Depression during mania. Treatment response to lithium or divalproex

Bipolar disorder

Bipolar disorder (manic-depressive illness) is a common, recurrent, and severe psychiatric disorder that affects 1% to 3% of the US population. The illness is characterized by episodes of mania, depression, or mixed states (simultaneously occurring manic and depressive symptoms). Bipolar disorder frequently goes unrecognized and untreated for many years without clinical vigilance. New screening tools have been developed to assist physicians in making the diagnosis. Fortunately, several medications are now available to treat the acute mood episodes of bipolar disorder and to prevent further episodes with maintenance treatment.

Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study

BACKGROUND

This study evaluated divalproex response in sex offenders with a bipolar disorder.

METHODS

We reviewed the records of all sex offenders who participated in a residential rehabilitative program who received divalproex for treatment of a bipolar disorder. Patients' mood symptoms and, when present, comorbid paraphilic symptoms, were retrospectively assessed using the CGI severity scale.

RESULTS

Sex offenders displayed significant improvement in manic symptoms with divalproex treatment. However, there was no significant improvement in paraphilic symptoms in the subset of patients admitting to these symptoms.

CONCLUSION

Divalproex may be effective for manic symptoms in sex offenders with a bipolar disorder. However, for bipolar sex offenders with comorbid paraphilias, the drug may not be effective for paraphilic symptoms.

LIMITATIONS

This study was limited by its retrospective, open-label design, lack of systematic means of assessing manic and paraphilic symptoms, and small sample size.

CLINICAL RELEVANCE

Divalproex may be a helpful adjunct in the treatment of the subset of sex offenders who have a bipolar disorder.

Novel treatments for bipolar disorder

Treatments other than lithium have recently emerged as equally important in the management of bipolar disorder. The spectrum of efficacy of newer treatments differs from lithium and among the novel drug treatments valproate, generally used as the better tolerated divalproex form, principally benefits manic symptomatology both acutely and in prophylaxis. Atypical antipsychotic drugs have demonstrated efficacy in reducing acute manic symptoms. No controlled evidence of efficacy in prophylaxis has been published. Lamotrigine has demonstrated efficacy in both acute bipolar depression and maintenance efficacy in rapid cycling bipolar patients, especially those patients with bipolar II disorder, which is principally manifested as depression. Randomised, double-blind, placebo- controlled studies provide good evidence that regimens of risperidone or olanzapine in combination with lithium or valproate provide greater improvement in acute mania than the mood stabilisers alone. Similarly, valproate combined with antipsychotics provided greater improvement in mania than antipsychotic medication alone and resulted in lower dosage of the antipsychotic medication. A positive but unclear placebo-controlled study of omega-3 fatty acids added to lithium in bipolar disorder needs confirmation in standard clinical trial paradigms. Several other drugs that were reported as beneficial in various facets of bipolar disorder in open trials have not differed from placebo when studied in randomised, placebo-controlled trials.

Bipolar disorders: new approaches to therapy

This article reviews the evidence supporting different somatic treatment strategies in the acute and maintenance treatment phases of bipolar disorder. Bipolar affective disorder is a chronic disorder with a life time incidence of 0.3 - 1.5/100 [1]. Severe affective disorder is associated with a risk of completed suicide of 6 - 15% [2,3]. Traditionally, bipolar disorder has been considered as an episodic disorder with good inter-episode recovery [4]. This is being increasingly challenged with patients demonstrating social, marital, occupational and cognitive dysfunction, even when euthymic [5]. The management of bipolar disorder should be considered in the context of; the type of episode, this may be manic, depressed or mixed; the degree and rate of recovery; the cycling frequency and precipitant, if any, for recurrence and the onset and evolution of the underlying illness. On average, four episodes occur every 10 years. However 13 - 24% of patients develop rapid cycling disorder, in which four or more episodes occur within a year. Patients with bipolar disorder often have co-morbid anxiety and substance abuse. Moreover, axis I co-morbidity may be associated with an earlier age at onset and worsening course of bipolar illness. [6]. Axis II co-morbidity is also common, this was highlighted in a study by Kay and colleagues who, after excluding patients with a history of alcohol misuse, demonstrated axis II co-morbidity in almost a quarter of euthymic bipolar patients [7]. Good practice relies on an overall management plan that incorporates somatic, psychological and social approaches. This paper will focus on one element of such a plan, the currently available somatic management strategies for bipolar disorder.

A pilot study of rapid lithium administration in the treatment of acute mania

OBJECTIVES

The use of rapid lithium dosage administration, a strategy that could lead to rapid improvement in mania, has been largely unexamined. In this open-label, pilot, acute-treatment study, we sought to determine the safety and tolerability of lithium administered at 20 mg/ kg/day. A secondary aim was to provide preliminary data regarding the efficacy of this strategy in ameliorating manic, depressive, and psychotic symptoms.

METHODS

Fifteen patients hospitalized with DSM-IV bipolar disorder, manic or mixed, and who provided written informed consent, received lithium 20 mg/kg/day for up to 10 days. Patients were evaluated for adverse effects daily. Lithium levels were obtained on days 2, 3, 4, 5, 7, and 10 or at study termination. Electrocardiograms (EKGs) were performed at baseline and on days 1-5, 7, and 10 or at study termination. Symptomatic improvement was assessed daily using the Young Mania Rating Scale, 24-item Hamilton Depression Rating Scale, and the Scale for Assessment of Positive Symptoms (SAPS).

RESULTS

Five of the 15 patients completed the 10-day study period. Two patients dropped out due to adverse events. Seven patients did not complete the inpatient trial because of improvement sufficient to allow hospital discharge. All patients achieved serum lithium concentrations > or =0.6 mEq/L after 1 day of treatment; the mean + SD concentration on day 5 was 1.1 (+/- 0.1) mEq/L on day 5. There were significant reductions from baseline to endpoint on all rating scales, except the SAPS bizarre behavior subscale.

