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Chakrabarti S, Jolly AJ, Singh P, Yadhav N. Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder. World J Psychiatry 2023; 13:495-510. [PMID: 37701540 PMCID: PMC10494771 DOI: 10.5498/wjp.v13.i8.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023] Open
Abstract
Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
| | - Amal J Jolly
- Department of Psychiatry, Black Country Healthcare NHS Foundation Trust, Dudley DY2 8PS, West Midlands, United Kingdom
| | - Pranshu Singh
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India
| | - Nidhi Yadhav
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
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2
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Takano C, Kato M, Adachi N, Kubota Y, Azekawa T, Ueda H, Edagawa K, Katsumoto E, Goto E, Hongo S, Miki K, Tsuboi T, Yasui-Furukori N, Nakagawa A, Kikuchi T, Watanabe K, Kinoshita T, Yoshimura R. Clinical characteristics and prescriptions associated with a 2-year course of rapid cycling and euthymia in bipolar disorder: a multicenter treatment survey for bipolar disorder in psychiatric clinics. Front Psychiatry 2023; 14:1183782. [PMID: 37265558 PMCID: PMC10229865 DOI: 10.3389/fpsyt.2023.1183782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023] Open
Abstract
Objective In patients with bipolar disorder (BD), rapid cycling (RC) presents a risk for a more severe illness, while euthymia (EUT) has a better prognosis. This study focused on the progression of RC and EUT, which are contrasting phenomenology, and aimed to clarify the influence of patient backgrounds and prescription patterns on these different progressions, using a large sample from the first and second iterations of a multicenter treatment survey for BD in psychiatric clinics (MUSUBI). Methods In the cross-sectional study (MUSUBI), a questionnaire based on a retrospective medical record survey of consecutive BD cases (N = 2,650) was distributed. The first survey was conducted in 2016, and the second one in 2017. The questionnaire collected information on patient backgrounds, current episodes, and clinical and prescribing characteristics. Results In the first survey, 10.6% of the participants had RC and 3.6% had RC for two consecutive years, which correlated with BP I (Bipolar disorder type I), suicidal ideation, duration of illness, and the use of lithium carbonate and antipsychotic medications. Possible risk factors for switching to RC were comorbid developmental disorders and the prescription of anxiolytics and sleep medication. Moreover, 16.4% of the participants presented EUT in the first survey, and 11.0% presented EUT for two consecutive years. Possible factors for achieving EUT included older age; employment; fewer psychotic symptoms and comorbid personality disorders; fewer antidepressants, antipsychotics, and anxiolytics, and more lithium prescriptions. Conclusion RC and EUT generally exhibit conflicting characteristics, and the conflicting social backgrounds and factors contributing to their outcomes were distinctive. Understanding these clinical characteristics may be helpful in clinical practice for management of patients with BD.
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Affiliation(s)
- Chikashi Takano
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan
| | - Masaki Kato
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
| | - Naoto Adachi
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Yukihisa Kubota
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | | | - Hitoshi Ueda
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Kouji Edagawa
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | | | - Eiichiro Goto
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Seiji Hongo
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Kazuhira Miki
- Japanese Association of Neuro-Psychiatric Clinics, Tokyo, Japan
| | - Takashi Tsuboi
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Norio Yasui-Furukori
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Psychiatry, Dokkyo Medical University, Tochigi, Japan
| | - Atsuo Nakagawa
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Kikuchi
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Koichiro Watanabe
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Toshihiko Kinoshita
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
| | - Reiji Yoshimura
- Japanese Society of Clinical Neuropsychopharmacology, Tokyo, Japan
- Department of Psychiatry, University of Occupational and Environmental Health, Fukuoka, Japan
