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Nuñez NA, Coombes BJ, Beaupre LM, Ozerdem A, Resendez MG, Romo-Nava F, Bond DJ, Veldic M, Singh B, Moore KM, Betcher HK, Kung S, Prieto ML, Fuentes M, Ercis M, Miola A, Sanchez Ruiz JA, Jenkins G, Batzler A, Leung JG, Cuellar-Barboza A, Tye SJ, McElroy SL, Biernacka JM, Frye MA. Pharmacogenomic overlap between antidepressant treatment response in major depression & antidepressant associated treatment emergent mania in bipolar disorder. Transl Psychiatry 2024; 14:93. [PMID: 38351009 PMCID: PMC10864308 DOI: 10.1038/s41398-024-02798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/16/2024] Open
Abstract
There is increasing interest in individualizing treatment selection for more than 25 regulatory approved treatments for major depressive disorder (MDD). Despite an inconclusive efficacy evidence base, antidepressants (ADs) are prescribed for the depressive phase of bipolar disorder (BD) with oftentimes, an inadequate treatment response and or clinical concern for mood destabilization. This study explored the relationship between antidepressant response in MDD and antidepressant-associated treatment emergent mania (TEM) in BD. We conducted a genome-wide association study (GWAS) and polygenic score analysis of TEM and tested its association in a subset of BD-type I patients treated with SSRIs or SNRIs. Our results did not identify any genome-wide significant variants although, we found that a higher polygenic score (PGS) for antidepressant response in MDD was associated with higher odds of TEM in BD. Future studies with larger transdiagnostic depressed cohorts treated with antidepressants are encouraged to identify a neurobiological mechanism associated with a spectrum of depression improvement from response to emergent mania.
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Affiliation(s)
- Nicolas A Nuñez
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Coombes
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - Aysegul Ozerdem
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Manuel Gardea Resendez
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Department of Psychiatry, Universidad Autónoma de Nuevo León, Monterrey, México
| | | | - David J Bond
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Marin Veldic
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Balwinder Singh
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Katherine M Moore
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Hannah K Betcher
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Simon Kung
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Miguel L Prieto
- Department of Psychiatry, Faculty of Medicine, Universidad de Los Andes, Santiago, Chile
| | - Manuel Fuentes
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Mete Ercis
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | - Alessandro Miola
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - Gregory Jenkins
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Anthony Batzler
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | - Susannah J Tye
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Queensland Brain Institute, The University of Queensland, St. Lucia, QLD, Australia
| | - Susan L McElroy
- Lindner Center of HOPE/University of Cincinnati, Cincinnati, OH, USA
| | - Joanna M Biernacka
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Mark A Frye
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA.
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Luo J, Wu Y, Liu M, Li Z, Wang Z, Zheng Y, Feng L, Lu J, He F. Differentiation between depression and bipolar disorder in child and adolescents by voice features. Child Adolesc Psychiatry Ment Health 2024; 18:19. [PMID: 38287442 PMCID: PMC10826007 DOI: 10.1186/s13034-024-00708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Major depressive disorder (MDD) and bipolar disorder (BD) are serious chronic disabling mental and emotional disorders, with symptoms that often manifest atypically in children and adolescents, making diagnosis difficult without objective physiological indicators. Therefore, we aimed to objectively identify MDD and BD in children and adolescents by exploring their voiceprint features. METHODS This study included a total of 150 participants, with 50 MDD patients, 50 BD patients, and 50 healthy controls aged between 6 and 16 years. After collecting voiceprint data, chi-square test was used to screen and extract voiceprint features specific to emotional disorders in children and adolescents. Then, selected characteristic voiceprint features were used to establish training and testing datasets with the ratio of 7:3. The performances of various machine learning and deep learning algorithms were compared using the training dataset, and the optimal algorithm was selected to classify the testing dataset and calculate the sensitivity, specificity, accuracy, and ROC curve. RESULTS The three groups showed differences in clustering centers for various voice features such as root mean square energy, power spectral slope, low-frequency percentile energy level, high-frequency spectral slope, spectral harmonic gain, and audio signal energy level. The model of linear SVM showed the best performance in the training dataset, achieving a total accuracy of 95.6% in classifying the three groups in the testing dataset, with sensitivity of 93.3% for MDD, 100% for BD, specificity of 93.3%, AUC of 1 for BD, and AUC of 0.967 for MDD. CONCLUSION By exploring the characteristics of voice features in children and adolescents, machine learning can effectively differentiate between MDD and BD in a population, and voice features hold promise as an objective physiological indicator for the auxiliary diagnosis of mood disorder in clinical practice.
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Affiliation(s)
- Jie Luo
- National Clinical Research Center for Mental Disorders, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing Institute for Brain Disorders Capital Medical University, De Sheng Men Wai An Kang Hu Tong 5 Hao, Xi Cheng Qu, Beijing, 100088, People's Republic of China
| | - Yuanzhen Wu
- National Clinical Research Center for Mental Disorders, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing Institute for Brain Disorders Capital Medical University, De Sheng Men Wai An Kang Hu Tong 5 Hao, Xi Cheng Qu, Beijing, 100088, People's Republic of China
| | - Mengqi Liu
- National Clinical Research Center for Mental Disorders, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing Institute for Brain Disorders Capital Medical University, De Sheng Men Wai An Kang Hu Tong 5 Hao, Xi Cheng Qu, Beijing, 100088, People's Republic of China
| | - Zhaojun Li
- Beijing Institute of Technology, School of Integrated Circuits and Electronics, Zhongguancun South Street 5 Hao, Hai Dian Qu, Beijing, 100081, China
| | - Zhuo Wang
- Beijing Institute of Technology, School of Integrated Circuits and Electronics, Zhongguancun South Street 5 Hao, Hai Dian Qu, Beijing, 100081, China
| | - Yi Zheng
- National Clinical Research Center for Mental Disorders, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing Institute for Brain Disorders Capital Medical University, De Sheng Men Wai An Kang Hu Tong 5 Hao, Xi Cheng Qu, Beijing, 100088, People's Republic of China
| | - Lihui Feng
- Beijing Institute of Technology, School of Optics and Photonics, Zhongguancun South Street 5 Hao, Hai Dian Qu, Beijing, 100081, China
| | - Jihua Lu
- Beijing Institute of Technology, School of Integrated Circuits and Electronics, Zhongguancun South Street 5 Hao, Hai Dian Qu, Beijing, 100081, China.
| | - Fan He
- National Clinical Research Center for Mental Disorders, Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing Institute for Brain Disorders Capital Medical University, De Sheng Men Wai An Kang Hu Tong 5 Hao, Xi Cheng Qu, Beijing, 100088, People's Republic of China.
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Shteinberg AS, Barkhatova AN, Berezkin AS, Sorokin SA. [Bipolar affective disorder occurring with psychopharmacotherapy-induced manic phases]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:9-14. [PMID: 39072560 DOI: 10.17116/jnevro20241240619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
To analyze the stages of development of the problem, identify the evolution of views and the main directions of current research in the field of bipolar affective disorder, which occurs with psychopharmacotherapy-induced manic phases, the search for publications by keywords «pharmaco-induced mania»", «bipolar affective disorder» was carried out in the PubMed/MEDLINE, Russian Citation index and other sources from the mid-19th century to the present. The issue of adequate treatment of bipolar depression became relevant back in the 20th century; numerous observations indicated the presence of associated risks when using antidepressants in patients with bipolar affective disorder, namely, the likelihood of affect inversion and aggravation of the course of the disease (accelerated cyclicity, continuum). In recent years, due to the expansion of research capabilities and the introduction of biological psychiatry, works have appeared that consider this problem from both clinical and pharmacodynamic, genetic and neurophysiological aspects, which opens up the prospect of developing advanced methods of personalized medicine for the diagnosis and treatment of bipolar disorder, taking into account the need to minimize iatrogenic effects.
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Affiliation(s)
| | | | | | - S A Sorokin
- Mental Health Research Centre, Moscow, Russia
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Cuellar-Barboza AB, Prieto ML, Coombes BJ, Gardea-Resendez M, Núñez N, Winham SJ, Romo-Nava F, González S, McElroy SL, Frye MA, Biernacka JM. Polygenic prediction of bipolar disorder in a Latin American sample. Am J Med Genet B Neuropsychiatr Genet 2023; 192:139-146. [PMID: 36919637 DOI: 10.1002/ajmg.b.32936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 01/31/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Abstract
To date, bipolar disorder (BD) genetic studies and polygenic risk scores (PRSs) for BD are based primarily on populations of European descent (EUR) and lack representation from other ancestries including Latin American (LAT). Here, we describe a new LAT cohort from the Mayo Clinic Bipolar Biobank (MCBB), a multisite collaboration with recruitment sites in the United States (EUR; 1,443 cases and 777 controls) and Mexico and Chile (LAT; 211 cases and 161 controls) and use the sample to explore the performance of a BD-PRS in a LAT population. Using results from the largest genome-wide association study of BD in EUR individuals, PRSice2 and LDpred2 were used to compute BD-PRSs in the LAT and EUR samples from the MCBB. PRSs explained up to 1.4% (PRSice) and 4% (LDpred2) of the phenotypic variance on the liability scale in the LAT sample compared to 3.8% (PRSice2) and 3.4% (LDpred2) in the EUR samples. Future larger studies should further explore the differential performance of different PRS approaches across ancestries. International multisite studies, such as this one, have the potential to address diversity-related limitations of prior genomic studies and ultimately contribute to the reduction of health disparities.
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Affiliation(s)
- Alfredo B Cuellar-Barboza
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Psychiatry, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Miguel L Prieto
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Psychiatry, Universidad de los Andes, Santiago, Chile
- Mental Health Service, Clinica Universidad de los Andes, Santiago, Chile
| | - Brandon J Coombes
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Nicolás Núñez
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stacey J Winham
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Sarai González
- Department of Psychiatry, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Susan L McElroy
- Lindner Center of HOPE/University of Cincinnati, Cincinnati, Ohio, USA
| | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joanna M Biernacka
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
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Olgiati P, Serretti A. Antidepressant emergent mood switch in major depressive disorder: onset, clinical correlates and impact on suicidality. Int Clin Psychopharmacol 2023; 38:342-351. [PMID: 37351585 PMCID: PMC10373846 DOI: 10.1097/yic.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/08/2023] [Indexed: 06/24/2023]
Abstract
Antidepressant (AD)- emergent mood switch (AEMS) is a common complication of bipolar depression. This study aimed to investigate the prevalence and clinical correlates of subthreshold AEMS (i.e. not fulfilling DSM criteria for hypomanic episodes) in major depressive disorder (MDD) and, prognostically, its impact on AD treatment outcome and suicidality. The study involved 425 outpatients with MDD followed during the acute phase (12 weeks) and continuation (weeks 13-28) AD treatment. AEMS was assessed through the Altman Self-Rating Mania scale (ASRM ≥ 6). Several clinical features differentiated individuals with or without subthreshold AEMS (n = 204 vs. 221): negative self-perception [odds ratio (OR) 1.017-1.565]; panic disorder (OR 1.000-1.091); subthreshold hypomanic episodes (OR 1.466-13.352); childhood emotional abuse (OR 1.053-2.447); lifetime suicidal behaviour (OR 1.027-1.236); AD-related remission (χ 2 = 22.903 P < 0.0001) and suicide ideation (χ 2 = 16.701 P < 0.0001). In AEMS earlier onset showed a strong correlation with bipolar spectrum disorder (overall score: P = 0.0053; mixed depression: P = 0.0154; subthreshold hypomania: P = 0.0150) whereas late-onset was associated with more severe suicidal behaviour ( P < 0.001). In conclusion, our results demonstrate that subthreshold mood switches occur frequently in unipolar depression during acute AD treatment as well as in continuation phase. Time of switch onset seems to have the greatest diagnostic and prognostic value.