CONCLUSIONS

These pilot data suggest that lithium 20 mg/kg/day was well tolerated and that this strategy may produce rapid improvement in affective and psychotic symptoms. These impressions require confirmation in double-blind, randomized trials.

Developments in mood stabilisers

Bipolar affective disorder is a life-long condition with profound effects on sufferers' social and occupational life. Despite efficacy in clinical trials and in some groups of patients, lithium's effectiveness in clinical practice is hampered by its side effect profile and limited concordance. Alternative and adjunctive treatments to lithium in bipolar disorder have been sought and the anticonvulsants carbamazepine and valproate show promise. Despite these advances, treatment resistance persists. Lamotrigine, a new anticonvulsant, is increasingly used in treatment-resistant cases under specialist supervision. Further pharmacological and non-pharmacological strategies for bipolar prophylaxis are currently under investigation. These developments are the focus of this review.

Expanding the group of bipolar disorders

The concept of bipolar disorder is an ongoing process. Its roots can be found in the work of the ancient Greek physician Aretaeus of Cappadocia, who assumed that melancholia and mania are two forms of one and the same disease; he actually believed that mania was a more severe form of melancholia. Falret [Bull. Acad. Natl. Med., Paris (1851)] and Baillarger [Ann. Méd-psychol. 6 (1854) 369] from France are the fathers of the modern understanding of bipolar disorders. But the definitive distinction of bipolar from unipolar disorders occurred in 1966 by Jules Angst and Carlo Perris in Europe, and later supported by Winokur and colleagues in the United States. Schizoaffective disorders should also be dichotomized into unipolar and bipolar forms. Another extension of the group of bipolar disorders is the contemporaneous rebirth of cyclothymia, originally described in the work of Kahlbaum (1882) and Hecker (1898) [Z. Prakt. Arzte 7 (1898) 6]; the main importance of cyclothymia today is its relevance for what Akiskal [Clin. Neuropharm. 15(1) (1992) 632] considers the realm of the 'soft bipolar spectrum.' A further interesting development is the renewed research in the field of 'mixed states' which originated in the classic Handbook of Kraepelin a century ago (1899).

A theoretical reappraisal of mixed states: dysphoria as a third dimension

Mixed states are heterogeneous clinical entities difficult to define precisely. The stringent actual DSM IV criteria are unsatisfactory for current clinical use. Many frequently encountered mixed patients benefit without an accurate diagnosis from biological therapeutic interventions such as the introduction of mood stabilizers. We propose a brief review of the definition and characteristics of mixed states and propose a new approach to the typology of mixed states. Based on recent literature data, we add to the depressive and manic syndrome the concept of dysphoria as a third dimension. Integrating this three dimensional approach with recent factor analysis, we describe in addition to the DSM IV mixed state (type I) two new subtypes of mixed states (type IIM and IID). This new typology can give the clinician a more accurate understanding of the complex and polymorphous reality of mixed states and help him make more specific therapeutic interventions. These subtypes of mixed states will need validation through prospective clinical studies. Biological differences, differential outcome over time, and differential response to treatment will be important validation criteria.

Vagus nerve stimulation. A potential therapy for resistant depression?

VNS builds on a long history of investigating the relationship of autonomic signals to limbic and cortical function and is one of the newest methods to physically alter brain function. VNS is a clinically useful anticonvulsant therapy in treatment resistant patients with epilepsy, and pilot data suggest that it has potential as an antidepressant therapy. The known anatomic projections of the vagus nerve suggest that VNS also might have other neuropsychiatric applications. Additional research is needed to clarify the mechanisms of action of VNS and the potential clinical utility of this intriguing new somatic portal into the CNS.

A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders

There is a pressing need for additional treatment options for refractory mood disorders. This controlled comparative study evaluated the efficacy of lamotrigine (LTG) and gabapentin (GBP) monotherapy versus placebo (PLC). Thirty-one patients with refractory bipolar and unipolar mood disorders participated in a double-blind, randomized, crossover series of three 6-week monotherapy evaluations including LTG, GBP, and PLC. There was a standardized blinded titration to assess clinical efficacy or to determine the maximum tolerated daily dose (LTG 500 mg or GBP 4,800 mg). The primary outcome measure was the Clinical Global Impressions Scale (CGI) for Bipolar Illness as supplemented by other standard rating instruments. The mean doses at week 6 were 274 +/- 128 mg for LTG and 3,987 +/- 856 mg for GBP. Response rates (CGI ratings of much or very much improved) were the following: LTG, 52% (16/31); GBP, 26% (8/31); and PLC, 23% (7/31) (Cochran's Q = 6.952, df = 2, N = 31, p = 0.031). Post hoc Q differences (df = 1, N = 31) were the following: LTG versus GBP (Qdiff = 5.33, p = 0.011); LTG versus PLC (Qdiff = 4.76, p = 0.022); and GBP versus PLC (Qdiff = 0.08, p = 0.70). With respect to anticonvulsant dose and gender, there was no difference between the responders and the nonresponders. The agents were generally well tolerated. This controlled investigation preliminarily suggests the efficacy of LTG in treatment-refractory affectively ill patients. Further definition of responsive subtypes and the role of these medications in the treatment of mood disorders requires additional study.

Neurogenesis and depression

The recognition that the brain continues to generate new neurons well into adulthood has made a marked impact on the field of neuroscience in general and specifically on neurobiological models of the pathogenesis of major depression. Stress, neuroendocrine activation, neurotransmitter systems, and other factors can down-regulate the process of neurogenesis and may contribute to certain morphological changes seen in depression. Evidence is emerging that antidepressant treatments may mitigate these effects by stimulating neurogenesis in particular regions of the brain. This review introduces the reader to recent literature on neurogenesis as it relates to the understanding and treatment of depression.