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3
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Munkholm K. The need for establishing optimal treatment strategies for patients with rapid cycling bipolar disorder remains. Acta Psychiatr Scand 2022; 146:287-289. [PMID: 36117289 DOI: 10.1111/acps.13495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 01/29/2023]
Affiliation(s)
- Klaus Munkholm
- Psychiatric Center Copenhagen, Rigshospitalet, Copenhagen, Denmark
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4
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Roosen L, Sienaert P. Evidence-based treatment strategies for rapid cycling bipolar disorder, a systematic review. J Affect Disord 2022; 311:69-77. [PMID: 35545157 DOI: 10.1016/j.jad.2022.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/27/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Rapid cycling is a phase of bipolar disorder with increased episode frequencies. It is a severe and disabling condition that often poses a major challenge to the clinician. The aim of this paper is to give an overview of the evidence-based treatment options for rapid cycling. METHODS A systematic search on Pubmed, Embase and Cochrane databases from inception until December 2021 was conducted according to the PRISMA guidelines. An additional search on clinicaltrials.gov was done. References of retrieved papers and key reviews were hand-searched. Randomized controlled trials including at least 10 patients with bipolar disorder, rapid cycling, reporting an objective outcome measure were selected. RESULTS Our search, initially revealing 1330 articles, resulted in 16 papers about treatment of an acute mood episode, relapse prevention or both. Lithium, anticonvulsants, second generation antipsychotics, antidepressants and thyroid hormone were assessed as treatment options in the presented data. Evidence supporting the use of aripiprazole, olanzapine, quetiapine, valproate and lamotrigine for treatment of rapid cycling bipolar disorder was found. LIMITATIONS Small sample sizes, different index episodes and variety of outcome measures. CONCLUSION Evidence regarding treatment of rapid cycling remains scarce. Evidence supports the use of aripiprazole, olanzapine, and valproate for acute manic or mixed episodes, quetiapine for acute depressive episodes and aripiprazole and lamotrigine for relapse prevention. Given the paucity of available evidence, and the burden that accompanies rapid cycling, future research is warranted.
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Affiliation(s)
- L Roosen
- KU Leuven, University Psychiatric Center KU Leuven, Herestraat 49, 3000 Leuven/Leuvensesteenweg 517, 3070 Kortenberg, Belgium.
| | - P Sienaert
- KU Leuven, University Psychiatric Center KU Leuven, Academic Center for ECT and Neuromodulation (AcCENT), Leuvensesteenweg 517, 3070 Kortenberg, Belgium
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5
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Lucchelli JP, Kourakou S, Ciraselli N. Treating bipolar disorder with rapid cycles: About a case. Encephale 2021; 48:722-724. [PMID: 34801234 DOI: 10.1016/j.encep.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- J P Lucchelli
- Hôpital du Jura Bernois, Pôle de Santé Mentale, L'Abbaye, 22713 Bellelay, Switzerland; Laboratoire de psychopathologie, E.A. 4050, Université de Rennes 2, place du Recteur Henri Le Moal, CS 24307, 35043 Rennes Cedex, France.
| | - S Kourakou
- Hôpital du Jura Bernois, Pôle de Santé Mentale, L'Abbaye, 22713 Bellelay, Switzerland
| | - N Ciraselli
- Hôpital du Jura Bernois, Pôle de Santé Mentale, L'Abbaye, 22713 Bellelay, Switzerland
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Ramos AL, Salgado H, Bragança M. Manic Episode Induced by Lamotrigine in Rapid Cycling Bipolar Disorder. Cureus 2021; 13:e16184. [PMID: 34367791 PMCID: PMC8335686 DOI: 10.7759/cureus.16184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/11/2022] Open
Abstract
Bipolar disorder is characterized by persistent and/or recurrent mood changes between depressive and manic poles. Rapid cycling is a frequent, although underrecognized, condition in bipolar disorder, and it is known to worsen the prognosis of the disease. With regard to the treatment of bipolar depression, there is a shortage of evidence‐supported treatment choices, and the literature on the subject includes few references to cases of manic switch induced by lamotrigine. The authors describe a case of a rapid cycling bipolar patient who presented manic symptoms after initiating treatment with lamotrigine.
