Bipolar depression: pharmacotherapy and related therapeutic strategies

Update on the assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form-2 (ATHF-SF2)

All definitions of treatment-resistant depression (TRD) require that patients have experienced insufficient benefit from one or more adequate antidepressant trials. Thus, identifying "failed, adequate trials" is key to the assessment of TRD. The Antidepressant Treatment History Form (ATHF) was one of the first and most widely used instruments that provided objective criteria in making these assessments. The original ATHF was updated in 2018 to the ATHF-SF, changing to a checklist format for scoring, and including specific pharmacotherapy, brain stimulation, and psychotherapy interventions as potentially adequate antidepressant treatments. The ATHF-SF2, presented here, is based on the consensus of the ATHF workgroup about the novel interventions introduced since the last revision and which should/should not be considered effective treatments for major depressive episodes. This document describes the rationale for these choices and, for each intervention, the minimal criteria for determining the adequacy of treatment administration. The Supplementary Material that accompanies this article provide the Scoring Checklist, Data Collection Forms (current episode and composite of previous episodes), and Instruction Manual for the ATHF-SF2.

Efficacy and safety of cariprazine in bipolar I depression: A double-blind, placebo-controlled phase 3 study

OBJECTIVE

To assess the efficacy, safety, and tolerability of cariprazine in the treatment of the depressed phase of bipolar I disorder in adults (NCT02670538).

METHODS

In this phase 3 double-blind placebo-controlled study, adult patients with bipolar I disorder according to the Diagnostic and Statistical Manual - 5th Edition criteria and a current depressive episode were randomized to placebo (n = 167), cariprazine 1.5 mg/day (n = 168) or cariprazine 3.0 mg/day (n = 158). Efficacy parameters were changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) total scores (primary) and Clinical Global Impressions - Severity (CGI-S) scores (secondary) from baseline to Week 6 compared to placebo. A mixed-model for repeated measures was used to estimate the least-squares mean differences (LSMD); P-values were adjusted for multiplicity. Adverse events (AEs), laboratory results, vital signs, and suicide risk were monitored.

RESULTS

Cariprazine 1.5 mg/day significantly reduced depressive symptoms on the primary (MADRS LSMD = -2.5; adjusted P = .0417) and secondary (CGI-S LSMD = -0.3; adjusted P = .0417) efficacy parameters vs placebo; differences were not statistically significant for cariprazine 3.0 mg/day. Common treatment-emergent AEs (≥5% in either cariprazine group and at least twice the incidence of placebo) were akathisia, restlessness, nausea, and fatigue. Mean metabolic parameter changes were low and generally comparable among groups; mean weight increases were ≤0.5 kg for all groups.

CONCLUSIONS

Cariprazine 1.5 mg/day significantly reduced depressive symptoms in adults with bipolar I depression compared to placebo, but differences were not significant for cariprazine 3.0 mg/day. The safety and tolerability profiles were similar to previous studies of cariprazine.

Factors associated with borderline personality disorder in major depressive patients and their relationship to bipolarity

Objective

To analyze the interface between borderline personality disorder (BPD) and bipolarity in depressed patients comorbid with BPD.

Methods

As part of National Multi-site Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 19 (3.9%) had comorbid BPD (BPD+), whereas 474 (96.1%) did not manifest this comorbidity (BPD−).

Results

Compared to BPD (−), BPD (+) patients displayed higher rates of bipolar (BP) disorders and temperaments, an earlier age at onset with a family history of affective illness, more comorbidity, more stressors before the first episode which was more often depressive or mixed, as well as a greater number and severity of affective episodes.

Conclusions

The hypothesis which fitted at best our findings was to consider BPD as a contributory factor in the development of BP disorder, which could have favoured the progression from unipolar major depression to BP disorder. We could not however exclude that some features of BP disorder may have contributed to the development of BPD.

Electrochemical Detection and Quantification of Lithium Ions in Authentic Human Saliva Using LiMn2O4-Modified Electrodes

We report an electrochemical sensor for the detection of lithium ions (Li⁺) in authentic human saliva at lithium manganese oxide (LiMn₂O₄)-modified glassy carbon electrodes (LMO-GCEs) and screen-printed electrodes (LMO-SPEs). The sensing strategy is based on an initial galvanostatic delithiation of LMO followed by linear stripping voltammetry (LSV) to detect the reinsertion of Li⁺ in the analyte. The process was investigated using powder X-ray diffraction and voltammetry. LSV measurements reveal a measurable lower limit of 50.0 μM in both LiClO₄ aqueous solutions and synthetic saliva samples, demonstrating the applicability of the proposed analytical method down to low Li⁺ concentrations. Four different samples of authentic human saliva were then analyzed with the established sensing strategy using LMO-SPEs, showing good linearity over a concentration range up to 5.0 mM Li⁺ with high reproducibility (RSD < 7%) and applicability for routine monitoring purposes. The total time needed to analyze a sample is less than 3 min.

Cariprazine Treatment of Bipolar Depression: A Randomized Double-Blind Placebo-Controlled Phase 3 Study

OBJECTIVE

Cariprazine, a dopamine D₃/D₂ and 5-HT_1A receptor partial agonist, was found to be effective in treating bipolar I depression in a previous phase 2 study. This phase 3 study further assessed the efficacy, safety, and tolerability of cariprazine in bipolar I depression.

METHODS

In a double-blind placebo-controlled study, adult participants (18-65 years old) who met DSM-5 criteria for bipolar I disorder and a current depressive episode were randomly assigned to receive placebo (N=158) or cariprazine at 1.5 mg/day (N=157) or 3.0 mg/day (N=165). The primary and secondary efficacy parameters were changes from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale (MADRS) score and Clinical Global Impressions severity (CGI-S) score, respectively. Least squares mean differences were estimated using a mixed model for repeated measures, and p values were adjusted for multiplicity.

RESULTS

Both dosages of cariprazine were significantly more effective than placebo in improving depressive symptoms (reducing MADRS total score); the least squares mean differences were -2.5 (95% CI=-4.6, -0.4) for cariprazine at 1.5 mg/day and -3.0 (95% CI=-5.1, -0.9) for cariprazine at 3.0 mg/day. Both cariprazine dosages were associated with lower CGI-S scores compared with placebo, but the differences did not reach statistical significance after adjustment for multiplicity (least squares mean difference, -0.2 [95% CI=-0.5, 0.0] for the 1.5 mg/day group and -0.3 [95% CI=-0.5, 0.0] for the 3.0 mg/day group). Common treatment-emergent adverse events (in at least 5% of participants in either cariprazine treatment group and twice the rate of the placebo group) were nausea, akathisia, dizziness, and sedation. Mean changes in weight and metabolic parameters were relatively small and comparable across groups.

CONCLUSIONS

Cariprazine, at both 1.5 mg/day and 3.0 mg/day, was effective, generally well tolerated, and relatively safe in reducing depressive symptoms in adults with bipolar I depression.

The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF)

There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.

Treatment and Prevention of Depression

Depression is one of the most common and debilitating psychiatric disorders and is a leading cause of suicide. Most people who become depressed will have multiple episodes, and some depressions are chronic. Persons with bipolar disorder will also have manic or hypomanic episodes. Given the recurrent nature of the disorder, it is important not just to treat the acute episode, but also to protect against its return and the onset of subsequent episodes.

Several types of interventions have been shown to be efficacious in treating depression. The antidepressant medications are relatively safe and work for many patients, but there is no evidence that they reduce risk of recurrence once their use is terminated. The different medication classes are roughly comparable in efficacy, although some are easier to tolerate than are others. About half of all patients will respond to a given medication, and many of those who do not will respond to some other agent or to a combination of medications. Electro-convulsive therapy is particularly effective for the most severe and resistant depressions, but raises concerns about possible deleterious effects on memory and cognition. It is rarely used until a number of different medications have been tried.

