Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment

Impact of postmenopause on bipolar depression: Insights from a prospective study

BACKGROUND

Existing research on menopause and Bipolar Disorder indicates a general exacerbation in depressive symptoms but lacks clear distinctions between menopausal stages, despite their specific hormonal and symptomatic profiles. This study assesses how postmenopause versus the reproductive phase impacts the progression and antidepressant responsiveness of bipolar depression in women with Bipolar I Disorder.

METHODS

This prospective cohort study included 364 women with moderate to severe depressive episodes. Participants were classified into postmenopausal and reproductive groups based on the Stages of Reproductive Aging Workshop + 10 criteria. Over four weeks, all participants received a personalized treatment, with depressive symptoms assessed weekly.

RESULTS

Similar depression severity was observed between groups at the outset of the study. However, women in postmenopause experienced worse treatment responses and lower remission rates, despite the application of more complex treatment strategies. Notably, the impact of postmenopause on treatment outcomes, despite a small effect size, proved independent of age and comorbidities.

CONCLUSIONS

This exploratory research is the first to specifically assess the impact of postmenopause on bipolar depression, revealing its independent and negative influence on treatment outcomes. The small outcomes differences observed between groups, achieved through the use of more complex treatment strategies, suggest that developing tailored therapeutic protocols could significantly improve the clinical management of these patients.

Effect of Cariprazine on Outcomes in Older-aged and Younger-aged Patients with Bipolar I Disorder: A Post-hoc Analysis

OBJECTIVES

To evaluate cariprazine in adults with older- and younger-age bipolar I disorder (OABD-I and YABD-I) and compare treatment effects between them.

DESIGN AND SETTING

Pooled post-hoc analysis of studies in depressive or acute manic/mixed episodes associated with bipolar I disorder.

PARTICIPANTS

475/1383 patients (34.3%) in 3 depression trials and 238/1037 patients (23.0%) in 3 manic/mixed trials were OABD-I.

INTERVENTIONS

Depression: placebo, cariprazine 1.5 mg/day, 3.0 mg/day, pooled 1.5-3.0 mg/day. Manic/mixed: placebo, cariprazine 3.0-6.0 mg/day, and 9.0-12.0 mg/day.

MEASUREMENTS

Montgomery-Åsberg Depression Rating Scale (MADRS), Clinical Global Impression of Severity (CGI-S), and Young Mania Rating Scale (YMRS).

RESULTS

In bipolar I depression, mean change from baseline in MADRS was significantly greater for the pooled cariprazine group vs. placebo in OABD-I (-13.72 vs. -11.98; p < 0.05) and for each cariprazine group vs. placebo among YABD-I. There was no significant difference in treatment effect between OABD-I and YABD-I for either individual cariprazine group vs. placebo. For mania/mixed states, mean change in YMRS was significantly greater for cariprazine 3.0-6.0 mg/day vs. placebo in OABD-I (-19.04 vs. -12.45; p < 0.001) and for both cariprazine groups in YABD-I (-12.49, -19.66 and -18.05 for placebo, cariprazine 3.0-6.0 mg/day and 9.0-12.0 mg/day, respectively [both p < 0.0001 vs. placebo]). There was no significant difference in treatment effect between OABD-I and YABD-I for cariprazine 3.0-6.0 mg/day vs. placebo; there was a significantly higher treatment effect for cariprazine 9.0-12.0 mg/day vs. placebo in the YABD-I subpopulation vs. OABD-I (4.20; p < 0.05).

CONCLUSIONS

Cariprazine appears to be effective for both depressive and manic/mixed episodes of bipolar I disorder, regardless of age.

Esketamine reduces postoperative depression in breast cancer through TREK-1 channel inhibition and neurotransmitter modulation

Postoperative depression significantly affects the quality of life of breast cancer patients. This study explores the potential therapeutic effects of esketamine on postoperative depression through modulation of the TREK-1 two-pore domain potassium channel. We analyzed data from 54 female breast cancer patients who underwent surgery at our hospital between 2019 and 2023, dividing them into experimental and control groups based on esketamine treatment. Transcriptomic sequencing of hippocampal neurons from rats identified potassium ion-related pathways and key regulatory genes, including TREK-1, influenced by esketamine. In vitro studies showed that esketamine primarily alleviates depressive symptoms by inhibiting TREK-1 protein expression, enhancing GABA neurotransmitter release, and improving neuronal activity, while overexpression of TREK-1 reversed these effects. Esketamine's inhibition of TREK-1 channels and promotion of hippocampal neuron activity effectively alleviate postoperative depression in breast cancer patients, suggesting a novel therapeutic strategy.

