Treatment-refractory bipolar disorder: classification to aid in clinical management

Challenges in defining treatment-resistant mania in adults: A systematic review

OBJECTIVES

To review the definitions of treatment-resistant mania (TRM) in the literature and propose criteria for an operationalized definition.

METHODS

A systematic search of five databases (MEDLINE, EMBASE, PsychInfo, Cochrane Central, and CINAHL) and data extraction of eligible articles.

RESULTS

In total, 47 articles addressing the concept of TRM were included, comprising 16 case reports, 11 case series, 3 randomized clinical trials, 8 open-label clinical trials, 1 experimental study, 7 narrative reviews, and 1 systematic review. While reviews discussed several challenges in defining TRM, definitions varied substantially based on different criteria for severity of mania, duration of mania, and use of specific therapeutic agents with minimal dosages and duration of treatment. Only a handful of the reviewed articles operationalized these criteria.

CONCLUSION

While the concept of TRM has been discussed in the literature for over three decades, we could not find an agreed-upon operationalized definition based on specific criteria. We propose and discuss a possible definition that could be used by clinicians to guide their practice and by researchers to assess the prevalence of TRM and develop and test interventions targeting TRM.

Treatment-Resistant Bipolar Depression: Therapeutic Trends, Challenges and Future Directions

INTRODUCTION

Bipolar disorder (BD) is a chronic mental illness impacting 1-2% of the population worldwide and causing high rates of functional impairment. Patients with BD spend most of their time in depressive episodes and up to one-third of patients do not respond to adequate doses of medications. Although no consensus exists for definition of treatment-resistant bipolar depression (TRBD), failure of symptoms improvement despite an adequate trial of two therapeutic agents is a common theme of TRBD. In this paper, we review the evidence base of therapeutic interventions, challenges, and potential future directions for TRBD.

METHODS

We conducted a literature search for randomized controlled trials on PubMed for the treatment of TRBD and ongoing trials for the treatment of TRBD/bipolar depression on clinicaltrials.gov.

RESULTS

Several therapeutic agents have been investigated for TRBD. Adjunctive pramipexole and modafinil have data supporting short-term efficacy in TRBD, along with limited data for racemic intravenous ketamine. Celecoxib augmentation of escitalopram and treatment with metformin in patients with insulin resistance showed promising results. Right unilateral electroconvulsive therapy displayed statistically significant response rate and improvement, but not remission compared to pharmacotherapy. Trials for transcranial magnetic stimulation (TMS) have failed to show a significant difference from sham treatment in TRBD.

FUTURE TRENDS

Pharmacological treatments with novel mechanisms of actions like brexpiprazole and vortioxetine are being investigated following successes in unipolar depression. Modified TMS protocols such as accelerated TMS are under investigation. Innovative approaches like psychedelic-assisted psychotherapy, interleukin-2, fecal microbiota transplantation and multipotent stromal cells are being studied.

CONCLUSION

Evidence on current treatment modalities for TRBD is limited with low efficacy. More research is needed for successful treatment of TRBD. Effective therapies and innovative approaches to treatment are being investigated and could show promise.

Gender and Body Mass Index-Related Serum Level of Adipokines and Metabolic Syndrome Components in Bipolar Patients who received Lithium and Valproic Acid

Background: This is the study to assess alterations on adiponectin, leptin, and metabolic syndrome components in women and men bipolar disorder (BD) patients with normal weight and obesity who received valproic acid (VPA) and lithium (Li). Methods: Thirty-six women and 51 men were included. Commercial kits were used to determine all parameters. Metabolic syndrome components were determined according to the NCEP ATP III criteria. Results: Patients who received Li and VPA significantly differ in waist circumference (WC) and triglyceride (TG) levels (in women and men). Normal weight patients received both drugs, significant differences were considered in high-density lipoprotein-cholesterol (HDL-C), WC, and TG levels compared to healthy controls, but there were significant differences in TG, leptin, and adiponectin levels in obese patients who received VPA. There were significant negative and positive correlation between leptin and adiponectin and WC and TG in women and men BD patients treated with VPA and Li. There were significant positive correlation between leptin and adiponectin and WC and TG and significant negative correlation with HDL-C in normal weight BD patients treated with VPA and Li, respectively, while there was only a significant positive correlation between leptin and adiponectin, and TG in obese BD patients treated with VPA. Conclusions: It looks like that patients treated with both drugs for our suggested time may increase leptin and adiponectin levels. Correlation differences between leptin and adiponectin, and metabolic syndrome components may be important parameters in women, men, normal weight, and obese BD patients. Monitoring of body composition and adipokines may benefit in medical care of these patients.

The association between leptin and adiponectin, and metabolic syndrome components and serum levels of lipid peroxidation in bipolar disorder patients treated with lithium and valproic acid

BACKGROUND

The aim of study is to assess a relation between the adiponectin and leptin levels, and metabolic syndrome components and lipid peroxidation treated with Li and VPA in bipolar disorder patients and compared with controls.

