Predictors of lithium prophylaxis in bipolar patients

Lifetime and point prevalence of psychotic symptoms in adults with bipolar disorders: a systematic review and meta-analysis

Psychotic symptoms, that we defined as delusions or hallucinations, are common in bipolar disorders (BD). This systematic review and meta-analysis aims to synthesise the literature on both lifetime and point prevalence rates of psychotic symptoms across different BD subtypes, including both BD type I (BDI) and BD type II (BDII). We performed a systematic search of Medline, PsycINFO, Embase and Cochrane Library until 5 August 2021. Fifty-four studies (N = 23 461) of adults with BD met the predefined inclusion criteria for evaluating lifetime prevalence, and 24 studies (N = 6480) for evaluating point prevalence. Quality assessment and assessment of publication bias were performed. Prevalence rates were calculated using random effects meta-analysis, here expressed as percentages with a 95% confidence interval (CI). In studies of at least moderate quality, the pooled lifetime prevalence of psychotic symptoms in BDI was 63% (95% CI 57.5-68) and 22% (95% CI 14-33) in BDII. For BDI inpatients, the pooled lifetime prevalence was 71% (95% CI 61-79). There were no studies of community samples or inpatient BDII. The pooled point prevalence of psychotic symptoms in BDI was 54% (95 CI 41-67). The point prevalence was 57% (95% CI 47-66) in manic episodes and 13% (95% CI 7-23.5) in depressive episodes. There were not enough studies in BDII, BDI depression, mixed episodes and outpatient BDI. The pooled prevalence of psychotic symptoms in BDI may be higher than previously reported. More studies are needed for depressive and mixed episodes and community samples.Prospero registration number: CRD 42017052706.

Socio-demographic and clinical predictors of outcome to long-term treatment with lithium in bipolar disorders: a systematic review of the contemporary literature and recommendations from the ISBD/IGSLI Task Force on treatment with lithium

Objective

To identify possible socio-demographic and clinical factors associated with Good Outcome (GO) as compared with Poor Outcome (PO) in adult patients diagnosed with Bipolar Disorder (BD) who received long-term treatment with lithium.

Methods

A comprehensive search of major electronic databases was performed to identify relevant studies that included adults patients (18 years or older) with a diagnosis of BD and reported sociodemographic and/or clinical variables associated with treatment response and/or with illness outcome during long-term treatment to lithium (> = 6 months). The quality of the studies was scored using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institute of Health.

Results

Following review, 34 publications (from 31 independent datasets) were eligible for inclusion in this review. Most of them (n = 25) used a retrospective design. Only 11 studies were graded as good or borderline good quality. Forty-three potential predictors of outcome to lithium were identified. Four factors were associated with PO to lithium: alcohol use disorder; personality disorders; higher lifetime number of hospital admissions and rapid cycling pattern. Two factors were associated with GO in patients treated with lithium: good social support and episodic evolution of BD. However, when the synthesis of findings was limited to the highest (good or borderline good) quality studies (11 studies), only higher lifetime number of hospitalization admissions remained associated with PO to lithium and no associations remained for GO to lithium.

Conclusion

Despite decades of research on lithium and its clinical use, besides lifetime number of hospital admissions, no factor being consistently associated with GO or PO to lithium was identified. Hence, there remains a substantial gap in our understanding of predictors of outcome of lithium treatment indicating there is a need of high quality research on large representative samples.

Clinical correlates associated with the long-term response of bipolar disorder patients to lithium, valproate or lamotrigine: A retrospective study

Background

Although mood stabilizers such as lithium (LIT), valproate (VAL), and lamotrigine (LMT) appear to be efficacious treatments for bipolar disorder (BD) in research settings, the long-term response to these mood stabilizers in clinical practice is highly variable among individuals. Thus, the present study examined the characteristics associated with good or insufficient responses to long-term treatment with LIT, VAL, or LMT for BD.

Methods

This study retrospectively analyzed the medical records of patients who visited an outpatient clinic with a diagnosis of BD I or II. Data from patients who were treated with one of three mood stabilizing medications (LIT, VAL, or LMT) for more than 6 months were selected, and the long-term treatment responses were evaluated using the Alda scale. For the purposes of this study, two response categories were formed: insufficient response (ISR), including non-response or poor response (Alda total score ≤ 6), and good response (GR; Alda total score ≥ 7).

