Renes et al.

Int J Bipolar Disord (2018) 6:22

https://doi.org/10.1186/s40345-018-0130-z

RESEARCH Open Access

A nationwide study on concordance

with multimodal treatment guidelines in bipolar
disorder
Joannes W. Renes1*, Eline J. Regeer1, Adriaan W. Hoogendoorn2, Willem A. Nolen3 and Ralph W. Kupka1,2

Abstract 
Background:  Most previous studies on concordance with treatment guidelines for bipolar disorder focused on phar-
macotherapy. Few studies have included other treatment modalities.
Aims:  To study concordance with the Dutch guideline of various treatment modalities in outpatient treatment set-
tings for patients with bipolar disorder and to identity factors associated with concordance.
Methods:  A nationwide non-interventional study using psychiatrists’ and patients’ surveys.
Results:  839 patients with bipolar or schizoaffective disorder bipolar type were included. Concordance with the
guideline was highest for participation of a psychiatrist in the treatment (98%) and for maintenance pharmacotherapy
(96%), but lower for supportive treatment (73.5%), use of an emergency plan (70.6%), psychotherapy (52.2%), group
psychoeducation (47.2%), and mood monitoring (47%). Presence of a written treatment plan, a more specialized treat-
ment setting, more years of education, and diagnosis of bipolar I disorder versus bipolar II, bipolar NOS, or schizoaffec-
tive disorder were significantly associated with better concordance.
Conclusion:  In contrast to pharmacotherapy, psychosocial treatments are only implemented to a limited extend
in everyday clinical practice in bipolar disorder. More effort is needed to implement non-pharmacological guideline
recommendations for bipolar disorder.
Keywords:  Bipolar, Guidelines, Concordance

Background (Altinbas et al. 2011; Farrelly et al. 2006; Kilbourne et al.

To improve the quality of care, several guidelines for 2005; Paterniti and Bisserbe 2013; Unutzer et  al. 2000;
the treatment of bipolar disorder (BD) have been pub- Walpoth-Niederwanger et  al. 2012; Wang et  al. 2014b)
lished in the past two decades, including in the Nether- on the primary outcome measure of concordance. These
lands (Kupka et  al. 2015; Nolen et  al. 2008). Studies on concordance rates are difficult to compare due to differ-
the naturalistic treatment of BD show that concordance ences in study design, treatment settings, and in what
with these guidelines varies considerably from less than phase of the illness concordance was studied. Most stud-
50% (Altinbas et  al. 2011; Baek et  al. 2014; Busch et  al. ies focused on pharmacotherapy only (including moni-
2007; Lim et  al. 2001), 50–70% (Arvilommi et  al. 2007; toring of plasma levels), and were retrospective in design.
Bauer et al. 2009; Farrelly et al. 2006; Freeland et al. 2015; Few studies have included other treatment modalities,
Huang et al. 2014; Marcus et al. 1999; Simon et al. 2004; such as psychoeducation or psychotherapy, or visits with
Smith et al. 2008; Wang et al. 2014a, 2015), or up to 90% health care providers (Busch et  al. 2007; Farrelly et  al.
2006; Kilbourne et al. 2005; Unutzer et al. 2000).
In these naturalistic studies on concordance with treat-
*Correspondence: j.renes@altrecht.nl ment guidelines, factors that have been found to be of
1
Altrecht Institute for Mental Health Care, Utrecht, Nieuwe Houtenseweg influence are type of mood episode (Baek et al. 2014; Far-
12, 3524 SH Utrecht, The Netherlands
Full list of author information is available at the end of the article relly et al. 2006; Huang et al. 2014; Paterniti and Bisserbe

