Treatment Options For Bipolar Disorder Research Articles

Bipolar Disorder: An Update

There has been a recent increase in the number of clinical trials and treatment options for bipolar disorder. This research has resulted in new treatment options. Most second-generation antipsychotics have demonstrated efficacy in the treatment of mania, both in monotherapy and as adjuncts to mood stabilizers. For bipolar depression, nearly all randomized, placebo-controlled studies have demonstrated that antidepressants do not provide any additional benefit to ongoing mood stabilizers. Additionally, antidepressants carry a risk of destabilization of bipolar disorder with an increase in mania, cycling, and chronic irritable dysphoria. Newer non-antidepressant treatments for depression include quetiapine, lamotrigine, modafinil, and pramipexole. These agents are effective for acute treatment and appear to be effective in maintenance. The least-studied phase of bipolar disorder is the maintenance phase. The use of multiple agents appears to be superior to monotherapy in relapse prevention. Despite the many advances in the pharmacotherapy of bipolar disorder, the overall prognosis of this severe illness does not appear to have changed.

CALM

Sir: The treatment of bipolar disorder remains a challenge, with some clinicians using antidepressants frequently,1 others promoting antipsychotics,2 and some advocating primarily lithium or anticonvulsants.3 For the practicing clinician, these debates can be confusing. We have devised the following mnemonic to help organize the treatment options for bipolar disorder: CALM. C = Control manic and mixed symptoms. First and foremost, control manic and mixed symptoms (especially insomnia, irritability, agitation, and anxiety). Control of these symptoms is pivotal to treatment success. Agitation and irritability disrupt work situations and social supports, and even subsyndromal manic symptoms during bipolar depression have been associated with increased risk for suicidal behavior.4,5 A = Antidepressants. Use antidepressants very selectively, if at all. Recent randomized data from the STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder) study showed adjunctive acute use of antidepressants to be of no help even in pure bipolar depression,6 and in bipolar depressed patients with as few as 2 or more concomitant manic symptoms, adjunctive antidepressant use was associated with “significantly higher mania symptom severity at the 3-month follow-up.”7 L = Longitudinal/long-term view. Take a longitudinal/long-term view of bipolar illness and treatment response. The long-term view of mood episodes over months to years is a key to making the diagnosis of bipolar disorder in the first place. Viewing only current cross-sectional symptoms may also interfere with the ability to accurately gauge the patient's response to treatment. M = Mood stabilizers. Emphasize mood stabilizers—especially lithium, divalproex, carbamazepine, and lamotrigine—as these remain the core building blocks of effective bipolar disorder regimens. Roger Sparhawk, M.D. St. Thomas Hospital, Summa Health System, Akron, Ohio S. Nassir Ghaemi, M.D., M.P.H. Bipolar Disorder Research Program, Department of Psychiatry, Emory University, Atlanta, Georgia

Treatment of bipolar disorder: a systematic review of available data and clinical perspectives

This paper is a systematic review of the available data concerning the treatment of bipolar disorder: a systematic Medline search concerning treatment guidelines and clinical trials. The search for treatment guidelines returned 583 articles and 913 papers for RCTs. The search was last performed on 1 March 2008. An additional search included repositories of clinical trials and previous systematic reviews in order to trace especially older trials. The literature suggests that lithium is useful during the acute manic and the maintenance phase. Both first- and second-generation antipsychotics are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also effective for treating bipolar depression, while olanzapine, quetiapine and aripiprazole are effective during the maintenance phase. Anticonvulsants, particularly valproate and carbamazepine have antimanic properties, whereas lamotrigine may be preferably effective in the treatment of depression but not mania. Antidepressants should always be used in combination with an antimanic agent because they were reported to induce switching to mania or hypomania, mixed episodes, and rapid cycling when given as monotherapy. The best evidence-based psychosocial interventions for bipolar disorder are group- and family-focused psychoeducation. Electroconvulsive therapy is an option for refractory patients. Although a variety of treatment options for bipolar disorder is currently available, their effectiveness is far from satisfactory, especially against bipolar depression and maintenance. Combination therapy may improve treatment outcome but it also carries the burden of more side-effects. Further research as well as the development of better guidelines and algorithms for step-by-step rational treatment are necessary.

Electroconvulsive therapy for bipolar depressive and mixed episode with high suicide risk after epilepsy surgery

Mood disturbance is a common comorbid condition of temporal lobe epilepsy before and after surgery. Suicide is more frequent in patients with epilepsy than in the general population. As suicide is a major issue in both epileptic and depressive patients, it is critical to treat aggressively any psychiatric illness with suicidal ideation. We describe two patients who, after temporal lobe surgery, developed a serious bipolar disorder that necessitated electroconvulsive therapy (ECT), despite better seizure control. Unfortunately they were not able to commit to a regular treatment plan with their psychiatrists to prevent a suicide. These patients underwent a course of ECT treatments. After the ECT regimen, acute suicidal intent remitted and was replaced by chronic suicidal ideation without active intent or plan. The patients were then able to commit to a treatment plan regarding their medications and control visits. These cases represent the safe utilization of ECT as a rapid and effective treatment option for bipolar disorder with suicide ideation following epilepsy surgery. Patients and parents should be advised about possible psychiatric disturbances and suicide risk after epilepsy surgery, especially in the presence of a temporal lobe epilepsy, even when seizure control is achieved postoperatively.

