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Post RM, Leverich GS, Altshuler LL, Frye MA, Suppes TM, Keck PE, McElroy SL, Kupka R, Nolen WA, Grunze H, Walden J. An overview of recent findings of the Stanley Foundation Bipolar Network (Part I). Bipolar Disord 2003; 5:310-9. [PMID: 14525551 DOI: 10.1034/j.1399-5618.2003.00051.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM AND METHODS Selected recent findings of the Stanley Foundation Bipolar Network are briefly reviewed and their clinical implications discussed. RESULTS Daily prospective ratings on the NIMH-LCM indicate a high degree of residual depressive morbidity (three times that of hypomania or mania) despite active psychopharmacological treatment with a variety of modalities including mood stabilizers, antidepressants, and benzodiazepines, as well as antipsychotics as necessary. The rates of switching into brief to full hypomania or mania during the use of antidepressants is described, and new data suggesting the potential utility of continuing antidepressants in the small group of patients showing an initial acute and persistent response is noted. Bipolar patients with a history of major environmental adversities in childhood have a more severe course of illness and an increased incidence of suicide attempts compared with those without. Preliminary open data suggest useful antidepressant effects of the atypical antipsychotic quetiapine, while a double-blind randomized controlled study failed to show efficacy of omega-3 fatty acids (6 g of eicosapentaenoic acid compared with placebo for 4 months) in the treatment of either acute depression or rapid cycling. The high prevalence of overweight and increased incidence of antithyroid antibodies in patients with bipolar illness is highlighted. CONCLUSIONS Together, these findings suggest a very high degree of comorbidity and treatment resistance in outpatients with bipolar illness treated in academic settings and the need to develop not only new treatment approaches, but also much earlier illness recognition, diagnosis, and intervention in an attempt to reverse or prevent this illness burden.
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Affiliation(s)
- Robert M Post
- Stanley Foundation Bipolar Network and Biological Psychiatry Branch, NIMH, NIH, DHHS, Bethesda, MD 20892-1272, USA.
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202
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Abstract
BACKGROUND Levetiracetam is a novel antiepileptic drug with a broad spectrum of efficacy in epilepsy. We have tested the antimanic properties of the drug as an add-on to haloperidol in an open trial. METHOD After giving informed written consent, 10 bipolar I acutely manic (DSM-IV) inpatients were investigated in an on-off-on study design. All patients were treated with 5 to 10 mg/day of haloperidol, depending on tolerability, throughout the investigation. Levetiracetam (up to 4000 mg/day) was added until day 14, then discontinued and reintroduced at day 21. The psychopathologic changes were assessed with the Young Mania Rating Scale (YMRS). RESULTS After a mean decrease of the YMRS scores from 29.6 to 17.2 during the first "on" phase, manic symptoms worsened during the "off" period (YMRS score 20.9) and ameliorated again during the second "on" phase, with a decrease of the mean YMRS score to 14.7 at the end of the study. The mean dose of levetiracetam was 3125 mg/day. At day 14, only 2 (20%) of 10 patients were responders (defined as a decrease in YMRS scores of 50%) compared with 7 (70%) of 10 responders at the end of the study at day 28. CONCLUSION The results from this open on-off-on add-on study suggest that levetiracetam exhibited additional antimanic effects. Controlled studies are clearly required.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry at the University of Munich, Germany.
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203
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Altshuler L, Suppes T, Black D, Nolen WA, Keck PE, Frye MA, McElroy S, Kupka R, Grunze H, Walden J, Leverich G, Denicoff K, Luckenbaugh D, Post R. Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up. Am J Psychiatry 2003; 160:1252-62. [PMID: 12832239 DOI: 10.1176/appi.ajp.160.7.1252] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE While guidelines for treating patients with bipolar depression recommend discontinuing antidepressants within 6 months after remission, few studies have assessed the implications of this strategy on the risk for depressive relapse. This study examined the effect of antidepressant discontinuation or continuation on depressive relapse risk among bipolar subjects successfully treated for an acute depressive episode. METHOD Eighty-four subjects with bipolar disorder who achieved remission from a depressive episode with the addition of an antidepressant to an ongoing mood stabilizer regimen were followed prospectively for 1 year. The risk of depressive relapse among 43 subjects who stopped antidepressant treatment within 6 months after remission ("discontinuation group") was compared with the risk among 41 subjects who continued taking antidepressants beyond 6 months ("continuation group"). RESULTS A Cox proportional hazards regression analysis indicated that shorter antidepressant exposure time following successful treatment was associated with a significantly shorter time to depressive relapse. Furthermore, patients who discontinued antidepressant treatment within the first 6 months after remission experienced a significantly shorter period of euthymia before depressive relapse over the length of 1-year follow-up. One year after successful antidepressant response, 70% of the antidepressant discontinuation group experienced a depressive relapse compared with 36% of the continuation group. By the 1-year follow-up evaluation, 15 (18%) of the 84 subjects had experienced a manic relapse; only six of these subjects were taking an antidepressant at the time of manic relapse. CONCLUSIONS The risk of depressive relapse in patients with bipolar illness was significantly associated with discontinuing antidepressants soon after remission. The risk of manic relapse was not significantly associated with continuing use of antidepressant medication and, overall, was substantially less than the risk of depressive relapse. Maintenance of antidepressant treatment in combination with a mood stabilizer may be warranted in some patients with bipolar disorder.
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204
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Abstract
BACKGROUND with increasing awareness of lithium's limitations, several new anticonvulsants had been tested for their mood stabilisation during recent years. Among the innovative third generation mood stabilizing anticonvulsants, gabapentin (GBP) seems to have a broad spectrum of efficacy, although no certain data are available as to its efficacy and use in clinical practice. Accordingly, an extensive review on this subject has been carried out. METHODS A computer-generated search of the biomedical literature and abstract books of the more important scientific psychiatric congresses until June 2000 was undertaken to identify all pertinent case reports, case series and studies of GBP as monotherapy or adjunctive therapy in mood disorders. We identified 40 open-label studies on the use of GBP in at least 600 patients with bipolar disorder (BP), manic, depressed, or mixed episodes and unipolar depression and four controlled studies. RESULTS The 40 open-label studies and two of the controlled trials suggested that GBP may have a role as adjunctive agent in the treatment of patients with bipolar disorders particularly when complicated by co-morbid anxiety disorder or substance abuse. GBP is usually very well tolerated and has no pharmacological interference with other mood stabilisers. However, in the other two double-blind studies GBP has not been found to be efficacious in the treatment of refractory mania or refractory bipolar depression. CONCLUSIONS Although failing to show clear antimanic efficacy in randomized trials, gabapentin still remains a clinically useful agent when it comes to combination treatment in refractory and co-morbid patients.
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Affiliation(s)
- Mauro Giovanni Carta
- Division of Psychiatry, Department of Public Health, University of Cagliari, Via Liguria 13, 09127 Cagliari, Italy.
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205
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Abstract
Before the rise of atypical antipsychotics, lithium used to be the most frequently investigated substance in the acute treatment of bipolar disorders, although studies are not always of the highest methodological standard. Due to the doubt about a sufficient efficacy of lithium expressed in recent years from various sides, and the simultaneous availability of newer treatment alternatives, this paper attempts to make a critical stocktaking of our knowledge about lithium in the acute treatment of bipolar disorders. Aspects concerning the changed disorder concept through the broadening of the bipolar spectrum, together with the available results from controlled and open studies with lithium, are presented and appraised. This shows that lithium should still be seen as an essential, but not the only corner stone in the differentiated treatment of bipolar patients. Provided that it is taken reliably and well-tolerated, lithium represents a first choice treatment, particularly for a classical course of manic-depressive illness (Bipolar I disorder), especially for mild to moderate manic syndromes.However, as antidepressive treatment, lithium should rather not be applied as a monotherapy, particularly in severe bipolar depression, since with the new generation of antidepressants and anticonvulsants well-tolerated and very effective alternatives are available. In combination treatment, lithium should be applied particularly when it has already shown good prophylactic efficacy and/or in patients for whom a high suicide risk must be presumed.