© The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 2 of 9

2013), psychotic features (Altinbas et al. 2011; Lim et al. previous 12 months or earlier for some treatment modal-
2001), bipolar disorder subtype (Simon et  al. 2004), age ities, lifetime illness characteristics, clinical outcome,
at onset (Dennehy et al. 2007), rapid cycling (Arvilommi quality of life and functioning, satisfaction with care,
et  al. 2007), treatment setting (Arvilommi et  al. 2007; and adherence to treatment. For each patient a clini-
Busch et  al. 2007), race (Kilbourne et  al. 2005), and cal diagnosis, according to DSM-IV-TR (American Psy-
higher medical complexity in elderly patients (Huang chiatric Association 2000), was supplied by the treating
et al. 2014). psychiatrist, including comorbid diagnoses. The study
In 2008 a revised guideline on the treatment of bipolar was approved by the Medical Ethical Committee of the
disorder in the Netherlands was published (Nolen et  al. University Medical Center Utrecht, the Netherlands,
2008). In this paper we present the outcomes of a nation- and independently reviewed by the scientific committees
wide naturalistic prospective study on treatment practice of the two main participating research centers, Altrecht
and concordance with this Dutch guideline in various Institute for Mental Health Care, Utrecht, the Nether-
treatment settings for patients with BD or schizoaffec- lands, and GGZ inGeest/VU University Medical Center,
tive disorder, bipolar type (SZA). We hypothesized that Amsterdam, the Netherlands. All participating patients
the guideline would be better implemented in centers gave written informed consent.
specialized in the treatment of mood disorders, and in
patients with bipolar I disorder (BD I) versus those with Outcome measures
bipolar II disorder (BD II), bipolar disorder NOS (BD Treatment modalities
NOS), or SZA. Since BD I is more clearly defined by the Patients were asked to tick the medication they were cur-
lifetime occurrence of full manic episodes, this diagnosis rently using from a list of maintenance medications (lith-
will represent a more homogeneous group of patients, ium, carbamazepine, valproate, lamotrigine, olanzapine,
for which providers probably better recognize treatment quetiapine, risperidone, or aripiprazole), and to add any
recommendations in the guideline. Moreover, guidelines other medication they were currently using for BD, and
often take BD I as their main focus. We further examined were asked if, and with what frequency, laboratory tests
the relationship of demographic, illness, and treatment were part of the treatment with lithium, valproate or car-
variables with concordance with the guideline. bamazepine. For psychosocial treatments, patients were
asked if they ever had participated in a group psychoedu-
Methods cation program, if they had ever received psychotherapy,
The Treatment of Bipolar Disorder in the Netherlands and if so, whether they had received it in the previous
study (TBDN) is a nationwide, multicenter, non-inter- year, if they had received supportive treatment in the
vention study on concordance with guideline recommen- previous year, if they had an emergency plan on how to
dations for the long-term treatment of BD and SZA in deal with early symptoms of an impending mood epi-
mental health outpatient treatment settings (Renes et al. sode, and if they regularly monitored their mood by com-
2014). The study was performed between December 2009 pleting prospective LifeCharts according to the NIMH
and June 2014. Life-Chart Method (Leverich and Post 1998), which is
well-known in the Netherlands.
Selection of psychiatrists and patients
Between December 2009 and February 2010 all psychi- Measurement of concordance with the Dutch guideline
atrists registered as member of the Dutch Psychiatric In the Dutch guideline recommendations may differ
Association received a short survey about their treat- for patients with specific clinical profiles. For our study
ment setting and whether they would be willing to par- we distinguished four clinical profiles. Table  1 indicates
ticipate in this study. All psychiatrists who indicated that which treatment modalities are, and which are not, rec-
they were treating adult patients with BD or SZA in an ommended to be part of the treatment for patients with
outpatient setting and were interested in participating in these profiles.
the study, received a questionnaire about their treatment Maintenance pharmacotherapy is recommended for
setting, organization of care, and the number of patients patients after three or more mood episodes, and for
currently in treatment for BD or SZA. Furthermore, they patients after two episodes if at least one of the episodes
were asked to send a letter to all these patients inviting was severe, or when the patient has a first degree rela-
them to participate in the study. tive with BD. Furthermore, maintenance pharmacother-
All patients who returned an informed consent form apy may be considered: (1) after a single severe manic
were sent two questionnaires: one for themselves and one episode, (2) after a single manic episode of any severity
for a spouse, relative or significant other. The patients’ and having a first degree relative with BD, or (3) after
questionnaire concerned care they had received in the two non-severe episodes without a family history of BD.
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 3 of 9

