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Roguski A, Ritter P, Smith DJ. Sensitivity to light in bipolar disorder: implications for research and clinical practice. Br J Psychiatry 2024; 224:143-146. [PMID: 38174418 PMCID: PMC7615859 DOI: 10.1192/bjp.2023.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Circadian dysfunction is a core feature of bipolar disorder and may be due, at least in part, to abnormalities of non-visual photoreception. We critically review the evidence for light hypersensitivity in bipolar disorder and discuss how this may shape future research and clinical innovation, with a focus on a possible novel mechanism of action for lithium.
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Affiliation(s)
- Amber Roguski
- Division of Psychiatry, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
| | - Philipp Ritter
- Clinic for Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technical University of Dresden, Dresden, Germany
| | - Daniel J. Smith
- Division of Psychiatry, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
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2
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Abstract
Lithium is the primary choice for preventing bipolar disorder relapses, endorsed by guidelines. A recent systematic review by Ulrichsen et al. showed limitations in assessing its specific impact, but data supports lithium's effectiveness in managing symptoms and preventing relapse. Comprehensive guidelines and research are crucial for its continued use.
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Affiliation(s)
- René Ernst Nielsen
- Department of Psychiatry, Aalborg University Hospital, Denmark; and Department of Clinical Medicine, Aalborg University, Denmark
| | - Rasmus W. Licht
- Department of Psychiatry, Aalborg University Hospital, Denmark; and Department of Clinical Medicine, Aalborg University, Denmark
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Pope E, Muthukrishnan S, Phillips J, Phillips S. A case of treatment-resistant depression in an older adult and a discussion of treatment options. BJPsych Bull 2022; 46:331-336. [PMID: 34782028 PMCID: PMC9813956 DOI: 10.1192/bjb.2021.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Treatment-resistant depression is a complex condition often requiring specialist psychiatric care. Many different psychiatric, physical and social factors can lead to a poor response to initial treatment of depression, and a careful assessment is required to determine the most appropriate management option. This can be particularly complex in the older population, who often have multiple physical and social comorbidities. We have used a fictional case to illustrate this, alongside an anonymised vignette of someone with personal experience of this condition. We have also provided an overview of the current evidence for treatment options, as well as a discussion of potential aetiological factors. By the end of this article, readers should understand the ambiguity of this diagnostic term, the aetiological factors that need to be assessed and the rationale for the treatment options available. They should be able to recognise how these ideas apply to the geriatric population.
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Affiliation(s)
| | - Sabari Muthukrishnan
- Avon and Wiltshire Mental Health Partnership NHS Trust, UK.,Kingshill Research Centre, UK
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Fitzgerald C, Christensen RHB, Simons J, Andersen PK, Benros ME, Nordentoft M, Erlangsen A, Hawton K. Effectiveness of medical treatment for bipolar disorder regarding suicide, self-harm and psychiatric hospital admission: between- and within-individual study on Danish national data. Br J Psychiatry 2022; 221:1-9. [PMID: 35450547 DOI: 10.1192/bjp.2022.54] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mood stabilisers are the main treatment for bipolar disorder. However, it is uncertain which drugs have the best outcomes. AIMS To investigate whether rates of suicide, self-harm and psychiatric hospital admission in individuals with bipolar disorder differ between mood stabilisers. METHOD A cohort design was applied to people aged ≥15 years who were diagnosed with bipolar disorder and living in Denmark during 1995-2016. Treatment with lithium, valproate, other mood stabilisers and antipsychotics were compared in between- and within-individual analyses, and adjusted for sociodemographic characteristics and previous self-harm. RESULTS A total of 33 337 individuals with bipolar disorder were included (266 900 person-years). When compared with individuals not receiving treatment, those receiving lithium had a lower rate of suicide (hazard ratio 0.40, 95% CI 0.31-0.51). When comparing treatment and non-treatment periods in the same individuals, lower rates of self-harm were found for lithium (hazard ratio 0.74, 95% CI 0.61-0.91). Lower rates of psychiatric hospital admission were found for all drug categories compared with non-treatment periods in within-individual analyses (P<0.001). The low rates of self-harm and hospital admission for lithium in within-individual analyses were supported by results of between-individual analyses. CONCLUSIONS Lithium was associated with lower rates of suicide, self-harm and psychiatric hospital readmission in all analyses. With respect to suicide, lithium was superior to no treatment. Although confounding by indication cannot be excluded, lithium seems to have better outcomes in the treatment of bipolar disorder than other mood stabilisers.
