Co-occurring Bipolar Disorder Research Articles

HIV-Infected Individuals with Co-occurring Bipolar Disorder Evidence Poor Antiretroviral and Psychiatric Medication Adherence

The contribution of bipolar disorder (BD), a prevalent serious mental illness characterized by impulsivity and mood instability, to antiretroviral (ART) and psychiatric medication adherence among HIV-infected (HIV+) individuals is unknown. We examined medication adherence among 44 HIV+/BD+ persons as compared to 33 demographically- and medically-comparable HIV+/BD- persons. Classification of adherent (≥ 90%) or non-adherent (<90%) based on proportion of correctly taken doses over 30 days was determined using electronic medication monitoring devices. HIV+/BD+ persons were significantly less likely to be ART adherent (47.7%) as compared to HIV+/BD- (90.9%) persons. Within the HIV+/BD+ group, mean psychiatric medication adherence was significantly worse than ART medication adherence, although there was a significant correlation between ART and psychiatric adherence levels. Importantly, 30-day ART adherence was associated with plasma virologic response among HIV+/BD+ individuals. Given the high overlap of HIV and BD, and the observed medication adherence difficulties for these persons, specialized adherence improvement interventions are needed.

Impact of Depressive Symptoms on Future Alcohol Use in Patients with Co‐Occurring Bipolar Disorder and Alcohol Dependence: A Prospective Analysis in an 8‐Week Randomized Controlled Trial of Acamprosate

Bipolar disorders and alcohol use disorders commonly co-occur, yet little is known about the proximal impact of bipolar symptoms on alcohol use in patients with this comorbidity. The present study examined the impact of depressive symptoms and alcohol craving on proximal alcohol use in patients with co-occurring bipolar disorder and alcohol dependence. Data were collected during an 8-week randomized controlled trial of acamprosate for individuals with co-occurring bipolar disorder and alcohol dependence (n = 30). Depressive symptoms and alcohol craving were assessed biweekly using the Montgomery Asberg Depression Rating Scale (MADRS) and the Obsessive Compulsive Drinking Scale (OCDS), respectively. Daily alcohol use data were available via administration of the Time-line Follow-back interview at baseline and at subsequent weekly study visits. Correlational analyses and hidden Markov modeling were used to examine the prospective relationships between depressive symptoms, alcohol craving, and alcohol use. Depressive symptoms and alcohol craving were significantly correlated with proximal (i.e., 1 week later) alcohol use across a variety of alcohol consumption summary measures. In hidden Markov models, depressive symptoms (OR = 1.3, 95% credible interval = [1.1, 1.5]) and alcohol craving (OR = 1.6, 95% credible interval = [1.4, 1.9]) significantly predicted transitioning from a light to a heavy drinking state, or remaining in a heavy drinking state. The results from the present study suggest that depressive symptoms and alcohol craving increase proximal risk for alcohol use in individuals with co-occurring bipolar and alcohol use disorders.

Comorbid anxiety disorders and baseline medication regimens predict clinical outcomes in individuals with co-occurring bipolar disorder and alcohol dependence: Results of a randomized controlled trial

Despite the high prevalence and detrimental impact of alcoholism on bipolar patients, the diagnostic and treatment factors associated with better or worse clinical outcomes in alcohol-dependent patients with bipolar disorder are not well understood. The present study investigated the prospective impact of baseline psychiatric comorbidities and treatment regimens on clinical outcomes in bipolar alcoholics. Data were drawn from an 8-week randomized controlled clinical trial of acamprosate for individuals (n=30) with co-occurring bipolar disorder and alcohol dependence. Depressive and manic symptoms, and alcohol craving and consumption were monitored longitudinally using standardized instruments. Path analysis was used to estimate the prospective associations between patient characteristics and outcomes. More than 50% of patients were diagnosed with at least one anxiety (76.7%) or drug dependence disorder (60.0%). Comorbid anxiety disorders were prospectively associated with increased depressive symptoms and alcohol use. Participants were prescribed an average of 2.6 psychotropic medications at baseline. Antipsychotics and anticonvulsants were prospectively associated with increased alcohol use; anticonvulsants and benzodiazepines were associated with increased alcohol craving. Antidepressants were associated with increased depressive symptoms. Conversely, lithium was associated with decreased alcohol craving and depressive symptoms. The findings from the present study suggest areas for future research in this population.

