A different depression: clinical distinctions between bipolar and unipolar depression

Delayed diagnosis or misdiagnosis can prolong the suffering of patients with bipolar disorder. Accurate early diagnosis is sometimes difficult, however, particularly because patients often present in the depressive phase, which can easily be mistaken for unipolar depression. Unfortunately, therapy appropriate for unipolar depression can increase the risk of manic switch or cycle acceleration in bipolar disorder, especially in those with a family history of bipolarity and suicide, although some antidepressants may be useful in some bipolar patients. In addition, most currently available mood stabilizers, though effective in managing mania, do not effectively resolve depression. In contrast, lamotrigine has shown activity in bipolar depression and has a very low risk of manic switch. Bipolar depression, compared with unipolar depression, is more likely to be associated with hypersomnia, motor retardation, mood lability, early onset, and a family history of bipolar disorder. Awareness of these distinctions can greatly improve diagnosis of bipolar disorder and provide an opportunity for effective therapeutic intervention.

Making optimal use of combination pharmacotherapy in bipolar disorder

Because patients with bipolar disorder often do not respond sufficiently to treatment with 1 mood stabilizer, psychiatrists frequently employ combination therapy and add antipsychotics, antiepileptics, or antidepressants to mood stabilizers. Combination therapy can be more effective than monotherapy in controlling breakthrough or treatment-resistant episodes. For example, atypical antipsychotics have been shown to be effective adjunctive treatments for mania and for patients with psychotic symptoms during a depressive episode, while the combination of a mood stabilizer and lamotrigine or an anti-depressant has been found to control bipolar depression. The American Psychiatric Association guideline for the treatment of bipolar disorder recommends optimizing individual medications before switching to combination therapy. Selecting a combination treatment regimen with an acceptable side effect profile is critically important because patients may discontinue therapy they cannot tolerate. Agents should be added carefully, with continued monitoring of adverse effects. Physicians should give patients only as much medication as needed.

Atypical antipsychotics in bipolar depression: potential mechanisms of action

"Conventional" antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs), bupropion, or serotonin-norepinephrine reuptake inhibitors, are not recommended as monotherapy for bipolar depression. Although they are likely to provide effective symptom relief in combination with mood stabilizers, the risk of precipitating a switch to mania often complicates their use even as combination therapy. Recently, 2 psychotropic medications approved for treating acute mania, olanzapine and quetiapine, have also been shown to possess antidepressant activity without destabilizing mood and, as such, are potential mood stabilizers. This article aims to review the mechanism of action of conventional antidepressants and newer agents that are effective in the treatment of bipolar depression. A number of mechanisms have been postulated to play a role in the effective treatment of bipolar depression, including targets as diverse as serotonin (5-HT), norepinephrine, dopamine, gamma-aminobutyric acid (GABA), glutamate, and various second messenger signaling pathways. A review of the data reveals an important point of commonality among the antidepressant treatments, olanzapine, and quetiapine. Antidepressant treatments, such as norepinephrine reuptake inhibitors, SSRIs, and electroconvulsive therapy, induce a reduction of 5-HT(2A) receptors. Both olanzapine and quetiapine not only are antagonists at this receptor but also induce downregulation of 5-HT(2A) receptors. It is possible that the antidepressant efficacy of these agents is mediated by this receptor, while the additional benefit of olanzapine and quetiapine over unimodal antidepressant treatments, in terms of stabilizing mood, may be provided by their concomitant dopamine D(2) antagonism. Further studies should be conducted to examine these hypotheses.

Serotonin gene polymorphisms and bipolar I disorder: focus on the serotonin transporter

The pathogenesis of bipolar disorder may involve, at least in part, aberrations in serotonergic neurotransmission. Hence, serotonergic genes are attractive targets for association studies of bipolar disorder. We have reviewed the literature in this field. It is difficult to synthesize results as only one polymorphism per gene was typically investigated in relatively small samples. Nevertheless, suggestive associations are available for the 5HT2A receptor and the serotonin transporter genes. With the availability of extensive polymorphism data and high throughput genotyping techniques, comprehensive evaluation of these genes using adequately powered samples is warranted. We also report on our investigations of the serotonin transporter, SLC6A4 (17q11.1-q12). An insertion/deletion polymorphism (5HTTLPR) in the promoter region of this gene has been investigated intensively. However, the results have been inconsistent. We reasoned that other polymorphism/s may contribute to the associations and the inconsistencies may be due to variations in linkage disequilibrium (LD) patterns between samples. Therefore, we conducted LD analyses, as well as association and linkage using 12 polymorphisms, including 5HTTLPR. We evaluated two samples. The first sample consisted of 135 US Caucasian nuclear families having a proband with bipolar I disorder (BDI, DSM IV criteria) and available parents. For case-control analyses, the patients from these families were compared with cord blood samples from local Caucasian live births (n = 182). Our second, independent sample was recruited through the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD, 545 cases, 548 controls). No significant associations were detected at the individual polymorphism or haplotype level using the case-control or family-based analyses. Our analyses do not support association between SLC6A4 and BDI families. Further studies using sub-groups of BDI are worthwhile.