Although it is still unclear whether traditional psychodynamic approaches are effective in treating depression, interpersonal psychotherapy (IPT) has fared well in controlled comparisons with medications and other types of psychotherapies. It also appears to have a delayed effect that improves the quality of social relationships and interpersonal skills. It has been shown to reduce acute distress and to prevent relapse and recurrence so long as it is continued or maintained. Treatment combining IPT with medication retains the quick results of pharmacotherapy and the greater interpersonal breadth of IPT, as well as boosting response in patients who are otherwise more difficult to treat. The main problem is that IPT has only recently entered clinical practice and is not widely available to those in need.

Cognitive behavior therapy (CBT) also appears to be efficacious in treating depression, and recent studies suggest that it can work for even severe depressions in the hands of experienced therapists. Not only can CBT relieve acute distress, but it also appears to reduce risk for the return of symptoms as long as it is continued or maintained. Moreover, it appears to have an enduring effect that reduces risk for relapse or recurrence long after treatment is over. Combined treatment with medication and CBT appears to be as efficacious as treatment with medication alone and to retain the enduring effects of CBT. There also are indications that the same strategies used to reduce risk in psychiatric patients following successful treatment can be used to prevent the initial onset of depression in persons at risk. More purely behavioral interventions have been studied less than the cognitive therapies, but have performed well in recent trials and exhibit many of the benefits of cognitive therapy.

Mood stabilizers like lithium or the anticonvulsants form the core treatment for bipolar disorder, but there is a growing recognition that the outcomes produced by modern pharmacology are not sufficient. Both IPT and CBT show promise as adjuncts to medication with such patients. The same is true for family-focused therapy, which is designed to reduce interpersonal conflict in the family. Clearly, more needs to be done with respect to treatment of the bipolar disorders.

Good medical management of depression can be hard to find, and the empirically supported psychotherapies are still not widely practiced. As a consequence, many patients do not have access to adequate treatment. Moreover, not everyone responds to the existing interventions, and not enough is known about what to do for people who are not helped by treatment. Although great strides have been made over the past few decades, much remains to be done with respect to the treatment of depression and the bipolar disorders.

Pilot study of a culturally adapted psychoeducation (CaPE) intervention for bipolar disorder in Pakistan

BACKGROUND

Despite the use of maintenance medication, recurrence rates in bipolar affective disorder (BPAD) are high. To date, there are no clinical trials that have investigated the use of psychological interventions in bipolar disorder in Pakistan.

AIM

The purpose of the study was to assess the feasibility and acceptability of a culturally adapted bipolar psychoeducation programme (CaPE) in Pakistan.

METHODS

Thirty-four euthymic bipolar I and II outpatients were randomized to either 12 weekly sessions of individual psychoeducation plus Treatment As Usual (Intervention) or Treatment As Usual (TAU) (Control). Outcomes were assessed using the Young Mania Rating Scale (YMRS), Beck Depression Inventory (BDI), EuroQoL (EQ-5D), Bipolar Knowledge and Attitudes and Questionnaire (BKAQ), and a self-reported measure of medication adherence (Morisky Medication Adherence Scale-4 items, MMAS-4). Effect sizes were derived from baseline adjusted standardized regression coefficients.

RESULTS

Retention in the study was good, 80% of patients in the TAU follow-up assessment and 100% of patients in the CaPE group attended all 12 sessions. Patient satisfaction was higher in the CaPE group relative to control (ES = 1.41). Further, there were large effect sizes shown for CaPE versus TAU for medication adherence (MMAS-4: ES = 0.81), knowledge and attitudes towards bipolar (BKAQ: ES = 0.68), mania (YMRS: ES = 1.18), depression (BDI: ES = 1.17) and quality of life measures (EQ-5D: ES ⇒ 0.88).

CONCLUSIONS

Culturally adapted psychoeducation intervention is acceptable and feasible, and can be effective in improving mood symptoms and knowledge and attitudes to BPAD when compared with TAU. Larger scale studies are needed to confirm our findings.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02210390.

The association of unipolar depression with thirty-day mortality after hospitalization for infection: A population-based cohort study in Denmark

OBJECTIVE

While depression is associated with higher risk of death due to chronic medical conditions, it is unknown if depression increases mortality following serious infections. We sought to determine if pre-existing unipolar depression is associated with increased mortality within 30days after hospitalization for a serious infection.

METHODS

We conducted a population-based cohort study of all adults hospitalized for an infection in Denmark between 2005 and 2013. Pre-existing unipolar depression was ascertained via psychiatrist diagnoses or at least two antidepressant prescription redemptions within a six month period. Our primary outcome was all-cause mortality within 30days after infection-related hospitalization. We also studied death due to infection within 30days after admission.

RESULTS

We identified 589,688 individuals who had a total of 703,158 hospitalizations for infections. After adjusting for demographics, infectious diagnosis and time since infection, socioeconomic factors and comorbidities, pre-existing unipolar depression was associated with slightly increased risk of all-cause mortality within 30days after infection-related hospitalization (Mortality Rate Ratio [MRR]: 1.07, 95% Confidence Interval [95% CI]: 1.05, 1.09). The association was strongest among persons who initiated antidepressant treatment within one year before the infection (MRR: 1.30, 95% CI: 1.25, 1.35). Pre-existing unipolar depression was associated with increased risk of death due to sepsis (MRR: 1.30, 95% CI: 1.17, 1.44), pneumonia (MRR: 1.23, 95% CI: 1.16, 1.29) and urinary tract infection (MRR: 1.25, 95% CI: 1.08, 1.44) after adjusting for demographics, infectious diagnosis at admission and time since infection.

CONCLUSIONS

Pre-existing unipolar depression is associated with slightly increased mortality following hospitalization for an infection.

Efficacy of Tranylcypromine in Bipolar Depression: A Systematic Review

OBJECTIVE

Currently, there is a paucity of treatment options with limited efficacy for bipolar depression. The monoamine oxidase inhibitor tranylcypromine might be an effective form of treatment. The current systematic review reassesses the efficacy and safety of tranylcypromine in bipolar depression.

METHODS

For this systematic review comparing tranylcypromine with placebo or active comparators in bipolar depression, relevant randomized controlled trials were identified from systematic searches of PubMed, EMBASE, and Cochrane library databases. A manual search of the references of the included studies was also performed.

RESULTS

Four studies with a total of 145 participants were identified. Response rates were higher in patients treated with tranylcypromine (60.0%-80.7%; overall response rate, 73.7%) compared with placebo, imipramine, and lamotrigine (the latter as add-on to a mood stabilizer) (12.9%-47.6%; overall response rate, 27.5%). The overall switch rate was 6.3% for patients treated with tranylcypromine and 18.4% for patients in the control group.

CONCLUSIONS

This systematic review provides evidence for the efficacy and safety of tranylcypromine treatment in bipolar depression. Additional research is required to establish the efficacy of tranylcypromine as add-on to a mood stabilizer.

Effect of quetiapine XR on depressive symptoms and sleep quality compared with lithium in patients with bipolar depression

BACKGROUND

Bipolar depression is one of the most serious psychiatric conditions. In addition, sleep disturbance in bipolar disorder is common, and therapeutic agents restoring sleep disturbances in bipolar disorder patients will be clinically beneficial. In the current study, we compared the effect of quetiapine XR with lithium on depressive symptoms and sleep in bipolar depression patients during 8 weeks of trial.

METHODS

An open-label, randomized comparison of sleep-activity and depressive symptoms between 8-week quetiapine XR monotherapy and lithium monotherapy for bipolar depression was conducted. Each assessment consisted of HDRS-17, Clinical Global Impression-severity (CGI-S), and self-reported Pittsburgh Sleep Quality Index (PSQI). Actigraphy-measured sleep parameters were assessed.

