Depression during mania. Treatment response to lithium or divalproex

Depression with versus without manic features in rapid-cycling bipolar disorder

Depression has been identified as a hallmark feature of rapid-cycling bipolar disorder, although less attention has been paid to the presence of manic features accompanying depression in rapid cyclers. To provide greater information about the extent to which depression arises with or without salient manic features in rapid cycling, we conducted a preliminary study of rapid cycling in outpatients seeking treatment at an academic specialty center for bipolar disorder. Forty DSM-IV affectively symptomatic bipolar outpatients with past year DSM-IV rapid cycling underwent systematic evaluation of symptoms and illness characteristics. Manic and depressive symptoms, treatments, and clinical features were rated by standardized scales. Major depression was present in most rapid cyclers (85%), but salient manic features were also evident in half of all depressed rapid cyclers. A lifetime history of suicide attempts was significantly more common in rapid cyclers who presented with major depression plus salient manic features than in those who presented with pure depression or pure mania (p = .033). Antidepressants were being prescribed for approximately one third of depressed rapid cycling patients regardless of the presence of concomitant manic features, whereas mood stabilizers tended to be used less often when manic features accompanied depression. Depression in conjunction with manic symptoms, rather than pure depression alone, may be more common among rapid-cycling bipolar patients who seek treatment. Lifetime suicide risk may be greater among rapid cycling patients whose depression occurs in tandem with manic symptoms. Prescribing habits in the community that favor antidepressants over mood stabilizers may promote further mood destabilization in this population. Further studies with larger sample sizes are needed to affirm these provisional findings.

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.

Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority

METHOD

For these guidelines, the CPG team reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and consumers.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of bipolar disorder by phase of illness, that is acute mania, mixed episodes and bipolar depression, and the prophylaxis of such episodes. It specifies the roles of various mood-stabilizing medications and of psychological treatments such as cognitive therapy and psycho-education.

Psychopharmacological treatment with lithium and antiepileptic drugs: suggested guidelines from the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark

A subcommittee under the Danish Psychiatric Association and the Child and Adolescent Psychiatric Association in Denmark have recently developed national guidelines for the psychopharmacological treatment with lithium and antiepileptic drugs, and the present translation aims at contributing to the international discussion on the development of proper guidelines for the treatment of bipolar disorder. Among the antiepileptic drugs, the report deals with valproate, carbamazepine and lamotrigine and to a lesser extent with oxcarbazepine, gabapentin and topiramate. The various drugs will be reviewed, outlining the scientific evidence for mood-stabilizing properties and discussing major side effects, the most important interactions with other drugs and practical use. Special considerations during pregnancy and lactation, during treatment of children and adolescents and during treatment of the elderly will also be presented. Antidepressants and antipsychotics are beyond the scope of the report, but due to the mood-stabilizing properties of at least some of the atypical antipsychotics, these agents will be brought into some focus in connection with the overall treatment guidelines for the different phases of bipolar disorder given at the end of this report.

Medication use in children and adolescents treated in the community for bipolar disorder

We assessed the use of mood stabilizers, stimulants, antipsychotic medication, and selective serotonin reuptake inhibitors in children being treated in the community for bipolar disorder (BPD). One hundred eleven patients were screened via parent phone interview for possible inclusion in a phenomenological study of BPD. Data were obtained on the patients' medication trials and side effects. The results of the study indicated that children and adolescents who carry a diagnosis of BPD are treated with a mean of 3.40 +/- 1.48 medications and have had a mean of 6.32 +/- 3.67 trials of psychotropic medication in the past. Ninety-eight percent have had a trial of a mood stabilizer or anticonvulsant, with the most common being valproate (79%), lithium (51%), and gabapentin (29%).

Cincinnati criteria for mixed mania and suicidality in patients with acute mania

The association between suicidality and diagnoses of mixed mania, as defined using both DSM-IV and Cincinnati criteria, was studied in 576 consecutive manic inpatients. Of the whole sample, 51 (8.9%) had suicidal ideation and 13 (2.3%) attempted suicide during the index episode. Suicidality was significantly more frequent in patients with a diagnosis of mixed mania, whether the diagnosis was made by DSM-IV or Cincinnati criteria. A multiple logistic regression analysis revealed that an additive combination of a diagnosis of mixed mania, the depression severity, and the Global Assessment of Functioning (GAF) score was significant in predicting suicidal ideation, when using the DSM-IV criteria. A diagnosis of mixed mania alone was significant in a similar analysis, when using the Cincinnati criteria. The adjusted odds ratio for a diagnosis of mixed mania to having suicidality was much higher when using the latter criteria (4.0 v 14.0). A subsequent logistic regression analysis indicated that the Cincinnati mixed mania alone, rather than an additive combination of the DSM-IV mixed mania and the depression severity, achieved the most appropriate prediction of suicidal ideation in the sample. These findings did not differ, even when suicidality was defined as having a suicide attempt during the index episode. Our finding that suicidality was more strongly associated with Cincinnati mixed mania than with DSM-IV mixed mania is probably due to that suicidal patients who do not meet DSM-IV criteria for mixed mania are classified into mixed mania, or/and that the depressive syndrome, related to suicidality, is more appropriately assessed among manic patients, when using the Cincinnati criteria. There was no evidence that marital status, employment, a lifetime history of alcohol or substance abuse, or a history of suicide attempts before the index episode was significantly associated with suicidality in the sample. Manic patients with suicidality may have a greater severity of residual depressive symptoms at discharge.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Treatment of acute mania

Mood stabilizers have evolved considerably over the past decade. Lithium, divalproex, and olanzapine are currently Food and Drug Administration-approved for the treatment of acute mania. A number of new and traditional medications have also been tested and are commonly used in clinical practice. Several strategies for managing treatment-resistant mania have been suggested, but few have been rigorously tested. Emphases on rapid stabilization and fewer side effects have raised the bar for what is expected from mood stabilizers and the successful treatment of mania involves a delicate balance between swiftness, short-term tolerability, and long-term safety.