A randomized, double-blind, placebo-controlled efficacy and safety study of quetiapine or lithium as monotherapy for mania in bipolar disorder

OBJECTIVE

To evaluate the efficacy and tolerability of quetiapine monotherapy versus placebo for the treatment of mania associated with bipolar disorder.

METHOD

In an international, multicenter, double-blind, parallel-group, 12-week study, patients with a DSM-IV diagnosis of bipolar I disorder (manic episode) were randomly assigned to treatment with quetiapine (flexibly dosed up to 800 mg/day), placebo, or lithium. The primary efficacy measure was change from baseline in Young Mania Rating Scale (YMRS) score at day 21. Data were gathered from April 2001 to May 2002.

RESULTS

More patients in the quetiapine (72/107) and lithium (67/98) groups completed the study compared with the placebo group (35/97). Improvement (reduction) in YMRS score was significantly greater for quetiapine than placebo at day 7 (-8.03 vs. -4.89; p < .01), and the difference between groups continued to increase over time to day 21 (-14.6 vs. -6.7; p < .001) and to endpoint at day 84 (-20.3 vs. -9.0; p < .001). Significantly more quetiapine patients compared with placebo patients fulfilled YMRS response criteria at day 21 (53.3% vs. 27.4%; p < .001) and at day 84 (72.0% vs. 41.1%; p < .001). Quetiapine was also superior to placebo in efficacy at day 21 and day 84 by all secondary measures. Lithium-treated patients improved significantly compared with placebo patients and similarly to quetiapine-treated patients on the primary efficacy measure. The most common adverse events for quetiapine were dry mouth, somnolence, and weight gain, while lithium was associated with tremor and insomnia. The quetiapine and placebo groups had similar, low levels of extrapyramidal symptom-related adverse events.

CONCLUSIONS

Quetiapine demonstrated superior efficacy to placebo in patients with bipolar mania and was well tolerated.

Relationship between serum valproate and lithium levels and efficacy and tolerability in bipolar maintenance therapy

Background. In spite of widespread recognition of the importance of maintenance treatment for bipolar disorder, there are relatively few available well-designed clinical trials that have provided rigorous evidence for the efficacy of specific agents. One approach used effectively in analyses of lithium studies has been the stratification of efficacy and tolerability results based on serum drug concentrations. Therefore, we conducted a similar analysis of the efficacy of divalproex or lithium, based on serum concentrations in the maintenance treatment of bipolar I disorder in a recent 12-month placebo-controlled trial. Methods. This was a post-hoc analysis of results obtained in a 12-month, double-blind, placebo-controlled trial of divalproex and lithium involving 372 patients (intent-to-treat). The patient set was stratified into four therapeutic drug concentration ranges (Non-therapeutic, Low Therapeutic, Medium Therapeutic, and High Therapeutic) for both divalproex and lithium. Efficacy measures were Kaplan-Meier survival analyses of time to discontinuation for any reason, time to discontinuation for a protocol-defined manic episode, and time to discontinuation for a manic or depressive episode. Results. Significant differences between divalproex at the Medium Therapeutic range (75-99.9 µg/ml) and placebo were demonstrated in Kaplan-Meier survival results for discontinuation for any reason (median survival time: divalproex, 8 months; placebo, 4 months; P<0.05) and for discontinuation for a manic or depressive episode (median survival time: divalproex, 8 months; placebo, 3 months, P=0.003). At 12 months, the proportion of divalproex-treated patients (Medium Therapeutic range) who did not discontinue for a protocol-defined manic episode (85%) was higher than the proportion of lithium (Medium Therapeutic range; 70%) or placebo-treated (83%) patients. Conclusions. Divalproex at the Medium Therapeutic range provided significantly better bipolar maintenance treatment response than placebo in survival analyses, suggesting a possible serum concentration target range for clinicians in providing optimal treatment response. The value of this analytic approach, used for the first time here for divalproex, is discussed, along with a call for further research into optimal therapeutic drug levels.