RESULTS

A total of 42 patients (35.7±10.9 years; gender: male 15, female 27) with bipolar depression were screened out. Out of 42 patients, six patients were excluded before randomization. After randomization, seven patients were withdrawn. Twenty-nine patients with more than two visits after randomization (lithium group: 17, quetiapine XR group: 12, mean age: 36.1±10.4, gender: male 13, female 16) were included in the final analysis. In both groups, Hamilton Depression Rating Scale (HDRS) scores were significantly decreased at weeks 1, 2, 4, 6, and 8 compared with baseline. Remission rate (HDRS≤7) in the quetiapine XR was significantly higher than that of the lithium group. In the quetiapine XR group, PSQI scores at weeks 1, 2, 4, 6, and 8 was significantly decreased compared with baseline. Sleep efficiency at weeks 6 and 8 was significantly increased. WASO at week 8 was significantly decreased.

LIMITATIONS

First, the present study was conducted with the relatively small number of study subjects. Second, bias could have affected the study results due to its open-label design. Third, study subjects were made up of high proportion of bipolar II disorder patients.

CONCLUSIONS

Quetiapine XR monotherapy was more effective in treating bipolar depression than lithium. In particular, quetiapine XR treatment improved both subjective and objective sleep quality in patients with bipolar depression. However, relationship between favorable sleep quality and depressive symptom improvement were limited.

The bipolar spectrum: diagnostic and pharmacologic considerations

Bipolar disorder represents a clinically challenging, episodic, lifelong medical illness that is both disabling and dangerous to the patient and is associated with a high risk of suicide. The prognosis for bipolar patients is likely to worsen with delays in accurate diagnosis and treatment as time is allowed for more extensive complications and morbidity to accrue and for alcohol or other substance use comorbidity to complicate the course of the illness. Physicians face several challenges when diagnosing bipolar disorder, including overlapping symptomatology and comorbidity with other disorders, as well as the somewhat restrictive and categorical approach taken by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the International Statistical Classification of Diseases, 10th Revision (ICD-10) diagnostic criteria. As a result, bipolar disorder is frequently unrecognized and misdiagnosed with considerable clinical and prognostic consequences for the patient. The accuracy of diagnosis of bipolar disorder could be improved through the introduction of a refined procedure for the identification and evaluation of a broader range of symptoms, and by careful attention to the presence of subthreshold symptomatology. A conceptual shift toward acceptance of a 'spectrum' model of bipolar disorder and the development of appropriate clinical diagnostic tools should assist physicians in differentiating bipolar disorder from other Axis I, Axis II, and personality disorders, as well as ensuring early diagnosis and therapeutic intervention.

Living with bipolar disorder

Bipolar disorder is a chronic, episodic disease characterized by intermittent episodes of depressive and manic symptoms. It causes significant and long-lasting distress, functional impairment and morbidity, and is associated with a high risk of mortality. Quality of life and disease burden, particularly in terms of lifestyle and general functioning, are gaining increasing recognition as valid therapeutic targets for intervention. Quality of life among patients with bipolar disorders is significantly impaired both during and between acute episodes. Somatic and mood symptoms, stigmatization, comorbid conditions, associated cognitive deficits and the burden of treatment all can combine to severely undermine patient quality of life and functioning at all levels. The tolerability of treatment is an important consideration when choosing a therapeutic option as patient satisfaction with, and adherence to, treatment can influence health outcomes and quality of life. Early intervention with the appropriate treatment can alter the course of bipolar disorder and improve the long-term experience of patients in their management of the disease.

Maintenance treatment in bipolar disorder: a focus on aripiprazole

Bipolar disorders (BD) are chronic medical syndromes heterogeneous in phenomenology, pathophysiology and treatment. The longitudinal course of bipolar disorders is often characterized by nonrecovery, subsyndromal symptoms, enduring cognitive deficits and impairment in psychosocial function. The risk for premature mortality from unnatural (e.g., suicide) as well as natural causes (e.g., cardiovascular disease) is significantly higher than the general population. The therapeutic objectives of maintenance therapy are to prevent relapse/recurrence, reduce the risk for premature mortality, promote functional restoration and enhance quality of life. A chronic disease management model, which includes pharmacologic and manual-based psychosocial interventions as paradigmatic components, provides a framework for best practice and optimal patient outcome. This article provides a succinct review of treatments approved by the US FDA for maintenance in bipolar disorders, with a focus on the most recently approved atypical antipsychotic, aripiprazole.

Managing patients with bipolar disorder at home: a family affair and a psychiatric challenge in home healthcare

Medicare has covered psychiatric home care for many years, but the delivery of psychiatric services in the home continues to raise questions related to coverage and criteria. What services do psychiatric nurses provide in the home? What are the rules and regulations governing this service? This article presents information related to psychiatric nursing in home care and specifically bipolar disease. These questions are answered within Chapter 7 of the Medicare Benefit Policy Manual, April 2011. Section 40.1.2.15.

The clinical management of bipolar disorder complexity using a stratified model

OBJECTIVE

To provide practical and clinically meaningful treatment recommendations that amalgamate clinical and research considerations for several common, and as yet understudied, bipolar disorder complex presentations, within the framework of a proposed stratified model.

METHODS

A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Web of Science) using key words (e.g., bipolar disorder, anxiety, rapid cycling, and subsyndromal). All relevant randomised controlled trials were examined, in addition to review papers, meta-analyses, and book chapters known to the authors. The findings formed the basis of the treatment recommendations within this paper.

RESULTS

In light of the many broad presentations of bipolar disorder, a stratified model of bipolar disorder complexity was developed to facilitate consideration of the myriad of complexities that can occur during the longitudinal course of illness and the appropriate selection of treatment. Evidence-based treatment recommendations are provided for the following bipolar disorder presentations: bipolar II disorder, subsyndromal symptoms, mixed states, rapid cycling, comorbid anxiety, comorbid substance abuse, and for the following special populations: young, elderly, and bipolar disorder around the time of pregnancy and birth. In addition, some key strategies for countering treatment non-response and alternative medication recommendations are provided.

CONCLUSIONS

Treatment recommendations for the more challenging presentations of bipolar disorder have historically received less attention, despite their prevalence. This review acknowledges the weaknesses in the current evidence base on which treatment recommendations are generally formulated, and additionally emphasises the need for high-quality research in this area. The stratified model provides a means for conceptualizing the complexity of many bipolar disorder presentations and considering their management.

Rumination in bipolar disorder: evidence for an unquiet mind

Depression in bipolar disorder has long been thought to be a state characterized by mental inactivity. However, recent research demonstrates that patients with bipolar disorder engage in rumination, a form of self-focused repetitive cognitive activity, in depressed as well as in manic states. While rumination has long been associated with depressed states in major depressive disorder, the finding that patients with bipolar disorder ruminate in manic states is unique to bipolar disorder and challenges explanations put forward for why people ruminate. We review the research on rumination in bipolar disorder and propose that rumination in bipolar disorder, in both manic and depressed states, reflects executive dysfunction. We also review the neurobiology of bipolar disorder and recent neuroimaging studies of rumination, which is consistent with our hypothesis that the tendency to ruminate reflects executive dysfunction in bipolar disorder. Finally, we relate the neurobiology of rumination to the neurobiology of emotion regulation, which is disrupted in bipolar disorder.

Bipolar depression: an evidence-based approach

Bipolar disorder is a complex, multidimensional illness that is often difficult to treat. Unfortunately, bipolar patients are much more likely to experience depression, which is all too often severe and a potentially lethal phase of the illness. In addition, pharmacotherapies with strong evidence for bipolar depression are limited. Most treatments are based on unsupported extrapolation from the treatment of unipolar depression or are derived largely from the clinical practice experience. In this article, we focus on the treatment of bipolar depression, with particular focus on evidence from the existing literature, to help guide readers in clinical practice.