Gender differences in bipolar disorder

The presentation and course of bipolar disorder differs between women and men. The onset of bipolar disorder tends to occur later in women than men, and women more often have a seasonal pattern of the mood disturbance. Women experience depressive episodes, mixed mania, and rapid cycling more often than men. Bipolar II disorder, which is predominated by depressive episodes, also appears to be more common in women than men. Comorbidity of medical and psychiatric disorders is more common in women than men and adversely affects recovery from bipolar disorder more often in women. Comorbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women than men, whereas substance use disorders are more common in men. Although the course and clinical features of bipolar disorder differ between women and men, there is no evidence that gender affects treatment response to mood stabilizers. However, women may be more susceptible to delayed diagnosis and treatment. Treatment of women during pregnancy and lactation is challenging because available mood stabilizers pose potential risks to the developing fetus and infant. Pregnancy neither protects nor exacerbates bipolar disorder, and many women require continuation of medication during the pregnancy. The postpartum period is a time of high risk for onset and recurrence of bipolar disorder in women, and prophylaxis with mood stabilizers might be needed. Individualized risk/benefit assessments of pregnant and postpartum women with bipolar disorder are required to promote the health of the woman and avoid or limit exposure of the fetus or infant to potential adverse effects of medication.

Lithium treatment of acute mania in adolescents: a large open trial

OBJECTIVE

To examine initial response to treatment in a large sample of acutely manic bipolar I adolescents and to examine potential predictors of nonresponse, such as the presence of prominent depressive features, psychosis, or psychiatric comorbidity.

METHOD

Adolescents, 12 to 18 years of age, with an acute manic episode were treated with open lithium. Response was defined as a decline in Young Mania Rating Scale total score of >or=33% and a rating of "much improved" or "very much improved" on the Clinical Global Impressions Improvement item at week 4. Remission of mania was defined as a Young Mania Rating Scale score of <or=6. Axis I diagnoses were assessed using the Lifetime Schedule for Affective Disorders and Schizophrenia for Adolescents.

RESULTS

Of 100 subjects, 63 met response criteria and 26 achieved remission of manic symptoms at the week 4 assessment. Prominent depressive features, age at first mood episode, severity of mania, and comorbidity with attention-deficit/hyperactivity disorder did not distinguish responders from nonresponders. When treated with adjunctive antipsychotic medication, subjects with psychotic features at baseline responded as well as subjects without psychosis.

CONCLUSIONS

In this largest systematic treatment trial of acutely manic adolescents to date, lithium appears effective for acute stabilization of symptoms. Controlled treatment studies in adolescents with acute mania are needed.

Optimizing lithium treatment in bipolar disorder: a review of the literature and clinical recommendations

While the past decade has witnessed a major proliferation of putative treatments for bipolar disorder, one medication--lithium--has proven its effectiveness through 50 years of clinical experience and scientific scrutiny. Unfortunately, because the generic compound, lithium, lacks the financial support of its newer, patented comparators, it is often neglected by clinicians who are exposed to continuing medical education (CME) and residency training programs that are heavily weighted towards the newer treatments. This article critically examines the medical literature on lithium's efficacy, anti-suicidal properties, and adverse effects. The authors present research-based recommendations for maximizing lithium's benefits and minimizing adverse effects associated with lithium in patients with bipolar disorder.

Randomized controlled trials in psychiatry. Part 1: methodology and critical evaluation

OBJECTIVE

To introduce clinicians to the methodology and critical appraisal of randomized controlled trials (RCTs) in psychiatry.

METHOD

The methodology of RCTs in psychiatry is discussed. Using a systematic approach to critical appraisal, a published RCT of treatments for severe depression is examined and evaluated.

RESULTS AND CONCLUSIONS

The RCT appraised illustrates certain problematic areas in the methodology of trials in psychiatry. A detailed knowledge of methodology and critique of RCTs is essential in determining whether reported results will influence clinicians' practice.

The effect of lithium in bipolar disorder: a review of recent research evidence

Recently published clinical research on lithium is briefly reviewed. The antimanic effect of lithium is supported by recent evidence. It is confirmed that a drastic reduction of affective morbidity is very frequent in bipolar patients receiving lithium prophylaxis regularly for several years, but that the impact of prophylaxis on the course of bipolar disorder is significantly limited by the high drop-out rate. Lithium does seem to be efficacious also in bipolar disorder with mood-incongruent psychotic features or with rapid cycling. The effect of lithium prophylaxis does not seem to decrease over time, at least in the large majority of patients. The recurrence risk is increased in the months following lithium discontinuation. Lithium seems to exert an antisuicidal effect in bipolar patients.

Valproate

OBJECTIVES

This article summarizes the role of valproate as a treatment for bipolar disorder and related conditions.

METHODS

Published studies and reviews were systematically reviewed. Results from randomized, parallel group, double-blind, placebo-controlled studies that included an active comparator are emphasized.

RESULTS

Valproate is an effective treatment for manic patients. Valproate was superior to placebo in one 1-year randomized, parallel group study in rate of recurrence requiring discontinuation, rate of depression requiring discontinuation, total early termination and time to 25% of patients relapsing with mania, and in controlling mild depressive symptoms. On some measures, including time to development of a manic episode, valproate did not differ from placebo. Assessments of maintenance efficacy of valproate and other putative prophylactic treatments for bipolar disorder are problematic, because of the need to analyze multiple indices of efficacy, and practical and ethical issues that limit generalizability of results of placebo-controlled studies. Valproate has some advantages over lithium in treatment of mania for persons with more severe illnesses. Valproate benefits a broader spectrum of bipolar conditions than lithium. Valproate appears at best modestly effective for bipolar depression. Used in combination with several other treatments, additive benefits result, that are greater than with any of the treatments as monotherapy. Side effects are generally mild and manageable, particularly with divalproex. Weight gain and pharmacokinetic interaction with lamotrigine are perhaps the most consistent problems in use. Valproate contributes to neural tube defects if taken during the first trimester of pregnancy, and this risk must be conveyed to women.

CONCLUSIONS

Valproate is an effective and useful treatment for bipolar disorder. Studies clarifying its spectrum of efficacy, its safety and efficacy in combination regimens, and its mechanisms of action are warranted.