Predictors of clinical trial dropout in individuals with co-occurring bipolar disorder and alcohol dependence

BackgroundIndividuals with co-occurring bipolar disorder and alcohol dependence have particularly low rates of retention in clinical trials. Past research has identified a variety of factors associated with dropout in this population, but few have been replicated. The present study investigated the ability of several baseline variables to predict clinical trial dropout in a sample of individuals with co-morbid bipolar and alcohol use disorders. MethodsDemographics, psychiatric diagnoses, recent alcohol use, mood pathology, and risk taking behavior (measured with the Balloon Analogue Risk Task) were evaluated as predictors of dropout from a randomized clinical trial of acamprosate for individuals with co-morbid bipolar and alcohol use disorders (n=30) using stepwise logistic regression. ResultsRisk taking behavior was the only significant predictor of dropout in the present study (OR=1.44, p=0.03); opiate dependence marginally predicted dropout as well (OR=13.46, p=0.08). A model consisting of these predictors, as well as acamprosate group status (p=0.13), provided excellent prediction of dropout (i.e., area under the ROC curve=0.94; R2=0.53). ConclusionsGiven the robust relationship between risk taking and dropout in the present study, the Balloon Analogue Risk Task may represent a valuable tool for researchers to predict who will drop out of clinical trials for comorbid bipolar and substance use disorders.

P01-223-Recovery of cognitive functioning in patients with co-occurring bipolar disorder and alcohol dependence during early remission from an acute mood episode

IntroductionPreliminary data suggest that patients who suffer from both bipolar disorder (BD) and alcohol dependence (AD) may be more vulnerable to cognitive dysfunction than patients with a single diagnosis, especially during periods that are clinically unstable.ObjectiveThe purpose of this study was to examine the cognitive recovery of dually-diagnosed patients during remission from an acute mood disturbance.AimThe study aimed to replicate our previous comparison of cognitive functioning between BD patients with and without AD, while on the inpatient unit, and to extend this investigation in a longitudinal design post-discharge.MethodFifty-five adult inpatients with bipolar I disorder completed a neuropsychological battery, mood measures and substance abuse measures upon discharge from the hospital and at a 3 month follow up. Analyses provided group comparisons on these measures between patients who presented with co-occurrence of AD (n = 21) in the year prior to hospital admission and patients without a Substance Use Disorder (SUD; n = 34).ResultsCompared to patients without SUD, dually-diagnosed patients scored significantly more poorly on measures of visual memory, verbal memory and executive functioning both at hospital discharge and follow-up. They also exhibited more limited recovery of these functions over the course of this period. Mood symptoms decreased in both groups from discharge to follow up.ConclusionsPatients with co-occurring BD and AD may suffer from more severe cognitive dysfunction and less favorable recovery of cognitive deficits than BD patients without SUD over the course of remission from a mood episode.

The Impact of Drug Use in Social Networks of Patients with Substance Use and Bipolar Disorders

In this exploratory analysis, we assessed the effect of drug use among social-network members on recovery from drug dependence in patients with co-occurring bipolar disorder. Patients (n = 57) enrolled in a group therapy study completed assessments over 15 months. Patients with zero to one drug users in their social networks at intake had few days of drug use during treatment and follow-up, whereas those with ≥ 2 drug users had significantly more days of drug use. Multivariate analysis showed that patients who consistently named multiple drug users in their social networks had a marked increase in drug use over 15 months, while those who never or occasionally named multiple drug users had a small decline in drug use over time. Multiple drug users in social networks of treatment-seeking drug-dependent patients with co-occurring bipolar disorder may indicate poor drug use outcomes; efforts to reduce the association with drug users may be useful. This clinical trial has been registered in a public trials registry at clinicaltrials.gov (identifier is NCT00227838).

The Relationship of Manic Episodes and Drug Abuse to Sexual Risk Behavior in Patients with Co-Occurring Bipolar and Substance Use Disorders: a 15-Month Prospective Analysis

Risky sexual behavior is common among individuals with bipolar and substance use disorders. This 15-month prospective study examined the effects of between-subject differences and within-subject changes in mood symptoms and drug use on sexual risk behavior among 61 patients with both disorders. Participants completed five post-treatment follow-up assessments at 3-month intervals. Using a multivariate mixed-effects model analysis, more average weeks of mania (between-subject difference) was associated with greater sexual risk, but change in weeks of mania (within-subject change) was not; depression was unrelated to sexual risk. In addition, within-subject increases in days of cocaine use predicted increases in sexual risk. Results underscore the importance of substance abuse treatment and suggest that bipolar patients with active and/or recurrent mania are in need of targeted HIV prevention services. Further research is needed to test whether individual differences in impulsivity may explain the association between mania and sexual risk.

