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Amerio A, Arduino G, Fesce F, Costanza A, Aguglia A, Amore M, Serafini G. Advances in the management of bipolar disorder in children and adolescents: an update on the literature. Expert Rev Neurother 2024; 24:1011-1024. [PMID: 39101769 DOI: 10.1080/14737175.2024.2386429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/25/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Early diagnosis and treatment concerning bipolar disorder (BD) are related to a better functioning over the long-term period. Although pharmacotherapy is indicated for approximately all youths with BD, nearly one-third of patients do not receive adequate medications for their condition. AREAS COVERED The authors discuss the available scientific evidence from the current literature about the management of BD in both children and adolescents, giving particular focus to the efficacy and tolerability of the available pharmacological agents. Studies were identified searching MEDLINE and retrieved from reference listings of relevant articles and through consultation with experts in the field. EXPERT OPINION Many D2-blockers, approved by the Food and Drug Administration (FDA) based on their antimanic properties in youths, are related to both short- and long-term side effects. Lurasidone was found to be effective for the treatment of acute juvenile bipolar depression, while lithium for the treatment and recurrence prevention of manic/mixed episodes. The most common anticonvulsants were found to be most useful as adjunctive antimanic agents in non-responders to first-line monotherapies. No data was found to support the use of antidepressants in juvenile BD.
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Affiliation(s)
- Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gabriele Arduino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Fesce
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Post RM, Rybakowski JK. What Patients with Bipolar Disorder Need to Know about Lithium. Pharmaceuticals (Basel) 2024; 17:1223. [PMID: 39338385 PMCID: PMC11435166 DOI: 10.3390/ph17091223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 08/29/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
Lithium is the superior first-line treatment for bipolar disorder (BD). Yet the percentage of patients receiving lithium is abysmally low, especially in the US. Since psychiatrists have failed to place lithium in its appropriate role, we make the case that patients with BD themselves need to be better educated about the unique characteristics and pre-eminence of the drug so that it can be used more often and appropriately. Lithium has a highly unfavorable popular reputation among would-be patients and many psychiatrists. Thus, a direct appeal to patients with BD appears appropriate to try to remediate this situation. The unique assets of lithium are underappreciated or not well known. Conversely, the side effects profile of lithium are overestimated. Here, we make the case that lithium's image needs to be revised not only with better and more accurate information but also with a wholesale renaming and rebranding of the drug. We will not only outline the unique qualities and new information about the side effects of the drug but attempt to change some of the terminology conventionally used to refer to lithium so that its use may be appropriately applied earlier and at an increased frequency for patients with BD.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, Chevy Chase, MD 20815, USA
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, 61-701 Poznań, Poland
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Lundberg M, Andersson P, Lundberg J, Desai Boström AE. Challenges and opportunities in the diagnosis and treatment of early-onset psychosis: a case series from the youth affective disorders clinic in Stockholm, Sweden. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:5. [PMID: 38172588 PMCID: PMC10851694 DOI: 10.1038/s41537-023-00427-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
Early-onset psychosis is linked to adverse long-term outcomes, recurrent disease course, and prolonged periods of untreated illness; thus highlighting the urgency of improving early identification and intervention. This paper discusses three cases where initial emphasis on psychosocial treatments led to diagnostic and therapeutic delays: (1) a 15-year-old misdiagnosed with emotionally unstable personality disorder and autism, who improved on bipolar medication and antipsychotics; (2) another 15-year-old misdiagnosed with autism, who stabilized on lithium and antipsychotics, subsequently allowing for gender dysphoria evaluation; (3) a 9-year-old autistic boy incorrectly treated for ADHD, who recovered with appropriate antipsychotic treatment. These cases illuminate the vital importance of adhering to a diagnostic hierarchy, prioritizing diagnostic utility, and conducting longitudinal evaluations to facilitate early targeted treatment of psychotic symptoms in early-onset psychosis. Adherence to such strategies can minimize delays in managing early-onset psychosis and improve long-term prognoses.
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Affiliation(s)
- Mathias Lundberg
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- The Affective Disorders Clinic, Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Andersson
- Department of Clinical Neuroscience/Psychology, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Johan Lundberg
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Adrian E Desai Boström
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden.
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Izadi N, Mitchell RHB, Giacobbe P, Nestor S, Steinberg R, Amini J, Sinyor M, Schaffer A. Suicide Assessment and Prevention in Bipolar Disorder: How Current Evidence Can Inform Clinical Practice. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:380-388. [PMID: 38695007 PMCID: PMC11058945 DOI: 10.1176/appi.focus.20230011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Bipolar disorder is associated with a considerable risk of suicide, and this fact must be incorporated into management of all patients with the condition. This article highlights the importance of a more nuanced understanding of the factors associated with the increased risk of suicidal behavior in people diagnosed as having bipolar disorder and interventions that could mitigate it. Several sociodemographic, clinical, environmental, and other variables have been associated with suicide attempts or deaths in bipolar disorder. Youths with bipolar disorder are a particularly vulnerable group, and their trajectory of illness could be modified by early interventions. Several medications have been studied regarding their relationship to suicide risk in bipolar disorder, and interventional psychiatry is a newer area of research focus. Finally, community-based approaches can be incorporated into a comprehensive approach to suicide prevention. This article summarizes the current understanding of key variables that can help inform a clinical risk assessment of individuals and interventions that can be employed in suicide prevention in bipolar disorder.
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Affiliation(s)
- Niloofar Izadi
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Rachel H B Mitchell
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Peter Giacobbe
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Sean Nestor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Rosalie Steinberg
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Jasmine Amini
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
| | - Ayal Schaffer
- Department of Psychiatry, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (all authors); Department of Psychiatry, University of Toronto, Toronto (Izadi, Mitchell, Giacobbe, Nestor, Steinberg, Sinyor, Schaffer)
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Assessment and Management of Bipolar Disorder. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:399-400. [PMID: 38695006 PMCID: PMC11058948 DOI: 10.1176/appi.focus.23021017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
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Elhosary MY, Merranko JA, Goldstein TR, Hafeman DM, Goldstein BI, Gill MK, Hower H, Axelson DA, Hunt JI, Yen S, Diler RS, Ryan ND, Keller MB, Weinstock LM, Strober M, Birmaher B. Examining Factors Associated With Medication Adherence in Youth With Bipolar Disorder. JAACAP OPEN 2023; 1:105-115. [PMID: 39381188 PMCID: PMC11460791 DOI: 10.1016/j.jaacop.2023.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
Abstract
Objective To assess medication adherence and factors associated with poor adherence in youth with bipolar disorder (BD) followed from adolescence through young adulthood. Method Participants with BD recruited through the Course and Outcome of Bipolar Youth (COBY) study were included in this study if they were prescribed psychotropic medications and had at least 3 follow-up assessments of medication adherence (N= 179, ages 12-36). Medication adherence had been evaluated for a median of 8 years using a questionnaire derived from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For the longitudinal evaluation, adherence was measured as the percentage of follow-up assessments in which the participants did not endorse any of the nonadherence items included in the questionnaire. Concurrent and future predictors of poor adherence were assessed using both univariate and multivariate longitudinal analyses. Results Among the participants, 51% reported poor adherence in more than 50% of their follow-up assessments. Younger age, family conflicts, polypharmacy, lower functioning, greater severity of mood symptoms, and comorbid disorders were associated with poor adherence in the univariate analyses. In the multivariate analyses, comorbid ADHD was the single most influential factor associated with concurrent and future poor adherence in all age groups. Participants' most reported reasons for poor adherence were forgetfulness (56%), negative attitudes toward medication treatment (10.5%), and disturbed daily routine (7%). Conclusions Poor medication adherence is a significant problem in youth with BD with the most influential factor being the presence of comorbid ADHD. Thus, it is important to identify and appropriately treat comorbid ADHD to improve medication adherence and patients' prognosis. Providers should also recommend tools to enhance consistent medication intake and address patients' concerns and negative beliefs about their illness and treatment.