A multivantaged behavioural method for measuring onset and sequence of the clinical actions of antidepressants

An aim in development of new antidepressants (ADs) now includes increasing speed of action. New drugs are tested primarily in outpatients who are less severely depressed than the patients treated in earlier trials of the tricyclic drugs. To determine early efficacy requires measures sensitive to initial changes in components of the illness as well as in the severity of the entire syndrome of depression. This paper describes the development of a brief 'multivantaged' (MV) method for assessing the major behavioural and affective components of depression. The revised Brief MV was significantly reduced from the original to make it more feasible to apply in outpatient studies. In this study we determined the Brief MV's (1) reliability and comparability to the original and (2) its ability to detect the onset of specific behavioural effects in outpatients treated with paroxetine for 6 wk. The latter is compared to the ability of the Hamilton Depression Scale (HAMD) to detect changes in global severity. The constructs derived from the Brief MV were found to be highly similar to those of the original version and as reliable. In depressed patients who responded to paroxetine, the HAMD and MV detected onset of improvement after 7 d of treatment. The Brief MV revealed that the improvement in global severity was due to the drug's action at this time on behaviours such as anxiety and distressed expression, as well as on a severity dimension of anxiety-agitation-somatization. Thus, the Brief MV, in uncovering underlying behavioural actions, represents an important addition to the current unidimensional HAMD approach in drug research.

Relationship of acute mania symptomatology to maintenance treatment response

Most treatment of bipolar disorders addresses maintenance objectives. In the past 4 years, several large, blinded, randomized, placebo-controlled maintenance studies involving more than 3000 patients with bipolar I illness have been published, with analyses of background, symptomatic, and acute treatment factors contributing to maintenance effectiveness. This article summarizes these findings. Generally, indices of greater severity predict lower response rates to most monotherapy treatments. Some findings have been unexpected. Mixed mania did not predict different maintenance response to divalproex or lithium but predicted more side effects with either drug, and reduced efficacy of olanzapine or lamotrigine.

13th National Congress of the South African Society of Psychiatrists, 20-23 September 2004

