Treatment of mania, mixed state, and rapid cycling

OBJECTIVES

To summarize the quality of evidence for the efficacy of different biological treatments in mania, mixed state, and rapid cycling and to propose guidelines for treatment of these conditions.

METHOD

Articles published on treatment of acute mania, mixed states, and rapid cycling were reviewed and rated for quality of evidence using Periodic Health Examination guidelines.

RESULTS

Lithium and divalproex sodium are effective in classical pure mania, whereas divalproex sodium and carbamazepine are likely more effective in mixed states. Divalproex sodium is likely more efficacious than carbamazepine and lithium when the mania is part of a rapid-cycling course. Typical neuroleptics are efficacious in acute mania, particularly in the presence of marked psychotic symptoms. Atypical neuroleptics can be useful in refractory mania. Some benzodiazepines do have antimanic effects, but they are increasingly being shown to have usefulness as adjuncts to mood stabilizers or neuroleptics rather than as primary antimanic agents. Electroconvulsive therapy (ECT) is an efficacious and broad-spectrum treatment.

CONCLUSIONS

Mania can present with or without mood-congruent or mood-incongruent psychotic features and as part of a rapid-cycling or nonrapid-cycling course. Mixed state is a common presentation in an acutely manic patient. The accurate assessment of these issues can serve as a guide in determining treatment options and choices.

Continuation and prophylactic treatment of bipolar disorder

OBJECTIVES

To summarize the evidence for efficacy from published literature of biological treatments in the continuation and maintenance phases of bipolar disorder, as well as the recommendations about different treatment options made by the working group within the Bipolar Sub-Committee of the Canadian Network for Mood and Anxiety Treatments (CANMAT).

METHODS

A review of relevant published literature and proceedings of international conferences was conducted. The quality of evidence was assessed and classified according to the Periodic Health Examination criteria. Treatment recommendations of the working group were based on quality of evidence, a consensus of expert views, and the opinions of psychiatrists and family physicians from across Canada.

RESULTS

There is overwhelming evidence for the efficacy of lithium in the prophylaxis of bipolar disorder. The evidence for carbamazepine is less robust. There are no published double-blind studies with adequate numbers of subjects treated with divalproex sodium.

CONCLUSIONS

During and at the end of the continuation phase it is recommended that mood stabilizers should remain the mainstay of therapy and that other treatments should be gradually discontinued or maintained only if there is valid reason to do so. Efficacious maintenance treatment can reduce morbidity and mortality significantly and improve patients' quality of life.

The foundations of effective management of bipolar disorder

OBJECTIVES

To understand the epidemiology and course of bipolar disorder; to outline the importance of accurate and reliable diagnosis of bipolar disorder both on a cross-sectional and longitudinal basis; and to emphasize the value of a collaborative therapeutic relationship, psychoeducation, and psychotherapy.

METHODS

A brief review of relevant literature to deal with the issues of diagnosis and laying the foundations for effective treatment.

RESULTS

Bipolar disorder may well be a heterogeneous group of conditions with varying forms of biphasic mood dysregulation and a changing course across a lifetime. A collaborative therapeutic relationship, psychoeducation, and psychotherapy can be the basis for effective management.

CONCLUSIONS

As the concept of bipolar disorder has broadened, the condition is being identified with increasing frequency in many clinical settings. It is a relapsing and recurring condition. It is now recognized that in addition to rational pharmacotherapy, there is a need to encourage a high level of treatment adherence while providing a holistic package of interventions.

Bipolar depression: treatment options

OBJECTIVE

To review studies on treatments for bipolar depression and make recommendations for practising clinicians treating patients with bipolar depression.

METHOD

Studies that examined various treatments for bipolar depression were evaluated and rated for evidence of efficacy using Periodic Health Examination criteria. The rating for classification of recommendation for an intervention was made taking both the efficacy and the side effects into consideration.

RESULTS

Mood stabilizers, cyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and electroconvulsive therapy (ECT) are all effective in treating bipolar depression. Almost all antidepressant treatments with the exception of mood stabilizers have been reported to induce a manic-hypomanic switch and rapid cycling.

CONCLUSIONS

Mood stabilizers, lithium in particular, are recommended as the first-line treatment. Addition of a second mood stabilizer or a cyclic antidepressant would be an appropriate next step. Newer agents such as lamotrigine offer considerable promise in treating bipolar depressed patients.

Reversed neurovegetative symptoms of depression: a community study of Ontario

OBJECTIVE

Most research on depression with reversed neurovegetative features (hypersomnia, hyperphagia, and weight gain) has been based on site-specific clinic-based samples. The goal of this study was to delineate the epidemiology of reversed symptoms in a large community sample and to use other symptom patterns for comparison.

METHOD

Interviewers assessed 8,116 subjects across Ontario, aged 15-64 years, by using the World Health Organization Composite International Diagnostic Interview. Individuals who met the DSM-III-R criteria for major depression, current or lifetime, were classified into four groups on the basis of lifetime neurovegetative symptoms: episodes of typical symptoms only, episodes of reversed symptoms only, neither type, or both types (fluctuating-symptom group). The groups were compared on demographic characteristics, comorbidity, disability, and health care utilization.

RESULTS

Of the 653 individuals with lifetime major depression, 11.3% had episodes of reversed symptoms only, and another 5.8% were classified as fluctuating. Most of the differences among the four groups were due to the unique characteristics of the groups with neither type of episode or a fluctuating pattern; individuals who had experienced only reversed symptoms were remarkably similar to those who had had only typical symptoms. The fluctuating-symptom group had high rates of comorbidity, substance abuse, and health care utilization.

CONCLUSIONS

Several popular beliefs about depression with reversed features did not hold true for this community sample. Identifying individuals who fluctuate between reversed and typical episodes may be important in studies of major depression, in particular when reversed neurovegetative symptoms are a consideration.

Mood disorders: rural/urban differences in prevalence, health care utilization, and disability in Ontario

This study examines whether rural Ontario differs from urban Ontario in mood disorder prevalence, health service use and concomitant disability. An epidemiologic community survey of 9953 individuals was conducted, with rural/urban status defined by population-density-related criteria. Overall, Ontario prevalence rates for depression, manic episode, and dysthymia were similar to previous studies, but rural rates were unexpectedly no different from urban ones. Nearly half of mood disorder subjects used no services, and one-third reported significant disability. Rural individuals with mood disorders were similar to their urban counterparts in service use and disability.