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Affiliation(s)
- Paolo Olgiati
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Goldberg JF. Perspectives on the success rate of current antidepressant pharmacotherapy. Expert Opin Pharmacother 2022; 23:1781-1791. [PMID: 36259350 DOI: 10.1080/14656566.2022.2138333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION There has been growing debate about the effectiveness of traditional antidepressants for the treatment of depression, and whether the clinical trials literature overstates the value of existing agents. Antidepressant efficacy is limited by suboptimal remission rates, lack of robust efficacy across diverse depressed subgroups, slow onset, and challenges managing tolerability. Clinicians can better navigate uncertainties in this area by recognizing patient-specific clinical and prognostic factors that influence the likelihood of antidepressant drug response. AREAS COVERED The author summarizes pertinent literature regarding drug-placebo differences in antidepressant outcome as well as patient-specific factors that influence antidepressant drug responsivity across subtypes of depressive disorders. EXPERT OPINION Standardized effect sizes for most monoaminergic antidepressants are relatively modest. At least one-third of treatment response derives from nonspecific (yet substantial) placebo effects, limiting the ability to compare antidepressant medication effects to that of "no treatment." Patients with high baseline depressive symptom severity are less likely to respond to placebo but may be more responsive to antidepressant pharmacotherapy than is the case in mild forms of depression. Patient satisfaction with antidepressant response must take into consideration not only efficacy for reducing symptoms but also drug tolerability/acceptability and tangible improvement in functional outcome and quality of life.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY
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7
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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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Pater ME. Cycling Without a Bike. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Post RM, Altshuler LL, Kupka R, McElroy SL, Frye MA, Grunze H, Suppes T, Keck PE, Nolen WA. 25 Years of the International Bipolar Collaborative Network (BCN). Int J Bipolar Disord 2021; 9:13. [PMID: 33811284 PMCID: PMC8019011 DOI: 10.1186/s40345-020-00218-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Stanley Foundation Bipolar Treatment Outcome Network (SFBN) recruited more than 900 outpatients from 1995 to 2002 from 4 sites in the United States (US) and 3 in the Netherlands and Germany (abbreviated as Europe). When funding was discontinued, the international group of investigators continued to work together as the Bipolar Collaborative Network (BCN), publishing so far 87 peer-reviewed manuscripts. On the 25th year anniversary of its founding, publication of a brief summary of some of the major findings appeared appropriate. Important insights into the course and treatment of adult outpatients with bipolar disorder were revealed and some methodological issues and lessons learned will be discussed. RESULTS The illness is recurrent and pernicious and difficult to bring to a long-term remission. Virtually all aspects of the illness were more prevalent in the US compared to Europe. This included vastly more patients with early onset illness and those with more psychosocial adversity in childhood; more genetic vulnerability; more anxiety and substance abuse comorbidity; more episodes and rapid cycling; and more treatment non-responsiveness. CONCLUSIONS The findings provide a road map for a new round of much needed clinical treatment research studies. They also emphasize the need for the formation of a new network focusing on child and youth onset of mood disorders with a goal to achieve early precision diagnostics for intervention and prevention in attempting to make the course of bipolar illness more benign.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, 5415 W Cedar Lane, Ste 201-B, Bethesda, 20814, MD, USA.
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, D.C., USA.
| | - Lori L Altshuler
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Psychiatry, VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Ralph Kupka
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA
- Biological Psychiatry Program, University of Cincinnati Medical College, Cincinnati, OH, USA
| | - Mark A Frye
- Department of Psychiatry& Psychology, Mayo Clinic, Rochester, MN, USA
| | - Heinz Grunze
- Psychiatrie Schwäbisch Hall GmbH & Paracelsus Medical University, Nuremberg, Germany.
| | - Trisha Suppes
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
- V.A. Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul E Keck
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Lindner Center of HOPE, Mason, OH, USA
| | - Willem A Nolen
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Diagnosing and treating major depressive episodes that lie along the mood disorders spectrum: focus on depression with mixed features. CNS Spectr 2021. [PMID: 33715657 DOI: 10.1017/s1092852921000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Growing evidence indicates that historical descriptions of mixed depression-broadly defined as major depressive episodes with subthreshold manic or hypomanic (hypo/manic) symptoms-are incredibly clinically relevant in this day-and-age. However, the first operational definition of mixed depression did not occur in the modern nomenclature until 2013 with publication of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and there has not been enough time to evaluate these criteria empirically. Thus, the most valid operational definition of a mixed depressive episode is still unknown, widely accepted treatment guidelines are not available, and no treatment has regulatory approval for mixed depression-whether associated with bipolar I disorder, bipolar II disorder, or major depressive disorder. This is despite seven drugs having regulatory indications for mixed episodes, defined as the co-occurrence of syndromal depression and syndromal mania, and now recognized as mania with mixed features by DSM-5. Indeed, we found only two randomized, placebo-controlled trials in patients with protocol defined mixed depression, one with ziprasidone and one with lurasidone. Both studies were positive, suggesting treatment with second-generation antipsychotics may be helpful for mixed depressive episodes associated with bipolar II or unipolar disorder. We found no randomized control trial of antidepressant monotherapy in mixed depression and many clinical reports that such treatment may worsen mixed depression Randomized, placebo-controlled trials of antidepressants, antipsychotics, and mood stabilizers-alone and in combination-in individuals with carefully defined mixed depression are needed before firm treatment guidelines can be produced.
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Bahji A, Ermacora D, Stephenson C, Hawken ER, Vazquez G. Comparative Efficacy and Tolerability of Adjunctive Pharmacotherapies for Acute Bipolar Depression: A Systematic Review and Network Meta-analysis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:274-288. [PMID: 33174452 PMCID: PMC7958200 DOI: 10.1177/0706743720970857] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We investigated the comparative efficacy and tolerability of augmentation strategies for bipolar depression. DATA SOURCES We conducted a systematic review and network meta-analysis of 8 electronic databases for double-blind, randomized controlled trials of adjunctive pharmacotherapies for acute bipolar depression. DATA EXTRACTION AND SYNTHESIS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and applied the Cochrane risk of bias tool for study quality appraisal. Two reviewers independently abstracted data. We resolved all discrepancies by consensus. MAIN OUTCOMES AND MEASURES Primary outcomes were response and completion of treatment. We estimated summary rate ratios (RRs) and standardized mean differences (SMDs) relative to placebo controls using frequentist random-effects network meta-analysis. RESULTS We identified 69 trials meeting eligibility criteria (8,007 participants, 42.8 years, 58.0% female). Adjunctive racemic intravenous ketamine, coenzyme Q10, pramipexole, fluoxetine, and lamotrigine were more effective than placebo. Summary RRs for response ranged between 1.51 (95% confidence interval [CI], 1.11 to 2.06) for fluoxetine and 12.49 (95% CI, 3.06 to 50.93) for racemic intravenous ketamine. For completion of treatment, risperidone appeared less tolerable than placebo (RR = 0.59; 95% CI, 0.38 to 0.94), while fluoxetine seemed more tolerable than placebo (RR = 1.13; 95% CI, 1.02 to 1.24). None of the investigated agents were associated with increased treatment-emergent mood switches. CONCLUSIONS AND RELEVANCE The evidence for augmentation strategies in bipolar depression is limited to a handful of agents. Fluoxetine appeared to have the most consistent evidence base for both efficacy and tolerability. There remains a need for additional research exploring novel treatment strategies for bipolar depression, particularly head-to-head studies.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Alberta, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Anees Bahji, MD, Addiction Psychiatry Fellow, Department of Psychiatry, University of Calgary, 2500 University Drive NW., Calgary, Alberta, Canada T2N 1N4. Emails: ;
| | - Dylan Ermacora
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Callum Stephenson
- School of Kinesiology and Health Studies, Queen’s University, Kingston, Ontario, Canada
| | - Emily R. Hawken
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Providence Care Hospital, Kingston, Ontario, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Providence Care Hospital, Kingston, Ontario, Canada
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12
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Köhler-Forsberg O, Sylvia LG, Fung V, Overhage L, Thase M, Calabrese JR, Deckersbach T, Tohen M, Bowden CL, McInnis M, Kocsis JH, Friedman ES, Ketter TA, McElroy SL, Shelton RC, Ostacher MJ, Iosifescu DV, Nierenberg AA. Adjunctive antidepressant treatment among 763 outpatients with bipolar disorder: Findings from the Bipolar CHOICE and LiTMUS trials. Depress Anxiety 2021; 38:114-123. [PMID: 32598093 DOI: 10.1002/da.23069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/12/2020] [Accepted: 06/03/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Adjunctive antidepressants are frequently used for bipolar depression but their clinical efficacy has been studied in few trials and little is known about how co-occurring manic symptoms affect treatment response. METHODS Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (N = 482) and Lithium Treatment Moderate-Dose Use Study (N = 281) were similar comparative effectiveness trials on outpatients with bipolar disorder comparing four different randomized treatment arms with adjunctive personalized guideline-based treatment for 24 weeks. Adjunctive antidepressant treatment could be used if clinically indicated and was assessed at every study visit. Adjusted mixed effects linear regression analyses compared users of antidepressants to nonusers overall and in different subcohorts. RESULTS Of the 763 patients, 282 (37.0%) used antidepressant drugs during the study. Antidepressant users had less improvement compared to nonusers on the Clinical Global Impression Scale for Bipolar Disorder and on measures of depression. This was particularly true among patients with co-occurring manic symptoms. Exclusion of individuals begun on antidepressants late in the study (potentially due to overall worse response) resulted in no differences between users and nonusers. We found no differences in treatment effects on mania scales. CONCLUSIONS In this large cohort of outpatients with bipolar disorder, clinically indicated and guideline-based adjunctive antidepressant treatment was not associated with lower depressive symptoms or higher mania symptoms. The treatment-by-indication confounding due to the nonrandomized design of the trials complicates causal interpretations, but no analyses indicated better treatment effects of adjunctive antidepressants.
