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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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Sleem A, El-Mallakh RS. Advances in the psychopharmacotherapy of bipolar disorder type I. Expert Opin Pharmacother 2021; 22:1267-1290. [PMID: 33612040 DOI: 10.1080/14656566.2021.1893306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Research into the pharmacologic management of bipolar type I illness continues to progress. AREAS COVERED Randomized clinical trials performed with type I bipolar disorder in the years 2015 to August 2020 are reviewed. There are new indications for the use of cariprazine, for bipolar mania and depression, and a long-acting injectable formulation of aripiprazole has also been approved for relapse prevention in bipolar illness. Most of the randomized clinical trials are effectiveness studies. EXPERT OPINION Over the 20 years from 1997 through 2016, the use of lithium and other mood stabilizers has declined by 50%, while the use of both second-generation antipsychotics (SGAs) and antidepressants has increased considerably. Over the same time period (1990-2017), disability-adjusted life years (DALYs) increased by 54.4%, from 6.02 million in 1990 to 9.29 million in 2017 which is greater than the 47.74% increase in incidence of the disease, suggesting that the changes in prescribing patterns have not been helpful for our patients. Furthermore, recent effectiveness studies continue to confirm the superiority of lithium and other mood stabilizers in the management of bipolar illness for both psychiatric and medical outcomes, reaffirming their role as foundational treatments in the management of type I bipolar disorder. Clinicians need to reassess their prescribing habits.
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Affiliation(s)
- Ahmad Sleem
- Mood Disorders Research Program, Depression Center Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rif S El-Mallakh
- Mood Disorders Research Program, Depression Center Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY, USA
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Marazziti D, Mucci F, Falaschi V, Dell'Osso L. Asenapine for the treatment of bipolar disorder. Expert Opin Pharmacother 2019; 20:1321-1330. [PMID: 31132287 DOI: 10.1080/14656566.2019.1617849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Bipolar I disorder (BDI) is amongst the most debilitating psychiatric conditions with a great impact on both patients and their families. A class of drugs commonly used in this condition is second-generation antipsychotics (SGAs) including asenapine, one of the latest to be introduced into the clinical practice worldwide to treat manic episodes in BDI. Areas covered: The aim of this paper is to critically review the literature on the pharmacological characteristics, tolerability, and safety data of asenapine, as well as on its short- and long-term clinical trials in manic episodes as both a monotherapy and as an add-on treatment. Expert opinion: The available data indicate that asenapine is an effective antimanic agent in both adult and pediatric patients and that it might also improve depressive symptoms and recurrences in BDI patients. Its tolerability profile is good, and its most common side effects are somnolence, light extrapyramidal symptoms, dizziness, weight gain, and oral (but reversible) hypoesthesia. Taken together, the published studies indicate that asenapine might be an effective therapeutic agent in BDI with a broad spectrum of clinical activities. Further double-blind, short- and long-term studies are, however, necessary to clarify its precise role in the treatment of BD.
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Affiliation(s)
- Donatella Marazziti
- a Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry , University of Pisa , Pisa , Italy
| | - Federico Mucci
- a Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry , University of Pisa , Pisa , Italy
| | - Valentina Falaschi
- a Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry , University of Pisa , Pisa , Italy
| | - Liliana Dell'Osso
- a Dipartimento di Medicina Clinica e Sperimentale, Section of Psychiatry , University of Pisa , Pisa , Italy
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