Maintenance Treatment Of Bipolar Disorder Research Articles

A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE EFFICACY AND SAFETY OF SODIUM VALPROATE FOR "OFF-LABEL" INDICATIONS IN MENTAL HEALTH

ObjectiveValproate is currently licensed for use in epilepsy and, in mental health practice, for the treatment of acute mania. It is also commonly used for the maintenance treatment of bipolar...

New facts of long-term prophylaxis for bipolar affective disorder

Lithium and with restrictions, carbamazepine, valproic acid, lamotrigine, olanzapine, aripiprazole and quetiapine, are approved in Germany for maintenance treatment of bipolar disorder. Lithium is the only drug that (I) proved to be effective for the prevention of depressive as well as manic episodes in state-of-the-art studies without an enriched design and that (II) is approved for the maintenance treatment of bipolar disorders without restrictions. It (III) is also the only drug which is recommended for maintenance treatment by the current German S3 guidelines on bipolar disorders with the highest degree of recommendation (A) and (IV) is the only drug with a well proven suicide preventive effect. Hence, lithium is the mood stabilizer of first choice. No patient should be deprived of lithium without a specific reason. Side effects and risks are manageable if both the physician and the patient are well informed. Detailed and practical information on a safe use of lithium can be found in the S3 guidelines on bipolar disorders. For patients who do not respond sufficiently to lithium, have contraindications or non-tolerable side effects, other mood stabilizers should be used. Restrictions in their respective approval as well as specific side effects and risks have to be taken into account. Because maintenance treatment is a long-term treatment, particular concern should be paid to drugs with the potential risk of a metabolic syndrome, particularly atypical antipsychotics.

The evolution of psychoeducation for bipolar disorder: from lithium clinics to integrative psychoeducation

Coping and living with bipolar disorder is complex and sometimes counterintuitive. It demands a number of attitudes and aptitudes that include a huge emotional insight, healthy and regular lifestyle, skills to identify subtle changes and motivation to reach full treatment adherence. Patients' engagement and proactive attitude are a must for a successful therapeutic outcome. This may partly explain the therapeutic impact of psychoeducational programs in this disorder. However, the history of group psychoeducation in bipolar disorder is full of ups and downs. Interestingly enough, worldwide-respected opinion leaders in group therapy were initially not very enthusiastic with the use of such strategy with bipolar patients. I. Yalom, for instance, defined a bipolar patient as “one of the worst calamities that could befall group therapy” 1. Since then, the practice of psychoeducation has been evolving together with the conceptualization of bipolar disorder.

Variant GADL1 and Response to Lithium Therapy in Bipolar I Disorder

BackgroundLithium has been a first-line choice for maintenance treatment of bipolar disorders to prevent relapse of mania and depression, but many patients do not have a response to lithium treatment.MethodsWe selected subgroups from a sample of 1761 patients of Han Chinese descent with bipolar I disorder who were recruited by the Taiwan Bipolar Consortium. We assessed their response to lithium treatment using the Alda scale and performed a genomewide association study on samples from one subgroup of 294 patients with bipolar I disorder who were receiving lithium treatment. We then tested the single-nucleotide polymorphisms (SNPs) that showed the strongest association with a response to lithium for association in a replication sample of 100 patients and tested them further in a follow-up sample of 24 patients. We sequenced the exons, exon–intron boundaries, and part of the promoter of the gene encoding glutamate decarboxylase–like protein 1 (GADL1) in 94 patients who had a response to lithium and in 94 patients who did not have a response in the genomewide association sample.ResultsTwo SNPs in high linkage disequilibrium, rs17026688 and rs17026651, that are located in the introns of GADL1 showed the strongest associations in the genomewide association study (P=5.50×10−37 and P=2.52×10−37, respectively) and in the replication sample of 100 patients (P=9.19×10−15 for each SNP). These two SNPs had a sensitivity of 93% for predicting a response to lithium and differentiated between patients with a good response and those with a poor response in the follow-up cohort. Resequencing of GADL1 revealed a novel variant, IVS8+48delG, which lies in intron 8 of the gene, is in complete linkage disequilibrium with rs17026688 and is predicted to affect splicing.ConclusionsGenetic variations in GADL1 are associated with the response to lithium maintenance treatment for bipolar I disorder in patients of Han Chinese descent. (Funded by Academia Sinica and others.)

