Olanzapine monotherapy and olanzapine combination therapy in the treatment of mania: 12-week results from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) observational study

Age-at-onset subsets of bipolar I disorders: A critical insight into admixture analyses

Gaussian mixture analysis is frequently used to model the age-at-onset (AAO) in bipolar I disorder and identify homogeneous subsets of patients. This study aimed to examine whether, using admixture analysis of AAO, cross-sectional designs (which cause right truncation), unreliable diagnosis for individuals younger than 10 years old (which causes left truncation) and the selection criterion used for admixture analysis impact the number of identified subsets. A simulation study was performed. Different criteria - the likelihood ratio test (LRT), the Akaike information criterion (AIC), and the Bayesian information criterion (BIC) - were compared using no, left and/or right truncation simulated data. The error rate of each criterion (percentage of erroneous number of detected subsets) was estimated. An application to two real databases, including 2,876 and 1,393 patients, is provided. Without data truncation and regardless of the distribution of AAO, the LRT and the AIC had much higher error rates (12% and 33%, respectively) than the BIC (1%). For a homogeneous population, the error rate increased with the introduction of left truncation. This study shows that the number of subsets identified using admixture analysis may depend on the sample size, the selection criterion, and the study design.

Anticonvulsants and suicide attempts in bipolar I disorders

OBJECTIVE

To identify risk factors for suicide attempts (SA) in individuals commencing treatment for a manic or mixed episode.

METHOD

A total of 3390 manic or mixed cases with bipolar disorder (BD) type I recruited from 14 European countries were included in a prospective, 2-year observational study. Poisson regression models were used to identify individual and treatment factors associated with new SA events. Two multivariate models were built, stratified for the presence or absence of prior SA.

RESULTS

A total of 302 SA were recorded prospectively; the peak incidence was 0-12 weeks after commencing treatment. In cases with a prior history of SA, risk of SA repetition was associated with younger age of first manic episode (P = 0.03), rapid cycling (P < 0.001), history of alcohol and/or substance use disorder (P < 0.001), number of psychotropic drugs prescribed (P < 0.001) and initiation of an anticonvulsant at study entry (P < 0.001). In cases with no previous SA, the first SA event was associated with rapid cycling (P = 0.02), lifetime history of alcohol use disorder (P = 0.02) and initiation of an anticonvulsant at study entry (P = 0.002).

CONCLUSION

The introduction of anticonvulsants for a recent-onset manic or mixed episode may be associated with an increased risk of SA. Further BD studies must determine whether this link is causal.

Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder

Breast milk is considered the best source of nutrients and provides much better protection than immune modified milk. However, the postpartum period is a phase of increased risk for all women to experience psychiatric symptoms and recurrences or new episodes of bipolar disorder (BD), especially in those who have discontinued treatment. This is a systematic review of the risks and benefits of mood stabilizers and antipsychotics during breastfeeding as they relate to the health and well-being of mothers and their infants. Evidence-based treatment advice for women with BD during lactation is also provided. This systematic review has been conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We included studies examining the exposure and the effects of antipsychotics and mood stabilizers used to treat BD on infants during breastfeeding clearly reporting the estimated amount of drug or effects on infants. The final selection included 56 studies. The available data supports the use of lithium as a possible treatment option during breastfeeding. Carbamazepine and valproic acid are also considered relatively safe. Lamotrigine can be used but at the lowest doses and considered for individual cases. Among the antipsychotics, quetiapine and olanzapine should be considered as first-line treatment options. Risperidone may be compatible with breastfeeding under medical supervision. Clozapine and amisulpiride are currently contraindicated. Long-term outcome studies evaluating the infant׳s health and psychosocial and cognitive functioning are needed.

Using admixture analysis to examine birth-cohort effects on age at onset of bipolar disorder

OBJECTIVE

It is suggested that age at onset (AAO) of bipolar I disorder (BP-I) is decreasing. We tested for a birth-cohort effect on AAO using admixture analysis.

METHOD

A clinical sample of 3896 BP-I cases was analysed using two approaches: (i) in a subsample with untruncated AAO × birth year distribution (n = 1865), we compared the best-fitting model for the observed AAO in patients born ≤1960 and >1960, (ii) to control for potential confounders, two separate subsamples born ≤1960 and >1960 were matched for age at interview (n = 250), and a further admixture analysis was undertaken.

RESULTS

The two approaches indicated that the proportion of cases in the early AAO category was significantly greater in cases born >1960; manic onsets were also more frequent in the early onset BP-I cases born >1960.

CONCLUSION

The decrease in AAO of BP-I in recent birth-cohorts appears to be associated with an increase in the proportion of cases in the early onset subgroup; not with a decrease in the mean AAO in each putative subgroup. This could indicate temporal changes in exposure to risk factors for mania.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility.

METHODS

Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSIONS

The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh.

INTERNATIONAL EXPERT ADVISORS

Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham.

AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS

Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Risk factors for rapid cycling in bipolar disorder

OBJECTIVES

The aim of this study was to investigate the clinical factors associated with the development of rapid cycling, as well as to elucidate the role of antidepressants.

METHODS

The present study (NCT01503489) is a prospective, naturalistic cohort study conducted in a sample of 289 patients diagnosed with bipolar disorder followed and treated for up to 14 years. The patients were divided into two groups on the basis of the development of a rapid cycling course (n = 48) or no development of such a course (n = 241), and compared regarding sociodemographic, clinical, and outcome variables.

