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Ahmed GK, Elbeh K, Khalifa H, Samaan MR. Impact of duration of untreated illness in bipolar I disorder (manic episodes) on clinical outcome, socioecnomic burden in Egyptian population. Psychiatry Res 2021; 296:113659. [PMID: 33360586 DOI: 10.1016/j.psychres.2020.113659] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Bipolar disorder (BD) is a serious and chronic mental illness that may result in disability. We evaluated effect of the duration of untreated of bipolar (DUB) (manic episodes) on clinical outcomes, including episode severity, residual symptoms, duration of hospitalization, and suicide attempts, and on socioeconomic status of patients. METHODS A total of 216 participants who had bipolar I disorder (manic state) recruited from November 2017-December 2019 from an inpatient psychiatric unit. Patients divided into 2 groups based on DUB: Group A, with DUB < 4 months; and Group B, with DUB ≥4 months. All participants had evaluation for demographic and clinical features, Socioeconomic scale, Young mania rating scale (YMRS) at admission and discharge. RESULTS Group A participants were more often male, urban residents, married, literate and educated, professionally employed. Group A had a younger age of onset, less duration of illness, less frequency of episode, less suicide attempts, less duration in hospital, high mean of socioeconomic, lower mean of YMRS at admission and discharge in compared to Group B. CONCLUSION A longer DUB (manic episodes)was associated with negative clinical outcomes (more frequent episode, more symptoms severity, longer hospital admission, more suicide severity, more residual symptoms) and low socioeconomic state of patients with BDI (manic episodes).
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Affiliation(s)
- Gellan K Ahmed
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt; Department of Child & Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London SE5 8AF, UK.
| | - Khalid Elbeh
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hossam Khalifa
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Maggi Raoof Samaan
- Department of Child & Adolescent Psychiatry, Assiut mental health hospital, Assiut, Egypt
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McIntyre RS, Masand PS, Earley W, Patel M. Cariprazine for the treatment of bipolar mania with mixed features: A post hoc pooled analysis of 3 trials. J Affect Disord 2019; 257:600-606. [PMID: 31344528 DOI: 10.1016/j.jad.2019.07.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 05/29/2019] [Accepted: 07/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND When bipolar I disorder (BP-I) mania is accompanied by subsyndromal depressive symptoms, a more complicated illness presentation results. To qualify for the mixed features specifier during mania, the DSM-5 requires ≥3 "non-overlapping" depressive symptoms (DS); notwithstanding, concerns of this definition's ecological validity and implications for timely diagnosis remain. METHODS Herein, patients were pooled from three similarly-designed pivotal trials of cariprazine compared to placebo for BP-I mania (NCT00488618/NCT01058096/NCT01058668) in post hoc analyses of mixed features using three criteria: ≥3 DS (DSM-5), ≥2 DS, and Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥10. Efficacy of cariprazine compared to placebo was assessed (Week 3) by Young Mania Rating Scale (YMRS) and MADRS scores and rates of mania response and remission. RESULTS In pooled patients (N = 1037), cariprazine significantly improved mean YMRS scores compared to placebo for each criterion; LSMDs were ≥3 DS = -3.79 (P = .0248), ≥2 DS = -2.91 (P = .0207), and ≥10 MADRS = -5.49 (P < .0001). More cariprazine- than placebo-treated patients met YMRS response and remission criteria, reaching significance for response in ≥2 DS (34% versus 47%; number-needed-to-treat [NNT] = 8, P = .0483) and ≥10 MADRS (31% versus 57%, NNT = 4, P < .0001) and for remission in ≥2 DS (27% versus 39%, NNT = 9, P = .0462), ≥10 MADRS (23% versus 44%, NNT = 5, P < .0001). Depressive symptoms were improved compared to placebo, reaching statistical significance in the MADRS ≥10 subgroup (LSMD = -1.59, P = .0082). LIMITATIONS Post hoc analysis, MADRS < 18 entry criterion may have prevented assessment of MADRS changes. CONCLUSIONS Cariprazine significantly reduced manic and depressive symptoms in patients with mixed features with differential efficacy across the subgroups analyzed herein.