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Affiliation(s)
- Cecilie Fitzgerald
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; and Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark
| | | | | | | | | | - Merete Nordentoft
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark; and Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Annette Erlangsen
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, USA; and Center of Mental Health Research, Australian National University, Australia
| | - Keith Hawton
- Centre for Suicide Research, University of Oxford, UK; and, Oxford Health NHS Foundation Trust, UK
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Limbu B, Deb S, Roy M, Lee R, Roy A, Taiwo O. Randomised controlled trials of mood stabilisers for people with autism spectrum disorder: systematic review and meta-analysis. BJPsych Open 2022; 8:e52. [PMID: 35197135 PMCID: PMC8935918 DOI: 10.1192/bjo.2022.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Despite the widespread use of psychotropic medications in people with autism spectrum disorder (ASD), there is limited evidence to suggest that psychotropic medications including mood stabilisers are effective in individuals with ASD. AIMS To carry out a systematic review and meta-analysis of randomised controlled trials (RCTs) that assessed the effectiveness of mood stabilisers in people with ASD. METHOD We searched the following databases: Cochrane Library, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. In addition, we hand-searched 12 relevant journals. We used the Cochrane Risk of Bias and Jadad scores to assess the quality of included RCTs. We carried out a meta-analysis using a random-effects model. RESULTS We included eight RCTs (four on valproate, two on levetiracetam, and one each on lamotrigine and topiramate) that included a total of 310 people with ASD, primarily children. Outcomes were based on core and associated ASD symptoms including irritability and aggression but not bipolar disorder. Only two small studies (25%) from the same group showed definite superiority over placebo and one over psychoeducation alone. Meta-analysis of pooled data on the Aberrant Behaviour Checklist-irritability, Clinical Global Impression Scale-improvement, and Overt Aggression Scale (OAS)/OAS-modified did not show any significant inter-group difference. The rates of adverse effects did not show any significant inter-group difference. CONCLUSIONS Given the methodological flaws in the included studies and the contradictory findings, it is difficult to draw any definitive conclusion about the effectiveness of mood stabilisers to treat either ASD core symptoms or associated behaviours. Robust large-scale RCTs are needed in the future to address this issue.PROSPERO registration: CRD42021255467 on 18 May 2021.
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Affiliation(s)
- Bharati Limbu
- Research Assistant, Department of Brain Sciences, Faculty of Medicine, Imperial College London, UK
| | - Shoumitro Deb
- Visiting Professor of Neuropsychiatry, Department of Brain Sciences, Faculty of Medicine, Imperial College London, UK
| | - Meera Roy
- Honorary Consultant Psychiatrist, Hereford and Worcestershire Health and Care Trust, UK
| | - Rachel Lee
- Specialty Registrar in Psychiatry of Intellectual Disabilities, Coventry and Warwickshire Partnership NHS Foundation Trust, UK
| | - Ashok Roy
- Honorary Professorial Fellow, Warwick Medical School, University of Warwick, UK
| | - Oluwafemi Taiwo
- Core Trainee in Psychiatry, Coventry and Warwickshire Partnership NHS Foundation Trust, UK
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Gibbons A, Sundram S, Dean B. Changes in Non-Coding RNA in Depression and Bipolar Disorder: Can They Be Used as Diagnostic or Theranostic Biomarkers? Noncoding RNA 2020; 6:E33. [PMID: 32846922 DOI: 10.3390/ncrna6030033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 12/14/2022] Open
Abstract
The similarities between the depressive symptoms of Major Depressive Disorders (MDD) and Bipolar Disorders (BD) suggest these disorders have some commonality in their molecular pathophysiologies, which is not apparent from the risk genes shared between MDD and BD. This is significant, given the growing literature suggesting that changes in non-coding RNA may be important in both MDD and BD, because they are causing dysfunctions in the control of biochemical pathways that are affected in both disorders. Therefore, understanding the changes in non-coding RNA in MDD and BD will lead to a better understanding of how and why these disorders develop. Furthermore, as a significant number of individuals suffering with MDD and BD do not respond to medication, identifying non-coding RNA that are altered by the drugs used to treat these disorders offer the potential to identify biomarkers that could predict medication response. Such biomarkers offer the potential to quickly identify patients who are unlikely to respond to traditional medications so clinicians can refocus treatment strategies to ensure more effective outcomes for the patient. This review will focus on the evidence supporting the involvement of non-coding RNA in MDD and BD and their potential use as biomarkers for treatment response.
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Carter B, Strawbridge R, Husain MI, Jones BDM, Short R, Cleare AJ, Tsapekos D, Patrick F, Marwood L, Taylor RW, Mantingh T, de Angel V, Nikolova VL, Carvalho AF, Young AH. Relative effectiveness of augmentation treatments for treatment-resistant depression: a systematic review and network meta-analysis. Int Rev Psychiatry 2020; 32:477-490. [PMID: 32498577 DOI: 10.1080/09540261.2020.1765748] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Most interventions for treatment-resistant depression (TRD) are added as augmenters. We aimed to determine the relative effectiveness of augmentation treatments for TRD. This systematic review and network meta-analysis (NMA) sought all randomized trials of pharmacological and psychological augmentation interventions for adults meeting the most common clinical criteria for TRD. The NMA compared the intervention effectiveness of depressive symptoms for TRD augmentation. Of 36 included trials, 27 were suitable for inclusion in NMA, and no psychological trials could be included in the absence of a common comparator. Antipsychotics (13 trials), mood stabilizers (three trials), NMDA-targeting medications (five trials), and other mechanisms (3 trials) were compared against placebo. NMDA treatments were markedly superior to placebo (ES = 0.91, 95% CI 0.67 to 1.16) and head-to-head NMA suggested that NMDA therapies had the highest chance of being an effective treatment option compared to other pharmacological classes. This study provides the most comprehensive evidence of augmenters' effectiveness for TRD, and our GRADE recommendations can be used to guide guidelines to optimize treatment choices. Although conclusions are limited by paucity of, and heterogeneity between, trials as well as inconsistent reports of treatment safety. This work supports the use of NMDA-targeting medications such as ketamine.