RESULTS

Among the 289 patients, 48 (16.6%) developed a rapid cycling course during the follow-up. Several differences were found between the two groups, but after performing Cox regression analysis, only atypical depressive symptoms (p = 0.001), age at onset (p = 0.015), and number of suicide attempts (p = 0.030) persisted as significantly associated with the development of a rapid cycling course.

CONCLUSIONS

The development of rapid cycling during the course of bipolar disorder is associated with a tendency to chronicity, with a poorer outcome, and with atypical depressive symptomatology. Our study also suggests that the development of rapid cycling is associated with a higher use of antidepressants.

Pharmacotherapy of acute mania: monotherapy or combination therapy with mood stabilizers and antipsychotics?

The use of combination therapy with mood stabilizers and antipsychotics in acute mania in bipolar disorder (BD) is widespread, although most treatment guidelines recommend monotherapy as the first option, and reserve combination therapy, which is associated with more frequent and more severe side effects, for when patients do not respond to the former treatment option. Reasons to prescribe combination therapy include the lack of efficacy of the current treatment (either real or due to undisclosed poor adherence), psychiatric comorbidities, severe previous course of illness, slow cross-tapering during treatment switching, and potential benefits from particular combinations. The decision to start with monotherapy or combination therapy may depend on the patient characteristics, and is still under debate. Clinical trials designed to ascertain whether combination therapy or monotherapy is more advantageous for patients in acute mania and beyond, according to illness severity, are urgently needed. Adding a third monotherapy arm to the conventional two-arm, adjunctive-design trials or initiating combination therapy from the beginning may help to shed some light on the issue.

Olanzapine-valproate combination versus olanzapine or valproate monotherapy in the treatment of bipolar I mania: a randomized controlled study in a Chinese population group

BACKGROUND

Bipolar disorder (BP) is a mental illness that has a high social burden estimated by disability-adjusted life years. In the present study, we investigated the efficacy of olanzapine-valproate combination therapy versus olanzapine or valproate monotherapy in the treatment of bipolar I mania in a Chinese population group.

SUBJECTS AND METHODS

Patients aged 19-58 years who had had an acute manic episode of BP were enrolled in the present study and randomly assigned to receive 600 mg sodium valproate daily (group A), 10 mg olanzapine daily (group B), or a combination of 600 mg olanzapine and 10 mg sodium valproate daily (group C) for 4 weeks. The primary outcome was reduction in Young Mania Rating Scale (YMRS) scores. The secondary outcome was assessed with the Clinical Global Impression - Bipolar (CGI-BP) scale. Adverse reactions, such as weight gain, sleepy, and dizziness were also evaluated. Statistical analysis was carried out on a per-protocol basis.

RESULTS

Patients in groups B and C showed significant improvement in YMRS scores compared with those in group A (P<0.01) during weeks 1-4 of treatment. Patients in group C showed significant improvement in YMRS scores compared with those in group B (P<0.01) only after 4 weeks of treatment. Furthermore, after 3-4 weeks of treatment, patients in groups B and C showed significantly greater improvement in CGI-BP scale scores compared with group A (P<0.05), while Group C demonstrated significantly greater improvement in CGI-BP scale scores than group B (P<0.01). No significant difference existed in extrapyramidal reactions among these groups. Adverse reactions, including weight gain, drowsiness, dizziness, and constipation, were stronger in groups B and C than in group A (P<0.05).

CONCLUSION

The combination therapy with olanzapine and sodium valproate had higher efficacy than monotherapy in patients with bipolar mania, which provides a crucial insight of the treatment regimen during clinical practice.

Age at onset in bipolar I affective disorder in the USA and Europe

OBJECTIVE

To test for differences in reported age at onset (AAO) of bipolar I affective disorder in clinical samples drawn from Europe and the USA.

METHODS

Admixture analysis was used to identify the model best fitting the observed AAO distributions of two large samples of bipolar I patients from Europe and USA (n = 3616 and n = 2275, respectively). Theoretical AAO functions were compared between the two samples.

RESULTS

The model best fitting the observed distribution of AAO in both samples was a mixture of three Gaussian distributions. The theoretical AAO functions of bipolar I disorder differed significantly between the European and USA populations, with further analyses indicating that (i) the proportion of patients belonging to the early-onset subgroup was higher in the USA sample (63 vs. 25%) and (ii) mean age at onset (±SD) in the early-onset subgroup was lower for the USA sample (14.5 ± 4.9 vs. 19 ± 2.7 years).

CONCLUSIONS

The models best describing the reported AAO distributions of European and USA bipolar I patients were remarkably stable. The intermediate- and late-onset subgroups had similar characteristics in the two samples. However, the theoretical AAO function differed significantly between the USA and European samples due to the higher proportion of patients in the early-onset subgroup and the lower mean age-at-onset in the USA sample.

Mixed states with predominant manic or depressive symptoms: baseline characteristics and 24-month outcomes of the EMBLEM cohort

BACKGROUND

While factors associated with mixed states have been extensively studied, data are scant regarding the clinical heterogeneity of mixed states. The EMBLEM study was a prospective, observational study on patients with manic and mixed states. We describe and compare baseline characteristics and 24-month clinical course of mixed states with predominant depressive symptoms (MSDS) and mixed states with predominant manic symptoms (MSMS).

METHODS

Adult inpatients/outpatients with bipolar disorder were enrolled within the standard course of care if they initiated or changed oral medication for acute mania or mixed states. A logistic regression was used to identify the baseline factors associated with each polarity. Comparisons with mixed episode without symptom predominance (OMS) were performed for informational purpose only.