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Affiliation(s)
- Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, ON M5T 2S8, Canada; Brain Cognition Discovery Foundation, Toronto, Ontario, Canada.
| | - Prakash S Masand
- Centers of Psychiatric Excellence, New York, New York, United States
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Ragazan DC, Eberhard J, Ösby U, Berge J. Gender influence on the bipolar disorder inpatient length of stay in Sweden, 2005-2014: A register-based study. J Affect Disord 2019; 256:183-191. [PMID: 31177046 DOI: 10.1016/j.jad.2019.05.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/03/2019] [Accepted: 05/27/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND The influence of gender on bipolar disorder is controversial and it is unclear if inpatient care differs between men and women. Here, we investigate for gender differences in the inpatient length of stay for Swedes admitted for bipolar disorder and explore other factors that could explain any observed association. METHODS Admission data were extracted from the Swedish National Patient Register and included all patients first admitted to a psychiatric inpatient unit with a bipolar disorder diagnosis, circa 2005-2014. Patients were then retrospectively followed for subsequent hospitalizations. Diagnostic subtypes were categorized by ICD-10 clusters: depressive, depressive with psychotic features, manic, manic with psychotic features, mixed, and other. Psychotropic therapies preceding the corresponding admissions were attained from the Prescribed Drug Register. Mixed-effects zero-truncated negative binomial regressions were employed to model the length of stay per admission. RESULTS Analysis included 39,653 admissions by 16,271 inpatients (60.0% women). Overall, when compared to men, women spent 7.5% (95% CI: 4.2-11.0%, p < 0.001) extra days hospitalized per admission. However, upon adjusting for candidate confounders, including the bipolar subtype, and selected comorbidities and psychotropics, the association weakened wherein women then spent 3.7% (95% CI: 0.1-6.9%, p = 0.028) extra days hospitalized per admission. LIMITATIONS The integrity of register data can be variable and the adherence to outpatient dispensed psychotropics could not be validated. CONCLUSION Although the influence of gender on the bipolar disorder inpatient length of stay is evident, other factors attenuate and better explain this crude observation.
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Affiliation(s)
- Dragos C Ragazan
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden.
| | - Jonas Eberhard
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden
| | - Urban Ösby
- Karolinska Institutet, Dept. of Clinical Neuroscience, Stockholm, Sweden
| | - Jonas Berge
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden
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Faurholt-Jepsen M, Frost M, Christensen EM, Bardram JE, Vinberg M, Kessing LV. The association between mixed symptoms, irritability and functioning measured using smartphones in bipolar disorder. Acta Psychiatr Scand 2019; 139:443-453. [PMID: 30865288 DOI: 10.1111/acps.13021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To (i) validate patient-evaluated mixed symptoms and irritability measured using smartphones against clinical evaluations; (ii) investigate associations between mixed symptoms and irritability with stress, quality of life and functioning, respectively, in patients with bipolar disorder. METHODS A total of 84 patients with bipolar disorder used a smartphone-based system for daily evaluation of mixed symptoms and irritability for nine months. Clinically evaluated symptoms, stress, quality of life and clinically rated functioning were collected multiple times during follow-up. RESULTS Patients presented mild affective symptoms. Patient-reported mixed symptoms and irritability correlated with clinical evaluations. In analyses including confounding factors there was a statistically significant association between both mixed symptoms and irritability and stress (P < 0.0001) and between irritability and both quality of life and functioning (P < 0.0001) respectively. There was no association between mixed mood and both quality of life and functioning. CONCLUSION Mixed symptoms and irritability can be validly self-reported using smartphones in patients with bipolar disorder. Mixed symptoms and irritability are associated with increased stress even during full or partial remission. Irritability is associated with decreased quality of life and functioning. The findings emphasize the clinical importance of identifying inter-episodic symptoms including irritability pointing towards smartphones as a valid tool.
