Overview of patient care issues and treatment in bipolar spectrum and bipolar II disorder

Managing Bipolar Disease Complicated with Psychosis in Conjunction with Polypharmacy, Parkinson’s Disease, and Multiple Comorbidities

The lifelong prevalence of bipolar disorder in adults, including subsyndromal forms, has increased over the years in the United States. By contrast, neurodegenerative diseases such as Parkinson’s disease have demonstrated an age-related rise in prevalence. As the global population manages to live longer thanks to sociomedical developments, it is expected to observe a rise in the occurrence of comorbid neuropsychiatric disorders. Herein, we present the case and management regimen of a 51-year-old female patient with multiple comorbidities and in the presence of polypharmacy. She was diagnosed with Parkinson’s disease and bipolar disorder type I alongside multiple comorbidities; her polypharmacy and medical history presented a significant clinical challenge in managing her condition. This case report focuses on the pharmacologic management of neuropsychiatric disorders titrated to this patient’s particular needs, which were complicated by psychosis and comorbidities.

Dynamic face processing impairments are associated with cognitive and positive psychotic symptoms across psychiatric disorders

Impairments in social cognition-including recognition of facial expressions-are increasingly recognised as a core deficit in schizophrenia. It remains unclear whether other aspects of face processing (such as identity recognition) are also impaired, and whether such deficits can be attributed to more general cognitive difficulties. Moreover, while the majority of past studies have used picture-based tasks to assess face recognition, literature suggests that video-based tasks elicit different neural activations and have greater ecological validity. This study aimed to characterise face processing using video-based stimuli in psychiatric inpatients with and without psychosis. Symptom correlates of face processing impairments were also examined. Eighty-six psychiatric inpatients and twenty healthy controls completed a series of tasks using video-based stimuli. These included two emotion recognition tasks, two non-emotional facial identity recognition tasks, and a non-face control task. Symptoms were assessed using the Positive and Negative Syndrome Scale. Schizophrenia and bipolar disorder groups were significantly impaired on the emotion-processing tasks and the non-face task compared to healthy controls and patients without psychosis. Patients with other forms of psychosis performed intermediately. Groups did not differ in non-emotional face processing. Positive symptoms of psychosis correlated directly with both emotion-processing performance and non-face discrimination across patients. We found that identity processing performance was inversely associated with cognition-related symptoms only. Findings suggest that deficits in emotion-processing reflect symptom pathology independent of diagnosis. Emotion-processing deficits in schizophrenia may be better accounted for by task-relevant factors-such as attention-that are not specific to emotion processing.

Safety and tolerability of cariprazine in patients with acute exacerbation of schizophrenia: a pooled analysis of four phase II/III randomized, double-blind, placebo-controlled studies

Cariprazine, a potent dopamine D3 and D2 receptor partial agonist antipsychotic with preferential binding to D3 receptors, is Food and Drug Administration approved for treating schizophrenia and manic or mixed episodes of bipolar I disorder. A post-hoc safety/tolerability analysis of data from the four acute trials in the cariprazine schizophrenia clinical development program (NCT00404573; NCT00694707; NCT01104766; NCT01104779) was carried out using the overall safety population (all patients who received ≥1 dose of study drug) and modal daily dose subgroups (1.5-3, 4.5-6, and 9-12 mg/day). These exploratory findings were summarized using descriptive statistics. Cariprazine was generally well tolerated. The incidence of treatment-emergent adverse events versus placebo was similar for cariprazine 1.5-3 mg/day and higher for cariprazine 4.5-6 and 9-12 mg/day; a dose-response relationship was observed for akathisia, extrapyramidal symptoms, and diastolic blood pressure. The mean changes in metabolic parameters were generally similar in cariprazine-treated and placebo-treated patients. There was no prolactin level increase or QTc value greater than 500 ms; small increases in mean body weight (∼1to2 kg) versus placebo were observed. Within the Food and Drug Administration-approved dose range (1.5-6 mg/day), cariprazine was generally safe and well tolerated in patients with schizophrenia.

Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder

Data emerging from both academic centers and from public and private outpatient facilities indicate that from 20% to 50% of all subjects that seek help for mood, anxiety, impulsive and addictive disorders turn out, after careful screening, to be affected by cyclothymia. The proportion of patients who can be classified as cyclothymic rises significantly if the diagnostic rules proposed by the DSM-5 are reconsidered and a broader approach is adopted. Unlike the DSM-5 definition based on the recurrence of low-grade hypomanic and depressive symptoms, cyclothymia is best identified as an exaggeration of cyclothymic temperament (basic mood and emotional instability) with early onset and extreme mood reactivity linked with interpersonal and separation sensitivity, frequent mixed features during depressive states, the dark side of hypomanic symptoms, multiple comorbidities, and a high risk of impulsive and suicidal behavior. Epidemiological and clinical research have shown the high prevalence of cyclothymia and the validity of the concept that it should be seen as a distinct form of bipolarity, not simply as a softer form. Misdiagnosis and consequent mistreatment are associated with a high risk of transforming cyclothymia into severe complex borderline-like bipolarity, especially with chronic and repetitive exposure to antidepressants and sedatives. The early detection and treatment of cyclothymia can guarantee a significant change in the long-term prognosis, when appropriate mood-stabilizing pharmacotherapy and specific psychological approaches and psychoeducation are adopted. The authors present and discuss clinical research in the field and their own expertise in the understanding and medical management of cyclothymia and its complex comorbidities.

Self-report tool for recognizing mania (SToRM): a new scale for aiding in the diagnosis of bipolar disorder

OBJECTIVE

Bipolar disorder is a disabling disease that is difficult to diagnose. Primary care physicians share in the burden of diagnosing and caring for significant mental illness, including bipolar disorder, but they lack an adequate screening and diagnostic tool that can fit into use in a primary care practice. Modeling after the Patient Health Questionnaire-9, we created the Self-report Tool for Recognizing Mania (SToRM) to aid primary care physicians in the screening and diagnosis of bipolar disorder.

METHODS

A 13-question tool was created and distributed to returning patients over an 11-month time period at the psychiatric clinic of a university health center. Each completed questionnaire was scored as positive or negative and then compared to the preexisting psychiatric diagnosis for that respondent, as shown on the problem list of the respondent's electronic medical record.

RESULTS

A total of 102 subjects completed and returned their questionnaires. Twenty-eight surveys were scored as positive for bipolar disorder while 25 subjects carried this diagnosis on their problem list, giving a sensitivity of 72% and a specificity of 87% (CI at 95%). When alternative scoring was used, sensitivity increased to 96% with only a slight decrease in specificity to 84%.

CONCLUSIONS

In this pilot study, we find that the SToRM shows potential in the pursuit of a highly reliable, self-report tool which could help primary care providers screen and diagnose bipolar disorder. As such, the SToRM deserves further study.

Dosing and switching of paliperidone ER in patients with schizophrenia: recommendations for clinical practice

Many patients with schizophrenia receive long-term treatment with antipsychotic medication. Switching of antipsychotic medication due to lack of efficacy, tolerability issues, and partial/non-adherence is common. Despite this, consensus strategies for switching between antipsychotics are lacking. This manuscript provides practical recommendations for switching antipsychotic medication to ensure optimal management of patients with schizophrenia, with a particular focus on paliperidone extended release (ER). The authors drew on their clinical experience supported by detailed discussion of literature describing antipsychotic switching techniques and strategies and findings from paliperidone ER clinical trials. Antipsychotic switching strategies should be individualized and take into consideration the pharmacokinetic (PK) and pharmacodynamic (PD) properties of the pre- and post-switch medication. The use of temporary concomitant medications may be appropriate in some scenarios. Abrupt withdrawal of pre-switch medication may be appropriate in some instances but carries a greater risk of rebound and withdrawal symptoms than other strategies. Cross-tapering is the method most widely used in clinical practice. Paliperidone ER can be initiated without dose titration. The EU SmPC recommended dose of paliperidone ER is 6 mg/day; but doses should be individualized within the approved range of 3-12 mg/day. Higher doses may be required due to insufficient efficacy of the previous antipsychotic or in patients with acute symptoms. Recently diagnosed patients, those with renal impairment, or patients who have previously experienced tolerability issues with other antipsychotics may require lower doses. When switching from risperidone, higher doses of paliperidone ER may be required compared with risperidone. When switching from antipsychotics that have sedative and/or significant anticholinergic activity, the pre-switch antipsychotic should be tapered off gradually. Antipsychotics with less sedating and little anticholinergic activity can be tapered off over a shorter period. Temporary concomitant sedative medication may be beneficial when switching from antipsychotics with relatively higher sedative propensities. Switching from another antipsychotic to paliperidone ER requires individualized switching strategies and dosing, dependent on the characteristics of the patient and the PK and PD properties of the pre-switch medication. Cross-tapering strategies should be considered as a means of reducing the risk of rebound and withdrawal symptoms.