List of abstacts and authors:1. Integrating the art and science of psychiatryEugene Allers2. Chronic pain as a predictor of outcome in an inpatient Psychiatric populationEugene Allers and Gerhard Grundling3. Recent advances in social phobiaChrister Allgulander4. Clinical management of patients with anxiety disordersChrister Allgulander5. Do elephants suffer from Schizophrenia? (Or do the Schizophrenias represent a disorder of self consciousness?) A Southern African perspectiveSean Exner Baumann6. Long term maintenance treatment of Bipolar Disorder: Preventing relapseCharles L. Bowden7. Predictors of response to treatments for Bipolar DisorderCharles L. Bowden8. Aids/HIV knowledge and high risk behaviour: A Geo-graphical comparison in a schizophrenia populationP Buckley, S van Vuuren, L Koen, J E Muller, C Seller, H Lategan, D J H Niehaus9. Does Marijuana make you go mad?David J Castle10. Understanding and management of Treatment Resistant SchizophreniaDavid J Castle11. Workshop on research and publishingDavid J Castle12. From victim to victor: Without a self-help bookBeatrix Jacqueline Coetzee13. The evaluation of the Gender Dysphoric patientFranco Colin14. Dissociation: A South African modelA M Dikobe, C K Mataboge, L M Motlana, B F Sokudela, C Kruger15. Designated smoking rooms...and other "Secret sins" of psychiatry: Tobacco cessation approaches in the severely mentally illCharl Els16. Dual diagnosis: Implications for treatment and prognosisCharl Els17. Body weight, glucose metabolism and the new generation antipsychoticsRobin Emsley18. Neurological abnormalities in first episode Schizophrenia: Temporal stability and clinical and outcome correlatesRobin Emsley, H Jadri Turner, Piet P Oosthuizen, Jonathan Carr19. Mythology of depressive illnesses among AfricansSenathi Fisha20. Substance use and High school dropoutAlan J. Flisher, Lorraine Townsend, Perpetual Chikobvu, Carl Lombard, Gary King21. Psychosis and Psychotic disordersA E Gangat 22. Vulnerability of individuals in a family system to develop a psychiatric disorderGerhard Grundling and Eugene Allers23. What does it Uberhaupt mean to "Integrate"?Jürgen Harms24. Research issues in South African child and adolescent psychiatryS M Hawkridge25. New religious movements and psychiatry: The Good NewsV H Hitzeroth26. The pregnant heroin addict: Integrating theory and practice in the development and provision of a service for this client groupV H Hitzeroth, L Kramer27. Autism spectrum disorderErick Hollander28. Recent advances and management in treatment resistanceEric Hollander29. Bipolar mixed statesM. Leigh Janet30. Profile of acute psychiatric inpatients tested for HIV - Helen Jospeh Hospital, JohannesburgA B R Janse van Rensburg31. ADHD - Using the art of film-making as an education mediumShabeer Ahmed Jeeva32. Treatment of adult ADHD co-morbiditiesShabeer Ahmed Jeeva33. Needs and services at ward one, Valkenberg HospitalDr J. A. Joska, Prof. A.J. Flisher34. Unanswered questions in the adequate treatment of depressionModerator: Dr Andre F JoubertExpert: Prof. Tony Hale35. Unanswered questions in treatment resistant depressionModerator: Dr Andre F JoubertExpert: Prof. Sidney Kennedy36. Are mentally ill people dangerous?Sen Z Kaliski37. The child custody circusSean Z. Kaliski38. The appropriatenes of certification of patients to psychiatric hospitalsV. N. Khanyile39. HIV/Aids Psychosocial responses and ethical dilemmasFred Kigozi40. Sex and PsychiatryB Levinson41. Violence and abuse in psychiatric in-patient institutions: A South African perspectiveMarilyn Lucas, John Weinkoove, Dean Stevenson42. Public health sector expenditure for mental health - A baseline study for South AfricaE N Madela-Mntla43. HIV in South Africa: Depression and CD4 countM Y H Moosa, F Y Jeenah44. Clinical strategies in dealing with treatment resistant schizophreniaPiet Oosthuizen, Dana Niehaus, Liezl Koen45. Buprenorphine/Naloxone maintenance in office practice: 18 months and 170 patients after the American releaseTed Parran Jr, Chris Adelman46. Integration of Pharmacotherapy for Opioid dependence into general psychiatric practice: Naltrexone, Methadone and Buprenorphine/ NaloxoneTed Parran47. Our African understanding of individulalism and communitarianismWillie Pienaar48. Healthy ageing and the prevention of DementiaFelix Potocnik, Susan van Rensburg, Christianne Bouwens49. Indigenous plants and methods used by traditional African healers for treatinf psychiatric patients in the Soutpansberg Area (Research was done in 1998)Ramovha Muvhango Rachel50. Symptom pattern & associated psychiatric disorders in subjects with possible & confirmed 22Q11 deletional syndromeJ.L. Roos, H.W. Pretorius, M. Karayiorgou51. Duration of antidepressant treatment: How long is long enough? How long is too longSteven P Roose52. A comparison study of early non-psychotic deviant behaviour in the first ten years of life, in Afrikaner patients with Schizophrenia, Schizo-affective disorder and Bipolar disorderMartin Scholtz, Melissa Janse van Rensburg, J. Louw Roos53. Treatment, treatment issues, and prevention of PTSD in women: An updateSoraya Seedat54. Fron neural networks to clinical practiceM Spitzer55. Opening keynote presentation: The art and science of PsychiatryM Spitzer56. The future of Pharmacotherapy for anxiety disordersDan J. Stein57. Neuropsychological deficits pre and post Electro Convulsive Therapy (ECT) thrice a week: A report of four casesUgash Subramaney, Yusuf Moosa58. Prevalence of and risk factors for Tradive Dyskinesia in a Xhosa population in the Eastern CapeDave Singler, Betty D. Patterson, Sandi Willows59. Eating disorders: Addictive disorders?Christopher Paul Szabo60. Ethical challenges and dilemmas of research in third world countriesGodfrey B. Tangwa61. The interface between Neurology and Psychiatry with specific focus on Somatoform dissociative disordersMichael Trimble62. Prevalence and correlates of depression and anxiety in doctors and teachersH Van der Bijl, P Oosthuizen63. Ingrid Jonker: A psychological analysisL. M. van der Merwe64. The strange world we live in, and the nature of the human subjectVasi van Deventer65. Art in psychiatry: Appendix or brain stem?C W van Staden66. Medical students on what "Soft skills" are about before and after curriculum reformC W van Staden, P M Joubert, A-M Bergh, G E Pickworth, W J Schurink, R R du Preez, J L Roos, C Kruger, S V Grey, B G Lindeque67. Attention deficit hyperactivity disorder (ADHD) - Medical management. Methylphenidate (Ritalin) or Atomoxetine (Strattera)Andre Venter68. A comprehensive guide to the treatment of adults with ADHDW J C Verbeeck69. Treatment of Insomnia: Stasis of the Art?G C Verster70. Are prisoners vulnerable research participants?Merryll Vorster71. Psychiatric disorders in the gymMerryl Vorster72. Ciprales: Effects on anxiety symptoms in Major Depressive DisorderBruce Lydiard

Phenomenology of rapid-cycling bipolar disorder: data from the first 500 participants in the Systematic Treatment Enhancement Program

OBJECTIVE

This study compared demographic and phenomenological variables between bipolar patients with and without rapid cycling as a function of bipolar I versus bipolar II status.

METHOD

The authors examined demographic, historical, and symptomatic features of patients with and without rapid cycling in a cross-sectional study of the first 500 patients with bipolar I or bipolar II disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder, a multicenter project funded by the National Institute of Mental Health designed to evaluate the longitudinal outcome of patients with bipolar disorder.

RESULTS

Rapid-cycling bipolar disorder occurred in 20% of the study group. Rapid-cycling patients were more likely to be women, although the effect was somewhat more pronounced among bipolar I patients than bipolar II patients. In addition, rapid-cycling bipolar patients experienced onset of their illness at a younger age, were more often depressed at study entry, and had poorer global functioning in the year before study entry than nonrapid-cycling patients. Rapid-cycling patients also experienced a significantly greater number of depressive and hypomanic/manic episodes in the prior year. A lifetime history of psychosis did not distinguish between rapid and nonrapid-cycling patients, although bipolar I patients were more likely to have experienced psychosis than bipolar II patients.