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Affiliation(s)
- M Faurholt-Jepsen
- Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - M Frost
- Monsenso ApS, Valby, Denmark
| | - E M Christensen
- Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - J E Bardram
- Department of Applied Mathematics and Computer Science, The Technical University of Denmark, Lyngby, Denmark
| | - M Vinberg
- Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - L V Kessing
- Copenhagen Affective Disorder Research Center (CADIC), Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
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González-Pinto A, López-Peña P, Bermúdez-Ampudia C, Vieta E, Martinez-Cengotitabengoa M. Can lithium salts prevent depressive episodes in the real world? Eur Neuropsychopharmacol 2018; 28:1351-1359. [PMID: 30243681 DOI: 10.1016/j.euroneuro.2018.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 12/11/2022]
Abstract
To critically examine the effectiveness of lithium in preventing depressive symptoms (mixed and depressive episodes) in real life settings, taking into account adherence to drug treatment and its implications for the clinical costs of the disease. Overall, 72 patients with bipolar disorder initially treated with lithium carbonate were included and followed-up for 10 years. Patients were assessed every 8 weeks for morbidity and alcohol/drug consumption. Patients with good adherence to lithium had fewer episodes with depressive features than poor adherers (B = 2.405, p = 0.046) and also fewer manic and hypomanic episodes (B = 2.572; p < 0.001), after controlling for confounders. Time to relapse into a depressive or mixed episode and into a manic or hypomanic episode was shorter in patients with poor adherence. The costs of the 1.95 ± 2.38 (mean ± standard deviation) admissions of adherent patients through the 10 years of follow-up were €10,349, while the costs of the 6.25 ± 4.92 admissions of non-adherent patients were €44,547. In clinical practice settings, long-term lithium salts seem to have a preventive effect on depressive symptoms.
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Affiliation(s)
- Ana González-Pinto
- CIBERSAM-BioAraba Research Institute, Vitoria, Spain; University of the Basque Country (EHU/UPV), Vitoria, Spain
| | - Purificación López-Peña
- CIBERSAM-BioAraba Research Institute, Vitoria, Spain; University of the Basque Country (EHU/UPV), Vitoria, Spain
| | | | - Eduard Vieta
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Mónica Martinez-Cengotitabengoa
- CIBERSAM-BioAraba Research Institute, Vitoria, Spain; University of the Basque Country (EHU/UPV), Vitoria, Spain; National Distance Education University Spain (UNED), Vitoria, Spain.
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McIntyre RS, Young AH, Haddad PM. Rethinking the spectrum of mood disorders: implications for diagnosis and management - Proceedings of a symposium presented at the 30th Annual European College of Neuropsychopharmacology Congress, 4 September 2017, Paris, France. Ther Adv Psychopharmacol 2018; 8:1-16. [PMID: 29977518 PMCID: PMC6022880 DOI: 10.1177/2045125318762911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/09/2018] [Indexed: 12/17/2022] Open
Abstract
The simultaneous occurrence of manic and depressive features has been recognized since classical times, but the term 'mixed state' was first used by Kraepelin at the end of the 19th century. From the 1980s, until the advent of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), psychiatric disorders were classified using a categorical approach. However, it was recognized that such an approach was too rigid to encompass the range of symptomatology encountered in clinical practice. Therefore, a dimensional approach was adopted in DSM-5, in which affective states are considered to be distributed across a continuum ranging from pure mania to pure depression. In addition, the copresence of symptoms of the opposite pole are captured using a 'with mixed features' specifier, applied when three or more nonoverlapping subthreshold symptoms of the opposite pole are present. Mixed features are common in patients with mood episodes, complicating the course of illness, reducing treatment response and worsening outcomes. However, research in this area is scarce and treatment options are limited. Current evidence indicates that antidepressants should be avoided for the treatment of bipolar mixed states. Evidence for bipolar mixed states supports the use of several second-generation antipsychotics, valproate and electroconvulsive therapy. One randomized controlled trial has demonstrated the efficacy of lurasidone, compared with placebo, in patients with major depressive disorder with mixed features, and there is limited evidence supporting the use of ziprasidone in such patients. Further research is required to determine whether other antipsychotic agents, or additional therapeutic approaches, might also be effective in this setting.
