Bipolar depression: management options

Characterization of Psychiatric Inpatients: The Role of Gender Differences in Clinical and Pharmacological Patterns

BACKGROUND

Severe mental disorders that require hospitalization are disabling conditions that contribute to the burden of mental diseases. They pose increased clinical challenges and highlight the need to thoroughly explore variables emerging from daily clinical practice. In this study, we assessed to what extent gender differences may characterize a large population of psychiatric inpatients.

METHODS

We conducted a cross-sectional study in 2 Italian teaching medical centers, which included 2358 patients who were consecutively admitted to the psychiatric emergency units. We explored and characterized gender differences for variables such as prevalence of psychiatric diagnosis, presence of suicidal ideation, suicide attempts, age at onset of psychiatric illness, presence of substance or alcohol abuse, length of stay, number of hospitalizations, presence of involuntary admission, type of discharge from the hospital, and pharmacological treatment at discharge.

RESULTS

Female patients were primarily diagnosed with bipolar disorder or personality disorders. Female patients had a significantly higher prevalence of lifetime suicide attempts (23.1% vs. 16.5%, P<0.001) and a longer length of hospitalization (11.43±10.73 d vs. 10.52±10.37 d, t=-2.099, gl=2356, P=0.036) compared with male patients. Male patients had more involuntary admissions (25.1% vs. 19.7%, χ2=9.616, gl=1, P=0.002), more use of illicit substances (34.1% vs. 20.9%, χ2=51.084, gl=1, P<0.001), and higher rates of alcohol abuse (21.3% vs. 14.7%, χ2=17.182, gl=1, P<0.001) compared with female patients. Finally, antidepressants and lithium were prescribed more frequently to the female patients, whereas other mood stabilizers were more often prescribed to the male patients.

CONCLUSIONS

Our real-world results highlighted gender differences among patients with severe mental disorders admitted to psychiatric units, and suggest further investigations that may help in understanding trajectories accompanying disabling clinical conditions.

Bipolar disorder and personality disorder

Patients with bipolar disorders experience cyclical changes in mood that present as a range of different syndromes. In classical mania, patients experience episodes of euphoria, whereas in depressive episodes they suffer from depression. In hypomania, patients experience a milder form of mania, and in mixed mania, patients may experience both manic and depressive symptoms simultaneously, or alternate between them rapidly. Because of this wide range of symptoms, bipolar disorders can appear to overlap with other mental disorders, especially personality disorders.

The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features

OBJECTIVE

We evaluated the effectiveness of Electroconvulsive Therapy (ECT) in the treatment of Bipolar Disorder (BD) in a large sample of bipolar patients with drug resistant depression, mania, mixed state and catatonic features.

METHOD

522 consecutive patients with DSM-IV-TR BD were evaluated prior to and after the ECT course. Responders and nonresponders were compared in subsamples of depressed and mixed patients. Descriptive analyses were reported for patients with mania and with catatonic features.

RESULTS

Of the original sample only 22 patients were excluded for the occurrence of side effects or consent withdrawal. After the ECT course, 344 (68.8%) patients were considered responders (final CGIi score ≤2) and 156 (31.2%) nonresponders. Response rates were respectively 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonic features. Length of current episode and global severity of the illness were the only statistically significant predictors of nonresponse.

CONCLUSION

ECT resulted to be an effective and safe treatment for all the phases of severe and drug-resistant BD. Positive response was observed in approximately two-thirds of the cases and in 80% of the catatonic patients. The duration of the current episode was the major predictor of nonresponse. The risk of ECT-induced mania is virtually absent and mood destabilization very unlikely. Our results clearly indicate that current algorithms for the treatment of depressive, mixed, manic and catatonic states should be modified and, at least for the most severe patients, ECT should not be considered as a "last resort".

Gender differences in the treatment of patients with bipolar disorder: a study of 7354 patients

BACKGROUND

Gender differences in treatment that are not supported by empirical evidence have been reported in several areas of medicine. Here, the aim was to evaluate potential gender differences in the treatment for bipolar disorder.

METHODS

Data was collected from the Swedish National Quality Assurance Register for bipolar disorder (BipoläR). Baseline registrations from the period 2004-2011 of 7354 patients were analyzed. Multiple logistic regression analysis was used to study the impact of gender on interventions.

RESULTS

Women were more often treated with antidepressants, lamotrigine, electroconvulsive therapy, benzodiazepines, and psychotherapy. Men were more often treated with lithium. There were no gender differences in treatment with mood stabilizers as a group, neuroleptics, or valproate. Subgroup analyses revealed that ECT was more common in women only in the bipolar I subgroup. Contrariwise, lamotrigine was more common in women only in the bipolar II subgroup.

LIMITATIONS

As BipoläR contains data on outpatient treatment of persons with bipolar disorder in Sweden, it is unclear if these findings translate to inpatient care and to outpatient treatment in other countries.

CONCLUSIONS

Men and women with bipolar disorder receive different treatments in routine clinical settings in Sweden. Gender differences in level of functioning, bipolar subtype, or severity of bipolar disorder could not explain the higher prevalence of pharmacological treatment, electroconvulsive therapy, and psychotherapy in women. Our results suggest that clinicians׳ treatment decisions are to some extent unduly influenced by patients׳ gender.

Treatment of bipolar depression: focus on pharmacologic therapies

Recent studies have highlighted significant limitations in our capacity to effectively treat bipolar depression. This article reviews the present status of treatments for this condition, highlighting emerging new pharmacotherapies such as lamotrigine, olanzapine and quetiapine, while also addressing modern psychologic interventions such as cognitive behavioral therapy and psychoeducation. The role of older treatments such as lithium and the antidepressants is also discussed, particularly as a recent meta-analysis has thrown into question current heightened concern over antidepressant-induced mania. The advent of new pharmacologic and psychologic treatments provides optimism for improved outcomes for this highly disabling condition.

