Patterns of treatment resistance in bipolar affective disorder

Who benefits from digital interventions for bipolar disorder? Stage of illness characteristics as predictors of changes in quality of life

OBJECTIVES

This study explored the potential role of stage-related variables in intervention outcomes in bipolar disorder (BD). Specifically, we aimed to identify which subgroups of individuals were most likely to experience improved quality of life following digitally delivered psychosocial interventions for BD.

METHODS

The study involved a secondary analysis of combined data from two randomised control trials (RCTs). Each trial assessed the effectiveness of digitally delivered interventions for improving quality of life, in late-stage (ORBIT RCT) or early-stage (BETTER RCT) BD. Three iterations of cluster analyses were performed, identifying subgroups of individuals based on (i) current phenomenology, (ii) course of illness and (iii) medication response. The resultant subgroups were compared with regard to changes in quality of life pre-post intervention, via repeated measures ANOVAs.

RESULTS

In each cluster analysis, two clusters were found. The current phenomenology clusters reflected two impairment levels, 'moderate impairment' and 'low impairment'. The course of illness clusters reflected 'more chronicity' and 'less chronicity' and the medication response clusters reflected 'good medication response' and 'poor medication response'. Differences in changes in quality of life over time were observed between the two current phenomenology clusters and between the medication response clusters, while the course of illness subgroups did not respond differently.

CONCLUSIONS

There are at least two distinct groups of treatment-seeking individuals with established BD, based on illness features with previously established links to different illness stages. Clusters within the current phenomenology and medication response domains demonstrated significantly different trajectories of QoL change over time in the context of our interventions, highlighting potential implications for treatment selection aligned with precision psychiatry.

Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.

Pharmacological Strategies for Bipolar Disorders in Acute Phases and Chronic Management with a Special Focus on Lithium, Valproic Acid, and Atypical Antipsychotics

Bipolar disorders (BDs) are a heterogeneous group of severe affective disorders generally described by the alternation of (hypo)manic, depressive, and mixed phases, with euthymic intervals of variable duration. BDs are burdened with high psychiatric and physical comorbidity, increased suicide risk and reduced life expectancy. In addition, BDs can progress into complicated forms (e.g., mixed states, rapid/irregular cycling), which are more difficult to treat and often require personalized pharmacological combinations. Mood stabilizers, particularly Lithium and Valproic acid (VPA), still represent the cornerstones of both acute and chronic pharmacotherapies of BDs. Lithium is the gold standard in BD-I and BDII with typical features, while VPA seems more effective for atypical forms (e.g., mixed-prevalence and rapid-cycling). However, despite appropriate mood stabilization, many patients show residual symptoms, and more than a half recur within 1-2 years, highlighting the need of additional strategies. Among these, the association of atypical antipsychotics (AAPs) with mood stabilizers is recurrent in the treatment of acute phases, but it is also being growingly explored in the maintenance pharmacotherapy. These combinations are clinically more aggressive and often needed in the acute phases, whereas simplifying pharmacotherapies to mood stabilizers only is preferable in the long-term, whenever possible. When mood stabilizers are not enough for maintenance treatment, Quetiapine and, less consistently, Aripiprazole have been proposed as the most advisable adjunctive strategies, for their safety and tolerability profiles. However, in view of the increased risk of serious adverse effects, a careful patient-centered balance between costs and benefits is mandatory.

Differences in course of illness between patients with bipolar II disorder with and without epileptiform discharges or other sharp activity on electroencephalograms: a cross-sectional study

BACKGROUND

A diagnosis of bipolar II disorder requires that the symptoms cannot be better explained by a medical condition. Epilepsy is in some cases associated with an affective syndrome mimicking an unstable bipolar II disorder. Epileptiform discharges on electroencephalograms (EEGs) are typical, but not pathognomonic, for epilepsy. A previous study has found a high frequency of epileptiform discharges and other sharp activity among patients with bipolar disorder. The aim of the study was to identify if epileptic discharges or other sharp activity per se are associated with an altered course of illness among patients with bipolar II disorder.

METHODS

Eighty six patients diagnosed with bipolar II disorder at two psychiatric departments were interviewed about prior course of illness and assessed with EEGs. The patients were split into two groups based on the presence (n = 12) or absence (n = 74) of epileptiform discharges or other sharp activity. Wilcoxon rank sum test, Fisher's exact test, and Pearson's chi squared test were used to assess differences between the groups on six variables of course of illness.

RESULTS

Patients with epileptiform discharges or other sharp activity had a history of more hypomanic episodes per year (median (interquartile range (IQR)) 1.5 (3.2) vs. 0.61 (1.1), p = 0.0090) and a higher hypomania:depression ratio (median (IQR) 3.2 (16) vs. 1.0 (1.0), p = 0.00091) as compared to patients without. None of the patients with epileptiform discharges or other sharp activity had self-reported epileptic seizures in their history.