Treatment-induced manic switch in the course of unipolar depression can predict bipolarity: cluster analysis based evidence

BACKGROUND

Antidepressants are known to induce manic switch in patients with depression. Treatment-induced mania is not considered as bipolar disorder in DSM IV. The aim of this study was to assess whether clinical characteristics of patients with unipolar depression with a history of treatment-induced mania were similar to those of patients with bipolar disorder.

METHOD

The study included 217 consecutive patients with DSM-IV mood disorders, diagnosed as: bipolar disorder type I (BP-I, n = 58) or type II (BP-II, n = 18) whose first episodes were depression, recurrent (unipolar) major depressive disorder with a history of antidepressant treatment-induced mania (switchers = sUD; n = 61) and without such an event (rUD; n = 80). First, the groups were compared with regard to clinical features and course specifiers using variance and chi-square analysis. Variables that differed significantly between the four groups were included in two-step cluster analysis to explore naturally occurring subgroups in all diagnoses. Subsequently, the relationship between the naturally occurring clusters and pre-defined DSM-IV diagnoses were investigated.

RESULTS

Two-step cluster analysis revealed two different naturally occurring groups. Higher severity of depressive episodes, with higher rate of melancholic features, higher number of hospitalization and suicide attempts were represented in one cluster where switchers (77%), bipolar I (94.8%) and II (83.3%) patients clustered together.

CONCLUSION

The findings of this study confirm that treatment-induced mania is a clinical phenomenon that belongs within the bipolar spectrum rather than a coincidental treatment complication, and that it should be placed under "bipolar disorders" in future classification systems.

LIMITATIONS

The study includes the limitations of any naturalistic retrospective study.

[Bipolar depression: a review of current therapeutic strategies]

It is now acknowledged that depressive symptoms dominate the natural history of bipolar affective disorder. Treating bipolar depression therefore represents a major therapeutic issue that has paradoxically been understudied compared to the treatment of acute manic or hypomanic episodes. Thanks to a computerized and manual bibliographic search, we reviewed the literature pertaining to the somatic treatments of bipolar depression. It is initially advisable to implement or optimize the thymoregulator treatment by carrying out a blood titration and by adjusting the therapeutic rates as well as possible towards the upper recommended levels. In the second place, the adjunction of another mood stabilizer may be necessary to obtain euthymia while preventing a mood switch to mania. Atypical antipsychotics may have some efficacy in treating bipolar depression, but further evidence is needed. Antidepressants are generally prohibited due to the risk of induction of mania or rapid cycling. Their use is generally limited to severe cases in which the association of at least two mood stabilizers has failed.

Level of response and safety of pharmacological monotherapy in the treatment of acute bipolar I disorder phases: a systematic review and meta-analysis

In recent years, combinations of pharmacological treatments have become common for the treatment of bipolar disorder type I (BP I); however, this practice is usually not evidence-based and rarely considers monotherapy drug regimen (MDR) as an option in the treatment of acute phases of BP I. Therefore, we evaluated comparative data of commonly prescribed MDRs for both manic and depressive phases of BP I. Medline, PsycINFO, EMBASE, the Cochrane Library, the ClinicalStudyResults.org and other data sources were searched from 1949 to March 2009 for placebo and active controlled randomized clinical trials (RCTs). Risk ratios (RRs) for response, remission, and discontinuation rates due to adverse events (AEs), lack of efficacy, or discontinuation due to any cause, and the number needed to treat or harm (NNT or NNH) were calculated for each medication individually and for all evaluable trials combined. The authors included 31 RCTs in the analyses comparing a MDR with placebo or with active treatment for acute mania, and 9 RCTs comparing a MDR with placebo or with active treatment for bipolar depression. According to the collected evidence, most of the MDRs when compared to placebo showed significant response and remission rates in acute mania. In the case of bipolar depression only quetiapine and, to a lesser extent, olanzapine showed efficacy as MDR. Overall, MDRs were well tolerated with low discontinuation rates due to any cause or AE, although AE profiles differed among treatments. We concluded that most MDRs were efficacious and safe in the treatment of manic episodes, but very few MDRs have demonstrated being efficacious for bipolar depressive episodes.

Efficacy and mood conversion rate of short-term fluoxetine monotherapy of bipolar II major depressive episode

OBJECTIVE

As part of a long-term, relapse-prevention study of antidepressant versus mood stabilizer monotherapy of bipolar II major depressive episode, we prospectively examined the efficacy and mood conversion rate of initial fluoxetine monotherapy. We hypothesized that there would be a statistically significant reduction in depressive symptoms without a clinically meaningful increase in mood conversion symptoms.

METHODS

Patients received open-label fluoxetine monotherapy 10 to 80 mg daily for up to 14 weeks. Primary outcome was change over time in Hamilton Depression Rating score, with secondary outcomes including the proportion of treatment responders and remitters, change over time in Young Mania Rating Scale (YMRS) score, and frequency of mood conversion episodes.

RESULTS

One hundred forty-eight patients had at least 1 post-baseline measurement. Mean Hamilton Depression Rating score decreased by 9.0 points (P < 0.0005). There were 88 responder patients (59.5%; 95% confidence interval [CI], 51.1%-67.4%) (P < 0.0005) and 86 remitter patients (58.1%; 95% CI, 49.7%-66.2%) (P < 0.0005). Mean time to remission was 64.4 days (95% CI, 59.1-69.7 days). Six patients (4.1%; 95% CI, 1.5%-8.6%) (P < 0.0005) had hypomania, and 29 patients (19.6%; 95% CI, 13.5%-26.9%) (P < 0.0005) had subsyndromal hypomania, which did not result in treatment discontinuation. Six patients (4.1%; 95% CI, 1.5%-8.6%) had a YMRS score of 8 or greater (P < 0.0005), and 4 patients (2.7%; 95% CI, 0.7%-6.8%) (P < 0.0005) had a YMRS score of 12 or greater at any study visit.

CONCLUSIONS

Although design limitations constrain the interpretation of the current findings, fluoxetine monotherapy may be an effective short-term treatment of bipolar II major depressive episode with a relatively low rate of syndromal hypomanic episodes.

[Acute psychotic disorders related to bupropion: review of the literature]

RATIONALE AND OBJECTIVES

Bupropion, or amfebutamone, is an atypical antidepressant also used during tobacco cessation. From a structural standpoint, it resembles amphetamine drugs with psychostimulant effects, and endogenous monoamines. From a pharmacological standpoint, bupropion, and two of its most important active metabolites, inhibit dopamine and norepinephrine reuptake. It has recently been discovered that bupropion may act as a non-competitive cholinergic nicotinic receptor antagonist, and that it may inhibit the activation of reward systems triggered by nicotine. Buproprion's efficacy as a smoking cessation aid has been demonstrated by numerous clinical trials that have compared its effects with those of placebo and other nicotinic substitutes. In 2001, buproprion SR received marketing authorization in France as a smoking cessation aid, under the name ZYBAN®. Tobacco addiction indeed remains a major public health issue. Among patients with psychiatric conditions, chronic tobacco consumption is frequent. The development of non-nicotinic drugs may therefore enhance therapeutic possibilities. However, the psychotropic effects of these molecules should be taken into account. We have recently reported the case of a patient with schizoaffective disorder, who presented two acute bupropion-induced psychotic episodes. We have also undertaken an exhaustive bibliographical research on this subject. The aim of the present study is to present the information available to us, in order to suggest aetiopathogenic hypotheses and therapeutic proposals.

DATA SOURCES

The following databases were consulted on a regular basis, with no date restriction: Medline, Cochrane and Elsevier. The present study identified 22 cases of psychotic conditions associated with buproprion, as well as randomized and pharmacovigilance studies published in English, from December 1985 to November 2008. Since 2002, there have been three published case-reports on patients who underwent a tobacco cessation program.

