Maintenance treatment of bipolar disorder: Applying research to clinical practice

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.

Rash in psychiatric and nonpsychiatric adolescent patients receiving lamotrigine in Korea: a retrospective cohort study

OBJECTIVE

Lamotrigine is a widely used medication for psychiatric disorders and epilepsy, but the adverse effects of this drug in adolescent Korean patients have not yet been investigated. In the present study, we sought to compare the incidence and impact of lamotrigine-induced skin rashes and different pattern of adverse events in psychiatric and nonpsychiatric adolescent patients.

METHODS

Using a retrospective cohort design, all of the charts were reviewed for adolescents (13 to 20 years old), treated with lamotrigine during the previous 2 years in the Child and Adolescent Psychiatric Clinic and Pediatric Neurologic Clinic of the Ulsan University Hospital in South Korea.

RESULTS

Of the 102 subjects, 23 patients developed a skin rash. All of these rashes were observed within 7 weeks of the initiation of the lamotrigine therapy. Only one subject developed a serious rash, which was diagnosed as Stevens-Johnson syndrome. Although the psychiatric subjects were administered statistically lower doses of lamotrigine during weeks 1 through 5 and at week 12, the likelihood of developing a rash was not significantly different between the psychiatric and nonpsychiatric patients.

CONCLUSION

Careful dose escalation and close observation of side effects for the first 7 weeks of treatment is important. The present study reveals the tolerability of lamotrigine in an adolescent population, although a double-blind, controlled trial is needed to confirm these findings.

Effectiveness of psychotropic medications in the maintenance phase of bipolar disorder: a meta-analysis of randomized controlled trials

The purpose of this meta-analysis was to examine the efficacy of maintenance treatments for bipolar disorder. Placebo-controlled or active comparator bipolar maintenance clinical trials of ≥6 months' duration with at least 15 patients/treatment group were identified using Medline, EMBASE, clinicaltrials.gov, and Cochrane databases (1993 to July 2010). The main outcome measure was relative risk for relapse for patients in remission. Twenty trials (5,364 patients) were identified. Overall, lithium and quetiapine were the most studied agents (eight and five trials, respectively). The majority of studies included patients who had previously responded to treatment for an acute episode. All interventions, with the exception of perphenazine+mood stabilizer, showed a relative risk for manic/mixed or depressive relapse below 1.0, although there was variation in the statistical significance of the findings vs. placebo. No monotherapy was associated with a significantly reduced risk for both manic/mixed and depressed relapse. Of the combination treatments, only quetiapine+lithium/divalproex, was associated with a significantly reduced risk vs. comparator (placebo+lithium/valproate) for relapse at both the manic/mixed and depressed poles of bipolar illness. Limitations for the analysis include differences in study durations and definitions of relapse. In conclusion, available maintenance therapies show considerable variation in efficacy. The efficacy of lithium and divalproex has been confirmed, but newer therapies, such as a number of atypical antipsychotics were also shown to be effective in bipolar disorder. Efficacy of all maintenance interventions needs to be balanced against the safety and tolerability profiles of individual agents.

Effectiveness of lamotrigine in maintaining symptom control in pediatric bipolar disorder

OBJECTIVE

The aim of this study was to test the effectiveness and safety of lamotrigine in maintenance of manic and depressive symptom control in pediatric bipolar disorder (PBD).

METHODS

A 14-week open trial was conducted with 46 subjects presenting with mania or hypomania. Lamotrigine was slowly titrated to a therapeutic dose over an 8-week period, during which acute symptoms were stabilized using second-generation antipsychotics (SGA), followed by a 6-week lamotrigine monotherapy phase.

RESULTS

The response rate on manic symptoms (Young Mania Rating Score [YMRS] <12) was 72%, on depressive symptoms was 82% (Children's Depression Rating Scale-Revised [CDRS-R] <40), and the remission rate was 56% at the 14-week end point, on an average end-point lamotrigine dose of 1.8 mg/lb. There was further reduction in depressive symptoms during the lamotrigine maintenance phase. Benign rash was noted in 6.4% of patients. Out of half of the subjects who were in remission at 8 week, 3 subjects (23%) relapsed by week 14.

CONCLUSION

Lamotrigine monotherapy appears to be effective in maintaining symptom control of manic and depressive symptoms in PBD and shows minimal adverse effects, although a future double-blind controlled trial is needed to confirm this finding. Portal of entry for lamotrigine treatment can be during acute illness and can sustain symptom control after establishing mood stabilization.

Psychiatric epidemiology: challenges and opportunities

This paper discusses challenges and prospects for increasing the clinical relevance of psychiatric epidemiological research. The discussion begins with a review of the structural determinants of the fact that current psychiatric epidemiological research has less clinical relevance than epidemiological research in other areas of medicine. The discussion then turns to ways in which the focus of psychiatric epidemiological research might be changed to increase its clinical relevance. A review is then presented of recent innovations in community psychiatric epidemiological research that were designed to increase clinical relevance. An argument is then made that the full clinical value of psychiatric epidemiology will only be realized when community epidemiology becomes better integrated with clinical epidemiology and the latter takes on a more prominent role than it currently has in psychiatric research. Existing initiatives to realize an integration of community psychiatric epidemiology with clinical epidemiology are then reviewed. Finally, an agenda is proposed for an expansion of clinical psychiatric epidemiology to include a focus on both naturalistic and quasi-experimental studies of illness course and treatment response in diverse clinical samples.