RESULTS

About 573 mixed patients were analyzed (23.7% of the cohort): 59.5% (n=341) had MSMS, 11.9% (n=68) had MSDS, and 28.6% (n=164) had OMS. At baseline, hallucinations/delusions during the index episode, inpatient status, high CGI-BP overall score, and low education level were more often associated with MSMS versus MSDS. Alcohol abuse or dependence and selective serotonin reuptake inhibitor (SSRI) or benzodiazepine use at inclusion were significantly more frequent with MSDS. MSDS had a significantly lower 24-month recurrence rate than MSMS; MSMS experienced more switches to mania whereas MSDS switched more to depression.

LIMITATIONS

The post hoc dimensional definitions in the study require caution in the interpretation of the results.

CONCLUSION

These results present evidence of clinical heterogeneity within mixed states. Predominant manic or depressive symptoms within mixed episode could influence clinicians' decisions in term of hospitalization, treatment, and perception of bipolar severity.

How assess drugs in the treatment of acute bipolar mania?

Bipolar affective disorder is a serious mental disease associated with significant morbidity and mortality. Good-quality research available to guide treatment strategies remains insufficient, particularly with regard to manic or hypomanic episodes. A critical review of the various stages of mania might be helpful for pharmaceutical companies and investigators as a prerequisite for the clinical evaluation of potential antimanic properties of medications. The main difficulty is with a comparison between anticonvulsants, antipsychotics, and mood stabilizers such as lithium (with equal efficacy in the acute phase and the prevention of recurrent manic episodes). No consensus has been reached with regard to the treatment of bouts of acute mania in various parts of the world. Controlled clinical trials have, at last, provided irrefutable evidence of the activity of lithium, which has long been used alone, as well as that of divalproate or its derivatives and, to a lesser extent, carbamazepine. The new antipsychotic agents have more recently established their efficacy, especially aripiprazole, asenapine, quetiapine; olanzapine, risperidone, and ziprasidone (not sure where the paradox is). In Europe, haloperidol is still the reference substance used in clinical trials despite the fact that it is not officially indicated in the treatment of mania. In the USA, lithium, divalproate, or antipsychotics can be prescribed as first-line treatment. In Europe, lithium remains the first-line medication, whereas divalproate and atypical antipsychotic agents are used only as second-line therapy. Although both types of medication (antipsychotics, normothymic agents, and/or anticonvulsants) have proved to be clinically effective in the management of mania by reducing the mania scores overall, the same does not apply, however, to all symptoms of mania. Factorial approaches to mania have all shown that since there are several clinical forms of mania, several clusters of manic symptoms can be identified. Antipsychotic and normothymic agents and/or anticonvulsants do not appear to have the same effects on each of these identifiable clusters of symptoms, mainly psychotic features. We believe that it is vitally important for future clinical trials of mania treatment to focus on the treatment effect by adopting a factorial approach to characterization of the episode using an appropriate methodological structure. These questions highlight the uncertainty shrouding the very structure of manic episodes, namely that these are predominantly of a thymic or psychotic nature. The Europeans undoubtedly consider mania to be more of a thymic episode and prefer lithium as the first-line treatment, whereas the Americans believe that psychotic symptoms dominate and widely prescribe antipsychotic agents. However, from the standpoint of clinical trials currently available, even though antipsychotic agents are certainly effective in reducing the scores on the mania scales, it is not clear whether they can be considered purely as antimania treatments.

New treatment guidelines for acute bipolar mania: a critical review

A number of treatment guidelines for bipolar disorder have been published and updated in the last few years. They are aimed at providing a synthesis of the best available scientific knowledge, and their application to every-day work should be helpful to clinicians. The aim of this report is to critically review recent guidelines focusing on the treatment of manic/hypomanic and mixed episodes. Guidelines are quite heterogeneous in methodology and conclusions, but they all agree that the treatment of manic/hypomanic and mixed episodes should generally be initiated with a medication such as lithium (Li), valproate (VPA) or atypical antipsychotics (AAP), including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone as monotherapy. All guidelines agree on stopping ongoing antidepressant medication during mania. Combination therapy including Li or VPA with an AAP is suggested usually as second-line choice, sometimes as first-choice treatment for severe mania. Carbamazepine is mostly suggested as second line and not recommended in combination. Other antiepileptic drugs are not recommended for the treatment of mania, although lamotrigine may be maintained if it was prescribed previously for the prevention of depressive episodes. Main sources of discrepancies among guidelines include benefit-risk ratio issues (how much priority is given to efficacy over safety and tolerability), starting with combination versus monotherapy, and how to deal with treatments which are more experience-based than evidence-based (i.e.: electroconvulsive therapy).

Safety and efficacy of olanzapine monotherapy and olanzapine with a mood stabilizer in 18-week treatment of manic/mixed episodes for Japanese patients with bipolar I disorder

OBJECTIVE

To assess the safety and efficacy of 18-week olanzapine monotherapy in Japanese patients with bipolar mania, following a 6-week, placebo- and haloperidol-controlled double-blind study (acute study). For those who discontinued the acute study due to lack of efficacy, safety and efficacy was assessed with a combination therapy of olanzapine and a mood stabilizer.