DATA SYNTHESIS

Psychotic disorders associated with buproprion appear after an average of 10 days of 300 mg/d bupropion intake. In about two third of cases, the patients have no history of psychiatric conditions. In one third of cases, they have a history of thymic disorders. In our review, auditory, visual or cenaesthetic hallucinations frequently occur (85% of the reported cases), and are sometimes characterized by single episodes and/or are rationalized. Some of them occur along with delusional episodes (mystical, paranoid, etc.). The patients are restless, confused, but seldom exhibit dissociative and thymic symptoms.

DISCUSSION AND CONCLUSIONS

From an aetiopathogenic, clinical and evolutive standpoint, buproprion-induced psychotic episodes share many similarities with acute organic or toxic psychosis (notably induced by amphetamines). The hypothesis of a dopaminergic hyper-reactivity should be analyzed. Moreover, most of these patients were taking other medication, and the possibility of a dopaminergic potentialization prior to buproprion intake could be suggested. In such cases, bupropion should be discontinued and complete remission is expected within an average of 10 days. Even though neuroleptic drugs are still frequently used in these cases, benzodiazepines could become a valid alternative, according to the model of amphetamine-induced acute psychosis.

Venlafaxine monotherapy in bipolar type II depressed patients unresponsive to prior lithium monotherapy

OBJECTIVE

We examine the safety and efficacy of venlafaxine monotherapy in bipolar type II (BP II) patients with major depressive episode (MDE) who were unresponsive to prior lithium monotherapy. We hypothesized that venlafaxine would be superior to lithium with a low hypomanic conversion rate.

METHOD

Seventeen patients who were unresponsive to prior lithium monotherapy were crossed to venlafaxine monotherapy for 12 weeks. The primary outcome was within-subject change in total Hamilton Depression Rating (HAM-D) score over time. Secondary outcomes included the change in Young Mania Rating (YMRS) and clinical global impressions severity (CGI/S) and change (CGI/C) scores.

RESULTS

Venlafaxine produced significantly greater reductions in HAM-D (P < 0.0005), CGI/S (P < 0.0005), and CGI/C (P < 0.0005) scores vs. prior lithium. There was no difference in mean YMRS scores between treatment conditions (P = 0.179).

CONCLUSION

Venlafaxine monotherapy may be a safe and effective monotherapy of BP II MDE with a low hypomanic conversion rate in lithium non-responders.

Rash in adult patients receiving lamotrigine to treat bipolar I disorder in Korea: a multicenter, prospective, naturalistic, open-label trial

The goal of this study was to assess the incidence of rash occurring in patients received lamotrigine to treat bipolar I disorder in a real world setting in Korea. We included a heterogeneous sample with multiple medications and medical comorbidities. Lamotrigine was added to the current therapy regime for DSM-IV bipolar I patients on an open-label basis for 12 weeks. The incidences of rash and other adverse events were assessed. The primary outcome measure was the incidence of rash. A total of 237 adult patients were included in the present study and 173 patients (73.0%) completed the 12 weeks of treatment. Thirty patients (12.7%) developed a rash, of whom 2 (0.8%) developed a serious rash. There were no patients who developed Stevens-Johnson syndrome or toxic epidermal necrolysis. The median time of rash onset was 16 days. As a group, patients who did not experience rash were significantly heavier than those who did. Our findings suggest that the incidence of serious rash associated with lamotrigine is low. The prescription of lamotrigine should be undertaken with appropriate consideration of the potential risk of adverse events including rash to the patient in relation to potential benefit from improvement of bipolar disorder.

Family focused treatment for patients with bipolar disorder in Turkey: a case series

Family-focused therapy (FFT) is a 9-month, 21-session structured psychoeducational treatment for bipolar disorder. Several US-based studies have documented its efficacy as adjunctive to medication for depression stabilization and relapse prevention. However, FFT has never been applied outside of the United States. The objective of this case series is to explore the applicability of FFT in a non-Western culture. Ten patients with bipolar disorder and their family members attended the 9-month FFT as adjunctive to pharmacotherapy in an outpatient specialty clinic in Izmir, Turkey. Patients improved in Global Assessment of Functioning Scores and Clinical Global Impression Scores from pre- to posttreatment. Case studies are given, which illustrate the differences between Western and non-Western families coping with bipolar disorder. FFT was easily applied to a Turkish sample with few changes in format or focus. Adaptations included substitution of oral for written therapeutic tasks or homework assignments. Randomized controlled trials are needed to test the clinical effectiveness of FFT and other psychosocial interventions in non-Western cultures.

Psychotherapy as monotherapy for the treatment of bipolar II depression: a proof of concept study

OBJECTIVES

We conducted a proof of concept study to determine the feasibility of using an individual psychotherapy, Interpersonal and Social Rhythm Therapy (IPSRT), as monotherapy for the acute treatment of bipolar II depression.

METHODS

Unmedicated individuals (n = 17) meeting DSM-IV criteria for bipolar II disorder and currently depressed received weekly psychotherapy (IPSRT) for 12 weeks. After 12 weeks of acute treatment, individuals received an additional 8 weeks of follow-up treatment consisting of continued weekly IPSRT with supplementary lamotrogine for IPSRT non-responders.

RESULTS

By week 12, 41% (n = 7) of the sample responded to IPSRT monotherapy (defined as > or =50% reduction in depression scores without an increase in mania scores), 41% (n = 7) dropped out of or were removed from the study, and 18% (n = 3) did not respond to treatment. By week 20, 53% (n = 9) had achieved a response and 29% (n = 5) achieved a full remission of symptoms.

CONCLUSIONS

Interpersonal and Social Rhythm Therapy appears to be a promising intervention for a subset of individuals with bipolar II depression. A randomized controlled trial is needed to systematically evaluate the efficacy of IPSRT as an acute monotherapy for bipolar II depression.

Venlafaxine versus lithium monotherapy of rapid and non-rapid cycling patients with bipolar II major depressive episode: a randomized, parallel group, open-label trial

BACKGROUND

There is a paucity of controlled clinical data on the best initial therapy for treating patients with bipolar type II (BP II) major depressive episode (MDE). In this analysis, we examined the safety and antidepressant efficacy of short-term venlafaxine versus lithium monotherapy in rapid and non-rapid cycling patients with BP II MDE. We hypothesized that lithium would have superior efficacy to venlafaxine, with fewer syndromal and sub-syndromal hypomanic and mixed mood conversions in the rapid cycling BP II MDE patients.

METHODS

Patients were randomized to monotherapy with either venlafaxine 37.5-375 mg daily or lithium 300-2100 mg daily for 12 weeks. The primary outcome measure was the 28-item Hamilton Depression Rating (HAM-D 28), with embedded 'typical' HAM-D 17 and 'atypical' HAM-D 17-R symptom scores. Secondary outcomes included the Young Mania Rating Scale (YMRS), clinical global impressions severity (CGI/S) and change (CGI/C) ratings, the proportion of responders (with > or =50% reduction in baseline HAM-D score) and remitters (with a final HAM-D score </=8), and the proportion of patients with syndromal and sub-syndromal mood conversions.

RESULTS

Forty-three patients received venlafaxine (12 rapid cycling) and 40 patients received lithium (15 rapid cycling): 48 (57.8%) were women and 69 (82.1%) were Caucasian. Thirty-three patients (39.8%) prematurely discontinued therapy: 11 for lack of efficacy, 13 for adverse events, 2 for non-compliance, and 7 who were lost to follow up. Venlafaxine produced a greater reduction in HAM-D 28 (p=0.001) and HAM-D 17 (p=0.002) scores (versus lithium) that was independent of cycling status (0.358). Venlafaxine also resulted in a higher rate of responders (p=0.021) and remitters (p=0.001) in rapid cycling patients. There was no significant difference in baseline mean YMRS scores, or mean YMRS change scores over time, between rapid and non-rapid cycling patients. Venlafaxine did not result in a higher proportion of mood conversions (versus lithium) in either the rapid or non-rapid cycling patients.

