Tryptophan for treatment of rapid-cycling bipolar disorder comorbid with fibromyalgia

Rapid cycling bipolar disorder: Literature review on pharmacological treatment illustrated by a case report on ketamine

INTRODUCTION

Rapid cycling bipolar disorder (RCBD) is defined as four or more affective episodes (depression, mania or hypomania) within 1 year. RCBD has a high point of prevalence (from 10% to 20% among clinical bipolar samples) and is associated with greater severity, longer illness duration, worse global functioning and higher suicidal risk, but there is no consensus on treatment option. The use of several pharmacological agents has been reported (levothyroxine, antipsychotics, antidepressants and mood stabilizers).

OBJECTIVE

The main objective of this review was to propose a critical review of the literature and to rank the pharmacological agent using a level of evidence (LEO) adapted from the Center for Evidence-Based Medicine, and to illustrate it with a case report on off-label intravenous ketamine.

METHOD

We conducted a review using the MeSH terms and keywords (bipolar [Title/Abstract]) AND (rapid [Title/Abstract]) AND (cycling [Title/Abstract]) AND (treatment [Title/Abstract]). Alexis Bourla and Stéphane Mouchabac screened 638 documents identified through literature search in Medline (PubMed) or by bibliographic references and 164 abstracts were then analyzed. Nonpharmacological treatments were excluded.

RESULT

Seventy articles were included in the review and divided into six categories: mood stabilizers, antipsychotics, hormonal treatments, ketamine and other pharmacological treatments.

DISCUSSION

Our review highlights the heterogeneity of the pharmacological treatment of RCBD and no clear consensus can emerge.

The high frequency of manic symptoms in fibromyalgia does influence the choice of treatment?

BACKGROUND

Mood disorders were found associated with fibromyalgia (FM) and clinical studies have revealed the efficacy of antidepressant drugs in the treatment of FM. However no specific instruments to identify manic symptoms were used.

OBJECTIVES

To assess the frequency of anxiety and mood disorders (particularly bipolar disorders and manic symptoms) in a consecutive sample of women affected by FM using standardized diagnostic tools and to compare the prevalence of these disorders with that observed in a sample of healthy controls from the general population.

METHODS

CASES

consecutive series of women (N = 37, mean age 50.1 +/- 21.0) attending a Rheumatology outpatient Unit at the University of Cagliari.

CONTROLS

148 women, drawn from the data bank of an epidemiological study matched for sex and age with controls according to a randomisation "after blocks" method. The Italian version of the Composite International Diagnostic Interview Simplified were carried out by physicians. Psychiatric diagnosis was formulated according to DSM-IV criteria. The Italian version of the Mood Disorder Questionnaire (MDQ) was administered to identify manic symptoms and bipolar disorders. Diagnosis of FM were carried out by rheumatologist according to the criteria of American College of Rheumatology.

RESULTS

Subjects with FM showed a higher comorbidity with Generalised Anxiety Disorder, Panic Disorder and Major Depressive Disorder than controls. The study showed a high frequency of manic symptoms (MDQ positive) in the sample of fibromyalgic patients (59%), approximately double that found in the control sample (P < 0.001).

DISCUSSION

Clinical studies have shown the efficacy of antidepressants, especially tricyclic antidepressants, in the treatment of FM. The clinical difficulty in identifying hypomanic episodes is well known particularly where previous and not present episodes are concerned as in depressive patients. These data would suggest further studies on the subject are needed and more caution also in prescribing antidepressants in a population apparently at high risk for bipolar disorders.

Electroconvulsive therapy (ECT) in a patient with a dual-chamber sensing, VDDR pacemaker

BACKGROUND

Because previous case reports involved old pacemaker models, it is unclear whether electroconvulsive therapy (ECT) may interfere with modern pacemaker function. Intracardiac voltages during ECT have not been measured previously.

METHOD

We present a 77-year-old man with a dual-chamber sensing VDDR pacemaker who was treated for a major depression with ECT. His pacemaker function was closely monitored throughout the ECT sessions.

RESULTS

An intracardiac electrogram showed low noise signals around 2 mV during ECT, which caused oversensing in the atrium. The intracardiac electrogram and pacemaker function normalized immediately after ECT. No arrhythmias or pacemaker malfunction was detected during and after several ECT sessions.

CONCLUSION

The presence of a pacemaker should not be a contraindication to receiving ECT. There was no need to convert the pacemaker to a fixed rate pacing or deactivate the pacemaker before ECT. However, careful monitoring for potential pacemaker interference by medical staff experienced in pacemaker management is advised during the first ECT sessions for patients with pacemakers.

Electroconvulsive therapy: present and future

Electroconvulsive therapy (ECT) has been used to treat patients for 60 years. It is a humane and effective treatment. It is now firmly established as an important and effective method of treating certain severe forms of depression. Still, very little is known about its mode of action. Research in the refinement of administration has reduced undesirable side effects. There are almost no absolute contraindications to its administration. Nurses are involved directly with patients before, during, and after treatment.