CONCLUSIONS

Epileptiform discharges or other sharp activity on EEGs are associated with more hypomanic episodes and an increased hypomania:depression ratio. Our results warrant replication in prospective studies, but suggest that EEG findings could be of prognostic importance for patients diagnosed with bipolar II disorder in psychiatric care.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT00201526 ).

The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder

BACKGROUND

Resistant bipolar disorder is a major mental health problem related to significant disability and overall cost. The aim of the current study was to perform a systematic review of the literature concerning (1) the definition of treatment resistance in bipolar disorder, (2) its clinical and (3) neurobiological correlates, and (4) the evidence-based treatment options for treatment-resistant bipolar disorder and for eventually developing guidelines for the treatment of this condition.

MATERIALS AND METHODS

The PRISMA method was used to identify all published papers relevant to the definition of treatment resistance in bipolar disorder and the associated evidence-based treatment options. The MEDLINE was searched to April 22, 2018.

RESULTS

Criteria were developed for the identification of resistance in bipolar disorder concerning all phases. The search of the literature identified all published studies concerning treatment options. The data were classified according to strength, and separate guidelines regarding resistant acute mania, acute bipolar depression, and the maintenance phase were developed.

DISCUSSION

The definition of resistance in bipolar disorder is by itself difficult due to the complexity of the clinical picture, course, and treatment options. The current guidelines are the first, to our knowledge, developed specifically for the treatment of resistant bipolar disorder patients, and they also include an operationalized definition of treatment resistance. They were based on a thorough and deep search of the literature and utilize as much as possible an evidence-based approach.

Anticonvulsants as mood stabilisers

Recent research has highlighted the fact that a significant number of patients with bipolar affective disorder have a poor outcome (Cole et al, 1993). The most common poor outcome is the development of rapid or ultra-rapid cycling, but mixed states, prolonged depression and severe mania are also associated with poor outcome. It is estimated that approximately one-third of patients with bipolar affective disorder do not respond fully to lithium and a significant number of patients discontinue lithium (Post, 1990) which may itself cause further problems.

Electrical mapping in bipolar disorder patients during the oddball paradigm

Bipolar disorder (BD) is characterized by an alternated occurrence between acute mania episodes and depression or remission moments. The objective of this study is to analyze the information processing changes in BP (Bipolar Patients) (euthymia, depression and mania) during the oddball paradigm, focusing on the P300 component, an electric potential of the cerebral cortex generated in response to external sensorial stimuli, which involves more complex neurophysiological processes related to stimulus interpretation. Twenty-eight bipolar disorder patients (BP) (17 women and 11 men with average age of 32.5, SD: 9.5) and eleven healthy controls (HC) (7 women and 4 men with average age of 29.78, SD: 6.89) were enrolled in this study. The bipolar patients were divided into 3 major groups (i.e., euthymic, depressive and maniac) according to the score on the Clinical Global Impression--Bipolar Version (CGI-BP). The subjects performed the oddball paradigm simultaneously to the EEG record. EEG data were also recorded before and after the execution of the task. A one-way ANOVA was applied to compare the P300 component among the groups. After observing P300 and the subcomponents P3a and P3b, a similarity of amplitude and latency between euthymic and depressive patients was observed, as well as small amplitude in the pre-frontal cortex and reduced P3a response. This can be evidence of impaired information processing, cognitive flexibility, working memory, executive functions and ability to shift the attention and processing to the target and away from distracting stimuli in BD. Such neuropsychological impairments are related to different BD symptoms, which should be known and considered, in order to develop effective clinical treatment strategies.

Endocannabinoid system dysfunction in mood and related disorders

OBJECTIVE

The endocannabinoid (EC) system is widely distributed throughout the brain and modulates many functions. It is involved in mood and related disorders, and its activity may be modified by exogenous cannabinoids. This article examines the therapeutic potential of cannabinoids in psychiatric disorders.

METHOD

An overview is presented of the literature focussed on the functions of the EC system, its dysfunction in mood disorders and the therapeutic potential of exogenous cannabinoids.

RESULTS

We propose (hypothesize) that the EC system, which is homoeostatic in cortical excitation and inhibition, is dysfunctional in mood and related disorders. Anandamide, tetrahydrocannabinol (THC) and cannabidiol (CBD) variously combine antidepressant, antipsychotic, anxiolytic, analgesic, anticonvulsant actions, suggesting a therapeutic potential in mood and related disorders. Currently, cannabinoids find a role in pain control. Post mortem and other studies report EC system abnormalities in depression, schizophrenia and suicide. Abnormalities in the cannabinoid-1 receptor (CNR1) gene that codes for cannabinoid-1 (CB1) receptors are reported in psychiatric disorders. However, efficacy trials of cannabinoids in psychiatric disorders are limited but offer some encouragement.