Biological predictors of lithium response in bipolar disorder

In order to prescribe lithium appropriately to patients with bipolar disorder, predictors of lithium response are helpful. The present paper reviews the biological predictors of lithium response. As a positive predictor of lithium response, the following have been reported: strong loudness dependence of the auditory-evoked N1/P2-response; higher brain lithium concentration; lower inositol monophosphatase (IMPase) mRNA expression; higher serotonin-induced calcium mobilization; increased N-acetyl-aspartate peak and decreased myo-inositol peak; white matter hyperintensity; decreased intracellular pH; higher frequency of phospholipase C gamma-1 (PLCG1)-5 repeat and PLCG1-8 repeat; and C973A polymorphism in the inositol polyphosphate 1-phosphatase gene. In contrast the following have been reported as a predictor of negative lithium response: epileptiform abnormality of electroencephalography; human leukocyte antigen type A3; decreased phosphocreatine peak area after photic stimulation; and homozygotes for the short variant of the serotonin transporter gene. Most of the possible biological predictors of better lithium response, such as lower IMPase mRNA levels, white matter hyperintensity, lower brain intracellular pH, enhanced calcium response, and PLCG1-5 repeat had been detected as risk factors for bipolar disorder, suggesting that bipolar disorder responding well to maintenance lithium treatment is a distinct category having a certain neurobiological basis, although these findings need further replication. The search for biological predictors of lithium response is still in its infancy. Most of the laboratory or neuroimaging techniques used in these studies are not easily performed in clinical settings, so the development of an easy and useful laboratory test is needed.

Transtorno de estresse pós-traumático e transtorno de humor bipolar

O Transtorno Bipolar (THB) não é somente uma condição endógena. Severos eventos negativos durante a vida influenciam o desenvolvimento do primeiro episódio e alteram o curso do THB durante a vida. O Transtorno de Estresse Pós-Traumático (TEPT) é uma severa e incapacitante doença mental que afeta uma significativa parcela da população, em algum momento de suas vidas. A presença concomitante de TEPT e THB parece mais freqüente que anteriormente sugerido, e pacientes psicóticos com história de trauma tem sintomas mais severos e maior tendência a abusar de substância psicoativas ilícitas. Pensamentos intrusivos e pesadelos ocorrem com freqüência nos pacientes com TEPT e têm sido associados aos transtornos de humor. O tratamento farmacológico dessa comorbidade ainda está relacionado a estudo empíricos ou não-controlados. Neste artigo, são revisados aspectos atuais relacionados a essa comorbidade e enfatizados aspectos referentes à epidemiologia, etiologia, curso e tratamento farmacológico da comorbidade entre TEPT e THB. Especialmente, este estudo enfatiza a importância de avaliar sistematicamente a história de trauma em pacientes com THB.

Adjunctive topiramate treatment for pediatric bipolar disorder: a retrospective chart review

OBJECTIVE

The objective of this study was to evaluate the effectiveness, safety, and tolerability of the anticonvulsant agent, topiramate, as adjunctive treatment for children and adolescents with bipolar disorders.

METHODS

The outpatient medical charts of children and adolescents with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of bipolar disorder, type I or II, and who were treated with topiramate were retrospectively reviewed by two child and adolescent psychiatrists using the Clinical Global Impression (CGI) scale and the Clinical Global Assessment Scale (CGAS). Separate CGI ratings were made for mania and overall bipolar illness.

RESULTS

Twenty-six patients (mean age 14 +/- 3.5 years) with bipolar disorder, type I (n = 23) or II (n = 3), who had been treated (mean duration 4.1 +/- 6.1 months) with topiramate (mean dose 104 +/- 77 mg/day) were identified. Response rate (defined by a CGI-Improvement score of < or = 2 at endpoint) was 73% for mania and 62% for overall illness. CGAS scores significantly improved from baseline to endpoint. No serious adverse events were reported.

CONCLUSIONS

Although controlled trials are necessary, this retrospective study suggests that topiramate is effective and well tolerated as an adjunctive treatment for children and adolescents with bipolar disorder.

Antidepressant properties of anticonvulsant drugs for bipolar disorder

A growing number of anticonvulsant drugs are receiving attention as possible mood stabilizers. This attention is based mainly on the assumption that the antimanic efficacy of anticonvulsants makes them suitable as mood stabilizers. However, their antidepressant properties have received less scrutiny. In this review, current evidence concerning the acute and prophylactic efficacy of divalproex, carbamazepine, gabapentin, lamotrigine, and topiramate in bipolar depression is evaluated. Clinical outcome data are considered, together with limitations of existing studies and the concept of unmet clinical needs. Findings in placebo-controlled trials suggest an acute and prophylactic antidepressant effect with lamotrigine monotherapy and more modest antidepressant benefits with other agents administered as monotherapies. Results of published studies are considered with respect to the conceptualization of mood stabilization as arising from antimanic and antidepressant efficacy in bipolar disorder.

Bipolar depression: management options

Bipolar depression is the predominant abnormal mood state in bipolar disorder. However, despite the key pertinence of this phase of the condition, the focus of research and indeed of clinical interest in the management of bipolar disorder has been mainly on mania. Bipolar depression has been largely neglected, and early studies often failed to distinguish depression due to major unipolar depression from that due to bipolar disorder. Consequently, many treatments used in the management of major depression have been adopted for use in bipolar depression without any robust evidence of efficacy. The selective serotonin reuptake inhibitors (SSRIs), bupropion, tricyclic antidepressants and monoamine oxidase inhibitors are all effective antidepressants in the management of bipolar depression. They are all associated with a small risk of antidepressant-induced mood instability. The mood stabilisers lithium, carbamazepine and valproate semisodium (divalproex sodium) all appear to have modest acute antidepressant properties. Among these, lithium is supported by the strongest data, but the use of lithium in the treatment of bipolar depression as a monotherapeutic agent is limited by its slow onset of action. Recently, there has been a growing body of evidence suggesting that lamotrigine may have particular effectiveness in both the acute and prophylactic management of bipolar depression. Clinical management of bipolar depression involves various combinations of antidepressants and mood stabilisers and is partly determined by the context in which the depressive episode occurs. In general, 'de novo' and 'breakthrough' (where the patient is already receiving medication) bipolar depression may be successfully managed by initiating mood stabiliser monotherapy, to which an antidepressant or second mood stabiliser may be added at a later date, if necessary. Breakthrough episodes of bipolar depression occurring in patients receiving combination therapy (two mood stabilisers or a mood stabiliser plus an antidepressant) require either switching of ongoing medications or further augmentation. If this fails, then novel strategies or ECT should be considered. Bipolar depression is a disabling illness and the predominant mood state for the vast majority of those with bipolar disorder. It therefore warrants prompt management once suitably diagnosed, especially as it is associated with a considerable risk of suicide and in the majority of instances is eminently treatable.