Recommandations Formalisées d’Experts de l’AFPBN : prescription des neuroleptiques et antipsychotiques d’action prolongée

Compliance is often partial with oral antipsychotics and underestimated for patients with serious mental illness. Despite their demonstrated advantages in terms of relapse prevention, depot formulations are still poorly used in routine. As part of a process to improve the quality of care, French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) Task Force elaborated a Formal Consensus for the prescription of depot antipsychotics in clinical practice. The Task Force recommends as first-line choice, the use of long-acting injectable (LAI) second-generation antipsychotics in patients with schizophrenia, schizoaffective disorder and delusional disorder. They can be considered as a second-line option as a monotherapy to prevent manic recurrence or in combination with mood stabilizer to prevent depressive recurrence in the maintenance treatment of bipolar disorder. LAI second-generation antipsychotics can also be used after a first episode of schizophrenia. Depot neuroleptics are not recommended during the early course of schizophrenia and are not appropriate in bipolar disorder. They are considered as a second-line option for maintenance treatment in schizophrenia. LAI formulations should be systematically proposed to any patients for whom maintenance antipsychotic treatment is indicated. LAI antipsychotics can be used preferentially for non-compliant patients with frequent relapses or aggressive behaviors. A specific information concerning the advantages and inconveniences of the LAI formulations, in the framework of shared-decision making must be delivered to each patient. Recommendations for switching from one oral/LAI form to another LAI and for using LAI antipsychotics in specific populations (pregnant women, elderly patients, subjects in a precarious situation, and subjects having to be treated in a prison establishment) are also proposed.

Clinical and regulatory implications of active run‐in phases in long‐term studies for bipolar disorder

The integration of new treatments into the market and routine clinical practice should be dependent on robustness of evidence from randomised controlled trials (RCTs). We assessed study designs of long-term studies for bipolar disorder of all second-generation antipsychotics (SGAs) submitted to the Food and Drug Administration (FDA) and the completeness of evidence submitted to the regulatory agency. Systematic review of double-blind RCTs comparing SGAs with placebo or active drugs in adults. FDA website and electronic databases were searched until July 2013. Six placebo-controlled trials comparing aripiprazole, olanzapine, quetiapine and ziprasidone were found in the FDA website. Electronic searches found four additional RCTs about aripiprazole, olanzapine or quetiapine. All RCTs (either submitted to FDA or not) selected patients who responded to acute treatment to increase the treatment effect observed in the long-term phase (enrichment design). By contrast, in the prescribing information sheets for all SGAs, the reported indication was 'maintenance treatment of bipolar disorder'. Extrapolation of results from enrichment studies to the more general population of patients should be carried out cautiously because average treatment benefits are likely to be less in unselected patients. Clear guidance for regulatory submission of RCTs is needed.

Randomized Placebo-Controlled Adjunctive Study of an Extract ofWithania somniferafor Cognitive Dysfunction in Bipolar Disorder

Cognitive impairments contribute significantly to inadequate functional recovery following illness episodes in bipolar disorder, yet data on treatment interventions are sparse. We assessed the cognitive effects of a standardized extract of the medicinal herb Withania somnifera (WSE) in bipolar disorder. Sixty euthymic subjects with DSM-IV bipolar disorder were enrolled in an 8-week, double-blind, placebo-controlled, randomized study of WSE (500 mg/d) as a procognitive agent added adjunctively to the medications being used as maintenance treatment for bipolar disorder. Study enrollment and data analyses were completed between December 2008 and September 2012. Cognitive testing at baseline and 8 weeks assessed primary efficacy outcomes. Psychopathology and adverse events were monitored at scheduled visits. Fifty-three patients completed the study (WSE, n = 24; placebo, n = 29), and the 2 groups were matched in terms of demographic, illness, and treatment characteristics. Compared to placebo, WSE provided significant benefits for 3 cognitive tasks: digit span backward (P = .035), Flanker neutral response time (P = .033), and the social cognition response rating of the Penn Emotional Acuity Test (P = .045). The size of the WSE treatment effect for digit span backward was in the medium range (Cohen d = 0.51; 95% CI, 0.25-0.77). None of the other cognitive tasks showed significant between-group differences. Mood and anxiety scale scores remained stable, and adverse events were minor. Although results are preliminary, WSE appears to improve auditory-verbal working memory (digit span backward), a measure of reaction time, and a measure of social cognition in bipolar disorder. Given the paucity of data for improving cognitive capacity in bipolar disorder, WSE offers promise, appears to have a benign side-effects profile, and merits further study. ClinicalTrials.gov identifier: NCT00761761.