Bipolar depression: pharmacotherapy and related therapeutic strategies

The depressed phase of bipolar affective disorder is a significant cause of suffering, disability, and mortality and represents a major challenge to treating clinicians. This article first briefly reviews the phenomenology and clinical correlates of bipolar depression and then focuses on the major pharmacological treatment options. We strongly recommend use of mood stabilizers as the first-line treatment for the type I form of bipolar depression, largely because longer-term preventative therapy with these agents almost certainly will be indicated. Depressive episodes that do not respond to lithium, divalproex, or another mood stabilizer, or episodes that "breakthrough" despite preventive treatment, often warrant treatment with an antidepressant or electroconvulsive therapy. The necessity of mood stabilizers in the type II form of bipolar depression is less certain, aside from the rapid cycling presentation. Both experts and practicing clinicians recommend bupropion and the selective serotonin reuptake inhibitors as coequal initial choices, with venlafaxine and monoamine oxidase inhibitors, such as tranylcypromine, preferred for more resistant cases. The risk of antidepressant-induced hypomania or mania with concomitant mood stabilizer therapy is low, on the order of 5% to 10% during acute phase therapy. Additional therapeutic options and optimal durations of therapy also are discussed.

Pharmacologic agents for the treatment of acute bipolar mania

The knowledge base regarding the medical treatment of acute bipolar mania is rapidly expanding. Information about agents with established antimanic properties is increasing, and more agents with putative antimanic properties are being identified. We first review the controlled studies supporting the efficacy of the established antimanic agents lithium, valproate, and carbamazepine and standard antipsychotics. We then review available research on two important classes of drugs that are emerging as potential treatments for acute mania: the novel antipsychotics, which include clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, and the new antiepileptics, which include gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and zonisamide. We conclude that although controlled data are accumulating to support the efficacy of several atypical antipsychotics in the treatment of acute bipolar mania, particularly olanzapine, ziprasidone, and risperidone, the novel antiepileptics need more extensive study before it can be concluded that any of them possess specific antimanic properties. We also conclude that as the medical options for acute bipolar mania expand, treatment guidelines must remain both evidence based and flexible, so that they represent cutting edge medical science yet can be tailored to the specific needs of individual patients.

Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders

Until recently it was believed that no more than 1% of the general population has bipolar disorder. Emerging transatlantic data are beginning to provide converging evidence for a higher prevalence of up to at least 5%. Manic states, even those with mood-incongruent features, as well as mixed (dysphoric) mania, are now formally included in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of bipolar patients over a lifetime; current evidence supports a broader definition of mixed states consisting of full-blown mania with two or more concomitant depressive symptoms. The largest increase in prevalence rates, however, is accounted for by 'softer' clinical expressions of bipolarity situated between the extremes of full-blown bipolar disorder where the person has at least one manic episode (bipolar I) and strictly defined unipolar major depressive disorder without personal or family history for excited periods. Bipolar II is the prototype for these intermediary conditions with major depressions and history of spontaneous hypomanic episodes; current evidence indicates that most hypomanias pursue a recurrent course and that their usual duration is 1-3 days, falling below the arbitrary 4-day cutoff required in DSM-IV. Depressions with antidepressant-associated hypomania (sometimes referred to as bipolar III) also appear, on the basis of extensive international research neglected by both ICD-10 and DSM-IV, to belong to the clinical spectrum of bipolar disorders. Broadly defined, the bipolar spectrum in studies conducted during the last decade accounts for 30-55% of all major depressions. Rapid-cycling, defined as alternation of depressive and excited (at least four per year), more often arise from a bipolar II than a bipolar I baseline; such cycling does not in the main appear to be a distinct clinical subtype - but rather a transient complication in 20% in the long-term course of bipolar disorder. Major depressions superimposed on cyclothymic oscillations represent a more severe variant of bipolar II, often mistaken for borderline or other personality disorders in the dramatic cluster. Moreover, atypical depressive features with reversed vegetative signs, anxiety states, as well as alcohol and substance abuse comorbidity, is common in these and other bipolar patients. The proper recognition of the entire clinical spectrum of bipolarity behind such 'masks' has important implications for psychiatric research and practice. Conditions which require further investigation include: (1) major depressive episodes where hyperthymic traits - lifelong hypomanic features without discrete hypomanic episodes - dominate the intermorbid or premorbid phases; and (2) depressive mixed states consisting of few hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-blown major depressive episodes - included in Kraepelin's schema of mixed states, but excluded by DSM-IV. These do not exhaust all potential diagnostic entities for possible inclusion in the clinical spectrum of bipolar disorders: the present review did not consider cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden, intermittently explosive or agitated psychiatric conditions for which the bipolar connection is less established. The concept of bipolar spectrum as used herein denotes overlapping clinical expressions, without necessarily implying underlying genetic homogeneity. In the course of the illness of the same patient, one often observes the varied manifestations described above - whether they be formal diagnostic categories or those which have remained outside the official nosology. Some form of life charting of illness with colored graphic representation of episodes, stressors, and treatments received can be used to document the uniquely varied course characteristic of each patient, thereby greatly enhancing clinical evaluation.

Pharmacotherapy of depression and mixed states in bipolar disorder

The treatment of bipolar depression requires the resolution of depression and the establishment of mood stability. A basic problem is that the treatments used in treating bipolar depression were developed and proven effective for other disease states: antidepressants for unipolar depression, and mood stabilizers for mania. The panel addressed four unresolved questions regarding depression in relation to bipolar disorder: (1) the relative effectiveness of different antidepressant treatments; (2) the relative likelihood of mood destabilization with different antidepressant treatments; (3) the effectiveness and role of mood-stabilizing medicines as antidepressants; and (4) the optimal approach to mixed states. The selection of an antidepressant depends both on its relative lack of mania- or hypomania-provoking potential and on its effectiveness against bipolar depression. There is little definitive evidence distinguishing effectiveness of the major groups of antidepressive agents, so side-effect profiles and pharmacokinetics are major considerations. The underlying bipolar disorder should be treated with mood stabilizers started simultaneously with any antidepressive treatments. Lithium, divalproex sodium and carbamazepine have all been found to be helpful, to some extent, in treating bipolar depressive episodes as well as for long-term mood stabilization. There is little evidence for long-term benefits of antidepressive agents in bipolar disorder, and some evidence that they may destabilize the disorder. Therefore, in contrast to the long-term use of mood-stabilizers, antidepressant use is recommended on a temporary basis. The duration of antidepressant treatment is determined by past history in terms of liability for mood destabilization, and by the ability of the patient to tolerate gradual antidepressant discontinuation without return of depression. Mixed states, where symptoms of depression and mania coexist, are regarded as a predictor of relatively poor response to lithium, and divalproex has been found to be more effective. Carbamazepine may too be useful in mixed states. Most patients with mixed states in actual practice require combinations of mood stabilizers, though there is little controlled data regarding such co-prescription, especially from a long-term perspective.