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Affiliation(s)
- Ana Lúcia Ramos
- Psychiatry, University Hospital Center of Sao Joao, Oporto, PRT
| | | | - Miguel Bragança
- Psychiatry, University Hospital Center of Sao Joao, Oporto, PRT
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7
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Girardi P, Brugnoli R, Manfredi G, Sani G. Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs R D 2018; 16:293-302. [PMID: 27770296 PMCID: PMC5114200 DOI: 10.1007/s40268-016-0139-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Lithium has been a gold standard in the treatment of bipolar disorder (BD) for several decades. Despite a general reduction in the use of lithium over the past several years, it is effective in the management of both manic and depressive episodes in BD and continues to be recommended as a first-line mood stabilizer. This review provides an overview of the pharmacology of lithium and highlights its clinical profile in the management of BD, focusing on the potential advantages of prolonged-release (PR) versus immediate-release (IR) formulations of lithium. A literature search using PubMed was performed to identify articles describing IR and PR lithium in BD using specific search terms like ‘lithium’, ‘prolonged-release’, ‘sustained-release’, ‘extended-release’, ‘bipolar disorder’, ‘adherence’ and ‘compliance’. Relevant pharmacodynamic and pharmacokinetic data were also included. Several clinical trials suggested that lithium is effective in the treatment of acute mania and prophylaxis of BD and reduces the risk of suicide in patients with BD; it may also be used in combination with other drugs in the treatment of bipolar depression. Treatment with lithium must be monitored to avoid lithium-associated toxicity. The prolonged PR formulation of lithium has several advantages including consistent serum lithium concentrations, fewer adverse events and improved adherence to therapy. Although direct comparative studies between PR and IR formulations of lithium are primarily limited to pharmacokinetic studies, PR formulation of lithium provides potential advantages over IR formulation and can be effectively used in the management of BD with lesser adverse events.
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Affiliation(s)
- Paolo Girardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), School of Medicine and Psychology, Sapienza University of Rome, Rome, Italy. .,Psychiatric Department of Saint Andrea Hospital of Rome, Via di Grottarossa 1037, 00189, Rome, Italy. .,Centro Lucio Bini, Rome, Italy.
| | - Roberto Brugnoli
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), School of Medicine and Psychology, Sapienza University of Rome, Rome, Italy.,Psychiatric Department of Saint Andrea Hospital of Rome, Via di Grottarossa 1037, 00189, Rome, Italy
| | - Giovanni Manfredi
- Psychiatric Department of Saint Andrea Hospital of Rome, Via di Grottarossa 1037, 00189, Rome, Italy.,Centro Lucio Bini, Rome, Italy
| | - Gabriele Sani
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), School of Medicine and Psychology, Sapienza University of Rome, Rome, Italy.,Psychiatric Department of Saint Andrea Hospital of Rome, Via di Grottarossa 1037, 00189, Rome, Italy.,Centro Lucio Bini, Rome, Italy
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Hsieh MH, Chuang PY, Wu CS, Chang CJ, Chung PF, Tang CH. Bipolar patients treated with long-acting injectable risperidone in Taiwan: A 1-year mirror-image study using a national claims database. J Affect Disord 2017; 218:327-334. [PMID: 28494390 DOI: 10.1016/j.jad.2017.04.074] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/07/2017] [Accepted: 04/24/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Bipolar disorder (BD) is burdensome for patients and healthcare systems. This study evaluated changes in concomitant medication patterns, healthcare utilization, and costs after the initiation of risperidone long-acting injection (RLAI) treatment among BD patients. METHOD 287 BD patients receiving regular RLAI treatment for 1 year were identified from the Taiwan National Health Insurance Research database during 2007-2012. The bootstrapping procedure was performed to create 1000 samples to generate normally distributed data. The paired t-tests with a correction for multiple comparisons using Bonferroni correction were used to compare the proportion of patients of concomitant psychiatric medication and resource use and costs between pre- and post-RLAI periods. Rapid and non-rapid cycling stratification was performed based on the number of change-in-mood episodes within 1 year prior to the index date. RESULTS The mean annual dose of RLAI was 638.41mg, which was equal to an average dose of 24.6mg every 2 weeks. The prevalence of concomitant use of conventional antipsychotics, atypical antipsychotics, lithium, and antidepressants decreased from the pre-RLAI period to the post-RLAI period by 23.75%, 31.91%, 1.29%, and 7.08%, respectively. RLAI use decreased emergency room (ER) visits, hospital admissions, length of hospital stay, and non-medication costs (all P<0.0001). The cost savings with RLAI were attributed to lower hospitalization costs in spite of higher medication costs. Moreover, rapid cycling patients (n=36) demonstrated greater reduction in ER and inpatient services with RLAI than non-rapid cycling patients (n=251). LIMITATIONS Of the patients who initiated RLAI, 15% of them who had regular treatment were included. Furthermore, data on measures of symptom severity, side effects, and hyperprolactinemia were not available. CONCLUSION BD patients had lower inpatient and ER utilization, and non-medication costs after using RLAI. In addition, RLAI use decreased the number of change-in-mood episodes in rapid cycling patients; which provides additional insights into the treatment of rapid cycling BD patients.