Valproic acid, valproate and divalproex in the maintenance treatment of bipolar disorder.

Valproic acid, valproate and divalproex in the maintenance treatment of bipolar disorder.

P.2.d.012 Clinical implications of the polarity index of drugs in maintenance treatment of bipolar disorder: a naturalistic study

P.2.d.012 Clinical implications of the polarity index of drugs in maintenance treatment of bipolar disorder: a naturalistic study

Clinical implications of predominant polarity and the polarity index in bipolar disorder: a naturalistic study

Predominant polarity (PP) is an important variable in maintenance treatment of bipolar disorder (BD). This study aimed at determining the role of polarity index (PI), a metric indicating antimanic versus antidepressive prophylactic potential of drugs, in clinical decision-making. Two hundred and fifty-seven of 604 (43%) of patients with BD-I or II fulfilled criteria for manic (MPP) or depressive PP (DPP). The PI, representing the ratio of number needed to treat (NNT) for depression prevention to NNT for mania prevention, was calculated for patients' current treatment. MPP and DPP groups were compared regarding sociodemographic, clinical and therapeutic characteristics. One hundred and forty-three patients (55.6%) fulfilled criteria for DPP and 114 (44.4%) for MPP. Total PI, Antipsychotics' PI, and mood stabilizers PI were higher, indicating a stronger antimanic action, in MPP. MPP presented higher prevalence of BD-I, male gender, younger age, age at onset and at first hospitalization, more hospitalizations, primary substance misuse, and psychotic symptoms. DP correlated with BD-II, depressive onset, primary life events, melancholia, and suicide attempts. The results confirm the usefulness of the PI. In this large sample, clinical differences among these groups justify differential treatment approach. The PI appears to be a useful operationalization of what clinicians do for maintenance therapy in BD.

Lamotrigine in Psychiatric Disorders

Owing to the prevalence of medication side effects and treatment resistance, prescribers often consider off-label uses of US Food and Drug Administration (FDA)-approved agents for the treatment of persistent symptoms. The authors review the available literature on the FDA-approved and non-FDA-approved uses of lamotrigine in adults with psychiatric disorders. We used PubMed, MEDLINE, and a hand search of relevant literature to find studies published between 1990 and 2012 and available in English language. The following keywords were searched: lamotrigine, psychiatric, mood disorders, depression, personality disorders, anxiety, schizophrenia, side effects, and rash. Data were selected from 29 randomized controlled trials (RCTs). When RCTs were not available, open-label trials (6), retrospective case reviews (10), and case series (4) were summarized. We extracted results of monotherapy and augmentation trials of lamotrigine on primary and secondary outcome measures. Lamotrigine is generally well tolerated, with the best evidence for the maintenance treatment of bipolar disorder, particularly in prevention of depressive episodes. In acute bipolar depression, meta-analyses suggested a modest benefit, especially for more severely depressed subjects, with switch rates similar to placebo. In unipolar depression, double-blind RCTs noted benefit on subsets of symptoms and improved response in more severely depressed subjects. Data are limited but promising in borderline personality disorder. Use of lamotrigine in schizophrenia and anxiety disorders has little supportive evidence. Lamotrigine is recommended in bipolar maintenance when depression is prominent. It also has a role in treating acute bipolar depression and unipolar depression, though the latter warrants more research. Data are too limited in other psychiatric disorders to recommend its use at this time.

Assessment of Response to Lithium Maintenance Treatment in Bipolar Disorder: A Consortium on Lithium Genetics (ConLiGen) Report

ObjectiveThe assessment of response to lithium maintenance treatment in bipolar disorder (BD) is complicated by variable length of treatment, unpredictable clinical course, and often inconsistent compliance. Prospective and retrospective methods of assessment of lithium response have been proposed in the literature. In this study we report the key phenotypic measures of the “Retrospective Criteria of Long-Term Treatment Response in Research Subjects with Bipolar Disorder” scale currently used in the Consortium on Lithium Genetics (ConLiGen) study.Materials and MethodsTwenty-nine ConLiGen sites took part in a two-stage case-vignette rating procedure to examine inter-rater agreement [Kappa (κ)] and reliability [intra-class correlation coefficient (ICC)] of lithium response. Annotated first-round vignettes and rating guidelines were circulated to expert research clinicians for training purposes between the two stages. Further, we analyzed the distributional properties of the treatment response scores available for 1,308 patients using mixture modeling.ResultsSubstantial and moderate agreement was shown across sites in the first and second sets of vignettes (κ = 0.66 and κ = 0.54, respectively), without significant improvement from training. However, definition of response using the A score as a quantitative trait and selecting cases with B criteria of 4 or less showed an improvement between the two stages (ICC1 = 0.71 and ICC2 = 0.75, respectively). Mixture modeling of score distribution indicated three subpopulations (full responders, partial responders, non responders).ConclusionsWe identified two definitions of lithium response, one dichotomous and the other continuous, with moderate to substantial inter-rater agreement and reliability. Accurate phenotypic measurement of lithium response is crucial for the ongoing ConLiGen pharmacogenomic study.