Table 1 Treatment modalities that  are recommended by  the  Dutch guideline for  the  treatment of  BD in  patients
with differential clinical profiles
Clinical profiles
Currently asymptomatic Currently asymptomatic, Currently asymptomatic, Currently
and no indication with an indication with an indication symptomatic
for maintenance for maintenance for maintenance
pharmacotherapy pharmacotherapy, and no pharmacotherapy,
episode in the previous year and an episode
in the previous year

Treatment ­modalitya
 Participation of a ­psychiatristb + + + +
 Group psychoeducation + + + +
 Emergency plan +/−c +/−c + +
 Maintenance pharmaco- – + + +
therapy
 Life charting − − + +
 Supportive ­treatmentd − − + +
 Psychotherapye − − − +
a
 “+” indicates the modality is recommended to be part of the treatment in case of that particular clinical profile, and “−” indicates the modality is not recommended
to be part of the treatment
b
  Patients with BD should have at least one visit/year with a psychiatrist or physician, when health care providers other than a psychiatrist/physician are part of the
treatment team
c
  For these patients an emergency plan is recommended as optional
d
  At least three visits with a psychiatrist or mental health nurse in the previous year
e
  Any form of psychotherapy in the previous year

Finally, maintenance pharmacotherapy is not recom- or biological burden on the patient. No points were sub-
mended for patients with a single non-severe manic epi- tracted in case of non-concordance.
sode in the absence of a first degree relative with BD.
To assess concordance with the Dutch guideline, a
composite score ranging from 0 to 100 for the degree of Assessment of symptoms and illness characteristics
concordance was developed based on the sum of scores The Quick Inventory of Depressive Symptomatology
for each treatment modality, taking into account an (QIDS) (Rush et  al. 1996), and the Altman Self-Rating
assumed impact factor of each treatment modality on Mania Scale (ASRM) (Altman et  al. 1997), were part of
treatment outcome as determined by consensus among the patient questionnaire to measure current severity of
the authors (JR, ER, WN, RK), when taking into account mood symptoms. The questionnaire also addressed vari-
the level of scientific evidence of recommendations as ous lifetime illness characteristics. Because these data
described in the guideline. Of notice, WN and RK had were obtained through self-reporting, some data could
been involved in the development of the guideline. The be missing or conflicting. When data were conflicting,
impact factors were rated as follows: pharmacotherapy consensus was first reached between the first two authors
40 points, group psychoeducation 20, psychotherapy 20, (JR, ER). The other authors (WN, RK) were consulted
participation of a psychiatrist 5, having an emergency when necessarily. Data that remained inconclusive were
plan on how to deal with emerging symptoms 5, mood excluded from analysis.
monitoring 5, and supportive treatment 5 points.
If, according to the guideline, a treatment modality
was recommended and accordingly applied, points were Statistical analyses
added to the total score; and similarly if a treatment SPSS 22 was used for statistical analysis. Descriptive sta-
modality was not recommended and accordingly not tistics were used for demographics and illness charac-
applied. If a treatment modality was recommended but teristics of the sample. Relationships with the total score
not applied, or applied despite not being recommended, of concordance were tested using simple and multiple
no points were added. The latter was based on the regression analyses.
assumption that a more intensive treatment is not nec-
essarily beneficial and might even pose a psychological
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 4 of 9

Short questionnaire to all members of Dutch

Association of Psychiatry: 2525

Response: 1579

Interested in further research: 616

Eligible to participate : 541
Including 6 additionally after the irst short
questionnaire: 547