LIMITATIONS

This was a secondary analysis of rapid versus non-rapid cycling BP II MDE patients. The study was originally powered to detect differences in efficacy between treatment conditions, and was not specifically powered to detect differences in efficacy or mood conversion episodes between rapid and non-rapid cycling groups. We used a conservative life-time definition of rapid cycling (i.e., an average > or =4 affective episodes per year). We did not employ a patient-recorded daily chrono-record to identify ultra-short mood conversions. The study used a randomized, parallel group, open-label design.

CONCLUSION

These observations from this exploratory analysis suggest that venlafaxine monotherapy may be more effective than lithium monotherapy, with a similar mood conversion rate, in rapid and non-rapid cycling patients with BP II MDE. These data support prior observations that venlafaxine monotherapy may be effective initial treatment for BP II MDE.

Acute dehydroepiandrosterone treatment exerts different effects on dopamine and serotonin turnover ratios in the rat corpus striatum and nucleus accumbens

It has been shown that the steroid dehydroepiandrosterone (DHEA) interacts with dopamine (DA) and serotonin (5-HT) neurotransmitter systems, which are involved in the pathophysiology of neurological and psychiatric diseases such as Parkinson's disease as well as mood and psychotic disorders. To explore if DHEA modulates DA and 5-HT metabolism we analyzed the content of both neurotransmitters and their metabolites in the rat corpus striatum (CS) and nucleus accumbens (NAc) 2 h after steroid administration (30, 60 and 120 mg/kg i.p.). DHEA treatment significantly reduced DA turnover (up to 33%) in the CS, but increased 5-HT turnover (up to 76%) in both regions. Those effects could be relevant to mood and neurodegenerative disorders.

ECNP consensus meeting. Bipolar depression. Nice, March 2007

DSM-IV, specifically its text revision DSM-IV-TR, remains the preferred diagnostic system. When employed in general population samples, prevalence estimates of bipolar disorder are relatively consistent across studies in Europe and USA. In community studies, first onset of bipolar mood disorder is usually in the mid-teenage years and twenties, and the occurrence of a major depressive episode or hypomania is usually its first manifestation. Since reliable criteria for delineating unipolar (UP) and bipolar (BI) depression cross-sectionally are currently lacking, there is a longitudinal risk - probably over 10% - that initial UP patients ultimately turn out as BP in the longer run. Its early onset implies a severe potential burden of disease in terms of impaired social and neuropsychological development, most of which is attributable to depression. BIPOLAR DEPRESSION IN CHILDREN: Bipolar I disorder is rare in prepubertal children, when defined according to unmodified DSM-IV-TR criteria. A broad diagnosis of bipolar disorder risks confounding with other childhood psychopathology and has less predictive value for bipolar disorder in adulthood than the conservative definition. Nevertheless, empirical studies of drug and other treatments and longitudinal studies to assess validity of the broadly defined phenotype in children and adolescents are desirable, rather than extrapolation from adult bipolar practice. The need for an increased capacity to conduct reliable trials in children and adolescents is a challenge to Europe, whose healthcare system should allow greater participation and collaboration than other regions, via clinical networks. ECNP will aspire to facilitate such developments. BIPOLAR DEPRESSION IN ADULTS - UNIPOLAR/BIPOLAR CONTRAST: Despite some differences in symptom profiles and severity measures, a cross-sectional categorical distinction between bipolar (BP) and unipolar (UP) depression is currently impossible. For regulatory purposes, a major depressive episode, meeting DSM-IV-TR criteria, remains the same diagnosis, irrespective of the overall course of the disorder. However, in refining diagnosis in future studies and DSM-V, a probabilistical approach to the UP/BP distinction is more likely to be informative as recommended by the International Society for Bipolar Disorders (ISBD). Anxiety is a commonly present, often at syndromal levels, in bipolar populations. Thus, RCT inclusion criteria for trials not targeting anxiety, should accept co-morbid anxiety disorders as part of the history and even current anxiety symptoms, where these are not dominating the mental state at recruitment to a study. Rapid cycling patients defined as those suffering from 4 or more episodes per year, may also be recruited into trials of bipolar depression without impairing assay sensitivity. Illness severity critically affects assay sensitivity. The minimum scores for entry into a bipolar depression trials should be >20 on HAM-D (17 item scale). However, efficacy is best detected in patients with HAM-D >24 at baseline. THE USE OF RATING SCALES IN BIPOLAR DEPRESSION: There is some dissatisfaction with the HAM-D or MADRS as the preferred primary outcome for trials, although they probably capture global severity adequately. Secondary measures to capture so-called atypical symptoms (such as hypersomnia or hyperphagia), or specific psychopathology more common in bipolar participants (such as lability of mood), could be informative as secondary measures. TREATMENT STUDIES IN BIPOLAR DEPRESSION: Monotherapy trials against placebo remain the gold-standard design for determining efficacy in bipolar depression. The confounding effects of co-medication are emerging from the literature on antidepressant studies in bipolar depression, often conducted in combination with antimanic agents to avoid possible switch to mood elevation. Three arm trials, including the compound to be tested, placebo, and a standard comparator, are generally preferred in order to ensure assay sensitivity and a better picture of benefit-risk ratio. However, in the absence of any gold-standard, two-arm trials may be enough. If efficacy happens to be proven as monotherapy, new compounds may be tested in adjunctive-medication placebo-controlled designs. Younger adults, without an established need for long-term medication, may be particularly suitable for clinical trials requiring placebo controls. The conversion rate of initial UP depression, converting to become BP in the long run is estimated to be 10%. Switch to mania or hypomania may be the consequence of active treatment for bipolar depression. Some medicines such as the tricyclic antidepressants and venlafaxine may be more likely to provoke switch than others, but this increased rate of switch may not be seen until about 10 weeks of treatment. Twelve week trials against placebo are necessary to determine the risk of switch and to establish continuing effects. Careful assessment at 6-8 weeks is required to ensure that patients who are failing to respond do not continue in a study for unacceptable periods of time. To capture a switch event, studies should include scales to define the phenomenology of the event (e.g. hypomania or mania) and its severity. These may be best applied shortly after the clinical decision that switch is occurring. Long-term treatment is commonly required in bipolar disorder. Trials to detect maintenance of effect or continued response in bipolar depression should follow a 'relapse prevention' design: i.e. patients are treated in an index episode with the medicine of interest and then randomized to either continue the active treatment or placebo. However, acute withdrawal of active medication after treatment response might artificially enhance effect size due to active drug withdrawal effects. A short taper is usually desirable. Longer periods of stabilisation are also desirable for up to 3 months: protocol compliance may then be difficult to achieve in practice and so will certainly make studies more difficult and expensive to conduct. The addition of a medicine to other agents during or after the resolution of a depressive or manic episode, and its subsequent investigation as monotherapy against placebo to prevent further relapse (as in the lamotrigine maintenance trials) is clinically informative. Assay sensitivity and patient acceptability are enhanced if the outcome in long-term studies is 'time to intervention for a new episode' for discontinuation designs.

Comparison of short-term venlafaxine versus lithium monotherapy for bipolar II major depressive episode: a randomized open-label study

OBJECTIVE

Practice guidelines for the initial treatment of bipolar II (BP II) major depressive episode (MDE) recommend mood stabilizer (MS) monotherapy or combined MS plus antidepressant drug (AD) therapy. We hypothesized that initial AD monotherapy would be superior to MS monotherapy for BP II MDE with a low hypomanic switch rate.