The use of antipsychotics in maintenance treatment of bipolar disorder

Antipsychotics are often used in the treatment of the acute phase of bipolar disorder; however, once the acute phase has resolved and patients enter the maintenance phase, there is some debate as to whether or not to continue the antipsychotic. This article reviews studies examining the use of antipsychotics in the maintenance phase of bipolar disorder.

Editorial: Elevating to new heights in neuropsychiatric pharmacy at the 2013 CPNP Annual Meeting

First and foremost, we were encouraged to elevate our knowledge. This was done primarily through the informative continuing education (CE) sessions provided throughout the conference. While all the sessions were informative, we have chosen to highlight a few of the presented topics in this month's issue. In this issue, the reader will find an article discussing the use of antipsychotics in the maintenance treatment of bipolar disorder. There is an article which highlights the use of pharmacotherapy in pediatric obsessive-compulsive disorder, to contrast with the presentation that focused on the use of cognitive-behavioral therapy (CBT) in this population. In addition, the reader will find a more indepth discussion of two of the clinical pearls that were presented in the general clinical pearls session; these articles relate to opioid induced analgesia and the urea cycle disorder.

Perinatal and Neonatal Outcomes of Lithium-Treated and Untreated Bipolar Women During Pregnancy: A Review of Present Literature

Many women with a bipolar disorder are in their reproductive age and will need to continue their psychopharmacological treatment during pregnancy, being abrupt discontinuation of these medications associated with an increase of the probability of relapse, high-risk behaviours, significant family dysfunction, and suicide. Lithium is a first line drug for acute and maintenance treatment of bipolar disorder. Its teratogenic and perinatal effects are controversial, so as its longterm effects on neurodevelopment of the children. Our purpose is to review the most up-to-date literature dealing with growth, neurological, cognitive and behavioural development of children exposed to Lithium in utero. A PubMed search was performed with the following keywords: bipolar disorder, Lithium, pregnancy, lactation, perinatal disease, child development. Studies were included in the review if they investigated one or more of the adverse events of interest. Of the 26 studies included in our review, some show an association between Lithium treatment and several grades of malformations (most commonly minor), both cardiac and involving other organs, and dysfunctions which are often reversible. Some studies reported no collateral effects due to in utero exposure to Lithium. Even though literature points out a slightly increased risk of major malformations due to Lithium therapy during pregnancy, the drug should not be discontinued, yet monitoring of serum Lithium levels and foetal echocardiography are recommended.

Aripiprazole as augmentation therapy in bipolar patients with current minor or subsyndromal mood symptoms.

BackgroundThis study aims to evaluate the effectiveness of aripiprazole augmentation of maintenance treatment for bipolar disorder in patients with minor or subsyndromal mood episodes while on a stable dose of a mood stabiliser and/or antidepressant.MethodsAll subjects had a diagnosis of bipolar I or II disorder (Diagnostic and Statistical Manual of Mental Disorders-4th Edition, Text Revision). Open-label aripiprazole was given over 8 weeks initially. The starting dose was 5 to 15 mg/day with a mean final dose of 11.5 mg (±4.6). Patients were assessed at weeks 0, 2, 4 and 8 with the Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Clinical Global Impression of Severity (CGI-S).Results and discussionSeventeen of 20 (85%) patients completed week 4, while 14 (70%) patients completed 8 weeks. For intention-to-treat data, there was a significant decrease in MADRS scores over the course of treatment, with a reduction of 6.40 points at endpoint (p < 0.0005). Improvement from baseline was significant at week 2 and remained through to week 8. Similarly, CGI-S scores significantly decreased over the course of study, but not YMRS scores. Aripiprazole was shown to be a modestly effective augmentation therapy for depressive symptoms in bipolar I and II in this small open-label study.

