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Inal N, Ermis C, Koc D, Aksoy S, Karacetin G, Tuncturk M, Eray S, Karabina B, Faruk Akca O, Ozgul D, Gunay Kilic B, Cikili Uytun M, Besenek M, Kavurma C, Bilac O, Gokcen C, Topal Z, Percinel Yazıcı I, Sapmaz SY, Ozyurt G, Diler RS. Index depressive episode and antidepressant exposure were associated with illness characteristics of pediatric bipolar disorder. Acta Psychiatr Scand 2022; 145:200-208. [PMID: 34076890 DOI: 10.1111/acps.13333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 05/31/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Pediatric bipolar disorder (PBD) is a serious, recurrent disorder leading to severe functional impairment. As a first mood episode, index episode could affect the long-term course of the illness. This study aimed to investigate the clinical characteristics of youth with PBD from our multicenter, nationwide, naturalistic follow-up samples and to identify (i) the effects of index mood episode and (ii) the effect of previous antidepressant treatments on the age at mania onset of PBD. METHOD The study sample consisted of 271 youth with BD-I followed by the child and adolescent psychiatry clinics of seven different university hospitals and three research state hospitals, representing six geographic regions across Turkey. All diagnoses were made according to structured interviews, and all data were retrospectively obtained from clinical records by the clinicians. RESULTS When patients with index depressive/mixed episodes (IDE, n=129) and patients with index (hypo)manic episodes (IME, n=142) were compared, the total number of mood episodes and rapid cycling feature were significantly higher in the IDE group than in the IME group. The Cox regression analysis adjusted for sociodemographic and illness characteristics revealed female adolescents in the IDE group treated with antidepressants were more likely to have an earlier onset of mania (hazard ratio=2.03, 95% confidence interval=1.31-3.12, p=0.001). CONCLUSION This is the first large-scale nationwide follow-up study in Turkey that indicated prior antidepressant treatments were associated with an earlier onset of mania in youth, particularly in adolescent females. Larger prospective studies are needed to identify neurodevelopmental processes underlying PBD and initiate prevention approaches.
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Affiliation(s)
- Neslihan Inal
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Cagatay Ermis
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Dogukan Koc
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Sena Aksoy
- Department of Child and Adolescent Psychiatry, Kastamonu Training and Research Hospital, Kastamonu, Turkey
| | - Gul Karacetin
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Mustafa Tuncturk
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Safak Eray
- Department of Child and Adolescent Psychiatry, Medical Faculty, Bursa Uludag University, Bursa, Turkey
| | - Berna Karabina
- Department of Child and Adolescent Psychiatry, Medical Faculty, Bursa Uludag University, Bursa, Turkey
| | - Omer Faruk Akca
- Department of Child and Adolescent Psychiatry, Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Dilek Ozgul
- Department of Child and Adolescent Psychiatry, Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Birim Gunay Kilic
- Department of Child and Adolescent Psychiatry, Medical Faculty, Ankara University, Ankara, Turkey
| | - Merve Cikili Uytun
- Department of Child and Adolescent Psychiatry, Medical Faculty, Ankara University, Ankara, Turkey
| | - Mert Besenek
- Department of Child and Adolescent Psychiatry, Recep Tayyip Erdogan University, Rize Training and Research Hospital, Rize, Turkey
| | - Canem Kavurma
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey
| | - Oznur Bilac
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey
| | - Cem Gokcen
- Department of Child and Adolescent Psychiatry, Medical Faculty, Gaziantep University, Gaziantep, Turkey
| | - Zehra Topal
- Department of Child and Adolescent Psychiatry, Medical Faculty, Gaziantep University, Gaziantep, Turkey
| | - Ipek Percinel Yazıcı
- Department of Child and Adolescent Psychiatry, Medical Faculty, Firat University, Elazig, Turkey
| | - Sermin Yalin Sapmaz
- Department of Child and Adolescent Psychiatry, Medical Faculty, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Gonca Ozyurt
- Department of Child and Adolescent Psychiatry, Medical Faculty, Izmir Katip Celebi University, İzmir, Turkey
| | - Rasim Somer Diler
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hawkins EM, Coryell W, Leung S, Parikh SV, Weston C, Nestadt P, Nurnberger JI, Kaplin A, Kumar A, Farooqui AA, El-Mallakh RS. Effects of somatic treatments on suicidal ideation and completed suicides. Brain Behav 2021; 11:e2381. [PMID: 34661999 PMCID: PMC8613439 DOI: 10.1002/brb3.2381] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/14/2021] [Accepted: 09/14/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide. METHODS Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides. RESULTS Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term. CONCLUSIONS Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.