Pharmacological management of bipolar depression: acute treatment, maintenance, and prophylaxis

Although the most distinctive clinical feature of bipolar disorder is the pathologically elevated mood, it does not usually constitute the prevalent mood state of bipolar illness. The majority of patients with bipolar disorder spend much more time in depressive episodes, including subsyndromal depressive symptoms, and bipolar depression accounts for the largest part of the morbidity and mortality of the illness. The pharmacological treatment of bipolar depression mostly consists of combinations of at least two drugs, including mood stabilizers (lithium and anticonvulsants), atypical antipsychotics, and antidepressants. Antidepressants are the most frequently prescribed drugs, but recommendations from evidence-based guidelines are not conclusive and do not overtly support their use. Among antidepressants, best evidence exists for fluoxetine, but in combination with olanzapine. Although some guidelines recommend the use of selective serotonin reuptake inhibitors or bupropion in combination with antimanic agents as first-choice treatment, others do not, based on the available evidence. Among anticonvulsants, the use of lamotrigine is overall recommended as a first-line choice, but acute monotherapy studies have failed. Valproate is generally mentioned as a second-line treatment. Lithium monotherapy is also suggested by most guidelines as a first-line treatment, but its efficacy in acute use is not totally clear. Amongst atypical antipsychotics, quetiapine, in monotherapy or as adjunctive treatment, is recommended by most guidelines as a first-line choice. Olanzapine monotherapy is also suggested by some guidelines and is approved in Japan. Armodafinil, pramipexole, ketamine, and lurasidone are recent proposals. Long-term treatment in bipolar disorder is strongly recommended, but guidelines do not recommend the use of antidepressants as a maintenance treatment. Lithium, lamotrigine, valproate, olanzapine, quetiapine, and aripiprazole are the recommended first-line maintenance options.

The science and practice of lithium therapy

INTRODUCTION

Despite more that 60 years of clinical experience, the effective use of lithium for the treatment of mood disorder, in particular bipolarity, is in danger of becoming obsolete. In part, this is because of exaggerated fears surrounding lithium toxicity, acute and long-term tolerability and the encumbrance of life-long plasma monitoring. Recent research has once again positioned lithium centre stage and amplified the importance of understanding its science and how this translates to clinical practice.

OBJECTIVE

The aim of this paper is to provide a sound knowledge base as regards the science and practice of lithium therapy.

METHOD

A comprehensive literature search using electronic databases was conducted along with a detailed review of articles known to the authors pertaining to the use of lithium. Studies were limited to English publications and those dealing with the management of psychiatric disorders in humans. The literature was synthesized and organized according to relevance to clinical practice and understanding.

RESULTS

Lithium has simple pharmacokinetics that require regular dosing and monitoring. Its mechanisms of action are complex and its effects are multi-faceted, extending beyond mood stability to neuroprotective and anti-suicidal properties. Its use in bipolar disorder is under-appreciated, particularly as it has the best evidence for prophylaxis, qualifying it perhaps as the only true mood stabilizer currently available. In practice, its risks and tolerability are exaggerated and can be readily minimized with knowledge of its clinical profile and judicious application.

CONCLUSION

Lithium is a safe and effective agent that should, whenever indicated, be used first-line for the treatment of bipolar disorder. A better understanding of its science alongside strategic management of its plasma levels will ensure both wider utility and improved outcomes.

Clinical profile and outcome of bipolar disorder patients receiving electroconvulsive therapy: a study from north India

BACKGROUND

Although electroconvulsive therapy (ECT) is used quite frequently among the bipolar patients in developing countries, very little data are available with regard to its effectiveness from the developing countries.

AIM

A retrospective case note review was carried out of bipolar disorder patients who were given ECT.

MATERIALS AND METHODS

Details of demographic and clinical profile, indications for ECT, response patterns, adverse effects, etc. were recorded.

RESULTS

Among all the patients who received ECT, 18% were diagnosed to have bipolar disorder. ECT was administered most commonly for mania with psychotic symptoms, followed by severe depression with psychotic symptoms. Comorbid physical problems were seen in many patients. Nearly 90% of patients in both the subgroups showed more than 50% response (based on reduction in the standardized rating scales) with ECT. Few patients (22%) reported some kind of side effects.

CONCLUSIONS

ECT is useful in the management of acute phase of mania and depression.

Efficacy and safety of electroconvulsive therapy in the treatment of bipolar disorder: a systematic review

OBJECTIVES

: To evaluate the efficacy and safety of electroconvulsive therapy (ECT) in bipolar disorder (BPD).

METHODS

: Clinical trials on the treatment of BPD with ECT were systematically reviewed. A comprehensive search of MEDLINE, PsycINFO, and ISI Web of Science databases was conducted in March 2010.

RESULTS

: A total of 51 articles met our selection criteria. Only 3 controlled or comparative prospective trials addressed the treatment of mania with ECT. In these studies, which had small samples, ECT was superior to simulated ECT, lithium, or the combination of lithium and haloperidol. We did not find any controlled or comparative prospective trial on the efficacy of ECT in bipolar depression. In the 4 retrospective studies that compared ECT with antidepressants, no difference was observed between them. In 9 of 10 trials that compared bipolar with unipolar depressed patients, ECT was equally efficacious for both groups of patients. Of the 6 studies of patients with BPD that performed a comparison between pre-ECT versus post-ECT, only 1 study showed a worsening in cognition after the treatment.

CONCLUSIONS

: There are no studies with adequate methodology on the treatment of BPD with ECT. The lack of scientific evidence contrasts with broad anecdotal clinical experience that suggests that ECT is an important tool in the treatment of BPD, especially in more severe or refractory cases. The marked stigma associated with ECT and the lack of large financial support may account for the paucity of ECT research.

The management of individuals with bipolar disorder: a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.