P.4.001 Clinical implications of polarity index of drugs in maintenance treatment of bipolar disorder: a naturalistic study

Changes in serum cytokines and altered neutrophin concentration have been associated with bipolar disorder (BD). Our aim here was to analyze peripheral blood biomarkers according to the clinical stages of BD.Euthymic BD-I patients were grouped according to their level of functioning in early-stage (n = 25) and late-stage (n = 23), and compared to healthy siblings (n = 23) and genetically unrelated healthy controls (n = 21). Neurotrophin (neurotrophin-3 and BDNF) concentration and biomarkers of inflammation, including cytokines (IL-6, IL-10 and TNF-α), leukocytes count and acute phase proteins, were measured.IL-10 concentration was significantly increased in early-stage patients compared to late-stage patients, healthy siblings and controls whereas TNF-α concentration was significantly increased in late-stage patients compared to controls. Total leukocytes, neutrophil and monocyte count were significantly increased in late-stage patients compared to healthy siblings and controls. The concentration of IL-6, neurotrophin-3 and BDNF was unchanged in euthymia. Healthy siblings did not show significant changes in any biomarker.The concentration of IL-10, TNF-α, neutrophil and monocytes subtype count in blood is altered in patients with BD during euthymic state. The link between peripheral inflammation and different stages in BD deserves further studies.

Retrospective analysis of factors associated with quetiapine dosage in the acute and subsequent six-month maintenance treatment of bipolar disorders

BackgroundAlthough quetiapine has often been used as monotherapy or adjunctive therapy in bipolar disorder, there is very limited clinical evidence regarding prescribing practices for quetiapine as maintenance treatment for bipolar disorder.MethodsWe reviewed the inpatient and outpatient records of 175 Chinese patients who received treatment with quetiapine for bipolar disorder both during and following hospitalization. We compared patients treated with high-dose (>300 mg/day) and low-dose (≤300 mg/day) quetiapine during the acute treatment phase and in the subsequent 6 months of maintenance treatment, with assessments at months 1, 3, and 6. Multifactor logistic regression analysis was performed to identify factors associated with quetiapine dosage.ResultsThe proportion of patients receiving combination therapy of quetiapine and a mood stabilizer as acute and maintenance treatment was 99.4% and 84.6%, respectively. The mean dose of quetiapine when used for acute treatment in the 175 patients was 395.7 mg/day. The following factors were found to be independently associated with use of high-dose quetiapine: male gender (odds ratio [OR] 2.712, 95% confidence interval [CI] 1.372–5.362, P < 0.01), a manic or mixed episode (OR 2.786, 95% CI 1.362–5.699, P < 0.01), and psychotic features (OR 2.658, 95% CI 1.318–5.361, P < 0.01). In the subsequent 6 months, the mean dose of quetiapine prescribed steadily decreased to 375.0 mg/day, 330.6 mg/day, and 293.7 mg/day at months 1, 3, and 6. The main factors associated with high-dose quetiapine in maintenance treatment were male gender (month 1, OR 2.761; month 3, OR 2.583; month 6, OR 2.686; P < 0.01) and a manic or mixed episode (month 1, OR 2.626; month 3, OR 2.334; P < 0.01).ConclusionHigher doses of quetiapine (>300 mg/day) are more likely to be prescribed to patients who are male, those who are experiencing a manic or mixed episode, and those who have psychotic features during acute treatment of bipolar disorder. For patients who remain clinically stable during the subsequent months, the quetiapine dose should be adjusted according to patient gender and the most recent type of episode experienced.

Effectiveness of a Clozapine–Aripiprazole Combination in Tourette Syndrome and Bipolar Spectrum Disorder

