Differential core pharmacotherapy in bipolar I versus bipolar II disorder and European versus American patients not in a syndromal episode

A naturalistic effectiveness study of maintenance therapies for the bipolar disorders

BACKGROUND

Treatment decision-making for individuals with bipolar disorder can be difficult. Recommendations from clinical practice guidelines can be affected by multiple methodological limitations, while pharmaco-epidemiological data suggest great variety in prescription practices across regions. Given these inconsistencies, this study aimed to provide an alternative perspective on the effectiveness of common bipolar disorder maintenance treatments through considering naturalistic data.

METHODS

A total of 246 individuals with bipolar disorder (84 bipolar I [BP-I], 162 bipolar II [BP-II]) were recruited through clinics and/or websites. All were euthymic and had trialled at least one mood stabiliser. They completed an online survey containing questions on demographics, clinical variables, symptomatology, and the effectiveness/side effect profiles of any mood stabilisers (MSTs) or atypical antipsychotics (AAPs) that they have taken.

RESULTS

Lithium and lamotrigine were the most commonly prescribed MSTs and the most effective at mood stabilisation. Lithium and lamotrigine appeared marginally more effective for BP-I and BP-II respectively, however, only the latter difference was statistically significant. Furthermore, lamotrigine had the more favourable side effect profile. Amongst the AAPs, quetiapine and olanzapine were the most commonly prescribed, but they were negligibly superior to other AAPs.

CONCLUSION

This study clearly established a preference for lamotrigine in the maintenance treatment of BP-II. While the literature consistently emphasises the primacy of lithium in bipolar disorder treatment, its side effect profile as observed in this study remains a concern. Future research considering moderators of treatment response and concomitant medications could help to identify further nuances to consider for treatment decision-making.

Differential characteristics of bipolar I and II disorders: a retrospective, cross-sectional evaluation of clinical features, illness course, and response to treatment

BACKGROUND

The distinction between bipolar I and bipolar II disorder and its treatment implications have been a matter of ongoing debate. The aim of this study was to examine differences between patients with bipolar I and II disorders with particular emphasis on the early phases of the disorders.

METHODS

808 subjects diagnosed with bipolar I (N = 587) or bipolar II disorder (N = 221) according to DSM-IV criteria were recruited between April 1994 and March 2022 from tertiary-level mood disorder clinics. Sociodemographic and clinical variables concerning psychiatric and medical comorbidities, family history, illness course, suicidal behavior, and response to treatment were compared between the bipolar disorder types.

RESULTS

Bipolar II disorder patients were more frequently women, older, married or widowed. Bipolar II disorder was associated with later "bipolar" presentation, higher age at first (hypo)mania and treatment, less frequent referral after a single episode, and more episodes before lithium treatment. A higher proportion of first-degree relatives of bipolar II patients were affected by major depression and anxiety disorders. The course of bipolar II disorder was typically characterized by depressive onset, early depressive episodes, multiple depressive recurrences, and depressive predominant polarity; less often by (hypo)mania or (hypo)mania-depression cycles at onset or during the early course. The lifetime clinical course was more frequently rated as chronic fluctuating than episodic. More patients with bipolar II disorder had a history of rapid cycling and/or high number of episodes. Mood stabilizers and antipsychotics were prescribed less frequently during the early course of bipolar II disorder, while antidepressants were more common. We found no differences in global functioning, lifetime suicide attempts, family history of suicide, age at onset of mood disorders and depressive episodes, and lithium response.

CONCLUSIONS

Differences between bipolar I and II disorders are not limited to the severity of (hypo)manic syndromes but include patterns of clinical course and family history. Caution in the use of potentially mood-destabilizing agents is warranted during the early course of bipolar II disorder.

Bipolar I and bipolar II subtypes in older age: Results from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) project

OBJECTIVES

The distinction between bipolar I disorder (BD-I) and bipolar II disorder (BD-II) has been a topic of long-lasting debate. This study examined differences between BD-I and BD-II in a large, global sample of OABD, focusing on general functioning, cognition and somatic burden as these domains are often affected in OABD.

METHODS

Cross-sectional analyses were conducted with data from the Global Aging and Geriatric Experiments in Bipolar Disorder (GAGE-BD) database. The sample included 963 participants aged ≥50 years (714 BD-I, 249 BD-II). Sociodemographic and clinical factors were compared between BD subtypes including adjustment for study cohort. Multivariable analyses were conducted with generalized linear mixed models (GLMMs) and estimated associations between BD subtype and (1) general functioning (GAF), (2) cognitive performance (g-score) and (3) somatic burden, with study cohort as random intercept.