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Affiliation(s)
- Heinz Grunze
- Psychiatriche Klinik der LMU Nussbaumstr. 7 80336 München, Germany.
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206
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Grunze H, Dittmann S. [Treatment of acute bipolar disorder. Intriguing balancing act between mania and depression]. MMW Fortschr Med 2003; 145 Suppl 2:27-30. [PMID: 14579481 DOI: pmid/14579481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The term bipolar disorder is no longer limited to the classical manic-depressive condition, but now subsumes a wide spectrum of illnesses. As a consequence of this expansion of the classification systems, the therapeutic utility of lithium and other mood stabilizing agents has to be defined anew. The majority treatment recommendations differentiate, symptom-related, between euphoric mania, mixed conditions, mania with psychotic symptoms and rapid cycling manic episodes. Current acute treatment includes, in addition to lithium, in particular carbamazepine and valproate, but also newer antiepileptic drugs such as lamotrigine or atypical neuroleptic agents such as olanzapine and risperidone. Due to the high suicidal risk, patients with bipolar depression often need to be given an antidepressant as well. It must, however, be remembered that in patients with rapid cycling, antidepressants may re-trigger mania.
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Affiliation(s)
- H Grunze
- Psychiatrische Klinik, LMU München.
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207
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Frye MA, Altshuler LL, McElroy SL, Suppes T, Keck PE, Denicoff K, Nolen WA, Kupka R, Leverich GS, Pollio C, Grunze H, Walden J, Post RM. Gender differences in prevalence, risk, and clinical correlates of alcoholism comorbidity in bipolar disorder. Am J Psychiatry 2003; 160:883-9. [PMID: 12727691 DOI: 10.1176/appi.ajp.160.5.883] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The prevalence of lifetime alcohol abuse and/or dependence (alcoholism) in patients with bipolar disorder has been reported to be higher than in all other axis I psychiatric diagnoses. This study examined gender-specific relationships between alcoholism and bipolar illness, which have previously received little systematic study. METHOD The prevalence of lifetime alcoholism in 267 outpatients enrolled in the Stanley Foundation Bipolar Network was evaluated by using the Structured Clinical Interview for DSM-IV. Alcoholism and its relationship to retrospectively assessed measures of the course of bipolar illness were evaluated by patient-rated and clinician-administered questionnaires. RESULTS As in the general population, more men (49%, 57 of 116) than women with bipolar disorder (29%, 44 of 151) met the criteria for lifetime alcoholism. However, the risk of having alcoholism was greater for women with bipolar disorder (odds ratio=7.35) than for men with bipolar disorder (odds ratio=2.77), compared with the general population. Alcoholism was associated with a history of polysubstance use in women with bipolar disorder and with a family history of alcoholism in men with bipolar disorder. CONCLUSIONS This study suggests that there are gender differences in the prevalence, risk, and clinical correlates of alcoholism in bipolar illness. Although this study is limited by the retrospective assessment of illness variables, the magnitude of these gender-specific differences is substantial and warrants further prospective study.
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Affiliation(s)
- Mark A Frye
- Department of Psychiatry and Biobehavioral Sciences, UCLA Bipolar Research Program, University of California-Los Angeles School of Medicine, 300 UCLA Medical Plaza, Suite 1544, Los Angeles, CA 90095, USA.
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208
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Leverich GS, Altshuler LL, Frye MA, Suppes T, Keck PE, McElroy SL, Denicoff KD, Obrocea G, Nolen WA, Kupka R, Walden J, Grunze H, Perez S, Luckenbaugh DA, Post RM. Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 2003; 64:506-15. [PMID: 12755652 DOI: 10.4088/jcp.v64n0503] [Citation(s) in RCA: 235] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clinical factors related to suicide and suicide attempts have been studied much more extensively in unipolar depression compared with bipolar disorder. We investigated demographic and course-of-illness variables to better understand the incidence and potential clinical correlates of serious suicide attempts in 648 outpatients with bipolar disorder. METHOD Patients with bipolar I or II disorder (DSM-IV criteria) diagnosed with structured interviews were evaluated using self-rated and clinician-rated questionnaires to assess incidence and correlates of serious suicide attempts prior to study entry. Clinician prospective ratings of illness severity were compared for patients with and without a history of suicide attempt. RESULTS The 34% of patients with a history of suicide attempts, compared with those without such a history, had a greater positive family history of drug abuse and suicide (or attempts); a greater personal history of early traumatic stressors and more stressors both at illness onset and for the most recent episode; more hospitalizations for depression; a course of increasing severity of mania; more Axis I, II, and III comorbidities; and more time ill on prospective follow-up. In a hierarchical logistic regression, a history of sexual abuse, lack of confidant prior to illness onset, more prior hospitalizations for depression, suicidal thoughts when depressed, and cluster B personality disorder remained significantly associated with a serious suicide attempt. CONCLUSION Our retrospective findings, supplemented by prospective follow-up, indicate that a history of suicide attempts is associated with a more difficult course of bipolar disorder and the occurrence of more psychosocial stressors at many different time domains. Greater attention to recognizing those at highest risk for suicide attempts and therapeutic efforts aimed at some of the correlates identified here could have an impact on bipolar illness-related morbidity and mortality.
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Affiliation(s)
- Gabriele S Leverich
- Stanley Foundation Bipolar Treatment Outcome Network, Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health, Biological Psychiatry Branch, Bethesda, MD 20892-1272, USA.
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209
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Schaefer M, Schmidt F, Folwaczny C, Lorenz R, Martin G, Schindlbeck N, Heldwein W, Soyka M, Grunze H, Koenig A, Loeschke K. Adherence and mental side effects during hepatitis C treatment with interferon alfa and ribavirin in psychiatric risk groups. Hepatology 2003; 37:443-51. [PMID: 12540795 DOI: 10.1053/jhep.2003.50031] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Psychiatric disorders or drug addiction are often regarded as contraindications against the use of interferon alfa (IFN-alpha) in patients with chronic hepatitis C. Our aim was to obtain prospective data on adherence to as well as efficacy and mental side effects of treatment with IFN-alpha in different psychiatric risk groups compared with controls. In a prospective trial, 81 patients with chronic hepatitis C (positive hepatitis C virus[HCV] RNA and elevated alanine aminotransferase[ALT] level) and psychiatric disorders (n = 16), methadone substitution (n = 21), former drug addiction (n = 21), or controls without a psychiatric history or drug addiction (n = 23) were treated with a combination of IFN-alpha-2a 3 MU 3 times weekly and ribavirin (1,000-1,200 mg/d). Sustained virologic response (overall, 37%) did not differ significantly between subgroups. No significant differences between groups were detected with respect to IFN-alpha-related development of depressions during treatment. However, in the psychiatric group, significantly more patients received antidepressants before and during treatment with IFN-alpha (P <.001). Most of those who dropped out of the study were patients with former drug addiction (43%; P =.04) compared with 14% in the methadone group, 13% in the control group, and 18% in the psychiatric group. No patient in the psychiatric group had to discontinue treatment because of psychiatric deterioration. In conclusion, our data do not confirm the supposed increased risk for IFN-alpha-induced mental side effects and dropouts in psychiatric patients if interdisciplinary care and antidepressant treatment are available. Preexisting psychiatric disorders or present methadone substitution should no longer be regarded as contraindications to treatment of chronic hepatitis C with IFN-alpha and ribavirin in an interdisciplinary setting.
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Affiliation(s)
- Martin Schaefer
- Department of Psychiatry, Charité, Humboldt University, Berlin, Germany.
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210
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Grunze H, Kasper S, Goodwin G, Bowden C, Baldwin D, Licht RW, Vieta E, Möller HJ. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania. World J Biol Psychiatry 2003; 4:5-13. [PMID: 12582971 DOI: 10.3109/15622970309167904] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Identical to the preceding guidelines of this series, these practice guidelines for the biological, mainly pharmacological treatment of acute bipolar mania were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was finally not only graded, but has also been commented by the experts of the task force to ensure practicability. Key words: bipolar disorder, mania, acute treatment, evidence-based guidelines, pharmacotherapy, antipsychotics, mood stabiliser, electroconvulsive therapy.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany.