RESEARCH DESIGN AND METHODS

In this open-label, multicenter extension study, patients who completed the acute study received olanzapine (5-20 mg/day) as monotherapy, and patients who discontinued the acute study due to lack of efficacy with greater Young Mania Rating Scale (YMRS) total score than the acute study baseline, received olanzapine in combination with one of three mood stabilizers: lithium, carbamazepine, or valproate. Safety was assessed by treatment-emergent adverse events (TEAEs), vital signs, weight, and extrapyramidal symptoms (EPSs). Efficacy measures included YMRS total score, and response and remission rates of manic symptoms.

MAIN OUTCOME AND MEASURES

There were no deaths or serious adverse events considered potentially related to olanzapine in the monotherapy group (N = 100) or the combination-therapy group (N = 39). TEAEs occurred in 59.0% and 79.5% of patients in the monotherapy and combination-therapy groups, respectively, and their severities were mostly mild or moderate. Regarding the efficacy measures, in the monotherapy group, mean YMRS change from extension study baseline to endpoint was -3.0, and the response and remission rates at endpoint were 97.0% and 93.0%, respectively. In the combination-therapy group, mean YMRS change from extension-study baseline was -19.8; response and remission rates increased from the extension-study baseline (both 0.0%) to 64.1% and 61.5% respectively by endpoint.

CONCLUSION

Olanzapine was generally well tolerated during the 18-week extension period in Japanese patients with bipolar mania. Results of both groups were also generally consistent with US and European studies. Monitoring of metabolic parameters is recommended.

Effectiveness of olanzapine monotherapy and olanzapine combination treatment in the long term following acute mania--results of a two year observational study in bipolar disorder (EMBLEM)

BACKGROUND

This study compared the 2-year outcomes of patients with a manic/mixed episode of bipolar disorder taking olanzapine monotherapy or olanzapine in combination with other agents.

METHODS

EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a 2-year, prospective, observational study of clinical and functional outcomes of bipolar patients with an index manic/mixed episode. The study consisted of two phases: acute (12 weeks) and maintenance (follow-up over 2 years). The longitudinal outcome measure was the Clinical Global Impression-Bipolar Disorder scale. Cox regression models compared outcomes of both therapy groups using intention-to-treat and switching medication analysis. Treatment-emergent adverse events were also assessed.

RESULTS

1076 patients were included in this analysis. 29% took olanzapine as monotherapy (n = 313) and 71% as combination (n = 763) at 12-weeks post-baseline (end of study acute phase). After adjusting for patient characteristics using switching medication analysis, only relapse rates differed (p = 0.01) in favour of monotherapy-treated patients. There was no significant difference in rates of improvement, remission, and recovery. Patients treated with combination therapy reported more tremor (OR 2.37, 95%CI 1.44-3.89) and polyuria (OR 3.08, 95%CI 1.45-6.54) treatment-emergent events than monotherapy, although weight change was greater in the monotherapy group.

LIMITATIONS

Unknown confounding and potential selection bias may differentially impact treatment outcomes.

CONCLUSIONS

EMBLEM patients benefitted from the selected therapy to a similar extent. Differences in patient characteristics between those prescribed monotherapy and combination therapy appear to be clinically relevant in the treatment decision. Physicians must balance the benefits and risks when determining appropriate treatment for individual patients.

Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM)

OBJECTIVES

To compare patients with and without a history of suicidal attempts in a large cohort of patients with bipolar disorder and to identify variables that are associated with suicidal behavior.

METHODS

European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a two-year, prospective, observational study that enrolled 3,684 adult patients with bipolar disorder and initiated or changed oral treatment for an acute manic/mixed episode. Of those, 2,416 patients were eligible for the two-year follow-up. Only baseline characteristics were studied in the present study, included sociodemographic data, psychiatric history and comorbidities, history of suicide attempts, history of substance use problems, compliance with treatment, inpatient admissions, and functional status. Symptom severity was assessed using the Clinical Global Impression-Bipolar Disorder (CGI-BP) scale, the Young Mania Rating Scale (YMRS), and the 5-item Hamilton Depression Rating Scale (HAMD-5). A logistic regression model identified baseline variables independently associated with a history of suicidal behavior.

RESULTS

Of the 2,219 patients who provided data on their lifetime history of suicide attempts, 663 (29.9%) had a history of suicidal behavior (at least one attempt). Baseline factors associated with a history of suicidal behavior included female gender, a history of alcohol abuse, a history of substance abuse, young age at first treatment for a mood episode, longer disease duration, greater depressive symptom severity (HAMD-5 total score), current benzodiazepine use, higher overall symptom severity (CGI-BP: mania and overall score), and poor compliance.

CONCLUSIONS

These factors may be considered as potential characteristics to identify subjects at risk for suicidal behavior throughout the course of bipolar disorder.

Dissimilar morbidity following initial mania versus mixed-states in type-I bipolar disorder

BACKGROUND

Mixed-states of bipolar disorders (BPD) may predict worse future illness and more depressive than manic morbidity, challenging a tendency to conflate mixed-states and mania.

METHODS

Patients (N=247) were followed-up systematically for 24 months following hospitalization for initial major episodes of DSM-IV type-I BPD and scored for weekly interval morbidity-types.

RESULTS

Overall morbidity during follow-up was 1.6-times greater following mixed (n=97) versus manic (n=150) first-episodes of BPD (60.0 vs. 37.8%-of-weeks; p<0.0001). Patients with initial mixed-states had a nearly 12-fold later excess of mixed-states, 6.5-times more major depression, and 69% more dysthymia during follow-up than those presenting in mania. In contrast, manic first-episodes were followed by over 10-times more mania, 6-times more hypomania, and 35% more psychotic illness.

LIMITATIONS

Estimates of longitudinal morbidity may be inaccurate, and ongoing treatment may distort them.