Is lithium in a class of its own? A brief profile of its clinical use

Lithium is a unique and effective psychotropic agent with a long-standing history of clinical use yet it is increasingly overlooked in lieu of newer agents. The purpose of the present paper was to succinctly review the therapeutic profile of lithium particularly with respect to the treatment of mood disorders and consider its unique properties and clinical utility. A comprehensive literature review pertaining to lithium was undertaken using electronic database search engines to identify relevant clinical trials, meta-analyses and Cochrane reviews. In addition articles and book chapters known to the authors were carefully reviewed, and the authors appraised published guidelines. The evidence from these sources was rated using National Health and Medical Research Council evidence levels and synthesized according to phenotype and mood states. In addition, the authors have drawn upon published guidelines and their own clinical experience. Lithium has specificity for mood disorders with proven efficacy in the treatment of both unipolar depression and bipolar disorder. The recommendations are based predominantly on Level I evidence, but its clinical use has to be tempered against potential side-effects and the need for ongoing monitoring. In practice, lithium should be considered a first-line option in bipolar disorder, especially in prophylaxis and when onset of action is not an imperative. Lithium has been in use in modern medicine for 60 years and as such has been tried and tested across the full range of mood disorders. Arguably, lithium is the only true mood stabilizer and because of its unique properties is in a class of its own.

Lithium: updated human knowledge using an evidence-based approach: Part I: Clinical efficacy in bipolar disorder

Although there has been a decrease in lithium use over several years, it is still recommended as a first-line mood stabilizer in all recent guidelines. It has been argued that many studies of lithium were conducted at a time when study design, assessment standards and the diagnostic criteria for patient selection were not as established as they presently are. However, recent placebo-controlled data from three-arm trials have demonstrated a definite efficacy of lithium in bipolar disorder. Regarding mania, recent trials of novel antimanic treatments (such as second-generation antipsychotics) that have included both placebo and lithium control groups have confirmed that lithium is effective in the treatment of moderate to severe manic episodes. The efficacy of lithium as monotherapy for acute bipolar depression is still controversial, but this therapy is recognized as a therapeutic option. For maintenance therapy, lithium is superior to placebo for the prevention of relapse or recurrence of mood episodes in bipolar I disorder patients with recent manic or hypomanic episodes. Lithium is more effective in preventing episodes of the manic/hypomanic type, including mixed episodes, than preventing depressive episodes. In rapid cycling patients, lithium improves clinical symptoms as efficiently as in nonrapid cycling persons, but is not likely to prevent recurrences. Finally, data from a number of studies suggest that lithium reduces the high suicide rates associated with mood disorders. A well designed cohort study and two independent meta-analyses are in agreement with this finding. In conclusion, most experts, and the most recent guidelines, continue to consider lithium as a keystone therapy of bipolar disorders.

Medicating mood with maintenance in mind: bipolar depression pharmacotherapy

OBJECTIVES

Bipolar depression is a core feature of bipolar disorder, a phase in which many patients spend the majority of time and one that confers a significant degree of burden and risk. The purpose of this paper is to briefly review the evidence base for the pharmacotherapy of bipolar depression and to discuss the recommendations for its optimal management.

METHODS

A detailed literature review was undertaken with a particular emphasis on pharmacological treatment strategies for bipolar depression across the acute and maintenance phases of the illness. Electronic library and Web-based searches were performed using recognised tools (MEDLINE, PubMED, EMBASE and PsychINFO) to identify the pertinent literature. A summary of the evidence base is outlined and then distilled into broad clinical recommendations to guide the pharmacological management of bipolar depression.

RESULTS

Partitioning treatment into acute and maintenance therapy is difficult based on the paucity of current evidence. The evidence from treatment trials favours the use of lithium and lamotrigine as first-line treatment in preference to valproate, and indicates that, for acute episodes, quetiapine and olanzapine have perhaps achieved equivalence at least in terms of efficacy. However, the effectiveness of the atypical antipsychotics in maintenance therapy is constrained by the potential for significant side effects of individual agents and the lack of both long-term research data and clinical experience in treating bipolar disorder as compared to other agents. Conversely, lithium and the anticonvulsants are generally slower to effect symptomatic change, and this limits their usefulness.

CONCLUSIONS

There has been a tendency for research trials of bipolar depression to differentiate the illness cross-sectionally into the acute and maintenance phases of bipolar depression; however, in clinical terms, bipolar depression invariably follows a longitudinal course in which the phases of illness are inextricably linked, and useful acute treatments are typically continued in maintenance. Therefore, when medicating mood in acute bipolar depression it is imperative to keep maintenance in mind as it is this aspect of treatment that determines long-term success.

Lithium specificity in bipolar illness: a classic agent for the classic disorder

For over half a century, lithium has been the gold standard amongst the pharmacological armamentarium used to treat bipolar disorder. Its ascendancy in this regard has been attributed partly to its primacy of discovery and clinical implementation; however, it is important to consider how it has achieved success and retained its prominence and whether this is because of its unique profile and specificity of actions. In this paper, we briefly discuss the clinical evidence in support of lithium specificity and argue for its continuing use in those patients most likely to benefit, namely, patients with 'classic' bipolar disorder. Further, we suggest that accurate characterization of 'lithium responders' through focused research is likely to yield novel treatments and assist in better understanding of the pathophysiology of the illness. In addition, the unique antisuicidal actions of lithium warrant further examination, as do its impressive properties as a prophylactic agent. This is particularly so given the high morbidity associated with bipolar disorder and its potential for suicide. Hence, in this paper, after describing the changing diagnostic backdrop against which much of the research to date has been conducted, we discuss the clinical therapeutic profile of lithium in both the acute and long-term management of bipolar disorder and its phenotypic specificity of action. We demonstrate that lithium possesses significant clinical and therapeutic efficacy that is very individual and thus remains the treatment of choice for bipolar disorder when used specifically in select patients.