Self-Medication, Bipolar Disorders, and Stimulant Dependence

Article AbstractSir: In the August 2008 issue of the Journal, Nejtek et al. present findings that both quetiapine and risperidone produced improvement in manic, mixed, and depressive symptoms. In turn, symptom reduction was associated with reduced drug cravings in patients with co-occurring bipolar and stimulant dependence disorders, albeit not affecting drug use. These are important findings in that (1) there is an extraordinarily high incidence of co-occurrence of substance abuse in general associated with bipolar disorders and, in particular, a high cooccurrence of stimulant abuse; and (2) there are few if any specific effective psychopharmacologic treatments for stimulant dependence.

Depression Precipitated by Alcohol Use in Patients With Co-Occurring Bipolar and Substance Use Disorders

Bipolar disorder and substance use disorder frequently co-occur. However, little is known about the near-term effects of substance use on bipolar disorder. Thus, the present study tests whether alcohol use precipitates depression among patients with co-occurring bipolar disorder and substance use disorder. This study uses data collected as part of 2 clinical trials (the first study was conducted from March 1999 through March 2004 and the second study was conducted from August 2003 through May 2007) of a manualized group therapy for patients with co-occurring bipolar disorder and substance dependence. One hundred fifteen participants were assessed at baseline and each month through month 8. Baseline diagnoses were made using the Structured Clinical Interview for DSM-IV, and monthly substance use and mood data were collected using the Longitudinal Interval Follow-Up Evaluation and the Addiction Severity Index. Generalized estimating equation methodology was used to analyze these longitudinal data. Our primary hypotheses were supported: days of alcohol use and an increase in days of alcohol use each significantly predicted the presence of a depressive episode in the subsequent month when controlling for current depression and current drug use. These data suggest that alcohol use in patients with bipolar disorder and substance dependence increases the risk of a depressive episode in the near term. This study draws on data generated during 2 clinical trials. One was exempt from trial registration; clinicaltrials.gov Identifier for other trial: NCT00227838.

Diagnostic and Treatment Considerations: Bipolar Patients with Comorbid Substance Use Disorders

&lt;p&gt;Diagnostic and Treatment Considerations: Bipolar Patients with Comorbid Substance Use Disorders &lt;/p&gt; &lt;p&gt;Comorbidity of bipolar disorder (BD) and alcoholism and substance use disorders (SUDs) represents a serious public health problem and a major challenge to treatment systems. Bipolar disorder is among the top causes of disabilities worldwide, and reportedly the fourth leading mental illness as a source of disease burden in established market economies. Large epidemiologic surveys in the United States have consistently confirmed a high association between bipolar disorder and SUDs. The Epidemiological Catchments Area Study reported bipolar I and bipolar II disorders as having the highest association with SUDs when compared with any other major psychiatric disorder. The prevalence of lifetime alcohol abuse or dependence in persons with bipolar I disorder and bipolar II disorders were found to be 46%, and 39.2% respectively. Similarly, the National Comorbidity Survey reported respondents with mania to be 8 to 9 times more likely to have an additional lifetime disorder of drug or alcohol dependence compared with the general population. The most recent and largest epidemiologic survey of more than 42,000 respondents in the United States, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reported that mania and hypomania were associated with very high rates of SUDs. Those with mania were 6 times more likely to have alcohol dependence and 14 times more likely to have drug dependence over the past 12 months. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHORS&lt;/h4&gt; &lt;p&gt;Ihsan Salloum, MD, MPH; and Lauren Williams, MD, are with the Department of Psychiatry and Behavioral Science, University of Miami Miller School of Medicine. Antoine Douaihy, MD, is with the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine.&lt;/p&gt;&lt;p&gt; Address correspondence to: Ihsan M. Salloum, MD, MPH, 1120 NW 14th Street, Miami, FL 33136; fax 305-243-1682; or e-mail &lt;a href="mailto:isalloum@med.miami.edu"&gt;isalloum@med.miami.edu&lt;/a&gt;.&lt;/p&gt;&lt;p&gt; Dr. Salloum and Dr. Williams have disclosed no relevant financial relationships. Dr. Douaihy has disclosed the following relevant financial relationship: AstraZeneca: Research grant recipient.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt;Develop knowledge about the frequency and clinical significance of bipolar disorder and substance use disorders comorbidity. &lt;/li&gt; &lt;li&gt;Demonstrate the diagnostic considerations in patients with co-occurring bipolar disorder and substance use disorder &lt;/li&gt; &lt;li&gt;Identify the latest research-based psychotherapy and pharmacotherapy treatments for this comorbidity. &lt;/li&gt; &lt;/ol&gt;