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Affiliation(s)
- Mohamed Y Elhosary
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John A Merranko
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tina R Goldstein
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Danella M Hafeman
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Benjamin I Goldstein
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Mary Kay Gill
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Heather Hower
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David A Axelson
- Nationwide Children's Hospital, and The Ohio State College of Medicine, Columbus, Ohio
| | - Jeffrey I Hunt
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Shirley Yen
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Massachusetts Mental Health Center and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Rasim Somer Diler
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neal D Ryan
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Martin B Keller
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Miller School of Medicine at the University of Miami, Miami, FL
| | - Lauren M Weinstock
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael Strober
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Boris Birmaher
- UPMC Western Psychiatric Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
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Ryan K, Hosanagar A. Ketamine Use in Child and Adolescent Psychiatry: Emerging Data in Treatment-Resistant Depression, Insights from Adults, and Future Directions. Curr Psychiatry Rep 2023; 25:337-344. [PMID: 37389787 DOI: 10.1007/s11920-023-01432-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE OF REVIEW The following review will explore ketamine's antidepressant and antisuicidal properties in adults, review of what is known about ketamine's safety in children, and summarize the limited information we have on ketamine's role in treating depression and suicidal ideation in adolescents with depression. Future directions for ketamine's role in child psychiatry based on animal and adult studies will also be explored. RECENT FINDINGS Over the past 20 years, ketamine has emerged as a novel treatment for depression and suicidal ideation in adults. In recent years, these studies have been extended to adolescents. In 2021, the first placebo-controlled trial examining ketamine's antidepressant potential in adolescents was performed, demonstrating superior efficacy over midazolam. Initial studies suggest that ketamine functions as a rapidly acting antidepressant in adolescents. Case reports suggest that ketamine may also reduce suicidal ideation in this population. However, existing studies are small, and more research is needed to solidify these findings and inform clinical practice.
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Affiliation(s)
- Kaitlyn Ryan
- Department of Psychiatry, Adolescent Partial Hospitalization Program, Trinity Health Ann Arbor Hospital, Ann Arbor, MI, USA.
| | - Avinash Hosanagar
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Chang JC, Hai-Ti-Lin, Wang YC, Gau SSF. Treatment-resistant depression in children and adolescents. PROGRESS IN BRAIN RESEARCH 2023; 281:1-24. [PMID: 37806711 DOI: 10.1016/bs.pbr.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Major depressive disorder (MDD) in children and adolescents is a significant health problem, causing profound impairments in social, academic, and family functioning and substantial morbidity and mortality. Up to 15% of children and adolescents suffer from MDD, and a proportion, around 30 to 40% of them, failed to respond to initial selective serotonin reuptake inhibitor (SSRI) treatment. The only evidence-based recommendation is medication switching to another SSRI and augmentation with cognitive behavioral therapy. Newly developing treatment, including ketamine, transcranial magnetic stimulation, psychotherapy other than cognitive behavioral therapy, and combined pharmacotherapy with other interventions, requires further longitudinal controlled trials regarding efficacy and safety in this vulnerable population.
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Affiliation(s)
- Jung-Chi Chang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Ti-Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Ching Wang
- Department of Psychiatry, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Susan Shur-Fen Gau
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Hughes JL, Horowitz LM, Ackerman JP, Adrian MC, Campo JV, Bridge JA. Suicide in young people: screening, risk assessment, and intervention. BMJ 2023; 381:e070630. [PMID: 37094838 DOI: 10.1136/bmj-2022-070630] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.
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Affiliation(s)
- Jennifer L Hughes
- Big Lots Behavioral Health Services at Nationwide Children's Hospital, Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Lisa M Horowitz
- Office of the Clinical Director, Intramural Research Program, National Institutes of Mental Health, NIH, Bethesda, MD, USA
| | - John P Ackerman
- Big Lots Behavioral Health Services at Nationwide Children's Hospital, Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Molly C Adrian
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - John V Campo
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey A Bridge
- Departments of Pediatrics and Psychiatry and Behavioral Health, The Abigail Wexner Research Institute at Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center College of Medicine, Columbus, OH, USA
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Regional clozapine, ECT and lithium usage inversely associated with excess suicide rates in male adolescents. Nat Commun 2023; 14:1281. [PMID: 36918566 PMCID: PMC10015020 DOI: 10.1038/s41467-023-36973-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/20/2023] [Indexed: 03/16/2023] Open
Abstract
Advanced psychiatric treatments remain uncertain in preventing suicide among adolescents. Across the 21 Swedish regions, using nationwide registers between 2016-2020, we found negative correlation between adolescent excess suicide mortality (AESM) and regional frequencies of clozapine, ECT, and lithium (CEL) usage among adolescents (β = -0.613, p = 0.0003, 95% CI: -0.338, -0.889) and males (β = -0.404, p = 0.009, 95% CI: -0.130, -0.678). No correlation was found among females (p = 0.197). Highest CEL usage among male adolescents was seen in regions with lowest quartile (Q1) AESM (W = 74, p = 0.012). Regional CEL treatment frequency in 15-19-year-olds was related to lower AESM in males, reflecting potential treatment efficacy, treatment compliance or better-quality mental health care. Suicide prevention may benefit from early recognition and CEL treatment for severe mental illness in male adolescents. The results indicate association but further research, using independent samples and both prospective and observational methodologies, is needed to confirm causality.
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Lin CH, Chan HY, Lin HY, Chen CC. Fourteen-year trends in the prescribing patterns of pediatric bipolar patients discharged from two public mental hospitals in Taiwan. Asia Pac Psychiatry 2023; 15:e12525. [PMID: 36584983 DOI: 10.1111/appy.12525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/19/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The management of pediatric bipolar disorder (PBD) requires pharmacotherapy to control acute symptoms, reduce relapse, prevent suicide, and improve psychosocial functioning. The purpose of this study was to investigate prescribing patterns among PBD patients discharged from two public mental hospitals in Taiwan, from 2006 to 2019. METHODS PBD patients discharged from the two study hospitals, from 1 January 2006 to 31 December 2019 (n = 420), were included in the analysis. Prescribed drugs at discharge, including mood stabilizers (i.e., lithium, valproate, carbamazepine, and lamotrigine), antipsychotics (i.e., second- and first-generation antipsychotics, SGAs and FGAs), and antidepressants, were explored. Complex polypharmacy was defined as the use of 3 or more agents among the prescribed drugs. Time trends of each prescribing pattern were analyzed using the Cochran-Armitage Trend test. RESULTS The most commonly prescribed psychotropic agents were SGAs (76.0%), followed by valproate (65.7%) and FGAs (24.8%). The prescription rates of SGAs, antidepressants, antidepressant plus antipsychotic, and antidepressant without mood stabilizer significantly increased over time, whereas the prescription rates of mood stabilizers, lithium, and FGAs significantly decreased. DISCUSSIONS Prescribing patterns changed greatly for PBD patients over time. However, much more evidence supporting the effectiveness of psychotropic agents in PBD patients is required.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan, Taiwan.,Department of Psychiatry, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsin-Yi Lin
- Department of Medical Education, Cathay General Hospital, Taipei, Taiwan
| | - Cheng-Chung Chen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
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Rybakowski JK, Ferensztajn-Rochowiak E. Updated perspectives on how and when lithium should be used in the treatment of mood disorders. Expert Rev Neurother 2023; 23:157-167. [PMID: 36809989 DOI: 10.1080/14737175.2023.2181076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Lithium is one of the most important drugs for the treatment of mood disorders. The appropriate guidelines can ensure that more patients benefit from its use in a personalized way. AREAS COVERED This manuscript provides an update on the application of lithium in mood disorders, including prophylaxis of bipolar and unipolar mood disorder, treatment of acute manic and depressive episodes, augmentation of antidepressants in treatment-resistant depression, and use of lithium in pregnancy and the postpartum period. EXPERT OPINION Lithium remains the gold standard for the prevention of recurrences in bipolar mood disorder. For long-term treatment/management of bipolar mood disorder, clinicians should also consider lithium's anti-suicidal effect. Furthermore, after prophylactic treatment, lithium may also be augmented with antidepressants in treatment-resistant depression. There have also been some demonstration of lithium having some efficacy in acute episodes of mania and bipolar depression as well as in the prophylaxis of unipolar depression.
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Affiliation(s)
- Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
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Ratheesh A, Hett D, Ramain J, Wong E, Berk L, Conus P, Fristad MA, Goldstein T, Hillegers M, Jauhar S, Kessing LV, Miklowitz DJ, Murray G, Scott J, Tohen M, Yatham LN, Young AH, Berk M, Marwaha S. A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention. Int J Bipolar Disord 2023; 11:1. [PMID: 36595095 PMCID: PMC9810772 DOI: 10.1186/s40345-022-00275-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/14/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II. METHODS We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the 'early course' of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach. RESULTS From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course. CONCLUSIONS AND RECOMMENDATIONS While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.