Outpatient Management of Bipolar Disorder in Older Adults

PURPOSEOF REVIEW

Old age bipolar disorder (OABD), increasingly common as the population ages, presents unique diagnostic and treatment challenges. This selective review focuses on issues especially relevant to outpatient management.

RECENT FINDINGS

People with OABD may have similar frequency and severity of mood episodes compared to younger adults. Depression predominates, and mixed symptoms in both depressive and manic episodes are common. Comorbidity and excess mortality are high, with a particular bidirectional association with cerebrovascular disease. Lithium may outperform valproic acid and second-generation antipsychotics in efficacy. Tolerability and long-term safety can be improved with relatively lower target drug therapeutic levels. Outpatient clinicians treating OABD should take an active role in the recognition and management of medical comorbidities. A careful history and examination might reveal subtle signs of bipolar disorder or mixed features and change treatment. A primary target for treatment is to reduce polypharmacy when appropriate. Further trials are needed to make specific and clear recommendations in OABD.

Comprehensive bibliometric analysis of pharmacotherapy for bipolar disorders: Present trends and future directions

BACKGROUND

Bipolar disorder (BD) is a severe mental illness characterized by significant mood swings. Effective drug treatment modalities are crucial for managing BD.

AIM

To analyze the current status and future trends of global research on BD drug treatment over the last decade.

METHODS

The Web of Science Core Collection database spanning from 2015 to 2024 was utilized to retrieve literature related to BD drug treatment. A total of 2624 articles were extracted. Data visualization and analysis were conducted using CiteSpace, VOSviewer, Pajek, Scimago Graphica, and R-studio bibliometrix to identify research hotspots, key contributors, and future trends.

RESULTS

The United States, China, and the United Kingdom have made the most significant contributions to research on BD drug treatment and formed notable research collaboration networks. The University of Pittsburgh, Massachusetts General Hospital, and the University of Michigan have been identified as the major research institutions in this field. The Journal of Affective Disorders is the most influential journal. A keyword analysis revealed research hotspots related to clinical symptoms, drug efficacy, and genetic mechanisms. A citation analysis identified the management guidelines published by Yatham et al in 2018 as the most cited paper.

CONCLUSION

This study provides a detailed overview of the field of BD drug treatment, highlighting key contributors, research hotspots, and future directions. The study findings can be employed as a reference for future research and policymaking, which may enable further development and optimization of BD pharmacotherapy.

Endoxifen in Bipolar Disorder With Hyperammonemia and Renal Impairment: A Case Report

Lithium, divalproex, and oxcarbazepine are commonly prescribed medications used for the management of bipolar disorder, but each of these drugs comes with its own gamut of adverse effects that make these agents unfavorable in certain medical conditions. Endoxifen, a protein kinase C inhibitor and selective estrogen receptor modulator, originally used in breast cancer treatment, has recently emerged as a potential therapeutic option for managing manic episodes in bipolar disorder. This case report highlights the use of endoxifen in the management of severe manic symptoms of bipolar disorder in a 65-year-old male patient with medical comorbidities arising from traditional mood stabilizer drugs and its potential as an alternative treatment over such drugs.

Facing Life in Old Age: Exploring Resilience in Older Adults with Bipolar Disorder