Clinical practice recommendations for bipolar disorder

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

Electroconvulsive therapy for bipolar depressive and mixed episode with high suicide risk after epilepsy surgery

Mood disturbance is a common comorbid condition of temporal lobe epilepsy before and after surgery. Suicide is more frequent in patients with epilepsy than in the general population. As suicide is a major issue in both epileptic and depressive patients, it is critical to treat aggressively any psychiatric illness with suicidal ideation. We describe two patients who, after temporal lobe surgery, developed a serious bipolar disorder that necessitated electroconvulsive therapy (ECT), despite better seizure control. Unfortunately they were not able to commit to a regular treatment plan with their psychiatrists to prevent a suicide. These patients underwent a course of ECT treatments. After the ECT regimen, acute suicidal intent remitted and was replaced by chronic suicidal ideation without active intent or plan. The patients were then able to commit to a treatment plan regarding their medications and control visits. These cases represent the safe utilization of ECT as a rapid and effective treatment option for bipolar disorder with suicide ideation following epilepsy surgery. Patients and parents should be advised about possible psychiatric disturbances and suicide risk after epilepsy surgery, especially in the presence of a temporal lobe epilepsy, even when seizure control is achieved postoperatively.

Lamotrigine in the acute treatment of bipolar depression: results of five double-blind, placebo-controlled clinical trials

OBJECTIVES

The efficacy of lamotrigine as maintenance treatment for bipolar disorder (BD), particularly for delaying depressive episodes, is well established, but its efficacy in the acute treatment of bipolar depression is less clear. This paper reports the results of five randomized, double-blind, placebo-controlled trials of lamotrigine monotherapy for the acute treatment of bipolar depression.

METHODS

Adult subjects with bipolar I or II disorder experiencing a depressive episode were randomized to placebo or lamotrigine monotherapy (after titration, at a fixed dose of 50 mg or 200 mg daily in Study 1; a flexible dose of 100-400 mg daily in Study 2; or a fixed dose of 200 mg daily in Studies 3, 4 and 5) for 7-10 weeks.

RESULTS

Lamotrigine did not differ significantly from placebo on primary efficacy endpoints [17-item Hamilton Depression Rating Scale in Studies 1 and 2; Montgomery-Asberg Depression Rating Scale (MADRS) in Studies 3, 4 and 5]. In Study 1, lamotrigine significantly separated from placebo on some secondary measures of efficacy, including the MADRS, the Clinical Global Impressions-Severity (CGI-S) and the CGI-Improvement (CGI-I), but seldom differed on secondary efficacy endpoints for the other studies.

CONCLUSIONS

Lamotrigine monotherapy did not demonstrate efficacy in the acute treatment of bipolar depression in four out of five placebo-controlled clinical studies. Lamotrigine was well tolerated in the acute treatment of bipolar depression.

Increased anterior cingulate cortex volume in bipolar I disorder

OBJECTIVE

Functional neuroimaging studies have implicated the anterior cingulate cortex (ACC) in the pathophysiology of bipolar disorder (BD), but findings from volumetric studies have been less consistent, therefore the purpose of the present study was to further investigate the existence of volumetric abnormalities in the ACC cortex of individuals with BD. In addition to methodological inconsistencies many previous studies have been lacking robustness clinically with respect to characterizing bipolar patients and comparison subjects. Hence, the present study matched the groups closely across a number of demographic parameters.

METHODS

Using magnetic resonance imaging, ACC volumes of 24 bipolar patients were compared to 24 gender-, age-, and education-matched control subjects, and these findings were further investigated in relation to both illness and treatment factors.

RESULTS

A significantly larger (26%) right ACC in bipolar patients than control subjects was seen, and this difference was not associated with a history of psychosis, familiality, or lithium treatment, after controlling for potential confounds. Patients reporting fewer affective episodes did, however, have significantly larger ACC volumes than controls, suggesting ACC volumetric changes early in the course of BD.

CONCLUSIONS

An increase in the size of the ACC may have important implications for the neurobiology of BD. It is suggested that attempts to control affective instability during the early stages of the illness necessitates greater ACC mediation via its role in conflict resolution and hence this is reflected in the increased size of the ACC early in the course of the illness.

Agomelatine adjunctive therapy for acute bipolar depression: preliminary open data

OBJECTIVES

Agomelatine has been shown to be safe and efficient in the treatment of major depressive disorder at 25 mg daily. The aim of this study was to gather preliminary data regarding the antidepressant efficacy of agomelatine in patients with bipolar I disorder experiencing a major depressive episode.

METHODS

Bipolar I patients on lithium (n = 14) or valpromide (n = 7), with a Hamilton Rating Scale for Depression (HAM-D-17) total score > or = 18, were given adjunctive open-label agomelatine at 25 mg/day for a minimum of 6 weeks followed by an optional extension of up to an additional 46 weeks.

RESULTS

Using intent-to-treat data, 81% of patients met criteria for marked improvement (>50% improvement from baseline in HAM-D score) at study endpoint. Patients were severely depressed at study entry (HAM-D of 25.2) and 47.6% responded as early as at one week of treatment. Nineteen patients entered the optional extension period for a mean of 211 days (range 6-325 days). Eleven patients completed the one-year extension on agomelatine. There were no dropouts due to adverse events during the acute phase of treatment (6 weeks). Six patients experienced serious adverse events during the one-year period. Three lithium-treated patients experienced manic or hypomanic episodes during the optional extension period, one of which was treatment-related.

CONCLUSIONS

These results indicate the effectiveness of agomelatine 25 mg in the treatment of depressed bipolar I patients co-medicated with lithium or valpromide. A randomized controlled trial is planned to confirm these results.

A growth in bipolar disorder?

OBJECTIVE

This case report suggests that screening of patients with psychiatric symptoms using modern neuroimaging can help identify organic causes of mental illness.

METHOD

A single case study was reported.