A review of randomized, controlled clinical trials in acute mania

This review considers the evidence supporting the use of somatic therapies (medications and electroconvulsive therapy) in the treatment of acute mania associated with bipolar disorder. Data from randomized, controlled clinical trials have established the efficacy of lithium, divalproex sodium, and carbamazepine in the treatment of acute mania. The use of combinations of mood stabilizers in the treatment of acute mania has not been well examined in controlled trials. Conventional antipsychotics and some atypical antipsychotics are frequently used as initial or adjunctive treatment. Similarly, benzodiazepines are frequently used as adjunctive agents. Preliminary data suggest that some calcium channel blockers and several anticonvulsants, e.g., lamotrigine, gabapentin, and topiramate, may have therapeutic value in the treatment of acute mania. In contrast, electroconvulsive therapy is generally accepted as being highly effective despite the lack of controlled evidence.

Medication treatment of bipolar disorder 2000: a summary of the expert consensus guidelines

The original Expert Consensus Guidelines on the Treatment of Bipolar Disorder were published in 1996. Since that time, a variety of new treatments for bipolar disorder have been reported; however, evidence for these treatments varies widely, with data especially limited regarding comparisons between treatments and how to sequence them. For this reason, a new survey of expert opinion was undertaken to bridge gaps between the research evidence and key clinical decisions. The results of this new survey, which was completed by 58 experts, are presented in The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000, which was published in April 2000 as a Postgraduate Medicine Special Report. In this article, the authors describe the methodology used in the survey and summarize the clinical recommendations given in the resulting guidelines. The expert panel reached consensus on many key strategies, including acute and preventive treatment of mania (euphoric, mixed, and dysphoric subtypes), depression, rapid cycling, and approaches to managing treatment resistance and comorbid psychiatric conditions. Use of a mood stabilizer is recommended in all phases of treatment. Divalproex (especially for mixed or dysphoric subtypes) and lithium are the primary mood stabilizers for both acute and preventive treatment of mania. If monotherapy with these agents fails, the next recommended intervention is to combine them. This combination of lithium and divalproex can then serve as the foundation to which other medications are added if needed. Carbamazepine is the leading alternative mood stabilizer for mania. The experts rated the other new anticonvulsants as second-line options (i.e., their use is recommended if lithium, divalproex, and carbamazepine fail or are contraindicated). For milder depression, a mood stabilizer, especially lithium, may be used as monotherapy. Divalproex and lamotrigine are other first-line choices. For more severe depression, the experts recommend combining a standard antidepressant with lithium or divalproex. Bupropion, selective serotonin reuptake inhibitors (SSRIs), and venlafaxine are preferred antidepressants. The antidepressants should usually be tapered 2-6 months after remission. Monotherapy with divalproex is recommended for the initial treatment of either depression or mania in rapid-cycling bipolar disorder. Antipsychotics are recommended for use in combination with the above regimens for mania or depression with psychosis, and as potential adjuncts in nonpsychotic episodes. Atypical antipsychotics, especially olanzapine and risperidone, were generally preferred over conventional antipsychotics. The guidelines also include recommendations concerning the use of electroconvulsive therapy (ECT), clozapine, thyroid hormone, stimulants, and various novel agents for patients with treatment-refractory bipolar illness. The experts reached high levels of consensus on key steps in treating bipolar disorder despite obvious gaps in high-quality data. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data; however, their recommendations are generally conservative. Experts give their strongest support to initial strategies and medications for which high-quality research data or longstanding patterns of clinical usage exist. Within the limits of expert opinion and with the understanding that new research data may take precedence, these guidelines provide clear pathways for addressing common clinical questions and can be used to inform clinicians and educate patients about the relative merits of a variety of interventions.

New drugs in psychiatry

Recent years have witnessed the rapid expansion of new psychotropic agents and psychotropic applications of primarily nonpsychiatric medications in nearly all domains of psychopathology. Increasingly, patients in emergency departments may be taking newer-generation antidepressants, antipsychotics, and mood-stabilizing drugs, and individuals with treatment-resistant psychiatric disorders are often prescribed complex, polypharmaceutical regimens. Current information on the use of psychiatric medications that have entered widespread use in the past 5 to 10 years is reviewed, with focus on indications and dosing, comparisons with older medications, management of patients with overdoses and toxicity states, and the medical and psychiatric effects of newer drugs on patients who may present to emergency departments.

Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania: a prospective, randomized, double-blind, placebo-controlled, multicenter study. European Valproate Mania Study Group

To compare the efficacy of sodium valproate administered as adjunct to neuroleptic medication for patients with acute mania with the efficacy of neuroleptics alone, the authors conducted a 21-day, randomized, double-blind, parallel-group, placebo-controlled trial. The study design closely reflected a clinical psychiatric setting in Europe where patients with acute mania commonly receive neuroleptic medication. In this trial, 136 hospitalized patients met the ICD-10 criteria for acute manic episodes; these patients received a fixed dose of 20 mg/kg of body weight of sodium valproate (Orfiril, Desitin Arzneimittel GmbH, Hamburg, Germany) orally, in addition to basic neuroleptic medication, preferably haloperidol and/or perazine. The primary outcome measure was the mean dose of neuroleptic medication (after conversion into haloperidol-equivalents) for the 21-day study period. Severity of symptoms was measured using the Young Mania Rating Scale (YMRS), the Global Assessment Scale, and the Clinical Global Impression Scale. Intent-to-treat analysis was based on 69 patients treated with valproate and 67 patients who received placebo. Groups were comparable with regard to demographic and clinical baseline data. Premature discontinuations occurred in only 13% of the patients. The mean neuroleptic dose declined continuously in the valproate group, whereas only slight variations were observed in the placebo group; the difference was statistically significant (p = 0.0007) for study weeks 2 and 3. The combination of neuroleptic and valproate proved superior to neuroleptics in attempts to alleviate manic symptoms. The proportion of responders (a 50% improvement rate shown on the YMRS) was higher for the combination with valproate than for the group receiving only neuroleptics (70% vs. 46%; p = 0.005). Adverse events consisted of those known for valproate or neuroleptics; the only adverse event was asthenia, which occurred more frequently with the combination therapy. Valproate represents a useful adjunct medication for the treatment of acute manic symptoms. Valproate is beneficial because it allows the administration of fewer neuroleptic medications and produces improved and quicker remission of manic symptoms.

The role of gender in mixed mania

This article reviews the literature regarding possible gender differences in adults with mixed mania. Studies examining gender differences in the prevalence of mixed mania, biological abnormalities, suicidality, long-term outcome, and treatment response were analyzed. Data from these studies suggest that mixed mania may occur more commonly in women than in men, especially when defined by narrow criteria. There were no significant differences between men and women with mixed mania in biological abnormalities, suicidality, outcome, and treatment response.

Vagus nerve stimulation (VNS) for treatment-resistant depressions: a multicenter study

BACKGROUND

Vagus Nerve Stimulation (VNS) delivered by the NeuroCybernetic Prosthesis (NCP) System was examined for its potential antidepressant effects.

METHODS

Adult outpatients (n = 30) with nonpsychotic, treatment-resistant major depressive (n = 21) or bipolar I (n = 4) or II (n = 5; depressed phase) disorders who had failed at least two robust medication trials in the current major depressive episode (MDE) while on stable medication regimens completed a baseline period followed by NCP System implantation. A 2-week, single-blind recovery period (no stimulation) was followed by 10 weeks of VNS.

RESULTS

In the current MDE (median length = 4.7 years), patients had not adequately responded to two (n = 9), three (n = 2), four (n = 6), or five or more (n = 13) robust antidepressant medication trials or electroconvulsive therapy (n = 17). Baseline 28-item Hamilton Depression Rating Scale (HDRS(28)) scores averaged 38.0. Response rates (> or =50% reduction in baseline scores) were 40% for both the HDRS(28) and the Clinical Global Impressions-Improvement index (score of 1 or 2) and 50% for the Montgomery-Asberg Depression Rating Scale. Symptomatic responses (accompanied by substantial functional improvement) have been largely sustained during long-term follow-up to date.

CONCLUSIONS

These open trial results suggest that VNS has antidepressant effects in treatment-resistant depressions.

Vagus nerve stimulation: a new tool for brain research and therapy

Biological psychiatry has a long history of using somatic therapies to treat neuropsychiatric illnesses and to understand brain function. These methods have included neurosurgery, electroconvulsive therapy, and, most recently, transcranial magnetic stimulation. Fourteen years ago researchers discovered that intermittent electrical stimulation of the vagus nerve produces inhibition of neural processes, which can alter brain electrical activity and terminate seizures in dogs. Since then, approximately 6000 people worldwide have received vagus nerve stimulation for treatment-resistant epilepsy. We review the neurobiology and anatomy of the vagus nerve and provide an overview of the vagus nerve stimulation technique. We also describe the safety and potential utility of vagus nerve stimulation as a neuroscience research tool and as a putative treatment for psychiatric conditions. Vagus nerve stimulation appears to be a promising new somatic intervention that may improve our understanding of brain function and has promise in the treatment of neuropsychiatric disorders.

Comprehensive review of the psychiatric uses of valproate

The therapeutic effects of valproate in psychiatric conditions are most substantially recognized in bipolar disorder. However, this well-tolerated medication may be beneficial in the treatment of other mental illnesses. In this article, the authors comprehensively review studies of valproate as treatment for psychiatric conditions, including bipolar, depressive, anxiety, and psychotic disorders; alcohol withdrawal and dependence; tardive dyskinesia; agitation associated with dementia; and borderline personality disorder. Valproate shows the most promising efficacy in treating mood and anxiety disorders, with possible efficacy in the treatment of agitation and impulsive aggression, and less convincing therapeutic response in treating psychosis and alcohol withdrawal or dependence. The authors conclude with a brief summary of its mechanism of action and therapeutic spectrum.

Intravenous valproate in neuropsychiatry

Valproic acid (VPA) is administered for a variety of indications in neurology and psychiatry. The intravenous form of VPA, valproate, has been used extensively by neurologists since the 1980s for patients with status epilepticus, as serum levels can be achieved rapidly and telemetry is not required during administration. Psychiatrists have less experience with intravenous valproate, and little is documented in the literature regarding its nonepileptic indications. Patients who are unable or unwilling to take drugs orally, or for whom rapid treatment is clinically indicated, may benefit from VPA. Neuroleptics and benzodiazepines often are given parenterally; however, they may be accompanied by side effects. Intravenous valproate was administered successfully to three patients with neuropsychiatric disorders. It is hoped that this report will increase clinicians' awareness of this important and well-tolerated treatment option.