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211
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Abstract
Although much progress has been made in successfully treating bipolar disorder, there is increasing awareness of the limitations of traditional treatment regimes, such as lithium or antipsychotics and the possible beneficial use of antiepileptic drugs. After the first generation of antiepileptic drugs such as phenytoin and clonazepam, the second generation is comprised of the frequently-used substances carbamazepine/oxcarbazepine and valproate. Lamotrigine, gabapentin, tiagabine, levetiracetam, zonisamide and topiramate will represent the third generation 5 years from now. Drugs such as retigabine might represent the next generation. However, the efficacy of antiepileptic drugs investigated in the treatment of bipolar disorder differs and most promising effects are seen in combination therapy with mood stabilizers. The authors review the main mechanisms of action of these drugs which may, in turn, improve our understanding of the pathophysiology of bipolar disorder.
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Affiliation(s)
- Benedikt Amann
- Dept. of Psychiatry, Ludwig-Maximilians University, Nussbaumstr.7, 80336 Munich, Germany.
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212
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Hummel B, Walden J, Stampfer R, Dittmann S, Amann B, Sterr A, Schaefer M, Frye MA, Grunze H. Acute antimanic efficacy and safety of oxcarbazepine in an open trial with an on-off-on design. Bipolar Disord 2002; 4:412-7. [PMID: 12519102 DOI: 10.1034/j.1399-5618.2002.02228.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
RATIONALE AND OBJECTIVES Carbamazepine has shown reasonable antimanic properties, but its use has been limited because of enzyme-inducing effects. The keto-derivative oxcarbazepine (OXC) is very similar to carbamazepine, however, the metabolic pathway is different. OXC is not metabolized to the 10, 11-epoxide, which seems to be responsible for several undesirable side-effects of carbamazepine and furthermore OXC has less enzyme-inducing properties. METHODS In this non-random open label study, patients were treated with OXC for 14 days, crossed over to no OXC for 7 days, and then crossed back over to OXC for the remaining 14 days. OXC was titrated to a final dose in a range of 900-2100 mg due to individual response. Treatment success was defined as a reduction of the original Young Mania Rating Scale (YMRS) score of more than 50% at the end of study period. RESULTS Four of the 12 included patients (33%) met defined response criteria at the end of study period. Fifty percentage of the patients had to be prematurely excluded from the trial. The mean YMRS scores of the on-periods were obviously different from the off-period. Forty-two percentage of the patients experienced side-effects leading to premature discontinuation in two of 12 patients. CONCLUSION Antimanic activity of OXC was demonstrated in this pilot study only for patients with mild or moderate manic symptoms. Further studies are encouraged to clarify OXC's role as mood-stabilizer and assess whether it has a profile similar to that of carbamazepine.
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Affiliation(s)
- Barbara Hummel
- Stanley Foundation Bipolar Network Centers, Department of Psychiatry, LMU Munich, Germany.
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213
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Post RM, Denicoff KD, Leverich GS, Altshuler LL, Frye MA, Suppes TM, Keck PE, McElroy SL, Kupka R, Nolen WA, Grunze H, Walden J. Presentations of depression in bipolar illness. ACTA ACUST UNITED AC 2002. [DOI: 10.1016/s1566-2772(02)00039-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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214
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Abstract
The so-called atypical forms of bipolar disorder are not a rarity, but instead are rather the rule. Particularly in specialized settings such as the bipolar disorder clinic, the majority of patients are characterized by atypical manifestations (). Mixed states, psychotic mania and a rapid cycling course of bipolar disorder are a challenge both to pharmacological and non-pharmacological treatment. The benefit of classical mood stabilizers such as lithium and carbamazepine is limited in monotherapy, although valproate has a broader spectrum of activity in atypical bipolar disorders and is often used in combination with other agents. Thus, new treatment alternatives are needed urgently for optimizing the treatment of atypical bipolar disorder. During the last decade, several new antiepileptic drugs have been released, e.g. lamotrigine, gabapentin, tiagabine, topiramate and levetiracetam. Others have been available for some time, but only recently have become the focus of bipolar disorder research; for example, phenytoin, and especially, oxcarbazepine. This review will consider our current knowledge of the benefit of these new and newly rediscovered anticonvulsants in treating bipolar disorders, with a special focus on their value in treating atypical manifestations.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry, LMU, Nussbaumstr. 7, D-80336 Munich, Germany.
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215
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Grunze H, Kasper S, Goodwin G, Bowden C, Baldwin D, Licht R, Vieta E, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of bipolar disorders. Part I: Treatment of bipolar depression. World J Biol Psychiatry 2002; 3:115-24. [PMID: 12478876 DOI: 10.3109/15622970209150612] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
These practice guidelines for the biological, mainly pharmacological treatment of bipolar depression were developed by an international task force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of bipolar depression. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, and from recent proceedings of key conferences and various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was not only graded, but also commented on by the experts of the task force to ensure practicability.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany.
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216
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Schaefer M, Engelbrecht MA, Gut O, Fiebich BL, Bauer J, Schmidt F, Grunze H, Lieb K. Interferon alpha (IFNalpha) and psychiatric syndromes: a review. Prog Neuropsychopharmacol Biol Psychiatry 2002; 26:731-46. [PMID: 12188106 DOI: 10.1016/s0278-5846(01)00324-4] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Interferon alpha (IFNalpha) is used for the treatment of several disorders, such as chronic hepatitis or malignant melanoma. During the therapy, IFNalpha may cause severe neuropsychiatric syndromes including depression with suicidal ideation, paranoid psychoses, or confusional states. The reasons and management of these side effects are widely unknown. Our aim is to review research evidence for the contribution of IFNalpha for the etiopathology of psychiatric syndromes. Therefore, research findings of neuropsychiatric syndromes induced by IFNalpha treatment, the putative mechanisms underlying those syndromes, and their treatment are-reviewed. Furthermore, neuropsychiatric syndromes in diseases with high IFNalpha levels such as systemic lupus erythematosus (SLE) are discussed. Finally, the question is addressed whether IFNalpha may contribute to the etiopathology of endogenous psychiatric disorders. IFNalpha may cause psychiatric syndromes in a subset of treated patients. The underlying pathogenetic mechanisms include various effects on neuroendocrine, cytokine, and neurotransmitter systems. Research data on the role of IFNalpha in the pathogenesis of endogenous psychiatric disorders are conflicting. Future research should improve our understanding of the role of IFNalpha for the etiopathology of psychiatric syndromes and has an impact on treatment of IFNalpha-induced psychiatric syndromes.
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Affiliation(s)
- Martin Schaefer
- Department of Psychiatry, Charité, Humboldt University, Humboldt, Germany
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217
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Normann C, Hummel B, Schärer LO, Hörn M, Grunze H, Walden J. Lamotrigine as adjunct to paroxetine in acute depression: a placebo-controlled, double-blind study. J Clin Psychiatry 2002; 63:337-44. [PMID: 12000208 DOI: 10.4088/jcp.v63n0411] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Mood stabilizers appear to be more potent in treating mania than depression. The anticonvulsant lamotrigine has been shown to be effective for bipolar depression. This study examines putative antidepressive properties of lamotrigine in a mainly unipolar routine clinical patient population. METHOD Forty patients with a depressive episode (DSM-IV criteria) requiring psychiatric intervention received lamotrigine or placebo using a fixed dose escalation scheme with a target dose of 200 mg/day for 9 weeks. Additionally, all patients were treated with paroxetine. Hamilton Rating Scale for Depression (HAM-D) and Clinical Global Impressions scale (CGI) ratings were used to monitor therapeutic efficacy. RESULTS Adjunctive treatment with lamotrigine did not result in a significant difference in HAM-D total score at the endpoint of the study when compared with paroxetine alone. However, lamotrigine demonstrated significant efficacy on core depressive symptoms as reflected by HAM-D items 1 (depressed mood; p = .0019), 2 (guilt feelings; p = .0011), and 7 (work and interest; p = .049) and the CGI-Severity of Illness scale (p < .0001). Patients receiving lamotrigine had fewer days on treatment with benzodiazepines and fewer withdrawals for treatment failure. Lamotrigine appeared to accelerate the onset of action of the antidepressant. Two patients on lamotrigine treatment developed neutropenia, and 1 developed a benign rash. There was no detectable pharmacokinetic interaction between lamotrigine and paroxetine. CONCLUSION Lamotrigine might have antidepressive properties in unipolar patients and may accelerate onset of action when given in combination with typical antidepressants.