CONCLUSIONS

Patients with rapid-cycling bipolar disorder demonstrate a greater severity of illness than nonrapid-cycling patients on a number of clinical measures. This study highlights the need to refine treatments for rapid cycling to reduce the overall morbidity and mortality of patients with this illness course modifier.

Risperidone in combination with mood stabilizers: a 10-week continuation phase study in bipolar I disorder

BACKGROUND

Combination therapy (risperidone and a mood stabilizer) for patients with a history of bipolar disorder (DSM-IV) and hospitalized for treatment of a manic episode was assessed in a 13-week study.

METHOD

Subjects received flexible doses of a mood stabilizer (lithium or divalproex) plus placebo, risperidone, or haloperidol in a 3-week double-blind study. They could then enter a 10-week open-label study during which they received risperidone combined with a mood stabilizer.

RESULTS

Of the 156 patients enrolled in the 3-week study, 85 entered the 10-week open-label extension, of whom 48 completed 10 weeks of treatment. The mean +/- SE doses of risperidone were 3.8 +/- 0.3 mg/day during the 3-week study and 3.1 +/- 0.2 mg/day during the 10-week study. At double-blind endpoint, mean reductions in Young Mania Rating Scale (YMRS) scores were significantly greater in patients receiving risperidone plus mood stabilizer than in those receiving placebo plus mood stabilizer (-14.3 vs. -8.2, p <.001). Further significant (p <.001) reductions were seen during the 10 weeks of treatment with risperidone plus mood stabilizer. Symptom remission (YMRS score <or= 12) was seen in 38 patients (79%) at the end of the 10-week study. Scores on the Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, and Clinical Global Impressions scale improved significantly (p <.05) during both the 3-week and 10-week studies. Treatment was well tolerated, and modest weight gain was observed during the 13-week study period.

CONCLUSION

The combination of risperidone and a mood stabilizer was efficacious and well tolerated in the continuation treatment of patients initially hospitalized for the management of an acute manic episode.

Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD)

BACKGROUND

Early onset of mood symptoms in bipolar disorder has been associated with poor outcome in many studies; however, the factors that might contribute to poor outcome have not been adequately investigated.

METHODS

The first consecutive 1000 adult bipolar patients enrolled in the National Institute of Mental Health's Systematic Treatment Enhancement Program for Bipolar Disorder were assessed at study entry to determine details of their age of onset of mood symptoms. Clinical course, comorbidity, and functional status and quality of life were compared for groups with very early (age < 13 years), early (age 13-18 years), and adult (age > 18 years) onset of mood symptoms.

RESULTS

Of 983 subjects in whom age of onset could be determined, 272 (27.7%) experienced very early onset, and 370 (37.6%) experienced early onset. Earlier onset was associated with greater rates of comorbid anxiety disorders and substance abuse, more recurrences, shorter periods of euthymia, greater likelihood of suicide attempts and violence, and greater likelihood of being in a mood episode at study entry.

CONCLUSIONS

Very early or early onset of bipolar disorder might herald a more severe disease course in terms of chronicity and comorbidity. Whether early intervention might modify this risk merits further investigation.

Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabiliser v. mood stabiliser alone

BACKGROUND

Few controlled studies have examined the use of atypical antipsychotic drugs for prevention of relapse in patients with bipolar I disorder. Aims To evaluate whether olanzapine plus either lithium or valproate reduces the rate of relapse, compared with lithium or valproate alone.

METHOD

Patients achieving syndromic remission after 6 weeks'treatment with olanzapine plus either lithium (0.6-1.2 mmol/l) or valproate (50-125 microg/ml) received lithium or valproate plus either olanzapine 5-20 mg/day (combination therapy) or placebo (monotherapy), and were followed in a double-masked trial for 18 months.

RESULTS

The treatment difference in time to relapse into either mania or depression was not significant for syndromic relapse (median time to relapse: combination therapy 94 days, monotherapy 40.5 days; P=0.742), but was significant for symptomatic relapse (combination therapy 163 days, monotherapy 42 days; P=0.023).

CONCLUSIONS

Patients taking olanzapine added to lithium or valproate experienced sustained symptomatic remission, but not syndromic remission, for longer than those receiving lithium or valproate monotherapy.

Lamotrigine treatment of bipolar disorder: data from the first 500 patients in STEP-BD

OBJECTIVE

To describe the frequency and correlates of lamotrigine therapy among the first 500 patients enrolled into the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study.

METHOD

Systematic recording of psychiatric history and medication data at intake into the STEP-BD project.

