Bipolar depression: issues in diagnosis and treatment

Should rTMS be considered a first-line treatment for major depressive episodes in adults?

Treatment-resistant depression (TRD) is an epidemic with rising social, economic, and political costs. In a patient whose major depressive episode (MDE) persists through an adequate antidepressant trial, insurance companies often cover alternative treatments which may include repetitive transcranial magnetic stimulation (rTMS). RTMS is an FDA-cleared neuromodulation technique for TRD which is safe, efficacious, noninvasive, and well-tolerated. Recent developments in the optimization of rTMS algorithms and targeting have increased the efficacy of rTMS in treating depression, improved the clinical convenience of these treatments, and decreased the cost of a course of rTMS. In this opinion paper, we make a case for why conventional FDA-cleared rTMS should be considered as a first-line treatment for all adult MDEs. RTMS is compared to other first-line treatments including psychotherapy and SSRIs. These observations suggest that rTMS has similar efficacy, fewer side-effects, lower risk of serious adverse events, comparable compliance, the potential for more rapid relief, and cost-effectiveness. This suggestion, however, would be strengthened by further research with an emphasis on treatment-naive subjects in their first depressive episode, and trials directly contrasting rTMS with SSRIs or psychotherapy.

Based on white matter microstructure to early identify bipolar disorder from patients with depressive episode

OBJECTIVE

Because of similar clinical manifestations, bipolar disorder (BD) patients are often misdiagnosed as major depressive disorder (MDD). This study aimed to compare the difference between depressed patients later converting to BD and unipolar depression (UD) according to diffusion tensor imaging (DTI).

METHOD

Patients with MDD (562 participants) in depressive episode states and healthy controls (HCs) (145 participants) were recruited over 10 years. Demographic and magnetic resonance imaging (MRI) data were collected at the time of recruitment. All patients with MDD were followed up for 5 years and classified into the transfer to BD (tBD) group (83 participants) and UD group (160 participants) according to the follow-up results. DTI and functional magnetic resonance imaging at baseline were compared.

RESULTS

Common abnormalities were found in both tBD and UD groups, including left superior cerebellar peduncle (SCP.L), right anterior limb of the internal capsule (ALIC.R), right superior fronto-occipital fasciculus (SFOF.R), and right inferior fronto-occipital fasciculus (IFOF.R). The tBD showed more extensive abnormalities than the UD in the body of corpus callosum, fornix, left superior corona radiata, left posterior corona radiata, left superior longitudinal fasciculus, and left superior fronto-occipital fasciculus.

CONCLUSION

The study demonstrated the common and distinct abnormalities of tBD and UD when compared to HC. The tBD group showed more extensive disruptions of white matter integrity, which could be a potential biomarker for the early identification of BD.

The Change of Suicidal Ideation Over a 12-Week Naturalistic Treatment of Depression: Comparison Between Young People and Older Adults

OBJECTIVE

We investigated the differences in suicidality between young people and older adults with depression over the course of 12-week naturalistic treatment with antidepressants.

METHODS

A total of 565 patients who had moderate to severe depression (Hamilton Depression Rating Scale [HAM-D] score ≥14) and significant suicidal ideation (Beck Scale for Suicide Ideation [SSI-B] score ≥6) were recruited from 18 hospitals. Participants were classified into two groups: the younger group (13-24 years of age, n=82) and the older group (≥25 years of age, n=483). Total scores over time on the SSI-B, HAM-D, and Hamilton Anxiety Rating Scale (HAM-A) were assessed and compared between the two groups.

RESULTS

At baseline, the younger group had lower HAM-D scores (21.0 vs. 22.2; p=0.028) but higher SSI-B scores (19.4 vs. 15.6; p<0.001) compared with the older group. The overall 12-week proportion of patients with resolved suicidality was 44.1% in the younger group and 69.2% in the older group. Although the improvement in the HAM-D and HAM-A scores did not differ between the groups, suicidal ideation in the younger group remained more severe than in the older group throughout the treatment. The ratio of the subjects who achieved HAM-D remission or response but did not achieve SSI-B remission was significantly higher in the younger group than in the older group.

CONCLUSION

These data suggest that in depressed youths, suicide risk is a serious concern throughout the course of depression even when favorable treatment outcomes are obtained.

Sleep Interventions in the Treatment of Schizophrenia and Bipolar Disorder

Due to the effects of sleep on the central nervous system, it is thought that sleep disorders have a special importance in the onset, course and treatment of psychiatric diseases. Although the negative effects of sleep problems on the occurrence, recurrence and clinical course of psychiatric disorders are well known, it is reported that clinicians do not spend enough time for sleep problems in practice. This may be related to the fact that patients underreport their complaints for various reasons, insufficient examination time, and clinicians' lack of knowledge about the importance of the subject. Pharmacotherapy, psychological and behavioral interventions are options among the therapeutic approaches to sleep problems. But, it seems that clinicians tend to prefer pharmacological approaches for the treatment of sleep problems. However, it is important to choose the appropriate treatment option with considering the method preferred by the patients, who already use many and high doses of pharmacological agents, the nature of the psychiatric disorder and the sleep problem. In this context, chronotherapeutic approaches such as bright light, sleep deprivation, interpersonal relations and social rhythm therapy, and cognitive behavioral therapy techniques adapted for patients with bipolar disorder can be used in the treatment of suitable patients. In this article, the current literature about sleep-related problems observed in patients with schizophrenia and bipolar disorder is reviewed comprehensively with presenting clinical phenotypes and treatment approaches.

Repetitive Transcranial Magnetic Stimulation in the Treatment of Bipolar Depression: Experience From a Clinical Setting

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive Food and Drug Administration (FDA)-approved treatment for unipolar treatment-resistant depression (TRD). rTMS has been utilized clinically to treat bipolar TRD; however, there remains a lack of evidence and support for effectively utilizing this intervention for bipolar TRD. We retrospectively analyzed data from a group of patients who were treated with rTMS for unipolar or bipolar TRD and describe a case example to further delineate management techniques for employing rTMS in the treatment of bipolar TRD.

METHODS

Records of 71 patients treated with rTMS for unipolar (n=54) or bipolar (n=17) TRD between 2008 and 2017 were reviewed. The primary outcome of depression severity, the Quick Inventory of Depressive Symptomatology, was completed at baseline and after every 5 sessions throughout the course of 30 treatments. Secondary outcomes involved a comparison of outcomes and clinical characteristics within and between the bipolar and unipolar TRD groups.

RESULTS

In the total sample, patients' depression improved significantly over the course of treatment. Patients with bipolar TRD showed greater response and remission rates over the course of treatment compared with patients with unipolar TRD, but this difference was not statistically significant. Both groups showed a similar pattern of depression response over treatment time. No manic or hypomanic episodes occurred during any patient's course of rTMS treatment. A case example is provided discussing the timing of rTMS in a patient with bipolar depression to decrease the likelihood of treatment-induced hypomania.

