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Yatham LN, Chakrabarty T, Bond DJ, Schaffer A, Beaulieu S, Parikh SV, McIntyre RS, Milev RV, Alda M, Vazquez G, Ravindran AV, Frey BN, Sharma V, Goldstein BI, Rej S, O'Donovan C, Tourjman V, Kozicky JM, Kauer-Sant'Anna M, Malhi G, Suppes T, Vieta E, Kapczinski F, Kanba S, Lam RW, Kennedy SH, Calabrese J, Berk M, Post R. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) recommendations for the management of patients with bipolar disorder with mixed presentations. Bipolar Disord 2021; 23:767-788. [PMID: 34599629 DOI: 10.1111/bdi.13135] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) guidelines provided clinicians with pragmatic treatment recommendations for bipolar disorder (BD). While these guidelines included commentary on how mixed features may direct treatment selection, specific recommendations were not provided-a critical gap which the current update aims to address. METHOD Overview of research regarding mixed presentations in BD, with treatment recommendations developed using a modified CANMAT/ISBD rating methodology. Limitations are discussed, including the dearth of high-quality data and reliance on expert opinion. RESULTS No agents met threshold for first-line treatment of DSM-5 manic or depressive episodes with mixed features. For mania + mixed features second-line treatment options include asenapine, cariprazine, divalproex, and aripiprazole. In depression + mixed features, cariprazine and lurasidone are recommended as second-line options. For DSM-IV defined mixed episodes, with a longer history of research, asenapine and aripiprazole are first-line, and olanzapine (monotherapy or combination), carbamazepine, and divalproex are second-line. Research on maintenance treatments following a DSM-5 mixed presentation is extremely limited, with third-line recommendations based on expert opinion. For maintenance treatment following a DSM-IV mixed episode, quetiapine (monotherapy or combination) is first-line, and lithium and olanzapine identified as second-line options. CONCLUSION The CANMAT and ISBD groups hope these guidelines provide valuable support for clinicians providing care to patients experiencing mixed presentations, as well as further influence investment in research to improve diagnosis and treatment of this common and complex clinical state.
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Affiliation(s)
- Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Trisha Chakrabarty
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - David J Bond
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ayal Schaffer
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Serge Beaulieu
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Sagar V Parikh
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Roumen V Milev
- Department of Psychiatry, Queens University, Kingston, Ontario, Canada
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queens University, Kingston, Ontario, Canada
| | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benicio N Frey
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Verinder Sharma
- Departments of Psychiatry and Obstetrics & Gynaecology, Western University, London, Ontario, Canada
| | | | - Soham Rej
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Claire O'Donovan
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Valerie Tourjman
- Department of Psychiatry and addiction, University of Montreal, Montreal, QC, Canada
| | | | - Marcia Kauer-Sant'Anna
- Department of Psychiatry, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gin Malhi
- Department of Psychiatry, University of Sydney, Sydney, Australia
| | - Trisha Suppes
- Department of Psychiatry and Behavioural Sciences, Stanford School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Shigenobu Kanba
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Calabrese
- Department of Psychiatry, Western Reserve University, Cleveland, Ohio, USA
| | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
| | - Robert Post
- Department of Psychiatry, George Washington University, Washington, District of Columbia, USA
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Abstract
PURPOSE OF REVIEW Mixed presentations in bipolar disorder have long posed clinical and nosological challenges. The DSM-5 mixed features specifier was developed to provide a more flexible and clinically relevant definition of mixed presentations compared with narrowly defined DSM-IV mixed episodes. However, there is little guidance on treating such presentations. Here, we summarize the evidence for biological treatments of DSM-5 and similarly defined mixed features (MFs). RECENT FINDINGS The literature on treating MFs is almost exclusively based on post hoc analyses. Within this limited evidence base is preliminary positive data for aripiprazole, asenapine, cariprazine, olanzapine, risperidone, and ziprasidone in treating acute mania with MFs, and cariprazine, lurasidone, olanzapine, and ziprasidone for depressive symptoms in depression with MFs. Divalproex may also be efficacious for acute mania with MFs. The few extant maintenance studies suggest that divalproex and olanzapine may have long-term efficacy in those with index MFs or for the prevention of MFs, respectively. The existing evidence suggests that clinicians consider atypical antipsychotics and divalproex for treating acute mixed presentations. However, adequately powered treatment trials-and studies of maintenance and neurostimulation therapies-are needed. Additionally, data-driven techniques to identify relevant symptom clusters may help improve our conceptualization of mixed presentations.
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Affiliation(s)
- Trisha Chakrabarty
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Kamyar Keramatian
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada.
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Verdolini N, Hidalgo-Mazzei D, Murru A, Pacchiarotti I, Samalin L, Young AH, Vieta E, Carvalho AF. Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines. Acta Psychiatr Scand 2018; 138:196-222. [PMID: 29756288 DOI: 10.1111/acps.12896] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states. METHOD The MEDLINE/PubMed and EMBASE databases were systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II. RESULTS The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood-stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines. CONCLUSION The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.