CONCLUSION

Research is needed to elucidate the role of the EC system in psychiatric disorders and for clinical trials with THC, CBD and synthetic cannabinoids to assess their therapeutic potential.

Longitudinal course of bipolar I disorder: duration of mood episodes

CONTEXT

The phenomenology of bipolar I disorder affects treatment and prognosis.

OBJECTIVE

To describe the duration of bipolar I mood episodes and factors associated with recovery from these episodes.

DESIGN

Subjects with Research Diagnostic Criteria bipolar I disorder were prospectively followed up for as long as 25 years. The probability of recovery over time from multiple successive mood episodes was examined with survival analytic techniques, including a mixed-effects grouped-time survival model.

SETTING

Five US academic medical centers.

PARTICIPANTS

Two hundred nineteen subjects with bipolar I disorder.

MAIN OUTCOME MEASURES

Level of psychopathology was assessed with the Longitudinal Interval Follow-up Evaluation every 6 months for the first 5 years of follow-up and annually thereafter.

RESULTS

The median duration of bipolar I mood episodes was 13 weeks. More than 75% of the subjects recovered from their mood episodes within 1 year of onset. The probability of recovery was significantly less for an episode with severe onset (psychosis or severe psychosocial impairment in week 1 of the episode) (hazard ratio [HR] = 0.746; 95% confidence interval [CI], 0.578-0.963; P = .02) and for subjects with greater cumulative morbidity (total number of years spent ill with any mood episode) (HR = 0.917; 95% CI, 0.886-0.948; P < .001). Compared with the probability of recovery from a major depressive episode, there was a significantly greater probability of recovery from an episode of mania (HR = 1.713; 95% CI, 1.373-2.137; P < .001), hypomania (HR = 4.502; 95% CI, 3.466-5.849; P < .001), or minor depression (HR = 2.027; 95% CI, 1.622-2.534; P < .001) and, conversely, a significantly reduced probability of recovery from a cycling episode (switching from one pole to the other without an intervening period of recovery) (HR = 0.438; 95% CI, 0.351-0.548; P < .001).

CONCLUSIONS

The median duration of bipolar I mood episodes was 13 weeks, and the probability of recovery was significantly decreased for cycling episodes, mood episodes with severe onset, and subjects with greater cumulative morbidity.

Risperidone in the treatment of mixed state bipolar patients: results from a 24-week, multicenter, open-label study in Korea

AIMS

The goal of the present study was to evaluate the efficacy of risperidone combined with mood stabilizers for treating bipolar mixed state.

METHODS

The present study was a 24-week, open-label, combination, prospective investigation of the efficacy of risperidone in combination with mood stabilizers. Risperidone (1-6 mg/day) was given in combination with mood stabilizers in flexible doses according to clinical response and tolerability for 114 patients in mixed or manic episode.

RESULTS

Forty-four patients met our criteria for mixed state bipolar disorder and 70 met the criteria for pure mania. Mean age for the subjects was 39.0 +/- 11.0 years and 55.3% were female. The combination of risperidone with mood stabilizers significantly improved the scores on the Young Mania Rating Scale (YMRS), 17-item Hamilton Rating Scale for Depression (HAMD), 18-item Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), and Clinical Global Impression Scale for use in bipolar illness Severity (CGI-BP) at 24 weeks (P < 0.0001). Analysis of the YMRS, BPRS, GAS, and CGI-BP scores showed significant improvement in both the manic and mixed groups. The rate of response in YMRS scores was 84.2% (n = 96) and the rate of YMRS remission was 77.2% (n = 88) at week 24 in the total population. Seventy-four patients met both YMRS < or = 12 and HAMD < or = 7 at week 24 (64.9%). Risperidone was well tolerated, and adverse events were mostly mild.

CONCLUSION

The combination of risperidone with mood stabilizers was an effective and safe treatment for manic symptoms and coexisting depressive symptoms of bipolar disorder.

Empirical typology of bipolar I mood episodes

BACKGROUND

Much remains unknown about the phenomenology of bipolar I disorder.

AIMS

To determine the type of bipolar I mood episodes that occur over time, and their relative frequency.

METHOD

A total of 219 individuals with Research Diagnostic Criteria bipolar I disorder were prospectively followed for up to 25 years (median 20 years). Psychopathology was assessed with the Longitudinal Interval Follow-up Evaluation.

RESULTS

Overall, 1208 mood episodes were prospectively observed. The episodes were empirically classified as follows: major depression, 30.9% (n = 373); minor depression, 13.0% (n = 157); mania, 20.4% (n = 246); hypomania, 10.4% (n = 126); cycling, 17.3% (n = 210); cycling plus mixed state, 7.8% (n = 94); and mixed, 0.2% (n = 2).