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Affiliation(s)
- A. Ratheesh
- grid.488501.00000 0004 8032 6923Orygen, 35 Poplar Road, Parkville, VIC Australia ,grid.1008.90000 0001 2179 088XCentre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - D. Hett
- grid.6572.60000 0004 1936 7486Institute for Mental Health, University of Birmingham, Birmingham, UK ,Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK
| | - J. Ramain
- grid.8515.90000 0001 0423 4662TIPP Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - E. Wong
- grid.1008.90000 0001 2179 088XCentre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - L. Berk
- grid.414257.10000 0004 0540 0062IMPACT-The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - P. Conus
- grid.8515.90000 0001 0423 4662TIPP Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - M. A. Fristad
- grid.261331.40000 0001 2285 7943Nationwide Children’s Hospital, The Ohio State University, Columbus, USA
| | - T. Goldstein
- grid.21925.3d0000 0004 1936 9000Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - M. Hillegers
- grid.5645.2000000040459992XDepartment of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S. Jauhar
- grid.13097.3c0000 0001 2322 6764Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.415717.10000 0001 2324 5535South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX UK
| | - L. V. Kessing
- grid.475435.4Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - D. J. Miklowitz
- grid.19006.3e0000 0000 9632 6718Semel Institute for Neuroscience and Human Behavior, Los Angeles School of Medicine, University of California, Los Angeles, USA
| | - G. Murray
- grid.1027.40000 0004 0409 2862Centre for Mental Health, Swinburne University of Technology, Melbourne, Australia
| | - J. Scott
- grid.1006.70000 0001 0462 7212Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK
| | - M. Tohen
- grid.266832.b0000 0001 2188 8502Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM USA
| | - L. N. Yatham
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - A. H. Young
- grid.13097.3c0000 0001 2322 6764Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.415717.10000 0001 2324 5535South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX UK
| | - M. Berk
- grid.414257.10000 0004 0540 0062IMPACT-The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - S. Marwaha
- grid.6572.60000 0004 1936 7486Institute for Mental Health, University of Birmingham, Birmingham, UK ,Birmingham and Solihull Mental Health NHS Trust, Birmingham, UK
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Khoubaeva D, Dimick M, Timmins VH, Fiksenbaum LM, Mitchell RHB, Schaffer A, Sinyor M, Goldstein BI. Clinical correlates of suicidality and self-injurious behaviour among Canadian adolescents with bipolar disorder. Eur Child Adolesc Psychiatry 2023; 32:41-51. [PMID: 34028609 DOI: 10.1007/s00787-021-01803-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 05/09/2021] [Indexed: 11/26/2022]
Abstract
There is high risk of suicidality in bipolar disorder (BD), particularly in early onset cases. The literature regarding correlates and putative predictors of suicide attempts (SA), non-suicidal self-injury (NSSI) and suicidal ideation (SI) among youth with BD remains sparse. Participants included 197 adolescents with BD, divided into 4 groups: SA (with or without NSSI), NSSI (with or without SI), SI only, and comparison group (CG; no SA/NSSI/SI). Diagnoses, treatment, and suicidality measures were determined via semi-structured interviews, conducted between 2009 and 2017. Univariate analyses were followed by multinomial regression. Overall, 73.6% of participants had history of SA, NSSI, and/or SI. In comparison to CG, SA and NSSI were each associated with BD-II/-NOS (odds ratio [OR] = 15.99, p = 0.002; OR = 16.76, p = 0.003), female sex (OR = 6.89, p = 0.006; OR = 3.76, p = 0.02), and emotion dysregulation (OR = 1.10, p < 0.001; OR = 1.07, p = 0.004). NSSI and SI were each associated with most severe lifetime depression (OR = 1.10, p = 0.01; OR = 1.10, p = 0.01). SA and SI were associated with psychiatric hospitalization (OR = 19.45, p = 0.001; OR = 6.09, p = 0.03). SA was associated with poorer global functioning at most severe episode (OR = 0.88, p = 0.008). NSSI was associated with not living with both natural parents (OR = 0.22, p = 0.009). Study limitations include cross-sectional and retrospective design, stringent cut-offs for SA and NSSI, and recruitment from a tertiary clinical setting. Three quarters of adolescents with BD have had suicidality and/or self-injury. SA and NSSI were most similar to one another, and most different from CG, supporting the broader construct of self-harm. Future research should address the gap in knowledge regarding how sex differences and neurobiology are associated with the observed clinical differences.
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Affiliation(s)
- Diana Khoubaeva
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, ON, M6J 1H4, Canada
| | - Mikaela Dimick
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, ON, M6J 1H4, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
| | - Vanessa H Timmins
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, ON, M6J 1H4, Canada
| | | | - Rachel H B Mitchell
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ayal Schaffer
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Benjamin I Goldstein
- Centre for Youth Bipolar Disorder, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, ON, M6J 1H4, Canada.
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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15
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Janiri D, Moccia L, Montanari S, Zani V, Prinari C, Monti L, Chieffo D, Mazza M, Simonetti A, Kotzalidis GD, Janiri L. Use of Lithium in Pediatric Bipolar Disorders and Externalizing Childhood- related Disorders: A Systematic Review of Randomized Controlled Trials. Curr Neuropharmacol 2023; 21:1329-1342. [PMID: 36703581 PMCID: PMC10324336 DOI: 10.2174/1570159x21666230126153105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/24/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Lithium is the standard treatment for bipolar disorders (BD) in adults. There is a dearth of data on its use in the pediatric age. This review aimed to investigate the use of lithium in pediatric bipolar disorder (BD) and other externalizing childhood-related disorders. METHODS We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify randomized controlled trials evaluating the use of lithium in pediatric (BD), conduct disorder (CD), attention deficit hyperactivity disorder, oppositional defiant disorder, and disruptive mood dysregulation disorder. The primary outcome of our study was to evaluate the efficacy of lithium compared to a placebo or other pharmacological agents. The secondary outcomes were acceptability and tolerability. RESULTS Twelve studies were eligible, 8 on BD and 4 on CD. Overall, 857 patients were treated with lithium. No studies for externalizing disorder diagnoses were identified. Regarding BD patients (n = 673), efficacy results suggested that lithium was superior to placebo in manic/mixed episodes but inferior to antipsychotics. Lithium efficacy ranged from 32% to 82.4%. Results on maintenance need to be expanded. Comorbidity rates with other externalizing disorders were extremely high, up to 98.6%. Results in CD patients (n= 184) suggested the efficacy of lithium, especially for aggressive behaviors. No severe adverse events directly related to lithium were reported in BD and CD; common side effects were similar to adults. CONCLUSION This systematic review supports the use of lithium in BD and CD as an efficacious and generally well-tolerated treatment in the pediatric age. However, evidence is limited due to the paucity of available data.
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Affiliation(s)
- Delfina Janiri
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Lorenzo Moccia
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Silvia Montanari
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Valentina Zani
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Claudia Prinari
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Laura Monti
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- UOS Clinical Psychology, Clinical Government, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy
| | - Daniela Chieffo
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- UOS Clinical Psychology, Clinical Government, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy
| | - Marianna Mazza
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
| | - Alessio Simonetti
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
- Centro Lucio Bini, Via Crescenzio 42, Rome, 00193, Italy
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1 Baylor Plaza, Houston, 77030, TX, USA
| | - Georgios D. Kotzalidis
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
- Centro Lucio Bini, Via Crescenzio 42, Rome, 00193, Italy
- NESMOS Department, La Sapienza, Faculty of Medicine and Psychology, Sant’Andrea University Hospital, University of Rome, Via di Grottarossa, 1035-1039, Rome, 00189, Italy
| | - Luigi Janiri
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Largo Francesco Vito 1, Rome, 00168, Italy
- Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, Rome, 00168, Italy
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16
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Hobbs E, Reed R, Lorberg B, Robb AS, Dorfman J. Psychopharmacological Treatment Algorithms of Manic/Mixed and Depressed Episodes in Pediatric Bipolar Disorder. J Child Adolesc Psychopharmacol 2022; 32:507-521. [PMID: 36472471 DOI: 10.1089/cap.2022.0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Pediatric bipolar disorder (PBD) is a severe psychiatric illness diagnosed before the age of 18, which is associated with extreme shifts in mood characterized by manic and depressive episodes. In 2005, AACAP published algorithms to guide pharmacological treatment of manic/mixed episodes associated with PBD. At that time, lithium was the only Food and Drug Administration (FDA)-approved treatment for pediatric bipolar manic/mixed episodes. The goal of this article is to review evidence that has emerged since the AACAP algorithm in 2005. Methods: Literature searches were conducted through PubMed and limited to studies published between 2005 and 2021, using keywords that focused on randomized controlled trials (RCTs) for available psychopharmacological medications. In addition, the authors conducted in-depth searches for articles providing evidence for agents included in the 2005 AACAP algorithm. Results: Since the publication of the AACAP algorithm in 2005, multiple RCTs have been conducted in PBD, leading to FDA approval of five medications (aripiprazole, asenapine, olanzapine, quetiapine, and risperidone) for the treatment of manic/mixed episodes and two medications (lurasidone and olanzapine-fluoxetine combination) for the treatment of depressed episodes. Divalproex sodium and oxcarbazepine were studied in pediatric RCTs and failed to separate from placebo. Conclusions: We offer an update to the 2005 AACAP algorithms for the treatment of pediatric bipolar mixed/manic episodes and added an evidence-based algorithm for the treatment of depression in PBD. In addition to treatment algorithms, we review current evidence for efficacy of agents proposed in the AACAP algorithm and provide tables summarizing medication side effects and efficacy.