Background: Older adults with bipolar disorder (OABD) are individuals aged 50 years and older with bipolar disorder (BD). People with BD may have fewer coping strategies or resilience. A long duration of the disease, as seen in this population, could affect the development of resilience strategies, but this remains under-researched. Therefore, this study aims to assess resilience levels within the OABD population and explore associated factors, hypothesizing that resilience could improve psychosocial functioning, wellbeing and quality of life of these patients. Methods: This study sampled 33 OABD patients from the cohort at the Bipolar and Depressive Disorders Unit of the Hospital Clinic of Barcelona. It was an observational, descriptive and cross-sectional study. Demographic and clinical variables as well as psychosocial functioning, resilience and cognitive reserve were analyzed. Resilience was measured using the CD-RISC-10. Non-parametric tests were used for statistical analysis. Results: The average CD-RISC-10 score was 25.67 points (SD 7.87). Resilience negatively correlated with the total number of episodes (p = 0.034), depressive episodes (p = 0.001), and the FAST (p < 0.001). Participants with normal resilience had a lower psychosocial functioning (p = 0.046), a higher cognitive reserve (p = 0.026), and earlier onset (p = 0.037) compared to those with low resilience. Conclusions: OABD individuals may have lower resilience levels which correlate with more psychiatric episodes, especially depressive episodes and worse psychosocial functioning and cognitive reserve. Better understanding and characterization of resilience could help in early identification of patients requiring additional support to foster resilience and enhance OABD management.

Response to electroconvulsive therapy in elderly patients with late-onset bipolar disorder: The impact of cerebral small vessel disease

OBJECTIVES

Cerebral Small Vessel Disease (CSVD) is a chronic, progressive vascular disorder that confers increased vulnerability to psychiatric syndromes, including late-life mood disorders. In this study, we investigated the impact of CSVD on electroconvulsive therapy (ECT) outcomes in patients with late-onset bipolar disorder (BD).

METHODS

A sample of 54 non-demented elderly patients (≥60 years) with late-onset BD and treatment-resistant major depression, mixed state, or catatonia who underwent bilateral ECT were included in this naturalistic observational study. A diagnosis of CSVD was established based on brain neuroimaging performed before ECT. All patients were evaluated before and after ECT using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Rating Scale for Depression (HAM-D), and the Clinical Global Impression scale (CGI).

RESULTS

Of the total sample, 19 patients were diagnosed with CSVD (35.2%). No significant differences were observed at baseline between patients with and without CSVD. Overall, a response was obtained in 66%-68.5% of patients, with remission in 56.2%. No significant differences in ECT outcomes were found between those with and without CSVD, and both groups exhibited substantial improvements in symptom severity following ECT.

CONCLUSIONS

The outcome of ECT in late-onset BD was not influenced by the presence of CSVD. This finding aligns with previous research on unipolar depression. Accordingly, ECT should be considered for elderly patients with late-onset BD, regardless of the presence of CSVD.

Biomarkers of Bipolar Disorder in Late Life: An Evidence-Based Systematic Review

PURPOSE OF REVIEW

Review the current evidence on biomarkers for bipolar disorder in the older adults. We conducted a systematic search of PubMed MEDLINE, PsycINFO, and Web of Science databases using the MeSH search terms "Biomarkers", "Bipolar Disorder", "Aged" and and "Aged, 80 and over". Studies were included if they met the following criteria: (1) the mean age of the study population was 50 years old or older, (2) the study included patients with bipolar disorder, and (3) the study examined one type of biomarkers or more including genetic, neuroimaging, and biochemical biomarkers. Reviews, case reports, studies not in English and studies for which no full text was available were excluded. A total of 26 papers were included in the final analysis.

RECENT FINDINGS

Genomic markers of bipolar disorder in older adults highlighted the implication of serotonin metabolism, while the expression of genes involved in angiogenesis was dysregulated. Peripheral blood markers were mainly related with low grade inflammation, axonal damage, endothelial dysfunction, and the dysregulation of the HPA axis. Neuroanatomical markers reflected a dysfunction of the frontal cortex, a loss of neurones in the anterior cingulate cortex and a reduction of the hippocampal volume (in patients older than 50 years old). While not necessarily limited to older adults, some of them may be useful for differential diagnosis (neurofilaments), disease staging (homocysteine, BDNF) and the monitoring of treatment outcomes (matrix metalloproteinases). Our review provides a comprehensive overview of the current evidence on biomarkers for bipolar disorder in the older adults. The identification of biomarkers may aid in the diagnosis, treatment selection, and monitoring of bipolar disorder in older adults, ultimately leading to improved outcomes for this population. Further research is needed to validate and further explore the potential clinical utility of biomarkers in this population.