CONCLUSIONS

Cycling episodes constituted 25% of all episodes. Work groups revising ICD-10 and DSM-IV should add a category for bipolar I cycling episode.

An update on the treatment of bipolar depression

BACKGROUND

Although depression accounts for a large part of the burden associated with bipolar disorder, its drug treatment has been under-studied.

OBJECTIVE

To provide the best available evidence supporting the pharmacotherapy of bipolar depression.

METHODS

A systematic review was conducted, focusing on randomized, controlled trials (RCTs) and meta-analyses.

RESULTS/CONCLUSIONS

Despite FDA approval of both the olanzapine-fluoxetine combination and quetiapine for the treatment of acute bipolar depression, independent RCTs (i.e., not trials conducted 'under the umbrella' of a drug company) have not found any drug to have antidepressant effects similar to those seen in unipolar depression. A practice-based suggestion, valuable for both short- and long-term treatment, might be to have a background of mood stabilizers and to add drugs, following one of several treatment options, trusting to find a drug with a degree of effectiveness by trial and error. The list of drugs that could be used would include all the current antidepressants, the olanzapine-fluoxetine combination and probably quetiapine too. Special features and situations might also influence treatment options.

Does tachyphylaxis occur after repeated antidepressant exposure in patients with Bipolar II major depressive episode?

OBJECTIVE

Tachyphylaxis often refers to the loss of antidepressant efficacy during long-term treatment. However, it may also refer to the gradual loss of efficacy after repeated antidepressant exposures over time. The aim of this study was to examine the phenomenon of tachyphylaxis in patients with Bipolar II major depression treated with either venlafaxine or lithium. We hypothesized that a greater number of prior antidepressant exposures would result in a reduced response to venlafaxine, but not lithium, therapy.

METHODS

83 patients were randomized to treatment with either venlafaxine (n=43) or lithium (n=40). The primary outcome was a >or= 50% reduction in baseline Hamilton Depression Rating score. A detailed history of prior drug therapy was obtained. Logistic regression was used to test the hypothesis that prior antidepressant exposure was associated with reduced response to venlafaxine therapy.

RESULTS

The mean number of prior antidepressant and mood stabilizer exposures was significantly higher in venlafaxine non-responders versus responders (p=0.02). There was no significant association between response to lithium and the number of prior antidepressant and mood stabilizer exposures (p=0.38). The odds of responding to venlafaxine or lithium therapy decreased with an increasing number of prior antidepressant exposures (p=0.04). Response was not significantly affected by the number of prior mood stabilizer exposures (p=0.30). Adjustment for clinical and demographic covariates sharpened the estimated impact of prior antidepressant exposure on treatment outcome.

LIMITATIONS

This study was a post hoc exploratory analysis. The study was not specifically powered to test the hypothesis of an association between number of prior antidepressant drug exposures and response to venlafaxine or lithium therapy.

CONCLUSION

These observations support earlier findings suggesting the presence of tachyphylaxis occurring after repeated antidepressant drug exposures. Possible mechanisms of tachyphylaxis may include genetic predisposition for non-response, physiological adaptation after repeated antidepressant exposures, and inherent illness and pharmacokinetic heterogeneity.

Pharmacotherapy of bipolar mixed states

OBJECTIVE

Mixed episodes comprise up to 40% of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options.

METHOD

Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state(s), mixed episode(s), treatment, therapy, study or trial.

RESULTS

Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a sub-group of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms.

CONCLUSIONS

More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target select aspects of these episodes.

Efficacy of electroconvulsive therapy in treatment-resistant bipolar disorder: a case series

The response to electroconvulsive therapy for six bipolar patients after pharmacotherapy failure is discussed.

METHODS

Inclusion criteria were as follows: (1) bipolar mood disorder, manic, depressive or mixed episode (DSM-IV); (2) failure of pharmacotherapy, that is, for mania, manic episode unresponsive to at least 2 adequate antimanic trials for 6 weeks; and for bipolar depression, bipolar depressive episode unresponsive to at least 2 adequate antidepressant trials for 8 weeks. The patients underwent 12 bilateral sessions of ECT 3 times per week. Clinical response was considered a reduction of 50% or greater in the Young Mania Rating Scale (YMRS) and in the Hamilton Rating Scale for Depression-21 items (HAMD-21). Final YMRS <6 and HAMD-21 <8 defined remission.

RESULTS

Six of the 9 referred patients consented to be submitted to ECT. Four were male, with ages ranging from 29 to 61 years, and their age at onset ranged from 19 to 49 years. Four showed psychotic features. All responded to ECT.

