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Original Research

Texas Medication Algorithm Project, Phase 3 (TMAP-3): Clinical Results for Patients With a History of Mania

Trisha Suppes, MD, PhD; A. John Rush, MD; Ellen B. Dennehy, PhD; M. Lynn Crismon, PharmD; T. Michael Kashner, PhD, JD, MPH; Marcia G. Toprac, PhD; Thomas J. Carmody, PhD; E. Sherwood Brown, PhD, MD; Melanie M. Biggs, PhD; Kathy Shores-Wilson, PhD; Bradley P. Witte, BS; Madhukar H. Trivedi, MD; Alexander L. Miller, MD; Kenneth Z. Altshuler, MD; and Steven P. Shon, MD

Published: April 15, 2003

Article Abstract

Background: The Texas Medication Algorithm Project (TMAP) assessed the clinical and economic impact of algorithm-driven treatment (ALGO) as compared with treatment-as-usual (TAU) in patients served in public mental health centers. This report presents clinical outcomes in patients with a history of mania (BD), including bipolar I and schizoaffective disorder, bipolar type, during 12 months of treatment beginning March 1998 and ending with the final active patient visit in April 2000.

Method: Patients were diagnosed with bipolar I disorder or schizoaffective disorder, bipolar type, according to DSM-IV criteria. ALGO was comprised of a medication algorithm and manual to guide treatment decisions. Physicians and clinical coordinators received training and expert consultation throughout the project. ALGO also provided a disorder-specific patient and family education package. TAU clinics had no exposure to the medication algorithms. Quarterly outcome evaluations were obtained by independent raters. Hierarchical linear modeling, based on a declining effects model, was used to assess clinical outcome of ALGO versus TAU.

Results: ALGO and TAU patients showed significant initial decreases in symptoms (p = .03 and p < .001, respectively) measured by the 24-item Brief Psychiatric Rating Scale (BPRS-24) at the 3-month assessment interval, with significantly greater effects for the ALGO group. Limited catch-up by TAU was observed over the remaining 3 quarters. Differences were also observed in measures of mania and psychosis but not in depression, side-effect burden, or functioning.

Conclusion: For patients with a history of mania, relative to TAU, the ALGO intervention package was associated with greater initial and sustained improvement on the primary clinical outcome measure, the BPRS-24, and the secondary outcome measure, the Clinician-Administered Rating Scale for Mania (CARS-M). Further research is planned to clarify which elements of the ALGO package contributed to this between-group difference.

Volume: 64

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