Bipolar symptoms, somatic burden and functioning in older-age bipolar disorder: A replication study from the global aging & geriatric experiments in bipolar disorder database (GAGE-BD) project

OBJECTIVES

The Global Aging & Geriatric Experiments in Bipolar Disorder Database (GAGE-BD) project pools archival datasets on older age bipolar disorder (OABD). An initial Wave 1 (W1; n = 1369) analysis found both manic and depressive symptoms reduced among older patients. To replicate this finding, we gathered an independent Wave 2 (W2; n = 1232, mean ± standard deviation age 47.2 ± 13.5, 65% women, 49% aged over 50) dataset.

DESIGN/METHODS

Using mixed models with random effects for cohort, we examined associations between BD symptoms, somatic burden and age and the contribution of these to functioning in W2 and the combined W1 + W2 sample (n = 2601).

RESULTS

Compared to W1, the W2 sample was younger (p < 0.001), less educated (p < 0.001), more symptomatic (p < 0.001), lower functioning (p < 0.001) and had fewer somatic conditions (p < 0.001). In the full W2, older individuals had reduced manic symptom severity, but age was not associated with depression severity. Age was not associated with functioning in W2. More severe BD symptoms (mania p ≤ 0.001, depression p ≤ 0.001) were associated with worse functioning. Older age was significantly associated with higher somatic burden in the W2 and the W1 + W2 samples, but this burden was not associated with poorer functioning.

CONCLUSIONS

In a large, independent sample, older age was associated with less severe mania and more somatic burden (consistent with previous findings), but there was no association of depression with age (different from previous findings). Similar to previous findings, worse BD symptom severity was associated with worse functioning, emphasizing the need for symptom relief in OABD to promote better functioning.

Increased metabolic variability in Korean patients with new onset bipolar disorder: a nationwide cohort study

Introduction

The aim of this study was to determine associations between changes of metabolic parameters and the development of BD using nationally representative data.

Methods

We used health examination data provided by the South Korean National Health Insurance System (NHIS) (n = 8,326,953). The variability of each metabolic parameter including weight circumference, blood pressure, fasting blood glucose, high-density lipoprotein cholesterol, and triglyceride levels was caculated using variability independent of mean (VIM) indices. The presence of metabolic syndrome was associated with new onset BD. Each metabolic parameter with high variability was associated with a higher risk of new onset BD compared to those with low variability after adjusting for age, sex, smoking, alcohol drinking, regular exercise, income status, baseline diabetes, hypertension, and dyslipidemia.

Results

As the number of highly variable metabolic parameters increased, the risk for new onset depression also increased even after covariates adjustment. The associations between new onset BD and metabolic variability were greater in populations with age > 50 years. In addition, these associations remained significant after adjusting for the presence of depression prior to diagnoses of BD.

Discussion

Our results suggest possibility of metabolic variability as an independent environmental risk factor for BD even after adjusting for the presence of metabolic syndrome.

From Unipolar to Bipolar: The Diagnostic Evolution in an Elderly Man

A pivotal concept in the field of mood disorders is the dichotomy between unipolar depression and bipolar disorder. Due to the unique treatment in older age bipolar disorder and the scarcity of research in this area, it is clinically important to raise the awareness of the diagnostic conversion of unipolar depression to bipolar disorder in the elderly population. We present a case of a 71-year-old Chinese man whose diagnosis was revised to bipolar disorder after 9 years of treatment for unipolar depression. Organic workup, including blood tests and brain imaging, was performed to rule out organic causes. This patient eventually responded well to the combined treatment of an antipsychotic and a mood stabilizer. This case report adds to the growing literature of challenges in identifying and managing bipolar disorder in the elderly. As unipolar depression and bipolar disorder have different disease courses and different treatment strategies, it is essential for clinicians to be aware of diagnostic conversion. Further research is needed to delineate bipolar disorder from unipolar depression in the elderly population.