Rapid cycling bipolar disorder: historical overview and focus on emerging treatments

OBJECTIVE

Rapid cycling bipolar disorder presents a significant challenge with respect to treatment. The cyclical nature of bipolar disorder has been well recognised for over a century, and following Dunner and Fieve's landmark paper in 1974, investigators have increasingly turned their attention to issues such as the definition of rapid cycling, demographic characterisation, treatment response and pharmacologic intervention.

METHODS

A literature search using Medline was performed, and selected articles which consider important developments in the definition, demographics and course of rapid cycling are reviewed. In addition, a systematic review of the literature published during the past 5 years (1999-2004) relating to treatment was conducted.

RESULTS

Relevant articles are reviewed.

CONCLUSIONS

This review highlights the important developments in our understanding of rapid cycling bipolar disorder, and focuses particularly on the recent literature regarding treatment.

Treatment-resistant bipolar disorder: a comparison of rapid cyclers and nonrapid cyclers

BACKGROUND

We investigated clinical factors to determine their relationship to treatment resistance among bipolar patients who had a consultation at a tertiary care facility.

METHODS

Patients were separated into two categories: rapid-cycling disorders and nonrapid-cycling disorders. We hypothesized that there would be less usage of lithium carbonate among nonrapid-cycling treatment-resistant patients than among rapid cyclers and also that there would be higher rates of comorbidity seen among nonrapid-cycling than rapid-cycling patients in order to account for these particular patients being treatment resistant.

FINDINGS

Continued recycling and persistent depression characterized rapid cyclers, whereas persistent depression characterized nonrapid cyclers. Less than 30% of patients had adequate lithium treatment and there was no significant difference comparing rapid cyclers with nonrapid cyclers. Rates of comorbidity were also not significantly different between these groups. We also assessed a number of other factors.

CONCLUSION

Some of these factors were significant, but when a Bonferonni correction was applied, these significant differences were not maintained. The study of treatment resistance among nonrapid-cycling bipolar patients merits further research.

Predictors of response to treatment in children and adolescents with mood disorders

Depression and bipolar disorder are frequently chronic disorders, with onset often beginning in childhood. Mood disorders are becoming more recognized in children and adolescents, and treatment of these disorders has received much attention, particularly in the past 10 years. Recent studies have demonstrated efficacy of antidepressant medications (particularly SSRIs) and specific psychotherapies (primarily CBT). Rates of remission (little or no symptoms) in these studies, however, have remained quite low (35% to 40% in most acute studies). Furthermore, recurrence is common in this population, and affects 40% to 50%. Early onset mood disorders are also associated with increased risk of developing other psychiatric disorders, substance abuse, and suicide, and having poor academic, work, and social functioning. The lifelong implications are serious. Identifying factors that may predict response to treatment, both in general and to specific treatments, may lead to improved outcomes for these patients. Unfortunately, studies have typically been inconsistent. Most studies do not identify demographic variables as predictive of outcome, although older age has been associated with poor prognosis in several studies. Psychosocial factors have yielded some results, particularly with regard to family environments. Generally, intact families with positive interaction styles and less dysfunction have been associated with better outcomes. Psychiatric disorders among parents not only predicts the development of the disorder, but is also associated with poorer prognosis. Finally, several clinical factors have been linked to poorer outcome in children and adolescents with mood disorders. More frequent episodes, increased severity (particularly suicidality and psychosis), and comorbid disorders are likely to lead to fewer recoveries, longer episodes, and increased rate of recurrence. Recent attention has focused on mediators and moderators of outcomes to treatment. In general, the theory is that enumerable factors contribute to the course of an individual's mood disorder, but that by identifying some of the variables that have more impact may allow for more specific or modified treatments to improve outcome. Many of the predictive factors explored in this article are examples of mediators and moderators that affect outcome. Each one alone may not provide definitive answers for predicting response to treatment, but each must be taken into account at the outset of treatment. It is clear that treatments must be individualized for each patient. Furthermore, selecting only one treatment exclusively for patients may hinder progress. The first step is to attempt to identify some of the underlying causes and the consequences of the disorder itself (i.e., decreased social interaction). The next step in successful treatment is to address both the causes and consequences of the disorder, through medication, psychotherapy, skills training, family intervention, or any other methods needed to assist the child to begin functioning better in all domains (social, academic, work, family, and so forth). Such a biopsychosocial approach to treatment of these disorders will likely improve overall outcome.

Rapid cycling bipolar disease: new concepts and treatments

Having been recognized by Kraeplin at the beginning of the 20th century, rapid cycling was first described as a specific entity by Dunner et al. in 1974. The prevalence of rapid cycling ranges from 12% to 20% in patients with bipolar disorder who are not selected for a high rate of cycling.

