The Controversies:
The bottom line overall here: antidepressants may carry much more risk for people with bipolar disorder than is generally recognized. That antidepressants can cause "switching", bringing on a manic or hypo manic phase, is generally accepted, although how often this occurs is still hotly debated (somewhere between 4% and 40% of the time?).
However, antidepressants may pose bigger risks in the long term. Substantial evidence suggests that antidepressants can induce "rapid cycling". Indeed, it is a standard recommendation for the treatment of rapid cycling to gradually withdraw any antidepressant. In addition, more subtle "destabilizing" effects are possible. Antidepressants may make it more difficult to get a good outcome from an otherwise ineffective mood stabilizer treatment. There is even a concern that antidepressants may permanently alter the course of a person's bipolar illness, through a phenomenon called "kindling".
Therefore, considerable caution should be used before starting an antidepressant in a patient with bipolar disorder. Because data suggest that antidepressants may not be effective at all in this condition, one can wonder why they should be used at all, given the accepted risks (switching, rapid cycling), let alone the more difficult-to-prove concerns about kindling.
Finally, some patients clearly do better if they stay on an antidepressant.
However, new evidence raises further questions about just how many patients meet this description.
In my view, nearly every patient with bipolar disorder deserves at least a significant trial, if not several, of a treatment approach without an antidepressant to see if this might work as well as when the antidepressant is included -- or, quite possibly, better.
Tuesday, December 23, 2008
Monday, December 15, 2008
Algorithm of Bipolar Disorder Treatment
The first step in the treatment of this population of patients is the detection and deletion drugs possible factors contributing to the formation and maintenance of effective volatility with rising phase formation. Given that all antidepressants, especially three cyclic can cause inversion phase, an attempt to repeal must be the first step in the conduct of patients with Bipolar Disorder. Even with the prevalence of depressive symptoms, preference should be given mood stabilizer therapy. The question of the appointment of antidepressants in the depressive phase should be decided based on the analysis of the inevitability of such a move based on an assessment of factors such as suicidal risk, duration and severity of depressive phases, the degree of violations brought by social adaptation of the patient, his family situation, the presence or absence of support from part of loved ones and so on psychosocial support can provide substantial assistance in treating depressive phase and reduce the intensity of recidivation.
Some psychosocial techniques designed specifically for BAR, can reduce interpersonal conflicts grade potential trigger mechanisms for the development phase and / or mitigate the circadian rhythmic.
When choosing mood stabilizer preference will be given anticonvulsive, given their greater efficiency in comparison with lithium carbonate in the Bipolar Disorder. When the ineffectiveness of the first designated mood stabilizer must decide on the future of therapeutic tactics - namely, change or conduct mood stabilizer FC, followed by the appointment mood stabilizer therapy. Perhaps, with heavy course of the disease effective deployed in phases, euthymic short period or a path over Bipolar Disorder appropriate early treatment. Carrying out maintenance Bipolar Disorder may in patients with previous efficiency stopped course Bipolar Disorder and inefficiency combined schemes mood stabilizer drugs.
With a combination of inefficiency have mood stabilizer therapy eutireoidnyh patients may introduce in the scheme of thyroid hormone (L-thyroxin or thyroid). It is first used replacement dosage L-thyroxin. In their inefficiency dose gradually increased under the control of blood tests for T4, prior to achieving greater than normal hormone content of no more than 150% (The Expert Consensus Guideline Series, 1996).
In resistant cases may also attempt to use calcium channel blockers, whose effectiveness when BAR displayed in a number of studies (AJ Giannini et al., 1984; SL Dubovsky et al., 1986; CC Hoschl et al., 1989; ES Garza-Trevino, et al ., 1992; GP Panteleeva et al, 1995; SA Walton, et al., 1996).
Therapy of Bipolar Symptoms is a complex task that requires careful systematic monitoring of the patient. Although the clinical need often determines the impossibility of postponing the intensification of therapy more than 4 months, you must do everything possible to maintain wait-and-see tactic, given the known effects of the timing of establishing any mood stabilizer therapy. Only such a tactic is an opportunity to get a real idea about the effectiveness of a dosage mood stabilizer until the maximum dose of portable, providing optimum efficiency. Increased doses mood stabilizer can help reduce faze formating process, as well as relief of manic or depressive symptoms during relapse. Such tactics, along with «therapy cover», in some cases to avoid the appointment of classical neyroleptikov in times of many antidepressants or during periods of depression and thus reduce the risk of provoking enhance cycling. Using benzodiazepinovyh tranquilizers, which are available in injectable forms, permits, in most cases, control psychomotor excitement with mania or expressed dismay with depression in a hospital. New opportunities for kupirovaniya anxiety with depression (W. Macfadden et al., 2004a) and kupirovaniya manic symptoms opens use atipichnyh antipsihotikov.