Neurocognitive impairment in patients with co-occurring bipolar disorder and alcohol dependence upon discharge from inpatient care

The current study explored the neurocognitive functioning of patients with co-occurring bipolar disorder and alcohol dependence upon discharge from inpatient care. The study compared scores of neuropsychological tests among three groups of bipolar I inpatients without a history of neurological injury or illness: 1) patients meeting DSM-IV diagnostic criteria for alcohol dependence in the past 6 months (n=13), 2) patients diagnosed with alcohol dependence in full remission (n=9), and 3) patients without a history of a substance use disorder (SUD; n=41). Analyses indicated that patients with co-occurring alcohol dependence exhibited more severe impairment on tests of executive functioning (i.e. Stroop Color–Word Interference Test, Wisconsin Card Sorting Test) than patients without SUD. In addition, the group meeting diagnostic criteria for alcohol dependence in the past 6 months exhibited greater decrements in verbal (California Verbal Learning Test — II) and visual (Rey Complex Figure Test) memory. Analysis further indicated that patients in full SUD remission scored lower on measures of fluid intelligence (Wechsler Abbreviated Scale of Intelligence — Performance IQ). Consistent with previous reports, in the current sample, co-occurring alcohol dependence predicted higher rates of disability status. It is possible that cognitive deficits of greater severity in dually diagnosed patients contribute to this unfavorable outcome. Recognizing the extent of cognitive impairment in dually diagnosed patients may facilitate the effort to ameliorate their condition.

Do Atypical Antipsychotics Effectively Treat Co-Occurring Bipolar Disorder and Stimulant Dependence?

The primary objective was to compare the efficacy and tolerability of quetiapine and risperidone in the treatment of mood symptoms, drug cravings, and drug use in outpatients with concurrent DSM-IV-defined bipolar I or II disorder and cocaine or methamphetamine dependence. Men and women of all ethnic origins, 20 to 50 years of age, were eligible to participate. Persons were excluded if they were inpatients, met DSM-IV criteria for substance-induced mood disorder, had any other substance dependence, were euthymic or suicidal, had any life-threatening illnesses, or were currently receiving antipsychotic medications. Duration of the trial was 20 weeks. Study participants attended weekly visits and were evaluated for mood symptoms, drug cravings, drug use, and medication side effects. Treatment outcomes were analyzed using linear mixed models. Fixed-effects terms for medication group, study week, and group-by-study-week were included in the models. The study was conducted between October 2002 and November 2006. Of 124 consenting outpatients, an evaluable sample of 80 patients who attended baseline and at least 1 follow-up study visit was formed. The mean +/- SD exit dose for quetiapine was 303.6 +/- 151.9 mg/day and 3.1 +/- 1.2 mg/day for risperidone. Both quetiapine (N = 42) and risperidone (N = 38) significantly improved manic and depressive symptoms and reduced drug cravings (p < .0005) compared to baseline. Decreased drug cravings were related to less frequent drug use (p = .03). The 2 medications did not significantly differ in their effects on mood symptoms, drug craving, or drug use. Relative to baseline mood and drug-craving status, both quetiapine and risperidone were associated with manic, mixed, and depressive symptom improvement and reduced drug cravings. Both medications were well tolerated. The interpretation of these results is limited by the absence of a placebo control. clinicaltrials.gov Identifier: NCT00227123.