Clinical correlates of therapeutic response in bipolar disorder

Interest in the factors associated with responsiveness to therapy in bipolar disorder has increased with evidence that lithium has differential rather than uniform effectiveness in bipolar disorder, and also with the broadening of therapeutic options, illustrated especially by the use of divalproex sodium (valproate). Lithium is effective acutely in patients with pure or elated mania, and in its prophylaxis, but may worsen depressive symptoms in such patients when used for long-term maintenance therapy. The nature of previous responses to lithium treatment predicts the type of response that can be expected during a further episode of the disorder. Mixed mania, secondary mania, and mania associated with substance abuse--as well as rapid cycling --generally respond poorly to lithium therapy. Divalproex sodium has a broader spectrum of efficacy and fewer factors that determine differential responsiveness. Data related to treatment with carbamazepine are sparse, but patients with rapid cycling may respond less well to this agent; on the other hand, limited data support the utility of carbamazepine in bipolar patients with extreme psychosis, including those with mood-incongruent features. Both classical and atypical neuroleptics (e.g. olanzapine) could profitably be used in acute mania and mixed states. Lamotrigine has recently been shown effective in bipolar depression and rapid cycling. Patients unresponsive to a single agent may show improvement with combined regimens, though this impression is based more on clinical experience than controlled randomized assignment.

Characterizing female bipolar alcoholic patients presenting for initial evaluation

This study examined gender differences of age and race-matched group of bipolar disorder (BPO) patients with comorbid alcohol dependence (AD; n = 65; males = 35, females = 30) to a group of BPO patients without comorbid AD (n = 61; males = 22, females = 39). The two groups were also similar on marital status and frequency of BPO subtypes. The results revealed that female bipolar alcoholic patients were more likely to report depressive symptoms as compared to either male bipolar alcoholics or both male and female non-alcoholic bipolar patients. When compared to male bipolar alcoholics, they had higher frequency of depressed mood, slow motor behavior, low self-esteem, decreased libido, decreased appetite, and higher general anxiety symptoms. On the other hand, female bipolar alcoholics differed from female non-alcoholic bipolar patients on reports of mood lability, depressed mood, low self-esteem, suicidal indicators, decreased libido, and general anxiety symptoms. These results raise the question of whether alcohol increases the frequency of depressive symptoms among female bipolar patients.

Electrophysiological and cognitive function in young euthymic patients with bipolar affective disorder

OBJECTIVES

EEG abnormalities and neurocognitive deficits have been reported in patients with bipolar affective disorder. The aim of this study was to ascertain whether brain function remains impaired in young bipolar patients who have become euthymic in response to treatment.

METHODS

Brain function was assessed by quantitative electroencephalographic (EEG) power-spectral mapping and by a battery of neuropsychological tests. The subjects were 29 euthymic bipolar patients aged 18-40 years and 26 healthy volunteers of similar age, IQ and socioeconomic status.

RESULTS

Grand means of spectral power of the resting EEG showed significantly (from p < 0.01 to p < 0.0001) greater power in all wave bands (delta, theta, alpha and beta) in patients compared with controls. The most marked increases were in right temporal theta and left occipital beta power (with eyes open) encompassing brain areas concerned in visuospatial processing. Neurocognitive performance was significantly impaired in the patients compared with controls in a range of visuospatial tasks.

CONCLUSIONS

The findings show significant disturbance of EEG activity and deficits in visuospatial processing in young bipolar patients despite clinical euthymia. The abnormalities were not related to age of onset or duration of illness and do not appear to be attributable to medication. The cognitive impairments were associated with the number of previous affective episodes.

Cerebral white matter lesions in bipolar affective disorder: relationship to outcome

BACKGROUND

Twenty per cent of patients with bipolar affective disorder suffer an illness that responds inadequately to treatment and has a poor outcome. Many patients, but not all, with bipolar disorder show white matter abnormalities on T(2)-weighted magnetic resonance imaging (MRI).

AIMS

To explore the hypothesis that white matter abnormalities on MRI are seen more frequently in subjects whose illness has a poor outcome compared with those with a good outcome or controls.

METHOD

Two groups of age- and gender-matched patients with bipolar disorder (14 with a good outcome and 15 with a poor outcome) and 15 controls, aged 20-65 years, were studied. Axial T(2)-weighted MRI scans were examined for the presence and severity of white matter abnormalities.

RESULTS

Significantly more poor outcome group members had deep subcortical punctate, but not periventricular, white matter hyperintensities than the good outcome group (P:=0.035) or controls (P:=0.003) and these abnormalities were of greater severity (P:=0.030 and P:<0.014, respectively).

CONCLUSIONS

Subcortical white matter lesions are associated with poor outcome bipolar disorder.