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Affiliation(s)
- Ole Köhler-Forsberg
- Psychosis Research Unit and the Department of Affective Disorders, Aarhus University Psychiatry Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Louisa G Sylvia
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Vicki Fung
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Lindsay Overhage
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Thase
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph R Calabrese
- Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
| | - Thilo Deckersbach
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mauricio Tohen
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, Texas
| | - Melvin McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - James H Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Edward S Friedman
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Susan L McElroy
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry, Lindner Center of HOPE, Mason, Ohio
| | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael J Ostacher
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Dan V Iosifescu
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
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13
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Gillett G, McGowan NM, Palmius N, Bilderbeck AC, Goodwin GM, Saunders KEA. Digital Communication Biomarkers of Mood and Diagnosis in Borderline Personality Disorder, Bipolar Disorder, and Healthy Control Populations. Front Psychiatry 2021; 12:610457. [PMID: 33897487 PMCID: PMC8060643 DOI: 10.3389/fpsyt.2021.610457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Remote monitoring and digital phenotyping harbor potential to aid clinical diagnosis, predict episode course and recognize early signs of mental health crises. Digital communication metrics, such as phone call and short message service (SMS) use may represent novel biomarkers of mood and diagnosis in Bipolar Disorder (BD) and Borderline Personality Disorder (BPD). Materials and Methods: BD (n = 17), BPD (n = 17) and Healthy Control (HC, n = 21) participants used a smartphone application which monitored phone calls and SMS messaging, alongside self-reported mood. Linear mixed-effects regression models were used to assess the association between digital communications and mood symptoms, mood state, trait-impulsivity, diagnosis and the interaction effect between mood and diagnosis. Results: Transdiagnostically, self-rated manic symptoms and manic state were positively associated with total and outgoing call frequency and cumulative total, incoming and outgoing call duration. Manic symptoms were also associated with total and outgoing SMS frequency. Transdiagnostic depressive symptoms were associated with increased mean incoming call duration. For the different diagnostic groups, BD was associated with increased total call frequency and BPD with increased total and outgoing SMS frequency and length compared to HC. Depression in BD, but not BPD, was associated with decreased total and outgoing call frequency, mean total and outgoing call duration and total and outgoing SMS frequency. Finally, trait-impulsivity was positively associated with total call frequency, total and outgoing SMS frequency and cumulative total and outgoing SMS length. Conclusion: These results identify a general increase in phone call and SMS communications associated with self-reported manic symptoms and a diagnosis-moderated decrease in communications associated with depression in BD, but not BPD, participants. These findings may inform the development of clinical tools to aid diagnosis and remote symptom monitoring, as well as informing understanding of differential psychopathologies in BD and BPD.
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Affiliation(s)
- George Gillett
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, The Cairns Library IT Corridor Level 3, Oxford, United Kingdom.,Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
| | - Niall M McGowan
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Niclas Palmius
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Amy C Bilderbeck
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom.,P1vital Products, Manor House, Howbery Business Park, Wallingford, United Kingdom
| | - Guy M Goodwin
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
| | - Kate E A Saunders
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
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14
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Singh MK, Pikalov A, Siu C, Tocco M, Loebel A. Lurasidone in Children and Adolescents with Bipolar Depression Presenting with Mixed (Subsyndromal Hypomanic) Features: Post Hoc Analysis of a Randomized Placebo-Controlled Trial. J Child Adolesc Psychopharmacol 2020; 30:590-598. [PMID: 32392455 PMCID: PMC7757594 DOI: 10.1089/cap.2020.0018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives: To evaluate the efficacy and safety of lurasidone in the treatment of children and adolescents with bipolar depression presenting with mixed (subsyndromal hypomanic) features. Methods: Patients, 10-17 years of age, with a Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), diagnosis of bipolar I depression were randomized to 6 weeks of double-blind treatment with once-daily flexible doses of lurasidone 20-80 mg or placebo. The presence of mixed (subsyndromal hypomanic) features in this pediatric bipolar depression trial was defined as a Young Mania Rating Scale score of 5 or greater at study baseline. Key efficacy measures included change from baseline to week 6 in the Children's Depression Rating Scale-Revised (CDRS-R) score (primary endpoint) and Clinical Global Impressions-Bipolar Severity (CGI-BP-S) score, using a mixed model for repeated measures analysis. Results: At baseline, subsyndromal hypomanic features were present in 54.2% of patients. Treatment with lurasidone (vs. placebo) was associated with significantly greater reductions in CDRS-R scores at week 6, independent of the presence (-21.5 vs. -15.9, p < 0.01; effect size d = 0.43) or absence (-20.5 vs. -14.9, p < 0.01; d = 0.44) of subsyndromal hypomanic features. Likewise, lurasidone (vs. placebo) was associated with significantly greater reductions in CGI-BP-S scores at week 6, independent of the presence (-1.6 vs. -1.1, p < 0.001, d = 0.51) or absence (-1.3 vs. -1.0, p = 0.05; d = 0.31) of these subsyndromal hypomanic features. Rates of protocol-defined treatment-emergent hypomania or mania were similar for lurasidone and placebo in patients with (lurasidone 8.2% vs. placebo 9.0%) or without subsyndromal hypomanic features (lurasidone 1.3% vs. placebo 3.7%). Conclusions: In this post hoc analysis of a randomized placebo-controlled trial, lurasidone was found to be efficacious in the treatment of child and adolescent patients with bipolar depression who presented with mixed (subsyndromal hypomanic) features. No differences in safety profile, including the risk of treatment-emergent mania, were observed in patients with or without subsyndromal hypomanic features in this study.
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Affiliation(s)
- Manpreet K. Singh
- Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
- Address correspondence to: Manpreet K. Singh, MD, MS, Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Andrei Pikalov
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts, and Fort Lee, New Jersey, USA
| | - Cynthia Siu
- COS and Associates Ltd., Central, Hong Kong, People's Republic of China
| | - Michael Tocco
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts, and Fort Lee, New Jersey, USA
| | - Antony Loebel
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts, and Fort Lee, New Jersey, USA
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15
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Stanislaus S, Vinberg M, Melbye S, Frost M, Busk J, Bardram JE, Kessing LV, Faurholt-Jepsen M. Smartphone-based activity measurements in patients with newly diagnosed bipolar disorder, unaffected relatives and control individuals. Int J Bipolar Disord 2020; 8:32. [PMID: 33135120 PMCID: PMC7604277 DOI: 10.1186/s40345-020-00195-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/23/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In DSM-5 activity is a core criterion for diagnosing hypomania and mania. However, there are no guidelines for quantifying changes in activity. The objectives of the study were (1) to investigate daily smartphone-based self-reported and automatically-generated activity, respectively, against validated measurements of activity; (2) to validate daily smartphone-based self-reported activity and automatically-generated activity against each other; (3) to investigate differences in daily self-reported and automatically-generated smartphone-based activity between patients with bipolar disorder (BD), unaffected relatives (UR) and healthy control individuals (HC). METHODS A total of 203 patients with BD, 54 UR, and 109 HC were included. On a smartphone-based app, the participants daily reported their activity level on a scale from -3 to + 3. Additionally, participants owning an android smartphone provided automatically-generated data, including step counts, screen on/off logs, and call- and text-logs. Smartphone-based activity was validated against an activity questionnaire the International Physical Activity Questionnaire (IPAQ) and activity items on observer-based rating scales of depression using the Hamilton Depression Rating scale (HAMD), mania using Young Mania Rating scale (YMRS) and functioning using the Functional Assessment Short Test (FAST). In these analyses, we calculated averages of smartphone-based activity measurements reported in the period corresponding to the days assessed by the questionnaires and rating scales. RESULTS (1) Smartphone-based self-reported activity was a valid measure according to scores on the IPAQ and activity items on the HAMD and YMRS, and was associated with FAST scores, whereas the majority of automatically-generated smartphone-based activity measurements were not. (2) Daily smartphone-based self-reported and automatically-generated activity correlated with each other with nearly all measurements. (3) Patients with BD had decreased daily self-reported activity compared with HC. Patients with BD had decreased physical (number of steps) and social activity (more missed calls) but a longer call duration compared with HC. UR also had decreased physical activity compared with HC but did not differ on daily self-reported activity or social activity. CONCLUSION Daily self-reported activity measured via smartphone represents overall activity and correlates with measurements of automatically generated smartphone-based activity. Detecting activity levels using smartphones may be clinically helpful in diagnosis and illness monitoring in patients with bipolar disorder. Trial registration clinicaltrials.gov NCT02888262.
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Affiliation(s)
- Sharleny Stanislaus
- The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Department O, 6243, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Maj Vinberg
- The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Department O, 6243, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Sigurd Melbye
- The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Department O, 6243, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Mads Frost
- Monsenso ApS, Langelinie Allé 47, Copenhagen, Denmark
| | - Jonas Busk
- Copenhagen Center for Health Technology (CACHET), Department of Health Technology, Technical University of Denmark, Lyngby, Denmark
| | - Jakob E Bardram
- Copenhagen Center for Health Technology (CACHET), Department of Health Technology, Technical University of Denmark, Lyngby, Denmark
| | - Lars Vedel Kessing
- The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Department O, 6243, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Maria Faurholt-Jepsen
- The Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Department O, 6243, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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16
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Cariprazine efficacy in bipolar I depression with and without concurrent manic symptoms: post hoc analysis of 3 randomized, placebo-controlled studies. CNS Spectr 2020; 25:502-510. [PMID: 31576791 PMCID: PMC7511904 DOI: 10.1017/s1092852919001287] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Mixed presentations, defined by simultaneous occurrence of depressive and manic symptoms, are difficult to treat. Antidepressants, although commonly used, have weak evidence of efficacy and may increase risk of mood destabilization. The aim of this pooled post hoc analysis was to evaluate the efficacy of cariprazine in the treatment of bipolar depression with or without concurrent manic symptoms. METHODS Patients from 3 randomized, double-blind, placebo-controlled studies who met DSM-IV-TR or DSM-5 criteria for bipolar I disorder with a current major depressive episode were identified to have concurrent manic symptoms by baseline Young Mania Rating Scale total score ≥4. Efficacy was assessed in cariprazine 1.5 and 3 mg/day dose groups versus placebo; analyses included the least squares mean change from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale (MADRS) total score. RESULTS Of 1383 patients randomized to treatment, 808 (58.4%) had concurrent manic symptoms. For patients with manic symptoms, mean reduction in MADRS total score from baseline to week 6 was significantly greater for both cariprazine 1.5 and 3 mg/day compared with placebo, with least squares mean differences (LSMDs) versus placebo of -2.5 (p = .0033) and -2.9 (p = .0010), respectively; for patients without manic symptoms, the LSMD was significant for 1.5 mg/day (-3.3; p = .0008), but not for 3 mg/day (-1.9; p = .0562). CONCLUSION The results of this post hoc analysis suggest that cariprazine may be an appropriate treatment option for patients with bipolar I depression with or without manic symptoms, with higher doses potentially more effective in patients with manic symptoms.