METHODS

Bipolar II MDE patients were randomized to a 12-week open-label treatment with either venlafaxine monotherapy (n = 43) or lithium carbonate monotherapy (n = 40). The primary outcome measure was the 28-item Hamilton Depression Rating Scale (HAM-D 28). The secondary outcome measures included the Young Mania Rating Scale (YMRS), clinical global impressions severity and change ratings, and the proportion of patients classified as responder (with > or = 50% reduction in baseline HAM-D score) or as remitter (final HAM-D score, < or = 8).

RESULTS

Thirty-four venlafaxine-treated patients (79.1%) and 15 lithium-treated patients (37.5%) completed the trial (P < 0.0005). Venlafaxine monotherapy produced a greater reduction in HAM-D 28 scores, with a difference in change of -6.57 points (95% confidence interval, -11.97 to -1.18) (P = 0.017) between treatment conditions. There was a greater proportion of venlafaxine-treated (vs lithium-treated) patients classified either as treatment responder (58.1% vs 20.0%; P < 0.0005) or as treatment remitter (44.2% vs 7.5%; P < 0.0005) for the HAM-D 28 scores. There was no significant increase in mean YMRS scores over time in the venlafaxine (vs lithium) treatment condition, and no significant increase in mean YMRS scores at any study visit compared with baseline for either treatment.

CONCLUSIONS

Results from this study suggest that AD monotherapy with venlafaxine may be an effective initial therapy for BP II MDE with a low hypomanic switch rate.

STEP-BD and bipolar depression: what have we learned?

This article summarizes recent findings from the STEP-BD project pertaining to bipolar depression treatment. Highlighted are four papers that report, in turn, a large, randomized controlled trial of adjunctive antidepressants; a large, randomized controlled trial of adjunctive psychosocial therapies (cognitive-behavioral therapy, interpersonal social rhythms therapy, and family-focused therapy); a small, randomized controlled trial contrasting lamotrigine, risperidone, and inositol as add-on therapies for refractory bipolar depression; and a naturalistic study of the risks of relapse during preventive therapy. The STEP-BD results highlight the challenge of treating bipolar depression to remission, illustrate the value of adjunctive psychotherapies, and point to new directions for research.

Lithium: underappreciated and underused?

Lithium is a remarkable drug with a fascinating history. Although less popular than other anticonvulsant and atypical antipsychotic mood-stabilizing drugs, lithium is beneficial in bipolar disorder and may be superior to other drugs for treatment-resistant depression and for reducing suicidal behaviors. Various studies have demonstrated that lithium has neuroprotective and neurotrophic cellular effects in the brain, suggesting it may be "brain healthy" for patients with mood disorders and useful for patients with other neurodegenerative disorders. In this article, I describe the history of lithium and review important aspects of its clinical use.

Pharmacogenetics and pharmacogenomics of schizophrenia: a review of last decade of research

The last decade of research into the pharmacogenetics of antipsychotics has seen the development of genetic tests to determine the patients' metabolic status and the first attempts at personalization of antipsychotic treatment. The most significant results are the association between drug metabolic polymorphisms, mainly in cytochrome P450 genes, with variations in drug metabolic rates and side effects. Patients with genetically determined CYP2D6 poor metabolizer (PMs) status may require lower doses of antipsychotic. Alternatively, CYP2D6 ultrarapid matabolizers (UMs) will need increased drug dosage to obtain therapeutic response. Additionally, polymorphisms in dopamine and serotonin receptor genes are repeatedly found associated with response phenotypes, probably reflecting the strong affinities that most antipsychotics display for these receptors. In particular, there is important evidence suggesting association between dopamine 2 receptor (D2) polymorphisms (Taq I and -141-C Ins/Del) and a dopamine 3 receptor (D3) polymorphism (Ser9Gly) with antipsychotic response and drug-induced tardive dyskinesia. Additionally, there is accumulating evidence indicating the influence of a 5-HT2C polymorphism (-759-T/C) in antipsychotic-induced weight gain. Application of this knowledge to clinical practice is slowly gathering pace, with pretreatment determination of individual's drug metabolic rates, via CYP genotyping, leading the field. Genetic determination of patients' metabolic status is expected to bring clinical benefits by helping to adjust therapeutic doses and reduce adverse reactions. Genetic tests for the pretreatment prediction of antipsychotic response, although still in its infancy, have obvious implications for the selection and improvement of antipsychotic treatment. These developments can be considered as successes, but the objectives of bringing pharmacogenetic and pharmacogenomic research in psychiatric clinical practice are far from being realized. Further development of genetic tests is required before the concept of tailored treatment can be applied to psychopharmatherapy. This review aims to summarize the key findings from the last decade of research in the field. Current knowledge on genetic prediction of drug metabolic status, general response and drug-induced side effects will be reviewed and future pharmacogenomic and epigenetic research will be discussed.

Bipolar disorder: how far are we from a rigorous definition and effective management?

Bipolar disorder is a pathological disturbance of mood, characterized by waxing and waning manic, depressive and, sometimes distinctly mixed states. A diagnosis of bipolar disorder can only be made with certainty when the manic syndrome declares itself. Most individuals who are diagnosed with this disorder will experience both poles of the illness recurrently, but depressive episodes are the commonest cause of morbidity and, indeed, of death by suicide. Twin, adoption and epidemiological studies suggest a strongly genetic aetiology. It is a genetically and phenotypically complex disorder. Thus, the genes contributing are likely to be numerous and of small effect. Individuals with bipolar disorder also display deficits on a range of neuropsychological tasks in both the acute and euthymic phases of illness and correlations between number of affective episodes experienced and task performance are commonly reported. Current self-report and observer-rated scales are optimized for unipolar depression and hence limited in their ability to accurately assess bipolar depression. The development of a specific depression rating scale will improve the assessment of bipolar depression in both research and clinical settings. It will improve the development of better treatments and interventions. Guidelines support the use of antidepressants for bipolar depression. With regard to the adverse effects of antidepressants for bipolar depression, double-blind, placebo-controlled data suggest that antidepressant monotherapy or the addition of a tricyclic antidepressant may worsen the course of bipolar disorder. Importantly, adjunctive psychotherapies add significantly (both statistically and clinically) to the efficacy of pharmacological treatment regimens. The successful management of bipolar disorder clearly demands improved recognition of bipolar disorder and effective long-term treatment for bipolar depression as well as mania.

Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program

CONTEXT

Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder.

OBJECTIVE

To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression.

DESIGN

Randomized controlled trial.

SETTING

Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention.

INTERVENTIONS

Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks.

MAIN OUTCOME MEASURES

Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months.

RESULTS

All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies.

CONCLUSIONS

Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00012558.

Bipolar depression: diagnostic and treatment considerations

Bipolar affective disorder is a recurrent, disabling, and potentially lethal illness that typically begins early in life. Although the disorder is defined by the manic and hypomanic episodes, for most people the depression episodes are the more virulent aspect of the illness. Specifically, the depressive episodes are more numerous, last longer, and are more difficult to treat than the manias, and depression is the principal cause of the illness's increased mortality due to suicide. For people with early-onset depression, predictors of subsequent bipolarity include a family history, psychotic features, and reverse neurovegetative features. Initial episodes of depression are commonly misdiagnosed, which often delays initiation of appropriate therapy and increases the likelihood of treatment with antidepressants alone. Unfortunately, the correct diagnosis is often not made until there has been a treatment-emergent affective switch. There are no treatments specifically approved for bipolar disorder in youth and, among antidepressants, only fluoxetine has received approved. When bipolarity is suspected, treatment with mood stabilizers, both conventional (i.e., lithium, valproate, and carbamazapine) and more recently classified (lamotrigine) and atypical antipsychotics should be prioritized. When antidepressants are indicated in combination with mood stabilizers, first choice options include bupropion and the selective serotonin reuptake inhibitors. Studies of adults indicate that several forms of focused psychotherapy may improve longer term outcomes.