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Affiliation(s)
- Elizabeth Hobbs
- Department of Psychiatry and Behavioral Sciences, Children's National Hospital, Washington, District of Columbia, USA
| | - Rachel Reed
- Department of Psychiatry and Behavioral Sciences, Children's National Hospital, Washington, District of Columbia, USA
| | - Boris Lorberg
- Adolescent Continuing Care Units, Department of Psychiatry, Worcester Recovery Center and Hospital, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Adelaide S Robb
- Department of Psychiatry and Behavioral Sciences, Children's National Hospital, Washington, District of Columbia, USA
| | - Julia Dorfman
- Department of Psychiatry and Behavioral Sciences, Children's National Hospital, Washington, District of Columbia, USA
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17
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Lima Santos JP, Bertocci M, Bebko G, Goldstein T, Kim T, Iyengar S, Bonar L, Gill M, Merranko J, Yendiki A, Birmaher B, Phillips ML, Versace A. White Matter Correlates of Early-Onset Bipolar Illness and Predictors of One-Year Recurrence of Depression in Adults with Bipolar Disorder. J Clin Med 2022; 11:3432. [PMID: 35743502 PMCID: PMC9225103 DOI: 10.3390/jcm11123432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Diffusion Magnetic Resonance Imaging (dMRI) studies have reported abnormalities in emotion regulation circuits in BD; however, no study has examined the contribution of previous illness on these mechanisms. Using global probabilistic tractography, we aimed to identify neural correlates of previous BD illness and the extent to which these can help predict one-year recurrence of depressive episodes. dMRI data were collected in 70 adults with early-onset BD who were clinically followed for up to 18 years and 39 healthy controls. Higher number of depressive episodes during childhood/adolescence and higher percentage of time with syndromic depression during longitudinal follow-up was associated with lower fractional anisotropy (FA) in focal regions of the forceps minor (left, F = 4.4, p = 0.003; right, F = 3.1, p = 0.021) and anterior cingulum bundle (left, F = 4.7, p = 0.002; right, F = 7.0, p < 0.001). Lower FA in these regions was also associated with higher depressive and anxiety symptoms at scan. Remarkably, those having higher FA in the right cluster of the forceps minor (AOR = 0.43, p = 0.017) and in a cluster of the posterior cingulum bundle (right, AOR = 0.50, p = 0.032) were protected against the recurrence of depressive episodes. Previous depressive symptomatology may cause neurodegenerative effects in the forceps minor that are associated with worsening of BD symptomatology in subsequent years. Abnormalities in the posterior cingulum may also play a role.
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Affiliation(s)
- João Paulo Lima Santos
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Michele Bertocci
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Genna Bebko
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Tina Goldstein
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Tae Kim
- Magnetic Resonance Research Center, Department of Radiology, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Satish Iyengar
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Lisa Bonar
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - MaryKay Gill
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - John Merranko
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Anastasia Yendiki
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA;
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Mary L. Phillips
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
| | - Amelia Versace
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA; (M.B.); (G.B.); (T.G.); (S.I.); (L.B.); (M.G.); (J.M.); (B.B.); (M.L.P.); (A.V.)
- Magnetic Resonance Research Center, Department of Radiology, University of Pittsburgh, Pittsburgh, PA 15260, USA;
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18
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Pediatric Bipolar Disorder - Misinformation with Unintended Negative Consequences for Children and Adolescents. Eur Neuropsychopharmacol 2022; 59:4-6. [PMID: 35320747 DOI: 10.1016/j.euroneuro.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/24/2022]
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19
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Masi G. Controversies In The Pharmacotherapy Of Adolescent Depression. Curr Pharm Des 2022; 28:1975-1984. [PMID: 35619257 DOI: 10.2174/1381612828666220526150153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although fluoxetine and, in the USA, escitalopram are approved for depression in adolescence, substantial concern surrounds antidepressant use in youth. Major controversies regarding efficacy and safety (increased suicidality). INTRODUCTION The cathegory of depression is very broad and overinclusive, in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity, not fully controlled considered in Randomized Controlled Trials (RCTs), may account for the disappointing results on both efficacy and safety. METHOD Based on the available literature, we will address the following topics: a) controversies regarding the definition of depression as a unique homogeneous condition with a unique type of pharmacological treatment; b) controversies about the interpretation of data from Randomized Controlled Trials (RCTs) on the efficacy of pharmacological treatments in adolescent depression; c) the interpretation of data regarding the safety of antidepressant treatment in adolescent depression, particularly in terms of increased suicidal risk. RESULTS According to RCTs, antidepressants are minimally to moderately more effective than placebo, principally based on very high placebo responses, and only fluoxetine showed more evidence of efficacy. These differences in meta-analyses are sometimes statistically, but not clinically significant. Depression is a heterogeneous condition in terms of etiology, role of psychosocial adversities severity, episodicity, presentation, relationship with bipolarity. This heterogeneity may partly explain the low drug-placebo difference and the high placebo response (possibly related to a high level of natural recovery of the adolescent depression). In the National Institute of Mental Health (NIMH)-funded studies, including a lower number of study sites and more reliable enrollment procedures, lower placebo response rates and greater group differences between medication and placebo were found. Robust evidence supports an increased risk of emergent suicidality after starting antidepressants. A clear age effect on suicidal risk after antidepressants is supported by a comprehensive meta-analysis, showing that suicidal risk increased with decreasing age, being markedly greater in subjects aged between 18 and 25 years. However, the term suicidality is too broad, as it includes suicidal ideation, suicidal attempts, and completed suicide, with a hugely wide range of severity and pervasiveness. If emergent suicidality should be actively and carefully explored, empirical evidence, albeit weak, suggests that combined pharmacotherapy (antidepressant and/or lithium) associated with psychotherapy may be helpful in reducing pretreatment suicidal ideation and suicidal risk. DISCUSSION Moderate to severe depression should be treated with psychotherapy and/or fluoxetine, the best-supported medication, and treatment-resistant adolescents should always receive combined treatment with psychotherapy. Suicidal ideation, particularly with a plan, should be actively explored before starting an antidepressant, as a reason for the closest monitoring. Emergent suicidality after starting antidepressants, as well as antidepressant-related activation, should also be closely monitored and may lead to antidepressant discontinuation. Although no response to pharmacotherapy and psychotherapy may occur in up to 40% of depressed adolescents, possible predictors or mediators of poorer response in adolescents are uncertain, and only a few studies support possible treatment strategies. Finally, studies exploring the efficacy of antidepressants in specific depression subtypes, i.e., based on prevalent psychopathological dimensions (apathy, withdrawal, impulsivity), are warranted.
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Affiliation(s)
- Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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20
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Drachman R, Colic L, Sankar A, Spencer L, Goldman DA, Villa LM, Kim JA, Oquendo MA, Pittman B, Blumberg HP. Rethinking "aggression" and impulsivity in bipolar disorder: Risk, clinical and brain circuitry features. J Affect Disord 2022; 303:331-339. [PMID: 35181384 PMCID: PMC9109470 DOI: 10.1016/j.jad.2022.02.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Elevated aggression and impulsivity are implicated in Bipolar Disorder (BD); however, relationships between these behavioral constructs have not been clarified, which can lead to misconceptions with negative consequences including stigma and adverse outcomes including suicide. The study aimed to clarify brain-based distinctions between the two constructs and their associations to risk factors, symptoms and suicide thoughts and behaviors. METHODS Self-rated Brown-Goodwin Aggression (BGA) and Barratt Impulsiveness Scale (BIS) scores were compared between adults with BD (n = 38, 74% female) and healthy controls (HC, n = 29, 64% female). Relationships were examined between BGA and BIS with childhood trauma questionnaire (CTQ), mood, comorbidities, and magnetic resonance imaging gray matter volume (GMV) assessments. RESULTS In BD, BGA and BIS total scores were both elevated and associated with childhood maltreatment (CM), particularly emotional CM, depression, substance use disorders (SUDs) and suicide attempts (SAs). BGA scores were increased by items corresponding to dysregulation of emotional and social behavior and associated with elevated mood states and suicide ideation and GMV decreases in bilateral orbitofrontal cortex and left posterior insula brain regions, previously associated with these behaviors and clinical features. BIS motor impulsiveness scores were associated with GMV decreases in anterior cingulate cortex implicated in mood and behavioral dyscontrol. LIMITATIONS modest sample size, self-reports CONCLUSIONS: The findings suggest separable brain-based domains of dysfunction in BD of motor impulsiveness versus emotionally dysregulated feelings that are primarily self-directed. Both domains are associated with suicide behavior and modifiable risk factors of CM, depression and SUDs that could be targeted for prevention.