RESULTS

Of the participants with bipolar disorder type I or II (n = 483), 77 (15.4%) were currently taking lamotrigine (mean dose: 258.12 mg/day) and 52 (10.4%) reported prior lamotrigine use. The groups were comparable with regard to duration of illness and mood state at study entry. Compared with participants who had never taken lamotrigine, those currently treated with lamotrigine were significantly more likely to have a prior history of rapid cycling (62.5% vs. 43.1%; p < 0.01) and an antidepressant-induced switch to (hypo)mania (49.3% vs. 33.3%; p < 0.01). In contrast, only 16.9% of lamotrigine-treated participants were taking an antidepressant at study intake, as compared with 29.1% of participants with no history of lamotrigine therapy (p < 0.03).

CONCLUSIONS

While noting the limitations of a cross-sectional assessment, these data suggest that lamotrigine therapy was commonly used in these academic centers for patients with bipolar disorder several years before it was recommended in the American Psychiatric Association practice guidelines, particularly in patients with a history of rapid cycling or antidepressant-induced mania.

A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder

BACKGROUND

Two clinical trials, prospectively designed for combined analysis, compared placebo, lithium, and lamotrigine for treatment of bipolar I disorder in recently depressed or manic patients.

METHOD

1315 bipolar I patients (DSM-IV) enrolled in the initial open-label phase, and 638 were stabilized and randomly assigned to 18 months of double-blind monotherapy with lamotrigine (N = 280; 50-400 mg/day fixed dose or 100-400 mg/day flexible dose), lithium (N = 167; serum level of 0.8-1.1 mEq/L), or placebo (N = 191). The primary endpoint was time from randomization to intervention for a mood episode. Data were gathered from August 1997 to August 2001.

RESULTS

Lamotrigine and lithium were superior to placebo for time to intervention for any mood episode (median survival: placebo, 86 days [95% CI = 58 to 121]; lithium, 184 days [95% CI = 119 to not calculable]; lamotrigine, 197 days [95% CI = 144 to 388]). Lamotrigine was superior to placebo for time to intervention for depression (median survival: placebo, 270 days [95% CI = 138 to not calculable]; lithium, median not calculable; lamotrigine, median not calculable). Lithium and lamotrigine were superior to placebo for time to intervention for mania (median survival not calculable for any group). Results of additional analyses adjusted for index mood were similar; however, only lithium was superior to placebo for intervention for mania. There was no evidence that either active treatment caused affective switch. Adverse event analysis indicated more diarrhea (19% vs. 7%, p <.05) and tremor (15% vs. 4%, p <.05) in lithium-treated patients compared with lamotrigine-treated patients.

CONCLUSIONS

Lamotrigine and lithium stabilized mood by delaying the time to treatment for a mood episode. Lamotrigine was effective against depression and mania, with more robust activity against depression. Lithium was effective against mania.

Onset and early behavioral effects of pharmacologically different antidepressants and placebo in depression

This study was aimed at resolving the time course of clinical action of antidepressants (ADs) and the type of early behavioral changes that precede recovery in treatment-responsive depressed patients. The first goal was to identify, during the first 2 weeks of treatment, the onset of clinical actions of the selective serotonin reuptake inhibitor (SSRI), paroxetine, and the selective noradrenergic reuptake inhibitor, desipramine (DMI). The second aim was to test the hypothesis that the two pharmacologic subtypes would induce different early behavioral changes in treatment-responsive patients. The design was a randomized, parallel group, placebo-controlled, double-blind study for 6 weeks of treatment following a 1-week washout period. The study utilized measures of the major behavioral components of the depressive disorder as well as overall severity. The results indicated that the onset of clinical actions of DMI ranged from 3 to 13 days, averaged 13 days for paroxetine, and was 16-42 days for placebo. Furthermore, as hypothesized, the different types of ADs initially impacted different behavioral aspects of the disorder. After 1 week of treatment, DMI produced greater reductions in motor retardation and depressed mood than did paroxetine and placebo, and this difference persisted at the second week of treatment. Early improvement in depressed mood-motor retardation differentiated patients who responded to DMI after 6 weeks of treatment from those that did not. Paroxetine initially reduced anxiety more in responders than in nonresponders, and by the second week, significantly improved depressed mood and distressed expression in responders to a greater extent. Depressed patients who responded to placebo showed no consistent early pattern of behavior improvement. Early drug-specific behavioral changes were highly predictive of ultimate clinical response to the different ADs, results that could eventually be applied directly to clinical practice.