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Affiliation(s)
- Elise M Hawkins
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky, USA
| | - William Coryell
- Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Stephen Leung
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Cody Weston
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John I Nurnberger
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Adam Kaplin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anupama Kumar
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ali A Farooqui
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Rif S El-Mallakh
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky, USA
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- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky, USA
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Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, Kowatch RA, Miklowitz DJ, Nery FG, Perez‐Algorta G, Van Meter A, Zeni CP, Correll CU, Kim H, Wozniak J, Chang KD, Hillegers M, Youngstrom EA. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord 2017; 19:524-543. [PMID: 28944987 PMCID: PMC5716873 DOI: 10.1111/bdi.12556] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/14/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings. METHODS An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps. RESULTS Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD. CONCLUSIONS As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.
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Affiliation(s)
- Benjamin I Goldstein
- Centre for Youth Bipolar DisorderSunnybrook Health Sciences CentreTorontoCanada,Departments of Psychiatry and PharmacologyUniversity of TorontoTorontoCanada
| | - Boris Birmaher
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Gabrielle A Carlson
- Department of PsychiatryStony Brook University School of MedicineStony BrookNYUSA
| | - Melissa P DelBello
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | - Robert L Findling
- Department of Psychiatry & Behavioral SciencesThe Johns Hopkins UniversityBaltimoreMDUSA
| | - Mary Fristad
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | - Robert A Kowatch
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | | | - Fabiano G Nery
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | | | - Anna Van Meter
- Ferkauf Graduate School of PsychologyYeshiva UniversityBronxNYUSA
| | | | - Christoph U Correll
- The Zucker Hillside HospitalDepartment of PsychiatryNorthwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineHofstra Northwell School of MedicineHempsteadNYUSA
| | - Hyo‐Won Kim
- Department of PsychiatryUniversity of Ulsan College of MedicineAsan Medical CenterSeoulKorea
| | - Janet Wozniak
- Clinical and Research Program in Pediatric PsychopharmacologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Kiki D Chang
- Department of PsychiatryStanford UniversityPalo AltoCAUSA
| | - Manon Hillegers
- Department of Child and Adolescent Psychiatry and PsychologyErasmus Medical Center‐SophiaRotterdamThe Netherlands
| | - Eric A Youngstrom
- Department of Psychology and NeuroscienceUniversity of North CarolinaChapel HillNCUSA
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Subramanian K, Sarkar S, Kattimani S. Bipolar disorder in Asia: Illness course and contributing factors. Asian J Psychiatr 2017; 29:16-29. [PMID: 29061417 DOI: 10.1016/j.ajp.2017.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 04/15/2017] [Accepted: 04/16/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors. METHODS A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated. RESULTS Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes. LIMITATIONS The effects of treatment and childhood BD course features were not discussed. CONCLUSIONS There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.
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Affiliation(s)
- Karthick Subramanian
- Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
| | - Siddharth Sarkar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India.
| | - Shivanand Kattimani
- Department of Psychiatry, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
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Chon MW, Lee J, Chung S, Kim Y, Kim HW. Prescription Pattern of Antidepressants for Children and Adolescents in Korea Based on Nationwide Data. J Korean Med Sci 2017; 32:1694-1701. [PMID: 28875616 PMCID: PMC5592186 DOI: 10.3346/jkms.2017.32.10.1694] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/24/2017] [Indexed: 01/26/2023] Open
Abstract
Antidepressant prescription for youths has recently been on the increase. There is a growing concern over the increasing off-label usage of antidepressants. Current data on off-label antidepressant usage vary across countries and healthcare systems. Therefore, we examined the extent and pattern of antidepressant prescription for Korean children and adolescents using population-based data. Our data was retrieved from the Korean National Health Insurance Service National Sample Cohort of the year 2013. Among 0.2 million children and adolescents aged 6-18 years from the cohort, subjects who had received any antidepressant medication in the year 2013 were investigated for the prescribed medication, concomitant psychotropic medication, and the associated diagnosis. A total of 2,190 children and adolescents (boys, 55.4%) received antidepressant medication. The most common diagnosis was depressive disorders (n = 469, 21.4%), followed by attention-deficit/hyperactivity disorder (n = 442, 20.2%). Among the prescriptions (n = 3,370), escitalopram (n = 650, 24.1%) and fluoxetine (n = 553, 20.5%) were the two most frequently prescribed drugs. A majority of prescriptions (n = 2,039, 60.5%) included concomitant psychotropic agents, consisting of antipsychotics (n = 901, 26.7%), sedatives (n = 263, 26.3%), medication for attention-deficit/hyperactivity disorder (n = 822, 24.4%), and some others. Our study shows the prescription pattern of antidepressants for children and adolescents in Korea, of which a large proportion is off-label. The results call for close monitoring by clinicians treating this population.