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Affiliation(s)
- Claus Normann
- Department of Psychiatry, University of Freiburg, Germany
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218
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McElroy SL, Frye MA, Suppes T, Dhavale D, Keck PE, Leverich GS, Altshuler L, Denicoff KD, Nolen WA, Kupka R, Grunze H, Walden J, Post RM. Correlates of overweight and obesity in 644 patients with bipolar disorder. J Clin Psychiatry 2002; 63:207-13. [PMID: 11926719 DOI: 10.4088/jcp.v63n0306] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Overweight and obesity are common clinical problems encountered in the treatment of bipolar disorder. We therefore assessed the prevalence and clinical correlates of overweight, obesity, and extreme obesity in 644 bipolar patients. METHOD 644 outpatients with DSM-IV bipolar disorder in the Stanley Foundation Bipolar Treatment Outcomes Network were evaluated with structured diagnostic interviews and clinician- and self-administered questionnaires to determine bipolar disorder diagnoses, demographic and historical illness characteristics, comorbid Axis I diagnoses, medical histories, health habits, and body mass indices (BMMs). RESULTS Fifty-eight percent of the patients with bipolar disorder were overweight, 21% were obese, and 5% were extremely obese. American patients had significantly higher mean (p < .0001) BMIs and significantly higher rates of obesity (p < .001) and extreme obesity (p < .001) than European patients. Significant associations (p < or = .001) were found between overweight, obesity. and extreme obesity and gender, age, income level, comorbid binge-eating disorder, hypertension, arthritis, diabetes mellitus, exercise habits, and coffee consumption. Current BMI and weight were each correlated with the number of weight gain-associated psychotropics to which patients had been exposed. Multinomial logistic regression (adjusted for site and eating disorder diagnosis and corrected for multiple comparisons) showed that (1) overweight was significantly associated with male gender and hypertension (p < .001), (2) obesity was significantly associated with hypertension (p < .001), and (3) extreme obesity was significantly associated with hypertension and arthritis (p < .001). CONCLUSION Overweight, obesity, and extreme obesity were common in this group of bipolar patients, although it was unclear that their prevalence rates were truly elevated, because overweight and obesity are increasingly common public health problems among the general population. Correlates of overweight and obesity in bipolar disorder include patient and treatment variables such as gender, geographical location, comorbid binge-eating disorder, age, income level, degree of exposure to weight gain-associated psychotropics, medical disorders associated with obesity, and health habits.
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Affiliation(s)
- Susan L McElroy
- Stanley Foundation Bipolar Treatment Outcome Network, Department of Psychiatry, University of Cincinnati College of Medicine, Ohio 45267-0559, USA
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219
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Schärer LO, Hartweg V, Valerius G, Graf M, Hoern M, Biedermann C, Walser S, Boensch A, Dittmann S, Forsthoff A, Hummel B, Grunze H, Walden J. Life charts on a palmtop computer: first results of a feasibility study with an electronic diary for bipolar patients. Bipolar Disord 2002; 4 Suppl 1:107-8. [PMID: 12479693 DOI: 10.1034/j.1399-5618.4.s1.51.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- L O Schärer
- Department of Psychiatry, University of Freiburg, Freiburg, Germany
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220
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Grunze H, Marcuse A, Schärer LO, Born C, Walden J. Nefazodone in psychotic unipolar and bipolar depression: a retrospective chart analysis and open prospective study on its efficacy and safety versus combined treatment with amitriptyline and haloperidol. Neuropsychobiology 2002; 46 Suppl 1:31-5. [PMID: 12571431 DOI: 10.1159/000068017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although atypical antipsychotics are on the rise, traditional treatment of psychotic (or delusional) depression mostly includes the addition of classical antipsychotics to antidepressants. As there are only few data supporting this approach compared with antidepressant monotherapy, and almost no data comparing it with antidepressants of the latest generation, we conducted a retrospective chart analysis and a prospective, randomized open study on the efficacy and tolerability of nefazodone monotherapy versus combined treatment with amitriptyline and haloperidol in psychotic depression. The results suggest that the addition of classical antipsychotics should be reserved for those with very severe psychotic symptoms, but may not be needed in milder forms.
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Affiliation(s)
- Heinz Grunze
- Department of Psychiatry, LMU Munich, Munich, Germany.
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221
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Grunze H, Walden J, Dittmann S, Berger M, Bergmann A, Bräunig P, Dose M, Emrich HM, Gastpar M, Greil W, Krüger S, Möller HJ, Uebelhack R. [Psychopharmacotherapy of bipolar affective diseases]. Nervenarzt 2002; 73:4-17; quiz 18-9. [PMID: 11975062 DOI: 10.1007/s115-002-8142-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The broadening of the classification systems for manic-depressive illness towards a spectrum of bipolar disorders implicates a more differentiated use of pharmacotherapies. However, many questions still remain open. This implies that all consensus guidelines and recommendations have to be considered as preliminary. On the other hand, research in the last decade has developed many new treatment alternatives, both for mood stabilizers and antidepressants as well as antipsychotics. These recommendations, which have been developed in the process of two consensus meetings, try to consider the broadening of the concept of bipolar disorder by differentiating between subgroups according to acute symptomatology and characteristics of the long-term course, e.g., rapid cycling. In particular, the emerging role and new indications of mood stabilizing antiepileptic drugs, atypical antipsychotics, and new antidepressants will be discussed.
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Affiliation(s)
- H Grunze
- Psychiatrische Klinik der Universität München
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222
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Abstract
Bipolar rapid cycling (RC) is defined as 4 or more affective episodes within 1 year. It has been postulated that RC is related to a poor response to lithium, to the same extent as mixed episodes or other atypical symptoms of the illness. This article reviews the current status of alternative pharmacological or otherwise supportive therapies of RC. Biological parameters and characteristics of the illness associated with RC like gender prevalence in women, hyperthyroidism, catecholamine-O-methyltransferase allele, the influence of sleep, different subtypes of bipolar disorder and the risk of antidepressant-induced cycling will be discussed in detail.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, LMU University Hospital, Munich, Germany.
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223
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Dittmann S, Biedermann NC, Grunze H, Hummel B, Schärer LO, Kleindienst N, Forsthoff A, Matzner N, Walser S, Walden J. The Stanley Foundation Bipolar Network: results of the naturalistic follow-up study after 2.5 years of follow-up in the German centres. Neuropsychobiology 2002; 46 Suppl 1:2-9. [PMID: 12571425 DOI: 10.1159/000068018] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The Stanley Foundation Bipolar Network (SFBN) is an international, multisite network investigating the characteristics and course of bipolar disorder. Methods (history, ratings and longitudinal follow-up) are standardized and equally applied in all 7 centres. This article describes demographics and illness characteristics of the first 152 German patients enrolled in the SFBN as well as the results of 2.5 years of follow-up. Patients in Germany were usually enrolled after hospitalisation. More than 72% of the study population suffered from bipolar I disorder and 25% from bipolar II disorder. The mean +/- SD age of the study participants was 42.08 +/- 13.5 years, and the mean +/- SD age of onset 24.44 +/- 10.9 years. More than 40% of the sample reported a rapid-cycling course in history, and even more a cycle acceleration over time. 37% attempted suicide at least once. 36% had an additional Axis I disorder, with alcohol abuse being the most common one, followed by anxiety disorders. During the follow-up period, only 27% remained stable, 56% had a recurrence, 12.8% perceived subsyndromal symptoms despite treatment and regular visits. 27% suffered from a rapid-cycling course during the follow-up period. Recurrences were significantly associated with bipolar I disorder, an additional comorbid Axis I disorder, rapid cycling in history, a higher number of mood stabilizers and the long-term use of typical antipsychotics. Rapid cycling during follow-up was only associated with a rapid-cycling course in history, a higher number of mood stabilizers and at least one suicide attempt in history.