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17
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Bahji A, Ermacora D, Stephenson C, Hawken ER, Vazquez G. Comparative efficacy and tolerability of pharmacological treatments for the treatment of acute bipolar depression: A systematic review and network meta-analysis. J Affect Disord 2020; 269:154-184. [PMID: 32339131 DOI: 10.1016/j.jad.2020.03.030] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We investigated the comparative efficacy and tolerability of pharmacological treatment strategies for the treatment of acute bipolar depression. DATA SOURCES A systematic review and network meta-analysis was conducted by searching eight registries for published and unpublished, double-blind, randomized controlled trials of pharmacotherapies for the acute treatment of bipolar depression. DATA EXTRACTION AND SYNTHESIS PRISMA guidelines were used for abstracting data, while the Cochrane Risk of Bias Tool was used to assess data quality. Data extraction was done independently by two reviewers, with discrepancies resolved by consensus. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES Primary outcomes were efficacy (response and remission rate) and acceptability (completion of treatment and dropouts due to adverse events). Summary odds ratios (ORs) were estimated using pairwise and network meta-analysis with random effects. RESULTS Identified citations (4,404) included 50 trials comprising 11,448 participants. Escitalopram, phenelzine, moclobemide, carbamazepine, sertraline, lithium, paroxetine, aripiprazole, gabapentin and ziprasidone appear to be ineffective as compared to placebo in treatment of bipolar depression. Divalproex, olanzapine/fluoxetine, olanzapine, quetiapine, cariprazine, and lamotrigine, appear to be effective as compared to placebo in treatment of bipolar depression according to the network meta-analysis. Aripiprazole showed higher discontinuation rates versus placebo due to the appearance of any adverse event. Quetiapine was better than placebo at reducing treatment-emergent affective switches. For Bipolar I Disorder, cariprazine, fluoxetine, imipramine, lamotrigine, lurasidone, olanzapine-fluoxetine, and olanzapine were significantly better than placebo at response, while fluoxetine, imipramine, cariprazine, lurasidone, olanzapine-fluoxetine, and olanzapine were significantly better than placebo at remission. CONCLUSIONS AND RELEVANCE These results could serve evidence-based practice and inform patients, physicians, guideline developers, and policymakers on the relative benefits of the different antidepressants, antipsychotics, and mood-stabilizing agents for the treatment of bipolar depression. REGISTRATION PROSPERO (CRD42019122172).
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Dylan Ermacora
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Callum Stephenson
- School of Kinesiology and Health Studies, Queen's University, Kingston, Ontario, Canada
| | - Emily R Hawken
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada; Providence Care Hospital, Kingston, Ontario, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
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Abstract
Mixed states are frequent clinical pictures in psychiatric practice but are not well described in nosologic systems. Debate exists as to defining mixed states. We review factor and cluster analytical studies and prominent clinical/conceptual models of mixed states. While mania involves standard manic symptoms and depression involves standard depressive symptoms, core additional features of the mixed state are, primarily, psychomotor activation and, secondarily, dysphoria. Those features are more pronounced in mixed mania than in mixed depression but are present in both.
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Affiliation(s)
- Sergio A Barroilhet
- Clínica Psiquiátrica Universitaria, Facultad Medicina Universidad de Chile, Santiago, Chile; Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA.
| | - S Nassir Ghaemi
- Department of Psychiatry, Tufts University, School of Medicine, Tufts Medical Center, Pratt Building, 3rd Floor, 800 Washington Street, Box 1007, Boston, MA 02111, USA; Department of Psychiatry, Harvard Medical School, Harvard University, Boston, MA, USA
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19
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Taş Hİ, Altinbaş K. Comparison of the Emotion Regulation and Temperament Characteristics Between Depressive Patients With and Without Mixed Features. ACTA ACUST UNITED AC 2020; 57:27-32. [PMID: 32110147 DOI: 10.29399/npa.23610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 08/25/2019] [Indexed: 11/07/2022]
Abstract
Introduction "Depressive disorder with mixed features" has been included in the official classification in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Hypothesizing that difficulties in emotion regulation and affective temperament scores are higher in mixed depression comparing to pure depression, we aimed to evaluate the relationship between these phenomena and mixed symptoms. Methods Depressive patients diagnosed by a psychiatrist according to the DSM-5 and had not received any psychiatric treatment for the last 3 months, were included in the study. The Hamilton Rating Scale (HDRS), modified Hypomania Checklist (mHCL), Difficulties in Emotion Regulation Scale (DERS), and the TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris, San Diego Autoquestionaire) were applied to all participants. Results Of the 63 participants, 40 (63.5%) were women. The mean age was 37.8±12.4 years while mean duration of education was 10.8±4.3 years. The proportion of mixed-depression assessed by the mHCL was 23.8% (n=15). No significant difference was found between the groups concerning gender, age, family history, age at onset of illness, the total number of episodes and temperament scores. Depressive patients with mixed features had significantly higher DERS nonacceptance subscale scores. Multiple regression analysis demonstrated that the cyclothymic temperament scale scores significantly affected the total mHCL scores. Conclusion In mixed depression group, higher scores in nonacceptance subscale seems to reflect a tendency to fluctuations in the emotional reactions of a person to the stress. Association between mixed depression, DERS nonacceptance subscale and cyclothymic temperament support the spectrum view that mixed depression is placed between pure depression and bipolarity.
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Affiliation(s)
- Halil İbrahim Taş
- Department of Psychiatry, Çanakkale Onsekiz Mart University School of Medicine, Çanakkale, Turkey
| | - Kürşat Altinbaş
- Department of Psychiatry, Selçuk University School of Medicine, Konya, Turkey
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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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Tavares DF, Dos Santos CGR, Valiengo LDCL, Klein I, Borrione L, Forte PM, Brunoni AR, Moreno RA. Efficacy, Safety, and Tolerability of Theta-Burst Stimulation in Mixed Depression: Design, Rationale, and Objectives of a Randomized, Double-Blinded, Sham-Controlled Trial. Front Psychiatry 2020; 11:435. [PMID: 32499730 PMCID: PMC7242745 DOI: 10.3389/fpsyt.2020.00435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/28/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mixed-specifier mood disorders are probably a different subgroup in terms of response to treatment, socio-demographic parameters, course, and family history. Here we describe the rationale and design of a clinical trial aimed to test the efficacy, safety, and tolerability of a non-pharmacological treatment known as theta-burst stimulation (TBS) for treating the mixed depressive episodes of both bipolar (I or II), and unipolar depression. METHODS The study is designed as a randomized, sham-controlled, double-blinded clinical trial evaluating TBS for the treatment of moderate or severe major depressive episodes with mixed features of patients receiving at least one first or second-line pharmacological treatment for depressive episodes without adequate response. Ninety adult (18 to 65 years old) patients will be enrolled and submitted to 6-week (comprising 5 consecutive days a week sessions for the first 3 weeks and then 2 days a week for a further 3 week) of inhibitory followed by excitatory TBS in dorsolateral prefrontal cortex. Participants will be assessed using clinical and neuropsychological tests before and after the intervention. The primary outcome is change in Montgomery-Åsberg Depression Scale (MADRS) score over time and across groups. Cognitive parameters will also be assessed with neuropsychological tests. RESULTS The clinical results will provide evidence about TBS as an adjunctive treatment for mixed depression treatment and neuropsychological parameters will contribute toward an improved understanding the effects of TBS in cognition. CONCLUSION Our results could introduce a novel therapeutic technique for mixed depressive episodes of both bipolar and unipolar disorders. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier NCT04123301; date of registration: 10/10/2019; URL: https://clinicaltrials.gov/ct2/show/NCT04123301?term=NCT04123301&rank=1.
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Affiliation(s)
| | | | | | - Izio Klein
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
| | - Lucas Borrione
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
| | | | - Andre R Brunoni
- Department of Psychiatry, University of São Paulo, São Paulo, Brazil
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22
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Goldberg JF. Determining Patient Candidacy for Antidepressant Use in Bipolar Disorder. Psychiatr Ann 2019. [DOI: 10.3928/00485713-20190807-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Goldberg JF. Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:206-217. [PMID: 32047366 PMCID: PMC6999206 DOI: 10.1176/appi.focus.20190005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City
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Abstract
Our current conceptualisation of mixed states, defined as co-occurring manic and depressive symptoms, is unlikely to advance our knowledge or inform clinical practice. Episodes of mixed states can no longer be coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the 'mixed features specifier' fails to capture the most common mixed state presentations. This reflects a lack of understanding of both the importance of mixed states and their underlying pathophysiology. Indeed, research into the nature of mixed states is scarce and uninformative, and most clinical practice guidelines fail to provide advice regarding their management. In this paper, we proffer a reconceptualisation of mixed states that provides a framework for informing clinical practice and research. It is based on the ACE model, which deconstructs mood disorders into three domains of symptoms: activity, cognition, and emotion. Symptoms within each domain vary independently over time and in different directions (towards either excitation or inhibition). By deconstructing mood disorders into component domains, mixed states can be explained as the product of different domains varying 'out of sync'. In most cases, the aetiology of mixed states is unknown. Alongside such idiopathic mixed states, we describe three potential causes of mixed states that are important to consider when formulating management: transitions, ultradian cycling, and treatment-emergent affective switches. In addition to providing guidance on the identification of various kinds of mixed states, we discuss practical strategies for their management, including the monitoring of ACE domains and functioning, to inform the use of psychoeducation and lifestyle changes, psychotherapy, pharmacology, and electroconvulsive therapy.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia.
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia.
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.
| | - Kristina Fritz
- Department of Psychology, California State University, Northridge, CA, USA
| | - Preeya Elangovan
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Irwin
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia
- Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia
- CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
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25
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Hooshmand F, Do D, Shah S, Gershon A, Park DY, Yuen LD, Dell'Osso B, Wang PW, Miller S, Ketter TA. Antidepressants have complex associations with longitudinal depressive burden in bipolar disorder. J Affect Disord 2019; 246:836-842. [PMID: 30795488 DOI: 10.1016/j.jad.2018.12.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/12/2018] [Accepted: 12/23/2018] [Indexed: 10/27/2022]
Abstract
AIMS Antidepressants are common in bipolar disorder (BD), but controversial due to questionable efficacy/tolerability. We assessed baseline antidepressant use/depression associations in BD. METHODS Stanford BD Clinic outpatients, enrolled during 2000-2011, assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, were monitored up to two years with the STEP-BD Clinical Monitoring Form while receiving naturalistic expert treatment. Prevalence/correlates of baseline antidepressant use in recovered (euthymic ≥8 weeks)/depressed patients were assessed. Kaplan-Meier survival analyses assessed times to depressive recurrence/recovery in patients with/without baseline antidepressant use, and Cox Proportional Hazard regression analyses assessed covariate effects. RESULTS Baseline antidepressant use was significantly (albeit without Bonferroni multiple comparison correction) less among 105 recovered (31.4%) versus 153 depressed (44.4%) patients, and among recovered patients (again without Bonferroni correction), associated with Caucasian race, earlier onset, worse Clinical Global Impression scores, and hastened depressive recurrence (only if mood elevation episodes were not censored), driven by lifetime anxiety disorder, and more (even with Bonferroni correction) bipolar II disorder, lifetime anxiety and eating disorders, and core psychotropics. Baseline antidepressant use among depressed patients was associated with significantly (again without Bonferroni correction) older age, female gender, and more (even with Bonferroni correction) anxiolytics/hypnotics, complex pharmacotherapy, and core psychotropics, but no other unfavorable illness characteristic/current mood symptom, and not time to depressive recovery. LIMITATIONS Tertiary BD clinic referral sample receiving open naturalistic expert treatment. Analyses without/with Bonferroni correction. CONCLUSIONS Additional research is required to assess the complex associations between baseline antidepressant use and longitudinal depressive burden in BD.