LIMITATIONS

Limitations included the small overall sample size, the smaller size of the patient group with bipolar TRD compared with the group with unipolar TRD, and the naturalistic setting of this study.

CONCLUSIONS

Our data suggest that rTMS may be equally effective and safe for patients with both unipolar and bipolar depression. Patients with bipolar TRD showed a similar response profile over treatment time compared with patients with unipolar TRD.

Trends of Polypharmacy and Prescription Patterns of Antidepressants in Asia

PURPOSE

Little is known regarding the trend of polypharmacy in Asia. We used data from 5 Asian countries to examine the patterns of antidepressant (AD) prescription and trends of psychotropic polypharmacy over time.

METHODS

We used the cross-sectional, pharmacoepidemiological data from 2004 and 2013 REAP-AD (Research on Asian Psychotropic Prescription Patterns for Antidepressants) to examine the patterns of AD prescriptions in clinical settings in China, Japan, Korea, Singapore, and Taiwan. We compared the trend in polypharmacy (ie, concomitant use of ≥2 classes of psychotropic) among individuals receiving AD prescriptions in 2004 and 2013 using multivariable logistic regression models in different diagnostic categories.

RESULTS

The proportion of patients with psychotropic polypharmacy decreased from 2004 to 2013 in all 3 diagnostic categories, including mood disorders (adjusted odds ratio [aOR], 0.44 [0.35-0.56]; P < 0.001), anxiety disorders (aOR, 0.58 [0.36-0.94]; P = 0.028), and psychotic disorders (aOR, 0.18 [0.05-0.60]; P = 0.006). Among individuals with AD prescriptions, concomitant use of anxiolytics (including sedative-hypnotics) decreased in patients with mood disorders (aOR, 0.34 [0.27-0.42]; P < 0.001) and anxiety disorders (aOR, 0.43 [0.27-0.67]; P < 0.001). In contrast, concomitant use of antipsychotics in patients with mood disorders increased (aOR, 1.43 [1.15-1.77]; P = 0.001), and concomitant use of mood stabilizers in patients with psychotic disorders also increased (aOR, 3.49 [1.50-8.14]; P = 0.004).

CONCLUSIONS

This is the first study examining trends in psychotropic polypharmacy in East Asia. We found a generally decreasing trend of psychotropic polypharmacy in contrast to the increasing trend reported from Western countries. These findings could offer significant implications for health system reform or policy making.

Repetitive Transcranial Magnetic Stimulation and Treatment-emergent Mania and Hypomania: A Review of the Literature

BACKGROUND

This review focuses on treatment-emergent mania/hypomania (TEM) associated with repetitive transcranial magnetic stimulation (rTMS).

METHODS

English-language studies involving possible rTMS-induced mania/hypomania published between 1966 and 2015 were retrieved through a Medline search using the search terms mania, hypomania, mixed affective state, treatment-emergent, repetitive transcranial magnetic stimulation, and rTMS. Fifteen case series and controlled studies describing TEM associated with rTMS treatment have been published involving 24 individuals, most of whom were diagnosed with either bipolar I or II disorder or major depressive disorder.

RESULTS

rTMS has been shown to possibly induce manic or hypomanic episodes in patients with depression, who are sometimes also taking antidepressants. Both high-frequency and low-frequency rTMS with different stimulus parameters may be associated with TEM in both males and females.

CONCLUSIONS

Given these findings, it is highly recommended that patients with bipolar disorder who are experiencing a depressive episode be prescribed a mood stabilizer and that patients diagnosed with major depressive disorder be reevaluated to consider the possibility that they might have bipolar disorder, before rTMS treatment is initiated. If TEM occurs, discontinuation of rTMS should be considered, while continuing mood-stabilizing medications. Further research is needed concerning the underlying neurobiological mechanisms and epidemiologic characteristics of TEM associated with rTMS.

An Open Effectiveness Trial of a Multimodal Inpatient Treatment for Depression and Anxiety Among Adults With Serious Mental Illness

OBJECTIVE

This prospective open effectiveness trial examined symptom change trajectories and rates of remission from depression and anxiety in an intensive multimodal inpatient treatment for adults with serious mental illness (SMI). Patient baseline characteristics were examined as mediators/moderators of treatment response.

METHODS

Adult inpatients with SMI (N = 994) completed an average of 39 days of inpatient treatment. Latent growth curve (LGC) methods were used to model symptom trajectories, estimating expected remission based on individual patterns of change observed across the sample.

RESULTS

Absolute reductions in symptoms were substantial, with large effect size improvements for both depression (d = 1.21, 95% CI [1.13, 1.29]) and anxiety (d = 1.13, 95% CI [1.05, 1.21]). For those presenting with elevated depressive symptoms (Patient Health Questionnaire-Depression ≥ 5.0; 87.5% of the sample), 46.9% evidenced remission from admission to discharge. Among patients presenting with significant anxiety (Patient Health Questionnaire-Generalized Anxiety Disorder Screener ≥ 5.0; 84.5% of the sample), 50.0% evidenced remission from admission to discharge. Mediation analyses revealed that depression and anxiety severity decreased more rapidly with increasing age and initial levels of experiential avoidance.

CONCLUSIONS

Rates of remission of depression and anxiety were greater than anticipated in this large cohort of adult SMI inpatients and may be related to intensity and length of hospitalization.

A negative double-blind controlled trial of sequential bilateral rTMS in the treatment of bipolar depression

BACKGROUND/OBJECTIVE

To explore the therapeutic benefit of sequential bilateral repetitive transcranial magnetic stimulation (rTMS) in the treatment of bipolar depression.

METHOD

A 2 arm randomized controlled parallel design trial comparing the use of active sequential bilateral rTMS to a sham form of stimulation in 49 patients with bipolar disorder and treatment resistant depression.

RESULTS

There was no significant difference in mean reduction in depression rating scale scores or response rates between active and sham stimulation.

LIMITATIONS

The study was of limited sample size and the use of bilateral rTMS limited generalizability to other forms of rTMS.

CONCLUSIONS

This study provides no support to the use of active sequential bilateral rTMS in the treatment of the depressive phase of bipolar affective disorder. Although this result is not definitive, we suggest that future research may be better focused on trials evaluating the use of unilateral types of rTMS.