Total number of psychiatrists that returned the irst

questionnaire: 123 (22.5%)
24 not eligible to participate
(20 no treatment in ambulatory settings, 1 only
child psychiatry, 1 no treatment of bipolar patients,
1 loss of contact)
Eligible to participate: 99 (18%)

2 withdrawal from study

(1 ending practice, 1 logistical problems)

Total number of psychiatrists

That invited patients to participate: 97

29 psychiatrists without inclusion of patients

Number of psychiatrists with inclusion of patients:

68 (12.4%)
• specialized centers for mood disorders: 34
• non-specialized centers: 34

Approximation number of patients invited to the

study: 3250*

Total number of patient that returned the informed

consent form: 1136 Drop-out: 12
(4 withdrawal informed consent,
3 not in treatment with participating psychiatrist,
4 various administrative reasons,
1 participating second time through a different
psychiatrist)
Number of patients with informed consent and
known DSM diagnosis: 1124

Number of patients that returned the baseline

questionnaire: 845
Exclusion of patients with a depressive or
cyclothymic disorder: 6

Number of patients included for analysis: 839

639 from specialized mood disorder centers
200 from non-specialized centers

* based on anonymous logs with number of patients invited by psychiatrists, or number of letters for patients
provided to the psychiatrists

Fig. 1  Inclusion of psychiatrists and patients

Renes et al. Int J Bipolar Disord (2018) 6:22 Page 5 of 9

Results respondents (85.6%) had three or more mood episodes.

Inclusion Data on total lifetime number of mood episodes were
The inclusion of psychiatrists and patients is presented in inconclusive or missing in 84 respondents (10%). Hospi-
Fig. 1. tal admission because of a mood episode was reported by
532 (63.4%) respondents. Data on admission were miss-
Socio‑demographic and illness characteristics ing in 65 respondents (7.7%). Of the respondents, 283
Five hundred and fifty-five respondents (66.2%) were (33.7%) had a first degree relative with bipolar disorder.
women. The average age was 49.5  years (s.d. 11.2). Five
hundred and one out of 833 (60.1%) respondents were Treatments
married or living together. The mean years of education The number of respondents receiving maintenance phar-
(n = 837) was 16.1  years (s.d. 4.3). Diagnoses were BD I macotherapy and various forms of psychosocial treat-
(n = 551; 65.7%), BD II (n = 211; 25.1%), BD NOS (n = 32; ments is reported in Table 2.
3.8%), and SZA (n = 45; 5.4%). At least one comor-
bid psychiatric diagnosis was present in 238 respond- Maintenance pharmacotherapy
ents (28.4%). The mean duration of illness (n = 712) Lithium, carbamazepine, valproate, lamotrigine or an
was 23.8  years (s.d. 12.3). The average age at onset for antipsychotic as maintenance medication was used by
(hypo)manic symptoms was 30.1  years (s.d. 11.8), and 804 (96.1%) respondents. Of the remaining 32 (3.9%) who
for depressive symptoms 26.1 years (s.d. 11.7). Only nine currently did not use any pharmacotherapy, 15 had BD
respondents (1.1%) experienced one single manic epi- I, 13 BD II, three BD NOS, and one SZA; all reported at
sode, 28 (3.3%) had two mood episodes, all other 718 least two previous mood episodes (data missing in one),

Table 2  Elements of current treatment as reported by the patients

Treatment ­modalitiesa n %

Current use of maintenance medication (n = 836)