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Affiliation(s)
- N Verdolini
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,FIDMAG Germanes Hospitalàries Research Foundation, Sant Boi de Llobregat, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain.,Division of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - D Hidalgo-Mazzei
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain.,Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A Murru
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - I Pacchiarotti
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - L Samalin
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,Department of Psychiatry, CHU Clermont-Ferrand, University of Auvergne, Clermont-Ferrand, France.,Fondation FondaMental, Pôle de Psychiatrie, Hôpital Albert Chenevier, Créteil, France
| | - A H Young
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - E Vieta
- Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.,CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Spain
| | - A F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre of Addiction and Mental Health (CAMH), Toronto, ON, Canada
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Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Azorin JM, Yatham L, Mosolov S, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry 2018; 19:2-58. [PMID: 29098925 DOI: 10.1080/15622975.2017.1384850] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults. METHODS Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode. RESULTS Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention. LIMITATIONS The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands. CONCLUSIONS Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
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Affiliation(s)
- Heinz Grunze
- a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK
- b Paracelsus Medical University , Nuremberg , Germany
- c Zentrum für Psychiatrie Weinsberg , Klinikum am Weissenhof , Weinsberg , Germany
| | - Eduard Vieta
- d Bipolar Disorders Programme, Institute of Neuroscience , Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM , Barcelona , Catalonia , Spain
| | - Guy M Goodwin
- e Department of Psychiatry , University of Oxford, Warneford Hospital , Oxford , UK
| | - Charles Bowden
- f Dept. of Psychiatry , University of Texas Health Science Center , San Antonio , TX , USA
| | - Rasmus W Licht
- g Psychiatric Research Unit, Psychiatry , Aalborg University Hospital , Aalborg , Denmark
- h Clinical Department of Medicine , Aalborg University , Aalborg , Denmark
| | - Jean-Michel Azorin
- i Department of Psychiatry , Hospital Ste. Marguerite , Marseille , France
| | - Lakshmi Yatham
- j Department of Psychiatry , University of British Columbia , Vancouver , BC , Canada
| | - Sergey Mosolov
- k Department for Therapy of Mental Disorders , Moscow Research Institute of Psychiatry , Moscow , Russia
| | - Hans-Jürgen Möller
- l Department of Psychiatry and Psychotherapy , Ludwigs-Maximilian University , Munich , Germany
| | - Siegfried Kasper
- m Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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5
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Abstract
Mixed states in bipolar disorder have been neglected, and the data concerning treatment of these conditions have been relatively obscure. To address this, we systematically reviewed published pharmacological treatment data for "mixed states/episodes" in mood disorders, including "with mixed features" in DSM-5. We searched PubMed, MEDLINE, The Cochrane Library, clinicaltrials.gov, and controlled-trials.com (with different combinations of the following keywords: "mixed states/features," "bipolar," "depressive symptoms/bipolar depression," "manic symptoms," "treatment," "DSM-5") through to October 2016. We applied a quality-of-evidence approach: first-degree evidence=randomized placebo-controlled studies of pharmacological interventions used as monotherapy; second-degree evidence=a similar design in the absence of a placebo or of a combination therapy as a comparative group; third-degree evidence=case reports, case series, and reviews of published studies. We found very few primary double-blind, placebo-controlled studies on the treatment of mixed states: the preponderance of available data derives from subgroup analysis performed on studies that originally involved manic patients. Future research should study the effects of treatments in mixed states defined using current criteria.
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Abstract
OBJECTIVES We reviewed the treatment of bipolar mixed states using efficacy data of licensed and non-licensed physical or pharmacological treatments. METHODS We conducted a literature search to identify published studies reporting data on mixed states. Grading was done using an in-house level of evidence and we compared the efficacy with treatment recommendations of mixed states in current bipolar disorder guidelines. RESULTS A total of 133 studies reported data on mixed states, and seven guidelines differentiate the acute treatment of mixed states from pure states. The strongest evidence in treating co-occurring manic and depressive symptoms was for monotherapy with aripiprazole, asenapine, extended release carbamazepine, valproate, olanzapine, and ziprasidone. Aripiprazole was recommended in three guidelines, asenapine in one, and carbamazepine and ziprasidone in two. As adjunctive treatment, the strongest evidence of efficacy was for olanzapine plus lithium or valproate. For maintenance, there is evidence for the efficacy of monotherapy with valproate, olanzapine, and quetiapine. In the six guidelines valproate or olanzapine are first line monotherapy options; one recommends quetiapine. Recommended add-on treatments are lithium or valproate plus quetiapine. CONCLUSIONS There is a lack of studies designed to address the efficacy of medications in mixed affective symptoms. Guidelines do not fully reflect the current evidences.
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Affiliation(s)
- Heinz Grunze
- Newcastle University, Institute of Neuroscience , Newcastle upon Tyne , UK
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7
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Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, O'Donovan C, Macqueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Milev R, Bond DJ, Frey BN, Goldstein BI, Lafer B, Birmaher B, Ha K, Nolen WA, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013; 15:1-44. [PMID: 23237061 DOI: 10.1111/bdi.12025] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.
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Affiliation(s)
- Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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