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Affiliation(s)
- S Dittmann
- Department of Psychiatry, University of Munich, Munich, Germany.
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224
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Abstract
We reviewed the available literature on the efficacy of a novel anticonvulsant, Tiagabine (TGB), in the treatment of bipolar disorder. Study results indicate that TGB does not represent a valid option in acute mania due its required slow, progressive titration. More rapid titration schemes may lead to severe complications. TGB may be an option as an adjunct long-term treatment approach in refractory patients, but further studies are clearly needed to support this.
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Affiliation(s)
- M G Carta
- Psychiatric Unit, Department of Public Health, University of Cagliari, Via Liguria 13, 09127 Cagliari, Italy.
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225
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Hummel B, Dittmann S, Forsthoff A, Matzner N, Amann B, Grunze H. Clozapine as add-on medication in the maintenance treatment of bipolar and schizoaffective disorders. A case series. Neuropsychobiology 2002; 45 Suppl 1:37-42. [PMID: 11893876 DOI: 10.1159/000049260] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Atypical neuroleptics are increasingly used in the treatment of bipolar and schizoaffective disorders. Currently, numerous controlled short-term studies are available for clozapine, olanzapine, risperidone or quetiapine, but long-term data are still missing. Three patients (2 with bipolar disorder, 1 with schizoaffective disorder) are described who showed a marked reduction of affective symptomatology after clozapine had been added to mood stabilizer pretreatment. The patients were seen once a month before and after the introduction of clozapine for at least 6 months. Treatment response was evaluated using different rating scales (IDS, YMRS; GAF; CGI-BP) and the NIMH Life Chart Methodology. All patients showed a marked improvement after the add-on treatment with clozapine had been initiated. Clozapine was tolerated well with only transient and moderate weight gain and fatigue as only side effects. This case series underlines the safety and efficacy of clozapine as add-on medication in the treatment of bipolar and schizoaffective disorders.
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Affiliation(s)
- B Hummel
- Department of Psychiatry, LMU University Hospital, Munich, Germany
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226
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Amann B, Stampfer R, Schmidt F, Mikhaiel P, Hummel B, Sterr A, Schäfer M, Grunze H. [Clinical relevance and treatment possibilities of rapid cycling in patients with bipolar disorder]. Fortschr Neurol Psychiatr 2001; 69:569-80. [PMID: 11753745 DOI: 10.1055/s-2001-19181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In the actual version of the WHO diagnostic guidelines, the ICD-10, subtypes of bipolar disorder are not specified, in contrast to the American DSM-IV, where bipolar disorder has already been differentiated in bipolar I (severe manic and depressive episodes) and bipolar II disorder (depressive and hypomanic episodes). Furthermore, aspects of the longitudinal course of the illness, like rapid cycling (RC), are reflected as well. Rapid cycling is defined as four or more affective episodes within one year of the illness. It has been postulated that rapid cycling is related with a poor response to lithium, to the same extent as mixed episodes or an atypical onset (depressive episode first) of the disease. Here, the current status of alternative pharmacological and supportive therapy of rapid cycling is presented and discussed. Furthermore, the article also displays biological parameters associated with rapid cycling like higher prevalence in women, hypothyreoidism, subtype of bipolar disorder, COMT-allele, influence of sleep or risk of antidepressant induced cycling.
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Affiliation(s)
- B Amann
- Psychiatrische Universitätsklinik, LMU München.
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227
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Abstract
BACKGROUND Using our routine documentation system we evaluated the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I depressed patients compared to unipolar depressed patients. METHOD Based on the data from 2032 consecutively admitted inpatients with unipolar or bipolar I depression we compared the efficacy of antidepressants in both groups. The outcome was assessed by the Global assessment scale (GAS), the duration of hospitalisation and the Apathic-, Depressive- and Manic Syndrome subscales of the Association for Methodology and Documentation in Psychiatry system. RESULTS Cohorts were comparable in treatment regimens and severity of depression at admission. At discharge, there were no statistically significant differences between bipolar I and unipolar depression for the outcome criteria Depressive Syndrome scale, GAS score and days in hospital. Bipolar patients showed a slightly decreased score of the Apathic Syndrome scale at discharge, also reflected by a slightly elevated score of the Manic Syndrome scale. LIMITATIONS This study did not check for differences in side effects such as switching or cycling commonly attributed to the use of tricyclic antidepressants in bipolar patients. Naturalistic data were obtained prospectively, analysis, however, was done retrospectively, thus limiting, but not completely excluding a possible selection bias. CONCLUSION Evaluating different outcome criteria, our naturalistic data of a large cohort seem to reject the hypothesis that antidepressants may be less effective in the acute treatment of bipolar I compared to unipolar depressed patients.
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Affiliation(s)
- H J Möller
- Department of Psychiatry of the Ludwig Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany.
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228
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Abstract
UNLABELLED Myelinolysis may occur as a severe complication of eating disorders, especially anorexia nervosa (AN). One of the most important reasons can be a rapid correction of hyponatremia caused by tubulopathy, water intoxication (WI), or abuse of diuretics in individuals with AN. METHOD AND RESULTS We report on a 24-year-old female patient with an 8-year history of AN. A rapid correction of severe hyponatremia and hypokalemia induced by WI led to central pontine myelinolysis, which was confirmed by magnetic resonance imaging (MRI) examination. Besides affective lability, incoherence, and an acute confusional state, surprisingly, no severe neurological symptoms emerged. CONCLUSION Thus, physicians should be aware of the risk of pontine myelinolysis with new psychiatric symptoms emerging in the absence of obvious neurological deficits.
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Affiliation(s)
- B Amann
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany.
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229
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Schäfer M, Schmidt F, Grunze H, Laakmann G, Loeschke K. [Interferon alpha-associated agranulocytosis during clozapine treatment. Case report and status of current knowledge]. Nervenarzt 2001; 72:872-5. [PMID: 11758095 DOI: 10.1007/s001150170022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Little is known about possibilities of chronic hepatitis C treatment with interferon-alpha (IFN-alpha) in psychiatric patients continuously taking antipsychotics. We report on a 28-year-old hepatitis C-positive man with paranoid psychosis. He was successfully treated with clozapine, an atypical antipsychotic drug which is known for the risk of granulocytopenia and agranulocytosis. With doses up to 200 mg/day over 3 years, he showed no remarkable changes in WBC. Because of the chronic hepatitis C with genotype 3a, additional treatment was started with IFN-alpha (s.c., 3 x 6 million IU/week). After 2 months of therapy he developed a severe agranulocytosis. Both clozapine and IFN-alpha were discontinued, and his WBC returned to normal. Results from bone marrow examination were compatible with a toxic reaction possibly caused by either or both medications. We discuss possible problems with IFN-alpha during the treatment of psychiatric patients, interactions with psychiatric medication, and hematotoxic side effects like those from clozapine. We recommend combining IFN-alpha with less "toxic" antipsychotics and weekly checks of WBC.
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Affiliation(s)
- M Schäfer
- Psychiatrische Klinik der Ludwig-Maximilians-Universität, Nussbaumstr. 7, 80336 München.