The Effects of Acupuncture Treatment on Sleep Quality and on Emotional Measures among Individuals Living with Schizophrenia: A Pilot Study

Purpose. To examine the effects of acupuncture on sleep quality and on emotional measures among patients with schizophrenia. Methods. Twenty patients with schizophrenia participated in the study. The study comprised a seven-day running-in no-treatment period, followed by an eight-week experimental period. During the experimental period, participants were treated with acupuncture twice a week. During the first week (no-treatment period) and the last week of the experimental period, participants filled out a broad spectrum of questionnaires and their sleep was continuously monitored by wrist actigraph. Results. A paired-sample t-test was conducted comparing objective and subjective sleep parameters manifested by participants before and after sequential acupuncture treatment. A significant effect of acupuncture treatment was observed for seven objective sleep variables: sleep onset latency, sleep percentage, mean activity level, wake time after sleep onset, mean number of wake episodes, mean wake episode and longest wake episode. However, no significant effects of acupuncture treatment were found for subjective sleep measures. Likewise, the results indicate that acupuncture treatment improved psychopathology levels and emotional measures, that is, depression level and anxiety level. Conclusions. Overall, the findings of this pilot study suggest that acupuncture has beneficial effects as a treatment for insomnia and psychopathology symptoms among patients with schizophrenia.

Use of asenapine in clinical practice for the management of bipolar mania

Bipolar disorder is a chronic mental illness associated with high levels of somatic morbidity, comorbidity and mortality. Treatment guidelines for bipolar mania generally recommend initiating first-line therapy with a second-generation antipsychotic or mood stabiliser, either alone or in combination. Asenapine is a second-generation antipsychotic with a unique receptor binding profile, licensed for the treatment of manic episodes in adults with bipolar I disorder. 'Real-world' data are needed to complement evidence from clinical trials, in order to provide clinicians with pragmatic information regarding the likely risks and benefits of using a new agent in clinical practice. Evidence from real-world case reports demonstrates that - as in clinical trials - asenapine is effective in treating mania and mixed episodes associated with bipolar I disorder, whether used as monotherapy or in combination with a mood stabiliser. It has a rapid onset of antimanic effect and an early improvement is associated with treatment outcome. Asenapine also shows promise in controlling depressive symptoms and clinically challenging mixed states. Asenapine has a favourable tolerability profile, compared with other first-line agents, having a minimal impact on weight and metabolic parameters. Asenapine should be considered a first-line treatment option for adults with bipolar I disorder.

Interactions between antiepileptics and second-generation antipsychotics

INTRODUCTION

Pharmacokinetic and pharmacodynamic drug interactions (DIs) can occur between antiepileptics (AEDs) and second-generation antipsychotics (SGAPs). Some AED and SGAP pharmacodynamic mechanisms are poorly understood. AED-SGAP combinations are used for treating comorbid illnesses or increasing efficacy, particularly in bipolar disorder.

AREAS COVERED

This article provides a comprehensive review of the interactions between antiepileptics and second-generation antipsychotics. The authors cover pharmacokinetic AED-SGAP DI studies, the newest drug pharmacokinetics in addition to the limited pharmacodynamic DI studies.