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Affiliation(s)
- Rebecca Drachman
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Lejla Colic
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA; Department of Psychiatry, Jena University Hospital, Jena, Germany
| | - Anjali Sankar
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Linda Spencer
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Danielle A Goldman
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA; Interdepartmental Neuroscience Program, Yale School of Medicine, New Haven, CT 06511, USA
| | - Luca M Villa
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Jihoon A Kim
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Maria A Oquendo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Pittman
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA
| | - Hilary P Blumberg
- Department of Psychiatry, Yale School of Medicine, 60 Temple Street, Suite 6B, New Haven, CT 06511, USA; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06511, USA; Child Study Center, Yale School of Medicine, New Haven, CT 06511, USA.
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21
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Güneş H, Tanıdır C, Doktur H, Karaçetin G, Kılıçoğlu AG, Yalçın Ö, Bahalı MK, Mutlu C, Üneri ÖŞ, Erdoğan A. Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey. J Child Adolesc Psychopharmacol 2022; 32:162-170. [PMID: 35384703 DOI: 10.1089/cap.2021.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.
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Affiliation(s)
- Hatice Güneş
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
| | - Canan Tanıdır
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
| | - Hilal Doktur
- Department of Child and Adolescent Psychiatry, Bakirkoy Training and Research Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey
| | - Gül Karaçetin
- Department of Child and Adolescent Psychiatry, Bakirkoy Training and Research Hospital for Mental Health and Neurological Disorders, Istanbul, Turkey
| | - Ali Güven Kılıçoğlu
- Department of Child and Adolescent Psychiatry, Bezm-i Alem Vakıf University, Istanbul, Turkey
| | - Özhan Yalçın
- Department of Child and Adolescent Psychiatry, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Caner Mutlu
- Department of Child and Adolescent Psychiatry, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Ayten Erdoğan
- Department of Psychology, Istanbul Gelisim University, Istanbul, Turkey
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22
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Sorter M, Chua J, Lamy M, Barzman D, Ryes L, Shekhtman JA. Management of Emotion Dysregulation and Outbursts in Children and Adolescents. Curr Psychiatry Rep 2022; 24:213-226. [PMID: 35316849 DOI: 10.1007/s11920-022-01325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice. RECENT FINDINGS There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.
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Affiliation(s)
- Michael Sorter
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Jaclyn Chua
- Children's Hospital of Philadelphia, Philadelphia, USA
| | - Martine Lamy
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Drew Barzman
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Louis Ryes
- Xavier University, Cincinnati, USA.,University of Kentucky College of Medicine, Lexington, USA
| | - Joshua Abraham Shekhtman
- The Ohio State University, Columbus, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
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23
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Mills J. Lithium: The Oldest-Known Metal in the Universe Can Prevent Suicide, and Nurses Should Be Using It More. Issues Ment Health Nurs 2022; 43:193-197. [PMID: 34797752 DOI: 10.1080/01612840.2021.1990584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Jeremy Mills
- Peninsula, a Division of Parkwest Medical Center, Knoxville, Tennessee, USA
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24
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Karthika C, Appu AP, Akter R, Rahman MH, Tagde P, Ashraf GM, Abdel-Daim MM, Hassan SSU, Abid A, Bungau S. Potential innovation against Alzheimer's disorder: a tricomponent combination of natural antioxidants (vitamin E, quercetin, and basil oil) and the development of its intranasal delivery. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:10950-10965. [PMID: 35000160 DOI: 10.1007/s11356-021-17830-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/24/2021] [Indexed: 06/14/2023]
Abstract
Alzheimer's disorder (AD) is very difficult to manage and treat. The complexity of the brain, the blood-brain barrier influencing a multitude of parameters/biomarkers, as well as numerous other factors involved often contribute to the decline in the chances of treatment success. Development of the new drug moiety also takes time, being necessary to consider both its toxicity and related issues. As a strategic plan, a combined strategy is being developed and considered to address AD pathology using several approaches. A combination of vitamin E, quercetin, and basil oil in a nano-based formulation is designed to be administered nasally. The antioxidant present in these natural-based products helps to treat and alleviate AD if a synergistic approach is considered. The three active substances mentioned above are well known for the treatment of neurodegenerative disorders. The nanoformulation helps the co-delivery of the drug moiety to the brain through the intranasal route. In this review, a correlation and use of vitamin E, quercetin, and basil oil in a nano-based formulation is described as an effective way to treat AD. The intranasal administration of drugs is a promising approach for the treatment of neurodegenerative and mental disorders, as this route is non-invasive, enhances the bioavailability, allows a drug dose reduction, bypasses the blood-brain barrier, and reduces the systemic undesired effect. The use of natural products is generally considered to be just as safe; therefore, by using this combined approach, the level of toxicity can be minimized.
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Affiliation(s)
- Chenmala Karthika
- Department of Pharmaceutics, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Nilgiris, Ooty, 643001, Tamil Nadu, India
| | | | - Rokeya Akter
- Department of Pharmacy, Jagannath University, Sadarghat, Dhaka, 1100, Bangladesh
- Department of Global Medical Science, Yonsei University Wonju College of Medicine, Yonsei University, Gangwon-do, Wonju, 26426, South Korea
| | - Md Habibur Rahman
- Department of Global Medical Science, Yonsei University Wonju College of Medicine, Yonsei University, Gangwon-do, Wonju, 26426, South Korea.
- Department of Pharmacy, Southeast University, Banani, Dhaka, 1213, Bangladesh.
| | - Priti Tagde
- Bhabha Pharmacy Research Institute, Bhabha University, Bhopal, Madhya Pradesh, 462026, India
| | - Ghulam Md Ashraf
- Pre-Clinical Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
- Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohamed M Abdel-Daim
- Department of Pharmaceutical Sciences, Batterjee Medical College, Jeddah, 21442, Saudi Arabia
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, 41522, Egypt
| | - Syed Shams Ul Hassan
- Shanghai Key Laboratory for Molecular Engineering of Chiral Drugs, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, 200240, China
- Department of Natural Product Chemistry, School of Pharmacy, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Areha Abid
- Department of Food Science, Faculty of Agricultural and Food Sciences, University of Debrecen, 4032, Debrecen, Hungary
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028, Oradea, Romania
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087, Oradea, Romania
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25
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Stutzman DL. Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. Ment Health Clin 2021; 11:320-333. [PMID: 34824957 PMCID: PMC8582767 DOI: 10.9740/mhc.2021.11.320] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.
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26
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Ochoa ELM. Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview. Cell Mol Neurobiol 2021; 42:85-97. [PMID: 34357564 DOI: 10.1007/s10571-021-01129-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
Lithium (Li+) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li+ ameliorates these abnormalities, it has been postulated that Li+ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li+'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li+-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li+'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.
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Affiliation(s)
- Enrique L M Ochoa
- Department of Psychiatry and Behavioral Sciences, Volunteer Clinical Faculty, University of California at Davis, 2230 Stockton Boulevard, Sacramento, CA, 95817, USA.
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27
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Abstract
Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.
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28
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Post RM, Grunze H. The Challenges of Children with Bipolar Disorder. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57060601. [PMID: 34207966 PMCID: PMC8230664 DOI: 10.3390/medicina57060601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 02/05/2023]
Abstract
Childhood onset bipolar disorder (CO-BD) presents a panoply of difficulties associated with early recognition and treatment. CO-BD is associated with a variety of precursors and comorbidities that have been inadequately studied, so treatment remains obscure. The earlier the onset, the longer is the delay to first treatment, and both early onset and treatment delay are associated with more depressive episodes and a poor prognosis in adulthood. Ultra-rapid and ultradian cycling, consistent with a diagnosis of BP-NOS, are highly prevalent in the youngest children and take long periods of time and complex treatment regimens to achieve euthymia. Lithium and atypical antipsychotics are effective in mania, but treatment of depression remains obscure, with the exception of lurasidone, for children ages 10-17. Treatment of the common comorbid anxiety disorders, oppositional defiant disorders, pathological habits, and substance abuse are all poorly studied and are off-label. Cognitive dysfunction after a first manic hospitalization improves over the next year only on the condition that no further episodes occur. Yet comprehensive expert treatment after an initial manic hospitalization results in many fewer relapses than traditional treatment as usual, emphasizing the need for combined pharmacological, psychosocial, and psycho-educational approaches to this difficult and highly recurrent illness.