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230
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Grunze H, Langosch J, Schirrmacher K, Bingmann D, Von Wegerer J, Walden J. Kava pyrones exert effects on neuronal transmission and transmembraneous cation currents similar to established mood stabilizers--a review. Prog Neuropsychopharmacol Biol Psychiatry 2001; 25:1555-70. [PMID: 11642654 DOI: 10.1016/s0278-5846(01)00208-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
1. Antiepileptic drugs that are successful as mood stabilizers, e.g. carbamazepine, valproate and lamotrigine, exhibit a characteristic pattern of action on ion fluxes. As a common target, they all affect Na+- and Ca2+ inward and K+ outward currents. 2. Furthermore, they have a variety of interactions with the metabolism and receptor occupation of biogenic amines and excitatory and inhibitory amino acids, and, by this, also influence long- term potentiation (LTP) to different degrees. 3. The kava pyrones (+/-)-kavain and dihydromethysticin are constituents of Piper methysticum. Anticonvulsant, analgesic and anxiolytic properties have been described in small open trials. 4. In the studies summarized in this article the effects mainly of (+/-)-kavain were tested on neurotransmission and especially on voltage gated ion channels. It is assumed that effects on ion channels may significantly contribute to clinical efficacy. 5. Experimental paradigms included current and voltage clamp recordings from rat hippocampal CA 1 pyramidal cells and dorsal root ganglia as well as field potential recordings in guinea pig hippocampal slices. 6. The findings suggest that (i) kava pyrones have a weak Na+ antagonistic effect that may contribute to their antiepileptic properties (ii) that they have pronounced L- type Ca2+ channel antagonistic properties and act as an positive modulator of the early K+ outward current. These two actions may be of importance for mood stabilization. (iii) Furthermore, kava pyrones have additive effects with the serotonin-1A agonist ipsapirone probably contributing to their anxiolytic and sleep- inducing effects. (iv) Finally, they show a distinct pattern of action on glutamatergic and GABAergic transmission without affecting LTP. The latter, however, seems not to be true for the spissum extract of Kava where suppression of LTP was observed. 7. In summary, kava pyrones exhibit a profile of cellular actions that shows a large overlap with several mood stabilizers, especially lamotrigine.
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Affiliation(s)
- H Grunze
- Dept of Psychiatry, LMU Munich, Germany
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231
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Grunze HC, Normann C, Langosch J, Schaefer M, Amann B, Sterr A, Schloesser S, Kleindienst N, Walden J. Antimanic efficacy of topiramate in 11 patients in an open trial with an on-off-on design. J Clin Psychiatry 2001; 62:464-8. [PMID: 11465524 DOI: 10.4088/jcp.v62n0610] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A series of open studies suggests that topiramate has efficacy in bipolar disorder. To further investigate the potential value of topiramate as an antimanic agent, we conducted an open trial in 11 manic patients. METHOD Eleven patients with bipolar I disorder with an acute manic episode (DSM-IV) were treated with a mood stabilizer and/or antipsychotics in sufficient and fixed doses. All had a Young Mania Rating Scale (YMRS) score of at least 24 (mean +/- SD = 33.5+/-8.1). Topiramate was added after stable plasma levels of concomitant mood stabilizers had been reached and was titrated within 1 week to a final dose in the range of 25 to 200 mg/day, depending on clinical efficacy and tolerability. Topiramate was discontinued after 10 days, while concomitant medication remained unchanged. After 5 days, topiramate was reintroduced at similar or increased dosages for another 7 days. Patients were assessed with the YMRS; the Clinical Global Impressions scale version for bipolar patients; and the 21-item Hamilton Rating Scale for Depression. RESULTS Seven of the 11 patients initially showed a good antimanic response with > 50% reduction in YMRS score. One patient showed psychotic features following rapid increase in topiramate dosage and dropped out on day 10. After discontinuation of topiramate, 7 of the remaining 10 patients worsened (increase of > or = 25% in YMRS score), 2 remained stable, and 1 discontinued follow-up after good recovery. After reintroducing topiramate, all patients improved again within a week, with 8 of 9 meeting the responder criterion of > or = 50% YMRS score reduction when comparing baseline values with those of day 22. With the exception of the patient who developed psychosis, topiramate was well tolerated. Concomitant medication did not interfere with plasma levels of drug, except for carbamazepine level in 1 patient. CONCLUSION The antimanic response among patients in this study appears reproducibly linked to the addition of topiramate.
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Affiliation(s)
- H C Grunze
- Department of Psychiatry, LMU Munich, Germany.
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232
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Post RM, Nolen WA, Kupka RW, Denicoff KD, Leverich GS, Keck PE, McElroy SL, Rush AJ, Suppes T, Altshuler LL, Frye MA, Grunze H, Walden J. The Stanley Foundation Bipolar Network. I. Rationale and methods. Br J Psychiatry 2001; 41:s169-76. [PMID: 11450179 DOI: 10.1192/bjp.178.41.s169] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Stanley Foundation Bipolar Network (SFBN) was created to address the paucity of help studies in bipolar illness. AIMS To describe the rationale and methods of the SFBN. METHOD The SFBN includes five core sites and a number of affiliated sites that have adopted consistent methodology for continuous longitudinal monitoring of patients. Open and controlled studies are performed as patients' symptomatology dictates. RESULTS The reliability of SFBN raters and the validity of the rating instruments have been established. More than 500 patients are in continuous daily longitudinal follow-up. More than 125 have been randomised to one of three of the newer antidepressants (bupropion, sertraline and venlafaxine) as adjuncts in a study of mood stabilizers and 93 to omega-3 fatty acids. A number of open clinical case series have been published. CONCLUSIONS Well-characterised patients are followed in a detailed continuous longitudinal fashion in both opportunistic case series and double-blind, randomised controlled trials with reliable and validated measures.
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Affiliation(s)
- R M Post
- National Institute of Mental Health, Bethesda, Maryland, USA
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233
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Amann B, Grunze H, Hoffmann J, Schäfer M, Kuss HJ. [Non-fatal effect of highly toxic amitriptyline level after suicide attempt. A case report]. Nervenarzt 2001; 72:52-5. [PMID: 11221556 DOI: 10.1007/s001150050711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pharmacotherapeutic intervention in psychiatric patients often bears the risk of drug abuse for suicide attempts. Especially intoxication with tricyclic antidepressants, e.g., amitriptyline, may cause severe complications such as cardiac arrhythmia. Even under intensive care conditions, 2-3% of intoxicated patients still die. Here, we report on a depressed female patient who, thanks to timely and intense intervention, survived a suicide attempt with amitriptyline despite highly toxic plasma levels.
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Affiliation(s)
- B Amann
- Psychiatrische Klinik der Universität München
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234
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Abstract
OBJECTIVES Patients with rapid cycling bipolar disorder are frequently observed to fail conventional treatment. We conducted a preliminary study to explore the potential efficacy of lamotrigine in the treatment of this refractory patient population. METHODS In an open longitudinal investigation, 14 patients with rapid cycling bipolar disorder were treated for 1 year with either lithium or lamotrigine as mood stabilizer. RESULTS Out of the seven patients with lithium, three out of seven (43%) had less than four and four out of seven (57%) had four or more episodes. In the lamotrigine group, six out of seven (86%) had less than four and one out of seven (14%) had more than four affective episodes (depressive, manic, hypomanic or mixed). In fact, three out of seven (43%) of the patients who were on lamotrigine therapy were without any further affective episodes. There was no evidence of a preferential antidepressant versus antimanic efficacy. CONCLUSIONS Although the study is limited by the small number of patients, the results are in line with other investigations, suggesting efficacy for lamotrigine and a suboptimal response for lithium in rapid cycling bipolar disorder. These preliminary data need to be confirmed with controlled double blind studies.
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Affiliation(s)
- J Walden
- Department of Psychiatry, University of Freiburg, Germany.