CONCLUSIONS

Based on detailed, prospective assessments among first-episode BPD patients, those presenting in mixed-states were more ill, and much more likely to experience mixed, depressive and dysthymic morbidity during follow-up, versus much more mania, hypomania, and perhaps more psychosis following mania. The findings support two markedly dissimilar subtypes of BPD, and call for more explicit therapeutic studies of mixed-states.

Twelve-month prospective, multinational, observational study of factors associated with recovery from mania in bipolar disorder in patients treated with atypical antipsychotics

OBJECTIVES

Atypical antipsychotic agents constitute one therapeutic approach for bipolar disorder. Since disease course and outcome are variable, further studies are needed to complement limited data supportive of clinical decisions at treatment initiation.

METHODS

This 12-month, prospective, observational study investigated factors associated with symptomatic remission (total YMRS score < or =12) and full clinical recovery (sustained reduction in CGI-BP-S overall score) in bipolar disorder during treatment with atypical antipsychotics (predominantly olanzapine, risperidone and quetiapine; alone or in combination with a psychotropic such as lithium or valproate) in actual clinical practice.

RESULTS

Amongst 872 enrolled and eligible patients, rates of symptomatic remission and full clinical recovery at 12 months were 93.0 and 78.5%, respectively. Of the baseline factors significantly (P< or =0.05) associated with symptomatic remission, the following categories were positively associated with a higher chance of symptomatic remission: Caucasian ethnicity; higher CGI-BP-S scores; family-dependent living; a previous manic episode; 1, 2 or > or =5 social activities; no work impairment; and being neither satisfied nor dissatisfied with life. Outpatient treatment and historically longer periods of mania were significantly positively associated with full clinical recovery.

CONCLUSIONS

While clinical status may also be associated with longer-term remission and recovery, factors relating to social functioning and quality of life are easily assessed and potentially modifiable. Such knowledge may aid physicians' clinical decisions regarding patients with bipolar mania treated with atypical antipsychotics.

Predictors of switching from mania to depression in a large observational study across Europe (EMBLEM)

BACKGROUND

The risk of switching from mania to depression in bipolar disorder has been poorly studied. Large observational studies may be useful in identifying variables that predict switch to depression after mania and provide data on medication use and outcomes in "real world" patients.

METHOD

EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a 2-year, prospective, observational study of patients with a manic/mixed episode. Symptom severity measures included Clinical Global Impression-Bipolar Disorder scale (CGI-BP), Young Mania Rating Scale (YMRS) and 5-item Hamilton Depression Rating Scale. Switching was defined using CGI-BP mania and depression such that patients changed from manic and not depressed to depressed but not manic over two consecutive observations within the first 12 weeks of follow-up. Cox proportional hazards models identified baseline variables independently associated with switch to depression.

RESULTS

Of 2390 patients who participated in the maintenance phase (i.e. up to 24 months), 120 (5.0%) switched to depression within the first 12 weeks. Factors associated with greater switching to depression include previous depressive episodes, substance abuse, greater CGI-BP overall severity and benzodiazepine use. Factors associated with lower switching rates were greater CGI-BP depression, lower YMRS severity and atypical antipsychotic use.

LIMITATIONS

The definition of switching biased against patients with mixed episodes being likely to switch.

CONCLUSIONS

Strictly defined, switch to depression from mania occurs in a small proportion of bipolar patients. Clinical history, illness severity, co-morbidities and treatment patterns are associated with switching to depression. Atypical antipsychotics may protect against switch to depression.

Longer-term treatment of patients with bipolar disorder: a 9-month observational study in Central and Eastern Europe, the Middle East and Africa

OBJECTIVE

To compare the longer-term outcomes of pharmacological treatment of patients with a diagnosis of bipolar affective disorder currently suffering a manic or hypomanic episode prescribed olanzapine or non-olanzapine medication in naturalistic, clinical practice settings in Bosnia-Herzegovina, Slovakia, Slovenia, Turkey, Saudi Arabia and Egypt.

RESEARCH DESIGN AND METHODS

Prospective, observational, non-interventional study conducted over 9 months. Inpatients or outpatients who initiated or changed oral bipolar mania medication were grouped into (1) those prescribed olanzapine at baseline (n = 569) and (2) those not prescribed olanzapine (n = 325).

MAIN OUTCOME MEASURE(S)

The change from baseline in the Clinical Global Impression Severity scale for bipolar disorder (CGI-BP-S), the rates of symptomatic response and remission (based on CGI-BP-S) and the frequency and nature of treatment-emergent adverse events. Analyses included (1) linear or logistic regression, with adjustment for confounders, based on the last observation carried forward and (2) weighted repeated measures models that adjusted for treatment switching and patient drop-out.

RESULTS

When results were adjusted for treatment switching and patient drop-out, patients prescribed olanzapine had significantly better CGI-BP-S scores (mean difference = -0.24; 95% confidence interval [CI] -0.33, -0.16; p < 0.001) and significantly greater odds of treatment response (odds ratio [OR] = 1.86; 95% CI 1.31, 2.65; p < 0.001) and symptom remission (OR = 1.65; 95% CI 1.18-2.32; p = 0.003) than those not prescribed olanzapine. The frequency of most adverse events decreased in both groups. Patients prescribed olanzapine had significantly greater weight gain from baseline (mean increase = 2.66 kg; 95% CI 2.35, 2.98) compared with those not prescribed olanzapine (mean increase = 1.85 kg; 95% CI 1.51, 2.19; p < 0.001).

