The AREDOC project and its implications for the definition and measurement of the bipolar disorders: A summary report

A naturalistic effectiveness study of maintenance therapies for the bipolar disorders

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of mood stabilizers on creativity

OBJECTIVE

While a DSM-5 criterion for both hypomania and mania is impaired functioning, the majority of those with a bipolar condition report improved functioning. When offered a mood stabilizer, many express concerns about any impact on their creativity. This piece seeks to address the question and attendant issues.

METHOD

Reference is made to the impact of differing mood stabilizers on cognitive performance and the limited data on any specific impact on creativity, while some personal observations are offered.

RESULTS

There appears to be a distinctive gradient in the cognitive impacts of differing mood stabilizers, with lithium offering the highest risk, carbamazepine and valproate providing a slight risk, and lamotrigine seemingly without cognitive side-effects.

CONCLUSIONS

The question not only invites a nuanced response from the clinician but argues for close observation of any cognitive side-effects when lithium is introduced.

Pseudo-hallucinations are for real in some patients with a bipolar disorder

OBJECTIVE

To provide exemplars of pseudo-hallucinations experienced by six individuals with bipolar disorder, suggest that they may be preferentially overrepresented in those with that condition and argue that their presence does not indicate that the individual is necessarily psychotic.

METHOD

Historical definitions of pseudo-hallucinations are overviewed and six profiles are presented considering manifestations in those with a bipolar disorder, their sequencing and response to medication.

RESULTS

The six patients initially judged such experiences as true hallucinations and, only over time, did they recognize their falsity. Clinical observation suggests that pseudo-hallucinations may be more common in those with a bipolar disorder and that they can precede, cooccur or follow disorder onset, can manifest during any phase of the condition and that they may or may not respond to medication prescribed for the bipolar disorder.

CONCLUSIONS

The exemplars of pseudo-hallucinations overviewed here indicate their richness of expression, their variable time course with illness stages and their variable response to medications prescribed for the bipolar condition.