The place of anticonvulsants and other putative mood stabilisers in the treatment of bipolar disorder

While lithium is an effective mood stabiliser still in widespread clinical use, a significant proportion of patients either respond poorly or are unable to tolerate its adverse effects. In the 1960s and 1970s preliminary reports of the possible effectiveness of carbamazepine and valproate began to appear, with confirmatory controlled studies being undertaken in the 1980s and 1990s. In recent years, further putative mood-stabilising agents have been described, in particular some of the newer anticonvulsants and the atypical antipsychotics. This paper critically evaluates the current evidential basis for claims for the efficacy of these compounds in bipolar disorder.

Methodological considerations for the development of new treatments for bipolar disorder

Lithium has been the drug of choice in treating bipolar disorder for 50 years and, therefore, patterns of response associated with its use define what we expect from treatment. Although efforts to establish some other agents as antimanic have been successful, it is difficult to assess their overall efficacy in relation to that of lithium without a better understanding of inclusion/exclusion criteria, subtypes, definitions of remission, relapse and recurrence, and duration of study. All of these factors need to be carefully addressed to identify the most important clinical targets for new drug development. Additional relevant information emerges from studies on combinations of mood stabilisers, efficacy of antimanic agents in different patient populations, analysis of rates of drop-out, non-compliance, suicide, drug abuse, and discontinuation especially with long-term treatment. Agents other than lithium that are effective in the acute phase treatment are still not well characterised as mood stabilisers. New agents need to be evaluated in the context of long-term treatment and the targeting of specific components of the syndrome beyond mania.

Mania: gender, transmitter function, and response to treatment

Noradrenergic and GABA systems may be involved in mania, but there is little information about relationships between the function of these systems and response to specific antimanic treatments. We investigated relationships between indices of catecholamine or GABA system function, pretreatment mania severity and antimanic response to divalproex, lithium, or placebo. Plasma GABA and urinary excretion of catecholamine metabolites were measured before randomization to lithium, divalproex or placebo in patients hospitalized for manic episodes. Severity of mania was evaluated using the Manic Syndrome, Behavior and Ideation and Mania Rating Scale scores from the SADS-C. Multiple regression analysis showed that pretreatment plasma GABA was related to severity of manic symptoms. This relationship seemed stronger in women. Multiple regression analysis showed that pretreatment levels of urinary MHPG correlated with improvement in manic syndrome scores. These data suggest that GABA and norepinephrine may be related to different aspects of the manic state and to its pharmacologic sensitivity.

Short-term and long-term treatment for bipolar patients: beyond the guidelines

This clinical review considers the different symptomatic forms of bipolar disorders and the influence of the clinical subtype on treatment. Therapy is required both to manage the various types of acute episodes of mania or depression and to prevent recurrence. For the latter purpose, continuous long-term or even lifetime prophylaxis may be required, continuing on after control of the acute episode. In this context, the roles and potential side-effects of lithium, divalproex sodium and carbamazepine, alone and in combination, are summarized, along with the proper use of antipsychotic drugs. The selection of mood-stabilizing agent or drug combination depends on the clinical manifestations of bipolar disorder, family history and previous treatment history of the patient. Particular caution must be exercised in those with a history of antidepressant-induced switches; many such patients appear prone to course aggravation and even rapid-cycling and will often need combined mood-stabilizer combinations.

Clinical picture and etiologic models of mixed states

Although conceptualized as polar opposites, manic and depressive symptoms often co-occur in bipolar disorder. This article explores the clinical characteristics, prevalence, biologic features, and response to treatments of mixed states. Issues of diagnosis and cause are considered. The course is often protracted beyond acute episodes, psychotic symptoms are common, and suicide is a major risk. Bipolar mixed states are over represented in women. Mixed states respond poorly to lithium salts; mood stabilizers, particularly divalproex, are the mainstay of modern treatment. Electroconvulsive therapy is also effective, and can be used in severe cases.

Differential effect of number of previous episodes of affective disorder on response to lithium or divalproex in acute mania

OBJECTIVE

The authors investigated the relationship between number of lifetime episodes of affective disorder and the antimanic response to lithium, divalproex, or placebo.

METHOD

The subjects were 154 of the 179 inpatients with acute mania who entered a 3-week parallel group, double-blind study. The primary efficacy measure was the manic syndrome score from the Schedule for Affective Disorders and Schizophrenia. The relationship between improvement and number of previous episodes was investigated by using nonlinear regression analysis.

RESULTS

An apparent transition in the relationship between number of previous episodes and response to antimanic medication occurred at about 10 previous episodes. For patients who had experienced more episodes, response to lithium resembled the response to placebo but was worse than response to divalproex. For patients who had experienced fewer episodes, however, the responses to lithium and divalproex did not differ and were better than the response to placebo. This differential response pattern was not related to rapid cycling or mixed states.

CONCLUSIONS

A history of many previous episodes was associated with poor response to lithium or placebo but not to divalproex.

How knowledge of regional brain dysfunction in depression will enable new somatic treatments in the next millennium

New knowledge about the specific brain regions involved in depression is rapidly evolving due to advances in functional neuroimaging techniques. Several new regionally specific somatic interventions build on this modern neuroanatomic information. These latest methods promise to revolutionize the understanding and treatment of depression. This article reviews the past and current use of these techniques, with an eye toward where they are heading in the next century.

Anticonvulsant Use in the Treatment of Bipolar Disorder: A Primer for Primary Care Physicians

Primary care physicians may be directly or indirectly involved in the management of the bipolar patient. Bipolar affective illness is a chronic, recurrent disorder. Patients, their families and support systems, and the general public can face profound and enduring consequences if the illness is untreated or poorly treated. Consequently, increasing attention has been directed at developing treatment strategies to control symptoms associated with bipolar disorder. While lithium has been the mainstay of treatment for many years, recent investigations have demonstrated the utility of a number of anticonvulsant medications in bipolar disorder. This review will discuss the literature on anticonvulsant efficacy in bipolar disorder in light of the treatment guidelines set forth by the Bipolar Treatment Expert Consensus Panel and the American Psychiatric Association. To orient the clinician, issues related to anticonvulsant use, dosing, adverse effects, and drug interactions are also discussed.