 Lithium 590 70.6
 Anticonvulsantsb 281 33.6
 Atypical ­antipsychoticsc 318 38.0
 Conventional antipsychotics 30 3.6
Ever participated in group psychoeducation (n = 836) 394 47.1
Emergency plan (n = 836) 484 57.9
Participation of a psychiatrist (n = 819) 803 98.0
Mood monitoring (n = 835) 229 27.4
Psychotherapy in the previous year (n = 681) 133 15.9
Supportive treatment (n = 809) 749 92.6
Patient reports that a treatment plan has been made (n = 825)
 Yes 502 60.8
 No 323 39.2
Patient is involved in decision-making (n = 827)
 Never 52 6.3
 Sometimes 166 20.1
 Mostly 279 33.7
 Always 330 39.9
Significant others have been asked to participate in the treatment (n = 828)
 Yes 677 81.8
 No 151 18.2
Patient uses the internet for information on bipolar disorders and treatments (n = 836)
 Yes 357 42.7
 No 479 57.3
a
  Sample size may differ among variables, depending on missing data points
b
  Valproate, lamotrigine, carbamazepine
c
  Olanzapine, quetiapine, risperidone, aripiprazole, clozapine
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 6 of 9

and eight had been admitted at least once (data missing In a multiple regression analysis age, absence of psychi-
in two). atric comorbidity, duration of illness, and whether or not
Polypharmacy was common. When all medications, it was asked to involve significant others in the treatment,
excluding benzodiazepines and somatic medications, did not contribute significantly to the model, although
were taken together, 328 (39.1%) respondents used two the latter almost reached significance. All other factors
drugs, and 117 (13.9%) three or more drugs with a maxi- were significant. The model explained almost 10% of vari-
mum of five. In addition to the medication already listed ance in concordance scores (see Table 3).
in the questionnaire, 169 (20.1%) respondents reported
the use of an antidepressant (14.2% BD I; 35.5% BD II; Discussion
25.0% BD NOS; 17.8% SZA). In 15 of these 169 respond- In this nationwide study of guideline concordance in
ents (BD I n = 4; BD II = 10; BD NOS = 1) the antidepres- routine clinical practice, we found that the use of main-
sant was not combined with lithium, an anticonvulsant tenance pharmacotherapy was highly concordant with
or an antipsychotic. Of the respondents using either the recommendations in the Dutch guideline for BD.
lithium, valproate or carbamazepine (n = 711), almost all This resembles outcomes in some of the previous stud-
(n = 702) reported an adequate frequency of laboratory ies in euthymic or unspecified BD. The high frequency of
testing. lithium use (70.6%) in our study is remarkable. In a recent
study in Denmark, lithium was prescribed less frequently,
Psychotherapy 41.7% during a 12-year study period, and its use had
Of the 133 respondents that received psychotherapy declined over the years (Kessing et al. 2016). In contrast
in the previous year, 77 (57.8%) reported that the ther- to pharmacotherapy, applying psychosocial treatments
apy was specifically aimed at treating their BD, and 50 was much less concordant with the Dutch guideline,
(37.6%) reported that the therapy had another focus. even in specialized centers for mood disorders. Especially
the low rate of concordance with the participation in
Concordance with treatment guideline (group) psychoeducation is relevant since its efficacy in
Concordance with the guideline for each treatment the maintenance treatment of bipolar disorder has been
modality was as follows: participation of a psychiatrist well established (Colom et al. 2003) and it is thus recom-
in 757 of 773 respondents (97.9%), maintenance phar- mended in the guideline for all BD patients. Moreover,
macotherapy in 754 of 786 (95.9%), supportive treat- group psychoeducation is widely available in the Nether-
ment in 560 of 762 (73.5%), use of an emergency plan in lands. Concordance-rates for mood monitoring and psy-
556 of 787 (70.6%), psychotherapy in 399 of 765 (52.2%), chotherapy were also relatively low. For psychotherapy,
group psychoeducation in 371 of 786 (47.2%), and mood this may be due to the fact that in the 2008 guideline the
monitoring in 369 of 785 respondents (47%). A guide- indications are still described in general terms. As a con-
line recommendation for maintenance pharmacotherapy sequence, measuring its concordance is less straightfor-
applied to almost all respondents. In only two respond- ward. Moreover, psychotherapy may have a wider focus
ents, both BD I, maintenance pharmacotherapy was not than only BD, as was indicated by a considerable num-
recommended according to the guideline, however one ber of participants. Specialization of treatment center,
was symptomatic and therefore concordance was scored years of education, type of diagnosis, and the fact that the
according to clinical profile “currently symptomatic” as patient was informed that a written treatment plan had
described in Table 1. For 30 respondents, data necessary been made, were all significantly associated with guide-
to determine the need for maintenance pharmacotherapy line concordance. This is an important finding since some
were either missing or inconclusive. of these factors (making a treatment plan and informing
patients about this, and taking into account the level of
Factors associated with concordance education of patient) can be easily optimized in every-
Factors associated with concordance are presented in day clinical practice. Especially the level of understand-
Table  3. Specialization for mood disorder of treatment ing of verbal communication can easily be overestimated.
setting, whether the respondents reported that a treat- Together with inviting a significant other to be involved
ment plan had been made, total years of education, bipo- in the treatment, these findings point in the direction
lar diagnosis, whether one or more significant others had that shared decision-making may result in more guide-
been asked to participate in the treatment, duration of line-concordant treatments. However, little is currently
illness, absence of psychiatric comorbidity, and age were known if and how shared decision-making may influence
all significantly associated with being better concordant clinical outcome in mental health care (Duncan et  al.
with the guideline. Age and duration of illness were nega- 2010). Although significant in univariate analysis, the
tively correlated with concordance (see Table 3). presence or absence of psychiatric comorbidity, duration
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 7 of 9