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Affiliation(s)
- Ming H Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Chi-Shin Wu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Jui Chang
- Department of Psychiatry, Cathay General Hospital, Taipei, Taiwan
| | | | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
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9
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Samalin L, Nourry A, Charpeaud T, Llorca PM. What is the evidence for the use of second-generation antipsychotic long-acting injectables as maintenance treatment in bipolar disorder? Nord J Psychiatry 2014; 68:227-35. [PMID: 23795859 DOI: 10.3109/08039488.2013.801078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In recent years, the use of second-generation antipsychotics long-acting injectable in the maintenance treatment of bipolar disorder has sparked interest in improving adherence and reducing the risk of relapse. AIMS This report aims to review the available evidence concerning the use of second-generation antipsychotics depot in bipolar disorder and specify the typology of patients that could be eligible for this formulation. METHODS A systematic review of the literature was conducted using Pubmed and EMBASE. RESULTS Data available for the clinician assessing the interests of second-generation antipsychotics depot in long-term treatment of bipolar disorder are limited to risperidone. It seems particularly relevant for bipolar patients with poor adherence or early in the course of illness and can be used as monotherapy with manic polarity. It should always be considered for use in combination with at least one other mood stabilizer in patients with depressive polarity. As for other medications, the benefit/risk ratio for a long-acting should be evaluated individually. CONCLUSIONS If using a depot formulation could be considered for all patients in order to approach a perfect compliance, patients with certain clinical profiles could be an argument for prioritizing the use of long-acting injectable as maintenance treatment. Additional studies are needed with other second-generation antipsychotics depot in bipolar patients to generalize their use in the maintenance treatment of bipolar disorder but the future golden standard of studies with long-acting formulations remains to be defined.
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Affiliation(s)
- Ludovic Samalin
- Department of Psychiatry B, University of Auvergne , 63000 Clermont-Ferrand , France
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10
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Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension. Compr Psychiatry 2012; 53:952-61. [PMID: 22560773 DOI: 10.1016/j.comppsych.2012.03.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 03/05/2012] [Accepted: 03/12/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Differential diagnosis between bipolar affective disorder type II and borderline personality disorder can be problematic yet a priority for effective treatment planning. Diagnosis is problematic when symptoms do not present enough intensity or duration to clear the issue but also when there is a relative overlap of criteria between both disorders. If for many patients, the diagnosis is more easily differentiated, confounding conditions are found in 20% of cases for which it becomes a significant issue. METHOD A research with the key words affective instability, borderline personality disorder, and bipolar disorder on Medline and Psych-Info was done. Other references were found through this review in related articles. Comparison of data about the affective dimensions concerning bipolar disorder and borderline personality disorder was noted. RESULTS Affective instability is a confounding factor: quality and intensity of affects, speed of fluctuations, affective response to social stress, and its modulation are core elements of affective instability that need to be analyzed to clarify a proper diagnosis. LIMITATIONS There is further necessity for research about affective instability in the 2 diagnoses. CONCLUSIONS Making a valid differential diagnosis has an important clinical value in order for the clinician to plan proper treatment. Analysis of the affective experience and its qualitative and quantitative facets can help establish it.
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Abstract
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.
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Affiliation(s)
- Gin S Malhi
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, Australia.