Mood stabilizers in children and adolescents

OBJECTIVE

The efficacy of mood stabilizers in children and adolescents has not been studied adequately. This article will review existing studies and highlight some important issues in designing future studies on these agents.

METHOD

Electronic databases including Medline, Psycholnfo, and CRISP were searched for data in children receiving compounds that have mood-stabilizing properties in adults.

RESULTS

Some open clinical data and an extremely modest amount of controlled research data suggest lithium, carbamazepine, and valproate may be effective mood stabilizers in children and adolescents. There are no controlled data on other potential mood stabilizers in children.

CONCLUSIONS

The disorders that may be responsive to mood stabilizers are among the most morbid in child psychiatry. More studies are needed to clarify the efficacy of these compounds in children and adolescents and to provide a rational basis for choosing among them.

A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents

Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.

Early childhood attention deficit hyperactivity disorder predicts poorer response to acute lithium therapy in adolescent mania

We compared the response to acute lithium therapy in 30 adolescents, 13-17 years of age, with mania and a prior history of early childhood attention deficit hyperactivity disorder (ADHD) to a sex- and age-matched control group of adolescent manics without premorbid psychiatric illness. Response to treatment was assessed daily over the course of 28 days using measures of global clinical improvement and severity ratings on the Bech-Rafaelsen Mania Scale (BRMS). BRMS scores decreased by a mean of 24.3 in the subgroup without prior ADHD compared to 16.7 in patients with ADHD (P = 0.0005). The average percent drop in BRMS scores over the study period in these two subgroups was 80.6% and 57.7%, respectively (P = 0.0005). Time to onset of sustained global clinical improvement was also assessed using Kaplan-Meier survival methods and possible covariates of time to improvement were tested in a Cox proportional hazards model. Median time to onset of sustained improvement was lengthened significantly in patients with early ADHD (23 days) compared to those without it (17 days; log rank chi2 = 7.2, P = 0.007). The results suggest that early childhood ADHD defines an important source of heterogeneity in bipolar illness with developmental, clinical, and neuropharmacogenetic implications.

Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. AACAP

Child and adolescent major depressive disorder and dysthymic disorder are common, chronic, familial, and recurrent conditions that usually persist into adulthood. These disorders appear to be manifesting at an earlier age in successive cohorts and are usually accompanied by comorbid psychiatric disorders, increased risk for suicide, substance abuse, and behavior problems. In addition, depressed youth frequently have poor psychosocial, academic, and family functioning, which highlights the importance of early identification and prompt treatment. Both psychotherapy and pharmacotherapy have been found to be beneficial for the acute treatment of youth with depressive disorders. Opinions vary regarding which of these treatments should be offered first and whether they should be offered in combination. In general, the choice of initial therapy depends on clinical and psychosocial factors and therapist's expertise. Based on the current literature and clinical experience, psychotherapy may be the first treatment for most depressed youth. However, antidepressants must be considered for those patients with psychosis, bipolar depression, severe depressions, and those who do not respond to an adequate trial of psychotherapy. All patients need continuation therapy and some patients may require maintenance treatment. Further research is needed on the etiology of depression; the efficacy of different types of psychotherapy; the differential effects of psychotherapy, pharmacotherapy, and integrated therapies; the continuation and maintenance treatment phases; treatment for dysthymia, treatment-resistant depression, and other subtypes of major depressive disorder; and preventive strategies for high-risk children and adolescents.

Gender, temperament, and the clinical picture in dysphoric mixed mania: findings from a French national study (EPIMAN)

BACKGROUND

This research derives from the French national multisite collaborative study on the clinical epidemiology of mania (EPIMAN). Our aim is to establish the validity of dysphoric mania along a "spectrum of mixity" extending into mixed mania with subthreshold depressive manifestations; to demonstrate the feasibility of obtaining clinically meaningful data on this entity on a national level; and to characterize the contribution of temperamental attributes and gender in its origin.

METHODS

EPIMAN involves training 23 French psychiatrists in four different sites, representing four regions of France; to rigorously apply a common protocol deriving from the criteria of DSM-IV and McElroy et al.; the use of such instruments as the Beigel-Murphy, Ahearn-Carroll, modified HAM-D; and measures of affective temperaments based on the Akiskal-Mallya criteria; obtaining data on comorbidity, and family history (according to Winokur's approach as incorporated into the FH-RDC); and prospective follow-up for at least 12 months. The present report concerns the clinical and temperamental features of 104 manic patients during the acute hospital phase.

RESULTS

Dysphoric mania (DM defined conservatively with fullblown depressive admixtures of five or more symptoms) occurred in 6.7%; the rate of dysphoric mania defined broadly (DM, presence of > or = 2 depressive symptoms) was 37%. Depressed mood and suicidal thoughts had the best positive predictive values for mixed mania. In comparison to pure mania (0-1 depressive symptoms), DM was characterized by female over-representation; lower frequency of such typical manic symptomatology as elation, grandiosity, and excessive involvement; higher prevalence of associated psychotic features; higher rate of mixed states in first episodes; and complex temperamental dysregulation along primarily depressive, but also cyclothymic, and irritable dimensions; such irritability was particularly apparent in mixed mania at the lowest threshold of depressive admixtures of two symptoms only.

LIMITATION

In a study involving hospitalized affectively unstable psychotic patients, it was difficult to assure that psychiatrists making the clinical diagnoses would be blind to the temperamental measures. However, bias was minimized by the systematic and/or semi-structured nature of all evaluations.