Unfortunately, in practice, especially in the hospital environment, an approach to therapy is carried out infrequently. This is partly due to the established time frame, officially designated hospital (on average - 2 months). Of course, kupiruyuschee effect mood stabilizer develops more slowly in comparison with traditional neyroleptikami and antidepressants, which determines the choice of a doctor in favor of the latter. At the same time, a heavy depression, especially with suitsidalnymi trends, to avoid the appointment of antidepressants is not possible. In these cases, used the tactic of treatment of bipolar depression, and after kupirovaniya symptoms again return to the methods to break BTS. However, the treatment of acute episode is carried out without lifting the previous normotimicheskoy therapy.
In the case of inefficiency selected in the first phase mood stabilizer therapy over a period of time equal to 3 cycles or within 6 months, we recommend a change of the drug. In the case of a partial effect, depending on the clinical need to be encouraged to continue the observation period, or joining the second mood stabilizer.
Antirecurrent therapy in the treatment of Bipolar Disorder in most cases persisted even when the course of the disease no longer meets the criteria. For patients with 1-3 episodes per year major efforts should be aimed at achieving a long-term remission with a view to maximizing improve their quality of life.
Atypic antipsychotic
In cases of resistance to therapy with mood stabilizer-anti convulsive use ET helps break the current BT and the subsequent more effective use of drugs mood stabilizer series. According to S.I. Mosolov, SY Moshchevitina (1990), 40% of patients with resistance to the use of ET therapy mood stabilizer achieves stopped effect, followed by fixation eutimich period of lithium salts. Another 30% of patients after the course ET an increase efficiency mood stabilizer therapy, expressed in reducing the frequency and severity effective and effective-delusional episodes. It should be noted that most patients with stopped effect of ET to be resistant to preventive therapy of lithium carbonate. It can be assumed that the lithium salt because delayed mood stabilizer effect of failing to show up at his frequent changes in phases, and that is why they are ineffective in the continuous flow BAR. Terminating effect of ET is more likely in patients with no evidence of organically inferior soil, with lesser duration of illness and the period of actual path of disease, as well as with a distinct remission scenes, the predominance of expression and greater depressive phases, compared with manic.
Electroconvulsive therapy (ET)
In cases of resistance to therapy mood stabilizer-anti convulsive use Electroconvulsive therapy helps break the current Electroconvulsive therapy and the subsequent more effective use of drugs mood stabilizer series.
According to S.I. Mosolov, SY Moshchevitina (1990), 40% of patients with resistance to the use of Electro convulsive therapy of mood stabilizer achieves stop effect, followed by fixation euthimic period of lithium salts. Another 30% of patients after the course of Electroconvulsive therapy can increase efficiency of mood stabilizer therapy, expressed in reducing the frequency and severity effective an defective-delusional episodes. It should be noted that most patients with cutoff effect of ET to be resistant to preventive therapy of lithium carbonate. It can be assumed that the lithium salt because abandon with mood stabilizer effect of failing to show up at his frequent changes in phases, and that is why they are ineffective in the continuous flow BAR.
Picker effect of ET is more likely in patients with no evidence of organically inferior soil, with lesser duration of illness and the period of actual path of disease, as well as with a distinct remission scenes, the predominance of expression and greater depressive phases, compared with manic.
According to S.I. Mosolov, SY Moshchevitina (1990), 40% of patients with resistance to the use of Electro convulsive therapy of mood stabilizer achieves stop effect, followed by fixation euthimic period of lithium salts. Another 30% of patients after the course of Electroconvulsive therapy can increase efficiency of mood stabilizer therapy, expressed in reducing the frequency and severity effective an defective-delusional episodes. It should be noted that most patients with cutoff effect of ET to be resistant to preventive therapy of lithium carbonate. It can be assumed that the lithium salt because abandon with mood stabilizer effect of failing to show up at his frequent changes in phases, and that is why they are ineffective in the continuous flow BAR.
Picker effect of ET is more likely in patients with no evidence of organically inferior soil, with lesser duration of illness and the period of actual path of disease, as well as with a distinct remission scenes, the predominance of expression and greater depressive phases, compared with manic.
Tuesday, December 9, 2008
Mood Stabilizer defenition
The term "mood stabilizer" is used rather loosely sometimes.