Significant Treatment Effect of Bupropion in Patients With Bipolar Disorder but Similar Phase-Shifting Rate as Other Antidepressants: A Meta-Analysis Following the PRISMA Guidelines

Bupropion is widely used for treating bipolar disorder (BD), and especially those with depressive mood, based on its good treatment effect, safety profile, and lower risk of phase shifting. However, increasing evidence indicates that the safety of bupropion in BD patients may not be as good as previously thought. The aim of this study was to summarize data on the treatment effect and safety profile of bupropion in the treatment of BD via a meta-analysis. Electronic search through PubMed and ClinicalTrials.gov was performed. The inclusion criteria were: (i) studies comparing changes in disease severity before and after bupropion treatment or articles comparing the treatment effect of bupropion in BD patients with those receiving other standard treatments; (ii) articles on clinical trials in humans. The exclusion criteria were (i) case reports/series, and (ii) nonclinical trials. All effect sizes from 10 clinical trials were pooled using a random effects model. We examined the possible confounding variables using meta-regression and subgroup analysis. Bupropion significantly improved the severity of disease in BD patients (P < 0.001), and the treatment effect was similar to other antidepressants/standard treatments (P = 0.220). There were no significant differences in the dropout rate (P = 0.285) and rate of phase shifting (P = 0.952) between BD patients who received bupropion and those who received other antidepressants. We could not perform a detailed meta-analysis of every category of antidepressant, nor could we rule out the possible confounding effect of concurrent psychotropics or include all drug side effects. Furthermore, the number of studies recruited in the meta-analysis was relatively small. Our findings reconfirm the benefits of bupropion for the treatment of bipolar depression, which are similar to those of other antidepressants. However, the rate of phase shifting with bupropion usage was not as low compared to other antidepressants as previously thought, which should serve to remind clinicians of the risk of phase shifting when prescribing bupropion to BD patients regardless of the suggestions of current clinical practice guidelines.

Self-reported benefits and risks of yoga in individuals with bipolar disorder

BACKGROUND

Although hatha yoga has frequently been recommended for patients with bipolar disorder (BD) and there is preliminary evidence that it alleviates depression, there are no published data on the benefits-and potential risks-of yoga for patients with BD. Thus, the goal of this study was to assess the risks and benefits of yoga in individuals with BD.

METHODS

We recruited self-identified yoga practitioners with BD (N=109) to complete an Internet survey that included measures of demographic and clinical information and open-ended questions about yoga practice and the impact of yoga.

RESULTS

86 respondents provided sufficient information for analysis, 70 of whom met positive screening criteria for a lifetime history of mania or hypomania. The most common styles of yoga preferred were hatha and vinyasa. When asked what impact yoga had on their life, participants responded most commonly with positive emotional effects, particularly reduced anxiety, positive cognitive effects (e.g., acceptance, focus, or "a break from my thoughts"), or positive physical effects (e.g., weight loss, increased energy). Some respondents considered yoga to be significantly life changing. The most common negative effect of yoga was physical injury or pain. Five respondents gave examples of specific instances or a yoga practice that they believed increased agitation or manic symptoms; five respondents gave examples of times that yoga increased depression or lethargy.

CONCLUSIONS

Many individuals who self-identify as having BD believe that yoga has benefits for mental health. However, yoga is not without potential risks. It is possible that yoga could serve as a useful adjunctive treatment for BD.

Drug safety evaluation of naltrexone/bupropion for the treatment of obesity

INTRODUCTION

Obesity is a known health risk for the development of several preventable diseases. Obesity-related metabolic alterations negatively impact different physiological mechanisms, which supports the rationale for the use of combined drug therapy. Naltrexone is an opioid antagonist for the treatment of opioid and alcohol dependency, whereas bupropion is a norepinephrine/dopamine reuptake inhibitor used to treat depression and smoking cessation. Although not effective as individual monotherapies for obesity, naltrexone and bupropion in combination produce weight loss and a metabolic profile beneficial for the potential treatment of obesity.

AREAS COVERED

This review examines the safety and antiobesity effects of naltrexone and bupropion alone and in combination. It reviews the results of four Phase III clinical trials of a novel fixed dose of sustained-released naltrexone/bupropion.

EXPERT OPINION

Naltrexone/bupropion has a greater weight loss efficacy than two FDA-approved medications, orlistat and lorcaserin. Although the weight loss produced by phentermine/topiramate is superior to naltrexone/bupropion, the safety profile of naltrexone/bupropion has less severe adverse effects. In addition, naltrexone/bupropion is well tolerated, with nausea being the most reported adverse event. Unlike other centrally acting medications, lorcaserin and phentermine/topiramate, naltrexone/bupropion has no abuse potential.

Frontotemporal White Matter in Adolescents with, and at-Risk for, Bipolar Disorder

Frontotemporal neural systems are highly implicated in the emotional dysregulation characteristic of bipolar disorder (BD). Convergent genetic, postmortem, behavioral and neuroimaging evidence suggests abnormalities in the development of frontotemporal white matter (WM) in the pathophysiology of BD. This review discusses evidence for the involvement of abnormal WM development in BD during adolescence, with a focus on frontotemporal WM. Findings from diffusion tensor imaging (DTI) studies in adults and adolescents are reviewed to explore possible progressive WM abnormalities in the disorder. Intra- and interhemispheric frontotemporal abnormalities were reported in adults with BD. Although evidence in children and adolescents with BD to date has been limited, similar intrahemispheric and interhemispheric findings have also been reported. The findings in youths suggest that these abnormalities may represent a trait marker present early in the course of BD. Functional connectivity studies, demonstrating a relationship between WM abnormalities and frontotemporal dysfunction in BD, and DTI studies of vulnerability in first-degree relatives of individuals with BD, are discussed. Together, findings suggest the involvement of abnormal frontotemporal WM development in the pathophysiology of BD and that these abnormalities may be early trait markers of vulnerability; however, more studies are critically needed.

Pharmacologic treatment of bipolar disorder in children and adolescents

This review focuses mainly on published articles regarding the treatment of school-aged children and adolescents with pediatric bipolar disorder. In light of systematic reviews, large randomized controlled trial data are emphasized wherever possible. This review addresses the treatment of acute manic/mixed episodes, including combination treatment, the preliminary literature regarding bipolar depression among youth, treatment in the face of comorbid conditions, and maintenance treatment. Suggestions regarding future directions are offered. A clinical vignette describing a teen with bipolar disorder is presented and bipolar medications, dosing, efficacy, side effects, contraindications, and succinct comments on each medication are summarized.

Psychotropic drug and polypharmacy use among adolescents and young adults: findings from the Finnish 1981 Nationwide Birth Cohort Study

BACKGROUND

Little is known about the timing of the start of psychotropic drug use and psychotropic polypharmacy use.

AIMS

This study describes these patterns in a Finnish representative cohort aged between 12 and 25.

METHODS

5525 subjects born in 1981 were followed up between 1994 and 2005 using the Finnish National Prescription Register.