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Affiliation(s)
- Robert M. Post
- School of Medicine, George Washington University, Washington, DC 20052, USA
- Bipolar Collaborative Network, 5415 W. Cedar Lane, Suite 201-B, Bethesda, MD 20814, USA
- Correspondence:
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall, Campus ZfPG, 74523 Schwäbisch Hall, Germany;
- Campus Nuremberg-Nord, Paracelsus Medical University, 90419 Nuremberg, Germany
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29
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Post RM, Altshuler LL, Kupka R, McElroy SL, Frye MA, Grunze H, Suppes T, Keck PE, Nolen WA. 25 Years of the International Bipolar Collaborative Network (BCN). Int J Bipolar Disord 2021; 9:13. [PMID: 33811284 PMCID: PMC8019011 DOI: 10.1186/s40345-020-00218-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Stanley Foundation Bipolar Treatment Outcome Network (SFBN) recruited more than 900 outpatients from 1995 to 2002 from 4 sites in the United States (US) and 3 in the Netherlands and Germany (abbreviated as Europe). When funding was discontinued, the international group of investigators continued to work together as the Bipolar Collaborative Network (BCN), publishing so far 87 peer-reviewed manuscripts. On the 25th year anniversary of its founding, publication of a brief summary of some of the major findings appeared appropriate. Important insights into the course and treatment of adult outpatients with bipolar disorder were revealed and some methodological issues and lessons learned will be discussed. RESULTS The illness is recurrent and pernicious and difficult to bring to a long-term remission. Virtually all aspects of the illness were more prevalent in the US compared to Europe. This included vastly more patients with early onset illness and those with more psychosocial adversity in childhood; more genetic vulnerability; more anxiety and substance abuse comorbidity; more episodes and rapid cycling; and more treatment non-responsiveness. CONCLUSIONS The findings provide a road map for a new round of much needed clinical treatment research studies. They also emphasize the need for the formation of a new network focusing on child and youth onset of mood disorders with a goal to achieve early precision diagnostics for intervention and prevention in attempting to make the course of bipolar illness more benign.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, 5415 W Cedar Lane, Ste 201-B, Bethesda, 20814, MD, USA.
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C., USA.
| | - Lori L Altshuler
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Psychiatry, VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Ralph Kupka
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA
- Biological Psychiatry Program, University of Cincinnati Medical College, Cincinnati, OH, USA
| | - Mark A Frye
- Department of Psychiatry& Psychology, Mayo Clinic, Rochester, MN, USA
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall GmbH & Paracelsus Medical University, Nuremberg, Germany.
| | - Trisha Suppes
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- V.A. Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul E Keck
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Lindner Center of HOPE, Mason, OH, USA
| | - Willem A Nolen
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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30
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Sharma A, McClellan J. Emotional and Behavioral Dysregulation in Severe Mental Illness. Child Adolesc Psychiatr Clin N Am 2021; 30:415-429. [PMID: 33743948 DOI: 10.1016/j.chc.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Emotional and behavioral dysregulation are common in severe mental illnesses, including schizophrenia, bipolar disorder, and borderline personality disorder. Emotional instability and behavioral outbursts can be driven by internal processes and/or environmental triggers and interpersonal interactions. Understanding the underlying diagnosis is important in determining the best course of treatment. Disorder-specific treatments are important in addressing underlying drivers of emotional dysregulation, irritability, and aggression. Coping skills training and behavioral modification strategies have broad applicability and are useful for aggression and irritability. Treatment planning to address emotion dysregulation and aggression in severe mental illness should address psychiatric comorbidities, substance use, and medication adherence.
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Affiliation(s)
- Aditi Sharma
- Department of Psychiatry and Behavioral Sciences, University of Washington, 4800 Sand Point WAY Northeast, MS OA.5.154, Seattle, WA 98105, USA
| | - Jon McClellan
- Department of Psychiatry and Behavioral Sciences, University of Washington, 8805 Steilacoom Boulevard Southwest, Lakewood, WA 98498, USA.
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31
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Pérez de Mendiola X, Hidalgo-Mazzei D, Vieta E, González-Pinto A. Overview of lithium's use: a nationwide survey. Int J Bipolar Disord 2021; 9:10. [PMID: 33687600 PMCID: PMC7941362 DOI: 10.1186/s40345-020-00215-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Lithium is considered the gold standard treatment for bipolar disorder (BD). Current clinical guidelines and scientific evidence support its use as a first-line treatment in BD. However, over the last two decades, there has been a downward tendency in lithium's use in several developed countries. Based on a nationwide survey, this study's objective is to analyze in a large sample of psychiatrists relevant issues of the use of lithium salts in BD. METHODS Data were collected through an anonymous survey sent by email among 500 psychiatrists who belong to a National Society of Psychiatry (Spanish Society of Biological Psychiatry). The survey is a self-administered questionnaire consisting of 21 items on the most key aspects of lithium's use (indication, dosage, monitoring, and information for patients). RESULTS 212 psychiatrists completed the survey. 70% of psychiatrists prescribe lithium to more than 50% of patients diagnosed with BD. Adverse effects are the main reason not to use lithium salts. Over 75% of the participants consider lithium salts the treatment of choice for the maintenance phase of BD, both in women and men. Most of the participants (> 50%) start lithium after the first affective episode, use conservative plasma concentrations (0.6-0.8 mmol/L), and generally prescribe it twice a day. 57% of psychiatrists who treat patients under 18 do not use lithium in this population. About 70% of the survey respondents use official protocols to inform and monitor patients on lithium treatment. CONCLUSIONS From the results of the present study, it can be concluded that the use of lithium in Spain is in line with the recommendations of the main international clinical guidelines and current scientific literature. The first reason not to prescribe lithium in our country is the perception of its adverse effects and not the aspects related to its practical use or its effectiveness. Considering that BD is a chronic disease with a typical onset in adolescence, the low rate of prescription of lithium salts in patients under 18 must be thoroughly studied.
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Affiliation(s)
- Xabier Pérez de Mendiola
- Bioaraba, Research Group on Severe Mental Illness; Osakidetza, Araba University Hospital, Psychiatry Service; Faculty of Medicine, Department of Neurosciences, University of the Basque Country UPV / EHU, Vitoria-Gasteiz, Spain.
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, Centre for Biomedical Research Network on Mental Health (CIBERSAM), Barcelona, Spain.
| | - Diego Hidalgo-Mazzei
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, Centre for Biomedical Research Network on Mental Health (CIBERSAM), Barcelona, Spain
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, Centre for Biomedical Research Network on Mental Health (CIBERSAM), Barcelona, Spain
| | - Ana González-Pinto
- Bioaraba, Research Group on Severe Mental Illness; Osakidetza, Araba University Hospital, Psychiatry Service; Faculty of Medicine, Department of Neurosciences, University of the Basque Country UPV / EHU, Vitoria-Gasteiz, Spain
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, Centre for Biomedical Research Network on Mental Health (CIBERSAM), Barcelona, Spain
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32
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Cirone C, Secci I, Favole I, Ricci F, Amianto F, Davico C, Vitiello B. What Do We Know about the Long-Term Course of Early Onset Bipolar Disorder? A Review of the Current Evidence. Brain Sci 2021; 11:brainsci11030341. [PMID: 33800274 PMCID: PMC8001096 DOI: 10.3390/brainsci11030341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
Abstract
Aim: Early onset of psychopathology is often an index of a more severe clinical course and worse prognosis. This review examined the course of bipolar disorder (BD) with onset in childhood and adolescence, with a focus on persistence of symptoms, severity of illness, comorbidity, and functional impairment. Methods: The databases of PubMed, Embase, and PsycInfo were systematically searched for publications since 1990 reporting on long-term (12 months or longer) assessments of patients with early onset BD. Results: Forty-two relevant publications were identified, which reported on data derived from 15 different patient cohorts, including 7 prospective research psychopathology studies, 4 medical record reviews, 2 follow-ups of clinical trial samples, 1 managed care database, and 1 nationwide registry, for a total of 10,187 patients. The length of follow-ups ranged from 1.0 to 15 years. Diagnostic stability of BD ranged from 73% to 100% over ten years. Recovery rate from an index episode was 81.5–100% and recurrence rate was 35–67%. Suicide attempt cumulative prevalence in five years was 18–20%. Earlier age at the first episode predicted a more severe clinical course. Conclusions: Early onset BD persists over time through adolescence, with homotypic diagnostic continuity over the years, but heterogeneity in the severity of the clinical course. Whether early identification and treatment improves distal prognosis remains to be further investigated.
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Affiliation(s)
- Carlotta Cirone
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
| | - Ilaria Secci
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
| | - Irene Favole
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
| | - Federica Ricci
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
| | - Federico Amianto
- Child and Adolescent Neuropsychiatry—Department of Neurosciences, Universita’ degli Studi di Torino, 10126 Turin, Italy;
| | - Chiara Davico
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
- Correspondence:
| | - Benedetto Vitiello
- Child and Adolescent Neuropsychiatry—Department of Public Health and Pediatric Sciences, Universita’ degli Studi di Torino, 10126 Turin, Italy; (C.C.); (I.S.); (I.F.); (F.R.); (B.V.)
