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Chakrabarti S, Jolly AJ, Singh P, Yadhav N. Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder. World J Psychiatry 2023; 13:495-510. [PMID: 37701540 PMCID: PMC10494771 DOI: 10.5498/wjp.v13.i8.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023] Open
Abstract
Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
| | - Amal J Jolly
- Department of Psychiatry, Black Country Healthcare NHS Foundation Trust, Dudley DY2 8PS, West Midlands, United Kingdom
| | - Pranshu Singh
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India
| | - Nidhi Yadhav
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
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Valentí M, Pacchiarotti I, Undurraga J, Bonnín CM, Popovic D, Goikolea JM, Torrent C, Hidalgo-Mazzei D, Colom F, Vieta E. Risk factors for rapid cycling in bipolar disorder. Bipolar Disord 2015; 17:549-59. [PMID: 25682854 DOI: 10.1111/bdi.12288] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/23/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the clinical factors associated with the development of rapid cycling, as well as to elucidate the role of antidepressants. METHODS The present study (NCT01503489) is a prospective, naturalistic cohort study conducted in a sample of 289 patients diagnosed with bipolar disorder followed and treated for up to 14 years. The patients were divided into two groups on the basis of the development of a rapid cycling course (n = 48) or no development of such a course (n = 241), and compared regarding sociodemographic, clinical, and outcome variables. RESULTS Among the 289 patients, 48 (16.6%) developed a rapid cycling course during the follow-up. Several differences were found between the two groups, but after performing Cox regression analysis, only atypical depressive symptoms (p = 0.001), age at onset (p = 0.015), and number of suicide attempts (p = 0.030) persisted as significantly associated with the development of a rapid cycling course. CONCLUSIONS The development of rapid cycling during the course of bipolar disorder is associated with a tendency to chronicity, with a poorer outcome, and with atypical depressive symptomatology. Our study also suggests that the development of rapid cycling is associated with a higher use of antidepressants.
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Affiliation(s)
- Marc Valentí
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Juan Undurraga
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain.,Department of Psychiatry, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - C Mar Bonnín
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Dina Popovic
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - José M Goikolea
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Carla Torrent
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Diego Hidalgo-Mazzei
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Francesc Colom
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Bipolar Disorders Program, Clinical Institute of Neurosciences, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
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P2RX7: expression responds to sleep deprivation and associates with rapid cycling in bipolar disorder type 1. PLoS One 2012; 7:e43057. [PMID: 22952630 PMCID: PMC3429455 DOI: 10.1371/journal.pone.0043057] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 07/16/2012] [Indexed: 12/30/2022] Open
Abstract
Context Rapid cycling is a severe form of bipolar disorder with an increased rate of episodes that is particularly treatment-responsive to chronotherapy and stable sleep-wake cycles. We hypothesized that the P2RX7 gene would be affected by sleep deprivation and be implicated in rapid cycling. Objectives To assess whether P2RX7 expression is affected by total sleep deprivation and if variation in P2RX7 is associated with rapid cycling in bipolar patients. Design Gene expression analysis in peripheral blood mononuclear cells (PBMCs) from healthy volunteers and case-case and case-control SNP/haplotype association analyses in patients. Participants Healthy volunteers at the sleep research center, University of California, Irvine Medical Center (UCIMC), USA (n = 8) and Swedish outpatients recruited from specialized psychiatric clinics for bipolar disorder, diagnosed with bipolar disorder type 1 (n = 569; rapid cycling: n = 121) and anonymous blood donor controls (n = 1,044). Results P2RX7 RNA levels were significantly increased during sleep deprivation in PBMCs from healthy volunteers (p = 2.3*10−9). The P2RX7 rs2230912 _A allele was more common (OR = 2.2, p = 0.002) and the ACGTTT haplotype in P2RX7 (rs1718119 to rs1621388) containing the protective rs2230912_G allele (OR = 0.45–0.49, p = 0.003–0.005) was less common, among rapid cycling cases compared to non-rapid cycling bipolar patients and blood donor controls. Conclusions Sleep deprivation increased P2RX7 expression in healthy persons and the putatively low-activity P2RX7 rs2230912 allele A variant was associated with rapid cycling in bipolar disorder. This supports earlier findings of P2RX7 associations to affective disorder and is in agreement with that particularly rapid cycling patients have a more vulnerable diurnal system.