RESULTS

Survival analysis revealed that the cumulative incidence of any psychotropic drug use was 1.3% by age 15, 6.1% by age 20 and 15.2% by age 25. Antidepressants and benzodiazepines were the most used drug groups, with cumulative incidences of 12.2% and 5.2%, respectively, by age 25. The cumulative incidence of polypharmacy was 0.02% by age 15, 0.9% by age 20 and 4.1% by age 25, i.e. having purchased at least two psychotropic drugs from different classes during the same day. Polypharmacy occurred among the majority of antipsychotic and benzodiazepine users, but among a minority of antidepressant users. More females than males had used any psychotropic drug, antidepressants, the antidepressant-benzodiazepine combination and the antidepressant-mood stabilizer combination.

CONCLUSIONS

Both general psychotropic drug use and psychotropic polypharmacy use was often started in late adolescence.

Toward caring for oneself in a life of intense ups and downs: a reflexive-collaborative exploration of recovery in bipolar disorder

In this article, we discuss processes of recovery in bipolar disorder. We utilized a hermeneutical-phenomenological approach developed within a reflexive-collaborative framework to examine what individuals do to promote improvement and positive change in their own lives. The study was designed and carried out in collaboration with an expert-by-experience group of 12 coresearchers with firsthand experiences of mental distress and recovery. In-depth interviews were conducted with 13 participants who acknowledged having lived and dealt with a bipolar disorder. Four core themes were drawn from our analysis: (a) handling ambivalence about letting go of manic states; (b) finding something to hang on to when the world is spinning around; (c) becoming aware of signals from self and others; and (d) finding ways of caring for oneself. Interrelationships between the four themes, along with limitations, strengths, and implications of the study are discussed.

Agomelatine in unipolar depression in clinical practice: a retrospective chart review

Agomelatine (Valdoxan), a synthetic melatonergic receptor agonist at the MT1 and MT2 receptors, was first used in the management of sleep disorder. Its 5HT2C receptor antagonistic properties support its antidepressant potential. It is currently licensed in the UK, Europe and USA for the treatment of major depressive disorder. Although the randomized controlled evidence base for its use is growing, there are no retrospective, naturalistic studies available. We aimed to determine the tolerability and clinical effectiveness of agomelatine in unipolar depression. We also examined whether being refractory to treatment altered clinical outcome. Forty-eight patient records were examined. Twenty-five percent were treatment refractory: Clinical Global Impression (CGI) Severity score at the start of treatment was 3.81 compared with 3.38 at the end of treatment. Fifty-four percent improved at least minimally; only 12.5% were much or very much improved. Treatment-refractory patients had a poorer outcome with higher discontinuation rates and lower CGI Improvement (p = 0.0205). Treatment-refractory patients also had a higher CGI Severity score at the end of treatment than at treatment commencement (3.92 versus 3.75), although this was not statistically significant.

Long-term treatment of bipolar disorder with a radioelectric asymmetric conveyor

BACKGROUND

The bipolar spectrum disorders are considered an important and frequent psychiatric problem. The clinical complexity of these illnesses due to the coexistence of depressive and excitative phases is correlated with the global difficulty of adequate treatment; consequently, the prognosis is not optimal. For this reason, in recent years, novel nonpharmacologic physical approaches have been tested for bipolar disorders, with encouraging results. The aim of this study was to evaluate the long-term effectiveness of a radioelectric asymmetric brain stimulation device associated with lithium (REAC-lithium) versus previous treatments in subjects with bipolar disorder I or II, evaluated as the number of recurrences compared with the period of illness preceding treatment with REAC-lithium.

METHODS

The charts of 56 bipolar patients attending our institute were retrospectively evaluated. Treatment with REAC-lithium was administered following the standard Rinaldi-Fontani Institute protocol. Add-on treatments were allowed in the event of manic or depressive recurrence. Eight patients (Group 1) were followed for 30.2 ± 3.0 months, 14 patients (Group 2) were followed for 25.3 ± 3.3 months, 25 patients (Group 3) were followed for 20.3 ± 1.6 months, and nine patients (Group 4) were followed for 16.2 ± 0.5 months.

RESULTS

After REAC-lithium treatment, the number of manic and depressive episodes in Group 1 decreased from 2.1 ± 0.6 and 3.0 ± 0.7 to 0.12 ± 0.0 and 0.8 ± 0.4, respectively. In Group 2, the number of manic and depressive episodes decreased from 2.4 ± 0.6 and 3.9 ± 0.7 to 0.14 ± 0.2 and 0.0 ± 0.0, respectively. In Group 3, the number of manic and depressive episodes decreased from 2.6 ± 0.8 and 3.6 ± 0.9 to 0.04 ± 0.0 and 0.0 ± 0.0, respectively. In Group 4, the number of manic and depressive episodes decreased from 2.6 ± 1.1 and 3.7 ± 1.0 to 0.1 ± 0.0 and 0.0 ± 0.0, respectively. All results were statistically significant.

CONCLUSION

REAC showed good efficacy in treating both the manic and depressive phases of bipolar disorder, and in the prevention of recurrences/relapses.

The 'resting-state hypothesis' of major depressive disorder-a translational subcortical-cortical framework for a system disorder

Major depressive disorder (MDD) has traditionally been characterized by various psychological symptoms, involvement of diverse functional systems (e.g., somatic, affect, cognition, reward, etc.), and with progress in neuroscience, an increasing number of brain regions. This has led to the general assumption that MDD is a stress-responsive brain 'system disorder' where either one or several alterations infiltrate a large number of functional systems in the brain that control the organism's somatic, affective, and cognitive life. However, while the effects or consequences of the abnormal changes in the functional systems of, for instance affect, cognition or reward have been investigated extensively, the underlying core mechanism(s) underlying MDD remain unknown. Hypotheses are proliferating rapidly, though. Based on recent findings, we will entertain an abnormality in the resting-state activity in MDD to be a core feature. Based on both animal and human data, we hypothesize that abnormal resting-state activity levels may impact stimulus-induced neural activity in medially situated core systems for self-representation as well as external stimulus (especially stress, specifically separation distress) interactions. Moreover, due to nested hierarchy between subcortical and cortical regions, we assume 'highjacking' of higher cortical affective and cognitive functions by lower subcortical primary-process emotional systems. This may account for the predominance of negative affect in somatic and cognitive functional system operations with the consecutive generation of the diverse symptoms in MDD. We will here focus on the neuroanatomical and biochemical basis of resting-state abnormalities in MDD including their linkage to the diverse psychopathological symptoms in depression. However, our 'resting-state hypothesis' may go well beyond that by being sufficiently precise to be linked to genetic, social, immunological, and endocrine dimensions and hypotheses as well as to clinical dimensions like endophenotypes and various diagnostic-prognostic biomarkers. Taken together, our 'resting-state hypothesis' may be considered a first tentative framework for MDD that integrates translational data, the various dimensions, and subcortical-cortical systems while at the same time providing the link to the clinical level of symptoms, endophenotypes and biomarkers.