CONCLUSIONS

Mixed mania, defined cross-sectionally by the simultaneous presence of at least two depressive symptoms, represents a prevalent and clinically distinct form of mania. Subthreshold depressive admixtures with mania actually appear to represent the more common expression of dysphoric mania. Moreover, an irritable dimension appears to be relevant to the definition of the expression of mixed mania with the lowest threshold of depressive symptoms. Neither an extreme, nor an endstage of mania, "mixity" is best conceptualized as intrusion of mania into its "opposite" temperament - especially that defined by lifelong depressive traits - and favored by female gender. These data suggest that reversal from a temperament to an episode of "opposite" polarity represents a fundamental aspect of the dysregulation that characterizes bipolar disorder. In both men and women with hyperthymic temperament, there appears "protection" against depressive symptom formation during a manic episode which, accordingly, remains relatively "pure". Because men have higher rates of this temperament, pure mania is overrepresented in men; on the other hand, the depressive temperament in manic women seems to be a clinical marker for the well-known female tendency for depression, hence the higher prevalence of mixed mania in women.

Drug treatment of mania: a critical review

While lithium is generally considered to be a first-line treatment for mania, the position of the anticonvulsants and the antipsychotics in the treatment of this disorder is currently under debate. For that reason, this paper reviews the original literature, in particular addressing the randomized controlled trials (RCTs) on lithium, anticonvulsants and antipsychotics, and the methodological limitations therein. As the treatment of mania needs to anticipate the future course of the illness, the data on prophylaxis will also be reviewed, albeit briefly. It is concluded that antipsychotics are powerful antimanics, which are particularly beneficial for some clinical presentations of severe mania. However, in general their use should not be prolonged into the maintenance phase. Lithium is still to be considered the mood-stabilizing drug par excellence, although it may be insufficient in mixed states and severe mania. The evidence for antimanic efficacy of valproate, in particular for mixed states, seems more convincing than that for carbamazepine, while the evidence for a prophylactic action of carbamazepine still exceeds that for valproate. Adjunctive treatment with benzodiazepines is often useful. Small sample sizes, highly selected study populations and high drop-out rates seem to be the most important limitations of the RCTs on mania. Quasi-experimental, naturalistic studies on unselected populations are needed to investigate how the various treatments work in clinical practice. Based on the available evidence, summary guidelines for treatment are proposed.

Lithium plus valproate as maintenance polypharmacy for patients with bipolar I disorder: a review

Standard pharmacotherapy for the maintenance treatment of patients with bipolar I disorder consists of lithium, valproate, or carbamazepine. However, many patients fail to respond to monotherapy with any of these agents, and as a result, psychiatrists often resort to polypharmacy. Findings from some open-label trials and retrospective chart reviews suggest this approach may be useful, but in the few controlled trials that have been conducted, the results have been negative. One drug combination that warrants further study as maintenance therapy is lithium plus valproate. Each is approved by the U.S. Food and Drug Administration for treatment of acute mania, and lithium has demonstrated efficacy for maintenance treatment as well. Some preliminary evidence suggests that the combination can be effective for patients who do not respond to monotherapy, and it seems to be no more dangerous than monotherapy. Concomitant administration of lithium plus valproate does not significantly alter lithium pharmacokinetics, and statistically significant changes that arise in valproate pharmacokinetics are not clinically significant. Although it is not known whether the drugs interact to augment response, many of their effects in the central nervous system do differ, and there is no indication of pharmacodynamic interactions that oppose each other. Finally, some evidence suggests that lithium and valproate may differ with regard to clinical variables that predict response to treatment.

Postpartum mood disorders: clinical perspectives

Mood disorders are common in women. A prepregnancy personal history of mood disorder (bipolar or major depression), premenstrual syndrome, or (possibly) postpartum blues places a woman at high risk for a postpartum exacerbation of symptoms. Untreated or unrecognized postpartum mood disorders can lead to serious psychologic and social consequences, in some cases even leading to suicide or infanticide. Women at risk for postpartum mood disorders need to be referred for psychiatric consultation before pregnancy and parturition. Informed, professional collaboration offers the best opportunities for prevention, as well as the earliest recognition and treatment of emergent symptoms.

Clinical subtypes of bipolar mixed states: validating a broader European definition in 143 cases

OBJECTIVE

To validate and clinically characterize mixed bipolar states derived from the concepts of Kraepelin and the Vienna School and defined as sustained instability of affective manifestations of opposite polarity--that usually fluctuate independently of one another--in the setting of marked emotional perplexity.

METHOD

Our criteria for mixed states represent a modified "user-friendly" operationalization of these classical concepts. We compared 143 mixed state patients, so defined, with 118 DSM III-R manic patients, systematically evaluated with the Semistructured Interview for Depression (SID) in our in-patient and day-hospital facilities.

RESULTS

The two groups were comparable from demographic and familial standpoints (including family history for bipolar disorder). Mixed states were predominant in the past history of index mixed patients who were more likely to have experienced stressors and to have attempted suicide; manic and hypomanic episodes were more common in the past history of the index manic patients who, in addition, had more episodes and hospitalizations. Although rates of chronicity and rapid cycling were not significantly different in the two groups, the modal episodes in the mixed states were 3-6 months, and in mania they were less than 3 months. Two thirds of both groups arose from a dysregulated baseline temperamental dysregulation, which in manics, was largely hyperthymic, and in mixed patients, was both hyperthymic and depressive. Of our 143 mixed states, only 54% met the DSM III-R criteria for mixed states (which conformed to "dysphoric mixed mania"); of the remaining, 17.5% could be described as "mixed agitated psychotic depressive states" with irritable mood and flight of ideas, and 26% as "unproductive-inhibited manic" with fatigue and indecisiveness. The family history and course of these "non-DSM III-R" mixed states were essentially similar to DSM III-R mixed states.

LIMITATION

Family history could not be obtained blind to clinical status in patients with severe psychotic mood states.

CLINICAL RELEVANCE

These data favor the classical European approach to mixed states over the grossly under-inclusive current official diagnostic systems.

CONCLUSION

The phenomenology of mixed states is more than the mere superposition of opposite affective symptoms and, in many instances, it represents an expansive-excited phase intruding into a depressive temperament, and a melancholic episode intruding into a hyperthymic temperament.