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The purpose of this research study is to learn whether or not people with bipolar disorder can reduce their risk of heart disease and related conditions by having a Care Manager provide self management and care management.
Background: Bipolar disorder is associated with significant personal and societal costs, and represents a substantial burden to the VA. Medical conditions, notably cardiovascular disease (CVD), are substantial contributors to increased morbidity and mortality in patients with bipolar disorder, in part because of behavioral and treatment factors. Despite the existence of effective medications for managing CVD-related risk factors (e.g., hypertension, hyperlipidemia, diabetes, obesity), outcomes for these conditions remain suboptimal among patients with bipolar disorder.
Objectives: The immediate objective of this study is to determine whether a manual-based Chronic Care Model (CCM) intervention compared to usual VA care improves control of intermediate physiological measures that represent risk factors of CVD for veterans with bipolar disorder. We hypothesize that, within 12 months of the intervention initiation, patients receiving the CCM intervention will be more likely to demonstrate improved control of CVD-related risk factors (blood pressure, fasting cholesterol) and report improved physical health-related quality of life.
Methods: This is a prospective, randomized, controlled, single-blind, single-site behavioral intervention trial of adult patients with a diagnosis of bipolar disorder receiving care in the VA Ann Arbor Healthcare System. Up to 300 subjects will be enrolled, of which 150 will be randomized to receive the intervention and 150 will receive usual VA care. All subjects will complete a baseline clinical assessment and then subsequent follow-up assessments at 3, 6, 12, and 24 months. The intervention's three core components will be implemented by a nurse Care Manager and include: 1) self-management behavioral sessions for patients addressing the reduction of CVD risk factors through symptom control and behavior change based on Social Cognitive Theory, 2) care management to promote patient behavior change and coordinate care, and 3) implementation of practice guidelines for providers on management of CVD risk factors in patients with bipolar disorder. Medical and psychiatric care, including medications, will continue to be provided by the patient's usual providers. Usual VA care will be enhanced and consist of guideline implementation and general patient education (attention control), but will not include self-management sessions or Care Manager contacts. Primary clinical outcomes include changes in cholesterol, and health-related quality of life (SF-12 physical health summary score). Linear regression models will be used to determine the effect of the intervention on each outcome. Mediators of treatment effect including symptoms and health behaviors will also be assessed.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Chronic Care Model for Bipolar Disorder | Experimental | An intervention group of patients with bipolar disorder and 1 or more risk factor for cardiovascular disease; group will receive self-management group sessions, followed by phone contacts by the Care Manager. This is the chronic care model for bipolar disorder |
|
| Enhanced Usual Care | No Intervention | A group of patients with bipolar disorder and one or more risk factors for cardiovascular disease will be randomized to receive enhanced usual care. This group will receive usual care, plus mailings on wellness topics (attention control), and their providers will receive information on guideline concordant care. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Chronic care model for Bipolar Disorder | Behavioral | The behavioral intervention is based on the Chronic Care Model (CCM) where patients receive information on managing bipolar symptoms and health habits in a group self-management session (up to 6 weekly sessions). The Care Manager then follows up with patients via phone contacts for 12 months following the intervention. The providers receive information on guidelines for care. |
| Measure | Description | Time Frame |
|---|---|---|
| Systolic and Diastolic Blood Pressure (SBP, DBP) | 24-month systolic and diastolic blood pressure (mm/Hg): lower is better | 24 months |
| Total Cholesterol | Total cholesterol in mg/dl- lower is better | 24 months |
| Physical Health-related Quality of Life Score | Physical health-related quality of life is based on the Short Form (SF)-12 survey physical health component (PCS) score- which ranges from 0 to 50, with higher scores indicating higher quality of life | 24 months |
| Measure | Description | Time Frame |
|---|---|---|
| Manic Symptoms | Manic symptoms based on the Internal State Scale (range is 0-500; higher score indicates more severe symptoms) | 24 months |
| Depressive Symptom Score | Depressive symptoms based on the Internal State Scale (Range: 0-200, higher score = more severe symptoms) |
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Inclusion Criteria:
We define this as a patient having a current diagnosis of or receiving treatment for at least one of the following medical conditions:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Amy M. Kilbourne, PhD MPH | VA Ann Arbor Healthcare System | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VA Ann Arbor Healthcare System | Ann Arbor | Michigan | 48113 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 23945460 | Derived | Kilbourne AM, Goodrich DE, Lai Z, Post EP, Schumacher K, Nord KM, Bramlet M, Chermack S, Bialy D, Bauer MS. Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT). J Clin Psychiatry. 2013 Jul;74(7):e655-62. doi: 10.4088/JCP.12m08082. |
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| ID | Title | Description |
|---|---|---|
| FG000 | Chronic Care Model for Bipolar Disorder | An intervention group of patients with bipolar disorder and 1 or more risk factor for cardiovascular disease; group will receive self-management group sessions, followed by phone contacts by the Care Manager. Chronic care model involving self-management educational sessions, care management for up to 1 year, and guideline dissemination: The behavioral intervention is based on the Chronic Care Model (CCM) where patients receive information on managing bipolar symptoms and health habits in a group self-management session (up to 6 weekly sessions). The Care Manager then follows up with patients via phone contacts for 12 months following the intervention. The providers receive information on guidelines for care. |