MATERIALS AND METHODS

56 patients and 31 healthy controls were enrolled. The ATP III criteria were used to determine metabolic syndrome components. Leptin, adiponectin, lipid peroxidation and lipid profiles were measured.

RESULTS

Malondialdehyde in Li patients was higher than VPA patients. BMI, waist circumference (WC), triglyceride, malondialdehyde and adiponectin levels were increased, whereas HDL-cholesterol (VPA treated patients) and leptin were decreased in patients compared with controls. Leptin and adiponectin were correlated with WC, triglyceride and malondialdehyde in both groups. Adiponectin was correlated with HDL-cholesterol in VPA patients.

CONCLUSION

Patients should be checked metabolic syndrome components, serum leptin and adiponectin level occasionally to prevent possible deficiency or pathologic increase of these parameters.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Effects of Valproate and Fluoxetine Combination on YMRS and MADRS Sores in Continuation Phase Treatment of Bipolar Disorder

Valproate is the most common drug to use in bipolar disorder in Indonesia and the only mood stabilizer drug in national formulary. Combination of valproate and fluoxetine are the most used combination in bipolar disorder therapy in Bhayangkara Hospital, Kediri. However, this combination has been controversial because of its risk of triggering mania or hipomania episode in 12 months. The aim of this study was to analyze mood change symptoms with YMRS and MADRS scale after treatment of valproate and fluoxetine combination in continuation phase treatment of bipolar disorder. This cross-sectional, observational study was conducted in psyciatry clinic in Bhayangkara Hospital Kediri between August 2016-October 2016 on 15 patients in YMRS. MADRS questionnaire was filled by physician before treatment and after 8 weeks treatments. Within 8 weeks, mean YMRS score changed from 1.4 to 1.26 (p>0.05). Whereas, mean MADRS score changed from 31.8 to 10.93 (p<0.05) after 8 weeks. There was no significant different in YMRS score between pre- and post-treatment, but there was significant different in MADRS score after treatment.

Evaluation of adiponectin and leptin levels and oxidative stress in bipolar disorder patients with metabolic syndrome treated by valproic acid

INTRODUCTION

An increased risk for metabolic syndrome (MS) has been described for people with psychotic and mood disorders. The aim of this study was to determine the influence of valproic acid (VPA) treatment on adiponectin, leptin levels and oxidative stress in bipolar disorder (BD).

METHODS

Forty patients with BD receiving VPA monotherapy and 20 healthy control subjects were included in this study. BD patients were divided into two groups with and without MS as group 1 and group 2, respectively. Twenty BD patients diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders (DSM IV) were assessed for MS according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III) criteria. Adiponectin, leptin, protein carbonyls, sulfhydryl (-SH) and malondialdehyde (MDA) levels were measured in 40 BD patients and 20 control subjects.

RESULTS

Serum adiponectin levels were significantly lower in group 1 patients than in group 2 and control subjects ( p<.001). Serum leptin levels were significantly higher in group 1 patients than in group 2 and control subjects ( p<.001). Serum -SH levels were significantly lower in group 2 patients than in group 1 ( p<.001) and control subjects ( p<.05). Serum carbonyl levels were significantly higher in group 1 and group 2 patients than in control subjects ( p<.001). Serum MDA levels were significantly higher in group 1 patients than in group 2 and control subjects ( p<.001).

CONCLUSION

These results provide further evidence that VPA treatment for patients with BD contributed to the metabolic disturbances, such as the decreased serum adiponectin and -SH levels, as well as the increased serum leptin, MDA and carbonyl levels.

Clinical and demographic predictors of response to rTMS treatment in unipolar and bipolar depressive disorders

OBJECTIVE

Previous studies investigated predictors of repetitive transcranial magnetic stimulation (rTMS) response in depressive disorders but there is still limited knowledge about clinical predictors. Moreover, predictors of rTMS response in bipolar depression (BDD) are less studied than unipolar depression (UDD).

METHODS

We performed a binary logistic regression analysis in 248 patients with depressive disorders (unipolar N=102, bipolar N=146) who received 20 sessions of DLPFC rTMS (High-frequency rTMS, low-frequency rTMS, bilateral rTMS) to investigate significant clinical and demographic predictors of rTMS response. We also investigated effects of depression type, response (yes, no) and time on reducing somatic and cognitive-affective symptoms of patients.

RESULTS

Depression type (unipolar vs. bipolar) did not have a significant effect on rTMS response. 45% of all patients, 51.5% of UDD patients and 41% of BDD patients, responded to rTMS treatment. Age was the only significant demographic predictor of treatment response in all patients. Cognitive-affective symptoms, compared to somatic symptoms were significant predictors for treatment response to rTMS. Common and unique clinical predictor for UDD and BDD were identified.