An open longitudinal study of patients with bipolar rapid cycling treated with lithium or lamotrigine for mood stabilization

OBJECTIVES

Patients with rapid cycling bipolar disorder are frequently observed to fail conventional treatment. We conducted a preliminary study to explore the potential efficacy of lamotrigine in the treatment of this refractory patient population.

METHODS

In an open longitudinal investigation, 14 patients with rapid cycling bipolar disorder were treated for 1 year with either lithium or lamotrigine as mood stabilizer.

RESULTS

Out of the seven patients with lithium, three out of seven (43%) had less than four and four out of seven (57%) had four or more episodes. In the lamotrigine group, six out of seven (86%) had less than four and one out of seven (14%) had more than four affective episodes (depressive, manic, hypomanic or mixed). In fact, three out of seven (43%) of the patients who were on lamotrigine therapy were without any further affective episodes. There was no evidence of a preferential antidepressant versus antimanic efficacy.

CONCLUSIONS

Although the study is limited by the small number of patients, the results are in line with other investigations, suggesting efficacy for lamotrigine and a suboptimal response for lithium in rapid cycling bipolar disorder. These preliminary data need to be confirmed with controlled double blind studies.

Rapid cycling bipolar affective disorder in people with intellectual disability: a systematic review

Rapid cycling bipolar affective disorder has attracted renewed interest in the general adult psychiatric literature, particularly as the response to lithium prophylaxis is poor in this subgroup of patients. The present paper describes a systematic Medline/Psyclit review of case studies and small series of patients with rapid cycling bipolar affective disorder in people with intellectual disability (ID). Rapid cycling bipolar affective disorder in people with ID may differ from its occurrence in the non-ID population in terms of a relative preponderance of males, an increased likelihood of rapid cycling onset in those with an early (prepubertal) onset of affective disorder and a different response to prophylactic drugs. The efficacy of treatment and prophylaxis of rapid cycling illnesses needs further investigation in the population with ID.

Clinical and quantitative EEG studies of mania

BACKGROUND

Earlier EEG studies reported essentially normal findings during acute manic episodes but some atypical EEG characteristics and distinctions between familial and sporadic cases were described. Recently quantitative EEG (qEEG) studies differentiating mania from schizophrenia and depression have been published.

METHODS

Clinical EEGs were obtained in 202 patients hospitalized for acute mania. EEGs were repeated in 75 patients rehospitalized for subsequent manic attacks. Quantitative EEGs were recorded in 37 patients who were able to cooperate after drug washout and again on completion of randomly assigned pharmacotherapy.

RESULTS

Normal EEGs were obtained in most patients. Moderately abnormal EEGs in 16% were significantly associated with absent family histories of affective disorder. Left sided abnormalities were more common than right. "Small sharp spikes" and "microsleep" were encountered in 17% and 10% respectively of patients who drowsed. EEG findings during subsequent episodes did not suggest increasing CNS vulnerability. qEEGs showed significant differences between each of the therapeutic agents compared-lithium, carbamazepine, and lithium combined with carbamazepine, haloperidol or risperidone. Nonresponders at baseline had significantly more diffuse theta activity than responders. During pharmacotherapy nonresponders had higher amplitudes in the left temporoparietal areas.

LIMITATION

Clinical EEG findings confirmed previous reports but did not contain original observations. Applications of qEEG were limited by requirements for patient cooperation.

The efficacy of lamotrigine in rapid cycling and non-rapid cycling patients with bipolar disorder

BACKGROUND

Patients with bipolar disorder (BD) who have rapid cycling features are often treatment refractory. Clear and conclusive evidence regarding effective treatments for this group is not available.

METHODS

Patients with diagnoses of refractory bipolar disorder who were currently experiencing manic, mixed, depressive, or hypomanic episodes were treated with lamotrigine as add-on therapy (60 patients) or monotherapy (15 patients). We compared the efficacy of lamotrigine in the 41 rapid cycling and 34 non-rapid cycling patients with BD.

RESULTS

Improvement from baseline to last visit was significant among both rapid cycling and non-rapid cycling patients for both depressive and manic symptomatology. For patients entering the study in a depressive episode, improvement in depressive symptomatology was equivalent in the two groups. Among patients entering the study in a manic, mixed, or hypomanic episode, those with rapid cycling improved less in manic symptomatology than did non-rapid cycling patients. Among rapid cycling patients with initial mild-to-moderate manic symptom severity, improvement was comparable to that in non-rapid cycling subjects; however, the subset of rapid cycling patients with severe initial manic symptomatology had little improvement in mania. Rapid cycling patients had earlier onset and more lifetime episodes of mania, depression, and mixed mania.

CONCLUSIONS

Lamotrigine was generally effective and well tolerated in this group of previously non-responsive, rapid cycling bipolar patients.