Auditory steady state response in bipolar disorder: relation to clinical state, cognitive performance, medication status, and substance disorders

OBJECTIVES

  Abnormalities in auditory steady state response (ASSR) at gamma range frequencies have been found in bipolar disorder, but the relationship of these neurophysiological disturbances to clinical factors has not been well characterized. We therefore evaluated the ASSR in bipolar disorder and examined its sensitivity to clinical symptoms, cognitive function, and pharmacological treatment.

METHODS

  A total of 68 patients with bipolar disorder and 77 control participants were evaluated. Click trains presented at 20, 30, 40, and 50 Hz evoked ASSRs. Mean trial power (MTP) and phase locking factor (PLF) measured response magnitude and phase synchronization of the ASSR at each stimulation frequency. Clinical state, pharmacological treatment, and neuropsychological performance were assessed, and their respective relationships with ASSR measures were evaluated.

RESULTS

  Patients with bipolar disorder showed reduced MTP and PLF compared to control participants. Bipolar disorder patients taking psychotropic medications had decreased PLF relative to patients withdrawn from medications. Control participants performed better on neuropsychological tests than bipolar disorder patients; however, test scores did not correlate with ASSR measures.

CONCLUSIONS

  Deficits in the generation and maintenance of ASSR are present in bipolar disorder, implicating disturbances in auditory pathways. ASSR may be sensitive to medication status. Other clinical features, including mood state, psychotic features, cognitive performance, smoking, or history of substance use disorder, were unrelated to MTP or PLF.

The role of quetiapine extended release in the treatment of bipolar depression

Bipolar disorder is a common, recurrent, and chronic condition associated with significant morbidity and reduced longevity mainly due to the depressive pole of the illness. Despite the great need for effective therapies, relatively few randomized controlled trials have been conducted and, to date, only two agents have been approved by the United States Food and Drug Administration for treatment of bipolar depression (olanzapine/fluoxetine combination and quetiapine). Quetiapine is the first approved monotherapy for treatment of bipolar depression, and an extended-release (XR) form of quetiapine is now available. This once-daily, bioequivalent formulation represents a useful alternative for patients who cannot tolerate twice-daily, immediate-release (IR) quetiapine. Here, we summarize the evidence supporting the efficacy of quetiapine for treatment of bipolar depression, and also review the similarities and differences between the two formulations. Additional research on longer-term use of quetiapine XR is needed to establish the durability of therapeutic effects and tolerability over months or years of therapy, both alone and in combination with other mood stabilizers. Studies on the potential utility of lower doses of quetiapine XR and head-to-head studies to evaluate relative efficacy and cost-effectiveness also are needed.

Identification of clinical factors associated with resistance to antidepressants in bipolar depression: results from an European Multicentre Study

This study is the first investigation to identify clinical factors associated with treatment resistance in bipolar depression (TRBD). TRBD is defined as failure to respond to at least two consecutive adequate antidepressant trials. The primary objective of this European Multicenter Study was to identify specific clinical and demographic factors associated with TRBD in a sample of bipolar patients treated for a major depressive episode. A total of 261 bipolar patients with major depressive episode were included in the analysis. Among them, 162 patients were considered as responders to treatment and the remaining 99 patients were considered as treatment resistant with a 17-item Hamilton Rating Scale for Depression Score remaining superior or equal to 17 after two consecutive adequate antidepressant trials. Cox regression analysis was used to examine the association between individual clinical variables and TRBD. We found four clinical variables to be significantly associated with TRBD: melancholia [P=0.01, odds ratio (OR)=2.4], comorbidity with social phobia (P=0.02, OR=2.3), current suicidal risk (P=0.02, OR=1.8) and severe intensity of current depressive episode (P=0.01, OR=1.8). Our findings identify four clinical variables associated with TRBD, which could be further investigated in controlled prospective trials.

The study protocol of the Norwegian randomized controlled trial of electroconvulsive therapy in treatment resistant depression in bipolar disorder

BACKGROUND

The treatment of depressive phases of bipolar disorder is challenging. The effects of the commonly used antidepressants in bipolar depression are questionable. Electroconvulsive therapy is generally considered to be the most effective treatment even if there are no randomized controlled trials of electroconvulsive therapy in bipolar depression. The safety of electroconvulsive therapy is well documented, but there are some controversies as to the cognitive side effects. The aim of this study is to compare the effects and side effects of electroconvulsive therapy to pharmacological treatment in treatment resistant bipolar depression. Cognitive changes and quality of life during the treatment will be assessed.

METHODS/DESIGN

A prospective, randomised controlled, multi-centre six- week acute treatment trial with seven clinical assessments. Follow up visit at 26 weeks or until remission (max 52 weeks). A neuropsychological test battery designed to be sensitive to changes in cognitive function will be used.

SETTING

Nine study centres across Norway, all acute psychiatric departments.

SAMPLE

n = 132 patients, aged 18 and over, who fulfil criteria for treatment resistant depression in bipolar disorder, Montgomery Asberg Depression Rating Scale Score of at least 25 at baseline.

INTERVENTION

INTERVENTION group: 3 sessions per week for up to 6 weeks, total up to 18 sessions.

CONTROL GROUP

algorithm-based pharmacological treatment as usual.

DISCUSSION

This study is the first randomized controlled trial that aims to investigate whether electroconvulsive therapy is better than pharmacological treatment as usual in treatment resistant bipolar depression. Possible long lasting cognitive side effects will be evaluated. The study is investigator initiated, without support from industry.

TRIAL REGISTRATION

NCT00664976.

Is subcortical-cortical midline activity in depression mediated by glutamate and GABA? A cross-species translational approach

Major depressive disorder has recently been characterized by abnormal resting state hyperactivity in anterior midline regions. The neurochemical mechanisms underlying resting state hyperactivity remain unclear. Since animal studies provide an opportunity to investigate subcortical regions and neurochemical mechanisms in more detail, we used a cross-species translational approach comparing a meta-analysis of human data to animal data on the functional anatomy and neurochemical modulation of resting state activity in depression. Animal and human data converged in showing resting state hyperactivity in various ventral midline regions. These were also characterized by abnormal concentrations of glutamate and gamma-aminobutyric acid (GABA) as well as by NMDA receptor up-regulation and AMPA and GABA receptor down-regulation. This cross-species translational investigation suggests that resting state hyperactivity in depression occurs in subcortical and cortical midline regions and is mediated by glutamate and GABA metabolism. This provides insight into the biochemical underpinnings of resting state activity in both depressed and healthy subjects.