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Affiliation(s)
- Farnaz Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Dennis Do
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Saloni Shah
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Anda Gershon
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Dong Yeon Park
- Department of Psychiatry, Seoul National Hospital, Seoul, South Korea
| | - Laura D Yuen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Bernardo Dell'Osso
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA; Department of Psychiatry, University of Milan, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Po W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Shefali Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA
| | - Terence A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5723, USA.
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26
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Fela-Thomas AL, Olotu OS, Esan O. Risk of manic switch with antidepressants use in patients with bipolar disorder in a Nigerian neuropsychiatric hospital. S Afr J Psychiatr 2018; 24:1215. [PMID: 30473882 PMCID: PMC6244419 DOI: 10.4102/sajpsychiatry.v24i0.1215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 08/21/2018] [Indexed: 11/03/2022] Open
Abstract
Background Depressive disorders are common among those with bipolar affective disorder (BAD) and may necessitate the use of antidepressants. This has been suggested to precipitate manic episodes in some patients. Objectives This study aims to determine the prevalence of and factors associated with manic switch in patients with BAD being treated with antidepressants. Methods Case notes of patients who were treated at a Nigerian neuropsychiatric hospital for a BAD from 2004 to 2015 were reviewed. BAD diagnosis was made using ICD-10 criteria. Treatment for bipolar depression included monotherapy (i.e. antidepressants, antipsychotics or mood stabilisers) or combination therapy (mood stabiliser with an antidepressant or a combination of mood stabilisers, antipsychotics and antidepressants). The primary outcome measure was a switch to mania or hypomania within 12 weeks of commencing an antidepressant. Results Manic or hypomanic switch (MS) was observed in 109 (44.3%) of the participants. Female gender, younger age, number of previous episodes and a past history of psychiatric hospitalisation were all significantly associated with a risk of MS. There was no significant difference in the rate of MS in either those treated with adjunct antidepressants therapy with a mood stabiliser or an antipsychotic or those placed on a combination of antidepressants, antipsychotics and mood-stabilising agents. Conclusion A large proportion of patients with BAD on antidepressants experience medication-induced manic or hypomanic switch.
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Affiliation(s)
| | - Osasu S Olotu
- Department of Clinical Sciences, Federal Neuropsychiatric Hospital, Nigeria
| | - Oluyomi Esan
- Department of Psychiatry, University of Ibadan, Nigeria
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27
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Abstract
Anxiety disorders are the most prevalent comorbid diagnoses in patients with bipolar disorder (BD). A comorbid anxiety diagnosis can significantly impact the severity of bipolar symptoms, increase the risk of suicidality, and decrease psychosocial functioning and quality of life. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force published recommendations for treatment in 2012 suggesting that specific anticonvulsant mood stabilizers and second-generation antipsychotics are the medications of choice to treat these comorbidities. Serotonergic antidepressant medications are first-line medications for the treatment of most anxiety disorders; however, this can be problematic for a patient with BD. Antidepressant use in BD has been associated with a risk of manic switch as well as potential destabilization of mood. Mood stabilizer therapy should be established for patients with comorbid BD and an anxiety disorder before other medications are added to address the anxiety disorder. While benzodiazepine medications are recommended as third-line therapy in the CANMAT task force recommendations, their use should be avoided in patients with comorbid BD, posttraumatic stress disorder, and substance use disorders. The use of benzodiazepines should in general be avoided for all patients if possible, based upon current clinical research. Interpersonal, cognitive behavioral, and relaxation therapy are effective for the treatment of anxiety symptoms, especially emotional experiences, in patients who are euthymic.
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Affiliation(s)
- Carol A Ott
- (Corresponding author) Clinical Professor of Pharmacy Practice, Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, Indiana; Clinical Pharmacy Specialist, Outpatient Psychiatry, Prevention and Recovery Center for Early Psychosis, Mood Disorders Clinic, Midtown Community Mental Health, Eskenazi Health, Indianapolis, Indiana,
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28
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Fornaro M, Anastasia A, Monaco F, Novello S, Fusco A, Iasevoli F, De Berardis D, Veronese N, Solmi M, de Bartolomeis A. Clinical and psychopathological features associated with treatment-emergent mania in bipolar-II depressed outpatients exposed to antidepressants. J Affect Disord 2018. [PMID: 29525354 DOI: 10.1016/j.jad.2018.02.085] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Treatment-emergent affective switch (TEAS), including treatment-emergent mania (TEM), carry significant burden in the clinical management of bipolar depression, whereas the use of antidepressants raises both efficacy, safety and tolerability concerns. The present study assesses the prevalence and clinical correlates of TEM in selected sample of Bipolar Disorder (BD) Type-II (BD-II) acute depression outpatients. METHODS Post-hoc analysis of the clinical and psychopathological features associated with TEM among 91 BD-II depressed outpatients exposed to antidepressants. RESULTS Second-generation antipsychotics (SGA) (p = .005), lithium (≤ .001), cyclothymic/irritable/hyperthymic temperaments (p = ≤ .001; p = .001; p = .003, respectively), rapid-cycling (p = .005) and depressive mixed features (p = .003) differed between TEM+ cases vs. TEM- controls. Upon multinomial logistic regression, the accounted psychopathological features correctly classified as much as 88.6% of TEM+ cases (35/91 overall sample, or 38.46% of the sample), yet not statistically significantly [Exp(B) = .032; p = ns]. Specifically, lithium [B = - 2.385; p = .001], SGAs [B = - 2.354; p = .002] predicted lower rates of TEM+ in contrast to the number of lifetime previous psychiatric hospitalizations [B = 2.380; p = .002], whereas mixed features did not [B = 1.267; p = ns]. LIMITATIONS Post-hoc analysis. Lack of systematic pharmacological history record; chance of recall bias and Berkson's biases. Permissive operational criterion for TEM. Relatively small sample size. CONCLUSIONS Cyclothymic temperament and mixed depression discriminated TEM+ between TEM- cases, although only lithium and the SGAs reliably predicted TEM+/- grouping. Larger-sampled/powered longitudinal replication studies are warranted to allow firm conclusions on the matter, ideally contributing to the identification of clear-cut sub-phenotypes of BD towards patient-tailored-pharmacotherapy.
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Affiliation(s)
- Michele Fornaro
- New York State Psychiatric Institute, Columbia University, NYC, NY, USA; Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Annalisa Anastasia
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Francesco Monaco
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neuroscience, University of Salerno, Salerno, Italy.
| | - Stefano Novello
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Andrea Fusco
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Felice Iasevoli
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital "G. Mazzini", ASL 4, 64100 Teramo, Italy.
| | | | - Marco Solmi
- Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy.
| | - Andrea de Bartolomeis
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
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Stringaris A, Vidal-Ribas P, Brotman MA, Leibenluft E. Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. J Child Psychol Psychiatry 2018; 59:721-739. [PMID: 29083031 DOI: 10.1111/jcpp.12823] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Irritability is one of the most common reasons for referral to child and adolescent mental health services and is the main characteristic of the new diagnosis of disruptive mood dysregulation disorder (DMDD). However, the recognition and management of irritability presents a major challenge in clinical practice and may be partly responsible for the dramatic increase in antipsychotic prescribing in recent years. METHODS In this review, we provide up-to-date information on the definition and mechanisms underlying irritability, and its assessment in clinical practice. We aim to discuss the latest research on DMDD, and the presence of severe irritability in the context of other disorders, as well as to recommend a treatment algorithm. RESULTS Severe irritability is associated with aberrant reward processing and bias toward threatening stimuli. Several measures are available to easily assess irritability. The recent diagnosis of DMDD captures children whose main problem is severe irritability and differ from those with bipolar disorder in longitudinal outcomes, family history, and behavioral and neural correlates. Treatment of irritability might depend on the context it appears. Indirect evidence suggests that parent management training (PMT) and cognitive behavioral therapy (CBT) are the most supported psychological treatments for irritability. CONCLUSIONS Irritability, recognized as a mood problem rather than a purely behavioral manifestation, is a common condition for young people. Practitioners should not ignore irritability as it is associated with substantial morbidity and impairment. Although there are no trials with irritability as main outcome, clinicians can apply several existing pharmacological and psychological interventions for its treatment. Also, new promising approaches relying on pathophysiological findings, such as exposure-based cognitive behavioral therapy techniques and interpretation bias training (IBT), are being currently investigated.
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Affiliation(s)
- Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.,Institute of Psychiatry, Psychology and Neuroscience, Department of Child and Adolescent Psychiatry, King's College London, London, UK
| | - Melissa A Brotman
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
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30
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Differential prevalence and demographic and clinical correlates of antidepressant use in American bipolar I versus bipolar II disorder patients. J Affect Disord 2018. [PMID: 29524749 DOI: 10.1016/j.jad.2018.02.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIMS Antidepressant use is controversial in bipolar disorder (BD) due to questionable efficacy/psychiatric tolerability. We assessed demographic/clinical characteristics of baseline antidepressant use in BD patients. METHODS Prevalence and correlates of baseline antidepressant use in 503 BD I and BD II outpatients referred to the Stanford Bipolar Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation. RESULTS Antidepressant use was 39.0%, overall, and was higher in BD II versus BD I (46.9% versus 30.5%, p = 0.0002). Both BD I and BD II antidepressant compared to non-antidepressant users had higher rates of complex pharmacotherapy (≥ 4 mood stabilizers, antipsychotics, and/or antidepressants) and use of other psychotropics. Antidepressant use in BD II versus BD I was higher during euthymia (44.0% vs. 28.0%) and subsyndromal symptoms (56.1% vs. 28.6%), but not depression or mood elevation. LIMITATIONS American tertiary BD clinic referral sample receiving open naturalistic treatment. CONCLUSIONS In our sample, antidepressant use was higher in BD II versus BD I patients, and was associated with markers of heightened illness severity in both BD I and BD II patients. Additional research is warranted to investigate these complex relationships.