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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33
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Zhang L, Chen M, Yao B, Zhang Y. Aggression and Non-Suicidal Self-Injury among Depressed Youths: The Mediating Effect of Resilience. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:288-296. [PMID: 33747992 PMCID: PMC7956094 DOI: 10.18502/ijph.v50i2.5342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The global spread of COVID-19 not only exerted an enormous impact on the public in different countries but also aggravated depression among youths. The aggressive tendencies of depressed individuals can harm their body and life and threaten those of others. The aggressive and non-suicidal self-injurious behaviors of depressed youths may seriously affect their physical and psychological health if not identified and mediated promptly. Method A total of 875 young respondents (including college students, community youths, migrant workers, and so on) from three provinces in China were surveyed in 2020 using a depression scale, non-suicidal self-injury scale, aggression scale, and resilience scale. Results Depression, non-suicidal self-injury, and aggression are significantly higher among the members of the depression group compared with the members of the healthy control group (P<0.001), and the resilience of the members of the former group is remarkably lower than that of the members of the latter group (P<0.001). Aggression among the depressed youths exhibits a significant positive correlation with non-suicidal self-injury (r= 0.43, P<0.01), whereas aggression (r= -0.18, P<0.05) and non-suicidal self-injury (r= -0.20, P<0.05) demonstrates significant negative correlations with resilience. The resilience of the youths in the depression group plays a partial mediating role in the relationship between aggression and non-suicidal self-injury. Conclusion The more aggressive the behaviors of the depressed youths, the more serious their non-suicidal self-injurious symptoms. Furthermore, resilience plays a partial mediating role in the relationship between aggression and non-suicidal self-injury.
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Affiliation(s)
- Ling Zhang
- Center for Mental Health, Shaoxing University, Shaoxing, China
| | - Meiai Chen
- School of Tourism and Health, Zhejiang A & F University, Hangzhou, China
| | - Benxian Yao
- College of Teacher Education, Hefei Normal University, Hefei, China
| | - Ying Zhang
- Center for Mental Health, Shaoxing University, Shaoxing, China
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Post RM. How to prevent the malignant progression of bipolar disorder. ACTA ACUST UNITED AC 2020; 42:552-557. [PMID: 32578689 PMCID: PMC7524411 DOI: 10.1590/1516-4446-2020-0874] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/06/2020] [Indexed: 12/20/2022]
Abstract
There is increasing recognition that, in a high percentage of cases, bipolar disorder is a progressive illness. Multiple types of sensitization (or increased reactivity to repetition of the same stimulus) drive illness progression. One of the clearest is that of episode sensitization, where increased numbers of prior episodes are associated with: faster recurrences; more dysfunction; disability; social, educational, and employment deficits; suicide; medical comorbidities; cognitive dysfunction; and an increased incidence of dementia in old age. Repetition of stressors and bouts of substance abuse can also result in sensitization. Each type of sensitization appears to have an epigenetic basis, such that preventing sensitization should minimize the accumulation of adverse epigenetic chemical marks on DNA, histones, and microRNA. New data emphasize the importance of early, consistent intervention after an initial manic episode. The cognitive dysfunction associated with a first episode improves only if there are no further episode recurrences during the next year. A randomized study has also shown that comprehensive multimodal prophylactic intervention for 2 years leads to improvements in illness course extending over a total of 6 years. Intensive treatment of the earliest stages of bipolar disorder can thus exert lasting positive effects on the course of illness.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, School of Medicine, George Washington University, Washington, USA
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35
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Goldstein BI, Korczak DJ. Links Between Child and Adolescent Psychiatric Disorders and Cardiovascular Risk. Can J Cardiol 2020; 36:1394-1405. [DOI: 10.1016/j.cjca.2020.06.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 12/27/2022] Open
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Post RM, Goldstein BI, Birmaher B, Findling RL, Frey BN, DelBello MP, Miklowitz DJ. Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data. J Affect Disord 2020; 272:508-520. [PMID: 32553395 PMCID: PMC8986089 DOI: 10.1016/j.jad.2020.03.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/03/2020] [Accepted: 03/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated. METHODS We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms. RESULTS A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database. LIMITATIONS Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study. CONCLUSIONS Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, Professor of Psychiatry George Washington Medical School, Bethesda, MD, Washington, DC, United States.
| | - Benjamin I Goldstein
- Departments of Psychiatry and Pharmacology, University of Toronto; Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre, Canada
| | - Boris Birmaher
- University of Pittsburgh School of Medicine, Psychiatry Research Pathway, United States
| | - Robert L Findling
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, United States
| | - Benicio N Frey
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Melissa P DelBello
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David J Miklowitz
- Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Dwyer JB, Stringaris A, Brent DA, Bloch MH. Annual Research Review: Defining and treating pediatric treatment-resistant depression. J Child Psychol Psychiatry 2020; 61:312-332. [PMID: 32020643 PMCID: PMC8314167 DOI: 10.1111/jcpp.13202] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adolescent major depressive disorder (MDD) is a significant health problem, associated with substantial morbidity, cost, and mortality. Depression is a significant risk factor for suicide, which is now the second leading cause of death in young people. Up to twenty per cent of adolescents will experience MDD before adulthood, and while a substantial proportion will improve with standard-of-care treatments (psychotherapy and medication), roughly one third will not. METHODS Here, we have reviewed the literature in order to discuss the concept of treatment-resistant depression (TRD) in adolescence, examine risk factors, diagnostic difficulties, and challenges in evaluating symptom improvement, and providing guidance on how to define adequate medication and psychotherapy treatment trials. RESULTS We propose a staging model for adolescent TRD and review the treatment literature. The evidence base for first- and second-line treatments primarily derives from four large pediatric clinical trials (TADS, TORDIA, ADAPT, and IMPACT). After two medications and a trial of evidence-based psychotherapy have failed to alleviate depressive symptoms, the evidence becomes quite thin for subsequent treatments. Here, we review the evidence for the effectiveness of medication switches, medication augmentation, psychotherapy augmentation, and interventional treatments (i.e., transcranial magnetic stimulation, electroconvulsive therapy, and ketamine) for adolescent TRD. Comparisons are drawn to the adult TRD literature, and areas for future pediatric depression research are highlighted. CONCLUSIONS As evidence is limited for treatments in this population, a careful consideration of the known risks and side effects of escalated treatments (e.g., mood stabilizers and atypical antipsychotics) is warranted and weighed against potential, but often untested, benefits.
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Affiliation(s)
- Jennifer B. Dwyer
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA,Yale Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Argyris Stringaris
- Mood Brain and Development Unit, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - David A. Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, PA, USA
| | - Michael H. Bloch
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA,Yale Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Hickie IB, Scott EM, Cross SP, Iorfino F, Davenport TA, Guastella AJ, Naismith SL, Carpenter JS, Rohleder C, Crouse JJ, Hermens DF, Koethe D, Markus Leweke F, Tickell AM, Sawrikar V, Scott J. Right care, first time: a highly personalised and measurement-based care model to manage youth mental health. Med J Aust 2020; 211 Suppl 9:S3-S46. [PMID: 31679171 DOI: 10.5694/mja2.50383] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change. Consequently, the effects of adolescent-onset mood and psychotic syndromes can have long term consequences. A key clinical challenge for youth mental health is to develop and test new systems that align with current evidence for comorbid presentations and underlying neurobiology, and are useful for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. Our highly personalised and measurement-based care model includes three core concepts: ▶ A multidimensional assessment and outcomes framework that includes: social and occupational function; self-harm, suicidal thoughts and behaviour; alcohol or other substance misuse; physical health; and illness trajectory. ▶ Clinical stage. ▶ Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on proposed pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). The model explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within this highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care as well as utilisation of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality, mental health care for young people. CHAPTER 1: MULTIDIMENSIONAL OUTCOMES IN YOUTH MENTAL HEALTH CARE: WHAT MATTERS AND WHY?: Mood and psychotic syndromes present one of the most serious public health challenges that we face in the 21st century. Factors including prevalence, age of onset, and chronicity contribute to substantial burden and secondary risks such as alcohol or other substance misuse. Mood and psychotic syndromes most often emerge during adolescence and young adulthood, a period characterised by major physical and social change; thus, effects can have long term consequences. We propose five key domains which make up a multidimensional outcomes framework that aims to address the specific needs of young people presenting to health services with emerging mental illness. These include social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Impairment and concurrent morbidity are well established in young people by the time they present for mental health care. Despite this, services and health professionals tend to focus on only one aspect of the presentation - illness type, stage and trajectory - and are often at odds with the preferences of young people and their families. There is a need to address the disconnect between mental health, physical health and social services and