Clinical EEG findings in mania

Clinical EEG findings from 202 hospitalized manic patients repeated during 131 recurrences of mania were described. Results were considered in the light of current issues in the literature including the incidence of EEG abnormalities and minor variations, relationships between EEG and family history, EEG lateralization and longitudinal course of illness. The majority of patients had normal EEGs or mild nonspecific deviations compatible with effects of psychoactive medications. More definitive EEG abnormalities were observed in 16-percent. Microsleep occurred in 19 percent and small sharp spikes were found in 17 percent of those who drowsed, with lower incidences of 14 and 6 positive bursts and 6 Hz spike-and-slow-waves. Significant relationships between moderate or severe EEG abnormalities and negative familial loading were identified. Lateralized EEG abnormalities appeared in 9 percent of cases, involving the left side significantly more often than the right. With one exception EEG recordings during subsequent episodes did not suggest structural brain changes. Clinical EEG studies are useful in discriminating between primary and secondary affective disorders. They are also sensitive to effects of lithium and other psychoactive medications. The significance of EEG variations including microsleep and other atypical features continues to be elusive. Issues relating to heritability, hemispheric dysfunction and longitudinal course of illness merit further investigation.

Rapid cycling bipolar affective disorder: lack of relation to hypothyroidism

Thyroid indices were measured after an extended period of medication-free evaluation averaging 6 weeks in 67 consecutively admitted patients with bipolar illness. Thyroid hormone levels -- thyroxine (T4), free T4 and triiodothyronine (T3) -- were not significantly different in the 31 rapid cyclers (> or = 4 affective episodes/year) than in 36 non-rapid cyclers. Analysis of covariance indicated a non-significant trend relation between higher T4 and a greater number of affective episodes in the year prior to admission and male gender when age was covaried. Several previous reports, primarily in medicated subjects, have suggested a link between rapid cycling patients and decreased peripheral thyroid indices (low hormone levels and elevated TSH), but now the majority of studies do not support such a relation. Among those in the literature, this study includes patients studied for the longest time off medications and further suggests that the commonly-cited relation between subclinical hypothyroidism and rapid cycling bipolar illness be reevaluated.

The influence of cognitive variables on recovery in depressed inpatients

Forty two unipolar depressed inpatients were assessed on admission to hospital and again two years after the onset of the index episode. Fifty seven per cent of the sample (n = 24) fulfilled NIMH recovery criteria within this period. Older age, female gender, severity of index episode, median prior duration of episode, higher levels of dysfunctional attitudes and low self-esteem significantly predicted chronicity of depression. Backward stepwise logistic regression identified that three of these variables measured at the time of admission: severity of index depression, higher levels of dysfunctional attitudes related to the need for approval, and low self-esteem provided a robust logistic model for predicting outcome. However, the small sample size and statistical analysis employed means that replication of our research is required. Larger scale studies could also include a factor analysis so that the common elements within the different instruments may be detected. If the association between cognitive dysfunction and chronicity is confirmed, we would recommend that inpatient treatment strategies are revised to incorporate more overt psychosocial interventions.

Eye movements and psychopathology in schizophrenia and bipolar disorder

The aim of this study was to examine multivariate patterns of relationships between oculomotor performance, psychopathology, and neuropsychology. Performance on smooth pursuit and saccadic eye movement tasks was assessed in three DSM-III-R diagnosis-based groups of subjects; normal (N = 55), schizophrenic (N = 29), and bipolar disorder (N = 26) and analyzed in relation to age, gender, scale for the Assessment of Negative Symptoms, Scale for the Assessment of Positive Symptoms, and Brief Psychiatric Rating Scale scores, Shipley intelligence quotient, and Wisconsin Card Sorting Test Performance. The greatest difference was a higher proportion of errors in the antisaccade task in the schizophrenic and bipolar groups, which was related to worse Wisconsin Card Sorting Test performance and was not accounted for by gender, age, education, or intelligence quotient. A significant gender and bipolar interaction showed bipolar women to have worse antisaccade performance. Abnormal smooth pursuit was more specific to schizophrenia. Antisaccade task and sine wave root-mean-square error were correlated in bipolar but not schizophrenic subjects. Scale for the Assessment of Negative Symptoms and Scale for the Assessment of Positive Symptoms scores had independent associations with the antisaccade task. Faster reaction times in the schizophrenic group to antisaccade errors were observed, suggesting an abnormality in visual attention processing and perhaps sensory gating functions. These results confirm abnormal smooth pursuit in schizophrenia and suggests that impairments in saccadic function are less specific to diagnostic group. Oculomotor performance and psychopathology seem related in complex ways to age, gender, intelligence quotient, and executive neuropsychological and possibly visual attention functions.