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Affiliation(s)
- Roger S McIntyre
- UHN-Toronto Western Hospital, Mood Disorders Psychopharmacology Unit, University of Toronto, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada
| | - Allan H Young
- Department of Psychological Medicine, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - Peter M Haddad
- Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK
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Lawn S, Zabeen S, Smith D, Wilson E, Miller C, Battersby M, Masman K. Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program. AUST HEALTH REV 2018; 42:542-549. [DOI: 10.1071/ah17099] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022]
Abstract
Objective
The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP).
Methods
A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model.
Results
The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs.
Conclusion
The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care.
What is known about the topic?
Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation.
What does this paper add?
This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system.
What are the implications for practitioners?
Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.
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Abstract
Mixed affective states, defined as the coexistence of depressive and manic symptoms, are complex presentations of manic-depressive illness that represent a challenge for clinicians at the levels of diagnosis, classification, and pharmacological treatment. The evidence shows that patients with bipolar disorder who have manic/hypomanic or depressive episodes with mixed features tend to have a more severe form of bipolar disorder along with a worse course of illness and higher rates of comorbid conditions than those with non-mixed presentations. In the updated Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), the definition of "mixed episode" has been removed, and subthreshold nonoverlapping symptoms of the opposite pole are captured using a "with mixed features" specifier applied to manic, hypomanic, and major depressive episodes. However, the list of symptoms proposed in the DSM-5 specifier has been widely criticized, because it includes typical manic symptoms (such as elevated mood and grandiosity) that are rare among patients with mixed depression, while excluding symptoms (such as irritability, psychomotor agitation, and distractibility) that are frequently reported in these patients. With the new classification, mixed depressive episodes are three times more common in bipolar II compared with unipolar depression, which partly contributes to the increased risk of suicide observed in bipolar depression compared to unipolar depression. Therefore, a specific diagnostic category would imply an increased diagnostic sensitivity, would help to foster early identification of symptoms and ensure specific treatment, as well as play a role in suicide prevention in this population.
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Reinares M, Bonnín CDM, Hidalgo-Mazzei D, Undurraga J, Mur M, Nieto E, Sáez C, Vieta E. Making sense of DSM-5 mania with depressive features. Aust N Z J Psychiatry 2015; 49:540-9. [PMID: 25943979 DOI: 10.1177/0004867415585583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The assessment of the depressive component during mania has become critical for the accurate diagnosis of mixed states, which were defined very narrowly in the past classification systems before Diagnostic and Statistical Manual of Mental Disorders (5th ed.). The aim of this study was to compare socio-demographic, clinical and therapeutic characteristics, as well as clinical and functional outcomes, between manic patients with and without mixed features to validate the relevance of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) mixed specifier. METHODS This is a subanalysis of a multicentre naturalistic study MANía Aguda y COnsumo de Recursos (acute mania and health resource consumption [MANACOR]) on the burden of mania in bipolar patients from four hospitals in Catalonia (Spain). The sample consisted of 169 adult patients presenting a manic episode and systematically assessed during a 6-month period. RESULTS A total of 27% (n = 46/169) of manic patients showed mixed features. Total number of episodes (p = 0.027), particularly depressive and mixed, was greater in manic patients with mixed features, as well as depressive onset (p = 0.018), suicide ideation (p = 0.036), rapid cycling (p = 0.035) and personality disorders (p = 0.071). In contrast, a higher percentage of pure manic subjects were inpatients (p = 0.035), started the illness with mania (p = 0.018) and showed family history of bipolar disorder (p = 0.037), congruent psychotic symptoms (p = 0.001) and cannabis use (p = 0.006). At baseline, pure manic patients received more risperidone (p = 0.028), while mixed patients received more valproate (p = 0.049) and antidepressants (p = 0.005). No differences were found in syndromic recovery at the end of the study. However, depressive change was higher in the mixed group (p = 0.010), while manic change was higher in the pure manic group (p = 0.029). At the end of follow-up, the group with mixed features showed a significant trend towards higher psychosocial dysfunction. CONCLUSION A total of 27% of manic patients showed mixed features. Groups differed regarding clinical characteristics, course of illness, psychosocial functioning, prescribed treatment and symptom progress. Depressive symptoms in mania should be routinely assessed and considered to guide treatment.
