are encouraged to live with their physical and mental health conditions long-term and full of hope.

Building on this approach, community mental health centers and other specialty providers are increasingly using peers to promote group work and mutual support to enable patients with mental health problems to draw on each other’s experiences regarding both mental health and general wellness. Mental health clinicians can also link patients to other established community self-management interventions located in health departments, health care organizations, and local non-profits. Through patient self-management, mental health clinicians can transfer the focus from managing symptoms to allowing patients to live well in the context of their mental illness and medical comorbidities. And, patient peers can help model behaviors aimed at improving both physical and mental health.

 Adams K, Greiner AC, Corrigan JM, eds. Report of a Summit. The 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities. Washington, DC: National Academies Press; 2004.


Living a Healthy Life With Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Asthma, Bronchitis, Emphysema and Others

. Palo Alto, CA: Bull Publishing Company; 2000.


 Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic diseases. 

 Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. 

 Bachman J, Swenson S, Reardon ME, Miller D. Patient self-management in the primary care treatment of depression. 

 Starnino VR, Mariscal S, Holter MC, et al. Outcomes of an illness self-management group using wellness recovery action planning. 

 Goldstrom ID, Campbell J, Rogers JA, et al. National estimates for mental health mutual support groups, self-help organizations, and consumer-operated services. 

 Tennessee Department of Mental Health and Developmental Disabilities. Building Recovery of Individual Dreams and Goals through Education and Support; 1995. 

http://www.tennessee.gov/mental/recovery/Bridges.html

 National Alliance on Mental Illness. Peer-to-Peer: NAMI’s Recovery Curriculum; 2005.

 http://nami.org/template.cfm?section=Peer-to-Peer

 Veteran Recovery. Vet-To-Vet Peer Program.

 http://www.veteranrecovery.org/peer_support/index.htm

 Druss BG, Zhao L, von Esenwein SA, et al. The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. 

 Parks J, Svendsen D, Singer P, et al, eds. 

Morbidity and Mortality in People With Serious Illness.

 Alexandria, VA: National Association of State Mental Health Program Directors; 2006.


 Lorig KR, Sobel DS, Steward AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. 

 Lorig KR, Ritter PL, Jacquez A. Outcomes of border health Spanish/English chronic disease self-management programs. 

 Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I). 

 Through patient self-management, mental health clinicians can transfer the focus from managing symptoms to allowing patients to live well in the context of their mental illness and medical comorbidities.

Chronic Disease Self-Management Programs in Psychiatry

Teaching patients is a central role for physicians, and it is especially important in chronic illnesses, such as bipolar disorder. For an illness in which misunderstanding of the condition is the norm and in which patients often do not follow treatment recommendations, it is clear that psychoeducation leads to substantially better outcomes.

What does a typical patient with newly diagnosed bipolar disorder know about his or her illness? Most likely very little-and what he

• I haven’t had a manic episode, so this diagnosis must not be correct

• They just want me to take handfuls of pills

• Lithium will make my kidneys fail/make me feel like a zombie/make me gain weight/etc

• I’ll never be well again/get a job/live on my own/get married/etc

• I’m better now; I don’t need to keep taking these medications

A new diagnosis of bipolar disorder is like a new diagnosis of diabetes mellitus. The patient’s world changes, or should change, and there is a vast amount to learn . . . more than a busy clinician alone can teach. In addition to using efficient teaching resources, you must strive to teach your patients how to learn about the illness on their own, rather than wait for someone to teach them-otherwise, bipolar disorder itself may be the teacher.

Fortunately, the clinician also benefits from this emphasis on patient education. One of the most frustrating experiences in your work is a patient’s failure to follow through on treatment recommendations, particularly when the result is another mood episode that you are expected to manage. Improved adherence and recognition of early symptoms can prevent some of these episodes. Moreover, improved adherence to treatment recommendations is likely to improve the overall treatment alliance, making your job more satisfying and maybe even a little easier.

(noun, from Latin docere): “To show, teach, cause to know.”

Although patients have a nearly infinite variety of questions, some issues are common to nearly everyone with bipolar disorder.

 Patients who have learned about these fundamentals have strikingly better outcomes than those who spent the same amount of time in a non-directive support group with experienced therapists.

 In a remarkable study from Barcelona, Spain, all patients started out well but unfortunately relapsed over time (

 But relapse rates were significantly lower among those who received education, not just support. As shown in the 

 the separation between treatment and control groups is maintained 5 years later.

lists the 21 group sessions (9 or 10 patients per group) in the Barcelona program. The well-organized manual for these sessions is available in English.

 In it, not only do the authors explain how each session is introduced, how they presented the material, and what handouts they used, but they also address potential pitfalls and even provide some of the amusing jokes they told in each session. This is a complete guide that even a less than fully experienced professional could use to repeat their exemplary work.

You may not be working in a setting where the efficiency of groups outweighs the complexity of organizing them (if you have done it, you know what this means). If not, how can you provide these basics without exhausting yourself, repeating the same material over and over with individual patients?