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12
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Macfadden W, Adler CM, Turkoz I, Haskins JT, Turner N, Alphs L. Adjunctive long-acting risperidone in patients with bipolar disorder who relapse frequently and have active mood symptoms. BMC Psychiatry 2011; 11:171. [PMID: 22034906 PMCID: PMC3219580 DOI: 10.1186/1471-244x-11-171] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 10/28/2011] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The objective of this exploratory analysis was to characterize efficacy and onset of action of a 3-month treatment period with risperidone long-acting injection (RLAI), adjunctive to an individual's treatment regimen, in subjects with symptomatic bipolar disorder who relapsed frequently and had significant symptoms of mania and/or depression. METHODS Subjects with bipolar disorder with ≥4 mood episodes in the past 12 months entered the open-label stabilization phase preceding a placebo-controlled, double-blind study. Subjects with significant depressive or manic/mixed symptoms at baseline were analyzed. Significant depressive symptoms were defined as Montgomery-Åsberg Depression Rating Scale (MADRS) ≥16 and Young Mania Rating Scale (YMRS) < 16; manic/mixed symptoms were YMRS ≥16 with any MADRS score. Subjects received open-label RLAI (25-50 mg every 2 weeks) for 16 weeks, adjunctive to a subject's individualized treatment for bipolar disorder (mood stabilizers, antidepressants, and/or anxiolytics). Clinical status was evaluated with the Clinical Global Impressions of Bipolar Disorder-Severity (CGI-BP-S) scale and changes on the MADRS and YMRS scales. Within-group changes were evaluated using paired t tests; categorical differences were assessed using Fisher exact test. No adjustment was made for multiplicity. RESULTS 162 subjects who relapsed frequently met criteria for significant mood symptoms at open-label baseline; 59/162 (36.4%) had depressive symptoms, 103/162 (63.6%) had manic/mixed symptoms. Most subjects (89.5%) were receiving ≥1 medication for bipolar disorder before enrollment. Significant improvements were observed for the total population on the CGI-BP-S, MADRS, and YMRS scales (p < .001 vs. baseline, all variables). Eighty-two (53.3%) subjects achieved remission at the week 16 LOCF end point. The subpopulation with depressive symptoms at open-label baseline experienced significant improvement on the CGI-BP-S and MADRS scales (p < .001 vs. baseline, all variables). Subjects with manic/mixed symptoms at baseline had significant improvements on the CGI-BP-S and YMRS scales (p < .001 vs. baseline, all variables). No unexpected tolerability findings were observed. CONCLUSIONS Exploratory analysis of changes in overall clinical status and depression/mania symptoms in subjects with symptomatic bipolar disorder who relapse frequently showed improvements in each of these areas after treatment with RLAI, adjunctive to a subject's individualized treatment. Prospective controlled studies are needed to confirm these findings.
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Affiliation(s)
- Wayne Macfadden
- Formerly, Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Caleb M Adler
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ibrahim Turkoz
- Johnson & Johnson Pharmaceutical Research and Development, LLC, Titusville, NJ, USA
| | - John T Haskins
- Johnson & Johnson Pharmaceutical Research and Development, LLC, Titusville, NJ, USA
| | - Norris Turner
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Larry Alphs
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
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13
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Malhi GS, Tanious M. Optimal frequency of lithium administration in the treatment of bipolar disorder: clinical and dosing considerations. CNS Drugs 2011; 25:289-98. [PMID: 21425882 DOI: 10.2165/11586970-000000000-00000] [Citation(s) in RCA: 201] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Bipolar disorder is a recurrent chronic illness distinguished by periods of mania and depression. Lithium has been used for about 60 years as a 'mood stabilizer' for bipolar disorder with proven efficacy in preventing relapse of both mania and depression. Despite its long history and ongoing use in current management of bipolar disorder, the optimal dosing of lithium is still the subject of ongoing debate. This article aims to evaluate different dosing schedules, in the light of the unique pharmacokinetic and pharmacodynamic properties of lithium, as well as its adverse-effect and toxicity profiles. This is all the more important given the narrow therapeutic index of lithium. Current recommendations mostly advocate that lithium be administered in multiple daily doses. However, single daily or alternate daily schedules may be viable options for administration. Multiple daily schedules are thought to be advantageous in maintaining more constant plasma lithium concentrations than single daily regimens, which are associated with significant fluctuations throughout the day. When comparing these two schedules with respect to plasma lithium concentrations, adverse-effect profiles and recurrence of symptoms, there are no significant differences between the two regimens. In fact, a single daily regimen may have added advantages in reducing the risk of long-term renal damage and increasing compliance. The evidence for alternate daily dosing is somewhat varied with regard to symptom recurrence; however, this schedule has been shown to be associated with decreased adverse effects, and further research into this issue is therefore warranted. Presently, therefore, clinicians should consider single daily administration of lithium to potentially minimize adverse effects and enhance compliance.