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Dell'Osso B, Buoli M, Riundi R, D'Urso N, Pozzoli S, Bassetti R, Mundo E, Altamura AC. Clinical characteristics and long-term response to mood stabilizers in patients with bipolar disorder and different age at onset. Neuropsychiatr Dis Treat 2009; 5:399-404. [PMID: 19649214 PMCID: PMC2714289 DOI: 10.2147/ndt.s5970] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Bipolar disorder (BD) is a prevalent, comorbid, and impairing condition. Potential predictors of response to pharmacological treatment are object of continuous investigation in patients with BD. The present naturalistic study was aimed to assess clinical features and long-term response to mood stabilizers in a sample of bipolar subjects with different ages at onset. METHODS The study sample included 108 euthymic patients, diagnosed as affected by BD, either type I or II, according to the DSM-IV-TR, who were started on mood stabilizer treatment. Patients were followed-up for 24 months and the occurrence of any mood episode collected. At the end of the follow-up, patients were divided in 3 subgroups according to the age at onset (early-onset </=30 years, middle-onset >30-</=45 years, and late-onset >45 years, respectively) and the long-term response to mood stabilizers was compared between them along with other clinical features. RESULTS The three subgroups showed significant differences in terms of clinical and demographic features and, with respect to long-term response to mood stabilizers, the early-onset subgroup showed a better outcome in terms of reduction of major depressive episodes during the 24-month follow-up compared to the other subgroups (one way ANOVA, F = 3.57, p = 0.032). CONCLUSIONS Even though further controlled studies are needed to clarify the relationship between age at onset and outcome in BD, the present follow-up study suggests clinical peculiarities and different patterns of response to mood stabilizers across distinct subgroups of patients with BD and different ages at onset.
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Affiliation(s)
- Bernardo Dell'Osso
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, Italy.
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Mallinger AG, Thase ME, Haskett R, Buttenfield J, Luckenbaugh DA, Frank E, Kupfer DJ, Manji HK. Verapamil augmentation of lithium treatment improves outcome in mania unresponsive to lithium alone: preliminary findings and a discussion of therapeutic mechanisms. Bipolar Disord 2008; 10:856-66. [PMID: 19594501 PMCID: PMC3387673 DOI: 10.1111/j.1399-5618.2008.00636.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Attenuation of protein kinase C (PKC) is a mechanism common to both established (lithium, valproate) and some novel (tamoxifen) antimanic agents. Verapamil, although primarily known as a calcium channel blocker, also has PKC inhibitory activity. Verapamil has shown antimanic activity in some but not all studies. Therefore, we investigated verapamil, used alone or as an adjunctive treatment, in manic patients who did not respond to an initial adequate trial of lithium. METHODS Each study phase lasted three weeks. Subjects were treated openly with lithium in Phase 1 (n = 45). Those who failed to respond were randomly assigned to double-blind treatment in Phase 2 with either verapamil (n = 10) or continued-lithium (n = 8). Phase 2 nonresponders (n = 10) were assigned to combined verapamil/lithium in Phase 3. RESULTS Response in Phase 2 did not differ significantly between verapamil and continued-lithium. During Phase 3, response to combined treatment was significantly better than overall response to monotherapy in Phase 2 (Fisher's Exact test, p = 0.043). Mania ratings improved during combined treatment in Phase 3 by 88.2% (linear mixed model analysis, F = 4.34, p = 0.013), compared with 10.5% improvement during Phase 2. CONCLUSIONS In this preliminary investigation, verapamil monotherapy did not demonstrate antimanic efficacy. By contrast, the combination of verapamil plus lithium was highly efficacious. Our findings thus suggest that verapamil may have potential utility as an adjunct to lithium. This effect may be mediated by additive actions on PKC inhibition, which may be an important mechanism for antimanic agents in general.