You must first consider how each patient learns best. Some are verbal learners: they will understand your verbal explanation of the eicosapentaenoic acid (EPA)/omega-3 ratio (must be greater than 60%, per a recent meta-analysis

). Visual learners will need to see the bottle and have you show them how to find EPA on the ingredients list. The learn-by-doing group will not really get it until they have gone to the store with your instructions and done it themselves.

When suggesting additional resources, make sure they are realistic for that particular patient. Does this patient like to read books? Does he have the money for the book you suggest? Can he handle going into a bookstore to buy it, or is his social avoidance likely to prevent that? If you are recommending a Web site or video, does your patient have access to an online computer? Is he comfortable using it?

What is already known about tools available for patient education in bipolar disorder? ? Thanks to researchers in Barcelona, Spain; Cardiff, Wales; and elsewhere, it is clear that patient and family education leads to improved outcomes.

What new information does this article provide? ? This article provides a review of some of the educational tools available for patients with bipolar disorder, from books to Web sites to video programs.

What are the implications for psychiatric practice? ? Every patient with a diagnosis of bipolar disorder should have access in some way to the kinds of information originally shown in Barcelona, Spain, to produce such dramatically improved outcomes. The challenge is to determine how that can be done in a busy practice. The tools reviewed here can help.

For your patients who learn well from reading a book, there are many to choose from. (Remember books? Those paper things with tables of contents, indexes, and easily recognized chapters?) The following selections represent only those that I use; there are surely others that might work as well. Ask your colleagues what books they have found effective. At least one title will likely appear on most of their lists: the 

Bipolar Disorder Survival Guide: What You and Your Family Need to Know.

 This covers most of the material in the Barcelona group education program and also places an emphasis on the family’s role in preventing relapse, effectively introducing family-focused therapy, a proven treatment that emphasizes patient education.

A similar “basics” presentation is Mondimore’s 

Bipolar Disorder: A Guide for Patients and Families.

 While their families read one of these guides, late adolescent and young adult patients can read Federman and Thomson’s Facing Bipolar: The Young Adult’s Guide to Dealing With Bipolar Disorder, an excellent introduction to bipolar disorder for those who have just been given the diagnosis.

Most of your patients are or will be struggling in their personal relationships, and the security of those relationships strongly affects mood stability. A book that would be very beneficial for these patients is 

Loving Someone With Bipolar Disorder: Understanding & Helping Your Partner

 (the second edition is currently in preparation).

Ask patients what they have found useful. Many find the big-picture view of bipolarity in Kay Jamison’s 

An Unquiet Mind: Memoir of Moods and Madness 

 But be careful: Jamison’s memoir describes bipolar I. This is not a book to recommend for patients with bipolar II, for whom it might fuel thoughts of “I don’t have bipolar disorder.” For patients with bipolar I, a very funny but very accurate account of the bipolar experience is Hilary Smith’s 

Welcome to the Jungle: Everything You Ever Wanted to Know About Bipolar but Were Too Freaked Out to Ask.

 The style is a modern 20-year-old’s, but the wisdom is akin to Kay Jamison’s.

Where should you send your patients on the Web? Hopefully, they are savvy enough to avoid the top advertisement links if they search “bipolar disorder.” Although each of the commercial sites presents general information about bipolar disorder, once one arrives at the treatment section, the company drug is prominently featured. Some patients and families might need to be warned about this.

An excellent introduction for patients is available from the Bipolar Education Program in Cardiff, Wales.

 Each of 14 topics, very similar to the Barcelona outline (

), is addressed with “Ten Top Messages” (one-liners). This represents a basic curriculum, in outline, with which all patients with bipolar disorder should be familiar.

For families and significant others who might be overwhelmed when looking at this information on their own, a nicely paced video program has also been developed by the Cardiff team.15 The program is systematic, gentle, and sticks to basics. More education will be needed afterward, but this video approach offers an excellent introduction for families and significant others who will not likely learn on their own with just the books.

The majority of patients with bipolar disorder have bipolar II (1-year prevalence 0.8% vs 0.6% for bipolar I; with an additional 1.4% who have “subthreshold” manic symptoms, akin to bipolar NOS [not otherwise specified]

 Patients with bipolar disorder need a great deal of information about the illness. Without this education, adherence to your recommendations is uncertain; with it, outcomes will likely be better (and your job easier).

Psychiatric Times Vol 29 No 1

Effects of Pharmacokinetic and Pharmacodynamic Changes in the Elderly

Introduction: The Integrated Approach to Addressing Comorbidities-Part 1

Chronic Disease Self-Management Programs in Psychiatry

Educating Patients About Bipolar Disorders

Introduction: Patient Education as Treatment Foundation

Treatment of Insomnia in Anxiety Disorders

Anesthesia Advances Add to Safety of ECT

The “Pseudocommando” Mass Murderer: A Blaze of Vainglory

Unfavorable Changes to Medicare Pay Loom for Psychiatrists

First Date