interventions, to ensure that youth mental health care focuses on the outcomes that matter to young people. CHAPTER 2: COMBINING CLINICAL STAGE AND PATHOPHYSIOLOGICAL MECHANISMS TO UNDERSTAND ILLNESS TRAJECTORIES IN YOUNG PEOPLE WITH EMERGING MOOD AND PSYCHOTIC SYNDROMES: Traditional diagnostic classification systems for mental disorders map poorly onto the early stages of illness experienced by young people, and purport categorical distinctions that are not readily supported by research into genetic, environmental and neurobiological risk factors. Consequently, a key clinical challenge in youth mental health is to develop and test new classification systems that align with current evidence on comorbid presentations, are consistent with current understanding of underlying neurobiology, and provide utility for predicting outcomes and guiding decisions regarding the provision of appropriate and effective care. This chapter outlines a transdiagnostic framework for classifying common adolescent-onset mood and psychotic syndromes, combining two independent but complementary dimensions: clinical staging, and three proposed pathophysiological mechanisms. Clinical staging reflects the progression of mental disorders and is in line with the concept used in general medicine, where more advanced stages are associated with a poorer prognosis and a need for more intensive interventions with a higher risk-to-benefit ratio. The three proposed pathophysiological mechanisms are neurodevelopmental abnormalities, hyperarousal and circadian dysfunction, which, over time, have illness trajectories (or pathways) to psychosis, anxious depression and bipolar spectrum disorders, respectively. The transdiagnostic framework has been evaluated in young people presenting to youth mental health clinics of the University of Sydney's Brain and Mind Centre, alongside a range of clinical and objective measures. Our research to date provides support for this framework, and we are now exploring its application to the development of more personalised models of care. CHAPTER 3: A COMPREHENSIVE ASSESSMENT FRAMEWORK FOR YOUTH MENTAL HEALTH: GUIDING HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE USING MULTIDIMENSIONAL AND OBJECTIVE MEASURES: There is an urgent need for improved care for young people with mental health problems, in particular those with subthreshold mental disorders that are not sufficiently severe to meet traditional diagnostic criteria. New comprehensive assessment frameworks are needed to capture the biopsychosocial profile of a young person to drive highly personalised and measurement-based mental health care. We present a range of multidimensional measures involving five key domains: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness type, stage and trajectory. Objective measures include: neuropsychological function; sleep-wake behaviours and circadian rhythms; metabolic and immune markers; and brain structure and function. The recommended multidimensional measures facilitate the development of a comprehensive clinical picture. The objective measures help to further develop informative and novel insights into underlying pathophysiological mechanisms and illness trajectories to guide personalised care plans. A panel of specific multidimensional and objective measures are recommended as standard clinical practice, while others are recommended secondarily to provide deeper insights with the aim of revealing alternative clinical paths for targeted interventions and treatments matched to the clinical stage and proposed pathophysiological mechanisms of the young person. CHAPTER 4: PERSONALISING CARE OPTIONS IN YOUTH MENTAL HEALTH: USING MULTIDIMENSIONAL ASSESSMENT, CLINICAL STAGE, PATHOPHYSIOLOGICAL MECHANISMS, AND INDIVIDUAL ILLNESS TRAJECTORIES TO GUIDE TREATMENT SELECTION: New models of mental health care for young people require that interventions be matched to illness type, clinical stage, underlying pathophysiological mechanisms and individual illness trajectories. Narrow syndrome-focused classifications often direct clinical attention away from other key factors such as functional impairment, self-harm and suicidality, alcohol or other substance misuse, and poor physical health. By contrast, we outline a treatment selection guide for early intervention for adolescent-onset mood and psychotic syndromes (ie, active treatments and indicated and more specific secondary prevention strategies). This guide is based on experiences with the Brain and Mind Centre's highly personalised and measurement-based care model to manage youth mental health. The model incorporates three complementary core concepts: ▶A multidimensional assessment and outcomes framework including: social and occupational function; self-harm, suicidal thoughts and behaviours; alcohol or other substance misuse; physical health; and illness trajectory. ▶Clinical stage. ▶Three common illness subtypes (psychosis, anxious depression, bipolar spectrum) based on three underlying pathophysiological mechanisms (neurodevelopmental, hyperarousal, circadian). These core concepts are not mutually exclusive and together may facilitate improved outcomes through a clinical stage-appropriate and transdiagnostic framework that helps guide decisions regarding the provision of appropriate and effective care options. Given its emphasis on adolescent-onset mood and psychotic syndromes, the Brain and Mind Centre's model of care also respects a fundamental developmental perspective - categorising childhood problems (eg, anxiety and neurodevelopmental difficulties) as risk factors and respecting the fact that young people are in a period of major biological and social transition. Based on these factors, a range of social, psychological and pharmacological interventions are recommended, with an emphasis on balancing the personal benefit-to-cost ratio. CHAPTER 5: A SERVICE DELIVERY MODEL TO SUPPORT HIGHLY PERSONALISED AND MEASUREMENT-BASED CARE IN YOUTH MENTAL HEALTH: Over the past decade, we have seen a growing focus on creating mental health service delivery models that better meet the unique needs of young Australians. Recent policy directives from the Australian Government recommend the adoption of stepped-care services to improve the appropriateness of care, determined by severity of need. Here, we propose that a highly personalised approach enhances stepped-care models by incorporating clinical staging and a young person's current and multidimensional needs. It explicitly aims to prevent progression to more complex and severe forms of illness and is better aligned to contemporary models of the patterns of emergence of psychopathology. Inherent within a highly personalised approach is the incorporation of other evidence-based processes, including real-time measurement-based care and use of multidisciplinary teams of health professionals. Data-driven local system modelling and personalised health information technologies provide crucial infrastructure support to these processes for better access to, and higher quality of, mental health care for young people.
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Affiliation(s)
- Ian B Hickie
- Brain and Mind Centre, University of Sydney, Sydney, NSW
| | - Elizabeth M Scott
- Brain and Mind Centre, University of Sydney, Sydney, NSW.,University of Notre Dame Australia, Sydney, NSW
| | - Shane P Cross
- Brain and Mind Centre, University of Sydney, Sydney, NSW
| | - Frank Iorfino
- Brain and Mind Centre, University of Sydney, Sydney, NSW
| | | | | | | | | | | | - Jacob J Crouse
- Brain and Mind Centre, University of Sydney, Sydney, NSW
| | - Daniel F Hermens
- Brain and Mind Centre, University of Sydney, Sydney, NSW.,Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Birtinya, QLD
| | - Dagmar Koethe
- Brain and Mind Centre, University of Sydney, Sydney, NSW
| | | | | | - Vilas Sawrikar
- Brain and Mind Centre, University of Sydney, Sydney, NSW.,University of Edinburgh, Edinburgh, UK
| | - Jan Scott
- Brain and Mind Centre, University of Sydney, Sydney, NSW.,Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK
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Simonetti A, Koukopoulos AE, Kotzalidis GD, Janiri D, De Chiara L, Janiri L, Sani G. Stabilization Beyond Mood: Stabilizing Patients With Bipolar Disorder in the Various Phases of Life. Front Psychiatry 2020; 11:247. [PMID: 32395107 PMCID: PMC7197486 DOI: 10.3389/fpsyt.2020.00247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND There are different ways to define stabilization and currently, the main standpoint regards it as no-depression/no-mania. Furthermore, each person is physiologically different from childhood to adulthood, and in old age, thus the meaning of stabilization should take into account both growth and maturity. We aimed to review systematically studies focusing on mood stabilization in all phases of bipolar disorder (BD) and across all life phases, including pregnancy and the perinatal period, which is still a different phase in women's life cycles. METHODS We carried out a PubMed search focusing on studies of bipolar disorder treated with drugs and aimed at stabilization with the following search strategy stabiliz*[ti] OR stabilis*[ti] OR stable[ti] OR stability[ti]) AND mood[ti] AND bipolar. In conducting our review, we followed the PRISMA statement. Agreement on inclusion was reached by consensus of all authors through a Delphi rounds procedure. RESULTS The above search strategy produced 509 records on January 25, 2020. Of them, 58 fitted our inclusion criteria and were discussed. The eligible studies spanned from September 1983 to July 6, 2019. CONCLUSIONS No clear-cut indications could be drawn due to a number of limitations involving sample inconsistency and different methods of assessing mood stabilization. The evidence collected so far does not allow recommended treatments for Adolescents, pregnant or perinatal women, and aged patients. However, adults, not within these groups, better focused upon. For their manic/mixed phases, second generation antipsychotic drugs may be useful in the short-to-medium run, alone or combined with mood stabilizers (MSs). However, MSs, and especially lithium, continue to be pivotal in chronic treatment. Bipolar depression should rely on MSs, but an antidepressant may be added on and can prove to be helpful. However, there are concerns with the tendency of antidepressants to induce the opposite polarity or mood instability, rendering the need for concurrent MS prescription mandatory.
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Affiliation(s)
- Alessio Simonetti
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.,Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.,Centro Lucio Bini, Rome, Italy
| | - Alexia E Koukopoulos
- Centro Lucio Bini, Rome, Italy.,Azienda Ospedaliera Universitaria Policlinico Umberto I, Sapienza School of Medicine and Dentistry, Sapienza University of Rome, Rome, Italy
| | - Georgios D Kotzalidis
- Centro Lucio Bini, Rome, Italy.,NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Delfina Janiri
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy.,Centro Lucio Bini, Rome, Italy
| | - Lavinia De Chiara
- Centro Lucio Bini, Rome, Italy.,NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Luigi Janiri
- Institute of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Gabriele Sani
- Institute of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy.,Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
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