RESULTS

We report the case of a 25-year-old woman with a recent diagnosis of bipolar II disorder having an magnetic resonance imaging (MRI) scan as part of a research project that reveals an intraventricular brain tumour. The latter is most likely the cause of her irritability and 'hypomanic' symptoms and is defined anatomically using diffusion tensor imaging and structural and functional imaging using MRI and positron emission tomography.

CONCLUSION

The lesion in this individual case most probably produces mood symptoms by impinging upon the fornix, a component of the limbic system. However, more generally, the increase in diagnosis of bipolar disorder has to be tempered against alternate causes of similar symptoms and necessitates vigilance of potential organic mechanisms.

Does dopamine dysfunction drive depression?

OBJECTIVE

To examine the evidence that dopamine (DA) dysfunction contributes to melancholic depression.

METHOD

Database (EMBASE, PsychLit and MEDLINE) searches using relevant key words were conducted and citations were scrutinized.

RESULTS

In this paper, we assume that the definition of melancholia is contingent upon the presence of psychomotor disturbance (PMD). In melancholic depression PMD comprises both a cognitive and motor component and DA is found to be important in both. DA neurotransmission modulates cognition in particular in attention, adaptation and motivational processes and has a pivotal role in motor function.

CONCLUSION

DA is a credible aetiological candidate for the PMD in melancholic depression. However, melancholia needs first to be characterized both clinically and in terms of its pathophysiology. In this regard, illnesses such as bipolar depression and Parkinson's disease warrant consideration as they provide suitable models of both the cognitive and motor aspects of PMD, and hold the necessary markers to better define melancholia.

Emerging drugs for bipolar disorder

Bipolar disorder is a relatively common condition characterised by recurrent episodes of mania and depression, and associated with high levels of morbidity and mortality. Although there have been substantial advances in the pharmacotherapeutics of this condition over the last 10-15 years, the benefits have been predominantly in terms of tolerability and safety, with no new treatments being demonstrated to be more effective than lithium--the prototype mood stabiliser. This article reviews current and emerging medications for bipolar disorder. Most of the emerging treatments in pharmaceutical industry developmental programmes are new or modified anticonvulsants or atypical antipsychotics. A number of possible future directions and challenges for the field are discussed. The treatment of bipolar disorder is unlikely to advance substantially until the causative pathogenetic molecular processes are elucidated.

Bipolar disorder as an emerging pathology in the scientific literature: a bibliometric approach

BACKGROUND

To carry out a bibliometric study on the scientific publications in relation to bipolar disorder.

METHODS

Using the EMBASE and MEDLINE databases, we selected those documents whose title included the descriptors bipolar disorder, bipolar illness, bipolar patient, bipolar mani, bipolar depress, bipolar spectrum, manic-depressive, and rapid cycling. We applied some bibliometric indicators, as Price's Law on the increase of scientific literature, or the participation index (PI) of the different countries. The bibliometric data have also been correlated with some social and health data from the countries that are most prolific in biomedical scientific production, such as number of physicians, total per capita expenditure on health and overall volume of production in the field of psychiatry.

RESULTS

A total of 4270 original documents published between 1980 and 2004 were downloaded, of which 1825 corresponded to aspects related to drug therapy. Our results state fulfilment of Price's Law, with scientific production on bipolar disorder showing exponential growth (correlation coefficient r = 0.947, as against an r = 0.849 after linear adjustment). The drugs most widely studied are lithium (1351 documents), valproate (544), carbamazepine (493), lamotrigine (240), and olanzapine (210). United States is the most productive country (participation index, PI = 44.2), followed by the United Kingdom (14.4), Netherlands (9.1) and France (4.1).

CONCLUSION

The publications on bipolar disorder and mood stabilizers have undergone exponential growth over the last 25 years, without evidence a saturation point.

Combined use of lamotrigine and electroconvulsive therapy in bipolar depression: a case series

OBJECTIVE

Lamotrigine and electroconvulsive therapy (ECT) are both safe and effective treatments for bipolar depression. Concerns exist that anticonvulsants may interfere with seizure expression during ECT or may exacerbate cognitive side effects, potentially affecting clinical response. This report examines the clinical use of concurrent ECT and lamotrigine for acute bipolar depression and the transition to maintenance therapy.

METHODS

Nine patients with acute bipolar depression were simultaneously treated with a course of ECT while titrating lamotrigine for maintenance therapy. We compared mean stimulus intensity, mean seizure duration, and mean time to orientation after treatment for each patient during treatment with their highest and lowest lamotrigine dose.

RESULTS

All 9 patients were treated to remission. From the lowest daily dose to the highest daily dose, mean increase in lamotrigine was 102.8 mg. Clinically adequate seizures were obtained in each patient. Lamotrigine had minimal effect on each measured ECT parameter. The interval between ECT treatments was spaced to a mean of 15.2 days. The treatment combination was well tolerated, with no serious adverse events, no rashes, and no worsening of cognitive side effects.

CONCLUSIONS

Concurrent use of lamotrigine with ECT in bipolar depression seems safe, did not interfere with routine ECT practice, and allowed for transition to maintenance pharmacotherapy.

Executive functioning and theory of mind in euthymic bipolar disorder

OBJECTIVES

To examine the nature of executive deficits in euthymic patients with bipolar disorder (BD).

METHODS

Fifteen euthymic BD patients and 13 controls were administered a battery of executive tasks including verbal fluency, Stroop, Theory of Mind (ToM) tests and selected subtests from the Cambridge Neuropsychological Test Automated Battery (CANTAB). Self-report and clinician ratings of mood and social and occupational functioning were also obtained.