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31
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Fornaro M, Anastasia A, Novello S, Fusco A, Solmi M, Monaco F, Veronese N, De Berardis D, de Bartolomeis A. Incidence, prevalence and clinical correlates of antidepressant-emergent mania in bipolar depression: a systematic review and meta-analysis. Bipolar Disord 2018; 20:195-227. [PMID: 29441650 DOI: 10.1111/bdi.12612] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 12/15/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment-emergent mania (TEM) represents a common phenomenon inconsistently reported across primary studies, warranting further assessment. METHODS A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were conducted. Major electronic databases were searched from inception to May 2017 to assess the incidence and prevalence rates and clinical features associated with manic switch among bipolar depressed patients receiving antidepressants, using meta-regression and subgroup analysis. RESULTS Overall, 10 098 depressed patients with bipolar disorder (BD) across 51 studies/arms were included in the quantitative analysis. The cumulative incidence of cases (TEM+ ) among 4767 patients with BD over 15 retrospective studies was 30.9% (95% confidence interval [CI] 19.6-45.0%, I2 = 97.9%). The cumulative incidence of TEM+ among 1929 patients with BD over 12 prospective open studies was 14.4% (95% CI 7.4-26.1%, I2 = 93.7%). The cumulative incidence of TEM+ among 1316 patients with BD over 20 randomized controlled trials (RCTs) was 11.8% (95% CI 8.4-16.34%, I2 = 73.46%). The pooled prevalence of TEM+ among 2086 patients with BD over four cross-sectional studies was 30.9% (95% CI 18.1-47.4%, I2 = 95.6%). Overall, concurrent lithium therapy predicted the lowest TEM rates. Inconsistent operational definitions of TEM were recorded, and the lack of information about age, sex, co-occurring anxiety, and other clinically relevant moderators precluded further stratification of the results. CONCLUSIONS Rates of TEM vary primarily depending on study setting, which is concordant with the high degree of heterogeneity of the included records. Forthcoming RCT studies should adopt consistent operational definitions of TEM and broaden the number of moderators, in order to contribute most effectively to the identification of clear-cut sub-phenotypes of BD and patient-tailored pharmacotherapy.
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Affiliation(s)
- Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Annalisa Anastasia
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Stefano Novello
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Andrea Fusco
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Marco Solmi
- Neuroscience Department, University of Padua, Padua, Italy.,Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy
| | - Francesco Monaco
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neuroscience, University of Salerno, Salerno, Italy
| | - Nicola Veronese
- Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy.,National Research Council, Aging Branch, Padua, Italy
| | - Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Teramo, Italy
| | - Andrea de Bartolomeis
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
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Bobo WV. The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update. Mayo Clin Proc 2017; 92:1532-1551. [PMID: 28888714 DOI: 10.1016/j.mayocp.2017.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/21/2022]
Abstract
Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.
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Affiliation(s)
- William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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33
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Barbuti M, Pacchiarotti I, Vieta E, Azorin JM, Angst J, Bowden CL, Mosolov S, Young AH, Perugi G. Antidepressant-induced hypomania/mania in patients with major depression: Evidence from the BRIDGE-II-MIX study. J Affect Disord 2017; 219:187-192. [PMID: 28558366 DOI: 10.1016/j.jad.2017.05.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/12/2017] [Accepted: 05/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The issue of antidepressant-induced mood switches to hypomania, mania, or mixed states within the course of mayor depressive disorder (MDD) has been a controversial topic. The present post-hoc analysis of the BRIDGE-II-MIX study focuses on the clinical features of patients with history of antidepressant-induced hypomania/mania (AIHM) in a large international sample of patients with major depressive episode (MDE). METHODS 2811 subjects with major depression were enrolled in this multicentre cross-sectional study. Current mixed symptoms, socio-demographic and other clinical variables were collected and compared among MDD-AIHM, MDD and BD patients. RESULTS 475 patients out of 2811 had history of AIHM (16.90%). In the MDD-AIHM group, familiarity for BD and rates of atypical features and comorbid anxiety, eating and borderline personality disorders were similar to BD and significantly more frequent compared to MDD group. MDD-AIHM patients had more frequently more than 3 episodes and reported higher rates of treatment resistance, mood lability and irritability following treatment with antidepressants. Frequencies of depression with mixed features and (hypo)manic symptoms were similar in patients of MDD-AIHM and BD groups and significantly higher in both groups than in MDD. LIMITATIONS there were widely varying rates of hospitalized patients across countries and the participating centres were not randomly selected. CONCLUSIONS Our results strongly support the DSM-5 inclusion of MDD patients with AIHM within the rubric of bipolar disorder. Differences with other MDD and BD were also observed suggesting the possibility that MDD-AIHM may represent a specific sub-population, particularly sensitive to exogenous input from antidepressants.
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Affiliation(s)
- Margherita Barbuti
- University of Pisa, Pisa, Italy; Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Isabella Pacchiarotti
- Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Barcelona Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | | | - Jules Angst
- Psychiatric Hospital, University of Zurich, Switzerland
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Tohen M, Gold AK, Sylvia LG, Montana RE, McElroy SL, Thase ME, Rabideau DJ, Nierenberg AA, Reilly-Harrington NA, Friedman ES, Shelton RC, Bowden CL, Singh V, Deckersbach T, Ketter TA, Calabrese JR, Bobo WV, McInnis MG. Bipolar mixed features - Results from the comparative effectiveness for bipolar disorder (Bipolar CHOICE) study. J Affect Disord 2017; 217:183-189. [PMID: 28411507 DOI: 10.1016/j.jad.2017.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/09/2017] [Accepted: 03/28/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND DSM-5 changed the criteria from DSM-IV for mixed features in mood disorder episodes to include non-overlapping symptoms of depression and hypomania/mania. It is unknown if, by changing these criteria, the same group would qualify for mixed features. We assessed how those meeting DSM-5 criteria for mixed features compare to those meeting DSM-IV criteria. METHODS We analyzed data from 482 adult bipolar patients in Bipolar CHOICE, a randomized comparative effectiveness trial. Bipolar diagnoses were confirmed through the MINI International Neuropsychiatric Interview (MINI). Presence and severity of mood symptoms were collected with the Bipolar Inventory of Symptoms Scale (BISS) and linked to DSM-5 and DSM-IV mixed features criteria. Baseline demographics and clinical variables were compared between mood episode groups using ANOVA for continuous variables and chi-square tests for categorical variables. RESULTS At baseline, the frequency of DSM-IV mixed episodes diagnoses obtained with the MINI was 17% and with the BISS was 20%. Using DSM-5 criteria, 9% of participants met criteria for hypomania/mania with mixed features and 12% met criteria for a depressive episode with mixed features. Symptom severity was also associated with increased mixed features with a high rate of mixed features in patients with mania/hypomania (63.8%) relative to those with depression (8.0%). LIMITATIONS Data on mixed features were collected at baseline only and thus do not reflect potential patterns in mixed features within this sample across the study duration. CONCLUSIONS The DSM-5 narrower, non-overlapping definition of mixed episodes resulted in fewer patients who met mixed criteria compared to DSM-IV.
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Affiliation(s)
- Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Health Sciences Center, Albuquerque, NM, USA.
| | - Alexandra K Gold
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Louisa G Sylvia
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca E Montana
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, USA; Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Dustin J Rabideau
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew A Nierenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Noreen A Reilly-Harrington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Richard C Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles L Bowden
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Vivek Singh
- Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thilo Deckersbach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Terence A Ketter
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph R Calabrese
- Bipolar Disorders Research Center, University Hospital's Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - William V Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Scott J, Brichant-Petitjean C, Etain B, Henry C, Kahn JP, Azorin JM, Leboyer M, Bellivier F. A re-examination of antidepressant treatment-emergent mania in bipolar disorders: evidence of gender differences. Acta Psychiatr Scand 2017; 135:479-488. [PMID: 28369709 DOI: 10.1111/acps.12728] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To explore the prevalence and clinical profile of males and females who develop antidepressant treatment-emergent mania (ATEM). METHOD From an original sample of 754 patients with BD, we identified ATEM+ cases (n = 75) and ATEM- controls (n = 135) that met stringent criteria. We specifically examined the combinations of clinical factors that best classified males and females as ATEM+ cases. RESULTS Seventy-five individuals were classified as ATEM+; 87% of ATEM events occurred during antidepressant monotherapy. Regression analyses demonstrated that the presence of an alcohol and/or substance use disorder [Odds Ratio (OR) 6.37], a history of one or more suicide attempts (OR 4.19) and higher number of depressive episodes per year of illness (OR 1.71) correctly classified 73% of males. In contrast, 84% of females were correctly classified on the basis of a positive history of thyroid disorder (OR 3.23), a positive family history of BD I (OR 2.68) and depressive onset polarity (OR 2.01). CONCLUSION Using stringent definitions of ATEM status to reduce the probability of inclusion of false-positive cases and false-negative controls, we identified for the first time that the risk profiles for the development of an ATEM differ significantly according to gender.
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Affiliation(s)
- J Scott
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Affective Disorders, IoPPN, Kings College, London, UK
| | - C Brichant-Petitjean
- Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, AP-HP, Paris, France.,INSERM, Unité UMR-S 1144, Variabilité de Réponse aux Psychotropes, Université Paris Descartes-Paris Diderot, Paris, France.,Université Paris Diderot, Paris, France
| | - B Etain
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France
| | - C Henry
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France.,Unité Perception et Mémoire, Institut Pasteur, Paris, France
| | - J-P Kahn
- Fondation FondaMental, Créteil, France.,Service de Psychiatrie et Psychologie Clinique, Centre Psychothérapique de Nancy et CHU de Nancy, Vandoeuvre les Nancy, France.,Université de Lorraine, Nancy, France
| | - J-M Azorin
- Fondation FondaMental, Créteil, France.,AP-HM, Pôle de psychiatrie, Hôpital Sainte Marguerite, Marseille, France
| | - M Leboyer
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France
| | - F Bellivier
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Affective Disorders, IoPPN, Kings College, London, UK.,Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, AP-HP, Paris, France.,Fondation FondaMental, Créteil, France
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Shiozawa P, Cordeiro Q, Cho HJ, Trevizol AP, Brietzke E. A critical review of trials of transcranial direct current stimulation and trigeminal nerve stimulation for depression: the issue of treatment-emergent mania. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2017; 39:48-53. [PMID: 28403323 DOI: 10.1590/2237-6089-2016-0027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/25/2016] [Indexed: 12/16/2022]
Abstract
Objective: This study is a critical review analyzing occurrence of treatment-emergent mania (TEM) related to transcranial direct current stimulation (tDCS) and trigeminal nerve stimulation (TNS). Method: We present a systematic review of the literature on TEM related to tDCS and TNS treatment for major depressive disorder (MDD), conducted in accordance with the recommendations from Cochrane Group and the PRISMA guidelines. Results: Our search identified few reported episodes of TEM in the literature. In fact, we found 11 trials focused on treatment of MDD (seven controlled trials of tDCS and four trials of TNS, three open label and one controlled). We highlight the need for safety assessment in clinical research settings to establish with precision and in larger samples the risks inherent to the technique under investigation. Conclusion: Safety assessment is of fundamental importance in clinical research. TEM is a very important safety issue in MDD trials. Further and larger controlled trials will help to clarify both the safety and the clinical effects of combinations of pharmacotherapy and tDCS or TNS in daily clinical practice.