Results

Of the 645 patients included in the present study, 172 were prescribed LIT, 320 were prescribed VAL, and 153 were prescribed LMT for at least 6 months. A binary logistic regression analysis revealed that a diagnosis of BD II (odds ratio [OR], 8.868; 95% confidence interval [CI], 1.123–70.046; p = 0.038), comorbid alcohol/substance use disorder (OR, 4.238; 95% CI, 1.154–15.566; p = 0.030), and a history of mixed episodes (OR, 4.363; 95% CI, 1.191–15.985; p = 0.026) were significant predictors of LIT-ISR. Additionally, a depressive-predominant polarity significantly predicted LMT-GR (OR, 8.586; 95% CI, 2.767–26.644; p < 0.001).

Conclusion

The present findings demonstrated that patients with a diagnosis of BD II, a comorbid alcohol/substance problem, or a history of mixed episodes were not likely to respond to LIT treatment. Additionally, LMT might be a better treatment choice for patients with a depressive-predominant polarity.

A systematic review and meta-analysis of clinical predictors of lithium response in bipolar disorder

OBJECTIVE

To determine clinical predictors of lithium response in bipolar disorder.

METHODS

Systematic review of studies examining clinical predictors of lithium response was conducted. Meta-analyses were performed when ≥2 studies examined the same potential predictor.

RESULTS

A total of 71 studies, including over 12 000 patients, identified six predictors of good response: mania-depression-interval sequence [odds ratio (OR): 4.27; 95% CI: 2.61, 6.97; P < 0.001], absence of rapid cycling (OR for rapid cycling: 0.30; 95% CI: 0.17, 0.53; P < 0.001), absence of psychotic symptoms (OR for psychotic symptoms: 0.52; 95% CI: 0.34, 0.79; P = 0.002), family history of bipolar disorder (OR: 1.61; 95% CI: 1.03, 2.52; P = 0.036), shorter prelithium illness duration [standardised mean difference (SMD): -0.26; 95% CI: -0.41, -0.12; P < 0.001] and later age of onset (SMD: 0.17; 95% CI: 0.02, 0.36; P = 0.029). Additionally, higher body mass index was associated with poor response in two studies (SMD: -0.61; 95% CI: -0.90, -0.32; P < 0.001). There was weak evidence for number of episodes prior to lithium treatment (SMD: -0.42; 95% CI: -0.84, -0.01; P = 0.046), number of hospitalisations before lithium (SMD: -0.40; 95% CI: -0.81, 0.01; P = 0.055) and family history of lithium response (OR: 10.28; 95% CI: 0.66, 161.26; P = 0.097).

CONCLUSIONS

The relative importance of these clinical characteristics should be interpreted with caution because of potential biases and confounding.

Assessing treatment response to prophylactic lithium use in patients with bipolar disorder

ABSTRACT Objetive To identify potential clinical and epidemiological predictors of long-term response to lithium treatment. Methods A total of 40 adult outpatients followed in an university hospital, with confirmed diagnosis of bipolar disorder and with history of lithium use for at least a six months period, had their response to this medication assessed through the use of a standardized instrument. The ALDA scale is based on retrospective clinical data, in our study assessed through a thoroughly reviewed of the medical charts, and is used to evaluate the clinical improvement with the treatment (Criterion A), corrected by the acknowledgement of possible confounding factors, such as duration of the treatment, compliance and concomitant use of additional medications (Criterion B), in order to estimate the response that can be specifically attributable to lithium. Results Our study found an inverse relation between the number of mood episodes with psychotic symptoms and lithium treatment outcome. Conclusion The results reinforce the hypothesis that lithium seems to be less efficacious in patients with bipolar disorder who present psychotic symptoms.

First-episode types in bipolar disorder: predictive associations with later illness

OBJECTIVE

Characteristics of initial illness in bipolar disorder (BD) may predict later morbidity.

METHOD

We reviewed computerized clinical records and life charts of DSM-IV-TR BD-I or BD-II patients at affiliated mood-disorder centers to ascertain relationships of initial major illnesses to later morbidity and other clinical characteristics.