Some experts have included in their definition the ability to prevent recurrence as well as treat current symptoms. This makes a lot of sense: why not start with the medications that have evidence for keeping you well, in addition to getting you well?
But the studies it takes to get such evidence are extremely costly to set up, and thus there are few such reports, only for the really well funded medications, basically mood stabilizer drugs are: olanzapine and lamotrigine (and lithium, because it was included in a lamotrigine study).
A recent review pointed out, using combinations of medications to sum their strengths is now the norm, not the exception, in the treatment of bipolar disorder.
This way of thinking leads to another definition sometimes used: "mood stabilizers" are a group of medications which can treat both mania and depression; or at minimum, they treat one of the two and rarely cause the other pole to become worse in the process. Thus they can be used together to make up combinations for a particular patient's symptoms and history.
This review tried to use precise rules for "evidence" for four aspects of treatment, including the ability to:
1. Treat a person who is currently having manic or hypomanic symptoms (“acute mania”);
2. Treat a person who is currently having depressive symptoms (“acute depression”);
3. Prevent recurrence into mania or hypomania;
4. Prevent recurrence into depression;
5. Cure Bipolar Disorder Symptoms
Some experts have included in their definition the ability to prevent recurrence as well as treat current symptoms. This makes a lot of sense: why not start with the medications that have evidence for keeping you well, in addition to getting you well?
But the studies it takes to get such evidence are extremely costly to set up, and thus there are few such reports, only for the really well funded medications, basically mood stabilizer drugs are: olanzapine and lamotrigine (and lithium, because it was included in a lamotrigine study).
A recent review pointed out, using combinations of medications to sum their strengths is now the norm, not the exception, in the treatment of bipolar disorder.
This way of thinking leads to another definition sometimes used: "mood stabilizers" are a group of medications which can treat both mania and depression; or at minimum, they treat one of the two and rarely cause the other pole to become worse in the process. Thus they can be used together to make up combinations for a particular patient's symptoms and history.
This review tried to use precise rules for "evidence" for four aspects of treatment, including the ability to:
1. Treat a person who is currently having manic or hypomanic symptoms (“acute mania”);
2. Treat a person who is currently having depressive symptoms (“acute depression”);
3. Prevent recurrence into mania or hypomania;
4. Prevent recurrence into depression;
5. Cure Bipolar Disorder Symptoms
Pharmacotherapy for Bipolar Dysorder Symptoms, part II
Mood Stabilizers
When treating patients with FC mood stabilizers be aware that lithium, unlike anticonvulsive insufficiently effective in these cases (JR Calabrese et al., 1995, 2000, etc.). The choice of drugs is carried out, especially taking into account the peculiarities of the disease, namely the prevailing polarity of phases: lithium carbonate and sodium valproat drugs are the first choice when the maniacal symptoms dominated the course of the disease, and carbamazepine and lamotrigine - with the dominant depressive symptoms. With FC remains a priority for carbamazeptine, valproatom and lamotrigine.
Step with anticonvulsive continuous and FC during phase behavior endogenous psychosis as a whole is developing faster than lithium carbonate SN Mosolov and others, 1994): from stable carbamazepine effect with the subsequent formation of remission can be noted in the first 3 months of treatment, but the sodium valproata earlier - after 1-2 months. Such efficiency, which is bluff continual flow in the early course of preventive therapy significantly correlated with favorable outcome of therapy in the next year. At the same time to judge the effectiveness of prophylactic lithium carbonate can be no earlier than 6 months of therapy.
Preparations slightly differ not only on speed but on the nature of reduction of the circular. If lytic version reductions observed more frequently in the application of lithium salts, is critical - anticvonvulsative. And a critical type in more than 2 times more often than with lithium carbonate is found in the application valproata sodium.
In the case of partial effect of lithium carbonate for more typical harmonic reduction of symptoms with a gradual transition to subefective register. In applying anticonvulsive often occurs disharmonic reduction in the opposite uneven development of individual components clinical picture, in violation of the integrity of circular triad and the emergence at the forefront of rudimentary raving, senesto-ipohondric or asthenic symptoms. Lithium carbonate therapy may lead to temporary intensification of symptoms (frequent relapses), followed over the years, their gradual reduction. In applying carbamazepine to 3-4-weeks may be be observed a peculiar depletion of the initial efficiency with increased past a circular symptoms (often manic pole), which requires an increase in dosage, which ensures the gradual extinction of aggravation. Perhaps this phenomenon can be attributed to the phenomen of enzymatic metabolism autoinduction carbamazepine(JW Faigle et al., 1975) and decrease its concentration in blood plasma, although convincing pharmacocinetic dates on the relationship between the content of the drug in blood plasma and its therapeutic efficacy is not currently available.