EXPERT OPINION

Dosing correction factors and measuring SGAP levels can help to compensate for the inductive properties of carbamazepine, phenytoin, phenobarbital and primidone. Further studies are needed to establish the clinical relevance of combining: i) AED strong inducers with amisulpride, asenapine, iloperidone, lurasidone and paliperidone; ii) valproate with aripiprazole, asenapine, clozapine and olanzapine; iii) high doses of oxcarbazepine (≥ 1500 mg/day) or topiramate (≥ 400 mg/day) with aripiprazole, lurasidone, quetiapine, risperidone, asenapine and olanzapine. Two pharmacodynamic DIs are beneficial: i) valproate-SGAP combinations may have additive effects in bipolar disorder, ii) combining topiramate or zonisamide with SGAPs may decrease weight gain. Three pharmacodynamic DIs contributing to decreased safety are common: sedation, weight gain and swallowing disturbances. A few AED-SGAP combinations may increase risk for osteoporosis or nausea. Three potentially lethal but rare pharmacodynamic DIs include pancreatitis, agranulocytosis/leukopenia and heat stroke. The authors believe that collaboration is needed from drug agencies and pharmaceutical companies, the clinicians using these combinations, researchers with expertise in meta-analyses, grant agencies, pharmacoepidemiologists and DI pharmacologists for future progression in this field.

Assessment of safety, tolerability and effectiveness of adjunctive aripiprazole to lithium/valproate in bipolar mania: a 46-week, open-label extension following a 6-week double-blind study

OBJECTIVE

This study evaluated the long-term tolerability and effectiveness of aripiprazole adjunctive to lithium or valproate in partial responders with bipolar mania.

METHODS

Completers of a 6-week double-blind comparison of adjunctive aripiprazole versus placebo in bipolar mania partially responsive to lithium or valproate monotherapy could enter a 46-week extension treatment with open-label adjunctive aripiprazole plus lithium (ARI + LI) or valproate (ARI + VAL). Safety, efficacy and functioning were assessed.

CLINICAL TRIAL REGISTRATION

CN138-134LT: Study of Aripiprazole in Patients With Bipolar I Disorder; ID number: NCT00257972; registry: www.clinicaltrials.gov.

RESULTS

In total, 283 (ARI + LI n = 108; ARI + VAL n = 175) patients entered and 146 (ARI + LI n = 55; ARI + VAL n = 91) completed the 46-week, open-label extension. Frequently reported adverse events (AEs) that occurred with ARI + LI vs. ARI + VAL were: tremor (17.0% vs. 12.1%), akathisia (6.6% vs. 8.6%), headache (6.6% vs. 4.0%), insomnia (9.4% vs. 10.3%), depression (7.5% vs. 9.2%) and weight increase (11.3% vs. 8.6%). Extrapyramidal symptom-related AEs occurred in 24 (22.6%) ARI + LI- and 38 (21.8%) ARI + VAL-treated patients, with eight discontinuations. The majority of new-onset events of akathisia and insomnia occurred early. Mean (SE) weight change from double-blind endpoint to Week 46 (LOCF) was 2.3 (0.6) kg with ARI + LI and 2.0 (0.4) kg with ARI + VAL. Significant improvements from baseline over the 52 weeks (LOCF) occurred with ARI + LI and ARI + VAL on mean (95%CI) YMRS total score (-16.5 [-18.1; -14.8] and -17.6 [-18.9; -16.3], both p < 0.001 vs. baseline) and MADRS total score (-1.7 [-3.3; -0.1], p < 0.05 vs. baseline vs. -2.7 [-4.0; -1.4], p < 0.001 vs. baseline). Over the 46-week extension, continued aripiprazole provided continued YMRS improvement with ARI + LI (-2.9) and ARI + VAL (-3.3), while mean MADRS total changes were +1.1 and +1.0, respectively, and LIFE-RIFT changes were 0.2 and -0.5, respectively.

CONCLUSIONS

Long-term aripiprazole adjunctive to lithium/valproate in bipolar mania was safe and well tolerated. Improvements in manic symptoms and functioning were maintained. Aripiprazole, adjunctive to either lithium or valproate, appeared to be equally safe and effective combinations for the treatment of bipolar disorder.