A community survey of the twelve-month prevalence and correlates of bipolar spectrum disorder in Hong Kong

BACKGROUND

Recent community and clinical epidemiological studies have indicated that bipolar spectrum disorder (BSD) is a common illness. No community-based epidemiological study of BSD has been conducted in Chinese and other Asian populations.

METHOD

A random sample of 3016 Chinese adults underwent a telephone-based community survey that examined their twelve-month prevalences of BSD, sociodemographic characteristics, level of distress, and role impairment using the Sheehan Disability Scale. Bipolar I disorder (BP-I) and bipolar II disorder (BP-II) were based on DSM-IV criteria. Soft bipolar II disorder (Soft BP-II) fulfilled the DSM-IV criteria of major depressive episode and hypomanic episode except that the hypomanic/manic symptoms lasted two to three days.

RESULTS

The lifetime prevalences of manic episode, hypomanic episode, and soft hypomanic episode were 2.2%, 2.2%, and 10.7% respectively. The twelve-month prevalences of BP-I, BP-II, and Soft BP-II were 1.4%, 0.5%, and 1.8%, respectively. Respondents with BSD were more likely to be female, younger, and single than those without. Impairment and distress associated with depressive symptoms were similar across the three groups of bipolar disorders, but those associated with manic/hypomanic symptoms were more severe among respondents with BP-I than BP-II and Soft BP-II. The number of manic/hypomanic symptoms and depressive symptoms did not differ across the three bipolar groups.

LIMITATION

Structured interview questions based on core DSM-IV mood symptoms might under-estimate hypomania. Detailed sociodemographic information was not available.

CONCLUSION

BSD was common among Chinese people in Hong Kong and exhibited an epidemiological profile comparable to that of western societies.

Burden of bipolar depression: impact of disorder and medications on quality of life

Bipolar disorder is a complex, chronic psychiatric condition characterized by recurring episodes of depressive illness and mania or hypomania. Although the manic or hypomanic episodes define the disorder, recent research has shown that depressive symptoms predominate over manic symptoms in the majority of patients, and that bipolar depression accounts for much of the significant morbidity and mortality associated with bipolar disorder. Given these findings, there has been a recent upsurge of interest in furthering our understanding of the burden of depression in bipolar disorder. At the same time, increasing scientific attention is now being paid to expanding the measurement of outcome in bipolar disorder to encompass broader indicators of response, one of which is the assessment of quality of life (QOL). In this review, we provide a summary of the current knowledge about QOL in the depressive phase of bipolar disorder, and the effects of pharmacological treatment interventions for bipolar disorder upon QOL. It appears that QOL is poorer in bipolar disorder than in other mood disorders and anxiety disorders, but that schizophrenia might compromise QOL more severely than bipolar disorder. Existing data also suggest that, for patients with bipolar disorder, QOL is negatively associated with depression, both as a cross-sectional mood state and perhaps also as a feature of the patient's course. Despite its clinical and public health importance, bipolar depression has only recently started to receive the attention it warrants in clinical trials, and many important questions about its optimal pharmacological management remain to be answered. There is also a paucity of information about the impact of pharmacological interventions on QOL in bipolar depression. To our knowledge, only two clinical trials to date have specifically examined the impact of medications on QOL in patients with bipolar depression. A small number of other studies have examined the effects of depressive symptoms on QOL in patients who are experiencing manic or mixed episodes. Nonetheless, QOL appears to be a meaningful and important indicator of outcome and recovery in this patient population, and one that warrants further scientific interest and energy.

Pharmacotherapy of mood disorders

The mood disorders-primarily major depressive disorder and bipolar affective disorder-constitute one of the world's greatest public health problems and are associated with significant reductions in productivity, health, and longevity. In addition, people who suffer from these common illnesses, along with their families and loved ones, experience an incalculable toll on quality of life. Dating to the introduction of the first effective therapies for mood disorders in the late 1950s and 1960s, various types of pharmacotherapy have become a mainstay for the management of mood disorders, particularly more severe, chronic, and recurrent forms of depression and most forms of bipolar disorder. This review examines recent developments in the pharmacotherapy of both forms of mood disorder, comparing the newer antidepressants such as the selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors with their predecessors (the monoamine oxidase inhibitors and tricyclic antidepressants) and likewise comparing the older standard for management of bipolar disorder, lithium, with newer classes of medications, such as a selected group of anticonvulsants and the atypical antipsychotics. Although these newer classes of medications have generally improved upon the earlier treatments in terms of better tolerability and safety, there are no universally effective pharmacologic treatments for mood disorders, and careful medical management of these medications is still warranted.

Improving treatment adherence in bipolar disorder: a review of current psychosocial treatment efficacy and recommendations for future treatment development

Treatment adherence is a frequent problem in bipolar disorder, with research showing that more than 60% of bipolar patients are at least partially nonadherent to medications. Treatment nonadherence is consistently predictive of a number of negative outcomes in bipolar samples, and the discontinuation of mood stabilizers places these patients at high risk for relapse. Several types of adjunctive treatment (family, psychoeducational, cognitive-behavioral) have been investigated for improving symptoms and functioning in bipolar patients with some success. To date, less attention has been paid to developing treatments specifically to promote treatment adherence to and engagement with pharmacological as well as behavioral treatments in patients with bipolar disorder. First, we review the effects of adjunctive interventions specifically on treatment adherence outcomes in 14 published clinical trials. Based on this empirical knowledge base, we present a preliminary description of the treatment strategies that appear most promising for improving adherence. The article also provides research recommendations for developing more effective interventions for the purpose of improving bipolar treatment adherence. Finally, special treatment considerations, including the potential impact of comorbid substance abuse and bipolar depression, are discussed.

Assessment of depressive symptom severity among patients with co-occurring bipolar disorder and substance dependence

BACKGROUND

We examined a modified version of the Hamilton Depression Rating Scale (HDRS) among treatment-seeking patients with co-occurring bipolar disorder and substance dependence in order to elucidate key features of depression in this specific population of patients.

METHODS

Patients with current bipolar disorder and substance dependence who were prescribed mood stabilizers (n=105) completed a 27-item version of the HDRS that was subjected to item and principal components analyses. Preliminary validity analysis consisted of comparing the derived total and component scores to the depressed mood indicators from the Addiction Severity Index (ASI).

RESULTS

Eleven items representing two related components labeled "melancholia" and "anxiety" were retained. The 11-item HDRS total and component scores were higher for those who reported serious depression, serious anxiety, cognitive problems, and suicidal ideation on the ASI than for those who did not report these problems.