Table 3  Demographic, illness related and  treatment related factors for  concordance with  the  Dutch guideline for  BD:
univariate and multivariate analyses
Univariate ­modela Multivariate ­modelb
B SE P B SE P

Demographic factors
 Gender: female (male)c − 0.65 1.38 .640
 Age − 0.15 0.06 .010 0.03 0.07 .670
 Marital status: living together or married (living alone, divorced, widowed)c 1.34 1.32 .309
 Education: total years of education 0.52 0.15 < .001 0.49 0.16 .002
Illness related factors
 Diagnosis: BD I (BD II, BD NOS or SZA)c 3.74 1.34 .005 2.98 1.43 .037
 Psychiatric comorbidity: absent (present)c 2.97 1.40 .035 2.63 1.50 .080
 Duration of illness − 0.15 0.06 .007 − 0.09 0.07 .193
Treatment related factors
 Treatment setting: specialized centers (non-specialized center)c 7.36 1.50 < .001 5.67 1.64 .001
 Patient reports that a treatment plan has been made: yes (no)c 5.65 1.32 < .001 5.37 1.44 < .001
 Significant others have been asked to participate in the treatment: yes (no)c 4.86 1.69 .004 3.43 1.81 .059
Patient is involved in decision-making: (never)c
 Sometimes − 0.08 3.09 .979
 Mostly 0.04 2.96 .989
 Always 0.67 2.92 .818
Other factor
 Patient uses the internet for information on bipolar disorder and treatments: yes (no)c 1.56 1.30 .229
a
  Univariate analysis from simple regression. Note: constants in the simple regression models with categorical factors: gender: 72.8, marital status: 72.6, diagnosis:
72.1, psychiatric comorbidity: 72.1, treatment setting: 70.7, whether or not a treatment plan has been made: 72.0, whether or not significant others have been asked
to participate: 71.1, patients’ involvement in decision-making: 72.6, and patients’ use of internet:  72.8
b
  The multivariate analysis includes all factors that are univariately associated with concordance (at the level of statistical significance of α = 0.05). The coefficient of
determination of the multivariate model R2 = 0.09 (p < 0.001)
c
  Reference category