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Affiliation(s)
- Myong Wuk Chon
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jungsun Lee
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seockhoon Chung
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yangsik Kim
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyo Won Kim
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Lamotrigine compared to placebo and other agents with antidepressant activity in patients with unipolar and bipolar depression: a comprehensive meta-analysis of efficacy and safety outcomes in short-term trials. CNS Spectr 2016; 21:403-418. [PMID: 27686028 DOI: 10.1017/s1092852916000523] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To meta-analytically summarize lamotrigine's effectiveness and safety in unipolar and bipolar depression. METHODS We conducted systematic PubMed and SCOPUS reviews (last search =10/01/2015) of randomized controlled trials comparing lamotrigine to placebo or other agents with antidepressant activity in unipolar or bipolar depression. We performed a random-effects meta-analysis of depression ratings, response, remission, and adverse effects calculating standardized mean difference (SMD) and risk ratio (RR) ±95% confidence intervals (CIs). RESULTS Eighteen studies (n=2152, duration=9.83 weeks) in patients with unipolar depression (studies=4, n=187; monotherapy vs lithium=1, augmentation of antidepressants vs placebo=3) or bipolar depression (studies=14, n=1965; monotherapy vs placebo=5, monotherapy vs lithium or olanzapine+fluoxetine=2, augmentation of antidepressants vs placebo=1, augmentation of mood stabilizers vs placebo=3, augmentation of mood stabilizers vs trancylpromine, citalopram, or inositol=3) were meta-analyzed. Lamotrigine's efficacy for depressive symptoms did not differ significantly in monotherapy vs augmentation studies (vs. placebo: p=0.98, I2=0%; vs active agents: p=0.48, I2=0%) or in unipolar vs bipolar patients (vs placebo: p=0.60, I2=0%), allowing pooling of each placebo-controlled and active-controlled trials. Lamotrigine outperformed placebo regarding depressive symptoms (studies=11, n=713 vs n=696; SMD=-0.15, 95% CI=-0.27, -0.02, p=0.02, heterogeneity: p=0.24) and response (after removing one extreme outlier; RR=1.42, 95% CI=1.13-1.78; p=0.003, heterogeneity: p=0.08). Conversely, lamotrigine did not differ regarding efficacy on depressive symptoms, response, or remission from lithium, olanzapine+fluoxetine, citalopram, or inositol (studies=6, n=306 vs n=318, p-values=0.85-0.92). Adverse effects and all-cause/specific-cause discontinuation were similar across all comparisons. CONCLUSIONS Lamotrigine was superior to placebo in improving unipolar and bipolar depressive symptoms, without causing more frequent adverse effects/discontinuations. Lamotrigine did not differ from lithium, olanzapine+fluoxetine, citalopram, or inositol.
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Gorwood P, Richard-Devantoy S, Sentissi O, Le Strat Y, Olié JP. The number of past manic episodes is the best predictor of antidepressant-emergent manic switch in a cohort of bipolar depressed patients. Psychiatry Res 2016; 240:288-294. [PMID: 27138820 DOI: 10.1016/j.psychres.2016.04.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 01/11/2016] [Accepted: 04/21/2016] [Indexed: 11/15/2022]
Abstract
The present study sought to identify factors associated with the onset of a manic or hypomanic episode during the month following a new antidepressant therapy in depressed bipolar patients. Patients receiving mood stabilizers for ≥3 months were screened from 400 French centers and were assessed for a 4-week period following prescription of a first or a new antidepressant. Of the 1242 included participants, 4.8% (n=60) experienced antidepressant-emergent manic switch (AEMS). AEMS was more frequently associated with lifetime manic, depressive, and total mood episodes, and with past AEMS. A higher score at two items of the Montgomery-Åsberg Depression Rating Scale (pessimistic and suicidal thoughts) were significantly associated with AEMS. Logistic regression analysis showed that the number of lifetime manic episodes and past AEMS were the two most factors associated with an AEMS. Having more than four past manic episodes was associated with a 2.84 fold increased risk of AEMS. Cumulative number of past mood episodes seems to be the most important factor for switching to a manic episode following antidepressants in patients with bipolar disorder. Longer-term studies are required to further delineate antidepressant causality from natural disease course.
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Affiliation(s)
- Philip Gorwood
- Sainte-Anne hospital, CMME, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM) U894, Paris, France
| | - Stéphane Richard-Devantoy
- McGill University, Department of Psychiatry & Douglas Mental Health University Institute, McGill Group for Suicide Studies, Douglas Institute, Frank B. Common Pavilion, 6875 LaSalle Boulevard, Montreal, Quebec, Canada H4H 1R3; Laboratoire de Psychologie des Pays de la Loire EA 4638, Université de Nantes et Angers, France.
| | - Othman Sentissi
- Département de Santé Mentale et de Psychiatrie, Service de Psychiatrie Générale, Centre Ambulatoire de la Jonction, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Yann Le Strat
- Institut National de la Santé et de la Recherche Médicale (INSERM) U894, Paris, France
| | - Jean Pierre Olié
- Institut National de la Santé et de la Recherche Médicale (INSERM) U894, Paris, France; Service Hospitalo - Universitaire (SHU), Sainte-Anne Hospital, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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