Phenotypic spectra of bipolar disorder in responders to lithium versus lamotrigine

OBJECTIVE

We conducted a study of clinical presentation and family history in patients responsive to either of two commonly used mood stabilizers, lithium and lamotrigine.

METHODS

The sample included 164 subjects from 21 families of bipolar probands, 14 responders to lithium and seven to lamotrigine. Diagnostic information on first-degree relatives was obtained in a blind fashion through a combination of direct interviews (SADS-L) and family history assessments (FH-RDC).

RESULTS

The probands differed with respect to clinical course (episodic in the lithium group, rapid cycling in the lamotrigine group), and comorbidity (panic attacks and substance abuse in the lamotrigine group). The relatives of lithium responders had significantly higher risk of bipolar disorder while relatives of lamotrigine responders had higher prevalence of schizoaffective disorder, major depression and panic attacks.

CONCLUSIONS

These findings suggest that lithium- and lamotrigine-responsive patients differ with respect to course of illness, comorbidity and family history and may represent distinct subtypes of bipolar disorder.

Frequency of manic symptoms during a depressive episode and unipolar 'depressive mixed state' as bipolar spectrum

OBJECTIVE

To report the frequency of intra-episode manic symptoms in depressive episodes, and to evaluate unipolar depressive mixed state (DMS) as bipolar spectrum.

METHOD

A total of 958 (863 unipolar, 25 bipolar II, and 70 bipolar I) depressive in-patients were assessed in terms of manic symptoms at admission, and several clinical variables using standardized methods.

RESULTS

The frequency of manic symptoms (flight of idea, logorrhea, aggression, excessive social contact, increased drive, irritability, racing thoughts, and distractibility) was significantly higher in bipolar depressives than in unipolar depressives. Unipolar depressives with DMS - defined as having two or more manic symptoms - had more similarities to bipolar depressives than to other unipolar depressives in clinical variables such as onset age, family history of bipolar disorder, and possibly suicidality.

CONCLUSION

Depressive mixed state is frequent, particular in bipolar depressives. Unipolar depressives with DMS may be better classified into bipolar spectrum.

Acute dysphoric mania: treatment response to olanzapine versus placebo

A substantial number of patients with mania have significant concomitant depressive features, and they may respond differently to mood stabilizers than patients with pure mania. This post-hoc analysis explored the response characteristics of olanzapine versus placebo in bipolar I manic patients with dysphoric and nondysphoric mania (differentiated by baseline Hamilton Depression Rating Scale [HAM-D] score of >20). Two similar, double-blind, randomized trials comparing olanzapine, 5-20 mg, to placebo were pooled for these analyses (N = 246). Mean changes in Young-Mania Rating Scale (Y-MRS) and HAM-D scores during 3 weeks of treatment were examined. Twenty-eight percent of patients had dysphoric mania (olanzapine, n = 33; placebo, n = 35). Among these patients, olanzapine-treated patients had greater improvement within 1 week than did placebo-treated patients on both mania ratings (Y-MRS: -9.7 vs. -3.0 points; = 0.011) and depressive symptom ratings (HAM-D: -9.9 vs. -5.4 points; = 0.025). Among those manic subjects without prominent depressive symptoms (olanzapine, n = 91; placebo, n = 87), mean Y-MRS improvement from baseline to endpoint with olanzapine (-11.5 points) versus placebo (-6.13 points) was comparable to the improvement seen with olanzapine versus placebo in the dysphoric mania subgroup ( = 0.476, test of interaction). In acutely ill manic patients with significant depressive symptoms, olanzapine demonstrated a broad spectrum of efficacy, effectively treating both manic and depressive symptoms. The magnitude of the antimanic response appears similar, regardless of baseline depressive features. Additional experience with putative mood stabilizers and atypical agents in mixed mania should include an exploration of their efficacy in treating both manic and depressive mood symptoms.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania

Identical to the preceding guidelines of this series, these practice guidelines for the biological, mainly pharmacological treatment of acute bipolar mania were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was finally not only graded, but has also been commented by the experts of the task force to ensure practicability. Key words: bipolar disorder, mania, acute treatment, evidence-based guidelines, pharmacotherapy, antipsychotics, mood stabiliser, electroconvulsive therapy.

Redefining mood stabilization

This review considers the definition of the term 'mood-stabilizer' in the context of new pharmacological agents for the treatment of bipolar disorder. Three definitions of a mood-stabilizer are described and the available data from randomized, double-blind, controlled trials for putative mood-stabilizers studied in the treatment of different aspects of bipolar disorder (mania, mixed states, depression, maintenance) are reviewed. No available agent meets the criteria for a comprehensive mood-stabilizer, although lithium comes the closest.

Proposed multidimensional structure of mania: beyond the euphoric-dysphoric dichotomy

BACKGROUND

Although the construct of depression has been subjected to numerous factor analytic studies and phenomenological subtypes of clinical relevance have been delineated, this is not the case for mania. The few available studies have reported at least two factors, which consist of euphoric versus dysphoric-hostile subtypes. Our objective was to replicate and further enrich this literature.

METHODS

In the EPIMAN French National Study we systematically evaluated 104 DSM-IV hospitalized manic patients in four university centers in different regions of France. Psychiatrists completed the Beigel-Murphy Manic State Rating Scale (MSRS), as well as the HAM-D(17), affective temperament scales, and the GAF Axis V from DSM-IV. Categorization of patients into pure versus dysphoric mania was made on the basis of clinical diagnosis, independent from psychometric measures.

RESULTS

On principal component analysis of the MSRS, three factors explained the largest variance: a global manic (23.3% variance), paranoid-hostile (14.8% variance), and psychotic (9.1% variance). After varimax rotation, we obtained seven independent factors: F1 Disinhibition-instability, F2 Paranoia-hostility, F3 Deficit, F4 Grandiosity-psychosis, F5 Elation-euphoria, F6 Depression, and F7 (Hyper)sexuality. We could not demonstrate significant correlations between the individual factors and impaired functioning on GAF. However, depressive and, to some extent, cyclothymic temperaments correlated with F6 Depression. Finally, intergroup comparisons between pure versus dysphoric mania diagnosed clinically showed high levels of F3 Deficit and F5 Elation in the pure, and of F6 Depression in dysphoric, mania; F2 Paranoia-hostility did not discriminate these two clinical forms of mania.