RESULTS

There were no significant differences between BD patients and controls on the primary measures of the following executive tasks: verbal fluency, attentional set-shifting, problem solving or planning. On secondary measures of speed, BD patients were slower to complete the first trial of the Stroop task (p = 0.001). Patients with BD committed more errors across all secondary measures. Patients performed poorly when compared with controls on tests of verbal ToM (p = 0.02), and although they performed non-verbal ToM tasks at a level comparable to controls (p = 0.60), they were slower to initiate a response (p = 0.006). ToM was not significantly correlated with any measure of social and occupational functioning; however it correlated with the achievement scores of the CANTAB Stockings of Cambridge task (Pearson's r = 0.68, p < 0.01).

CONCLUSIONS

Deficits found in euthymic bipolar patients suggest fronto-subcortical pathway dysfunction. This is consistent with other neuropsychological and neuroimaging research that points to a trait deficit in BD. Further investigation is necessary perhaps using more real-world tests.

Considerations in the management of bipolar disorder in women

OBJECTIVE

Recent research has emphasized important gender differences in the epidemiology, course, comorbidity and treatment of bipolar disorder. This article aims to provide an overview of these important findings in order to assist the clinician in treating women with bipolar disorder. Complex issues regarding the treatment of bipolar disorder during pregnancy and the post-partum period are discussed.

METHOD

A literature review was undertaken using Medline (1966-current), PsychInfo and PubMed databases. Search terms used were gender, sex, women, bipolar disorder, suicide, epidemiology, rapid cycling, mixed episode, treatment, mood stabilizers, antidepressants, antipsychotics, pregnancy, post-partum, menopause, lactation and breast-feeding.

RESULTS

The lifetime prevalence of bipolar I disorder is equal in men and women; however, bipolar II appears to be more common in women. Gender differences have been reported in the phenomenology, course and outcome of this condition. Some comorbid disorders, such as thyroid disease and anxiety disorders have more relevance to women. Increasingly, sex differences in the pharmacokinetics and pharmacodynamics of medications used in bipolar disorder are being reported.

CONCLUSIONS

There is increasing evidence for gender differences in a number of clinical features of bipolar disorder that have relevance to management. Although more studies are needed, it is important for clinicians to be aware of these issues to optimize treatment of women with this condition.

A typical mood stabilizers: a "typical role for atypical antipsychotics

OBJECTIVE

To assess the potential role of atypical antipsychotics as mood stabilizers.

METHOD

A MedLine, PsychLIT, PubMed, and EMBASE literature search of papers published up to December 2004 was conducted using the names of atypical antipsychotics and a number of key terms relevant to bipolar disorder. Additional articles were retrieved by scrutinizing the bibliographies of review papers and literature known to the authors. Data pertinent to the objective was reviewed according to the various phases of bipolar disorder.

RESULTS

The data is most substantive for the use of atypical antipsychotics in mania, to the extent that an argument for a class effect of significant efficacy can be made. This does not extend to bipolar depression, however, good data is now emerging for some agents and will need to be considered for each individual agent as it accumulates. As regards mixed states and rapid cycling the evidence is thus far sparse and too few maintenance studies have been conducted to make any firm assertions. However, with respect to long-term therapy the atypical antipsychotics do have clinically significant side-effects of which clinicians need to be aware.

CONCLUSION

Based on the evidence thus far it is perhaps premature to describe the atypical antipsychotics as mood stabilizers. Individual agents may eventually be able to claim this label, however, much further research is needed especially with respect to maintenance and relapse prevention.

When euthymia is just not good enough: the neuropsychology of bipolar disorder

Bipolar disorder (BD) is a debilitating psychiatric illness that is uniquely characterized by switching between psychopathologically contrasting phases of mania and depression, often with intervening periods of euthymia. However, these periods of apparent clinical recovery (euthymia) are marked by subtle social, occupational, and cognitive impairments, profiled by recent neuropsychological investigations. Determining the cognitive changes across these three phases may help differentiate the disruptions that are mood state-dependent from those associated with underlying pathology. This article therefore critically reviews the reported neuropsychological impairments in BD and the methodological limitations facing such research. Integration of the available evidence, principally from the field of neuropsychology, when synthesized, implicates the prefrontal cortex in the etiopathogenesis of BD and posits cortical-subcortical-limbic disruption in recovered euthymic patients that manifests as cognitive dysfunction.

Lamotrigine for bipolar disorder: translating research into clinical practice

Lamotrigine (Lamictal, GlaxoSmithKline) is a recently developed anticonvulsant which has been investigated for efficacy in bipolar disorder. Increasing evidence indicates that it may have a different therapeutic profile than more established first-line mood stabilizers such as lithium and valproate. In particular, evidence from well-designed trials suggests efficacy for acute management and prophylaxis of bipolar depression but not mania. However, clinically relevant drug interactions and side effects can occur with lamotrigine, including benign to serious rash. The objectives of this drug profile are to review the basic chemical and pharmacological characteristics of lamotrigine, critically examine the growing body of research literature on its clinical use in the treatment of bipolar disorder, and review the safety and tolerability of lamotrigine as well as drug interactions relevant to clinical practice. Practical recommendations regarding titration and the management of rash are offered.

'Bipolar missed states': the diagnosis and clinical salience of bipolar mixed states

OBJECTIVE

To explore diagnostic and treatment issues concerning bipolar mixed states.

METHOD

Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed.

RESULT

Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression.

CONCLUSIONS

The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.

Psychological interventions in bipolar disorder: From wishful thinking to an evidence-based approach

OBJECTIVE

We aimed to examine the historical and current relevance of psychosocial approaches to bipolar illness by conducting a systematic review of prospective studies assessing the effectiveness of psychological interventions for bipolar disorder.

METHOD

A systematic literature search was conducted using EMBASE, MedLine and PsychLIT and reference sections of papers were scrutinized for further relevant reports. Only four trials met the criteria of a prospective study and achieved the necessary methodological standards.

RESULTS

The studies showed benefits for patients in terms of relapse prevention and the reduction of hospitalization rates. Psychoeducation (delivered in groups or as part of a family intervention) and cognitive behavioural therapy were also found to be effective prophylactic treatments for bipolar disorder in medicated patients. Other interventions do not appear to be supported by sufficient evidence.