In terms of the evidentiary requirements of modern medicine, with the Fc examined only one normothymic - lamotrigin. Its effectiveness was shown in a randomized double-blind placebo-controlled study including 182 patients (JR Calabrese et al., 2000). The study showed that the average time before the attrition of patients from the study for any reason, including the need for additional therapy, group of patients receiving lamotrigin was 14 weeks, and placebo group - 8 weeks (p = 0036 in terms of «survival» in the study ). Moreover, the percentage of patients who have achieved clinical stability throughout the course of therapy was significantly higher (p = 0,03) in group lamotridzhina (41%) compared with placebo (26%). The number of patients who need additional therapy for the bipolar dysorder symptoms was lower among recipients lamotrigin compared with the placebo group (p = 0007), and the time before the next phase in the treatment of depressive with lamotriginem was higher compared to placebo (DR Goldsmith et al. , 2003).
The effect of monotherapy with lamotrigine was higher in the Bipolar Disorder symptoms-II compared to its effect in the Bipolar Disorder symptoms-I. Among the first mean time to attrition from the study group lamotrigine was more than twice as high (p <0,05), compared with a placebo, and the percentage of patients with clinically stable condition throughout the treatment period (46 to 18%; p <0 , 05). For patients with Bipolar Disorder Symptoms-I distinguish these figures in the group receiving lamotrigine and placebo were less pronounced and did not reach statistical significance.
Thus, lamotrigine has expressed mood stabilizers act with the most malignant form of current bipolar disorder symptoms with rapid change in phases, especially when Bipolar Disorder Symptoms-II, which is probably linked to its greater efficiency in the prevention depressive phases, compared with manic.
Control of depressive episodes in the FC is a pressing clinical challenge, given that their frequency may be 2-3 times exceed the frequency of manic phases.
When treating patients with FC mood stabilizers be aware that lithium, unlike anticonvulsive insufficiently effective in these cases (JR Calabrese et al., 1995, 2000, etc.). The choice of drugs is carried out, especially taking into account the peculiarities of the disease, namely the prevailing polarity of phases: lithium carbonate and sodium valproat drugs are the first choice when the maniacal symptoms dominated the course of the disease, and carbamazepine and lamotrigine - with the dominant depressive symptoms. With FC remains a priority for carbamazeptine, valproatom and lamotrigine.
Step with anticonvulsive continuous and FC during phase behavior endogenous psychosis as a whole is developing faster than lithium carbonate SN Mosolov and others, 1994): from stable carbamazepine effect with the subsequent formation of remission can be noted in the first 3 months of treatment, but the sodium valproata earlier - after 1-2 months. Such efficiency, which is bluff continual flow in the early course of preventive therapy significantly correlated with favorable outcome of therapy in the next year. At the same time to judge the effectiveness of prophylactic lithium carbonate can be no earlier than 6 months of therapy.
Preparations slightly differ not only on speed but on the nature of reduction of the circular. If lytic version reductions observed more frequently in the application of lithium salts, is critical - anticvonvulsative. And a critical type in more than 2 times more often than with lithium carbonate is found in the application valproata sodium.
In the case of partial effect of lithium carbonate for more typical harmonic reduction of symptoms with a gradual transition to subefective register. In applying anticonvulsive often occurs disharmonic reduction in the opposite uneven development of individual components clinical picture, in violation of the integrity of circular triad and the emergence at the forefront of rudimentary raving, senesto-ipohondric or asthenic symptoms. Lithium carbonate therapy may lead to temporary intensification of symptoms (frequent relapses), followed over the years, their gradual reduction. In applying carbamazepine to 3-4-weeks may be be observed a peculiar depletion of the initial efficiency with increased past a circular symptoms (often manic pole), which requires an increase in dosage, which ensures the gradual extinction of aggravation. Perhaps this phenomenon can be attributed to the phenomen of enzymatic metabolism autoinduction carbamazepine(JW Faigle et al., 1975) and decrease its concentration in blood plasma, although convincing pharmacocinetic dates on the relationship between the content of the drug in blood plasma and its therapeutic efficacy is not currently available.