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Affiliation(s)
- Gin S Malhi
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, New South Wales, Australia.
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14
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Parikh SV, LeBlanc SR, Ovanessian MM. Advancing bipolar disorder: key lessons from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2010; 55:136-43. [PMID: 20370963 DOI: 10.1177/070674371005500304] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To review the overall clinical research findings from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), the world's largest study of BD. METHODS STEP-BD was conducted from 1998 to 2005, enrolling participants (n = 4361) across 22 clinical sites in the United States. Each individual was followed for up to 2 years in naturalistic practice with blinded research assessments, while subgroups participated in randomized controlled trials (RCTs) for bipolar depression. The naturalistic database was used to examine the course of BD, comorbidity with other psychiatric disorders, and suicidality. Relevant studies in English, published from January 1, 1994, to May 31, 2009, were identified using computerized searches of electronic databases (PubMed, PsycINFO, and Cochrane Register of Clinical Trials), inspection of bibliographies, and review of other major reports. RESULTS One large RCT involving the addition of either paroxetine or bupropion to mood stabilizers in acute depression found neither more effective than placebo in achieving sustained recovery (8 weeks of euthymia). A second large RCT found intensive psychosocial interventions superior to a brief psychosocial intervention as an adjunct to medication in acute depression. A third small RCT found minimal effects of lamotrigine, risperidone, or inositol in refractory depression. Recovery was difficult to achieve, with subsyndromal symptoms or full relapse very common. Anxiety disorders and smoking in particular were treatable conditions that adversely affected the course of BD. CONCLUSIONS STEP-BD yielded numerous clinical and systems observations that provide fresh direction for research and treatment of BD, including setting new benchmarks for outcome and demonstrating the viability of large BD networks.
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&NA;. Lithium is still a first-line option in the treatment of patients with bipolar disorder. DRUGS & THERAPY PERSPECTIVES 2010. [DOI: 10.2165/11203610-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Macfadden W, Alphs L, Haskins JT, Turner N, Turkoz I, Bossie C, Kujawa M, Mahmoud R. A randomized, double-blind, placebo-controlled study of maintenance treatment with adjunctive risperidone long-acting therapy in patients with bipolar I disorder who relapse frequently. Bipolar Disord 2009; 11:827-39. [PMID: 19922552 DOI: 10.1111/j.1399-5618.2009.00761.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE No large controlled trials have evaluated adjunctive maintenance treatment with long-acting injectable antipsychotics in patients with bipolar disorder. This study assessed whether adjunctive maintenance treatment with risperidone long-acting therapy (RLAT), added to treatment-as-usual (TAU) medications for bipolar disorder, delays relapse in patients with bipolar disorder type I. METHODS This study included patients with bipolar disorder type I with > or = four mood episodes in the 12 months prior to study entry. Following a 16-week, open-label stabilization phase with RLAT plus TAU, remitted patients entered a 52-week, double-blind, placebo-controlled, relapse-prevention phase. Randomized patients continued treatment with adjunctive RLAT (25-50 mg every two weeks) plus TAU (n = 65) or switched to adjunctive placebo injection plus TAU (n = 59). The primary outcome measure was time to relapse to any mood episode. RESULTS Of 240 enrolled patients, 124 entered double-blind treatment. Time to relapse was longer in patients receiving adjunctive RLAT (p = 0.010). Relapse rates were 23.1% (n = 15) with adjunctive RLAT versus 45.8% (n = 27) with adjunctive placebo; relative relapse risk was 2.3-fold higher with adjunctive placebo (p = 0.011). Completion rates were: adjunctive RLAT, 60.0% (n = 39) and adjunctive placebo, 42.4% (n = 25; p = 0.050). Adverse event (AE)-related discontinuations were 4.6% (n = 3) and 1.7% (n = 1), respectively. Common AEs (adjunctive RLAT versus adjunctive placebo) were: tremor (24.6% versus 10.2%), insomnia (20.0% versus 18.6%), muscle rigidity (12.3% versus 5.1%), weight increased (6.2% versus 1.7%), and hypokinesia (7.7% versus 0.0%). CONCLUSIONS Adjunctive RLAT significantly delayed time to relapse in patients with bipolar disorder type I who relapse frequently. Safety and tolerability of RLAT were generally consistent with that previously observed.