RESULTS

Adult BD patient-subjects (N=1081; 59.8% BD-I; 58.1% women; 43% ever hospitalized) were followed 15.7±12.8 years after onsets ranking: depression (59%)>mania (13%)>psychosis (8.0%)≥anxiety (7.6%)≥hypomania (6.7%)>mixed states (5.5%). Onset types differed in clinical characteristics and strongly predicted later morbidity. By initial episode types, total time-ill ranked: mania≥hypomania≥mixed-states≥psychosis>depression>anxiety. Depression was most prevalent long-term, overall; its ratio to mania-like illness (D/M, by per cent-time-ill) ranked by onset type: anxiety (4.75)>depression (3.27)>mixed states (1.39)>others (all<1.00). The MDI (mania or hypomania-depression-euthymia interval) course-pattern was most common (34.4%) and associated with psychotic or manic onset; the depression before mania (DMI) pattern (25.0%) most often followed anxiety (38.8%), depression (30.8%), or mixed onsets (13.3%); both were predicted by initial mania depression sequences.

CONCLUSION

First-lifetime illnesses and cycles predicted later morbidity patterns among BD patients, indicating value of early morbidity for prognosis and long-term planning.

Predictors of lithium response in bipolar disorder

While lithium is generally regarded as the first-line agent for patients with bipolar disorder, it does not work for everyone, which raises the question: can we predict who will be most likely to respond? In this paper, we review the most compelling clinical, biologic, and genetic predictors of lithium response in bipolar disorder. Among clinical factors, the strongest predictors of good response are fewer hospitalizations preceding treatment, an episodic course characterized by an illness pattern of mania followed by depression, and a later age at onset of bipolar disorder. While several biologic predictors have been studied, the results are preliminary and require replication with studies of larger patient samples over longer observation periods. Neuroimaging is a particularly promising method given that it might concurrently illuminate pathophysiologic underpinnings of bipolar disorder, the mechanism of action of lithium, and potential predictors of lithium response. The first genome-wide association study of lithium response was recently completed. No definitive results emerged, perhaps because the study was underpowered. With major new initiatives in progress aiming to identify genes and genetic variations associated with lithium response, there is much reason to be hopeful that clinically useful information might be generated within the next several years. This could ultimately translate into tests that could guide the choice of mood-stabilizing medication for patients. In addition, it might facilitate pharmacologic research aimed at developing newer, more effective medications that might act more quickly and yield fewer side effects.

Impact of psychotic features on morbidity and course of illness in patients with bipolar disorder

OBJECTIVE

In this study, we aimed to compare the clinical features and response patterns to the long-term prophylaxis of bipolar patients with or without psychotic features.

METHOD

The life charts of patients with bipolar I disorder were evaluated. Two hundred and eighty-one patients who suffer with bipolar disorder for at least 4 years and who had at least three mood episodes were included to the study. The patients whose all episodes are psychotic (psychotic group) and the patients who never experienced psychotic episode (non-psychotic group) were assigned as comparison groups. The clinical features and the response to long-term prophylaxis were compared across the groups.

RESULTS

The psychotic group consists of 43 patients; non-psychotic group consists of 54 patients. The history of bipolar disorder among the first-degree relatives was remarkably more prevalent in non-psychotic group (p=0.032). The predominance of manic/hypomanic episodes was significantly higher in psychotic group than non-psychotic group; and the rate of depressive episodes were higher in non-psychotic group than psychotic group (p=0.013). Episodes were more severe (p<0.001) and hospitalization rates were higher (p=0.023) in psychotic group. The response to lithium monotherapy was better in non-psychotic group (p<0.001).

CONCLUSION

The well identified psychotic subtype of bipolar patients may give important predictions about long term course and prophylaxis of bipolar disorder.

Effects of treatment latency on response to maintenance treatment in manic-depressive disorders

OBJECTIVES

To further test the hypothesis that past illness episodes and delay of long-term treatment do not limit maintenance treatment response among patients with manic-depressive illnesses (MDI).