Predictors of dropout from group therapy among patients with bipolar and substance use disorders

Objective Bipolar and substance use disorders frequently co-occur. Integrated treatment for these disorders has been shown to be effective at reducing substance use, but no study has examined attrition from dual diagnosis group therapy. The current study identified baseline demographic and clinical characteristics that predict treatment dropout among patients with co-occurring bipolar and substance use disorders. Method Using binary and multivariate analyses, baseline data were analyzed as part of a randomized controlled trial of integrated group therapy for bipolar and substance use disorders. Results Cigarette smoking, recent mood episode, and lack of a college education were strong predictors of dropout after controlling for demographic and substance use variables. Conclusions Given the strength of smoking as a predictor of dropout as well as the high rate of smoking among this population, a greater focus on the relationship between smoking and bipolar disorder is warranted.

HIV risk behavior among patients with co-occurring bipolar and substance use disorders: Associations with mania and drug abuse

Background Bipolar and substance use disorders frequently co-occur, and both are associated with impulsivity, impaired judgment, and risk-taking. Objectives This study aimed to: (1) describe the rates of HIV sexual and drug risk behaviors among patients with co-occurring bipolar and substance use disorders, (2) test whether acute mania, psychiatric severity, and drug severity independently predict HIV risk, and (3) examine the relationship between specific substance dependencies and sexual risk behaviors. Method Participants ( N = 101) were assessed for psychiatric diagnoses, substance abuse, and HIV risk behavior using structured clinical interviews and self-report questionnaires. Results The majority (75%) were sexually active in the past 6 months and reported high rates of sexual risk behaviors, including unprotected intercourse (69%), multiple partners (39%), sex with prostitutes (24%, men only), and sex trading (10%). In a multivariate linear regression model, recent manic episode, lower psychiatric severity, and greater drug severity were independent predictors of total HIV risk. Cocaine dependence was associated with increased risk of sex trading. Conclusions Results underscore the importance of HIV prevention for this population.

Assessment of depressive symptom severity among patients with co-occurring bipolar disorder and substance dependence

Background We examined a modified version of the Hamilton Depression Rating Scale (HDRS) among treatment-seeking patients with co-occurring bipolar disorder and substance dependence in order to elucidate key features of depression in this specific population of patients. Methods Patients with current bipolar disorder and substance dependence who were prescribed mood stabilizers ( n = 105) completed a 27-item version of the HDRS that was subjected to item and principal components analyses. Preliminary validity analysis consisted of comparing the derived total and component scores to the depressed mood indicators from the Addiction Severity Index (ASI). Results Eleven items representing two related components labeled “melancholia” and “anxiety” were retained. The 11-item HDRS total and component scores were higher for those who reported serious depression, serious anxiety, cognitive problems, and suicidal ideation on the ASI than for those who did not report these problems. Limitations We conducted the analyses with a relatively small sample of patients who were primarily white and were diagnosed with bipolar I disorder, thus limiting the generalizability of findings. Moreover, we obtained limited data regarding construct validity of the 11-item scale. Conclusions Our psychometric evaluation of the HDRS led us to retain 11 items representing primarily melancholic and neurovegetative symptoms of depression. These findings suggest that sample-specific item characteristics of the HDRS need to be evaluated prior to using this scale to assess depressive symptom severity among patients with complex diagnostic and treatment characteristics.

Ask the Expert: Treatment Strategy for Co-occurring Bipolar Disorder and Alcohol Abuse

Ask the Expert: Treatment Strategy for Co-occurring Bipolar Disorder and Alcohol Abuse