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Affiliation(s)
- Wayne Macfadden
- Ortho-McNeil Janssen Scientific Affairs, LLC, Titusville, NJ 08560, USA.
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Grandjean EM, Aubry JM. Lithium: updated human knowledge using an evidence-based approach: Part I: Clinical efficacy in bipolar disorder. CNS Drugs 2009; 23:225-40. [PMID: 19320531 DOI: 10.2165/00023210-200923030-00004] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
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Begemann M, Sargin D, Rossner MJ, Bartels C, Theis F, Wichert SP, Stender N, Fischer B, Sperling S, Stawicki S, Wiedl A, Falkai P, Nave KA, Ehrenreich H. Episode-specific differential gene expression of peripheral blood mononuclear cells in rapid cycling supports novel treatment approaches. Mol Med 2008; 14:546-52. [PMID: 18552976 DOI: 10.2119/2008-00053.begemann] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 06/04/2008] [Indexed: 12/29/2022] Open
Abstract
Molecular mechanisms underlying bipolar affective disorders are unknown. Difficulties arise from genetic and phenotypic heterogeneity of patients and the lack of animal models. Thus, we focused on only one patient (n = 1) with an extreme form of rapid cycling. Ribonucleic acid (RNA) from peripheral blood mononuclear cells (PBMC) was analyzed in a three-tiered approach under widely standardized conditions. Firstly, RNA was extracted from PBMC of eight blood samples, obtained on two consecutive days within one particular episode, including two different consecutive depressive and two different consecutive manic episodes, and submitted to (1) screening by microarray hybridizations, followed by (2) detailed bioinformatic analysis, and (3) confirmation of episode-specific regulation of genes by quantitative real-time polymerase chain reaction (qRT-PCR).Secondly, results were validated in additional blood samples obtained one to two years later. Among gene transcripts elevated in depressed episodes were prostaglandin D synthetase (PTGDS) and prostaglandin D2 11-ketoreductase (AKR1C3), both involved in hibernation. We hypothesized them to account for some of the rapid cycling symptoms. A subsequent treatment approach over 5 months applying the cyclooxygenase inhibitor celecoxib (2 x 200 mg daily) resulted in reduced severity rating of both depressed and manic episodes. This case suggests that rapid cycling is a systemic disease, resembling hibernation, with prostaglandins playing a mediator role.
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Affiliation(s)
- Martin Begemann
- Division of Clinical Neuroscience, Max Planck Institute of Experimental Medicine, Göttingen, Germany
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Abstract
OBJECTIVES This paper reviews the literature to examine the DSM-IV diagnostic criteria for rapid cycling in bipolar disorder. METHODS Studies on the clinical characteristics of rapid cycling bipolar disorder were reviewed. To identify relevant papers, literature searches using PubMed and MEDLINE were undertaken. RESULTS First observed in the prepharmacologic era, rapid cycling subsequently has been associated with a relatively poor response to pharmacologic treatment. Rapid cycling can be conceptualized as either a high frequency of episodes of any polarity or as a temporal sequence of episodes of opposite polarity. The DSM-IV defines rapid cycling as a course specifier, signifying at least four episodes of major depression, mania, mixed mania, or hypomania in the past year, occurring in any combination or order. It is estimated that rapid cycling is present in about 12-24% of patients at specialized mood disorder clinics. However, apart from episode frequency, studies over the past 30 years have been unable to determine clinical characteristics that define patients with rapid cycling as a specific subgroup. Furthermore, rapid cycling is a transient phenomenon in many patients. CONCLUSIONS While a dimensional approach to episode frequency as a continuum between the extremes of no cycling and continuous cycling may be more appropriate and provide a framework to include ultra-rapid and ultradian cycling, the evidence does not exist today to refine the DSM-IV definition in a less arbitrary manner. Continued use of the DSM-IV definition also enables comparisons between past and future studies, and it should be included in the next release of the ICD. Further scientific investigation into rapid cycling is needed. In addition to improving the diagnostic criteria, insight into neurophysiologic mechanisms of mood switching and episode frequency may have important implications for clinical care.