LIMITATIONS

As an open-label extension study with a low completion rate, a conservative interpretation of the findings is warranted. Additionally, the study population was not randomly selected but chosen at the discretion of the investigator, and patients did not maintain therapeutic levels of their mood stabiliser consistently.

The role of lithium in modulation of brain genes: relevance for aetiology and treatment of bipolar disorder

Bipolar disorder is a debilitating disorder of the brain with a lifetime prevalence of 1.0% for bipolar I, 1.1% for bipolar II disorder and 2.4-4.7% for subthreshold bipolar disorder. Medications, including lithium, have demonstrated efficacy in the treatment of bipolar disorder, but their molecular targets and mode of action are largely unknown. A few studies have begun to shed light on potential targets of lithium treatment that may be involved in lithium's therapeutic effect. We have recently conducted a microarray study of rat frontal cortex following chronic treatment (21 days) with lithium. Chronic treatment with lithium led to a significant (at least 1.5-fold) down-regulation of 151 genes and up-regulation of 57 genes. We discuss our results in the context of previous microarray studies involving lithium and gene-association studies to identify key genes associated with chronic lithium treatment. A number of genes associated with bipolar disorder, including Comt (catechol-O-methyltransferase), Vapa (vesicle-associated membrane protein-associated protein A), Dtnb (dystrobrevin beta) and Pkd1 (polycystic kidney disease 1), were significantly altered in our microarray dataset along with genes associated with synaptic transmission, apoptosis and transport among other functions.

Employing multiple models, methods and mechanisms in bipolar disorder research

BD (bipolar disorder) is a devastating condition, giving rise to debilitating mood swings and a greatly increased likelihood of suicide. Research into the origins, progression and treatment of BD has been slow, primarily due to lack of suitable model systems for BD research. However, the complexity of the neurological basis for mood, variability in patient populations and the lack of clear readouts for BD diagnosis also provide significant problems for research in this area. In this Biochemical Society Focused Meeting, held at Royal Holloway University of London, approx. 40 national and international delegates met to discuss current research into understanding BD. The talks presented at this conference covered research examining the genetic basis of the disorder, changes in patient populations, pharmacological actions of BD drugs and the development of new models systems for this research. The focus of these talks and the following papers is to help to unify and disseminate research into this important but poorly understood medical condition.

A community survey of the twelve-month prevalence and correlates of bipolar spectrum disorder in Hong Kong

BACKGROUND

Recent community and clinical epidemiological studies have indicated that bipolar spectrum disorder (BSD) is a common illness. No community-based epidemiological study of BSD has been conducted in Chinese and other Asian populations.

METHOD

A random sample of 3016 Chinese adults underwent a telephone-based community survey that examined their twelve-month prevalences of BSD, sociodemographic characteristics, level of distress, and role impairment using the Sheehan Disability Scale. Bipolar I disorder (BP-I) and bipolar II disorder (BP-II) were based on DSM-IV criteria. Soft bipolar II disorder (Soft BP-II) fulfilled the DSM-IV criteria of major depressive episode and hypomanic episode except that the hypomanic/manic symptoms lasted two to three days.

RESULTS

The lifetime prevalences of manic episode, hypomanic episode, and soft hypomanic episode were 2.2%, 2.2%, and 10.7% respectively. The twelve-month prevalences of BP-I, BP-II, and Soft BP-II were 1.4%, 0.5%, and 1.8%, respectively. Respondents with BSD were more likely to be female, younger, and single than those without. Impairment and distress associated with depressive symptoms were similar across the three groups of bipolar disorders, but those associated with manic/hypomanic symptoms were more severe among respondents with BP-I than BP-II and Soft BP-II. The number of manic/hypomanic symptoms and depressive symptoms did not differ across the three bipolar groups.

LIMITATION

Structured interview questions based on core DSM-IV mood symptoms might under-estimate hypomania. Detailed sociodemographic information was not available.

CONCLUSION

BSD was common among Chinese people in Hong Kong and exhibited an epidemiological profile comparable to that of western societies.