RESULTS

After adjustment for study cohort, BD-II patients more often had a late onset ≥50 years (p = 0.008) and more current severe depression (p = 0.041). BD-I patients were more likely to have a history of psychiatric hospitalization (p < 0.001) and current use of anti-psychotics (p = 0.003). Multivariable analyses showed that BD subtype was not related to GAF, cognitive g-score or somatic burden.

CONCLUSION

BD-I and BD-II patients did not differ in terms of general functioning, cognitive impairment or somatic burden. Some clinical differences were observed between the groups, which could be the consequence of diagnostic definitions. The distinction between BD-I and BD-II is not the best way to subtype OABD patients. Future research should investigate other disease specifiers in this population.

Lamotrigine-induced mania: warning report for the identification of vulnerable populations and expert clinical recommendations for prescription

Lamotrigine (LTG) is an anticonvulsant drug used for the prevention of depressive episodes in bipolar disorder (BD) that might induce manic episodes in some cases. A 38-year-old man, stabilized with asenapine due to a brief psychotic episode, presented depressive symptoms and LTG was titrated up to 200 mg/day in 6 weeks. One week later he was diagnosed with a first manic episode with psychotic symptoms [Young Mania Rating Scale (YMRS = 31)] and type I BD (BD-I). LTG was withdrawn and he was treated with lithium and lurasidone. The episode remitted in 1 week. A 45-year-old woman with BD presented persistent depressive symptoms and received LTG 25 mg/day. After 3 weeks she was diagnosed with a manic episode with psychotic symptoms (YMRS = 35). LTG was suspended and aripiprazole increased. The episode remitted within 10 days. Both patients remained euthymic with no further episodes after 1-year follow-up. The propensity of LTG to induce manic episodes may be related to its lack of antimanic effects, along with its antidepressant properties, probably related to decreased glutamate release. Secondary analyses from LTG randomized clinical trials have excluded subjects with higher vulnerability to manic switches so that the risk of LTG-induced mania might have been underestimated. LTG-induced mania may be more likely to happen in patients with BD-I, manic predominant polarity, an index manic episode, or those with a history of the antidepressant manic switch. Therefore, in BD patients with the aforementioned risk factors, LTG use should be carefully managed: starting with low doses, extending tapering lengths, using adjunctive treatments and close monitoring manic symptoms.

Adjunctive antidepressants for the acute treatment of bipolar depression: A systematic review and meta-analysis

BACKGROUND

The depressive phase of bipolar disorder causes significant functional impairment and disease burden. The efficacy and safety of antidepressants in the treatment of bipolar depression has long been a subject of debate.

AIMS

To synthesize evidence of the effectiveness, risk of mood switching, and tolerability of adjunctive antidepressants in acute bipolar depression compared to using mood stabilizers or antipsychotics alone.

METHOD

Multiple databases were searched for randomized controlled trials, including open label and double-blinded, for patients ages 18 or older with acute bipolar depression, comparing efficacy and adverse events in those who used adjunctive antidepressants versus without. Risk of bias and outcomes were assessed using the Cochrane Risk of Bias Tool. This study has PROSPERO registration CRD42016037701.

RESULTS

Nineteen studies met inclusion criteria. Adjunctive antidepressants showed no significant effect on improving response rate (RR=1.10, 95%CI: 0.98-1.23). Subgroup analysis showed that adjunctive antidepressants with antipsychotics had a small but significantly better response rate compared to antipsychotics alone, which was not seen with adjunctive antidepressants with mood stabilizers. However, that finding was limited by studies predominantly using olanzapine as the antipsychotic medication. Adjunctive antidepressants had no clinically significant impact (but a small statistically significant impact) on improving depressive symptoms (SMD=-0.13, 95%CI: -0.24 to -0.02). There was no association with increased mood switch (RR=0.97, 95%CI: 0.68-1.39) and there was an association with lower dropout due to inefficacy (RR=0.66, 95%CI: 0.45∼0.98).

CONCLUSIONS

There is no evidence of adjunctive antidepressants clinically improving response rate or depressive symptoms for acute bipolar depression. They are well tolerated, without increasing the risk of short-term mood switch.