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Affiliation(s)
- Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Blader JC, Kafantaris V. Pharmacological treatment of bipolar disorder among children and adolescents. Expert Rev Neurother 2007; 7:259-70. [PMID: 17341174 PMCID: PMC2946413 DOI: 10.1586/14737175.7.3.259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is growing recognition that bipolar disorder frequently first presents in adolescence. Preadolescents with volatile behavior and severe mood swings also comprise a large group of patients whose difficulties may lie within the bipolar spectrum. However, the preponderance of scientific effort and clinical trials for this condition has focused on adults. This review summarizes the complexity of bipolar disorder and diagnosis of the disease among young people. It proceeds to review the principles of pharmacotherapy, assess current treatment options and to highlight areas where evidence-based guidance is lacking. Recent developments have enlarged the range of potential treatments for bipolar disorder. Nonetheless, differences in the phenomenology, course and sequelae of bipolar disorder among young people compel greater attention to the benefits and liabilities of therapy for those affected by this illness' early onset. By summarizing current research and opinion on diagnostic issues and treatment approaches, this review aims to provide an update on a clinically important yet controversial topic.
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Affiliation(s)
- Joseph C. Blader
- Psychiatry Stony Brook State University of New York T: (631) 632-8675 F: (631) 632-8953
| | - Vivian Kafantaris
- Psychiatry and Behavioral Sciences Albert Einstein College of Medicine T: (718) 470-8556 F: (718) 343-1659
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Cookson J, Keck PE, Ketter TA, Macfadden W. Number needed to treat and time to response/remission for quetiapine monotherapy efficacy in acute bipolar depression: evidence from a large, randomized, placebo-controlled study. Int Clin Psychopharmacol 2007; 22:93-100. [PMID: 17293709 DOI: 10.1097/yic.0b013e3280119dfb] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The objectives of this analysis are to elucidate the clinical significance of antidepressant effects with quetiapine by evaluating number needed to treat as well as time to response and remission with quetiapine monotherapy in patients with acute bipolar depression. A post-hoc analysis was conducted of 542 patients with bipolar I or II disorder, (moderate to severe depression), randomized to 8 weeks of double-blind treatment with quetiapine 600 mg/day (n=180), quetiapine 300 mg/day (n=181), or placebo (n=181). Number needed to treat, time to response (> or =50% reduction from baseline in Montgomery-Asberg Depression Rating Scale total score) and time to remission (Montgomery-Asberg Depression Rating Scale total score < or =12) were evaluated. Response rates at week 8 were 58.2 and 57.6% for quetiapine 600 and 300 mg/day, respectively, and 36.1% for placebo (P<0.001). Remission rates were 52.9% for both quetiapine groups and 28.4% for placebo (P<0.001). The number needed to treat was five for both response and remission for quetiapine (600 and 300 mg/day) compared with placebo. Median time to response and remission were significantly shorter with quetiapine 600 and 300 mg/day than placebo. No between-group difference was found in the incidence of treatment-emergent mania or hypomania (quetiapine 600 mg/day: 2.2%, quetiapine 300 mg/day: 3.9, and placebo: 3.9%). In conclusion, quetiapine compared with placebo significantly reduces time to response and remission compared with placebo, and has a favorable number needed to treat.
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Affiliation(s)
- John Cookson
- The Department of Psychiatry, Royal London Hospital, London, UK.
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Born C, Seemüller F, Grunze H. Quetiapine: an approach for the treatment of bipolar disorders. FUTURE NEUROLOGY 2006. [DOI: 10.2217/14796708.1.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Quetiapine is one of the atypical antipsychotics that are formally approved by the US FDA for use in bipolar disorders. In recent Phase III clinical studies, it has provided satisfactory efficacy in the treatment of mania. In ongoing Phase III trials, its efficacy in depression is being investigated. Current data also support its efficacy in special conditions of bipolar disorders, such as rapid cycling and mixed states, the treatment of children and subjects suffering from comorbidities, which is a condition often seen in bipolar patients, and the reason for the combination of several agents. Quetiapine is well tolerated widely and provides minimal interaction with other treatments.
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