LIMITATIONS

Although the present analyses on the Beigel-Murphy represent the largest sample studied to date, they are still underpowered and do not guarantee a stable factorial structure. Our findings are cross-sectional and require prospective validation.

CONCLUSIONS

Our data suggest that 'dysphoria' as used in the literature to qualify mania is insufficiently precise, and is best further specified as 'depressive' versus 'irritable.' Moreover, our data extend the rich multidimensional phenomenology of mania beyond the existing literature: we submit that disinhibition-instability (a core 'activation' component) can, on the one hand, be associated with distinct emotional presentations (euphoric, depressive, or irritable-hostile), as well as psychotic and deficit symptomatology on the other.

Valproate for acute mood episodes in bipolar disorder

BACKGROUND

Bipolar disorder is a common debilitating illness, characterised by acute affective episodes with full or partial inter-episode remission. Effective and acceptable treatment of acute episodes is required. Valproate has become a leading adjunctive and alternative mood stabilising treatment to lithium in bipolar disorder.

OBJECTIVES

To determine the efficacy and acceptability of valproate in the treatment of acute episodes of bipolar disorder.

SEARCH STRATEGY

The search included the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registrar (CCDANCTR), the Cochrane Controlled Clinical Trials Register (CCTR), reference lists of relevant papers and books, and contact with authors of trials, experts and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing valproate with placebo, other mood stabilisers and antipsychotic medication in the treatment of any bipolar affective episode. Participants were of both sexes, of all ages, with a diagnosis of bipolar affective disorder approximating to ICD 10 Code F31 and DSM IV 296.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed independently by two reviewers blind to the authorship and source of papers. Ten randomised controlled trials were found comparing valproate with other interventions in mania. None was found examining its use in depression or mixed affective episodes. Data were extracted on the main outcome 'failure to respond by the end of the study' assessed by a less than 50% reduction in the Young Mania Rating Scale or the SADS-S mania scale. Three trials (316 participants) compared valproate with placebo. Three trials (158 participants) compared valproate with lithium. Two trials (363 participants) compared valproate with olanzapine. One trial (36 participants) compared valproate with haloperidol. Two trials (59 patients) compared valproate with carbamazepine. Acceptability of treatment was estimated using the outcome measure 'total number of subjects withdrawing from the study'. Three trials (321 patients) contributed to the comparison between valproate and placebo, two studies (144 patients) contributed to the comparison with lithium. One study (30 patients) provided data on this outcome in the comparison between valproate and carbamazepine. Pooled relative risks (with 95% confidence intervals) were calculated using fixed effect approaches.

MAIN RESULTS

Valproate was more efficacious than placebo (RRR 38%; RR 0.62; 95% C.I. 0.51 to 0.77) in the treatment of mania. There was no significant difference between valproate and lithium (RRI 5%; RR 1.05; 95% C.I. 0.74-1.50) or between valproate and carbamazepine (RRR 34%; RR 0.66; 95% C.I. 0.38 to 1.16). Valproate was less effective than olanzapine (failure to achieve clinical response; RRI 25%; RR 1.25, 95% C.I. 1.01 to 1.54; average of 2.8 point less change on the Mania Rating Scale (95% CI 0.83 to 4.79). There were no significant differences in acceptability as measured by total number of subjects withdrawing from the study. There were significant differences in the side effect profiles of valproate and olanzapine, with more sedation and weight gain on olanzapine.

REVIEWER'S CONCLUSIONS

There is consistent, if limited, evidence to suggest that valproate is an efficacious treatment for acute mania. Valproate may be less effective than olanzapine but may cause less sedation and weight gain. More well designed, randomised controlled trials investigating the relative efficacy and acceptability of valproate in the treatment of the full range of acute affective episodes occurring in bipolar disorder are required.

Review of the use of topiramate for treatment of bipolar disorders

Lithium alone or in combination with other psychotherapeutic drugs has long been the gold standard of management for bipolar disorder (BD). Recognition of its limitations in the acute and chronic management of BD has led to the development of alternative therapies. One such approach involves the use of antiepileptic drugs (AEDs). The AED topiramate is currently being studied in the efficacy and management of BD. Topiramate has mechanisms in common with other AEDs, including sodium channel-blocking activity and enhancement of cerebral GABA concentrations. Open-label trials have evaluated topiramate at mean daily doses of 100 to 300 mg in various BD subtypes, including acute mania, depression, rapid-cycling, mixed states, and BD refractory to other medications. Results from these trials suggest topiramate may be efficacious in BD subtypes, particularly in rapid-cycling patients and those refractory to conventional treatment. Its side effect profile appears benign when used as monotherapy or in combination with other mood stabilizers. Placebo-controlled, double-blind studies are warranted to evaluate topiramate further in BD.

Relevance of new and newly rediscovered anticonvulsants for atypical forms of bipolar disorder

The so-called atypical forms of bipolar disorder are not a rarity, but instead are rather the rule. Particularly in specialized settings such as the bipolar disorder clinic, the majority of patients are characterized by atypical manifestations (). Mixed states, psychotic mania and a rapid cycling course of bipolar disorder are a challenge both to pharmacological and non-pharmacological treatment. The benefit of classical mood stabilizers such as lithium and carbamazepine is limited in monotherapy, although valproate has a broader spectrum of activity in atypical bipolar disorders and is often used in combination with other agents. Thus, new treatment alternatives are needed urgently for optimizing the treatment of atypical bipolar disorder. During the last decade, several new antiepileptic drugs have been released, e.g. lamotrigine, gabapentin, tiagabine, topiramate and levetiracetam. Others have been available for some time, but only recently have become the focus of bipolar disorder research; for example, phenytoin, and especially, oxcarbazepine. This review will consider our current knowledge of the benefit of these new and newly rediscovered anticonvulsants in treating bipolar disorders, with a special focus on their value in treating atypical manifestations.