| FG001 | Enhanced Usual Care | A group of patients with bipolar disorder and one or more risk factors for cardiovascular disease will be randomized to receive enhanced usual care. This group will receive usual care, plus mailings on wellness topics (attention control), and their providers will receive information on guideline concordant care. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Chronic Care Model for Bipolar Disorder | An intervention group of patients with bipolar disorder and 1 or more risk factor for cardiovascular disease (CVD); group will receive self-management group sessions, followed by phone contacts by the Care Manager. Chronic care model involving self-management educational sessions, care management for up to 1 year, and guideline dissemination: The behavioral intervention is based on the Chronic Care Model (CCM) where patients receive information on managing bipolar symptoms and health habits in a group self-management session (up to 6 weekly sessions). The Care Manager then follows up with patients via phone contacts for 12 months following the intervention. The providers receive information on guidelines for care. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Systolic and Diastolic Blood Pressure (SBP, DBP) | 24-month systolic and diastolic blood pressure (mm/Hg): lower is better | Posted | Mean | Standard Deviation | mm/Hg | 24 months |
|
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Arm 1 | An intervention group of patients with bipolar disorder and 1 or more risk factor for cardiovascular disease; group will receive self-management group sessions, followed by phone contacts by the Care Manager. Chronic care model involving self-management educational sessions, care management for up to 1 year, and guideline dissemination: The behavioral intervention is based on the Chronic Care Model (CCM) where patients receive information on managing bipolar symptoms and health habits in a group self-management session (up to 6 weekly sessions). The Care Manager then follows up with patients via phone contacts for 12 months following the intervention. The providers receive information on guidelines for care. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Amy M. Kilbourne, PhD, MPH | Department of Veterans Affairs | 734-845-3502 | Amy.Kilbourne@va.gov |
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| ID | Term |
|---|---|
| D001714 | Bipolar Disorder |
| D002318 | Cardiovascular Diseases |
| D002908 | Chronic Disease |
| D015438 | Health Behavior |
| ID | Term |
|---|---|
| D000068105 | Bipolar and Related Disorders |
| D019964 | Mood Disorders |
| D001523 | Mental Disorders |
| D020969 | Disease Attributes |
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| ID | Term |
|---|---|
| D000099057 | Chronic Care Model |
| C101544 | MD1 |
| ID | Term |
|---|---|
| D019033 | Delivery of Health Care, Integrated |
| D003695 | Delivery of Health Care |
| D010346 | Patient Care Management |
| D006298 | Health Services Administration |
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|
| 24 months |
| Disability Based on WHO-DAS Score | Disability based on the WHO Disability Assessment Scale (WHO-DAS); range = 0-24, higher score equals greater disability | 24 months |
| Body Mass Index (BMI) | Body mass index (BMI) is reported in kilograms divided by meters squared (kg/m^2) with a normal (healthy) range of 18-24, in which >=25 is considered overweight, and >=30 is the definition of obesity | 24 months |
| BG001 | Enhanced Usual Care | A group of patients with bipolar disorder and one or more risk factors for cardiovascular disease (CVD) will be randomized to receive enhanced usual care. This group will receive usual care, plus mailings on wellness topics (attention control), and their providers will receive information on guideline concordant care. |
| BG002 | Total | Total of all reporting groups |
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Region of Enrollment | Number | participants |
|
| OG001 | Enhanced Usual Care | A group of patients with bipolar disorder and one or more risk factors for cardiovascular disease will be randomized to receive enhanced usual care. This group will receive usual care, plus mailings on wellness topics (attention control), and their providers will receive information on guideline concordant care. |
|
|
|
| Secondary | Manic Symptoms | Manic symptoms based on the Internal State Scale (range is 0-500; higher score indicates more severe symptoms) | Posted | Mean | Standard Deviation | units on a scale | 24 months |
|
|
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| Primary | Total Cholesterol | Total cholesterol in mg/dl- lower is better | Posted | Mean | Standard Deviation | mg/dL | 24 months |
|
|
|
| Primary | Physical Health-related Quality of Life Score | Physical health-related quality of life is based on the Short Form (SF)-12 survey physical health component (PCS) score- which ranges from 0 to 50, with higher scores indicating higher quality of life | Posted | Mean | Standard Deviation | units on a scale | 24 months |
|
|
|
| Secondary | Depressive Symptom Score | Depressive symptoms based on the Internal State Scale (Range: 0-200, higher score = more severe symptoms) | Posted | Mean | Standard Deviation | units on a scale | 24 months |
|
|
|
| Secondary | Disability Based on WHO-DAS Score | Disability based on the WHO Disability Assessment Scale (WHO-DAS); range = 0-24, higher score equals greater disability | Posted | Mean | Standard Deviation | units on a scale | 24 months |
|
|
|
| Secondary | Body Mass Index (BMI) | Body mass index (BMI) is reported in kilograms divided by meters squared (kg/m^2) with a normal (healthy) range of 18-24, in which >=25 is considered overweight, and >=30 is the definition of obesity | Posted | Mean | Standard Deviation | kg/m^2 | 24 months |
|
|
|
| 0 |
| 58 |
| 0 |
| 58 |
| EG001 | Arm 2 | A group of patients with bipolar disorder and one or more risk factors for cardiovascular disease will be randomized to receive enhanced usual care. This group will receive usual care, plus mailings on wellness topics (attention control), and their providers will receive information on guideline concordant care. | 0 | 60 | 0 | 60 |
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| D010335 |
| Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D001519 | Behavior |