LIMITATIONS

We conducted the analyses with a relatively small sample of patients who were primarily white and were diagnosed with bipolar I disorder, thus limiting the generalizability of findings. Moreover, we obtained limited data regarding construct validity of the 11-item scale.

CONCLUSIONS

Our psychometric evaluation of the HDRS led us to retain 11 items representing primarily melancholic and neurovegetative symptoms of depression. These findings suggest that sample-specific item characteristics of the HDRS need to be evaluated prior to using this scale to assess depressive symptom severity among patients with complex diagnostic and treatment characteristics.

Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation

This review focused on the treatment-emergent mania/hypomania (TEM) associated with repetitive transcranial magnetic stimulation (rTMS) treatment of depression. English-language literature published from 1966-2006 and indexed in Medline was searched. Ten of 53 randomized controlled trials on rTMS treatment of depression specifically addressed TEM. The pooled TEM rate is 0.84% for the active treatment group and 0.73% for the sham group. The difference is not statistically significant. Along with case reports, a total of 13 cases of TEM associated with rTMS treatment of depression have been published. Most of these patients were diagnosed with bipolar disorder and the majority of patients experiencing TEM took medication concurrent with rTMS. The parameters of rTMS used in these cases were scattered over the spectrum of major parameters explored in previous studies. Most train durations and intervals were within the published safety guidelines of the field. Reducing the frequency of sessions from two per day to one per day might be associated with a lower likelihood of TEM recurrence. The severity of manic symptoms varied significantly, but all cases responded to treatment that included a decrease or discontinuation of antidepressant and/or rTMS treatment and/or use of anti-manic medication. Current data suggests that rTMS treatment carries a slight risk of TEM that is not statistically higher than that associated with sham treatment. More systematic studies are needed to better understand TEM associated with rTMS. Special precautions and measures should be adopted to prevent, monitor, and manage TEM in research and practice.

Current issues in bipolar disorder: a critical review

Although awareness on bipolar disorder has increased during the last decade, this condition remains characterized by a disabling burden, in terms of morbidity and functional impairment. This paper aims to review some critical issues in the current knowledge on Bipolar disorder. Although large European epidemiological studies are lacking, Bipolar disorder is characterized by a set of severe features, including an early age of onset, a chronic outcome and an important suicidal risk. A majority of bipolar patients also experience a comorbid Axis I condition, including substance abuse, anxiety disorder and attention-deficit hyperactivity disorder. This situation presents a therapeutic challenge, since antidepressants or methylphenidate may be associated with the risk of inducing mania. Recently, a large number of studies have provided evidence for the efficacy of new compounds in the treatment of both mania and bipolar depression, but also in long-term relapse prevention. Recent research has also allowed for the redefinition of the concept of mood stabilizer and for improving existing guidelines on the clinical management of Bipolar disorder.

Bipolar disorder pharmacotherapy

Treatment options in the management of bipolar disorder continue to proliferate. Currently, all of the commonly prescribed atypical antipsychotics are indicated for the treatment of mania. Quetiapine and olanzapine/fluoxetine in combination are US FDA approved in the treatment of bipolar depression. Aripiprazole and lamotrigine have been FDA approved as maintenance therapies in the long-term management of bipolar disorder. Topiramate and gabapentin have been effectively discredited as first-line options in acute mania. This update seeks to summarize recent developments in bipolar disorder pharmacotherapy, offer insight into the nuance of using these newer agents effectively, review risks and benefits of using standard antidepressants in the treatment of bipolar depression and draw to the attention of readers the strengths and limitations of some of the studies that are shaping contemporary psychiatry’s approach to the patient with bipolar disorder.

BOLDER II study of quetiapine therapy for bipolar depression

Remarkably few randomized, controlled trials have evaluated therapies for the depressed phase of bipolar affective disorder. Two similar, 8-week, placebo-controlled bipolar depression studies (known by the acronyms BOLDER I and BOLDER II) were conducted to evaluate the efficacy and tolerability of the atypical antipsychotic quetiapine (300 and 600 mg/day) as monotherapy for bipolar type I and type II depressive episodes. Results of BOLDER II, summarized herein, replicated the findings of BOLDER I. Both doses of quetiapine were significantly more effective than placebo on primary and secondary measures of depressive symptoms. Remission rates on the Montgomery–Asberg Depression Rating Scale were also significantly greater in both quetiapine dose groups (300 mg: 52%; 600 mg: 52%) compared with placebo (37%). Quetiapine therapy was effective in all subtypes of bipolar depression studied. There were no efficacy differences between the two doses of quetiapine. Common adverse events included dry mouth, sedation, somnolence, dizziness and constipation; tolerability tended to be better in the lower quetiapine dose group. Results of the BOLDER II study confirmed that quetiapine is effective as monotherapy for bipolar depression. The 300 mg/day dose is as effective as the 600 mg/day dose. Additional research is needed to determine the minimum effective dose of quetiapine, as well as the efficacy of quetiapine in combination with antidepressants and for prevention of relapse following successful treatment of bipolar depression.

A placebo-controlled trial of bupropion SR in the treatment of chronic posttraumatic stress disorder

OBJECTIVE

Although selective serotonin reuptake inhibitors have been the most empirically studied pharmacotherapy for posttraumatic stress disorder (PTSD), a need remains for the investigation of additional pharmacological agents in the treatment of PTSD. The present study examined the use of bupropion sustained release (SR) as compared with placebo for symptom reduction in patients with PTSD: approximately half who were already prescribed an selective serotonin reuptake inhibitor and half who were not.

METHOD

Thirty patients (mean age, 50 years) with civilian- or military-related PTSD enrolled in an 8-week evaluation of bupropion SR versus placebo assigned in a 2:1 ratio in addition to their usual pharmacological care. Statistical tests included analyzing both study completers and using an intent-to-treat analysis, as well as post hoc examination of responders versus nonresponders.

RESULTS

Although no between-group differences were detected, both groups reported a reduction in PTSD symptoms. In a hypothesis-generating post hoc analysis of responders versus nonresponders in the bupropion SR condition (defined as a Clinician Global Improvement score of at least minimally improved), it seemed that younger patients not currently on another antidepressant were more likely to benefit from bupropion.

CONCLUSIONS

Bupropion SR in the treatment of PTSD had no significant effect in the current sample. Factors contributing to the absence of an effect need further study. Our analysis points to the inclusion of age and concomitant antidepressant treatment as important variables in any future larger-scale study.