A double-blind, randomized, placebo-controlled study of quetiapine as adjunctive treatment for adolescent mania

OBJECTIVES

This randomized, double-blind, placebo-controlled study examined the efficacy and tolerability of quetiapine in combination with divalproex (DVP) for acute mania in adolescents with bipolar disorder. It was hypothesized that DVP in combination with quetiapine would be more effective than DVP alone for treating mania associated with adolescent bipolar disorder. Furthermore, it was hypothesized that quetiapine would be well tolerated.

METHOD

Thirty manic or mixed bipolar I adolescents (12-18 years) received an initial DVP dose of 20 mg/kg and were randomly assigned to 6 weeks of combination therapy with quetiapine, which was titrated to 450 mg/day (n = 15) or placebo (n = 15). Primary efficacy measures were change from baseline to endpoint in Young Mania Rating Scale (YMRS) score and YMRS response rate. Safety and tolerability were assessed weekly.

RESULTS

The DVP + quetiapine group demonstrated a statistically significantly greater reduction in YMRS scores from baseline to endpoint than the DVP + placebo group (F(1,27) = 5.04, p =.03). Moreover, YMRS response rate was significantly greater in the DVP + quetiapine group than in the DVP + placebo group (87% versus 53%; Fisher exact test, p =.05). No significant group differences from baseline to endpoint in safety measures were noted. Sedation, rated as mild or moderate, was significantly more common in the DVP + quetiapine group than in the DVP + placebo group.

CONCLUSIONS

The findings of this study indicate that quetiapine in combination with DVP is more effective for the treatment of adolescent bipolar mania than DVP alone. In addition, the results suggest that quetiapine is well tolerated when used in combination with DVP for the treatment of mania.

What makes a drug a primary mood stabilizer?

The term 'mood stabilizer' has been applied to a number of medications for the treatment of patients with bipolar disorder. The operational definition of the properties of a mood-stabilizing medication has varied according to the properties of specific medications and the clinical characteristics of the illness. Randomized controlled trials of agents accepted or proposed as mood stabilizers are reviewed to marshall the available evidence in support of this claim. In addition, potential pharmacological mechanisms underlying mood-stabilizing effects of established compounds are reviewed.

The boundary between mixed and manic episodes in the ICD-10 classification

OBJECTIVE

To investigate the boundary between ICD-10 mixed and manic episodes, which has apparently remained understudied.

METHOD

In-patients with ICD-10 mixed (n=36) and manic episodes (n=145) were compared in terms of demographic, clinical, therapeutical and outcome variables.

RESULTS

Of in-patients with manic episode, 26 (18%) had several depressive symptoms at admission. These patients (dysphoric manic patients) were very similar to patients with ICD-10 mixed episode in terms of current symptomatic presentations and several clinical and therapeutic variables, which were significantly different from those in patients with pure mania.

CONCLUSION

The ICD-10 boundary between mixed and manic episodes is unlikely to be effective although experienced clinicians made the diagnoses. The system may have a high probability of diagnosing dysphoric manic patients as having manic episode, despite their great similarities to patients with mixed episode in terms of current psychopathological presentations as well as clinically important variables.

Limitations in randomised controlled trials evaluating drug effects in mania

Considering the increasing number of drugs evaluated for mania in randomised controlled trials (RCTs) and the potential discrepancies between recommendations based on RCTs and the antimanic treatment given in clinical practice, this paper addresses some issues related to RCTs on drug effects in mania. One major question raised in the paper is to what extent selection prior to the point of randomisation in RCTs in mania may limit the applicability of study results to patients seen in ordinary clinical practice. Although such limitations in generalisability can be difficult to investigate empirically, it is emphasised that they should be openly discussed in the reports of RCTs. Another major focus is the issue of evaluation and interpretation of outcome, including a discussion of various response criteria based on mania rating scale scores. It is pointed out that essential criteria of dimensionality have only been sufficiently evaluated for the Bech-Rafaelsen Mania Rating Scale, although the fulfilment of such criteria are prerequisites for adding up the item scores to a total score reflecting the severity of mania. It is suggested that response defined as a decline in mania score below a certain limit may have some advantages over the commonly used 50% reduction criterion. The issues arising from the unusual high drop-out rates of around 50% are also addressed. Despite the fact that we need rigorous placebo-controlled trials to establish antimanic efficacy of new compounds, we also need large scale pragmatic studies using broad inclusion criteria, comparing the various treatments, alone or in combination, to investigate how they work in clinical practice. These studies maybe randomised but open and use simple but relevant outcome measures.

The expanding pharmacopoeia for bipolar disorder

Over the past decade, the number of treatments available for bipolar disorder has undergone an extraordinary expansion. In that period, valproate and olanzapine have received regulatory approval in the United States for the acute treatment of mania, and carbamazepine has been indicated for this condition in many other countries. In addition to those agents, a number of other anticonvulsants (in particular lamotrigine, gabapentin, and topiramate) are in trials, as are the atypical antipsychotics clozapine and risperidone, and other novel compounds. This article critically reviews the evidence from controlled trials of these proposed "mood stabilizers," highlighting the strengths and limitations of the data for each compound. A major challenge to the field is the capacity to prove the prophylactic properties of agents for which effectiveness in acute mania and/or bipolar depression has been demonstrated. Finally, as the mechanisms of agents such as lithium are now becoming apparent, and the possibility of understanding the molecular defects underpinning the condition is no longer highly fanciful, the prospect of targeted therapies is considered feasible by both academia and the pharmaceutical industry.

The "good enough" mood stabilizer: a review of the clinical evidence

A growing family of medications is used for mood stabilization in bipolar disorder. These medications fall into two broad categories according to likely mechanisms of action. Within the categories, specific drugs may vary in their efficacy for different phases of the disorder. The first category, including lithium, anticonvulsants, and some novel treatments, appears to have mechanisms related to intracellular second messengers. These medications have more pronounced antimanic than antidepressant effects, except for lamotrigine, which has antidepressant effects without precipitating mania. The second group of mood stabilizers is the atypical antipsychotics, which act through dopamine and other monoamines. Olanzapine and in all likelihood other drugs in the class possess marked, acute antimanic properties and possible antidepressant properties, but require further study before they can be used as routine options in long-term care. It is clear that the advent of multiple mood stabilizer candidates has not yet led to a single ideal therapy for bipolar disorder, but rather to options that can be flexibly tailored to the lifetime needs of individual patients, in sequences or combinations, and perhaps in conjunction with other classes of psychotropics.