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Affiliation(s)
- María Reinares
- Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain
| | - Caterina del Mar Bonnín
- Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain
| | - Diego Hidalgo-Mazzei
- Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain
| | - Juan Undurraga
- Department of Psychiatry, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile
| | - Maria Mur
- Psychiatric Service, Hospital Santa Maria, University of Lleida, IRBLleida (Biomedicine Research Institute), Lleida, Spain
| | - Evaristo Nieto
- Althaia, Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Cristina Sáez
- University Psychiatric Hospital, Institut Pere Mata, CIBERSAM, Reus, Spain
| | - Eduard Vieta
- Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain
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Lee Mortensen G, Vinberg M, Lee Mortensen S, Balslev Jørgensen M, Eberhard J. Bipolar patients' quality of life in mixed states: a preliminary qualitative study. Psychopathology 2015; 48:192-201. [PMID: 25895658 DOI: 10.1159/000381479] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 03/09/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Approximately 20% of patients with bipolar disorder experience mixed states. Mixed states are associated with more comorbidity, poorer treatment response and prognosis, increased relapse rate, and decreased functioning. This study aimed to produce in-depth knowledge about bipolar patients' quality of life (QoL) and functioning related to mixed states. SAMPLING AND METHODS This study used qualitative research methods. A semi-structured interview guide based on a literature study was applied in interviews with 6 remitted bipolar I patients having experienced mixed states. A medical anthropological approach was applied to analyse the data. RESULTS Participants described mixed states as worse than other bipolar disorder states and their residual symptoms were prolonged. Mixed states affected the functioning of patients in key life domains such as self-esteem, family, love and social life, physical well-being, and working capability. CONCLUSIONS Mixed states may severely affect the QoL and functioning of bipolar patients. Our results indicate that improving these should be a main goal of patient treatment. With an aim of adequately identifying and treating mixed states, our findings highlight the need for knowledge about this particularly severe expression of bipolar disorder. These results should be confirmed in a larger sample of patients with varying socioeconomic status.
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Tohen M, McIntyre RS, Kanba S, Fujikoshi S, Katagiri H. Efficacy of olanzapine in the treatment of bipolar mania with mixed features defined by DSM-5. J Affect Disord 2014; 168:136-41. [PMID: 25046739 DOI: 10.1016/j.jad.2014.06.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 06/24/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND These analyses compared efficacy of olanzapine in patients with bipolar mania with or without mixed features, as defined in the DSM-5. METHODS Pooled data from 3 placebo-controlled olanzapine studies in patients having bipolar I disorder with manic/mixed episode were analyzed (N=228 olanzapine; N=219 placebo). Patients were categorized for mixed features by number of concurrent depressive symptoms at baseline (0, 1, and 2 [category A; without mixed features], and ≥3 [category B; with mixed features]), as determined by HAM-D17 item score ≥1. Depressive symptoms corresponded to 6 HAM-D17 items in the DSM-5 definition of manic episode with mixed features. Primary efficacy was evaluated by changes in the baseline-to-3-week YMRS total score. RESULTS Patients were categorized into A (N=322; 72.0%) or B (N=125; 28.0%). Mean baseline YMRS total scores were 28.1 in category A and 27.8 in category B. Least-squares mean change of YMRS total scores in categories A and B (olanzapine versus placebo) were -11.78 versus -6.86 and -13.21 versus -4.72, respectively. Patients in the olanzapine- compared with placebo-group experienced a greater decrease in YMRS total score for both categories (p<0.001). An interaction between mixed features and treatment was seen in YMRS change at a 0.3 significance level (p=0.175). LIMITATIONS The results are from post-hoc analyses. CONCLUSIONS Olanzapine was efficacious in the treatment of bipolar I mania, in patients both with and without mixed features, defined by DSM-5; however, greater efficacy was observed in patients with mixed features having more severe depressive symptoms.