Treatment of bipolar disorder: a systematic review of available data

Analysis of results: The literature suggests that lithium is useful during all phases of bipolar illness and it has a specific effectiveness on suicide prevention. Both first and second generation antipsychotics are efficacious in the treatment of acute mania. Quetiapine and olanzapine are also effective for treating bipolar depression. Anticonvulsants, particularly valproate and carbamazepine have antimanic properties, whereas lamotrigine may be preferably effective in the treatment of depression but not mania. Antidepressants should always be used in combination with an antimanic agent, because they may induce switching to mania or hypomania, mixed episodes and rapid cycling. The first line of psychosocial intervention in BD is psychoeducation, family-focused psychoeducation, and cognitive-behavioral therapy. Electroconvulsive therapy and transcranial magnetic stimulation are options for refractory patients. Conclusions Although a variety of treatment options for bipolar disorder are available today, their effectiveness is far from satisfactory, especially against bipolar depression. Combination techniques might improve the outcome; however there is still lack of data in this field. Research in this field is necessary as well as the development of better guidelines for step-by-step combination treatment. from International Society on Brain and Behaviour: 3rd International Congress on Brain and Behaviour Thessaloniki, Greece. 28 November – 2 December 2007

Bipolar disorder

Four-part clinical focus on bipolar disorder, covering epidemiology, risk factors and diagnosis, making the diagnosis, treatment options for bipolar disorder, and prognosis and physical health

Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies

Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.

New medication treatment options for bipolar disorders.

To assess new treatment options for bipolar disorders. Controlled studies of new treatments for bipolar disorders were identified by computerized searches and reviews of scientific meeting proceedings, and were compiled by drug category. Two main categories of medications, newer anticonvulsants and newer antipsychotics, are yielding emerging new treatment options for bipolar disorders. Newer anticonvulsants have diverse psychotropic profiles, and although not generally effective for acute mania, may have utility for other aspects of bipolar disorders (e.g. lamotrigine for maintenance or acute bipolar depression), or for comorbid conditions (e.g. gabapentin for anxiety or pain, topiramate for obesity, bulimia, alcohol dependence, or migraine, and zonisamide for obesity). In contrast, newer antipsychotics generally appear effective for acute mania, and some may ultimately prove effective in acute depression (e.g. olanzapine combined with fluoxetine, quetiapine) and maintenance (e.g. olanzapine). Emerging research is yielding new treatment options for bipolar disorders and comorbid conditions.

Demystifying the Disease State: Understanding Diagnosis and Treatment Across the Bipolar Spectrum

It is estimated that only one-third of the people with bipolar disorder are correctly diagnosed, and even fewer are receiving appropriate treatment. This information is of concern, particularly in light of emerging data reflecting the potential negative consequences of failed or delayed diagnosis and lack of focused treatment. The article attempts to illuminate this complex disorder by describing the bipolar spectrum through a review of the criteria for diagnosis, aswell as practical advice on improving the detection of the disorder. Treatment options for bipolar disorder, with a focus on the latest pharmacological evidence base, as well as clinical recommendations regarding the safe and effective use of mood stabilizers and antidepressants are presented.

Emerging roles of new antipsychotics in bipolar disorders

Recent years have seen the emergence of important new treatment options for bipolar disorders (BD), including new anticonvulsants and antipsychotics. New antipsychotics have displaced older ones, based on their superior tolerability, and emerging evidence of efficacy in BD. All new antipsychotics, including risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole, have recent placebo-controlled data showing acute mania efficacy. Data demonstrating olanzapine efficacy in acute BD depression and utility in longer-term treatment of BD are emerging. Taken together, the wealth of new data suggesting BD efficacy with new antipsychotics suggest that these agents as a class will have an increasingly important role in the management of BD. Additional research should help determine the validity of this notion.

Unmet clinical needs in bipolar disorder.

Bipolar disorder is a complex, chronic condition associated with considerable morbidity and mortality, including a high rate of suicide. Currently available treatment options for bipolar disorder fail to adequately address many of the important needs of bipolar patients. Long-term maintenance therapy with lithium has been shown to prevent further episodes of mania and depression and to decrease the likelihood of suicide. However, many patients stop lithium treatment after only a few weeks, because of either untoward side effects or other factors, such as the belief that they no longer require medication. Even when lithium is taken regularly and at adequate doses, many patients continue to exhibit severe functional disability and also fail to achieve remission. Bipolar depression is also poorly understood and difficult to treat. A number of adjunctive medications are used in combination with lithium, but residual symptoms and recurring episodes of mania and depression remain common. Recently, atypical antipsychotics, such as olanzapine, risperidone, and quetiapine, have been evaluated for the treatment of bipolar disorder. Although considerable research is still needed, preliminary findings suggest that some of these agents may act as mood stabilizers, improving the acute symptoms of mania without inducing depression or rapid cycling. The role of atypical antipsychotics in maintenance therapy for bipolar disorder is currently being evaluated in a number of large clinical trials.

Stabilization of Mood From Below Versus Above Baseline in Bipolar Disorder

Management of bipolar disorder has traditionally emphasized the acute treatment of mania. Although acute treatment of mania is a critical aspect of care, this emphasis has tended to overshadow other important phases of bipolar disorder, such as depression, hypomania, and subsyndromal symptoms. We offer a reconceptualization of bipolar disorder that highlights unmet needs and the importance of differential spectra of efficacy. In this reconceptualization, bipolar disorder can be viewed as an aberration of mood, behavior, and cognition from baseline (euthymia). "Below baseline" is characterized by depression and subsyndromal depression. "Above baseline" is characterized by mania, mixed states, hypomania, and subsyndromal mood elevation. In contrast to the treatment options for mania, the options for depression are limited. This new nomenclature emphasizes the need to develop mood stabilizers that possess the ability to stabilize mood "from below baseline," either alone or in combination with other agents. In this article, the treatment options for bipolar disorder, with a focus on depression and rapid cycling, are discussed according to this new conceptualization of management from below and above baseline.

Emerging treatment options for bipolar disorder

Emerging treatment options for bipolar disorder