Bipolar Disorder Among Older Adults: Newer Evidence to Guide Clinical Practice

The term older-age bipolar disorder (OABD) refers to patients with bipolar disorder who are ages 50 and older. Research findings suggest important differences, including the attenuation of manic symptoms with age and the occurrence of multiple somatic comorbid conditions. Although the pharmacological treatment of OABD is fairly similar, adverse effects, somatic comorbidity, and drug-drug interactions are more common. Lithium is effective in treating OABD and may have the potential to be neuroprotective. Anticonvulsants and second-generation antipsychotics have a growing evidence supporting their use in treating OABD. Behavioral intervention can be a helpful adjunct to pharmacological treatment. Clinicians and health care systems need to be prepared to provide care and services to individuals with bipolar disorder throughout the life span. Although older adults have typically been excluded from bipolar disorder RCTs, emerging efforts organized by global advocates and harnessing teams of clinicians and scientists have the potential to advance care.

Characterizing mild cognitive impairment to predict incident dementia in adults with bipolar disorder: What should the benchmark be?

Objective: Although mild cognitive impairment (MCI) is generally considered a risk state for dementia, its prevalence and association with dementia are impacted by the number of tests and cut-points used to assess cognition and define "impairment," and sources of norms. Here, we investigate how these methodological variations impact estimates of incident dementia in adults with bipolar disorder (BD), a vulnerable population with pre-existing cognitive deficits and increased dementia risk. Method: Neuropsychological data from 148 adults with BD and 13,610 healthy controls (HC) were drawn from the National Alzheimer's Coordinating Center. BD participants' scores were standardized against published norms and again using regression-based norms generated from HC within the same catchment area as individual BD patients ("site-specific norms"), varying the number of within-domain tests (one vs. two) and the cut-points (-1 vs. -1.5 SD) used to operationalize MCI. Results: Site-specific norms were more sensitive to incident dementia (88.6%-94.3%) than published norms (74.3%-88.6%), but only when using a "single test" definition of impairment. Specificity (22.1%-74.3%), accuracy (37.8%-68.9%), and positive predictive values (26.1%-38.3%) were overall poor. Applying a "single test" definition of impairment resulted in better negative predictive values using site-specific (92.3%-93.3%) than published norms (83.6%-86.2%), and a substantial increase in relative risk of incident dementia relative to published norms. Conclusions: Neuropsychologists should define "impairment" as scores below -1.0 or -1.5 SD on at least two within-domain measures when using published norms to interpret cognitive performance in adults with BD.

Manic Episodes in a Patient With Neurosyphilis Following Brief Discontinuation of Bipolar Medication

Bipolar disorder is a mood disorder resulting in episodes of either mania or hypomania. The episodes can manifest themselves as a period of abnormally and persistently elevated mood, abnormally and persistently increased activity or energy, distractibility, insomnia, grandiosity, flight of ideas, increased activity, pressured speech, and racing thoughts. Neurosyphilis is a progression of syphilis infection involving the brain, meninges, or spinal cord. The interaction between bipolar disorder and neurosyphilis has not been extensively studied, but it has been theorized that neurosyphilis can exacerbate mood disorders. This case study details a patient with concurrent late-onset bipolar disorder and neurosyphilis and how the discontinuation of bipolar medication resulted in an acute manic episode. In addition, this case underscores the importance of differentiating the presenting symptoms between bipolar disorder and neurosyphilis.

The Role of Gasotransmitter-Dependent Signaling Mechanisms in Apoptotic Cell Death in Cardiovascular, Rheumatic, Kidney, and Neurodegenerative Diseases and Mental Disorders

Cardiovascular, rheumatic, kidney, and neurodegenerative diseases and mental disorders are a common cause of deterioration in the quality of life up to severe disability and death worldwide. Many pathological conditions, including this group of diseases, are based on increased cell death through apoptosis. It is known that this process is associated with signaling pathways controlled by a group of gaseous signaling molecules called gasotransmitters. They are unique messengers that can control the process of apoptosis at different stages of its implementation. However, their role in the regulation of apoptotic signaling in these pathological conditions is often controversial and not completely clear. This review analyzes the role of nitric oxide (NO), carbon monoxide (CO), hydrogen sulfide (H₂S), and sulfur dioxide (SO₂) in apoptotic cell death in cardiovascular, rheumatic, kidney, and neurodegenerative diseases. The signaling processes involved in apoptosis in schizophrenia, bipolar, depressive, and anxiety disorders are also considered. The role of gasotransmitters in apoptosis in these diseases is largely determined by cell specificity and concentration. NO has the greatest dualism; scales are more prone to apoptosis. At the same time, CO, H₂S, and SO₂ are more involved in cytoprotective processes.