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235
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Greene R, Bergeron R, McCarley R, Coyle JT, Grunze H. Short-term and long-term effects of N-methyl-D-aspartate receptor hypofunction. Arch Gen Psychiatry 2000; 57:1180-1; author reply 1182-3. [PMID: 11115333 DOI: 10.1001/archpsyc.57.12.1180] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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236
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Grunze H, Amann B, Schäfer M, Sterr A, Schaerer L, Wild E, Walden J. [Effectiveness, safety and practicality of delayed-release minitablets of valproate in bipolar affective disorders]. Fortschr Neurol Psychiatr 2000; 68:496-502. [PMID: 11144934 DOI: 10.1055/s-2000-10034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
UNLABELLED Valproate has recently emerged as a drug of first choice in treating acute mania because of its efficacy and relative safety. It can be administered as an intravenous, oral non-sustained release or oral sustained release loading therapy. A new sustained release formulation of valproate consists of "mini-tablets" with the possible advantage of a less problematic and more reliable administration of the drug. We report on eleven patients with an acute manic exacerbation who were investigated for sufficient control of manic symptoms and the duration of building up and maintaining sufficient blood levels of valproate in once/d versus twice/d administration of valproate delayed release mini-tablets (VPA mrt.). Acute and prophylactic effectiveness in mania were rated with the Young-Mania Rating Scale (YMRS), respectively the Global Clinical Impression Scale for Bipolar Disorder (CGI-BP). RESULTS Within a short period of time sufficient blood levels in both groups (once/d versus twice/d administration) were built up. Seven of eleven patients were responders according to a reduction of 50% of the YMRS. In respect of prophylactic treatment all of the ten patients showed satisfactory results and no re-exacerbation of manic symptoms or depression.
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Affiliation(s)
- H Grunze
- Psychiatrische Universitätsklinik, LMU München.
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237
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Abstract
PURPOSE To investigate the effects of lamotrigine (LTG), a new anticonvulsant, on neuronal excitability, synaptic transmission, and long-term potentiation (LTP) in guinea pig hippocampal slices. METHODS Electrically evoked field excitatory postsynaptic potentials (fEPSPs) and population spikes (PSs) were investigated in the CA1 region of the hippocampus. RESULTS The concentration-response curves showed different actions of LTG in concentrations near therapeutic plasma levels (10 microM) on fEPSPs and PSs. The initial slopes of fEPSPs were not affected, whereas the amplitudes of PSs were significantly decreased. Higher concentrations of LTG decreased both fEPSP slopes and PS amplitudes; however, the effects on PSs were much stronger. Also, there were no differences in fEPSP slopes or PS amplitudes compared with controls when LTP was induced in the presence of LTG (10 microM). CONCLUSIONS Our data are in contrast to previous findings that suggest LTG acts primarily on presynaptic sites by blocking the release of excitatory amino acids. Further, LTP was not affected by LTG.
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Affiliation(s)
- J M Langosch
- Department of Psychiatry, University of Freiburg, Germany.
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238
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Abstract
Bipolar disorder has attracted numerous research from different neurobiological angles. This review will summarize selected findings focusing on the role of disturbed transmem-braneous ion fluxes. Several mood stabilizers exhibit a distinct profile including effects on sodium, calcium and potassium conductance. In summary, some decisive mechanisms of action as calcium antagonism and modulation of potassium currents may play a crucial role in the success of any given mood stabilizer in bipolar disorder.
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Affiliation(s)
- H C Grunze
- 1Department of Psychiatry,LMU München,Germany
| | - J Langosch
- 2Department of Psychiatry,University of Freiburg,Freiburg,Germany
| | - C Normann
- 2Department of Psychiatry,University of Freiburg,Freiburg,Germany
| | - D Rujescu
- 1Department of Psychiatry,LMU München,Germany
| | - B Amann
- 1Department of Psychiatry,LMU München,Germany
| | - J Waiden
- 2Department of Psychiatry,University of Freiburg,Freiburg,Germany
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239
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Abstract
In contrast to mania, bipolar depression is usually characterised by longer-lasting episodes and a higher incidence of treatment refractoriness. Additionally, the risks of antidepressive standard treatment regimens are increasingly recognised, especially the risk of a switch into mania or induction of a rapid cycling course. Mood stabilisers, e.g. lithium, and some anticonvulsants, appear to have at least some antidepressant efficacy, which, however, may not be sufficient for treating severe depression. Currently, their use as a monotherapy of mild depression and at the start as a co-medication to antidepressants in severe depression is under consideration. The potential usefulness and risks of currently applied antidepressive treatment strategies as well as potential future developments will be reviewed in this article. At this stage, at least in severe depression, the use of true antidepressants still appears to be mandatory, especially because of the risk of suicide. However, initial combination with a mood stabiliser can be recommended. The treatment of depressive episodes only responsive to ECT should include combination with a mood stabiliser, in this case lithium, right from the start. In patients with lithium refractoriness, mood stabilising anticonvulsants should be initiated directly after the end of the ECT cycle. In order to reach sufficient plasma levels and thus reduce the risk of a switch, a loading therapy is recommended.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336 Munich, Germany
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240
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Müller-Oerlinghausen B, Retzow A, Henn FA, Giedke H, Walden J. Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania: a prospective, randomized, double-blind, placebo-controlled, multicenter study. European Valproate Mania Study Group. J Clin Psychopharmacol 2000; 20:195-203. [PMID: 10770458 DOI: 10.1097/00004714-200004000-00012] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To compare the efficacy of sodium valproate administered as adjunct to neuroleptic medication for patients with acute mania with the efficacy of neuroleptics alone, the authors conducted a 21-day, randomized, double-blind, parallel-group, placebo-controlled trial. The study design closely reflected a clinical psychiatric setting in Europe where patients with acute mania commonly receive neuroleptic medication. In this trial, 136 hospitalized patients met the ICD-10 criteria for acute manic episodes; these patients received a fixed dose of 20 mg/kg of body weight of sodium valproate (Orfiril, Desitin Arzneimittel GmbH, Hamburg, Germany) orally, in addition to basic neuroleptic medication, preferably haloperidol and/or perazine. The primary outcome measure was the mean dose of neuroleptic medication (after conversion into haloperidol-equivalents) for the 21-day study period. Severity of symptoms was measured using the Young Mania Rating Scale (YMRS), the Global Assessment Scale, and the Clinical Global Impression Scale. Intent-to-treat analysis was based on 69 patients treated with valproate and 67 patients who received placebo. Groups were comparable with regard to demographic and clinical baseline data. Premature discontinuations occurred in only 13% of the patients. The mean neuroleptic dose declined continuously in the valproate group, whereas only slight variations were observed in the placebo group; the difference was statistically significant (p = 0.0007) for study weeks 2 and 3. The combination of neuroleptic and valproate proved superior to neuroleptics in attempts to alleviate manic symptoms. The proportion of responders (a 50% improvement rate shown on the YMRS) was higher for the combination with valproate than for the group receiving only neuroleptics (70% vs. 46%; p = 0.005). Adverse events consisted of those known for valproate or neuroleptics; the only adverse event was asthenia, which occurred more frequently with the combination therapy. Valproate represents a useful adjunct medication for the treatment of acute manic symptoms. Valproate is beneficial because it allows the administration of fewer neuroleptic medications and produces improved and quicker remission of manic symptoms.
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241
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Abstract
Bupropion is increasingly used for nicotine withdrawal and in the treatment of major depression, especially in bipolar patients. We present the case of a 38-year-old female schizoaffective, rapid-cycling patient treated with bupropion for a depressive episode. After 4 weeks of successful treatment (300 mg/day), the patient developed a circumscribed unilateral impairment of sensory trigeminal nerve function. Symptoms completely recovered after discontinuation of bupropion. When re-exposed to bupropion, mild symptoms reappeared, leading to final discontinuation of bupropion. With this natural on-off-on-off design, a causative role of bupropion for trigeminal impairment in this patient can be assumed. To our knowledge, a similar side-effect of bupropion has not been described to date.