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Affiliation(s)
- Mauricio Tohen
- University of New Mexico, Health Sciences Center, Department of Psychiatry, Albuquerque, NM, USA
| | - Roger S McIntyre
- University of Toronto, Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Canada
| | - Shigenobu Kanba
- Kyushu University, Department of Neuropsychiatry, Fukuoka, Japan; East Asian Bipolar Forum, Fukuoka, Japan
| | - Shinji Fujikoshi
- Eli Lilly Japan K.K., Lilly Research Laboratories, Statistical Science, Kobe, Japan
| | - Hideaki Katagiri
- Eli Lilly Japan K.K., Lilly Research Laboratories, Medical Science, Sannomiya Plaza Building, 7-1-5, Isogamidori, Chuo-ku, Kobe 651-0086, Japan.
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Karamustafalıoğlu O, Reif A, Atmaca M, Gonzalez D, Moreno-Manzanaro M, Gonzalez MA, Medina E, Bellomo A. Hospital stay in patients admitted for acute bipolar manic episodes prescribed quetiapine immediate or extended release: a retrospective non-interventional cohort study (HOME). BMC Psychiatry 2014; 14:246. [PMID: 25174996 PMCID: PMC4159508 DOI: 10.1186/s12888-014-0246-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/19/2014] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Bipolar manic episodes often require hospital admission to ensure patient safety. The antipsychotic quetiapine is a common treatment for bipolar mania and is available in immediate release (IR) and extended release (XR) formulations; however, outcomes in patients receiving these different formulations have not been directly compared in an acute hospital setting. METHODS We conducted a multinational, observational, retrospective cohort study to describe and compare hospital stay in patients admitted for an acute bipolar manic episode treated with quetiapine IR or XR from 1 October 2009-1 October 2010. The primary outcome measure was comparison of length of stay (LOS) using zero-truncated negative binomial regression. RESULTS In total, 1230 patients were included (659 in the IR cohort; 571 in the XR cohort). The median LOS (interquartile range) was 18.0 days (12.0, 28.0) in the IR cohort and 20.0 days (12.0, 34.0) in the XR cohort, respectively. LOS was not significantly associated with quetiapine formulation irrespective of whether or not clinical characteristics were taken into account (p = 0.820 and p = 0.386, respectively). Overall, 84.2% and 84.4% of patients in the IR and XR cohorts, respectively, had not previously used quetiapine; of these patients, 78.7% and 68.9% received one total daily dose, and 14.4% and 23.9% received dose titration. Over half of patients received antipsychotic monotherapy (53.1% and 58.3% in the IR and XR cohorts, respectively) and most received a daily quetiapine dose ≥ 400 mg (64.9% and 71.8%, respectively, for quetiapine monotherapy and 59.9% and 80.3%, respectively, for combination treatment). As a secondary outcome, multivariate analysis was used to identify other factors that affect LOS. Factors associated with a longer hospital stay included public funding versus private, maximum number of new medications administered, did not receive lithium and did not receive anxiolytics, sedatives/hypnotics (all p < 0.0001). Factors associated with a shorter hospital stay included presence of drug/alcohol abuse, living accompanied and having a psychiatric medical history (all p < 0.05). CONCLUSIONS LOS was not found to be associated with quetiapine formulation. However, most patients received only one total daily dose of quetiapine without dose titration, which was unexpected and contrary to current recommendations. TRIAL REGISTRATION TRIAL REGISTRATION NCT01239589.