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Affiliation(s)
- Pedro Shiozawa
- Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Quirino Cordeiro
- Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | | | - Alisson Paulino Trevizol
- Centro Interdisciplinar de Neuromodulação Clínica, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Elisa Brietzke
- Laboratório Interdisciplinar de Neurociências Clínicas (LiNC), Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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What is the role of conventional antidepressants in the treatment of major depressive episodes with Mixed Features Specifier? CNS Spectr 2017; 22:120-125. [PMID: 27831463 DOI: 10.1017/s1092852916000493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The newly introduced Mixed Features Specifier of Major Depressive Episode and Disorder (MDE/MDD) is especially challenging in terms of pharmacological management. Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms of the mixed features specifier were intradepressive hypomanic symptoms, always and only associated with bipolar disorder (BD). Intradepressive hypomanic symptoms, mostly referred to as depressive mixed states (DMX), have been poorly characterized, and their treatment offers significant challenges. To understand the diagnostic context of DMX, we trace the nosological changes and collocation of intradepressive hypomanic symptoms, and examine diagnostic and prognostic implications of such mixed features. One of the reasons so little is known about the treatment of DMX is that depressed patients with rapid cycling, substance abuse disorder, and suicidal ideation/attempts are routinely excluded from clinical trials of antidepressants. The exclusion of DMX patients from clinical trials has prevented an assessment of the safety and tolerability of short- and long-term use of antidepressants. Therefore, the generalization of data obtained in clinical trials for unipolar depression to patients with intradepressive hypomanic features is inappropriate and methodologically flawed. A selective review of the literature shows that antidepressants alone have limited efficacy in DMX, but they have the potential to induce, maintain, or worsen mixed features during depressive episodes in BD. On the other hand, preliminary evidence supports the effective use of some atypical antipsychotics in the treatment of DMX.
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Abstract
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier provides a less restrictive definition of mixed mood states, compared to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), including mood episodes that manifest with subthreshold symptoms of the opposite mood state. A limited number of studies have assessed the efficacy of treatments specifically for DSM-5-defined mixed features in mood disorders. As such, there is currently an inadequate amount of data to appropriately inform evidence-based treatment guidelines of DSM-5 defined mixed features. However, given the high prevalence and morbidity of mixed features, treatment recommendations based on the currently available evidence along with expert opinion may be of benefit. This article serves to provide these interim treatment recommendations while humbly acknowledging the limited amount of evidence currently available. Second-generation antipsychotics (SGAs) appear to have the greatest promise in the treatment of bipolar disorder (BD) with mixed features. Conventional mood stabilizing agents (ie, lithium and divalproex) may also be of benefit; however, they have been inadequately studied. In the treatment of major depressive disorder (MDD) with mixed features, the comparable efficacy of antidepressants versus other treatments, such as SGAs, remains unknown. As such, antidepressants remain first-line treatment of MDD with or without mixed features; however, there are significant safety concerns associated with antidepressant monotherapy when mixed features are present, which merits increased monitoring. Lurasidone is the only SGA monotherapy that has been shown to be efficacious specifically in the treatment of MDD with mixed features. Further research is needed to accurately determine the efficacy, safety, and tolerability of treatments specifically for mood episodes with mixed features to adequately inform future treatment guidelines.
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Abstract
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.
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40
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Çelik SB, Bucaktepe GE, Uludağ A, Bulut İU, Erdem Ö, Altınbaş K. Screening mixed depression and bipolarity in the postpartum period at a primary health care center. Compr Psychiatry 2016; 71:57-62. [PMID: 27632572 DOI: 10.1016/j.comppsych.2016.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Mixed depression is a clinical condition accompanied by the symptoms of (hypo)mania and is considered to be a predictor for bipolar disorder. Compared to pure major depression, mixed depression is worse in progress. There are limited data on the prevalence of mixed depression since it is a relatively new entity. Therefore, the present study aimed to investigate the prevalence of mixed depression during the postpartum period which is risky for mood disorders. METHODS The study included 63 postpartum women. The participants were administered Beck Depression Scale, Edinburgh Postnatal Depression Scale (EPDS), Mood Disorders Questionnaire (MDQ), and Modified Hypomania Symptom Checklist-32 (mHCL-32). RESULTS The MDQ scores of the women with expected depression according to the EPDS cut-off scores, were significantly higher than the women with lower EPDS scores (t=-4.968; p<0.001). The modified hypomania scores were significantly higher in the women with higher depression scores compared to the women under EPDS cut-off scores (t=-4.713; p<0.001). According to the EPDS and BDS results, 27 (42.9%) and 14 (22.2%) women needed additional clinical examination for depression, respectively. In addition, 3 (4.8%) women require additional clinical examination for bipolar disorder. The scores for the first item of MDQ were above the cut-off value in 11 (17.5%) women. According to the mHCL-32 results, 50 (79.4%) women had at least 1 symptom, 45 (71.4%) women had at least 3 symptoms, and 43 (68.3%) women had at least 5 symptoms of mixed depression. CONCLUSION Postpartum mixed depression should be promptly diagnosed by using appropriate diagnostic tools, particularly by primary health care physicians. Patients with mixed depression should be closely monitored to avoid manic switch.
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Affiliation(s)
| | | | - Ayşegül Uludağ
- Department of Family Medicine, Canakkale Onsekiz Mart University Medical School, Canakkale, Turkey
| | | | - Özgür Erdem
- Kayapınar Peyas, Family Health Center, Diyarbakır, Turkey
| | - Kürşat Altınbaş
- Department of Psychiatry, Canakkale Onsekiz Mart University Medical School, Canakkale, Turkey.
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Kim H, Kim W, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definition by permitting overlapping and non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:199-206. [PMID: 27137894 DOI: 10.1111/acps.12580] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to assess the strengths and limitations of a mixed bipolar depression definition made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by counting not only 'non-overlapping' mood elevation symptoms (NOMES) as in DSM-5, but also 'overlapping' mood elevation symptoms (OMES, psychomotor agitation, distractibility, and irritability). METHODS Among bipolar disorder (BD) out-patients assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using more inclusive (≥3 NOMES/OMES) and less inclusive DSM-5 (≥3 NOMES) definitions. RESULTS Among 153 depressed BD, counting not only NOMES but also OMES yielded a three-fold higher mixed depression rate (22.9% vs. 7.2%) and important statistically significant clinical correlates for mixed compared to pure depression (more lifetime anxiety disorder comorbidity, more current irritability, and less current antidepressant use), which were not significant using the DSM-5 threshold. CONCLUSION To conclude, further studies with larger numbers of patients with DSM-5 bipolar mixed depression assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including efforts to ascertain whether or not OMES should count toward mixed depression.
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Affiliation(s)
- H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Kim W, Kim H, Citrome L, Akiskal HS, Goffin KC, Miller S, Holtzman JN, Hooshmand F, Wang PW, Hill SJ, Ketter TA. More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms. Acta Psychiatr Scand 2016; 134:189-98. [PMID: 26989836 DOI: 10.1111/acps.12563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Assess strengths and limitations of mixed bipolar depression definitions made more inclusive than that of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) by requiring fewer than three 'non-overlapping' mood elevation symptoms (NOMES). METHOD Among bipolar disorder (BD) out-patients assessed with Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation, we assessed prevalence, demographics, and clinical correlates of mixed vs. pure depression, using less inclusive (≥3 NOMES, DSM-5), more inclusive (≥2 NOMES), and most inclusive (≥1 NOMES) definitions. RESULTS Among 153 depressed BD, compared to less inclusive DSM-5 threshold, our more and most inclusive thresholds, yielded approximately two- and five-fold higher mixed depression rates (7.2%, 15.0%, and 34.6% respectively), and important statistically significant clinical correlates for mixed compared to pure depression (e.g. more lifetime anxiety disorder comorbidity, more current irritability), which were not significant using the DSM-5 threshold. CONCLUSION Further studies assessing strengths and limitations of more inclusive mixed depression definitions are warranted, including assessing the extent to which enhanced statistical power vs. other factors contributes to more vs. less inclusive mixed bipolar depression thresholds having more statistically significant clinical correlates, and whether 'overlapping' mood elevation symptoms should be counted.
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Affiliation(s)
- W Kim
- Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, South Korea
| | - H Kim
- Department of Psychiatry, Ilsan Paik Hospital, Inje University School of Medicine, Goyang, South Korea
| | - L Citrome
- New York Medical College, Valhalla, NY, USA
| | - H S Akiskal
- International Mood Centre, University of California and Veterans Administration Hospital, San Diego, CA, USA
| | - K C Goffin
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S Miller
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J N Holtzman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - F Hooshmand
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - P W Wang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - S J Hill
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - T A Ketter
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Faurholt-Jepsen M, Busk J, Frost M, Vinberg M, Christensen EM, Winther O, Bardram JE, Kessing LV. Voice analysis as an objective state marker in bipolar disorder. Transl Psychiatry 2016; 6:e856. [PMID: 27434490 PMCID: PMC5545710 DOI: 10.1038/tp.2016.123] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/04/2016] [Accepted: 05/05/2016] [Indexed: 12/30/2022] Open
Abstract
Changes in speech have been suggested as sensitive and valid measures of depression and mania in bipolar disorder. The present study aimed at investigating (1) voice features collected during phone calls as objective markers of affective states in bipolar disorder and (2) if combining voice features with automatically generated objective smartphone data on behavioral activities (for example, number of text messages and phone calls per day) and electronic self-monitored data (mood) on illness activity would increase the accuracy as a marker of affective states. Using smartphones, voice features, automatically generated objective smartphone data on behavioral activities and electronic self-monitored data were collected from 28 outpatients with bipolar disorder in naturalistic settings on a daily basis during a period of 12 weeks. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale 17-item and the Young Mania Rating Scale, respectively, by a researcher blinded to smartphone data. Data were analyzed using random forest algorithms. Affective states were classified using voice features extracted during everyday life phone calls. Voice features were found to be more accurate, sensitive and specific in the classification of manic or mixed states with an area under the curve (AUC)=0.89 compared with an AUC=0.78 for the classification of depressive states. Combining voice features with automatically generated objective smartphone data on behavioral activities and electronic self-monitored data increased the accuracy, sensitivity and specificity of classification of affective states slightly. Voice features collected in naturalistic settings using smartphones may be used as objective state markers in patients with bipolar disorder.