The interface between borderline personality disorder and bipolar spectrum disorders

OBJECTIVE

This review examines whether borderline personality disorder (BPD) should be considered part of the bipolar spectrum.

METHODS

A literature review examined studies of co-occurrence, phenomenology, family prevalence, medication response, longitudinal course, and etiology.

RESULTS

Borderline personality disorder and bipolar disorder co-occur, but their relationship is not consistent or specific. There are overlaps but important differences in phenomenology and in medication response. Family studies suggest clear distinctions, and it is unusual for BPD to evolve into bipolar disorder. Research is insufficient to establish whether these disorders have a common etiology.

CONCLUSIONS

Existing data fail to support the conclusion that BPD and bipolar disorders exist on a spectrum but allows for the possibility of partially overlapping etiologies.

Adjunctive topiramate treatment in refractory obese bipolar patients: a descriptive open label study

OBJECTIVES

To examine efficacy and tolerability of topiramate as an adjunctive treatment for overweight refractory bipolar patients.

METHOD

Patients (n=30) with Bipolar I or II, were provided with an open label treatment with topiramate as an add-on therapy. All patients deemed refractory to at least one mood stabilizer, were overweight, and were treated with topiramate as an adjuvant to existing medication for at least 12 weeks. The primary effectiveness measure was the Clinical Global Impression Scale (CGI). Other scales included the Young's Mania Rating Scale (YMRS), and the Hamilton Depression scale (HAMD21). Measures prior to adding topiramate were compared to those repeated at 4, 8 and 12 weeks. Tolerance, and weight changes were monitored.

RESULTS

There was significant reduction in both depressive and manic symptoms with adjunctive treatment. The mean BMI at 12 weeks of topiramate treatment dropped by 2 points (p<0.0001).

CONCLUSION

Topiramate is an effective adjunctive treatment in bipolar refractory patients and the significant weight reduction effects may result in important medical risk reductions, and make topiramate attractive for some obese bipolar patients.

The course and outcome of psychiatric illness in people with Prader-Willi syndrome: implications for management and treatment

BACKGROUND

This study is part of a larger UK-wide study investigating psychiatric illness in people with Prader-Willi syndrome (PWS), and describes the longitudinal aspect of psychiatric illness, in particular psychotic illness, and examines the use and role of psychotropic medication.

METHOD

A total of 119 individuals with genetically confirmed PWS were included in the study. An informant-based questionnaire was administered for each participant to screen for a history of psychopathology. Those who screened positive were visited at their homes to obtain further information. This assessment included a full psychiatric history and mental state examination using the Psychiatric Assessment Schedule for Adults with Developmental Disability and the Operational Criteria Checklist for psychotic and affective illness to collect information regarding phenomenology and course of illness, and a modified life events questionnaire. At the end of the study period, informant-based telephone interviews were again carried out, up to 2.5 years after the initial screening. Information regarding medication usage was collected.

RESULTS

The results confirm previous findings that psychiatric illness in people with PWS resembles an affective disorder. Individuals with the maternal uniparental disomy genetic subtype had a more severe course of illness than those with the deletion genetic subtype in terms of a greater risk of recurrence, more episodes, higher incidence and a possibly poorer response to medication with more side-effects. Individuals with a recurrent episode during the follow-up period had a poorer course of illness. Selective serotonin reuptake inhibitor medication is frequently used, and beneficial effects may reflect fundamental pathological processes in PWS. Mood-stabilizing medication was found to be of little benefit and reasons for this are examined.

CONCLUSION

The longitudinal course of psychiatric illness and response to medication in people with PWS is fully described. Further research is needed regarding the effect of psychotropic medications, particularly mood-stabilizing medication. These data will enable informed decisions to be made regarding management options and provide information on the possible long-term outcome of illness.

Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study)

This study evaluated the efficacy and tolerability of quetiapine monotherapy for depressive episodes in patients with bipolar I or II disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) who were randomized to 8 weeks of double-blind treatment with quetiapine (300 or 600 mg/d; once daily, evening dosing) or placebo. Patients were assessed weekly using the Montgomery-Asberg Depression Rating Scale (MADRS) and Hamilton Depression Rating Scale (HAM-D). The primary end point was change in MADRS total score from baseline to Week 8 (analysis of covariance/last-observation-carried-forward analysis). Of 509 patients randomized, 59% completed the study. Improvements from baseline in mean MADRS total scores were significantly greater with quetiapine 300 and 600 mg/d than with placebo from first evaluation (Week 1) through Week 8 (both P <or= 0.001 vs. placebo). Therapeutic effect sizes at Week 8 were 0.61 and 0.54 for quetiapine 300 and 600 mg/d, respectively. Improvements in mean HAM-D scores were also significantly greater with both quetiapine doses than with placebo (P < 0.001) as early as Week 1 and throughout the study. The MADRS response and remission rates were also significantly greater in both quetiapine dose groups compared with placebo. Improvements in primary and secondary outcomes were observed with both 300 and 600 mg/d quetiapine without major differences between the doses. Common adverse events included dry mouth, sedation, somnolence, dizziness, and constipation. The incidence of treatment-emergent mania or hypomania was lower with quetiapine treatment than placebo. This study demonstrates that quetiapine monotherapy is an effective and well-tolerated treatment for depressive episodes in bipolar disorder, confirming the results observed from a previous study (BipOLar DEpRession [BOLDER] I).

Pharmacotherapy of bipolar depression: an update

Bipolar affective disorder is a virulent illness with high rates of recurrence, disability, social impairment, and suicide. Although the manic or hypomanic episodes define the disorder, the depressions are more numerous and less responsive to treatment. As the initial depressive episodes are commonly misdiagnosed, initiation of therapy with mood stabilizers is often delayed, increasing the likelihood of treatment-emergent affective switches on antidepressant monotherapy. The empirical basis for selecting treatments for people with bipolar depression is weak, and only the combination of olanzapine and fluoxetine has received US Food and Drug Administration (FDA) approval. Conventional mood stabilizers are preferred for first-line therapies, although atypical antipsychotics are increasingly used, and FDA approval of quetiapine is pending. Antidepressants--particularly selective serotonin reuptake inhibitors and bupropion--are indicated when mood stabilizers are ineffective and for "breakthrough" depressions.

Antidepressants and suicidal behavior in bipolar disorder

Patients with bipolar disorder are at very high risk for suicidal ideation, non-fatal suicidal behaviors and suicide and are frequently treated with antidepressants. However, no prospective, randomized, controlled study specifically evaluating an antidepressant on suicidality in bipolar disorder has yet been completed. Indeed, antidepressants have not yet been shown to reduce suicide attempts or suicide in depressive disorders and may increase suicidal behavior in pediatric, and possibly adult, major depressive disorder. Available data on the effects of antidepressants on suicidality in bipolar disorder are mixed. Considerable research indicates that mixed states are associated with suicidality and that antidepressants, especially when administered as monotherapy, are associated with both suicidality and manic conversion. In contrast, growing research suggests that antidepressants administered in combination with mood stabilizers may reduce depressive symptoms in patients with bipolar depression. Further, the only prospective, long-term study evaluating antidepressant treatment and mortality in bipolar disorder, although open-label, found antidepressants and/or antipsychotics in combination with lithium, but not lithium alone, reduced suicide in bipolar and unipolar patients (Angst F, et al. J Affect Disord 2002: 68: 167-181). We conclude that antidepressants may induce suicidality in a subset of persons with depressive (and probably anxious) presentations; that this induction may represent a form of manic conversion, and hence a bipolar phenotype, and that lithium's therapeutic properties may include the ability to prevent antidepressant-induced suicidality.