CONCLUSIONS

Inclusion of olanzapine is of benefit for pharmacological treatment of patients with bipolar disorder. However, the favourable outcomes observed cannot be directly attributed to olanzapine alone because of the high prevalence of polypharmacy in the patient population.

Advantages and disadvantages of combination treatment with antipsychotics ECNP Consensus Meeting, March 2008, Nice

TERMINOLOGY AND PRINCIPLES OF COMBINING ANTIPSYCHOTICS WITH A SECOND MEDICATION: The term "combination" includes virtually all the ways in which one medication may be added to another. The other commonly used terms are "augmentation" which implies an additive effect from adding a second medicine to that obtained from prescribing a first, an "add on" which implies adding on to existing, possibly effective treatment which, for one reason or another, cannot or should not be stopped. The issues that arise in all potential indications are: a) how long it is reasonable to wait to prove insufficiency of response to monotherapy; b) by what criteria that response should be defined; c) how optimal is the dose of the first monotherapy and, therefore, how confident can one be that its lack of effect is due to a truly inadequate response? Before one considers combination treatment, one or more of the following criteria should be met; a) monotherapy has been only partially effective on core symptoms; b) monotherapy has been effective on some concurrent symptoms but not others, for which a further medicine is believed to be required; c) a particular combination might be indicated de novo in some indications; d) The combination could improve tolerability because two compounds may be employed below their individual dose thresholds for side effects. Regulators have been concerned primarily with a and, in principle at least, c above. In clinical practice, the use of combination treatment reflects the often unsatisfactory outcome of treatment with single agents. ANTIPSYCHOTICS IN MANIA: There is good evidence that most antipsychotics tested show efficacy in acute mania when added to lithium or valproate for patients showing no or a partial response to lithium or valproate alone. Conventional 2-armed trial designs could benefit from a third antipsychotic monotherapy arm. In the long term treatment of bipolar disorder, in patients responding acutely to the addition of quetiapine to lithium or valproate, this combination reduces the subsequent risk of relapse to depression, mania or mixed states compared to monotherapy with lithium or valproate. Comparable data is not available for combination with other antipsychotics. ANTIPSYCHOTICS IN MAJOR DEPRESSION: Some atypical antipsychotics have been shown to induce remission when added to an antidepressant (usually a SSRI or SNRI) in unipolar patients in a major depressive episode unresponsive to the antidepressant monotherapy. Refractoriness is defined as at least 6 weeks without meeting an adequate pre-defined treatment response. Long term data is not yet available to support continuing efficacy. SCHIZOPHRENIA: There is only limited evidence to support the combination of two or more antipsychotics in schizophrenia. Any monotherapy should be given at the maximal tolerated dose and at least two antipsychotics of different action/tolerability and clozapine should be given as a monotherapy before a combination is considered. The addition of a high potency D2/3 antagonist to a low potency antagonist like clozapine or quetiapine is the logical combination to treat positive symptoms, although further evidence from well conducted clinical trials is needed. Other mechanisms of action than D2/3 blockade, and hence other combinations might be more relevant for negative, cognitive or affective symptoms. OBSESSIVE-COMPULSIVE DISORDER: SSRI monotherapy has moderate overall average benefit in OCD and can take as long as 3 months for benefit to be decided. Antipsychotic addition may be considered in OCD with tic disorder and in refractory OCD. For OCD with poor insight (OCD with "psychotic features"), treatment of choice should be medium to high dose of SSRI, and only in refractory cases, augmentation with antipsychotics might be considered. Augmentation with haloperidol and risperidone was found to be effective (symptom reduction of more than 35%) for patients with tics. For refractory OCD, there is data suggesting a specific role for haloperidol and risperidone as well, and some data with regard to potential therapeutic benefit with olanzapine and quetiapine. ANTIPSYCHOTICS AND ADVERSE EFFECTS IN SEVERE MENTAL ILLNESS: Cardio-metabolic risk in patients with severe mental illness and especially when treated with antipsychotic agents are now much better recognized and efforts to ensure improved physical health screening and prevention are becoming established.

Observational study designs for bipolar disorder - what can they tell us about treatment in acute mania?

Randomised controlled trials may have generalisability limitations when applied to the complex treatment of patients with bipolar disorder. Observational study designs can inform us about the diversity of bipolar disorder treatment in naturalistic settings. The aim of this paper was to describe the treatments prescribed for acute mania in a large prospective observational study of bipolar disorder. Patients with a manic/mixed episode were enrolled in EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) if they initiated or changed oral medication with antipsychotics, lithium and/or anticonvulsants. The use of monotherapy or combination therapy for treatment of acute mania, concomitant medications and rate of treatment switching during the 12-week acute treatment phase were assessed. Of the 3459 patients, 36% were treated with one drug and 64% with combination therapy. 55% of patients initiating combination therapy started on an atypical antipsychotic plus lithium or an anticonvulsant. Patients prescribed combination therapy at baseline were more clinically severe, were more often treated as inpatients and had more manic episodes in the previous year compared with the monotherapy group. Treatment switching occurred in 54.4% of patients over the 12-week acute phase. Many patients were taking at least one concomitant medication at baseline (69.4%) and week 12 (50.5%). The results of this observational study show that treatment for mania is complex with multiple combinations of treatment and frequent switching during an acute episode.

Mixed states vs. pure mania in the French sample of the EMBLEM study: results at baseline and 24 months--European mania in bipolar longitudinal evaluation of medication

BACKGROUND

To describe the clinical course and treatment patterns over 24 months of patients experiencing an acute manic/mixed episode within the standard course of care.