METHODS

In a sample of 764 MDI patients in Cagliari and Berlin, 77% of whom had bipolar disorder (BPD), we: (i) correlated treatment latency or pretreatment episode counts versus hospitalized morbidity during treatment; (ii) correlated treatment duration versus pretreatment morbidity; (iii) correlated treatment latency versus pretreatment or treated morbidity; (iv) modeled factors associated with longer treatment latency; (v) compared treatment latencies at extremes of treatment outcomes, and (vi) compared pretreatment morbidity within 2 years of the longest versus shortest treatment latency quartiles.

RESULTS

Pretreatment morbidity was strongly correlated with shorter treatment latency, but morbidity during treatment was unrelated to treatment latency, pretreatment episode counts, sex, diagnosis, treatment type or treatment duration. In multivariate modeling, treatment latency was longer among patients who had experienced an early onset of illness, mainly in depressive disorders (BPD II and major depression) and among women, but was unrelated to morbidity during treatment. Patients with no illness recurrences during treatment and those who were ill at least 50% of the time had similar treatment latencies. Pretreatment morbidity occurring just prior to the initiation of long-term treatment was very similar at the highest and lowest treatment latencies.

CONCLUSIONS

These findings support the therapeutically favorable conclusion that prior episode counts and treatment delay have little association with morbidity during prophylaxis with mood-stabilizing agents. Comparisons of morbidity during versus before treatment in episodic disorders are misleading because overall morbidity becomes diluted with longer time-at-risk, whereas therapeutic intervention is typically determined by immediately preceding illness.

Which clinical factors predict response to prophylactic lithium? A systematic review for bipolar disorders

OBJECTIVES

The aim of this study was to systematically integrate the available evidence on response prediction to prophylactic lithium based on clinical factors.

METHODS

Each clinical variable that was related to lithium response in at least one prior study was examined with respect to response prediction. If several studies were located for the same variable, results were integrated using the meta-analytic approach as suggested by DerSimonian and Laird which was developed for substantial heterogeneity in primary studies.

RESULTS

Of 42 potential clinical predictors investigated, five variables were identified as possible response predictors of prophylactic lithium: [1] An episodic pattern of mania-depression-interval, and [2] a high age of illness onset were identified as potentially protective against a recurrence under lithium. [3] A high number of previous hospitalizations, [4] an episodic pattern of depression-mania-interval, and [5] continuous cycling were identified as potential risk factors. Six further variables were found to be significantly related to lithium response, though calculation of fail-safe numbers indicates that current evidence is not sufficient to hold these variables as reliable predictors of lithium response. All effect-sizes relating clinical predictors to response were small to moderate.

CONCLUSIONS

Although a few variables are quite robustly supported as response-predictors in this review, a more in-depth analysis of each potential predictor is needed. As none of the potential predictors had a very strong impact on response, prediction of lithium response should be based on a multitude of variables.

Predicting response to lithium in mood disorders: role of genetic polymorphisms

Lithium is considered to be the first choice mood stabilizer in recurrent mood disorders. Its widespread and large-scale use is the result of its proven efficacy. In spite of this fact, patients have been observed to show a variable response to lithium treatment: in some cases it is completely effective in preventing manic or depressive relapses, while in other cases it appears to show no influence on the disease course. The possible definition of a genetic liability profile for adverse effects and efficacy will be of great help, as lithium therapy needs at least 6 months to be effective in stabilizing mood disorders. During the last few years, a number of groups have reported possible liability genes. Lithium long-term prophylactic efficacy has been associated with serotonin transporter protein, tryptophan hydroxylase and inositol polyphosphate 1-phosphatase variants. A number of other candidate genes and anonymous markers did not yield positive associations. Therefore, even if some positive results have been reported, no unequivocal susceptibility gene for lithium efficacy has been identified. Although the available data may not currently allow a meaningful prediction of lithium response, future research is aimed at the development of individualized treament of mood disorders, including the possibility of 'pharmacological genetic counseling'.

Treatment-latency and previous episodes: relationships to pretreatment morbidity and response to maintenance treatment in bipolar I and II disorders

OBJECTIVE

To clarify relationships of treatment delay and pretreatment episode count with pretreatment morbidity and responses to maintenance treatments in bipolar disorders.

METHODS

In 450 DSM-IV bipolar I (n = 293) or II (n = 157) patients (280 women, 170 men), we evaluated correlations of latency from illness-onset to starting maintenance treatment and pretreatment episode counts with pretreatment morbidity and treatment response. We considered morbidity measures before and during treatment, and their differences.