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Affiliation(s)
- Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London
| | - Rebecca Strawbridge
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Muhammad Ishrat Husain
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Brett D M Jones
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roxanna Short
- Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony J Cleare
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dimosthenis Tsapekos
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Fiona Patrick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Lindsey Marwood
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rachael W Taylor
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tim Mantingh
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valeria de Angel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Viktoriya L Nikolova
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Abstract
Interruption of ongoing treatment with benzodiazepines, antidepressants, antipsychotics and mood stabilisers including lithium can be followed by clinically significant withdrawal reactions within hours or days, as well as later increases in relapses or recurrences of the illness being treated. Such observations support the view that stopping treatment is not equivalent to being untreated. With lithium, antipsychotics and antidepressants, there is consistent evidence that abrupt or rapid discontinuation is followed by earlier clinical worsening than with more gradual removal of treatment. Moreover, treatment discontinuation can complicate interpretation of responses to changes in treatment, including in clinical practice and in experimental treatment trials. Notably, terminating preceding treatments can lead to both discontinuation and carry-over effects that can have an impact on the interpretation of observed outcomes.
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Affiliation(s)
- Leonardo Tondo
- Department of Psychiatry, Harvard Medical SchoolUSA; International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, USA; Director, Lucio Bini Mood Disorder Center, Italy
| | - Ross J Baldessarini
- Professor of Psychiatry (Neuroscience), Department of Psychiatry, Harvard Medical School; and International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, USA
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Stip E, Javaid S, Bayard-Diotte J, Abdel Aziz K, Arnone D. Use of long acting antipsychotics and relationship to newly diagnosed bipolar disorder: a pragmatic longitudinal study based on a Canadian health registry. Ther Adv Psychopharmacol 2020; 10:2045125320957118. [PMID: 32974000 PMCID: PMC7493262 DOI: 10.1177/2045125320957118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is limited data from large naturalistic studies to inform prescribing of long-acting injectable medication (LAIs). Guidance is particularly rare in the case of primary mood disorders. METHODS This study describes prescribing trends of LAIs in 3879 patients in Quebec, Canada, over a period of 4 years. Health register data from the Quebec provincial health plan were reviewed. RESULTS In this specific registry, 32% of patients who received LAIs drugs for schizophrenia had a confirmed diagnosis of bipolar disorder and 17% had a diagnosis of major depressive disorder. Non-schizophrenia syndromes were preferentially prescribed risperidone long-acting antipsychotic, whereas patients with schizophrenia were prescribed an excess of haloperidol decanoate. Patients with non-schizophrenia disorders prescribed long-acting antipsychotics were more frequently treated in primary care compared with patients with schizophrenia. CONCLUSION Data from a large number of patients treated naturalistically in Quebec with long-acting antipsychotics suggests that these compounds, prescribed to treat symptoms of schizophrenia and schizoaffective disorders, were maintained when mood symptoms emerged, even in cases when the diagnosis changed to bipolar disorder. This pragmatic study supports the need to explore this intervention as potential treatment for affective disorders.
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Affiliation(s)
- Emmanuel Stip
- Department of Psychiatry and Behavioural science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates; Centre Hospitalier Universitaire de Montreal (CHUM), Institute Universitaireen Santé Mentale de Montréal, Université de Montreal, Canada E-mail:
| | - Syed Javaid
- Department of Psychiatry and Behavioural science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Jonathan Bayard-Diotte
- Centre Hospitalier Universitaire de Montreal (CHUM), Université de Montréal, Montreal, Canada
| | - Karim Abdel Aziz
- Department of Psychiatry and Behavioural science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
| | - Danilo Arnone
- Department of Psychiatry and Behavioural science, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates; Kings' College London, Institute of Psychiatry, Psychology, Neuroscience, Department of Psychological Medicine, Centre for Affective Disorders, London, UK
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Abstract
BACKGROUND Research on the risk of stroke following the use of mood stabilisers specific to patients with bipolar disorder is limited.AimsIn this study, we investigated the risk of stroke following the exposure to mood stabilisers in patients with bipolar disorder. METHOD Data for this nationwide population-based study were derived from the Taiwan National Health Insurance Research Database. Among a retrospective cohort of patients with bipolar disorder (n = 19 433), 609 new-onset cases of stroke were identified from 1999 to 2012. A case-crossover study design utilising 14-day windows was applied to assess the acute exposure effect of individual mood stabilisers on the risk of ischaemic, haemorrhagic and other types of stroke in patients with bipolar disorder. RESULTS Mood stabilisers as a group were significantly associated with the increased risk of stroke in patients with bipolar disorder (adjusted risk ratio, 1.26; P = 0.041). Among individual mood stabilisers, acute exposure to carbamazepine had the highest risk of stroke (adjusted risk ratio, 1.68; P = 0.018), particularly the ischaemic type (adjusted risk ratio, 1.81; P = 0.037). In addition, acute exposure to valproic acid elevated the risk of haemorrhagic stroke (adjusted risk ratio, 1.76; P = 0.022). In contrast, acute exposure to lithium and lamotrigine did not significantly increase the risk of any type of stroke. CONCLUSIONS Use of carbamazepine and valproic acid, but not lithium and lamotrigine, is associated with increased risk of stroke in patients with bipolar disorder.Declaration of interestNone.