METHODS

EMBLEM was a 2-year European prospective, observational study on outcomes of patients experiencing a manic/mixed episode. Adults with bipolar disorder were enrolled within the standard course of care as in/outpatients if they initiated or changed oral medication for treatment of acute mania. After completing 12 weeks of acute phase, patients were assessed every 3-6 months during the maintenance phase. We present the 24 month results, with subgroup analysis for mixed states (MS) and pure mania (PM). These subgroup analyses are driven by the high proportion of antidepressants prescribed in this cohort.

RESULTS

In France, 771 patients were eligible for the maintenance phase. 69% of patients completed the follow up over 24 months. The mean age was 45.5 years (sd = 13.6) with 57% of women. 504 (66%) patients were experiencing a PM and 262 (34%) a MS at baseline. The main significant differences in MS vs. PM at baseline were: a higher rate of women, and in the previous 12 months, a higher frequency of episodes (manic/mixed and depressive), more suicide attempts, more rapid cycling, fewer social activities and more work impairment. Over the 24 months of follow-up the MS group had a significantly lower recovery than PM (36% vs. 46%, p = 0.006). Overall, 42% of all patients were started on monotherapy and 58% on combination therapy; of those 35% and 30% respectively remained on their initial medication throughout the 24 months. At baseline, 36% were treated with an antidepressant, this proportion remains high throughout the follow-up period, with a significantly higher rate for MS vs. PM at 24 months (55% vs. 27%, p < 0.001).

CONCLUSION

In this large sample, MS occur frequently (34%), they are more severe at baseline and have a worse functional prognosis than PM. Although antidepressants are not recommended in MS and PM, they were frequently prescribed at baseline and are maintained during the 24 months of follow-up.

Bipolar disorder and aggression

AIMS

In clinical practice, overt aggressive behaviour is frequently observed in patients diagnosed with bipolar disorder. It can be dangerous and complicates patient care. Nevertheless, it has not been adequately studied as a phenomenon that is separate from other symptoms such as agitation. The aim of this review is to provide information on the prevalence, clinical context, and clinical management of aggression in patients with bipolar disorder.

METHODS

MEDLINE and PsycInfo data bases were searched for articles published between 1966 and November 2008 using the combination of key words 'aggression' or 'violence' with 'bipolar disorder'. For the treatment searches, generic names of mood stabilisers and antipsychotics were used in combination with key words 'bipolar disorder' and 'aggression'. No language constraint was applied. Articles dealing with children and adolescents were not included.

RESULTS

Acutely ill hospitalised bipolar patients have a higher risk for aggression than other inpatients. In a population survey, the prevalence of aggressive behaviour after age 15 years was 0.66% in persons without lifetime psychiatric disorder, but 25.34% in bipolar I disorder. Comorbidity with personality disorders and substance use disorders is frequent, and it elevates the risk of aggression in bipolar patients. Impulsive aggression appears to be the most frequent subtype observed in bipolar patients. Clinical management of aggression combines pharmacological and non-pharmacological approaches.

DISCUSSION

A major problem with the evidence is that aggression is frequently reported only as one of the items contributing to the total score on a scale or a subscale. This makes it impossible to ascertain specifically aggressive behaviour. Large controlled head-to-head randomised controlled studies comparing treatments for aggressive behaviour in bipolar disorder are not yet available. There is some evidence favouring divalproex, but it is not particularly strong .We do not know if there are any efficacy differences among antipsychotics for this indication.

Akathisia and second-generation antipsychotic drugs

PURPOSE OF REVIEW

Akathisa is one of the most common and distressing neuroleptic-induced extrapyramidal side effects. Although it is well recognized in the context of conventional antipsychotic medications, there have been recent concerns raised by clinicians and researchers that this syndrome is overlooked in relation to second-generation or atypical antipsychotics. This review examines the recent literature relevant to second-generation antipsychotic (SGA)-induced akathisia.

RECENT FINDINGS

Recent studies using large databases clearly indicate that extrapyramidal side effects, in particular akathisia, do occur with the SGAs, although the frequency is not as high as with the conventional antipsychotics. Risk factors include use of high doses, high potency SGAs, or combinations of SGAs with other psychotropic drugs, bipolar depression, palliative care settings, and comorbid substance abuse in psychosis. The dopamine hypothesis remains plausible for understanding the pathophysiology of akathisia. There is emerging evidence that mirtazapine may be useful in the treatment of acute akathisia.

SUMMARY

Even though akathisia is less prevalent with SGAs than with the first-generation drugs, it remains clinically important and all clinicians should be conversant with its recognition and management.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania

These updated guidelines are based on a first edition that was published in 2003, and have been edited and updated with the available scientific evidence until end of 2008. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania in adults. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A-F). As these guidelines are intended for clinical use, the scientific evidence was finally asigned different grades of recommendation to ensure practicability.

Acute and long-term treatment of mania

The treatment of mania starts with a correct diagnosis and elementary measures to prevent risks for the patient, relatives, and others. Sometimes, compulsory admission and treatment may be required for a few days. Patients with psychotic or mixed mania may be more difficult to treat. At the present time, there is solid evidence supporting the use of lithium, the anticonvulsants valproate and carbamazepine, and the antipsychotics chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and asenapine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, combination therapy is the rule rather than the exception. The treatment of acute mania deserves a long-term view, and the evidence base for some treatments may be stronger than for others. When taking decisions about treatment, tolerability should also be a major concern, as differences in safety and tolerability may exceed differences in efficacy for most compounds. Psychoeducation of patients and caregivers is a powerful tool that should be used in combination with medication for optimal long-term outcome. Functional recovery should be the ultimate goal.