Safety and Tolerability of Lamotrigine for Bipolar Disorder

Tolerability and safety are important considerations in optimising pharmacotherapy for bipolar disorder. This paper reviews the tolerability and safety of lamotrigine, an anticonvulsant recommended in the 2002 American Psychiatric Association guidelines as a first-line treatment for acute depression in bipolar disorder and one of several options for maintenance therapy. This paper reviews the tolerability and safety of lamotrigine using data available from a large programme of eight placebo-controlled clinical trials of lamotrigine enrolling a total of nearly 1800 patients with bipolar disorder. This review is the first to collate all the safety information from these clinical trials, including data from four unpublished studies. The results these trials in which 827 patients with bipolar disorder were given lamotrigine as monotherapy or adjunctive therapy for up to 18 months for a total of 280 patient-years of exposure demonstrated that lamotrigine is well-tolerated with an adverse-event profile generally comparable with that of placebo. The most common adverse event with lamotrigine was headache. Lamotrigine did not appear to destabilise mood and was not associated with sexual adverse effects, weight gain, or withdrawal symptoms. Few patients experienced serious adverse events with lamotrigine, and the incidence of withdrawals because of adverse events was low. Serious rash occurred rarely (0.1% incidence) in the clinical development programme including both controlled and uncontrolled clinical trials. These findings - considered in the context of data showing lamotrigine to be effective for bipolar depression - establish lamotrigine as a well-tolerated addition to the psychotropic armamentarium.

A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently depressed patients with bipolar I disorder

BACKGROUND

The anticonvulsant lamotrigine was previously shown to be effective for bipolar depression. This study assessed the efficacy and tolerability of lamotrigine and lithium compared with placebo for the prevention of mood episodes in bipolar disorder.

METHOD

During an 8- to 16-week open-label phase, lamotrigine (titrated to 200 mg/day) was added to current therapy for currently or recently depressed DSM-IV-defined bipolar I outpatients (N = 966) and concomitant drugs were gradually withdrawn. Patients stabilized on open-label treatment (N = 463) were then randomly assigned to lamotrigine (50, 200, or 400 mg/day; N = 221), lithium (0.8-1.1 mEq/L; N = 121), or placebo (N = 121) monotherapy for up to 18 months. The primary outcome measure was time from randomization to intervention (addition of pharmacotherapy) for any mood episode (depressive, manic, hypomanic, or mixed). Data were gathered from September 1997 to August 2001.

RESULTS

Time to intervention for any mood episode was statistically superior (p = .029) for both lamotrigine and lithium compared with placebo-median survival times were 200, 170, and 93 days, respectively. Intervention for depression was more frequent than for mania by a factor of nearly 3:1. Lamotrigine was statistically superior to placebo at prolonging the time to intervention for a depressive episode (p = .047). The proportions of patients who were intervention-free for depression at 1 year were lamotrigine 57%, lithium 46%, and placebo 45%. Lithium was statistically superior to placebo at prolonging the time to intervention for a manic or hypomanic episode (p = .026). The proportions of patients who were intervention-free for mania at 1 year were lamotrigine 77%, lithium 86%, and placebo 72%. Headache was the most frequent adverse event for all 3 treatment groups.

CONCLUSION

Lamotrigine and lithium were superior to placebo for the prevention of mood episodes in bipolar I patients, with lamotrigine predominantly effective against depression and lithium predominantly effective against mania.

Acute and maintenance treatment with mood stabilizers

Treatment of bipolar disorder is complicated by the multiple phases of the illness, dimensional symptomatology that varies considerably across individuals, and a limited spectrum of activity for all mood stabilizers. Randomized, blinded, placebo-controlled studies provide clear guidelines to the overall efficacy of treatments for mania. However, for secondary questions, such as the treatment to employ when lithium or valproate is inadequate as monotherapy, evidence is incomplete, and usually derived from both smaller and less well-designed studies. For mania, the spectrum of efficacy of valproate is broader than for other mood stabilizers. However, many patients obtain inadequate benefit from monotherapy regimens of all mood stabilizers. Recent studies indicate that for patients who develop mania while taking a mood stabilizer, combinations of an antipsychotic and a mood stabilizer yield greater improvement than does continuation of the mood stabilizer alone. Maintenance-treatment studies support the efficacy of lithium, valproate and lamotrigine, although with a different spectrum of benefits and limitations for each. Valproate and lithium provide greater benefits for prevention of manic relapses and control of manic symptomatology than for depression. Several studies indicate actual worsening in depressive aspects of bipolar disorder with lithium treatment. Lamotrigine appears effective in delaying relapse into a new episode, with most benefits limited to delaying time to depression. Lamotrigine has not shown anti-manic activity in placebo-controlled studies. In contrast to traditional antidepressant medications, lamotrigine has not been associated with induction of mania, or of rapid-cycling illness symptomatology. Recent studies reported that carbamazepine was inferior to valproate in acute mania, and inferior to lithium in maintenance treatment. Other putative mood stabilizers have to date yielded negative or inconclusive results in studies in mania. Systematic studies are needed to clarify treatment guidelines for youth with bipolar disorder, and for other special populations, e.g. pregnant women and the elderly.