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Affiliation(s)
- Pao-Huan Chen
- Lecturer,Department of Psychiatry,School of Medicine,College of Medicine,Taipei Medical University and Attending Psychiatrist,Department of Psychiatry and Psychiatric Research Center,Taipei Medical University Hospital,Taiwan
| | - Shang-Ying Tsai
- Professor,Department of Psychiatry,School of Medicine,College of Medicine,Taipei Medical University and Attending Psychiatrist,Department of Psychiatry and Psychiatric Research Center,Taipei Medical University Hospital,Taiwan
| | - Chun-Hung Pan
- Attending Psychiatrist,Taipei City Psychiatric Center,Taipei City Hospital and Lecturer,Department of Psychology,National Chengchi University,Taiwan
| | - Chi-Kang Chang
- Attending Psychiatrist,Taipei City Psychiatric Center,Taipei City Hospital,Taiwan
| | - Sheng-Shiang Su
- Research Assistant,Taipei City Psychiatric Center,Taipei City Hospital,Taiwan
| | - Chiao-Chicy Chen
- Professor,Department of Psychiatry, School of Medicine,College of Medicine,Taipei Medical University and Psychiatric Research Center, Taipei Medical University Hospital and Professor,Department of Psychiatry,Mackay Memorial Hospital and Department of Psychiatry,Mackay Medical College,Taiwan
| | - Chian-Jue Kuo
- Attending Psychiatrist,Taipei City Psychiatric Center,Taipei City Hospital and Associate Professor,Department of Psychiatry,School of Medicine,College of Medicine,Taipei Medical University,Taiwan
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Einat H, Ezer I, Kara NZ, Belzung C. Individual responses of rodents in modelling of affective disorders and in their treatment: prospective review. Acta Neuropsychiatr 2018; 30:323-33. [PMID: 29909818 DOI: 10.1017/neu.2018.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IntroductionLack of good animal models for affective disorders, including major depression and bipolar disorder, is noted as a major bottleneck in attempts to study these disorders and develop better treatments. We suggest that an important approach that can help in the development and use of better models is attention to variability between model animals. RESULTS: Differences between mice strains were studied for some decades now, and sex differences get more attention than in the past. It is suggested that one factor that is mostly neglected, individual variability within groups, should get much more attention. The importance of individual differences in behavioral biology and ecology was repeatedly mentioned but its application to models of affective illness or to the study of drug response was not heavily studied. The standard approach is to overcome variability by standardization and by increasing the number of animals per group. CONCLUSIONS: Possibly, the individuality of specific animals and their unique responses to a variety of stimuli and drugs, can be helpful in deciphering the underlying biology of affective behaviors as well as offer better prediction of drug responses in patients.
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Abstract
Lithium is widely prescribed, but the timing of key effects remains uncertain. The timing of onset of its relapse prevention effects is clarified by placebo-controlled randomised trials (3 studies, n = 1120). Lithium reduced relapse into any mood episode over the first 2 weeks of treatment (hazard ratio 0.40, 95% CI 0.16-0.97). Fewer manic relapses were evident within the first 4 weeks, however, early effects on depressive relapse were not demonstrated. There is an early onset of lithium relapse prevention effects in bipolar disorder, particularly against manic relapse. Full effects against depressive relapse may develop over a longer period.Declaration of interestM.J.T. reports personal fees from Sunovion, Otsuka, Lundbeck, outside the submitted work.
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Affiliation(s)
- Matthew J Taylor
- Consultant Psychiatrist,University Department of Psychiatry, Warneford Hospital,Oxford OX3 7JX,UKandClinical Senior Lecturer in Bipolar Disorder,Institute of Psychiatry, Psychology & Neuroscience, King's College London,UK.