Protective Effects of Lamotrigine, Aripiprazole and Escitalopram on Depression-induced Oxidative Stress in Rat Brain

We investigated the effects of lamotrigine, aripiprazole and escitalopram administration and experimental depression on lipid peroxidation (LP) and antioxidant levels in cortex of the brain in rats. Forty male wistar rats were randomly divided into five groups. First group was used as control although second group was depression-induced group. Aripiprazole, lamotrigine and escitalopram per day were orally supplemented to chronic mild stress (CMS) depression-induced rats constituting the third, fourth and fifth groups for 28 days, respectively. Depression resulted in significant decrease in the glutathione peroxidase (GSH-Px) activity, reduced glutathione and vitamin C of cortex of the brain although their levels and beta-carotene concentrations were increased by the three drugs administrations to the animals of CMS induced depression group. The LP levels in the cortex of the brain and plasma of depression group were elevated although their levels were decreased by the administrations. The increases of antioxidant values in lamotrigine group were higher according to aripiprazole and escitalopram supplemented groups. Vitamin A level did not change in the five groups. In conclusion, the experimental depression is associated with elevated oxidative stress although treatment with lamotrigine has most protective effects on the oxidative stress within three medicines.

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.

Circadian genes, rhythms and the biology of mood disorders

For many years, researchers have suggested that abnormalities in circadian rhythms may underlie the development of mood disorders such as bipolar disorder (BPD), major depression and seasonal affective disorder (SAD). Furthermore, some of the treatments that are currently employed to treat mood disorders are thought to act by shifting or "resetting" the circadian clock, including total sleep deprivation (TSD) and bright light therapy. There is also reason to suspect that many of the mood stabilizers and antidepressants used to treat these disorders may derive at least some of their therapeutic efficacy by affecting the circadian clock. Recent genetic, molecular and behavioral studies implicate individual genes that make up the clock in mood regulation. As well, important functions of these genes in brain regions and neurotransmitter systems associated with mood regulation are becoming apparent. In this review, the evidence linking circadian rhythms and mood disorders, and what is known about the underlying biology of this association, is presented.

Venlafaxine Modulates Depression-Induced Oxidative Stress in Brain and Medulla of Rat

Venlafaxine is an approved antidepressant that is an inhibitor of both serotonin and norepinephrine transporters. Medical treatment with oral venlafaxine can be beneficial to depression due to reducing free radical production in the brain and medulla of depression-induced rats because oxidative stress may a play role in some depression. We investigated the effect of venlafaxine administration and experimental depression on lipid peroxidation and antioxidant levels in cortex brain, medulla and erythrocytes of rats. Thirty male wistar rats were used and were randomly divided into three groups. Venlafaxine (20 mg/kg) was orally supplemented to depression-induced rats constituting the first group for four week. Second group was depression-induced group although third group was used as control. Depressions in the first and second groups were induced on day zero of the study by chronic mild stress. Brain, medulla and erythrocytes samples were taken from all animals on day 28. Depression resulted in significant decrease in the glutathione peroxidase (GSH-Px) activity and vitamin C concentrations of cortex brain, glutathione (GSH) value of medulla although their levels were increased by venlafaxine administration to the animals of depression group. The lipid peroxidation levels in the three tissues and nitric oxide value in cortex brain elevated although their levels were decreased by venlafaxine administration. There were no significant changes in cortex brain vitamin A, erythrocytes vitamin C, GSH-Px and GSH, medulla vitamin A, GSH and GSH-Px values. In conclusion, cortex brain within the three tissues was most affected by oxidative stress although there was the beneficial effect of venlafaxine in the brain of depression-induced rats on investigated antioxidant defenses in the rat model. The treatment of depression by venlafaxine may also play a role in preventing oxidative stress.

Role for the Clock gene in bipolar disorder

Nearly all patients with bipolar disorder have severely disrupted circadian rhythms. Treatment with mood stabilizers can restore these daily rhythms, and this is correlated with patient recovery. However, it is still uncertain whether clock abnormalities are the cause of bipolar disorder or if these rhythm disruptions are secondary to alterations in other circuits. Furthermore, the mechanism by which the circadian clock might influence mood is still unclear. With cloning and characterization of the circadian genes and recent advances in molecular biology, we are starting to understand this strong association between circadian rhythms and bipolar disorder. Recent human genetic and mouse behavioral studies indicate that the Clock gene is particularly relevant in the mood disruptions associated with this disorder. Furthermore, it appears that Clock expression outside of the central pacemaker of the suprachiasmatic nucleus (SCN) is involved in mood regulation. In this chapter, the evidence linking circadian rhythms, the Clock gene, and bipolar disorder is discussed, along with the possible biology that underlies this connection.

Current practices in depression care

Despite improved awareness among the medical community concerning common mental health disorders, the high prevalence of depression in the United States remains unchanged and has been compounded by increasing evidence of gaps in mental health care for ethnic and racial minorities. Thus, there is a strong need for the timely creation of comprehensive educational initiatives aimed at improving the quality of care provided by mental health professionals and primary care physicians. Fundamental to this process is the examination of current treatment standards, as well as identification of practices that require improved physician education. Consistent use of appropriate screening tools, diagnostic accuracy and timeliness, continual assessment of illness severity, adherence to practice guidelines, and individualized patient care need heightened attention to improve outcomes. This article describes the most prevalent types of depression and summarizes current practices in depression care, with an emphasis on treatment standards and opportunities for improved performance.

Enhancing effects of chronic lithium on memory in the rat

BACKGROUND

In spite of recent enrichment of neurochemical and behavioural data establishing a neuroprotective role for lithium, its primary effects on cognitive functioning remain ambiguous. This study examines chronic lithium effects on spatial working memory and long-term retention.

METHODS

In three discrete experiments, rats subjected to 30 daily intraperitoneal injections (2mmol/kg) of lithium (lithium groups: serum lithium=0.5+/-0.4mEq/l, 12h post-injection) or saline (controls) were trained in 0-s delay T-maze alternation and then tested in 30-, 45- and 60-s delay alternation (Experiments 1, 2, 3, respectively). Animals from Experiment 1 were further tested in one-trial step-through passive avoidance under mild shock parameters (0.5mA, 1s). Retention was assessed 6h later. Daily lithium or saline injections continued throughout behavioural testing.

RESULTS

Lithium animals were indistinguishable from controls during 0-delay alternation baseline (Experiments 1-3, accuracy>88%) but showed significantly higher accuracy than controls at 30- and 45-s delays (93% versus 85% and 92% versus 82%, Experiments 1 and 2, respectively). At 60-s delay (Experiment 3) this beneficial effect of lithium was no longer apparent (lithium and control accuracy=78%). In Experiment 4, the shock used did not support 6-h passive avoidance retention in controls, whereas lithium animals showed significant step-through latency increases.

CONCLUSIONS

Chronic lithium enhanced spatial working memory and promoted long-term retention of a weak aversive contingency. The results suggest that lithium may have potential as a cognitive enhancer.