RESULTS

Latency averaged 7.8 years, with 9.0 episodes per patient, before various maintenance treatments started. Morbidity (percentage of time-ill, episodes per year, first wellness-interval, or proportion of subjects hospitalized or having no recurrences) during maintenance treatment averaging 4.2 years was unrelated to treatment latency or pretreatment episode count. However, pretreatment morbidity was greater with shorter latency, resulting in larger relative reduction of morbidity after earlier treatment.

CONCLUSIONS

Greater treatment latency and pretreatment episode count were not followed by greater morbidity during treatment, although longer delay yielded smaller during-versus-before treatment reduction in morbidity. Predictions that longer treatment delay or more pretreatment episodes lead to poorer responses to various maintenance treatments in bipolar I or II disorder were not supported.

Unipolar mania: a distinct disorder?

BACKGROUND

This study aimed to identify the differences between unipolar mania and classical bipolar disorder.

METHODS

Patients with at least four manic episodes and at least 4 years of follow-up without any depressive episodes were classified as unipolar mania. This group was compared to other bipolar-I patients defined according to DSM-IV regarding their clinical and socio-demographic variables.

RESULTS

The rate for unipolar mania as defined by the study criteria was found to be 16.3% in the whole group of bipolar-I patients. Unipolar manic patients tended to have more psychotic features and be less responsive to lithium prophylaxis compared to other bipolar-I patients.

LIMITATIONS

Because it was a retrospective study, there may be some minor depressive episodes left unrecorded in the unipolar mania group despite careful and thorough investigation. In addition, even with our fairly strict criteria for the diagnosis of unipolar mania, the possibility of a future depressive episode cannot be excluded.

CONCLUSIONS

Unipolar mania may be the presentation of a nosologically distinct entity.

O papel dos antipsicóticos atípicos no tratamento do transtorno bipolar: revisão da literatura

Estudos recentes têm demonstrado que a eficácia do lítio é significativamente inferior à descrita pelos primeiros trabalhos, embora ainda seja a medicação de referência no tratamento do transtorno afetivo bipolar. Apesar de um perfil de segurança desfavorável, os antipsicóticos clássicos sempre apresentaram um papel importante no tratamento desse transtorno psiquiátrico, especialmente como coadjuvante em sua fase maníaca aguda. Os autores, utilizando informação obtida no Medline, fizeram uma revisão acerca do papel dos antipsicóticos atípicos no tratamento dos pacientes bipolares. Baseado nos dados da literatura, a olanzapina mostrou-se bastante eficaz no manejo da mania aguda, quando uma média de 63,5% dos pacientes apresentaram melhora significativa em estudos duplo-cego controlados, apresentando ganho de peso como único efeito colateral relevante. A clozapina e, mais ainda, a risperidona apresentaram dados menos consistentes, grande parte em função de deficiências metodológicas dos poucos estudos conduzidos até o presente estudo. Os dados preliminares relativos à eficácia desse grupo farmacológico nos quadros refratários e nos sintomas depressivos são promissores, mas ainda não definitivos. Em relação a seus efeitos potenciais como estabilizadores do humor, não existem evidências conclusivas oriundas de estudos controlados, mas há interesse considerável para realização de investigações em pacientes bipolares tratados com antipsicóticos atípicos por períodos de tempo mais prolongados. Pesquisas futuras poderão tornar mais claras essas possíveis características terapêuticas.

Lithium long-term treatment in mood disorders: clinical and genetic predictors

Lithium is the most widely used long-term treatment for recurrent mood disorders. Despite its proven efficacy, patients show a variable response, ranging from complete efficacy to no influence at all. This paper reviews possible predictors of response focusing on molecular genetic studies. The functional polymorphism in the upstream regulatory region of the serotonin transporter gene (5-HTTLPR) has been associated with lithium long-term efficacy in two independent studies, marginal associations have been reported for tryptophan hydroxylase and inositol polyphosphate 1-phosphatase (INPP1). A number of other candidate genes and anonymous markers did not yield positive associations. Therefore, even though some positive results have been reported, no unequivocal susceptibility gene for lithium efficacy has been identified.