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Köhler-Forsberg O, Sylvia L, Deckersbach T, Ostacher MJ, McInnis M, Iosifescu D, Bowden C, McElroy S, Calabrese J, Thase M, Shelton RC, Tohen M, Kocsis J, Friedman E, Ketter T, Nierenberg AA. Clinically relevant and simple immune system measure is related to symptom burden in bipolar disorder. Acta Neuropsychiatr 2018; 30:297-305. [PMID: 29212563 DOI: 10.1017/neu.2017.34] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Immunological theories, particularly the sickness syndrome theory, may explain psychopathology in mood disorders. However, no clinical trials have investigated the association between overall immune system markers with a wide range of specific symptoms including potential gender differences. METHODS We included two similar clinical trials, the lithium treatment moderate-dose use study and clinical and health outcomes initiatives in comparative effectiveness for bipolar disorder study, enrolling 765 participants with bipolar disorder. At study entry, white blood cell (WBC) count was measured and psychopathology assessed with the Montgomery and Aasberg depression rating scale (MADRS). We performed analysis of variance and linear regression analyses to investigate the relationship between the deviation from the median WBC, and multinomial regression analysis between different WBC levels. All analyses were performed gender-specific and adjusted for age, body mass index, smoking, race, and somatic diseases. RESULTS The overall MADRS score increased significantly for each 1.0×109/l deviation from the median WBC among 322 men (coefficient=1.10; 95% CI=0.32-1.89; p=0.006), but not among 443 women (coefficient=0.56; 95% CI=-0.19-1.31; p=0.14). Among men, WBC deviations were associated with increased severity of sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, inability to feel, and suicidal thoughts. Among women, WBC deviations were associated with increased severity of reduced appetite, concentration difficulties, lassitude, inability to feel, and pessimistic thoughts. Both higher and lower WBC levels were associated with increased severity of several specific symptoms. CONCLUSION Immune system alterations were associated with increased severity of specific mood symptoms, particularly among men. Our results support the sickness syndrome theory, but furthermore emphasise the relevance to study immune suppression in bipolar disorder. Due to the explorative nature and cross-sectional design, future studies need to confirm these findings.
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Malhi GS, Porter R, Irwin L, Hamilton A, Morris G, Bassett D, Baune BT, Boyce P, Hopwood MJ, Mulder R, Parker G, Mannie Z, Outhred T, Das P, Singh AB. Defining a mood stabiliser: novel framework for research and clinical practice. BJPsych Open 2018; 4:278-281. [PMID: 30083379 PMCID: PMC6066982 DOI: 10.1192/bjo.2018.36] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 05/17/2018] [Accepted: 05/28/2018] [Indexed: 01/05/2023] Open
Abstract
UNLABELLED The term 'mood stabiliser' is ill-defined and lacks clinical utility. We propose a framework to evaluate medications and effectively communicate their mood stabilising properties - their acute and prophylactic efficacy across the domains of mania and depression. The standardised framework provides a common definition to facilitate research and clinical practice. DECLARATION OF INTEREST The Treatment Algorithm Group (TAG) was supported logistically by Servier who provided financial assistance with travel and accommodation for those TAG members travelling interstate or overseas to attend the meeting in Sydney (held on 18 November 2017). None of the committee were paid to participate in this project and Servier have not had any input into the content, format or outputs from this project.
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Affiliation(s)
- Gin S Malhi
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Richard Porter
- Treatment Algorithm Group (TAG) and Department of Psychological Medicine, University of Otago - Christchurch, New Zealand
| | - Lauren Irwin
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Amber Hamilton
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Grace Morris
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Darryl Bassett
- Treatment Algorithm Group (TAG) and University of Western Australian Medical School, Australia, Faculty of Health and Medical Science, University of Western Australia, Australia
| | - Bernhard T Baune
- Treatment Algorithm Group (TAG) and Discipline of Psychiatry, University of Adelaide, Australia
| | - Philip Boyce
- Treatment Algorithm Group (TAG) and Discipline of Psychiatry, Sydney Medical School, Australia and Westmead Clinical School, University of Sydney, Australia
| | - Malcolm J Hopwood
- Treatment Algorithm Group (TAG) and Department of Psychiatry, University of Melbourne, Australia
| | - Roger Mulder
- Treatment Algorithm Group (TAG) and Department of Psychological Medicine, University of Otago - Christchurch, New Zealand
| | - Gordon Parker
- Treatment Algorithm Group (TAG) and School of Psychiatry, University of New South Wales, Australia and Black Dog Institute, Australia
| | - Zola Mannie
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Tim Outhred
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Pritha Das
- Treatment Algorithm Group (TAG), Academic Department of Psychiatry, Northern Sydney Local Health District, Sydney Medical School Northern, University of Sydney, Australia and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local Health District, Australia
| | - Ajeet B Singh
- Treatment Algorithm Group (TAG) and School of Medicine, IMPACT Strategic Research Centre, Deakin University, Barwon Health, Australia
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15
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Bartoli F, Clerici M, Di Brita C, Riboldi I, Crocamo C, Carrà G. Effect of clinical response to active drugs and placebo on antipsychotics and mood stabilizers relative efficacy for bipolar depression and mania: A meta-regression analysis. J Psychopharmacol 2018; 32:416-422. [PMID: 29338576 DOI: 10.1177/0269881117749851] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Randomised placebo-controlled trials investigating treatments for bipolar disorder have been hampered by wide variations of active drugs and placebo clinical response rates. It is important to estimate whether the active drug or placebo response has a greater influence in determining the relative efficacy of drugs for psychosis (antipsychotics) and relapse prevention (mood stabilisers) for bipolar depression and mania. METHODS We identified 53 randomised, placebo-controlled trials assessing antipsychotic or mood stabiliser monotherapy ('active drugs') for bipolar depression or mania. We carried out random-effects meta-regressions, estimating the influence of active drugs and placebo response rates on treatment relative efficacy. RESULTS Meta-regressions showed that treatment relative efficacy for bipolar mania was influenced by the magnitude of clinical response to active drugs ( p=0.002), but not to placebo ( p=0.60). On the other hand, treatment relative efficacy for bipolar depression was influenced by response to placebo ( p=0.047), but not to active drugs ( p=0.98). CONCLUSIONS Despite several limitations, our unexpected findings showed that antipsychotics / mood stabilisers relative efficacy for bipolar depression seems unrelated to active drugs response rates, depending only on clinical response to placebo. Future research should explore strategies to reduce placebo-related issues in randomised, placebo-controlled trials for bipolar depression.