Back to table of contents Previous article Next article LettersFull AccessEffectiveness of a Clozapine–Aripiprazole Combination in Tourette Syndrome and Bipolar Spectrum DisorderArmando Piccinni, M.D., Antonello Veltri, M.D., Donatella Marazziti, M.D., Ilenia Moroni, M.D., and Liliana Dell’Osso, M.D.Armando PiccinniSearch for more papers by this author, M.D., Antonello VeltriSearch for more papers by this author, M.D., Donatella MarazzitiSearch for more papers by this author, M.D., Ilenia MoroniSearch for more papers by this author, M.D., and Liliana Dell’OssoSearch for more papers by this author, M.D.Published Online:1 Jan 2013https://doi.org/10.1176/appi.neuropsych.12020032AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Antipsychotic combination is a common strategy used in both bipolar disorder and schizophrenia, although just a few trials are available exploring its effectiveness.1 We report herein the case of a patient suffering from severe Tourette syndrome (TS) and bipolar spectrum disorder who benefited from a combination of clozapine and aripiprazole.Case Report“Mr. FS,” a 39-year-old art-craft worker, had been suffering from TS since his early childhood. During the adolescence, TS was characterized by mouth opening and shoulder rotation, complex motor tics, such as trunk-bending or gyrating, screaming, and complex phonic tics. He was treated with pimozide 8 mg/day, which led to a complete remission of tics for about 20 years, although the clinical picture was complicated by the onset of mood shifts associated with impulsive behaviors and obsessions (numerical obsessions, rituals of order and symmetry, disproportionate aggressiveness).In 2007, when he was 35, he visited us for a major depressive episode with suicidal thoughts, panic attacks, and agoraphobic avoidance. Paroxetine (20 mg/day) led to a fast improvement of mood and anxiety symptoms, albeit being ineffective on tics. Only transient responses were obtained with the association of various drugs (haloperidol, risperidone, olanzapine, amisulpiride) to paroxetine and mood stabilizers (valproic acid, 600 mg/day). After about 2 years of different combinations, a significant improvement was obtained with tetrabenazine 75 mg/day + clozapine 25 mg/day + valproic acid 600 mg/day and fluvoxamine 150 mg/day. This strategy had a good impact only on the affective and obsessive symptoms, while tics remained stable. Therefore, tetrabenazine, fluvoxamine, and valproic acid were tapered down. At the same time, aripiprazole (15 mg/day) was introduced, and, after about 1 month, we observed a dramatic improvement of TS symptoms. The improvement is still maintained at 2-year follow-up, so that currently the patient, who is regularly taking clozapine 25 mg/day and aripiprazole 15 mg/day with no significant side effects, shows a good affective balance, with no impulsive behavior, obsessions, or tics.Clozapine is considered a standard treatment for schizophrenia and bipolar disorder,2 whereas it has been reported to exacerbate obsessions and tics, although this topic is controversial.3 The effectiveness of aripiprazole in bipolar disorder is well documented, and preliminary data do exist for its possible use in obsessive-compulsive (OCD) and related disorders.4 Our case report highlights the possible usefulness of combining clozapine and aripiprazole in TS comorbid with bipolar spectrum disorders, perhaps due to the different and not overlapping pharmacological profile of these two antipsychotics. Aripiprazole has much higher affinity for D2 receptors than clozapine and, since it behaves as a 5-HT2A antagonist and 5-HT2C partial agonist, may have a robust anti-obsessional (and perhaps anti-tic) activity.5Further controlled studies are necessary to investigate the benefits of antipsychotic polypharmacy in patients suffering from both bipolar and OCD spectrum disorders.Dept. of Clinical and Experimental Medicine University of Pisa Pisa, ItalyCorrespondence: Armando Piccinni, M.D.; e-mail: a.[email protected]unipi.itReferences1 Tapp A, Wood AE, Secrest L, et al.: Combination antipsychotic therapy in clinical practice. Psychiatr Serv 2003; 54:55–59Crossref, Medline, Google Scholar2 Rybakowski J: Maintenance treatment of bipolar disorders. Neuro Endocrinol Lett 2005; 26 Suppl 1:49–65Google Scholar3 Bastiampillai T, Dhillon R, Mohindra R: Exacerbation of tics secondary to clozapine therapy. Aust N Z J Psychiatry 2008; 42:1068–1070Medline, Google Scholar4 Pessina E, Albert U, Bogetto F, et al.: Aripiprazole augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a 12-week open-label preliminary study. Int Clin Psychopharmacol 2009; 24:265–269Crossref, Medline, Google Scholar5 Shapiro DA, Renock S, Arrington ER, et al.: Aripiprazole, a novel atypical antipsychotic drug with a unique and robust pharmacology. Neuropsychopharmacology 2003; 28:1400–1411Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByFrontiers in Behavioral Neuroscience, Vol. 13Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Psychopharmacology, Vol. 26, No. 2 Volume 25Issue 1 Winter 2013Pages E45-E45 Metrics PDF download History Published online 1 January 2013 Published in print 1 January 2013

A Simple Question Answered: Adding Moderate-Dosage Lithium Does Not Help Patients With Bipolar Disorder

A Simple Question Answered: Adding Moderate-Dosage Lithium Does Not Help Patients With Bipolar Disorder