of illness, and age did not contribute significantly in the patient symptoms. In that study a multifaceted treatment
regression model. In contrast to our hypothesis, gender, program including the medication guidelines was studied
marital status, and use of internet by the patient, were in several intervention clinics, and compared with treat-
not associated with better concordance with the guide- ment as usual in non-intervention clinics. Adherence to
line. The involvement of the patient in decision-making the guideline was only studied in the intervention clinics.
in the treatment was also not associated with better con- Kilbourne et  al. (2010) implemented composite quality
cordance, although this was probably due to the fact that metrics to measure the quality of processes of care from
the majority of patients stated that they were involved. various treatment guidelines in a study using medical
records, including assessments of symptoms, comorbid-
Strengths and limitations ity, cardiometabolic outcomes, and documentation of
Our study has several strong points. To the best of patient treatment experience.
our knowledge this is a first nation-wide study that it Our study has several limitations. First, although a
includes a large number of patients in long-term psychi- great effort was made to include a representative cohort
atric outpatient treatment. Moreover, concordance with in a wide variety of mental health care treatment settings,
the treatment guideline was assessed for a wide variety it is likely that a bias towards psychiatrists and patients
of guideline recommended treatment modalities, and with particular interest in our study will have occurred,
quantified in a composite score taking into account dif- since many participating patients were treated in spe-
ferent clinical profiles of patients in maintenance treat- cialized mood disorder centers. This will limit the gen-
ment. Dennehey et al. (2005) used a composite score for eralizability of our results to non-specialized centers and
adherence to the medication guidelines from the Texas private practice. Therefore, outcomes may reflect more
Medication Algorithm Project (TMAP). This score meas- guideline-concordant care than in settings where psychi-
ured visit schedules, medication/dosing, and response to atrists (and therefore their patients) did not participate
Renes et al. Int J Bipolar Disord (2018) 6:22 Page 8 of 9

in this study. On the other hand, this could suggest that Competing interests
J.W. Renes and E.J. Regeer received speaker’s fees from AstraZeneca, Bristol-
measures to improve guideline concordance may be Myers Squibb, and Ely Lilly. A. W. Hoogendoorn reports no potential compet-
even more vital in those settings. A second limitation is ing interests. W.A. Nolen has received grants from the Netherlands Organiza-
that maintenance pharmacotherapy was not assessed in tion for Health Research and Development, the European Union; has received
honoraria/speaker’s fees from Lundbeck and Aristo Pharma, and has served as
detail but was defined as the use of at least one mainte- consultant for Daleco Pharma. R.W. Kupka received speaker’s fees for lectures
nance drug recommended in the guideline. Whether the on symposia sponsored by AstraZeneca, Bristol-Myers Squibb, Lundbeck,
choice or dosage of medication was optimized accord- Sanofi, and Janssen. W.A. Nolen and R.W. Kupka were member of subsequent
Dutch bipolar disorder guideline committees.
ing to guideline recommendations, was not taken into
account. Use of antidepressants may have been under- Availability of data and materials
reported since information was provided at the initiative The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
of the respondent. As will be the case in studies using
patient surveys, not all nuances of individual treatments Consent for publication
could be included in the assessment of concordance with Not applicable.
the guideline, and answers may have been incomplete or Ethics approval and consent to participate
inconsistent. Although an updated guideline was pub- The study was approved by the Medical Ethical Committee of the University
lished in 2015, after the study was completed, we assume Medical Center Utrecht, the Netherlands. All participating patients gave writ-
ten informed consent.
that the findings of our study are still relevant today, since
there were no major changes in the recommendations for Funding
long-term treatment strategies in the 2015 guideline. The R.W. Kupka received an unrestricted research grant for this study from
AstraZeneca.
differences between these guidelines concern recommen-
dations in pharmacotherapy and psychological treatment
of a more detailed level than addressed in our study. Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.

Conclusions Received: 30 June 2018 Accepted: 17 August 2018

Overall, we conclude that in everyday clinical practice,
more than pharmacotherapy, the implementation of
psychosocial treatments still needs considerable effort.
Actively involving the patient in the treatment may References
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The authors thank the participating psychiatrists and patients for their contri- Algorithm Project. Psychol Med. 2005;35(12):1695–706.
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