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Affiliation(s)
- M Faurholt-Jepsen
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark,Psychiatric Center Copenhagen, Rigshospitalet, Blegdamsvej 9, DK- 2100 Copenhagen, Denmark. E-mail:
| | - J Busk
- DTU Compute, Technical University of Denmark (DTU), Lyngby, Denmark
| | - M Frost
- The Pervasive Interaction Laboratory, IT University of Copenhagen, Copenhagen, Denmark
| | - M Vinberg
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - E M Christensen
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - O Winther
- DTU Compute, Technical University of Denmark (DTU), Lyngby, Denmark
| | - J E Bardram
- DTU Compute, Technical University of Denmark (DTU), Lyngby, Denmark
| | - L V Kessing
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
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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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Abstract
Bipolar depression is the most common and difficult-to-treat phase of bipolar disorder. Antidepressants for unipolar depression are among the most widely used drugs, but recent data and meta-analyses indicate a lack of efficacy. Many of the drugs discussed here are graded provisionally for the strength of the findings in the literature, safety and tolerability, and likely utility of use in patients with bipolar disorder. Successful long-term treatment of bipolar depression is critical to preventing illness-related morbidity, disability, cognitive decline, suicide, and premature loss of years of life expectancy largely from the excess medical mortality associated with cardiovascular disorders.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, 5415 West Cedar Lane, Suite 201-B, Bethesda, MD 20814, USA.
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Li DJ, Tseng PT, Chen YW, Wu CK, Lin PY. Significant Treatment Effect of Bupropion in Patients With Bipolar Disorder but Similar Phase-Shifting Rate as Other Antidepressants: A Meta-Analysis Following the PRISMA Guidelines. Medicine (Baltimore) 2016; 95:e3165. [PMID: 27043678 PMCID: PMC4998539 DOI: 10.1097/md.0000000000003165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Bupropion is widely used for treating bipolar disorder (BD), and especially those with depressive mood, based on its good treatment effect, safety profile, and lower risk of phase shifting. However, increasing evidence indicates that the safety of bupropion in BD patients may not be as good as previously thought. The aim of this study was to summarize data on the treatment effect and safety profile of bupropion in the treatment of BD via a meta-analysis. Electronic search through PubMed and ClinicalTrials.gov was performed. The inclusion criteria were: (i) studies comparing changes in disease severity before and after bupropion treatment or articles comparing the treatment effect of bupropion in BD patients with those receiving other standard treatments; (ii) articles on clinical trials in humans. The exclusion criteria were (i) case reports/series, and (ii) nonclinical trials. All effect sizes from 10 clinical trials were pooled using a random effects model. We examined the possible confounding variables using meta-regression and subgroup analysis. Bupropion significantly improved the severity of disease in BD patients (P < 0.001), and the treatment effect was similar to other antidepressants/standard treatments (P = 0.220). There were no significant differences in the dropout rate (P = 0.285) and rate of phase shifting (P = 0.952) between BD patients who received bupropion and those who received other antidepressants. We could not perform a detailed meta-analysis of every category of antidepressant, nor could we rule out the possible confounding effect of concurrent psychotropics or include all drug side effects. Furthermore, the number of studies recruited in the meta-analysis was relatively small. Our findings reconfirm the benefits of bupropion for the treatment of bipolar depression, which are similar to those of other antidepressants. However, the rate of phase shifting with bupropion usage was not as low compared to other antidepressants as previously thought, which should serve to remind clinicians of the risk of phase shifting when prescribing bupropion to BD patients regardless of the suggestions of current clinical practice guidelines.
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Affiliation(s)
- Dian-Jeng Li
- From the Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (D-JL), Kaohsiung; Department of Psychiatry (P-TT, C-KW), Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home; Department of Neurology (Y-WC), E-Da Hospital; Department of Psychiatry (P-YL), Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine; and Institute for Translational Research in Biomedical Sciences (P-YL), Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Kessing LV, Vradi E, Andersen PK. Nationwide and population-based prescription patterns in bipolar disorder. Bipolar Disord 2016; 18:174-82. [PMID: 26890465 DOI: 10.1111/bdi.12371] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 11/02/2015] [Accepted: 12/04/2015] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The aim of the present study was to describe prescription patterns and changes in these patterns over the last decade for patients diagnosed with bipolar disorder in mental healthcare, using population-based and nationwide data, and to relate the findings to recommendations from international guidelines. METHODS A population-based, nationwide study was carried out. It included register-based longitudinal data on all patients with a first-ever contact with mental healthcare with a diagnosis of mania/bipolar disorder from the entire Danish population, and all prescription data for this population during the decade from 2000 to 2011, inclusive. RESULTS A total of 3,205 patients were included in the study. Lithium was prescribed less, and antiepileptic and atypical antipsychotic agents were prescribed substantially more during the study period. Lithium went from being the first drug prescribed to being the last, and was replaced by atypical antipsychotic agents. Antiepileptic agents went from being the fourth to the second drug class prescribed, and the prescription of antidepressants was virtually unchanged, at a high level, during the decade (one-year value 40-60%). The prescription of lamotrigine and quetiapine increased substantially. Combination therapy increased for all drug combinations, except for lithium combined with antidepressants. CONCLUSIONS Major changes took place in drug prescriptions during the study period. The decrease in the use of lithium and the constant high use of antidepressants do not align with recommendations from international guidelines.
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Affiliation(s)
- Lars Vedel Kessing
- Psychiatric Center Copenhagen, Department O, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Eleni Vradi
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Per Kragh Andersen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
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Abstract
Chronobiological therapies for mood disorders include manipulations of the sleep-wake cycle such as sleep deprivation and sleep phase advance and the controlled exposure to light and darkness. Their antidepressant efficacy can overcome drug resistance and targets the core depressive symptoms including suicide, thus making them treatment options to be tried either alone or as adjunctive treatments combined with common psychopharmacological interventions. The specific pattern of mood change observed with chronobiological therapies is characterized by rapid and sustained effects, when used among themselves or combined with drugs. Effects sizes are the same reported for the most effective psychiatric treatments, but side effects are usually marginal or absent. New treatment protocols are developed to adapt them in different clinical settings. This review deals with the general principles of clinical chronobiology and the latest findings in this rapidly developing field.
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Affiliation(s)
- Sara Dallaspezia
- Dipartimento di Neuroscienze Cliniche, Istituto Scientifico Universitario Ospedale San Raffaele, San Raffaele Turro, Via Stamira d'Ancona 20, 20127, Milano, Italy.
| | - Masahiro Suzuki
- Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan
| | - Francesco Benedetti
- Dipartimento di Neuroscienze Cliniche, Istituto Scientifico Universitario Ospedale San Raffaele, San Raffaele Turro, Via Stamira d'Ancona 20, 20127, Milano, Italy
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Faurholt-Jepsen M, Vinberg M, Frost M, Christensen EM, Bardram JE, Kessing LV. Smartphone data as an electronic biomarker of illness activity in bipolar disorder. Bipolar Disord 2015; 17:715-28. [PMID: 26395972 DOI: 10.1111/bdi.12332] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/24/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Objective methods are lacking for continuous monitoring of illness activity in bipolar disorder. Smartphones offer unique opportunities for continuous monitoring and automatic collection of real-time data. The objectives of the paper were to test the hypotheses that (i) daily electronic self-monitored data and (ii) automatically generated objective data collected using smartphones correlate with clinical ratings of depressive and manic symptoms in patients with bipolar disorder. METHODS Software for smartphones (the MONARCA I system) that collects automatically generated objective data and self-monitored data on illness activity in patients with bipolar disorder was developed by the authors. A total of 61 patients aged 18-60 years and with a diagnosis of bipolar disorder according to ICD-10 used the MONARCA I system for six months. Depressive and manic symptoms were assessed monthly using the Hamilton Depression Rating Scale 17-item (HDRS-17) and the Young Mania Rating Scale (YMRS), respectively. Data are representative of over 400 clinical ratings. Analyses were computed using linear mixed-effect regression models allowing for both between individual variation and within individual variation over time. RESULTS Analyses showed significant positive correlations between the duration of incoming and outgoing calls/day and scores on the HDRS-17, and significant positive correlations between the number and duration of incoming calls/day and scores on the YMRS; the number of and duration of outgoing calls/day and scores on the YMRS; and the number of outgoing text messages/day and scores on the YMRS. Analyses showed significant negative correlations between self-monitored data (i.e., mood and activity) and scores on the HDRS-17, and significant positive correlations between self-monitored data (i.e., mood and activity) and scores on the YMRS. Finally, the automatically generated objective data were able to discriminate between affective states. CONCLUSIONS Automatically generated objective data and self-monitored data collected using smartphones correlate with clinically rated depressive and manic symptoms and differ between affective states in patients with bipolar disorder. Smartphone apps represent an easy and objective way to monitor illness activity with real-time data in bipolar disorder and may serve as an electronic biomarker of illness activity.
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Affiliation(s)
- Maria Faurholt-Jepsen
- The Copenhagen Clinic for Affective Disorder, Rigshospitalet, Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Maj Vinberg
- The Copenhagen Clinic for Affective Disorder, Rigshospitalet, Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Mads Frost
- The Pervasive Interaction Laboratory (PIT Lab), IT University of Copenhagen, Copenhagen, Denmark
| | - Ellen Margrethe Christensen
- The Copenhagen Clinic for Affective Disorder, Rigshospitalet, Psychiatric Center Copenhagen, Copenhagen, Denmark
| | - Jakob E Bardram
- The Pervasive Interaction Laboratory (PIT Lab), IT University of Copenhagen, Copenhagen, Denmark
| | - Lars Vedel Kessing
- The Copenhagen Clinic for Affective Disorder, Rigshospitalet, Psychiatric Center Copenhagen, Copenhagen, Denmark
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Bowden CL, Singh V. The use of antidepressants in bipolar disorder patients with depression. Expert Opin Pharmacother 2015; 17:17-25. [PMID: 26479314 DOI: 10.1517/14656566.2016.1104299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The proportion of time that bipolar patients experience depressive symptoms and clinical states, with associated psychosocial impairment and elevated risk of suicide, is significantly greater than the time spent in manic/hypomanic forms of bipolar disorders. Yet, manic states and symptoms have been the focus and interest of most clinical research over the past quarter century. Not a single antidepressant approved for treatment of major depressive disorder, as monotherapy, has received regulatory approval for treatment of bipolar depression as monotherapy, despite their common use in bipolar depression. AREAS COVERED We reviewed randomized studies, particularly ones initially intended for registration purposes, and systematic treatment guidelines, in development of this guide to treatment decision and implementation of interventions for depression in bipolar disorders. EXPERT OPINION The Expert Opinion section emphasizes strategies, not individual agents. The efficacious performance of mood stabilizers and second-generation antipsychotics as a component of the strategy is strongly supported by published studies. However, this section relies largely on secondary publications and our combined clinical experience, as few randomized, blinded studies have had, as their focus, the comparison of combined regimens for depression. This article summarizes the design features and results of studies dealing with depressive features and intervention strategies for bipolar disorders. The emphasis of the recommendations is on pragmatic treatment decisions that clinicians can make to enhance the probability of both short and long term benefits for patients.
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Affiliation(s)
- Charles L Bowden
- a Clinical Professor of Psychiatry and Pharmacology , University of Texas Health Science Center at San Antonio , San Antonio , TX , USA
| | - Vivek Singh
- b Professor and Chairman for Department of Psychiatry, Paul L. Foster School of Medicine , Texas Tech University Health Sciences Center , El Paso , TX , USA
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