Rapid-cycling bipolar I disorder: course and treatment outcome of a large sample across Europe

OBJECTIVES

To evaluate the baseline characteristics and follow-up outcomes of rapid-cycling (RC) bipolar I patients in a large, prospective, observational study.

METHODS

EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a long-term prospective observational study of in- and outpatients with an acute mania/mixed episode conducted in 14 European countries. Demographic and clinical variables were collected at baseline, including the presence or absence of DSM-IV rapid-cycling during the past year. Outcome measures included the 5-item Hamilton Depression Rating Scale (HAMD-5) and Young Mania Rating Scale (YMRS) over 12 weeks, as well as the Clinical Global Impressions-Bipolar Disorder Scale (CGI-BP overall, mania and depression) over 12 months.

RESULTS

Of 3684 patients enrolled, 3089 patients provided reliable data to qualify for either RC (N=535, 17.3%) or non-RC (NRC, N=2554), according to DSM-IV. RC prevalence varied across countries (p<0.001). Baseline and 12 week outcomes on the YMRS and HAMD-5, 12 month ratings on the CGI-BP subscales and work impairment at 12 months were significantly different (p<0.001) between groups, being worse in RC. RC patients were more likely to receive antidepressants and lamotrigine (p<0.001). Using logistic regression, RC was associated to country (p<0.001), female sex (p=0.029), outpatients (p=0.035), more history of attempted suicide (p<0.001) and alcohol abuse (p<0.001).

CONCLUSIONS

The EMBLEM results suggest that in naturalistic settings, patients with mania and RC differ from NRC in socio-demographic characteristics, treatment prescriptions and clinical outcome measures with a consistently worse occupational outcome and comorbidities. RC represents a longitudinally severe form of bipolar disorder, with poorly evidence-based diagnostic and therapeutic tools.

Efficacy and safety of quetiapine in combination with lithium or divalproex for maintenance of patients with bipolar I disorder (international trial 126)

BACKGROUND

This study examined the efficacy and safety of quetiapine in combination with lithium or divalproex compared with placebo with lithium or divalproex in the prevention of recurrent mood events in bipolar I patients, most recent episode mania, depression, or mixed.

METHODS

Patients received open-label quetiapine (400-800 mg/day; flexible, divided doses) with lithium or divalproex (target serum concentrations 0.5-1.2 mEq/L and 50-125 microg/mL, respectively) for up to 36 weeks to achieve at least 12 weeks of clinical stability. Patients were subsequently randomized to double-blind treatment with quetiapine (400-800 mg/day) plus lithium/divalproex or placebo plus lithium/divalproex for up to 104 weeks. The primary endpoint was time to recurrence of any mood event.

RESULTS

Treatment with quetiapine in combination with lithium/divalproex significantly increased the time to recurrence of any mood event compared with placebo plus lithium/divalproex. The proportion of patients having a mood event was markedly lower in the quetiapine than in the placebo group (18.5% versus 49.0%). The hazard ratio for time to recurrence of a mood event was 0.28 (P<0.001), a mania event 0.30 (P<0.001), and a depression event 0.26 (P<0.001) corresponding to risk reductions of 72%, 70%, and 74%, respectively. During the randomization phase, the most common adverse events occurring in > or =5% in the quetiapine group were somnolence, nasopharyngitis, and headache. Insomnia was more common in the placebo group. During the randomization phase, there was an increase in weight of 0.5 kg in the quetiapine group and a reduction of 1.9 kg in the placebo group. The incidence and incidence density of a single emergent fasting blood glucose value> or =126 mg/dL was higher with quetiapine than with placebo (9.3% versus 4.1%; 17.6 versus 9.5 patients per 100 patient-years).

LIMITATIONS

This was an enriched sample of patients with bipolar I disorder responding to treatment with quetiapine plus lithium/divalproex.

CONCLUSIONS

Maintenance treatment with quetiapine in combination with lithium/divalproex significantly increased time to recurrence of any event (mania, depression, or mixed) irrespective of the polarity of the index episode compared with placebo with lithium/divalproex. Long-term treatment with quetiapine was generally well-tolerated. Quetiapine with lithium/divalproex can provide an effective long-term treatment option for bipolar I disorder to prevent recurrences not only of mania but also depression.

Weight gain in bipolar disorder: pharmacological treatment as a contributing factor

OBJECTIVE

The aim of this paper was to review the association of most commonly used psychopharmacological drugs with weight gain in bipolar disorder.

METHOD

Information was retrieved from a PubMed/Medline literature search reviewing weight gain in pharmacological studies in bipolar disorder.

RESULTS

Obesity and overweight in bipolar disorder are partly related to prescribed drugs with a strong effect of clozapine and olanzapine. Lesser but still relevant weight gain is caused by quetiapine, risperidone, lithium, valproate, gabapentin and by some antidepressants. Ziprasidone, aripiprazole, carbamazepine and lamotrigine do not seem to cause significant overweight.

CONCLUSION

Careful monitoring of weight changes in patients before and after drug prescription should be implemented in the clinical routine and drugs which potentially cause weight gain should be avoided in overweight patients with bipolar disorder. Furthermore, eating habits and daily activities should be targeted as they may also have a significant impact on overall health and weight-related issues.