CONCLUSIONS

Younger patients and those with cognitive-affective rather than somatic symptoms benefit more from DLPFC rTMS treatment. rTMS is effective in UDD and BDD patients. Patients should be selected based on clinical and demographic profile.

SIGNIFICANCE

Findings are based on the largest thus far reported sample of patients with depressive disorders that received DLPFC rTMS.

Two years' outcome of acute mania in bipolar disorder: different effects of age and age of onset

BACKGROUND

Information about differences between younger and older patients with bipolar disorder and between older patients with early and late age of onset of illness during long-term treatment is scarce.

OBJECTIVES

This study aimed to investigate the differences in treatment and treatment outcome between older and younger manic bipolar patients and between early-onset bipolar (EOB) and late-onset bipolar (LOB) older patients.

METHOD

The European Mania in Bipolar Longitudinal Evaluation of Medication study was a 2-year prospective, observational study in 3459 bipolar patients on the treatment and outcome of patients with an acute manic or mixed episode. Patients were assessed at 6, 12, 18, and 24 months post-baseline. We calculated the number of patients with a remission, recovery, relapse, and recurrence and the mean time to achieve this.

RESULTS

Older patients did not differ from younger bipolar patients in achieving remission and recovery or suffering a relapse and in the time to achieve this. However, more older patients recurred and in shorter time. Older patients used less atypical antipsychotics and more antidepressants and other concomitant psychiatric medication. Older EOB and LOB patients did not differ in treatment, but more older LOB patients tended to recover than older EOB patients.

CONCLUSION

Older bipolar manic patients did not differ from younger bipolar patients in short-term treatment outcome (remission and recovery), but in the long term, this may be more difficult to maintain. Distinguishing age groups in bipolar study populations may be useful when considering treatment and treatment outcome and warrants further study.

Allopurinol augmentation in the outpatient treatment of bipolar mania: a pilot study

BACKGROUND

Allopurinol promotes the salvage of purines, possibly increasing endogenous adenosine levels. Recent studies suggest that adenosine has neuroprotective and inhibitory effects. Two previous inpatient trials demonstrated that allopurinol has anti-manic activity. Our objective was to test allopurinol as an adjunct to standard medications in bipolar disorder manic outpatients.

METHODS

In this double-blind, placebo-controlled trial, 27 subjects who met DSM-IV criteria for bipolar disorder and scored ≥ 14 on the Young Mania Rating Scale (YMRS) were randomized to augmentation with allopurinol or placebo for six weeks. The primary efficacy measure was the YMRS. The primary safety measure was the Treatment Emergent Symptom Scale.

RESULTS

The effect of allopurinol augmentation in decreasing mean YMRS scores was modest, with an overall effect size of -0.25 (Cohen's d). Allopurinol-treated individuals who abstained from caffeine (n = 4) had a greater decrease in YMRS scores (-15.3 ± 1.8) than subjects using caffeine (n = 5) (-9.6 ± 3.4, p = 0.219), with an effect size of -0.86.

CONCLUSION

In this small outpatient pilot study, allopurinol augmentation did not show a statistically significant improvement over placebo in attenuating manic symptoms. Subjects with restricted caffeine use showed a greater effect size compared to caffeine users. This finding may be interpreted as corroborating the hypothesized mechanism of action of allopurinol's anti-manic effect in previous studies.

Pharmacogenomics of mood stabilizers in the treatment of bipolar disorder

Bipolar disorder (BD) is a chronic and often severe psychiatric illness characterized by manic and depressive episodes. Among the most effective treatments, mood stabilizers represent the keystone in acute mania, depression, and maintenance treatment of BD. However, treatment response is a highly heterogeneous trait, thus emphasizing the need for a structured informational framework of phenotypic and genetic predictors. In this paper, we present the current state of pharmacogenomic research on long-term treatment in BD, specifically focusing on mood stabilizers. While the results provided so far support the key role of genetic factors in modulating the response phenotype, strong evidence for genetic predictors is still lacking. In order to facilitate implementation of pharmacogenomics into clinical settings (i.e., the creation of personalized therapy), further research efforts are needed.

Bipolar depression: overview and commentary

Depressive phases are the most prevalent component of bipolar disorders, even with modern treatment. Bipolar depressive morbidity is often misdiagnosed and is limited in response to available treatments. These conditions are especially debilitating and are associated with psychiatric comorbidity, substance abuse, functional disability, and increased mortality owing to early suicide and accidents, and later medical illnesses. There is growing awareness that bipolar depression is one of the greatest challenges in modern psychiatry. It is essential to differentiate various forms of depression, dysthymia, and dysphoric mixed states of bipolar disorders from the clinical features of more common, unipolar major depressive disorders. In bipolar depression, antidepressant responses often are unsatisfactory, and these agents probably are overused. Emerging treatments, including several anticonvulsant and modern antipsychotic drugs, as well as lithium-alone or in selected combinations-are partially effective for bipolar depression. Interest in recognizing bipolar depression and seeking more effective, specific, and safer treatments for it are growing.