Bipolar Disorder and Outcomes of Monotherapy with Lithium, Valproate, Quetiapine, Olanzapine, Venlafaxine, and Citalopram

INTRODUCTION

The aim of this study was to compare the outcomes of monotherapy in individuals with bipolar disorder who are prescribed lithium, valproate, quetiapine, olanzapine, venlafaxine, or citalopram in private psychiatric practices in Germany.

METHODS

This retrospective study included bipolar disorder patients who had initially started on a monotherapy with lithium, valproate, quetiapine, olanzapine, venlafaxine, or citalopram in 93 private neuropsychiatric practices in Germany between January 2006 and December 2017. Treatment failure was defined as time to discontinuation of medication or addition of another mood stabilizer, antipsychotic, antidepressant, or benzodiazepine.

RESULTS

A total of 4990 bipolar patients was examined for the period between 2006 and 2019. Initially, monotherapy with lithium (n=1.098), valproate (n=502), quetiapine (n=927), olanzapine (n=927), venlafaxine (n=574), or citalopram (n=962) was prescribed. Within 24 months, treatment failure had occurred in 76.3% (lithium), 85.1% (valproate), 84.6% (quetiapine), 85.2% (venlafaxine), 92.1% (olanzapine), and 86.6% (citalopram) of patients, respectively. The hazard ratio for treatment failure compared to lithium as reference was highest for olanzapine at 1.66 (1.46-1.88), followed by citalopram 1.27 (1.15-1.39), quetiapine 1.18 (1.07-1.29), valproate 1.18 (1.06-1.33), and venlafaxine 1.14 (1.02-1.27).

CONCLUSIONS

Our results underline the importance of lithium in the maintenance treatment of bipolar disorders.

Effectiveness, tolerability, and dropout rates of vortioxetine in comorbid depression: A naturalistic study

OBJECTIVE

Vortioxetine is a novel antidepressant whose safety, tolerability, and therapeutic action have been supported by several studies. The present naturalistic study aimed to characterize its effectiveness, tolerability, and dropout rate in the real world.

METHODS

Total sample consisted of 66 outpatients with major depressive episode, treated with vortioxetine, whose clinical variables were evaluated over three time points.

RESULTS

Most common primary diagnoses were major depressive disorder (45.5%) and bipolar disorder (33.4%), with an overall comorbidity rate of 48.5% and concomitant medications in the 89.4%. The mean vortioxetine daily dosage was 12.90 ± 5.65 mg. Effectiveness of vortioxetine through a significant improvement on specific psychometric scales emerged, while only a nonsignificant trend of association between higher dosage and effectiveness was found. In the total sample, 51.5% were classified as responders and 36.4% as remitters. Two-thirds of subjects did not report side effects, while in the remaining patients, gastrointestinal ones were the most frequent (72.7%). Almost two-thirds of the sample could complete the follow-up, while 36.4% dropped out; the main reasons for dropout were side effects (37.5%) and lack of efficacy (29.2%).

CONCLUSIONS

Larger sample studies are warranted to better characterize vortioxetine effectiveness and tolerability in the real world.

Drug treatment for patients with bipolar disorders in psychiatric practices in Germany in 2009 and 2018

AIMS

The aim of this study was to describe the treatment of bipolar disorder patients in psychiatric private practices in Germany in 2009 and 2018.

METHODS

This retrospective study included patients with bipolar disorder who had received at least one prescription for antidepressants, antipsychotics, antiepileptic drugs or benzodiazepines in 93 neuropsychiatric private practices in Germany between January 2009 and December 2018. Outcomes of this study were the prevalence of prescriptions for defined mood stabilizers, antipsychotics, antidepressants, and benzodiazepines, and the prevalence of mono and combination therapy in 2009 and 2018.

RESULTS

1,815 and 2,322 patients with bipolar disorder were examined in 2009 and 2018, respectively. Compared to 2009, there was a decrease in the proportion of prescriptions for mood stabilizers by 2018 (58.6% to 49.5%) especially for lithium (from 31.4% to 26.2%) and an increase in the prescription of antipsychotics (38.4% in 2009 and 53.1% in 2018) and antidepressants (32.6% in 2009 and 45.1% in 2018). The share of combination therapy increased moderately from 39.3% to 41%.

CONCLUSIONS

Quetiapine has displaced lithium from the number one medication of the most commonly prescribed drugs in patients with bipolar disorders. The rate of patients in this study receiving monotherapy was surprisingly high.