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Affiliation(s)
- B Amann
- Department of Psychiatry, University of Munich, Germany
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242
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Grunze H, Gallinat J, Haag C, Hegerl U. Psychopathological and auditory evoked potential correlates of ketamine psychosis--a single case report. Schizophr Res 2000; 41:386-8. [PMID: 10708350 DOI: pmid/10708350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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243
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Schäfer M, Schmidt F, Amann B, Schlösser S, Loeschke K, Grunze H. Adding low-dose antidepressants to interferon alpha treatment for chronic hepatitis C improved psychiatric tolerability in a patient with schizoaffective psychosis. Neuropsychobiology 2000; 42 Suppl 1:43-5. [PMID: 11093071 DOI: 10.1159/000054852] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Treatment of chronic hepatitis C with interferon alpha (IFN-alpha) is relatively contraindicated in patients with psychiatric disorders because of possible severe psychiatric side effects. We report on a case of a female patient with a chronic schizoaffective psychosis, who was treated for 3 months with 3 x 3 mio IE IFN-alpha s.c./week because of a chronic hepatitis C (genotype 1b). Psychosis was stable with flupentixol monotherapy. After 2 months, she developed a severe depressive syndrome which lead to suicidal ideation. Until this time, she was without any antidepressive medication. Depressive symptoms disappeared after interferon therapy was stopped. Under prophylactic treatment with low-dose trimipramine (50 mg) or nefazodone (200 mg/day) therapy with IFN-alpha 3 x 3 mio IE/week was re-established after several months and again 2 years later adding ribavirin 1200 mg/day, a virustaticum. In contrast to the symptoms during monotherapy with IFN-alpha, during the time of both combination treatments, no psychiatric side effects occurred. While for ribavirin antidepressant effects are not known, we suppose that antidepressants may prevent changes in serotonergic or noradrenergic neurotransmission caused by IFN-alpha.
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Affiliation(s)
- M Schäfer
- Department of Psychiatry, Klinikum Innenstadt, Ludwig-Maximilians-University, Munich, Germany.
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244
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Amann B, Sterr A, Thoma H, Messer T, Kapfhammer HP, Grunze H. Psychopathological changes preceding motor symptoms in Huntington's disease: a report on four cases. World J Biol Psychiatry 2000; 1:55-8. [PMID: 12607233 DOI: 10.3109/15622970009150566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neurodegenerative disorders often exhibit "classical" psychiatric symptoms as an initial presentation of the disease. Here we present four patients with different psychopathological abnormalities who were later diagnosed as having Huntington's disease. The range of symptoms covered affective and psychotic symptoms, antisocial behavior, cognitive problems reminiscent of dementia and suicidal idealisation. The pattern of progress of neuronal degeneration may be helpful in explaining the antecedent manifestation of psychiatric symptoms.
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Affiliation(s)
- B Amann
- Psychiatric Hospital, Ludwig-Maximilian-University, Nussbaumstr. 7 D-80336 Munich, Germany
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245
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Abstract
This study was aimed at investigating the effects of lamotrigine (LTG) on electrically evoked field excitatory postsynaptic potentials (fEPSP) and population spikes in the CA1 hippocampal region of guinea pigs. The concentration response curves showed different actions of LTG on fEPSP and on population spikes. The data are in contrast to previous findings that suggest the drug acts primarily on presynaptic sites via a blockade of the release of excitatory amino acids. In the range of therapeutic plasma levels, synaptic transmission was not affected.
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Affiliation(s)
- J M Langosch
- Department of Psychiatry, University of Freiburg Medical School, Freiburg i.Br., Germany
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246
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Grunze H, Langosch J, von Loewenich C, Walden J. Modulation of neural cell membrane conductance by the herbal anxiolytic and antiepileptic drug aswal. Neuropsychobiology 2000; 42 Suppl 1:28-32. [PMID: 11093068 DOI: 10.1159/000054849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To evaluate the effects of aswal on ionic fluxes and neuronal excitation, we performed extracellular and whole cell patch clamp recordings on CA1 pyramidal neurons of guinea pigs and Long-Evans rats. Aswal (100- 250 mg/l) was administered systemically, and its effects on the rate of synchronized extracellular field potentials (EFP), membrane parameters, action potentials and postsynaptic potentials were recorded. The extracellular results obtained are consistent with calcium antagonistic properties. Intracellular recordings suggest that a direct sodium antagonistic effect as seen in many antiepileptic drugs plays no significant role. Further effects on ligand gated ion channels are discussed controversially. In summary, the cellular action of aswal appears heterogeneous with calcium antagonism playing a prominent role in counteracting excitation which may be a common feature in epilepsy and different psychiatric conditions as mood and anxiety disorder.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, LMU University Hospital, Munich, Germany.
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247
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Abstract
This paper gives a critical review of recommendations concerning the drug treatment of acute bipolar depression. The suggestions of different guidelines and consensus papers, especially in US-American and Canadian psychiatry, have a strong tendency against antidepressants in bipolar depression; they prefer mono-therapy with mood stabilizers and, in the case of co-medication with mood stabilizers and antidepressants in severe depression, to withdraw the antidepressant as early as possible. The intention of this restrictive use is to avoid the risk of mania and the risk of rapid cycling induced by antidepressants. However, apparently the risk of suicidal acts, which is as prominent in bipolar depression as in unipolar depression, has been totally neglected. Furthermore, the fact that none of the mood stabilizers have proven their antidepressive efficacy leads not only to the risk of depression-related suicidal behavior but also to the risk of chronicity of depressive symptoms due to undertreatment. Altogether the view expressed in some guidelines and consensus papers appears not well balanced. Furthermore, the fact that apparently the selective serotonin re-uptake inhibitors and possibly some other modern antidepressants have only a low risk of inducing a switch to mania should stimulate a rewriting of the guidelines on drug treatment in acute bipolar depression in a less restrictive way concerning the use of antidepressants.
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Affiliation(s)
- H J Möller
- Psychiatrische Klinik der Ludwig-Maximilian-Universität, Munich, Germany
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248
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249
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Abstract
BACKGROUND Because a GABAergic hypofunction has been implied in the pathophysiology of mania, we have tested the antimanic properties of the GABA transporter 1 inhibitor tiagabine. METHOD An open trial was conducted in 8 acutely manic inpatients with DSM-IV bipolar I disorder, 2 of them with tiagabine monotherapy and 6 with tiagabine as an add-on to previously insufficient mood-stabilizing medication. The study duration was 14 days. Changes in psychopathology were assessed by the Bech-Rafaelsen Mania Rating Scale. RESULTS None of the patients showed clear-cut relief from manic symptoms during the 2-week observation period. In 2 patients, we saw pronounced side effects (nausea and vomiting in one and a generalized tonic-clonic seizure in the other). CONCLUSION The results from this open trial suggest that tiagabine seems to have no pronounced antimanic efficacy compared with standard treatments such as valproate, lithium, or neuroleptics. It also appears that rapid dosage increases for antimanic treatment can cause potentially severe side effects.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, University of Munich, Germany.
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250
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Grunze H, Erfurth A, Walden J. Trimipramine fails to exert antimanic efficacy: a case of the discrepancy between in vitro rationale and clinical efficacy. Clin Neuropharmacol 1999; 22:298-300. [PMID: 10516883 DOI: pmid/10516883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Standard mood stabilizers, such as lithium and haloperidol, and anticonvulsants show effectiveness in a maximum of 60%-70% of acutely manic patients. Obviously, there is a clinical need to evaluate other treatment options. Current pathophysiologic concepts suggest that substances with an ameliorating effect on dopaminergic hyperfunction, serotonergic hypofunction, or GABAergic hypofunction might be useful, as may be substances with calcium-antagonistic effects. In vitro, the antidepressant trimipramine exerts dopamine- and calcium-antagonistic properties. Therefore, we conducted an open trial to screen it for antimanic action. We found no clinical benefit in four acutely manic patients receiving up to 400 mg/d of trimipramine. It is concluded that, at least in the case of trimipramine, the pharmacologic profile is not helpful in predicting potential effectiveness in mania.
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Affiliation(s)
- H Grunze
- Department of Psychiatry, LMU München, Germany
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