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Affiliation(s)
- Francesco Bartoli
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Massimo Clerici
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Carmen Di Brita
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Ilaria Riboldi
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Cristina Crocamo
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Giuseppe Carrà
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy.,2 Division of Psychiatry, University College London, UK
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16
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McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V, Green L, Gregoire A, Howard LM, Jones I, Khalifeh H, Lingford-Hughes A, McDonald E, Micali N, Pariante CM, Peters L, Roberts A, Smith NC, Taylor D, Wieck A, Yates LM, Young AH. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. J Psychopharmacol 2017; 31:519-552. [PMID: 28440103 DOI: 10.1177/0269881117699361] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.
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Affiliation(s)
- R Hamish McAllister-Williams
- 1 Institute of Neuroscience, Newcastle University, Newcastle, UK.,2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David S Baldwin
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,4 University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | - Abby Easter
- 6 Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Eilish Gilvarry
- 2 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,7 Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Vivette Glover
- 8 Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Lucian Green
- 9 Ealing, Hounslow, Hammersmith & Fulham Perinatal Mental Health Service, West London Mental Health Trust, London, UK
| | - Alain Gregoire
- 3 Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,10 Hampshire Perinatal Mental Health Service, Winchester, UK
| | - Louise M Howard
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | - Ian Jones
- 13 National Centre for Mental Health, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Hind Khalifeh
- 11 Section of Women's Mental Health, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.,12 South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Elizabeth McDonald
- 15 Royal College of Psychiatrists, London, UK.,16 East London Foundation Trust, London, UK.,17 Tavistock and Portman NHS Foundation Trust, London, UK
| | - Nadia Micali
- 18 Behavioural and Brain Sciences Unit, GOSH Institute of Child Health, University College London, London, UK
| | - Carmine M Pariante
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Ann Roberts
- 20 St Martin's Healthcare Services CIC, Leeds, UK.,21 Hertfordshire Partnership University NHS Foundation Trust, Hatfield, Hertfordshire, UK.,22 Postgraduate School of Medicine, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Natalie C Smith
- 23 Tees, Esk and Wear Valleys NHS Foundation Trust, Darlington, County Durham, UK
| | - David Taylor
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,24 Institute of Pharmaceutical Science, King's College London, London, UK
| | - Angelika Wieck
- 25 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.,26 University of Manchester, Manchester, UK
| | - Laura M Yates
- 27 UK Teratology Information Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,28 Institute of Genetic Medicine, Newcastle University, Newcastle, UK
| | - Allan H Young
- 12 South London and Maudsley NHS Foundation Trust, London, UK.,19 Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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17
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Park SC, Lee MS, Hahn SW, Si TM, Kanba S, Chong MY, Yoon CK, Udomratn P, Tripathi A, Sartorius N, Shinfuku N, Maramis MM, Park YC. Suicidal thoughts/acts and clinical correlates in patients with depressive disorders in Asians: results from the REAP-AD study. Acta Neuropsychiatr 2016; 28:337-45. [PMID: 27305958 DOI: 10.1017/neu.2016.27] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Using data from the Research on Asian Psychotropic Prescription Patterns for Antidepressants (REAP-AD) study, we aimed to present the rates and clinical correlates of suicidal thoughts/acts in patients recruited from a total of 40 centres in 10 Asian countries/areas: China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand. METHODS Data from 1122 patients with depressive disorders in the REAP-AD study were used. The ICD-10 was employed to diagnose depressive episodes and recurrent depressive disorder. The presence or absence of suicidal thoughts/acts and profile of other depressive symptoms was established using the National Institute for Health and Clinical Excellence guidelines for depression. Country/area differences in rates of suicidal thoughts/acts were evaluated with the χ2 test. In addition, depressive symptom profiles, other clinical characteristics, and patterns of psychotropic drug prescription in depressed patients with and without suicidal thoughts/acts were compared using analysis of covariance for continuous variables and logistic regression analysis for discrete variables to adjust the effects of covariates. RESULTS The rates of suicidal thoughts/acts in 10 countries/areas varied from 12.8% in Japan to 36.3% in China. Patients with suicidal thoughts/acts presented more persistent sadness (adjusted odds ratio [aOR]=2.64, p<0.001), loss of interest (aOR=2.33, p<0.001), fatigue (aOR=1.58, p<0.001), insomnia (aOR=1.74, p<0.001), poor concentration (aOR=1.88, p<0.001), low self-confidence (aOR=1.78, p<0.001), poor appetite (aOR=2.27, p<0.001), guilt/self-blame (aOR=3.03, p<0.001), and use of mood stabilisers (aOR=1.79, p<0.001) than those without suicidal thoughts/acts. CONCLUSION Suicidal thoughts/acts can indicate greater severity of depression, and are associated with a poorer response to antidepressants and increased burden of illness. Hence, suicidal thoughts/acts can provide a clinical index reflecting the clinical status of depressive disorders in Asians.