The impact of response to previous mood stabilizer therapy on response to olanzapine versus placebo for acute mania

OBJECTIVES

A clinically important question for any new treatment for bipolar disorder is whether its efficacy extends to patients who have both responded and failed to respond to other mood stabilizers. In this secondary analysis of a placebo-controlled trial demonstrating olanzapine's efficacy for acute mania, we explore whether its usefulness extends to those patients with a history of poor response to other mood stabilizers.

METHODS

This 4-week, double-blind, placebo-controlled trial studied olanzapine monotherapy 5-20 mg/day for hospitalized patients in acute manic or mixed bipolar episodes. The primary outcome variable was beginning to endpoint change in the Young-Mania Rating Scale (Y-MRS) total score. We investigated whether prospectively identified history of recent failure to respond to other mood stabilizers predicted response to olanzapine.

RESULTS

As previously reported, olanzapine-treated patients experienced significantly greater improvement in Y-MRS total score and higher remission rates relative to placebo-treated patients. The current analysis compared these outcome parameters in patients with known poor prior response to lithium and/or valproate with all other patients and found no significant group by treatment interactions, i.e., treatment effects were not significantly diminished in non-responders to older mood stabilizing agents.

CONCLUSIONS

Olanzapine has been shown to be superior to placebo for the treatment of mania. This secondary analysis suggests that olanzapine monotherapy is similarly effective for patients whether or not they previously have failed to respond to another mood stabilizer for mania. A study limitation is that response to lithium or valproate was determined retrospectively.

The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues

BACKGROUND

Although symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder, the pathophysiologic, theoretical, and clinical significance of their co-occurrence has not been well studied.

METHODS

The epidemiological and clinical studies that have assessed the overlap of bipolar and anxiety disorders are reviewed, with focus on panic disorder and obsessive-compulsive disorder (OCD), and to a lesser extent, social phobia and post-traumatic stress disorder. Potential neural mechanism and treatment response data are also reviewed.

RESULTS

A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder. Psychobiological mechanisms that may account for these high comorbidity rates likely involve a complicated interplay among various neurotransmitter systems, particularly norepinephrine, dopamine, gamma-aminobutyric acid (GABA), and serotonin. The second-messenger system constituent, inositol, may also be involved. Little controlled data are available regarding the treatment of bipolar disorder complicated by an anxiety disorder. However, adequate mood stabilization should be achieved before antidepressants are used to treat residual anxiety symptoms so as to minimize antidepressant-induced mania or cycling. Moreover, preliminary data suggesting that certain antimanic agents may have anxiolytic properties (e.g. valproate and possibly antipsychotics), and that some anxiolytics may not induce mania (e.g. gabapentin and benzodiazepines other than alprazolam) indicate that these agents may be particularly useful for anxious bipolar patients.

CONCLUSIONS

Comorbid anxiety symptoms and disorders must be considered when diagnosing and treating patients with bipolar disorder. Conversely, patients presenting with anxiety disorders must be assessed for comorbid mood disorders, including bipolar disorder. Pathophysiological, theoretical, and clinical implications of the overlap of bipolar and anxiety disorders are discussed.

Clinical predictors of response to lamotrigine and gabapentin monotherapy in refractory affective disorders

BACKGROUND

The objective of the current study was to examine possible clinical predictors of positive response to lamotrigine or gabapentin monotherapy in treatment-refractory affectively ill patients.

METHODS

Forty-five patients with treatment refractory bipolar (n = 35) or unipolar (n = 10) affective disorder participated in a clinical study evaluating six weeks of treatment with lamotrigine, gabapentin, or placebo monotherapy given in a double-blind, randomized fashion with two subsequent cross-overs to the other agents. Patients received daily mood ratings and weekly cross-sectional scales. Much or very much improved on the Clinical Global Impression scale modified for bipolar illness was considered a positive response. Degree of response was correlated with a number of baseline demographic and course of illness variables in a univariate analysis and then by linear regression.

RESULTS

Response rates to lamotrigine (51%) exceeded those to gabapentin (28%) and placebo (21%). A positive response to lamotrigine monotherapy was associated with a bipolar diagnosis; fewer hospitalizations; fewer prior medication trials; and male gender (of which the latter two variables survived logistic regression). For gabapentin, degree of response correlated with shorter duration of illness; younger age; and lower baseline weight (with the latter two surviving linear regression).

CONCLUSIONS

In this highly treatment-refractory population, lamotrigine appeared most effective for male patients with fewer prior medication trials. Gabapentin monotherapy, although not better than placebo, appeared most effective in those with younger age and lower baseline weight. These preliminary data in a treatment refractory subgroup may help in the further definition of the range of clinical utility of these widely used anticonvulsants.

Current research on rapid cycling bipolar disorder and its treatment

Rapid cycling is a pattern of presentation of bipolar disorder that specifies the course of the illness and is associated with a greater morbidity. The validity of rapid cycling as a distinct course modifier for bipolar disorder has been demonstrated and the term has been incorporated into the DSM-IV. The phenomenon of rapid cycling tends to appear late in the course of the disorder, occurs more frequently among females, and is more frequently seen in patients with bipolar type II disorder. Stimulants such as cocaine may also play some role in rapid-cycling. It is generally accepted that a recent history of rapid cycling predicts non-response to monotherapy with lithium and probably carbamazepine as well; however it is also possible that concurrent use of antidepressants may play a role in destabilizing the illness course under these agents. Thus, clinical considerations suggest that discontinuing antidepressants may facilitate the recovery process. Among clinically available monotherapies, valproate and lamotrigine appear to be the most useful clinically. However, other treatments such as lithium, carbamazepine, the atypical antipsychotic agents, thyroid hormone, and bupropion are frequently needed augmentation strategies. Electroconvulsive therapy may also prove efficacious in selected cases. The present paper provides a critical review of the evidence for the foregoing clinical issues in rapid cycling.

Adjunctive antipsychotic treatment of adolescents with bipolar psychosis

BACKGROUND

A combination of an antipsychotic medication and a mood stabilizer is often used for initial treatment of acute psychotic mania. However, the optimal duration of this adjunctive antipsychotic medication is unknown.