CONCLUSION

Psychological approaches, and particularly psychoeducation and cognitive-behavioural therapies, are evidence-based prophylactic therapies for bipolar patients receiving pharmacotherapy. They should be used as adjuncts to medication where possible in the prevention of bipolar disorder.

Bipolar depression: phenomenological overview and clinical characteristics

OBJECTIVES

There has been increasing interest in the depressed phase of bipolar disorder (bipolar depression). This paper aims to review the clinical characteristics of bipolar depression, focusing upon its prevalence and phenomenology, related neuropsychological dysfunction, suicidal behaviour, disability and treatment responsiveness.

METHODS

Studies on the prevalence of depression in bipolar disorder, the comparative phenomenology of bipolar and unipolar depression, as well as neuropsychology and brain imaging studies, are reviewed. To identify relevant papers, a literature search using MEDLINE and PubMed was undertaken.

RESULTS

Depression is the predominant mood disturbance in bipolar disorder, and most frequently presents as subsyndromal, minor or dysthymic depression. Compared with major depressive disorder (unipolar depression), bipolar depression is more likely to manifest with psychosis, melancholic symptoms, psychomotor retardation (in bipolar I disorder) and 'atypical' symptoms. The few neuropsychological studies undertaken indicate greater impairment in bipolar depression. Suicide rates are high in bipolar disorder, with suicidal ideation, suicide attempts and completed suicides all occurring predominantly in the depressed phase of this condition. Furthermore, the depressed phase (even subsyndromal) appears to be the major contributant to the disability related to this condition.

CONCLUSIONS

The significance of the depressed phase of bipolar disorder has been markedly underestimated. Bipolar depression accounts for most of the morbidity and mortality due to this illness. Current treatments have significant limitations.

Bipolar disorder: it's all in your mind? The neuropsychological profile of a biological disorder

OBJECTIVE

To compare and contrast the neuropsychological profile of the 3 phases of bipolar disorder (BD) to achieve a better definition of BD and to identify potential state and trait deficits.

METHODS

We conducted a search for English-language papers published in journals from 1965 onward, using the following terms in Medline and Embase: neuropsychology or neuropsychological and BD, depression, mania, and euthymia. We scrutinized suitable subheadings and retrieved familiar papers and literature.

RESULTS

We initially identified more than 100 articles and then excluded reviews and papers that did not directly administer neuropsychological tests. This left 27 papers, which we further examined and the findings of which we tabulated and discussed. Cognitive and executive functioning deficits were found, including set-shifting, verbal fluency, planning, attention, and memory.

CONCLUSIONS

The neuropsychological deficits found in bipolar depression, mania or hypomania, and euthymia provide important insights into the pathophysiology of BD and may, in future studies, form the basis of clinically meaningful subtypes.

Bipolaroids: functional imaging in bipolar disorder

OBJECTIVE

To evaluate the literature pertaining to the use of functional magnetic resonance imaging (fMRI) in bipolar disorder research.

METHOD

A search for papers published in English in journals from 1984 onwards was conducted using MedLine and EMBASE with the following terms: functional neuroimaging or fMRI and depression or bipolar disorder. In addition, retrieved papers and literature known to the authors was also scrutinized for further relevant reports.

RESULTS

The research findings from 26 articles are tabulated and the results from 10 articles dealing specifically with bipolar disorder are discussed in detail.

CONCLUSION

fMRI is a useful tool for investigating bipolar disorder. Preliminary studies point to trait and state abnormalities involving structures known to be associated with the generation and modulation of emotion. The patterns of fMRI activation are different to those found in healthy subjects and patients with major depression. FMRI studies are likely to provide valuable insights into the pathophysiology of bipolar disorder.

Major advances in bipolar disorder

There have been major advances in clinical understanding and treatment of bipolar disorder over the past decade. Randomised controlled trials of pharmacological treatments and psychological interventions have shown that there are effective short-term and long-term treatments for the disorder. Despite advances in treatment, diagnosis is often delayed or mistaken, and many people who could benefit are not using the treatments available. Functional and symptomatic recovery from episodes of bipolar disorder is frequently less complete than previously considered, and disability is often profound. Although manic episodes are the distinguishing feature of bipolar disorder, it appears that depression is the predominant mood disturbance and that much of the functional impairment associated with bipolar disorder results from this. Comorbidity with anxiety disorders or substance misuse is common. Advances in genetics, brain imaging and basic pharmacology are starting to provide understanding of the complex causative processes.

Cognitive generation of affect in hypomania: an fMRI study

OBJECTIVE

To identify the brain regions associated with the cognitive generation of affect in hypomanic bipolar patients.

METHODS

The study examined 10 hypomanic female subjects with bipolar affective disorder, and 10 age- and sex-matched comparison subjects using functional magnetic resonance imaging (fMRI) while viewing alternating blocks of captioned-pictures designed to evoke negative, positive or no affective change. The activation paradigm involved the presentation of the same visual materials over three experiments alternating (a) negative and reference, (b) positive and reference and (c) positive and negative captioned-pictures.

RESULTS

The stimuli produced activation in both patients and comparison subjects in brain regions previously implicated in the generation and modulation of affect, in particular the prefrontal cortex. Activation in patients involved additional subcortical regions namely the caudate and thalamus.

CONCLUSIONS

This preliminary study suggests that hypomanic patients recruit additional subcortical limbic systems for emotional evaluation when advanced prefrontal cortical processing is no longer sufficient. The differential patterns of activation inform us about bipolar disorder and may have potential diagnostic and therapeutic significance.