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Prakash C, Hatters-Friedman S, Moller-Olsen C, North A. Maternal and Fetal Outcomes After Lamotrigine Use in Pregnancy: A Retrospective Analysis from an Urban Maternal Mental Health Centre in New Zealand. Psychopharmacol Bull 2016; 46:63-69. [PMID: 27738382 PMCID: PMC5044470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Pregnancy is a vulnerable period for recurrence of bipolar disorder. Discontinuation of mood stabilisers during pregnancy and the postpartum period can significantly increase the risk of recurrence of bipolar disorder. Lamotrigine is an anti-epileptic drug that has been approved for the maintenance treatment of bipolar disorder. Epilepsy literature has indicated that lamotrigine has a reassuring safety profile in pregnancy but there is little information on its effectiveness and safety in pregnant women with mental disorders. METHOD We conducted a retrospective review of all pregnant women who presented to an urban maternal mental health centre in Auckland, New Zealand between 2012 and 2014 and were treated with antipsychotics and/or mood stabilisers. Pregnancy outcome, obstetric and perinatal complications, congenital malformations and maternal mental health in the postnatal period were considered. RESULTS Here, we present the outcomes in the subset of six women who were treated with lamotrigine 100-400 mg/day for the entire pregnancy. Five were diagnosed with bipolar disorder and one with major depression. Three women received additional psychotropic medication during pregnancy. No women needed psychiatric hospitalisation. All babies were live birth after 36 weeks gestation. Two babies had low birth weight and required NICU admissions. Two women required lower segment caesarean section and the other 4 were induced. A trachea-esophageal fistula was noted in one baby. Four babies who were breastfed while their mothers received uninterrupted treatment with lamotrigine, experienced no complications. DISCUSSION This naturalistic study indicates that lamotrigine can be an effective treatment option for maintenance of bipolar illness in women of childbearing age.
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Affiliation(s)
- Chandni Prakash
- Dr. Prakash, MBBS, MD (Psych), Maternal Mental Health, Auckland District Health Board, NZ. Dr. Hatters-Friedman, MD, Department of Psychological Medicine, University of Auckland, NZ. Dr. Moller-Olsen, MBChB, Registrar Psychiatry, Auckland District Health Board, NZ. Ms. North, medical student, University of Auckland, NZ
| | - Susan Hatters-Friedman
- Dr. Prakash, MBBS, MD (Psych), Maternal Mental Health, Auckland District Health Board, NZ. Dr. Hatters-Friedman, MD, Department of Psychological Medicine, University of Auckland, NZ. Dr. Moller-Olsen, MBChB, Registrar Psychiatry, Auckland District Health Board, NZ. Ms. North, medical student, University of Auckland, NZ
| | - Charmian Moller-Olsen
- Dr. Prakash, MBBS, MD (Psych), Maternal Mental Health, Auckland District Health Board, NZ. Dr. Hatters-Friedman, MD, Department of Psychological Medicine, University of Auckland, NZ. Dr. Moller-Olsen, MBChB, Registrar Psychiatry, Auckland District Health Board, NZ. Ms. North, medical student, University of Auckland, NZ
| | - Abigail North
- Dr. Prakash, MBBS, MD (Psych), Maternal Mental Health, Auckland District Health Board, NZ. Dr. Hatters-Friedman, MD, Department of Psychological Medicine, University of Auckland, NZ. Dr. Moller-Olsen, MBChB, Registrar Psychiatry, Auckland District Health Board, NZ. Ms. North, medical student, University of Auckland, NZ
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19
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Bjørklund L, Horsdal HT, Mors O, Østergaard SD, Gasse C. Trends in the psychopharmacological treatment of bipolar disorder: a nationwide register-based study. Acta Neuropsychiatr 2016; 28:75-84. [PMID: 26357986 DOI: 10.1017/neu.2015.52] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In bipolar disorder, treatment with antidepressants without concomitant use of mood stabilisers (antidepressant monotherapy) is associated with development of mania and rapid cycling and is therefore not recommended. The present study aimed to investigate the psychopharmacological treatment patterns in bipolar disorder over time, with a focus on antidepressant monotherapy. METHODS Cohort study with annual cross-sectional assessment of the use of psychotropic medications between 1995 and 2012 for all Danish residents aged 10 years or older with a diagnosis of bipolar disorder registered in the Danish Psychiatric Central Research Register. Users of a given psychotropic medication were defined as individuals having filled at least one prescription for that particular medication in the year of interest. RESULTS We identified 20 618 individuals with bipolar disorder. The proportion of patients with bipolar disorder using antidepressants, atypical antipsychotics and anticonvulsants increased over the study period, while the proportion of patients using lithium, typical antipsychotics and benzodiazepines/sedatives decreased. The proportion of patients treated with antidepressant monotherapy decreased from 20.5% in 1997 to 12.1% in 2012, and among antidepressant users, the proportion in monotherapy decreased from 47.7% to 23.9%, primarily driven by a decrease in the use of tricyclic antidepressants. CONCLUSION The results show an increase in the proportion of patients with bipolar disorder being treated with antidepressants in the period from 1997 to 2012. However, in accordance with international treatment guidelines, the extent of antidepressant monotherapy decreased during the same period.