METHOD

As part of a lithium efficacy study, acutely manic adolescents with psychotic features were given open combination treatment with lithium and an adjunctive antipsychotic medication. If the psychosis resolved, the antipsychotic medication dose was gradually tapered and discontinued after 4 weeks of therapeutic lithium levels. The subject was then given a trial of maintenance lithium monotherapy for up to 4 weeks.

RESULTS

Significant improvement was seen in 64% of the sample with psychotic features after 4 weeks of combination treatment. However, few maintained their response after discontinuation of the antipsychotic medication. Successful discontinuation of antipsychotic medication in this sample was associated with first episode, shorter duration of psychosis, and the presence of thought disorder at baseline.

CONCLUSIONS

Adjunctive antipsychotic medication needs to be maintained for longer than 4 weeks in the vast majority of adolescents with psychotic mania, even though the manic and psychotic symptoms have resolved and lithium treatment is maintained. Future studies to determine the optimal duration of adjunctive antipsychotic medication treatment are warranted.

Origin and development of concepts of bipolar mixed states

This paper reviews the historical origins of the contemporaneous resurgence of interest in mixed states. This is a classical concept whose origins can be traced back to ancient times. In more modern times, already in the pre-Kraepelinian era we can find descriptions and classifications of "mixed states". For example, in his classification of mental disorders described "mixtures of exaltations and depression", and he distinguished among "mixed mood disorders", "mixed mental disorders", and "mixed volition disorders". Subsequently, (the father of empirical and biological psychiatric research in Germany) described the "mid-forms". Half a century later we encounter the crucial role of Emil Kraepelin and the development and systemization of his views between 1899 and 1913--leading to the characterization of such conditions as "depressive-anxious mania", "excited depression", and "stuporous mania". The remainder of this article focuses on the essential points of the first book on mixed states in the psychiatric literature: On The Mixed States of Manic-Depressive Insanity by. For much of the present 20th century nothing new emerges, followed by a contemporary renaissance of mixed states, particularly in the United States. The paper concludes with proposal of mixed states as temperament intruding into an episode of opposite polarity.

Structure of mania: depressive, irritable, and psychotic clusters with different retrospectively-assessed course patterns of illness in randomized clinical trial participants

BACKGROUND

We investigated the structure of manic episodes by determining whether there was evidence for distinct groups of patients differing in clinical characteristics and course of illness.

METHODS

The subjects were 162 patients hospitalized for manic episodes who underwent comprehensive evaluations of behavior, symptoms, and history before a treatment study. Pretreatment behavior ratings (Schedule for Affective Disorders and Schizophrenia, rated by clinicians, and Affective Disorder Rating Scale, rated by nurses) entered a principal components factor analysis, followed by a cluster analysis of the subjects based on their factor scores. Members of the resulting clusters were compared with respect to clinical characteristics and history of illness.

RESULTS

The six factors were impulsivity, hyperactivity, anxious pessimism, distressed appearance, hostility, and psychosis. The four clusters were characterized as depressive, with high anxious pessimism (n=22), delusional, with high psychosis (n=39), classic (n=72), and irritable, with high distressed appearance and hostility (n=29). Depressive manics had the earliest onset of illness and the highest density of episodes/year, while irritable manics had later onset and the fewest previous episodes.

LIMITATIONS

The number of subjects was smaller than ideal for multivariate analysis, subjects were limited to those able to consent and meet criteria for a randomized clinical trial, and course of illness was determined retrospectively.

CONCLUSIONS

Manic episodes have a dimensional structure but appear to fall naturalistically into types that differ with respect to previous history, symptoms, and clinical characteristics. Whether these are distinct clinical subtypes will require further research.

Clinical correlates of therapeutic response in bipolar disorder

Interest in the factors associated with responsiveness to therapy in bipolar disorder has increased with evidence that lithium has differential rather than uniform effectiveness in bipolar disorder, and also with the broadening of therapeutic options, illustrated especially by the use of divalproex sodium (valproate). Lithium is effective acutely in patients with pure or elated mania, and in its prophylaxis, but may worsen depressive symptoms in such patients when used for long-term maintenance therapy. The nature of previous responses to lithium treatment predicts the type of response that can be expected during a further episode of the disorder. Mixed mania, secondary mania, and mania associated with substance abuse--as well as rapid cycling --generally respond poorly to lithium therapy. Divalproex sodium has a broader spectrum of efficacy and fewer factors that determine differential responsiveness. Data related to treatment with carbamazepine are sparse, but patients with rapid cycling may respond less well to this agent; on the other hand, limited data support the utility of carbamazepine in bipolar patients with extreme psychosis, including those with mood-incongruent features. Both classical and atypical neuroleptics (e.g. olanzapine) could profitably be used in acute mania and mixed states. Lamotrigine has recently been shown effective in bipolar depression and rapid cycling. Patients unresponsive to a single agent may show improvement with combined regimens, though this impression is based more on clinical experience than controlled randomized assignment.

Lithium treatment at 52

The paper reviews briefly and comments in detail on selected events in the history of lithium treatment. The events include Cade's discovery of lithium's antimanic action, the discovery and establishment of its prophylactic action, the ensuing debate, amelioration and prevention of side effects and risks, use during pregnancy, non-compliance, selection of patients, information and instruction, the question whether new and better prophylactic agents are about to oust lithium, the use of combination treatment, the effect of lithium on suicidal behavior, the benefits of prophylactic lithium treatment, and the design of future comparative trials.

Self-Reported Mood Changes following 6 Months of Vagus Nerve Stimulation in Epilepsy Patients

Vagus nerve stimulation (VNS) for treatment of drug-resistant epileptic seizures has been reported to have additional positive mood effects as obtained by psychiatric ratings. To avoid rater bias effects, this study used self-report questionnaires and examined changes in self-reported mood and health-related quality of life following 6 months of VNS treatment. From 40 adult patients treated with VNS since the beginning of the study, 28 patients (mean age: 35.4 years) with unchanged medication were included. Repeated-measures MANOVA revealed a significant general mood improvement. Post hoc univariate tests obtained improvements of tenseness and dysphoria but not of depression, level of activity, or health-related quality of life. Mood and seizure outcome were correlated. VNS may improve unspecific states of indisposition and dysphoria. Absolute seizure reduction contributes to this antidysphoric effect. Since baseline depression scores were low, findings do not contradict but complement earlier reports of an antidepressive effect of VNS.