The effect of comprehensive individual motivational-educational program on medication adherence in elderly patients with bipolar disorders: An experimental study

BACKGROUND

The number of older adults with bipolar disorder is increasing and medication non-adherence is a major problem that negatively impacts the course of bipolar disorder. This study aimed to determine the effect of a comprehensive individual motivational-educational program on medication adherence in elderly patients with bipolar disorder.

MATERIALS AND METHOD

An experimental study with pretest-posttest repeated measures with a control group was conducted on two groups of 62 elderly people with bipolar disorders hospitalized at Ibn Sina Hospital in Mashhad, Northeast Iran, 2019. For the elderly in the intervention group, a comprehensive motivational-educational program was administered for one month (four 30-45 minute sessions), and for the elderly in the control group, routine clinical care was performed. Medication adherence in both elderly groups was measured before, immediately after, one and two months after the intervention. Data were analyzed by SPSS statistical software (version 16) using descriptive statistics and independent t-test, Mann-Whitney, paired t-test, repeated measures analysis of variance (ANOVA), and Chi-square tests.

RESULTS

The mean age of elderlies in the intervention and control groups were 69.03 ± 5.75 and 68.50 ± 6.73 years, respectively. Regardless of the groups to which the patients were assigned, a significant difference in medication adherence scores was observed during the study period (time effect; P < 0.001). Also, the medication adherence score was significantly lower in the intervention group, compared to the control group (group effect; P < 0.001). Also, there was a group time interaction between the medication adherence score and the time of evaluation (P < 0.001).

CONCLUSION

The results of the present study confirm the positive effect of a comprehensive educational-motivational program on improving medication adherence in elderly patients with bipolar disorder.

Lithium use in childhood and adolescence, peripartum, and old age: an umbrella review

BACKGROUND

Lithium is one of the most consistently effective treatment for mood disorders. However, patients may show a high level of heterogeneity in treatment response across the lifespan. In particular, the benefits of lithium use may vary in special clinical conditions. The aim of this study was to test this hypothesis by conducting an umbrella review on the efficacy and safety of lithium in childhood and adolescence, peripartum and old age.

METHODS

We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify systematic reviews/meta-analyses on the efficacy and/or safety of lithium in mood disorders in special clinical conditions: (i) childhood and adolescence; (ii) peripartum (pregnancy, postpartum and lactation); (iii) old age. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool was used to assess the risk of bias. Overlap in primary studies across systematic reviews was calculated through the Corrected Covered Area (CCA).

RESULTS

We included 20 independent studies, for a total of 8209 individuals treated with lithium. Regarding paediatric age, efficacy and safety results suggested that lithium may be superior to placebo in bipolar disorders (BD) and not associated with serious adverse events. Nevertheless, primary available data are very limited. Efficacy in paediatric major depressive disorder (MDD) is not clear. During peripartum, lithium use was superior to non-lithium in preventing mood episodes and it was associated with low risk of congenital anomalies and with normal child neurodevelopment. Regarding old age, limited evidence supported lithium as an effective treatment in BD and resistant MDD; low doses should be used in this population. Systematic reviews on paediatric age showed the lowest risk of bias (80% of the studies at low risk). The CCA range of included studies was 13-47%.

CONCLUSIONS

This umbrella review supports the use of lithium across the lifespan, including special clinical condition. Nevertheless, more studies with increased methodological homogeneity are needed.

Tailoring the mental health assessment to older adults

ABSTRACT

This article discusses selected considerations for mental health assessment in older adults. Adopting a biopsychosocial model and trauma-informed approach to care creates a safe structure for a more comprehensive assessment. Selecting appropriate tools to improve diagnostic reasoning sets the foundation for further workup and tailored interventions.

Electroconvulsive therapy following incident bipolar disorder: When, how, and for whom?

OBJECTIVE

The use of electroconvulsive therapy (ECT) in the treatment of bipolar disorder (BD) remains poorly described. Based on data from Danish registries with complete nationwide coverage, this study of patients with incident BD aimed to describe when, how, and for whom ECT is used in the context of BD.