In terms of the evidentiary requirements of modern medicine, with the Fc examined only one normothymic - lamotrigin. Its effectiveness was shown in a randomized double-blind placebo-controlled study including 182 patients (JR Calabrese et al., 2000). The study showed that the average time before the attrition of patients from the study for any reason, including the need for additional therapy, group of patients receiving lamotrigin was 14 weeks, and placebo group - 8 weeks (p = 0036 in terms of «survival» in the study ). Moreover, the percentage of patients who have achieved clinical stability throughout the course of therapy was significantly higher (p = 0,03) in group lamotridzhina (41%) compared with placebo (26%). The number of patients who need additional therapy for the bipolar dysorder symptoms was lower among recipients lamotrigin compared with the placebo group (p = 0007), and the time before the next phase in the treatment of depressive with lamotriginem was higher compared to placebo (DR Goldsmith et al. , 2003).
The effect of monotherapy with lamotrigine was higher in the Bipolar Disorder symptoms-II compared to its effect in the Bipolar Disorder symptoms-I. Among the first mean time to attrition from the study group lamotrigine was more than twice as high (p <0,05), compared with a placebo, and the percentage of patients with clinically stable condition throughout the treatment period (46 to 18%; p <0 , 05). For patients with Bipolar Disorder Symptoms-I distinguish these figures in the group receiving lamotrigine and placebo were less pronounced and did not reach statistical significance.
Thus, lamotrigine has expressed mood stabilizers act with the most malignant form of current bipolar disorder symptoms with rapid change in phases, especially when Bipolar Disorder Symptoms-II, which is probably linked to its greater efficiency in the prevention depressive phases, compared with manic.
Control of depressive episodes in the FC is a pressing clinical challenge, given that their frequency may be 2-3 times exceed the frequency of manic phases.
Friday, December 5, 2008
Pharmacotherapy for Bipolar Dysorder Symptoms
Objectives and Strategy pharmacotherapy
The goal of therapy is the FC cliff path currents, the achievement and maintenance of ethimic period. When treating patients with Bipolar Disorder Symptoms over FC respected the general principles of preventive therapy bipolar disorder. Drug of first choice is mood stabilizer.
In doing so, however, should take into account some features of these therapies most patients illness with Bipolar Disorder Symptoms .
Bipolar Disorder often provoked during the introduction or exclusion of factors that could destabilize effective scope or provoke a cycle (see above).
In the case of manic symptoms following the lifting of antidepressants in patients with BD with the FC over possible resumption of the scheme therapy used in reduction acute condition, followed by a gradual lifting after a remission.
Availability reduction disorder itself can be regarded as one of the possible reasons for the formation of secondary fast cycling (FC) currents, especially when it comes to obsessive-compulsive or panic disorder, bulimia, attention deficit syndrome or migraine.
If the commonly used drugs for the treatment of co morbid disorders are potentially dangerous in terms of enhancing cycling are encouraged, first of all, the appointment mood stabilizer or intensification of existing mood stabilizer therapy.
We show that some of mood stabilizer in varying degrees effective in co morbid disorders. In the case of their inefficiency should apply alternative therapy is not causing acceleration cycling.
Drugs that could cause enhanced phase formation, may be appointed only in third place with the ineffectiveness of other activities, such as when severe obsessive-compulsive disorder, sensitive only to the action of selective serotonin inhibitors reverse the seizure.
This should be their minimum dosage, allowing for psychotherapy
The goal of therapy is the FC cliff path currents, the achievement and maintenance of ethimic period. When treating patients with Bipolar Disorder Symptoms over FC respected the general principles of preventive therapy bipolar disorder. Drug of first choice is mood stabilizer.
In doing so, however, should take into account some features of these therapies most patients illness with Bipolar Disorder Symptoms .
Bipolar Disorder often provoked during the introduction or exclusion of factors that could destabilize effective scope or provoke a cycle (see above).
In the case of manic symptoms following the lifting of antidepressants in patients with BD with the FC over possible resumption of the scheme therapy used in reduction acute condition, followed by a gradual lifting after a remission.
Availability reduction disorder itself can be regarded as one of the possible reasons for the formation of secondary fast cycling (FC) currents, especially when it comes to obsessive-compulsive or panic disorder, bulimia, attention deficit syndrome or migraine.
If the commonly used drugs for the treatment of co morbid disorders are potentially dangerous in terms of enhancing cycling are encouraged, first of all, the appointment mood stabilizer or intensification of existing mood stabilizer therapy.
We show that some of mood stabilizer in varying degrees effective in co morbid disorders. In the case of their inefficiency should apply alternative therapy is not causing acceleration cycling.
Drugs that could cause enhanced phase formation, may be appointed only in third place with the ineffectiveness of other activities, such as when severe obsessive-compulsive disorder, sensitive only to the action of selective serotonin inhibitors reverse the seizure.
This should be their minimum dosage, allowing for psychotherapy
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