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20
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Saunders KEA, Hawton K. Clinical assessment and crisis intervention for the suicidal bipolar disorder patient. Bipolar Disord 2013; 15:575-83. [PMID: 23565916 DOI: 10.1111/bdi.12065] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 10/27/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Suicidal behaviour is common in people suffering with bipolar disorder, and suicide is a leading cause of death in this group. Our aim in this review is to provide an overview of key assessment and management strategies, highlight research findings relevant to suicide prevention, and identify important areas for future research. METHODS We reviewed the published literature regarding the risk factors for and management of suicida\l behaviour in individuals with bipolar disorder using the Pubmed and PsychINFO databases. Where available, we focused our search on systematic reviews. RESULTS Suicide is usually associated with a depressive phase, although mixed affective states also convey increased risk. All individuals with bipolar disorder should have an up-to-date crisis management plan which outlines the action to be taken should suicidal behaviour emerge. Timely clinical assessment is essential in ensuring that those at high risk are identified. This should include mental state examination, consideration of risk factors, and evaluation of issues such as access to means, preparatory acts before suicide, and also protective factors. While pharmacological approaches are the mainstay of management, less specific measures, such as the removal of access to means, are also important in ensuring safety in the acute situation. Intensifying the clinical support of both patients and relatives, and the sharing of risk information with other health agencies are essential in management. Specific psychological treatments are likely to be helpful in preventing crises, although the evidence base is limited. CONCLUSIONS The aetiology of suicidal behaviour in bipolar disorder is multifactorial and requires proactive crisis planning and management. A range of issues need to be addressed in the assessment of at-risk patients. Determining the efficacy of interventions specific to reducing suicidality in bipolar disorder should be a research priority.
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Affiliation(s)
- Kate E A Saunders
- Centre for Suicide Research, Department of Psychiatry, Oxford University, Warneford Hospital, Oxford, UK
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21
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Abstract
BACKGROUND: Topiramate is a new antiepileptic drug, originally designed as an oral hypoglycaemic subsequently approved as anticonvulsant. It has increasingly been used in the treatment of numerous psychiatric conditions and it has also been associated with weight loss potentially relevant in reversing weight gain induced by psychotropic medications. This article reviews pharmacokinetic and pharmacodynamic profile of topiramate, its biological putative role in treating psychiatric disorders and its relevance in clinical practice. METHODS: A comprehensive search from a range of databases was conducted and papers addressing the topic were selected. RESULTS: Thirty-two published reports met criteria for inclusion, 4 controlled and 28 uncontrolled studies. Five unpublished controlled studies were also identified in the treatment of acute mania. CONCLUSIONS: Topiramate lacks efficacy in the treatment of acute mania. Increasing evidence, based on controlled studies, supports the use of topiramate in binge eating disorders, bulimia nervosa, alcohol dependence and possibly in bipolar disorders in depressive phase. In the treatment of rapid cycling bipolar disorders, as adjunctive treatment in refractory bipolar disorder in adults and children, schizophrenia, posttraumatic stress disorder, unipolar depression, emotionally unstable personality disorder and Gilles de la Tourette's syndrome the evidence is entirely based on open label studies, case reports and case series. Regarding weight loss, findings are encouraging and have potential implications in reversing increased body weight, normalisation of glycemic control and blood pressure. Topiramate was generally well tolerated and serious adverse events were rare.
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Affiliation(s)
- Danilo Arnone
- Department of Psychiatry, Springfield University Hospital, St George's Medical School, London, UK.
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