Adjunctive use of modafinil in bipolar patients: just another stimulant or not?

A Medical Resident with a History of Alcohol Abuse and Suicidal Ideation: A Challenge for Both Psychiatry and Occupational Medicine in the Context of the First Wave of the COVID-19 Pandemic

This case study draws attention to the hazards of physicians with a history of alcohol addiction and a particular psychopathology framework in the context of occupational health surveillance, particularly during the challenging working conditions brought about by the COVID-19 pandemic. The case involves a hospital resident in her thirties, with a previous history of addiction and attempts at suicide, who was assigned to a COVID-19 unit of an Italian hospital. In this case study, we discuss the preventive intervention put in place in order to protect physicians' health and work. What emerges is the key role that rapid substantive communications between specialists play in formulating an effective strategy for dealing with these conditions. We believe this case is noteworthy for the lessons that can be learned for tailoring prevention and treatment pathways for health care workers with addiction.

Use of adjunctive stimulants in adult bipolar depression

Bipolar depression represents a high priority research field, due to its pervasiveness, and high economic and personal (suicidality, impaired function, quality of life) costs, and the limited evidence base to inform therapeutics. Mood stabilizers and second-generation antipsychotics for bipolar depression are commonly only partially effective, and their side-effects may overlap with depressive symptoms such as hypersomnia, daytime drowsiness, fatigue, psychomotor retardation, and weight gain. Moreover, the use of antidepressants in bipolar depression is controversial due to concerns regarding the risks of inefficacy or switching to mood elevation. Stimulants and related compounds such as modafinil and armodafinil have on occasion been used as adjuncts in bipolar depressed patients with encouraging results, but their use is limited by the paucity of systematic evidence of efficacy and safety. The present review aims to provide an updated perspective on the use of stimulants and stimulant-like medications in adult bipolar depression, considering not only recent randomized controlled trials, but also open naturalistic studies, in order to clarify the strengths and limitations of using these agents.

Pharmacological treatments for bipolar disorder: present recommendations and future prospects

In selecting and adapting medications to treat the specific clinical features of a patient with bipolar disorder (BPD) over time, a foundation strategy is to have good working knowledge of up-to-date practice guidelines. The World Federation of Societies of Biological Psychiatry Guidelines has the reasoned advantage of weighing safety/tolerability as high as efficacy. Most successful treatments for BPD start to separate from placebo within 1 week; most differences between regimens occur within the first 4 weeks. This observation extrapolates to a strategy of discontinuing or adding a second drug for symptoms unimproved within 1 month of treatment initiation. The weight of evidence argues against starting treatment with combination regimens, despite evidence that over time most patients do receive combination drug regimens and appear to tolerate them well. The current design paradigm for adjunctive trials generally strongly weights trials in favor of the sponsor drug.Well managed, BPD is often compatible with fully good health, both symptomatically and functionally. Consequently, for whatever regimens are found to accomplish excellent symptom control, it is important to achieve regimens that are well tolerated by all bodily systems. This chapter emphasizes the tactics needed to accomplish this specific to individual medications. The chapter also addresses the serious, broad failure of pharmaceutical companies to develop new drugs with novel mechanisms for BPD therapy and proposes a series of steps that might reenergize drug development to the benefit of psychiatrists and patients alike.

Mania and attention-deficit/hyperactivity disorder: common symptomatology, common pathophysiology and common treatment?

PURPOSE OF REVIEW

Attention-deficit/hyperactivity disorder (ADHD) and mania show broad symptom overlap, and high comorbidity exists between ADHD and bipolar disorder. This raises the question concerning common neurobiological pathomechanisms and concerning common treatments.

RECENT FINDINGS

On genetic, biochemical, electrophysiological, brain morphological and neuropsychological levels, the commonalities of ADHD and mania and the commonalities between ADHD and bipolar disorder (independent of manic state) are outlined. An intriguing finding is that both ADHD and mania are characterized by an unstable wakefulness regulation assessed by EEG measures of vigilance, by ratings of sleepiness and by deficits in sustained attention tasks. In both mania and ADHD, this unstable wakefulness regulation is supposed to be a central pathogenetic factor leading to attention deficits and inducing the hyperactive, impulsive and sensation-seeking behavior as an autoregulatory attempt to stabilize wakefulness by increasing external stimulation. Evidence is accumulating to suggest that psychostimulants do not have a high risk of triggering or aggravating mania, but might even be a treatment option in acute mania.

SUMMARY

ADHD and mania share many symptoms and several pathogenetic aspects. The common belief that stimulants are contraindicated in mania has been challenged, and controlled trials to study the possible antimanic effects of vigilance-stabilizing drugs such as stimulants are justified and necessary.