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Affiliation(s)
- Oğuz Karamustafalıoğlu
- />Department of Psychiatry, Şişli Etfal Teaching and Research Hospital, Istanbul, Turkey
| | - Andreas Reif
- />Department of Psychiatry, Psychosomatics and Psychotherapy, Head Psychiatric Neurobiology and Bipolar Disorder Program, University of Würzburg, Würzburg, Germany
| | - Murad Atmaca
- />Department of Psychiatry, Firat University School of Medicine, Elazig, Turkey
| | - Domingo Gonzalez
- />Assertive Outreach, Birmingham & Solihull Mental Health Trust, Birmingham, UK
| | | | | | | | - Antonello Bellomo
- />Department of Clinical and Experimental Sciences, Section of Psychiatry and Clinical Psychology, University of Foggia, Foggia, Italy
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Crowe M, Porter R. Inpatient treatment for mania: A review and rationale for adjunctive interventions. Aust N Z J Psychiatry 2014; 48:716-21. [PMID: 24965582 DOI: 10.1177/0004867414540754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the evidence for adjunctive non-pharmacological interventions in the treatment of mania in an acute inpatient setting. METHOD A selective review of original and review papers was conducted. The electronic databases PsycINFO and PubMed were searched using the following MeSH terms: mania, mania treatment and inpatient. RESULTS Four studies were identified in the search for non-psychopharmacological interventions for mania that commenced in an inpatient setting: Interpersonal and Social Rhythm Therapy (IPSRT), Group Cognitive Behavioural Therapy (G-CBT), sensory room, and dark room therapy. Only two of these were designed exclusively for patients with bipolar disorder and the other two included these patients in a heterogeneous group of acute psychiatric inpatients. CONCLUSIONS Sleep and circadian regulation (Social Rhythm Therapy) that focuses on the establishment and maintenance of regular daily rhythms, particularly in relation to sleep-wake times, meal times and socialization, provides a potentially useful model for managing mania in the inpatient setting. However, there is an urgent need for further research into the effective treatment of mania.
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Affiliation(s)
- Marie Crowe
- University of Otago, Christchurch, Christchurch, New Zealand
| | - Richard Porter
- University of Otago, Christchurch, Christchurch, New Zealand
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14
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Sawyer L, Azorin JM, Chang S, Rinciog C, Guiraud-Diawara A, Marre C, Hansen K. Cost-effectiveness of asenapine in the treatment of bipolar I disorder patients with mixed episodes. J Med Econ 2014; 17:508-19. [PMID: 24720805 DOI: 10.3111/13696998.2014.914030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Around one-third of patients with bipolar I disorder (BD-I) experience mixed episodes, characterized by both mania and depression, which tend to be more difficult and costly to treat. Atypical antipsychotics are recommended for the treatment of mixed episodes, although evidence of their efficacy, tolerability, and cost in these patients is limited. This study evaluates, from a UK National Health Service perspective, the cost-effectiveness of asenapine vs olanzapine in BD-I patients with mixed episodes. METHODS Cost-effectiveness was assessed using a Markov model. Efficacy was informed by a post-hoc analysis of two short-term clinical trials, with response measured as a composite Young Mania Rating Score and Montgomery-Åsberg Depression Rating Scale end-point. Probabilities of discontinuation and relapse to manic, mixed, and depressive episodes were sourced from published meta-analyses. Direct costs (2012-2013 values) included drug acquisition, monitoring, and resource use related to bipolar disorder as well as selected adverse events. Benefits were measured as quality-adjusted life years (QALYs). RESULTS For treating mixed episodes, asenapine generated 0.0187 more QALYs for an additional cost of £24 compared to olanzapine over a 5-year period, corresponding to a £1302 incremental cost-effectiveness ratio. The higher acquisition cost of asenapine was roughly offset by the healthcare savings conferred through its greater efficacy in treating these patients. The model shows that benefits were driven by earlier response to asenapine during acute treatment and were maintained during longer-term follow-up. RESULTS were sensitive to changes in key parameters including short and longer-term efficacy, unit cost, and utilities, but conclusions remained relatively robust. CONCLUSIONS RESULTS suggest that asenapine is a cost-effective alternative to olanzapine in mixed episode BD-I patients, and may have specific advantages in this population, potentially leading to healthcare sector savings and improved outcomes. Limitations of the analysis stem from gaps in clinical and economic evidence for these patients and should be addressed by future clinical trials.