Maintenance efficacy of divalproex in the prevention of bipolar depression

Breakthrough depression is a common problem in the treatment of bipolar disorder. Only one, recently published, double-blind, placebo-controlled trial has examined the efficacy of divalproex in the prevention of depressive episodes in bipolar patients. This report describes, in further detail, the findings from that trial of the effect of divalproex on multiple dimensions of depressive morbidity in bipolar disorder. A randomized, double-blind, parallel-group, multicenter study was conducted over a 52-week maintenance period. Bipolar I patients, who may have been treated with open-label lithium or divalproex and who met recovery criteria within 3 months of onset of an index manic episode, were randomized to maintenance treatment with divalproex, lithium, or placebo in a 2 : 1 : 1 ratio. Adjunctive paroxetine or sertraline for breakthrough depression was allowed in maintenance phase. Outcome measures were the rate of early discontinuation for depression, time to depressive relapse, proportion of patients with depressive relapse, mean change in Depressive Syndrome Scale score, proportion of patients receiving antidepressants, and time in the study. Among patients taking an antidepressant, a higher percentage of patients on placebo than divalproex discontinued early for depression. Patients who were previously hospitalized for affective episodes or took divalproex in the open period relapsed later on divalproex than on lithium during the maintenance period. Divalproex-treated patients had less worsening of depressive symptoms than lithium-treated patients during maintenance. Indices of severity of prestudy illness course predicted worse outcome in all treatment groups. Divalproex improved several dimensions of depressive morbidity and reduced the probability of depressive relapse in bipolar disorder, particularly in patients who had responded to divalproex when manic, and among patients with a more severe course of illness.

Valproate

OBJECTIVES

This article summarizes the role of valproate as a treatment for bipolar disorder and related conditions.

METHODS

Published studies and reviews were systematically reviewed. Results from randomized, parallel group, double-blind, placebo-controlled studies that included an active comparator are emphasized.

RESULTS

Valproate is an effective treatment for manic patients. Valproate was superior to placebo in one 1-year randomized, parallel group study in rate of recurrence requiring discontinuation, rate of depression requiring discontinuation, total early termination and time to 25% of patients relapsing with mania, and in controlling mild depressive symptoms. On some measures, including time to development of a manic episode, valproate did not differ from placebo. Assessments of maintenance efficacy of valproate and other putative prophylactic treatments for bipolar disorder are problematic, because of the need to analyze multiple indices of efficacy, and practical and ethical issues that limit generalizability of results of placebo-controlled studies. Valproate has some advantages over lithium in treatment of mania for persons with more severe illnesses. Valproate benefits a broader spectrum of bipolar conditions than lithium. Valproate appears at best modestly effective for bipolar depression. Used in combination with several other treatments, additive benefits result, that are greater than with any of the treatments as monotherapy. Side effects are generally mild and manageable, particularly with divalproex. Weight gain and pharmacokinetic interaction with lamotrigine are perhaps the most consistent problems in use. Valproate contributes to neural tube defects if taken during the first trimester of pregnancy, and this risk must be conveyed to women.

CONCLUSIONS

Valproate is an effective and useful treatment for bipolar disorder. Studies clarifying its spectrum of efficacy, its safety and efficacy in combination regimens, and its mechanisms of action are warranted.

A placebo-controlled 18-month trial of lamotrigine and lithium maintenance treatment in recently manic or hypomanic patients with bipolar I disorder

BACKGROUND

Lamotrigine has been shown to be an effective treatment for bipolar depression and rapid cycling in placebo-controlled clinical trials. This double-blind, placebo-controlled study was conducted to assess the efficacy and tolerability of lamotrigine and lithium compared with placebo for the prevention of relapse or recurrence of mood episodes in recently manic or hypomanic patients with bipolar I disorder.

METHODS

After an 8- to 16-week open-label phase during which treatment with lamotrigine was initiated and other psychotropic drug regimens were discontinued, patients were randomized to lamotrigine (100-400 mg daily), lithium (0.8-1.1 mEq/L), or placebo as double-blind maintenance treatment for as long as 18 months.

RESULTS

Of 349 patients who met screening criteria and entered the open-label phase, 175 met stabilization criteria and were randomized to double-blind maintenance treatment (lamotrigine, 59 patients; lithium, 46 patients; and placebo, 70 patients). Both lamotrigine and lithium were superior to placebo at prolonging the time to intervention for any mood episode (lamotrigine vs placebo, P =.02; lithium vs placebo, P =.006). Lamotrigine was superior to placebo at prolonging the time to a depressive episode (P =.02). Lithium was superior to placebo at prolonging the time to a manic, hypomanic, or mixed episode (P =.006). The most common adverse event reported for lamotrigine was headache.

CONCLUSIONS

Both lamotrigine and lithium were superior to placebo for the prevention of relapse or recurrence of mood episodes in patients with bipolar I disorder who had recently experienced a manic or hypomanic episode. The results indicate that lamotrigine is an effective, well-tolerated maintenance treatment for bipolar disorder, particularly for prophylaxis of depression.