Models of bipolar disease and their clinical implications

Mood stabilizers for patients with bipolar disorder: the state of the art

Bipolar disorder (BD) is a prevalent and disabling condition, often comorbid with other medical and psychiatric conditions and frequently misdiagnosed. International treatment guidelines for BD recommend the use of mood stabilizers - either in monotherapy or in association - as the gold standard in both acute and long-term therapy. Commonly used in the clinical practice of BD, mood stabilizers have represented an evolving field over the last few years. The concept of stabilization, in fact, has been stressed as the ultimate objective of the treatment of BD, given the chronic and recurrent nature of the illness, which accounts for its significant levels of impairment and disability. To date, different compounds are included within the broad class of mood stabilizers, with lithium, anticonvulsants and, more recently, atypical antipsychotics being the most representative agents. This article is aimed at providing an updated review of the available literature in relation to the role of mood stabilizers in BD, with particular emphasis on their mechanism of action, main clinical aspects and specific use in the different phases of BD treatment, according to the most recently published international treatment guidelines.

Bipolar mixed states and their treatment

Bipolar mixed states remain a nosologic dilemma, diagnostic challenge and neglected area of therapeutic research. While the outcome of mixed states is generally poorer than that of pure manic and depressive episodes, little is known about how to treat such a condition. The aim of this report is to investigate the results of clinical trials, including mixed bipolar patients, in order to provide some hints on the efficacy of the different compounds on this specific subpopulation. As a result of this research, it becomes clear that only dysphoric mania has been reasonably addressed in clinical trials, and unfortunately very little is known about the treatment of other mixed states. There is some indirect evidence that mixed mania may be more responsive to anticonvulsants than to lithium. Divalproate, and to a lesser extent carbamazepine, may be used either in monotherapy or as adjuncts to lithium. Use of other anticonvulsants, such as gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate or zonisamide is not yet supported by controlled data. The use of antidepressants is largely discouraged, as they may worsen this condition. On the other hand, atypical antipsychotics may be effective and safe either in monotherapy or in combination with lithium or valproate. Further research is urgently needed in this neglected area of psychiatry.