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Affiliation(s)
- Alan G Mallinger
- Mood and Anxiety Disorders Program, National Institutes of Health Intramural Research Program, Building 10, Room 3N210, MSC 1290, Bethesda, MD 20892, USA.
| | - Michael E Thase
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh,Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Roger Haskett
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh
| | - Joan Buttenfield
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh
| | - David A Luckenbaugh
- Mood and Anxiety Disorders Program, National Institutes of Health Intramural Research Program, Bethesda, MD
| | - Ellen Frank
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh
| | - David J Kupfer
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh
| | - Husseini K Manji
- Mood and Anxiety Disorders Program, National Institutes of Health Intramural Research Program, Bethesda, MD
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Cruz N, Vieta E, Comes M, Haro JM, Reed C, Bertsch J. Rapid-cycling bipolar I disorder: course and treatment outcome of a large sample across Europe. J Psychiatr Res 2008; 42:1068-75. [PMID: 18262204 DOI: 10.1016/j.jpsychires.2007.12.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Revised: 12/14/2007] [Accepted: 12/17/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the baseline characteristics and follow-up outcomes of rapid-cycling (RC) bipolar I patients in a large, prospective, observational study. METHODS EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a long-term prospective observational study of in- and outpatients with an acute mania/mixed episode conducted in 14 European countries. Demographic and clinical variables were collected at baseline, including the presence or absence of DSM-IV rapid-cycling during the past year. Outcome measures included the 5-item Hamilton Depression Rating Scale (HAMD-5) and Young Mania Rating Scale (YMRS) over 12 weeks, as well as the Clinical Global Impressions-Bipolar Disorder Scale (CGI-BP overall, mania and depression) over 12 months. RESULTS Of 3684 patients enrolled, 3089 patients provided reliable data to qualify for either RC (N=535, 17.3%) or non-RC (NRC, N=2554), according to DSM-IV. RC prevalence varied across countries (p<0.001). Baseline and 12 week outcomes on the YMRS and HAMD-5, 12 month ratings on the CGI-BP subscales and work impairment at 12 months were significantly different (p<0.001) between groups, being worse in RC. RC patients were more likely to receive antidepressants and lamotrigine (p<0.001). Using logistic regression, RC was associated to country (p<0.001), female sex (p=0.029), outpatients (p=0.035), more history of attempted suicide (p<0.001) and alcohol abuse (p<0.001). CONCLUSIONS The EMBLEM results suggest that in naturalistic settings, patients with mania and RC differ from NRC in socio-demographic characteristics, treatment prescriptions and clinical outcome measures with a consistently worse occupational outcome and comorbidities. RC represents a longitudinally severe form of bipolar disorder, with poorly evidence-based diagnostic and therapeutic tools.
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Affiliation(s)
- N Cruz
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBER-SAM, Barcelona, Spain
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Abstract
This article discusses current practices in the treatment of bipolar depression. In the absence of more definitive research, the treatment of bipolar depression is guided by clinical experience and expert opinion, and sometimes by marketing and popular trends, as much as it is by hard data. Considering the limitations of current knowledge is an essential component of the scientific practice of psychiatry.
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Affiliation(s)
- Steven L Dubovsky
- Department of Psychiatry, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215, USA.
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Abstract
OBJECTIVE Rapid cycling bipolar disorder presents a significant challenge with respect to treatment. The cyclical nature of bipolar disorder has been well recognised for over a century, and following Dunner and Fieve's landmark paper in 1974, investigators have increasingly turned their attention to issues such as the definition of rapid cycling, demographic characterisation, treatment response and pharmacologic intervention. METHODS A literature search using Medline was performed, and selected articles which consider important developments in the definition, demographics and course of rapid cycling are reviewed. In addition, a systematic review of the literature published during the past 5 years (1999-2004) relating to treatment was conducted. RESULTS Relevant articles are reviewed. CONCLUSIONS This review highlights the important developments in our understanding of rapid cycling bipolar disorder, and focuses particularly on the recent literature regarding treatment.
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Affiliation(s)
- Paul Mackin
- School of Neurology, Neurobiology and Psychiatry, Department of Psychiatry, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
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