A review of acute treatments for bipolar depression

Bipolar patients generally spend much more time in the depressed phase of their illness than the manic phase, and there are many more bipolar type II and bipolar spectrum disorder patients than there are bipolar type I. Additionally, there is a significant risk of suicide in bipolar patients when depressed. The treatment of the depressed phase of bipolar disorder is therefore a matter of some priority. Here, we review current evidence supporting the use of five groups of treatments: anti-depressants; lithium; anti-convulsants (valproate, and carbamazepine, lamotrigine, gabapentin); anti-psychotics; and other treatments (electroconvulsive therapy, benzodiazepines, sleep-deprivation, and dopamine agonists). From this review, it is apparent that the literature regarding the treatment of bipolar depression is significantly limited in several key areas. Nonetheless, from the evidence currently available, the treatments with the best evidence for efficacy are selective serotonin reuptake inhibitors (SSRIs) and lamotrigine. There is also some evidence in favour of bupropion and moclobemide. Although lithium and olanzapine monotherapies can also be beneficial, they appear less efficacious than antidepressants. One of the major concerns about treatment with antidepressants has been the risk of precipitating a switch into mania. However, recent studies suggest that, if a mood stabilizer and antidepressant are given concurrently, then the risk of switching is minimized. There is also recent evidence for an independent antidepressant action for at least one atypical antipsychotic. Therefore, the conclusion from this review, in contrast to previous suggestions, is that a combination of an atypical antipsychotic and either an SSRI or lamotrigine may provide a useful first-line treatment for depressed bipolar disorder patients. Further research is clearly required to examine this approach and compare it with other possible treatment options.

Medication options in the treatment of treatment-resistant depression

AIM

Less than half of those suffering major depressive episodes achieve remission with the first antidepressant provided and one-third of all patients suffering depression have a chronic condition. Clinical experience indicates that a substantial proportion of patients suffer treatment-resistant depression (TRD). Our aim is to explore the literature reporting the drug treatment of TRD, and to present such information as would be of interest to clinical psychiatrists.

METHOD

Literature searches were conducted using PubMed and entering the words antidepressant, augmentation, combined antidepressants, treatment resistant depression and the names of individual antidepressant medications.

RESULTS

Most authors recommended that TRD should be first approached by reassessing the diagnosis, adding psychotherapy and attending to psychosocial factors. Details of the following pharmacological options were identified: (i) augmentation of the currently employed antidepressant with a medication which is not an antidepressant; (ii) change of antidepressant; and (iii) addition of a second antidepressant to the current antidepressant, or commencement of a combination of two antidepressants.

CONCLUSIONS

When monotherapy provided at the maximum manufacturer-recommended doses for 3-4 weeks has failed to provide remission in depression, the diagnosis should be confirmed, psychotherapy added and psychosocial factors should receive attention. In the sustained absence of remission, a better outcome may be obtained by augmenting the antidepressant, changing from a single-action to a double- or multiple-action drug, or by combining antidepressants.

Cognitive generation of affect in bipolar depression: an fMRI study

Individuals with bipolar disorder manifest the full spectrum of emotions ranging from depression to mania. In attempting to understand the functional substrates of mood we attempted to identify brain regions associated with the cognitive generation of affect in bipolar depressed patients. We therefore examined ten depressed female subjects with bipolar affective disorder, and ten age-matched and sex-matched healthy comparison subjects using functional magnetic resonance imaging (fMRI) while viewing alternating blocks of captioned pictures designed to evoke negative, positive or no affective change. The activation paradigm involved the presentation of the same visual materials over three experiments alternating (experiment 1) negative and reference; (experiment 2) positive and reference and (experiment 3) positive and negative captioned pictures. The stimuli produced activation in both patients and comparison subjects in brain regions previously implicated in the generation and modulation of affect, in particular the prefrontal and anterior cingulate cortices. The activation in patients, when compared with healthy subjects, involved additional subcortical regions, in particular the amygdala, thalamus, hypothalamus and medial globus pallidus. Patients and comparison subjects displayed differential sensitivity to affective change with negative (experiment 1) and positive (experiment 2) affect induction producing converse patterns of activation. We conclude that bipolar depressed patients perhaps recruit additional subcortical limbic systems for emotional evaluation and this may reflect state-related or trait-related dysfunction. The differential patterns of activation inform us about bipolar depression and have potential diagnostic and therapeutic significance.

Effect of acute and chronic lamotrigine on basal and stimulated extracellular 5-hydroxytryptamine and dopamine in the hippocampus of the freely moving rat

1. We have studied the effects of acute and chronic treatment with the anticonvulsant lamotrigine (LTG) on basal and stimulated extracellular 5-hydroxytryptamine (5-HT), dopamine (DA) and their metabolites in the hippocampus of freely moving rats using in vivo microdialysis. 2. Acute LTG (10 and 20 mg kg(-1)) decreased extracellular 5-HT, but had no effect on its metabolite 5-hydroxyindoleacetic acid (5-HIAA). Dialysate DA was also decreased by LTG as were its metabolites dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA). When transmitter release was stimulated by either 50 microm veratridine or 100 mm K(+), marked increases in the release of both transmitters occurred, but LTG was entirely without effect on this. 3. In chronic experiments, rats were dialysed after 2, 4, 7, 14 and 21 days of LTG treatment (5 mg kg(-1), twice daily). During this period a progressively different response to the drug was seen. After 2 days, basal extracellular 5-HT was significantly greater in treated rats than control rats. This effect persisted up to 14 days, but by 21 days 5-HT levels had returned to control values. 5-HIAA levels were unaltered and there was no effect of LTG on veratridine or K(+) stimulated 5-HT release. 4. Similarly, DA concentrations significantly increased after 2-7 days of LTG treatment, but returned and remained at basal values thereafter. During the treatment period LTG had no effect on extracellular DOPAC, but HVA followed a similar pattern to its parent transmitter. As with 5-HT, at no time point did LTG have any effect on stimulated DA release. 5. These neurochemical findings observed in these experiments are considered in relation to the use of LTG in bipolar disorder.