Effects of Topiramate

Back to table of contents Previous article Next article Letters to the EditorFull AccessEffects of TopiramateSTEFAN P. KRUSZEWSKI M.D.,STEVEN G. KLOTZ M.D.,STEFAN P. KRUSZEWSKI M.D.Search for more papers by this author,STEVEN G. KLOTZ M.D.Search for more papers by this author,Published Online:1 Mar 2007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Drew H. Barzman, M.D., and Melissa P. DelBello, M.D., published a case report in the August 2006 edition of The American Journal of Psychiatry titled "Topiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior Disorders" (1) . This case report suggests that topiramate is "helpful" in the treatment of bipolar disorder and that topiramate monotherapy may be "effective in treating disruptive behavior disorders independent of its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling in adults” ( 1 , p. 1452). The authors make a broad scientific claim regarding the benefits of topiramate. They suggest a link in efficacy for this anticonvulsant/anti-migraine agent based on observed diagnostic classification, but do not address the possibility that disorders that are related by phenotypic expression may be unrelated genotypically or mechanistically. We are concerned that the authors present information suggesting effectiveness of topiramate without offering balanced commentary regarding the significant side-effects of topiramate, including word-finding difficulty, impaired concentration, depression, confusion, encephalopathy, and memory interference (2 , 3) . These and other problems with topiramate were recently highlighted elsewhere (4) . Finally, we find little basis for the authors, suggestion that the actions of topiramate, a gamma-aminobutyric acidergic (GABAergic) drug, has beneficial effects independent of any possible antimanic effects. The statement that topiramate monotherapy may be similarly efficacious in treating disruptive disorders in children, gambling in adults, binge eating, and borderline personality disorder suggests a mechanism of action for topiramate that is not supported by current research.Harrisburg, Pa.Lancaster, Pa.Dr. Kruszewski has served on the speakers" bureaus of Pfizer, GlaxoSmithKline, Janssen (Johnson & Johnson), AstraZeneca, Wallace Labs, Eli Lilly, GE-Amersham Biosciences; and an Eli Lilly Northeast Advisory Panel. Dr. Klotz is on the speakers" bureau of Pfizer and has served as a speaker and consultant to Bristol Myers-Squibb/Otsuka American Pharmaceuticals.

The Efficacy and Tolerability of Quetiapine versus Divalproex for the Treatment of Impulsivity and Reactive Aggression in Adolescents with Co-Occurring Bipolar Disorder and Disruptive Behavior Disorder(s)

The aim of this study was to compare the efficacy and tolerability of quetiapine and divalproex for the treatment of impulsivity and reactive aggression in adolescents with co-occurring bipolar disorder and disruptive behavior disorders. Patients were included in this post hoc analysis if they scored > or = 14 on the Positive and Negative Syndrome Scale (PANSS) Excited Component (EC) and > or = 4 on at least one of the PANSS EC items, had a current diagnosis of bipolar I disorder, manic or mixed episode, and had a lifetime and/or current diagnosis of a disruptive behavioral disorder (DBD) [conduct disorder (CD) or oppositional defiant disorder (ODD)]. Thirty-three (92%) of the 36 subjects with bipolar disorder and DBD met the PANSS EC inclusion criteria. These thirty-three adolescents were randomized to quetiapine (400-600 mg/day) or divalproex (serum level 80-120 microg/mL) for 28 days in this double-blinded study. The primary efficacy measure was change in PANSS Excited Component (EC) score over the study period and at each time point. Repeated measures analysis of variance (ANOVA) demonstrated statistically significant within-treatment-group effects for divalproex (baseline = 20.6, end point = 13.3, p < 0.0001) and quetiapine (baseline = 18.8, end point = 10.8, p < 0.0001) for the PANSS EC. There were no statistically significant treatment group differences in PANSS EC changes from baseline to end point scores (p = 0.7, d = 0.14). Mixed regression analyses (comparison of slopes, DAY*TREATMENT) revealed that there was no significant difference in the rate of improvement in the PANSS EC scores between the two treatment groups [F(1,31) = 0.78, p = 0.39, d = 0.28]. Quetiapine and divalproex showed similar efficacy for the treatment of impulsivity and reactive aggression related to co-occurring bipolar and disruptive behavior disorders in adolescents. Quetiapine and divalproex are both useful as monotherapy for the treatment of impulsivity and reactive aggression in adolescents with bipolar and disruptive behavior disorders. Placebo-controlled studies are necessary.

Topiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior Disorders

Back to table of contents Previous article Next article Letters to the EditorFull AccessTopiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior DisordersDREW H. BARZMAN M.D.MELISSA P. DELBELLO M.D.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DELBELLO M.D.Search for more papers by this author,Published Online:1 Aug 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although studies have suggested that topiramate is helpful in the treatment of bipolar disorder, no study, to our knowledge, has examined its usefulness in treating co-occurring bipolar disorder and disruptive behavior disorders in children and adolescents (1) . The literature on co-occurring bipolar disorder and disruptive behavior disorders is rather limited. In our case study presented here, we defined response with an endpoint Clinical Global Impression (CGI) improvement rating of 1 (“very much improved”) or 2 (“much improved”) for both mania and overall illness (including bipolar disorder and disruptive behavior disorders). Six (67%) out of nine of our hospitalized patients (ages 10 to 14) with bipolar disorder and disruptive behavior disorders responded to adjunctive topiramate with good tolerability. The mean dose was 78 mg/day (range=50–150 mg/day).“Miss A” was a 14-year-old African American girl with conduct disorder, bipolar disorder, and reactive attachment disorder. She had no history of substance abuse. She was arrested for domestic violence and had a history of lying, running away, felony assault, stealing, carrying firearms, truancy, destroying property, and arson. Approximately 2 months prior to being detained in juvenile detention, the patient had discontinued her medications, which included haloperidol, aripiprazole, quetiapine, and glucophage because of weight gain. She subsequently lost approximately 40 pounds. While in juvenile detention, the patient continued to display prominent disruptive behaviors of arguing, physical fighting, destroying property, deceitfulness, oppositionality, and defiance. Besides mood lability, distractibility, and acts of self-harm, there was no evidence of depression or mania. The patient refused mood stabilizers and atypical antipsychotics because of the possibility of weight gain.Doses of topiramate started at 25 mg once in the morning for 5 days and then increased to 25 mg twice daily. After 15 days taking 50 mg/day, the patient’s dose of topiramate was increased to 25 mg in the morning and 50 mg at bedtime. For the next 7 days, she was administered a dose of 75 mg/day and had no behavioral outbursts. She became more cooperative with staff and did not require restraints. The staff noted a significant improvement in her disruptive behaviors as well.Although her mania was much improved, she continued to display some emotional lability and distractibility. Therefore, her disruptive behavior symptoms improved independently and more significantly than her mood-related symptoms. She had CGI improvement ratings of 2 for mania and 1 for overall illness. Despite her reports of poor concentration and transient hyperactivity, there was no evidence for these or other side effects, such as weight gain or difficulties with verbal communication.As illustrated, topiramate monotherapy may be effective in treating disruptive behavior disorders, independent from its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling disorder in adults. Because of a favorable side effect profile, including possible weight loss, medication compliance may be less of a problem. Further randomized controlled studies of adjunctive and monotherapy topiramate treatment are needed. Future studies should assess aggression as an outcome measure with the Overt Aggression Scale.Cincinnati, OhioReference1. Barzman DH, DelBello MP, Kowatch RA, Warner J, Rofey D, Stanford K, Rappaport K, Daniels JP, Strakowski SM: Adjunctive topiramate in hospitalized pediatric patients with bipolar disorders. J Child Adolesc Psychopharmacol 2005; 15:931–937Google Scholar FiguresReferencesCited byDetailsCited ByTopiramate augmentation of clozapine in schizophrenia: a double-blind, placebo-controlled study8 July 2010 | Journal of Psychopharmacology, Vol. 25, No. 5Determination of plasma topiramate concentration using LC-MS/MS for pharmacokinetic and bioequivalence studies in healthy Korean volunteersBiomedical Chromatography, Vol. 22, No. 8Medical Management of Pediatric Mood DisordersPediatric Annals, Vol. 36, No. 9Pharmacotherapy for Child and Adolescent Mood DisordersPsychiatric Annals, Vol. 37, No. 7Effects of TopiramateSTEFAN P. KRUSZEWSKIM.D.,STEVEN G. KLOTZM.D.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Drs. Barzman and DelBello ReplyDREW H. BARZMAN, M.D.MELISSA P. DelBelloM.D., M.S.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Current awareness: Pharmacoepidemiology and drug safety1 January 2007 | Pharmacoepidemiology and Drug Safety, Vol. 16, No. 2 Volume 163Issue 8 August, 2006Pages 1451-1452THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 8 Metrics PDF download History Published online 1 August 2006 Published in print 1 August 2006

Topiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior Disorders

Back to table of contents Previous article Next article Letters to the EditorFull AccessTopiramate for Co-Occurring Bipolar Disorder and Disruptive Behavior DisordersDREW H. BARZMAN M.D.MELISSA P. DELBELLO M.D.,DREW H. BARZMAN M.D.Search for more papers by this authorMELISSA P. DELBELLO M.D.Search for more papers by this author,Published Online:1 Aug 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although studies have suggested that topiramate is helpful in the treatment of bipolar disorder, no study, to our knowledge, has examined its usefulness in treating co-occurring bipolar disorder and disruptive behavior disorders in children and adolescents (1) . The literature on co-occurring bipolar disorder and disruptive behavior disorders is rather limited. In our case study presented here, we defined response with an endpoint Clinical Global Impression (CGI) improvement rating of 1 (“very much improved”) or 2 (“much improved”) for both mania and overall illness (including bipolar disorder and disruptive behavior disorders). Six (67%) out of nine of our hospitalized patients (ages 10 to 14) with bipolar disorder and disruptive behavior disorders responded to adjunctive topiramate with good tolerability. The mean dose was 78 mg/day (range=50–150 mg/day).“Miss A” was a 14-year-old African American girl with conduct disorder, bipolar disorder, and reactive attachment disorder. She had no history of substance abuse. She was arrested for domestic violence and had a history of lying, running away, felony assault, stealing, carrying firearms, truancy, destroying property, and arson. Approximately 2 months prior to being detained in juvenile detention, the patient had discontinued her medications, which included haloperidol, aripiprazole, quetiapine, and glucophage because of weight gain. She subsequently lost approximately 40 pounds. While in juvenile detention, the patient continued to display prominent disruptive behaviors of arguing, physical fighting, destroying property, deceitfulness, oppositionality, and defiance. Besides mood lability, distractibility, and acts of self-harm, there was no evidence of depression or mania. The patient refused mood stabilizers and atypical antipsychotics because of the possibility of weight gain.Doses of topiramate started at 25 mg once in the morning for 5 days and then increased to 25 mg twice daily. After 15 days taking 50 mg/day, the patient’s dose of topiramate was increased to 25 mg in the morning and 50 mg at bedtime. For the next 7 days, she was administered a dose of 75 mg/day and had no behavioral outbursts. She became more cooperative with staff and did not require restraints. The staff noted a significant improvement in her disruptive behaviors as well.Although her mania was much improved, she continued to display some emotional lability and distractibility. Therefore, her disruptive behavior symptoms improved independently and more significantly than her mood-related symptoms. She had CGI improvement ratings of 2 for mania and 1 for overall illness. Despite her reports of poor concentration and transient hyperactivity, there was no evidence for these or other side effects, such as weight gain or difficulties with verbal communication.As illustrated, topiramate monotherapy may be effective in treating disruptive behavior disorders, independent from its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling disorder in adults. Because of a favorable side effect profile, including possible weight loss, medication compliance may be less of a problem. Further randomized controlled studies of adjunctive and monotherapy topiramate treatment are needed. Future studies should assess aggression as an outcome measure with the Overt Aggression Scale.Cincinnati, OhioReference1. Barzman DH, DelBello MP, Kowatch RA, Warner J, Rofey D, Stanford K, Rappaport K, Daniels JP, Strakowski SM: Adjunctive topiramate in hospitalized pediatric patients with bipolar disorders. J Child Adolesc Psychopharmacol 2005; 15:931–937Google Scholar FiguresReferencesCited byDetailsCited byTopiramate augmentation of clozapine in schizophrenia: a double-blind, placebo-controlled study8 July 2010 | Journal of Psychopharmacology, Vol. 25, No. 5Determination of plasma topiramate concentration using LC-MS/MS for pharmacokinetic and bioequivalence studies in healthy Korean volunteersBiomedical Chromatography, Vol. 22, No. 8Medical Management of Pediatric Mood DisordersPediatric Annals, Vol. 36, No. 9Pharmacotherapy for Child and Adolescent Mood DisordersPsychiatric Annals, Vol. 37, No. 7Effects of TopiramateSTEFAN P. KRUSZEWSKIM.D.,STEVEN G. KLOTZM.D.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Drs. Barzman and DelBello ReplyDREW H. BARZMAN, M.D.MELISSA P. DelBelloM.D., M.S.,1 March 2007 | American Journal of Psychiatry, Vol. 164, No. 3Current awareness: Pharmacoepidemiology and drug safety1 January 2007 | Pharmacoepidemiology and Drug Safety, Vol. 16, No. 2 Volume 163Issue 8 August, 2006Pages 1451-1452THE AMERICAN JOURNAL OF PSYCHIATRY August 2006 Volume 163 Number 8 Metrics PDF download History Published online 1 August 2006 Published in print 1 August 2006