METHODS

We identified patients receiving their first diagnosis of BD in the period from 2008 to 2018, who subsequently received ECT. Descriptive statistics were used to clarify when, how, and for whom ECT is used.

RESULTS

We identified 1338 patients with incident BD who subsequently received ECT. The median age at the first ECT session was 50.6 years (interquartile range [IQR]: 26.4), and 62% of those treated with ECT were female. The median time from the diagnosis of BD to the first ECT treatment was 0.6 years (IQR: 2.6), and 58% of the patients receiving ECT had the first treatment within the first year after being diagnosed with BD. The most common indication for the first ECT treatment was depression (mainly non-psychotic depression), followed by mania (mainly psychotic mania). The first ECT session was typically provided to inpatients (97%), upon patient consent (98%) and with bilateral electrode placement (60%).

CONCLUSIONS

A substantial proportion of the patients with incident BD who receive ECT require this treatment within the first year after the diagnosis. The most common indication for ECT is depression followed by (psychotic) mania. Inpatient voluntary ECT using bilateral electrode placement is the most common form of administration.

Why lithium should be used in patients with bipolar disorder? A scoping review and an expert opinion paper

INTRODUCTION

Lithium treatment is considered the gold standard for the long-term management of bipolar disorder and recurrent unipolar depression. It is also extremely effective in other psychiatric conditions characterized by impulsivity and aggression, and for the prevention of suicidal behaviours.

AREAS COVERED

This paper provides a scoping review and an expert commentary regarding the use of lithium in adult patients. Available information about efficacy, tolerability, dosing, and switching is analyzed, and the strategies that may be most useful in real-world clinical settings are highlighted.

EXPERT OPINION

Lithium is effective on different domains of bipolar disorder, including the long-term prevention of recurrences of affective episodes, management of acute mania as well as in the prophylaxis of all affective episodes. Lithium has been defined a 'forgotten drug,' since its use in routine clinical practice has been declined over the last 20 or 30 years. Reasons for this trend include lack of adequate training on the management of lithium side effects. Considering its efficacy, use of lithium in ordinary clinical practice should be promoted. Several strategies, such as using slow-release formulations, can be easily implemented in order to minimize lithium side effects and improve its tolerability profile.

Comparing the efficacy of aripiprazole as an add-on to valproate with other second-generation antipsychotics in acute mania symptoms in manic patients in Iran

BACKGROUND

Given the great importance of treating patients with bipolar disorder, the aim of this study was to compare the efficacy of aripiprazole with other second-generation antipsychotics in relieving acute symptoms of mania.

MATERIALS AND METHODS

In this study, 50 patients with bipolar I disorder, manic episode, were divided into two groups receiving aripiprazole (n = 25) and other second-generation antipsychotics (risperidone, olanzapine, and quetiapine) (n = 25) for 6 weeks. The disease severity was evaluated and compared according to YMRS and CGI criteria.

RESULTS

The mean severity of mania according to YMRS and CGI, at week 0 in comparison with weeks 2, 4 and 6 in both groups was significantly different (p < 0.0001) and the treatment with Aripiprazole at week 2 (p < 0.0001) and 4 (p = 0.0002) was significantly better than the other second-generation antipsychotics. The two groups also showed an overall improvement in CGI-based results at weeks 4 and 6 (p = 0.002). In addition, the efficacy index for aripiprazole at weeks 4 (p = 0.011) and 6 (p < 0.0001) as well as disease improvement in the second (p < 0.0001) and fourth (p = 0.026) weeks after treatment were better than the other second-generation antipsychotics.

CONCLUSIONS

Aripiprazole and other second-generation antipsychotics, 2 weeks after initiation of treatment, significantly reduced mania severity in patients with bipolar disorder, however, aripiprazole seems to be more efficient and faster for controlling mania in patients with bipolar disorder.KEY POINTSAripiprazole and other second-generation antipsychotics, 2 weeks after initiation of treatment, significantly reduced mania severity in patients with bipolar disorder.Comparison between the two drugs, aripiprazole showed a more beneficial role in the second and fourth weeks than second-generation antipsychotics.Due to the fact that the possible mechanisms involved in the role of aripiprazole have not been considered compared to other antipsychotics in patients with bipolar disorder, there is a need for more extensive studies in this field.