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Dassa D, Dubois M, Maurel M, Fakra E, Pringuey D, Belzeaux R, Kaladjian A, Cermolacce M, Azorin JM. Traitements anti- maniaques dans les états mixtes. Encephale 2013; 39 Suppl 3:S172-8. [DOI: 10.1016/s0013-7006(13)70118-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hannemann S, Gao B, Galán JE. Salmonella modulation of host cell gene expression promotes its intracellular growth. PLoS Pathog 2013; 9:e1003668. [PMID: 24098123 PMCID: PMC3789771 DOI: 10.1371/journal.ppat.1003668] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 08/14/2013] [Indexed: 01/05/2023] Open
Abstract
Salmonella Typhimurium has evolved a complex functional interface with its host cell largely determined by two type III secretion systems (T3SS), which through the delivery of bacterial effector proteins modulate a variety of cellular processes. We show here that Salmonella Typhimurium infection of epithelial cells results in a profound transcriptional reprogramming that changes over time. This response is triggered by Salmonella T3SS effector proteins, which stimulate unique signal transduction pathways leading to STAT3 activation. We found that the Salmonella-stimulated changes in host cell gene expression are required for the formation of its specialized vesicular compartment that is permissive for its intracellular replication. This study uncovers a cell-autonomous process required for Salmonella pathogenesis potentially opening up new avenues for the development of anti-infective strategies that target relevant host pathways. Essential for the ability of Salmonella Typhimurium to cause disease is the function of a type III secretion system (T3SS) encoded within its pathogenicity island 1 (SPI-1), which through the delivery of bacterial effector proteins modulates a variety of cellular functions. This study reports that the infection of mammalian cells with Salmonella Typhimurium results in a profound reprogramming of gene expression that changes over time. The stimulation of this response requires the activity of a specific subset of bacterial T3SS effector proteins, which stimulate unique signal transduction pathways leading to STAT3 activation. We found that the Salmonella-stimulated changes in host cell gene expression are required for its intracellular replication. Targeting the mechanisms described in this study may lead to the development of novel anti-infective strategies.
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Affiliation(s)
- Sebastian Hannemann
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Beile Gao
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Jorge E. Galán
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
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Vieta E, Valentí M. Mixed states in DSM-5: implications for clinical care, education, and research. J Affect Disord 2013; 148:28-36. [PMID: 23561484 DOI: 10.1016/j.jad.2013.03.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 02/08/2023]
Abstract
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) nomenclature for the co-occurrence of manic and depressive symptoms (mixed states) has been revised in the new DSM-5 version to accommodate a mixed categorical-dimensional concept. The new classification will capture subthreshold non-overlapping symptoms of the opposite pole using a "with mixed features" specifier to be applied to manic episodes in bipolar disorder I (BD I), hypomanic, and major depressive episodes experienced in BD I, BD II, bipolar disorder not otherwise specified, and major depressive disorder. The revision will have a substantial impact in several fields: epidemiology, diagnosis, treatment, research, education, and regulations. The new concept is data-driven and overcomes the problems derived from the extremely narrow definition in the DSM-IV-TR. However, it is unclear how clinicians will deal with the possibility of diagnosing major depression with mixed features and how this may impact the bipolar-unipolar dichotomy and diagnostic reliability. Clinical trials may also need to address treatment effects according to the presence or absence of mixed features. The medications that are effective in treating mixed episodes per the DSM-IV-TR definition may also be effective in treating mixed features per the DSM-5, but new studies are needed to demonstrate it.
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Affiliation(s)
- Eduard Vieta
- Bipolar Disorder Programme, Institute of Neuroscience, University of Barcelona Hospital Clínic, IDIBAPS, CIBERSAM, C/Villarroel 170, Barcelona 08036, Catalonia, Spain.
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