How to treat mania Pacchiarotti, I.; Anmella, G.; Colomer, L. ...
Acta psychiatrica Scandinavica,
September 2020, 2020-09-00, 20200901, Letnik:
142, Številka:
3
Journal Article
Recenzirano
Objective
In this paper, we aimed at reviewing evidence‐based treatment options for bipolar mania and proposed tentative evidence‐based clinical suggestions regarding the management of a manic ...episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication.
Method
A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices.
Results
To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment‐refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long‐term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence.
Discussion
Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long‐term.
Objective
This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states.
Method
The MEDLINE/PubMed and EMBASE databases were ...systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation‐AGREE II.
Results
The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood‐stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines.
Conclusion
The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.
•Most ecological studies about lithium in drinking water report a reduction in suicide in general population, mostly in males.•Most trials, uncontrolled and controlled open label, show a reduction in ...the risk of suicide under long-term lithium use.•Evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its efficacy as mood stabilizer.
Suicide contributes to 1–4 % of deaths worldwide every year. We conducted a systematic review aimed at summarizing evidence on the use of lithium for the prevention of suicide risk both in mood disorders and in the general population.
We followed the PRISMA methodology (keywords: “lithium”, “suicide” AND “suicidal” on Pubmed, Cochrane CENTRAL, Clinicaltrial.gov, other databases). Inclusion criteria: lithium therapy in mood disorder or found in drinking water or scalp in the general population. Exclusion criteria: no lithium administration.
From 918 screened references, 18 prospective (number of participants: 153786), 10 retrospective (number of participants: 61088) and 16 ecological studies (total sample: 2062) were included. Most of the observational studies reported a reduction in suicide in patients with mood disorders. All studies about lithium treatment’s duration reported that long-term lithium give more benefits than short-term lithium in suicide risk
The evidence seems to attribute an intrinsic anti-suicidal property of lithium, independent of its proven efficacy as a mood stabilizer.
Abstract Objective To identify clinical and neurocognitive predictors of long-term functional outcome in patients with bipolar disorder Methods A total of 32 subjects who met criteria for bipolar I ...or II disorder were recruited from the Barcelona Bipolar Disorder Program and were assessed clinically and neuropsychologically at baseline. After an average 4-year follow-up, they were interviewed with the Functioning Assessment Short Test (FAST) to assess functional outcome. Multivariate analyses were applied to identify clinical and neurocognitive predictors of functional outcome. Results The main regression model for predictors of overall psychosocial functioning identified subclinical depressive symptoms ( ß = 0.516, t = 3.51, p = 0.002), and free delayed recall in a verbal memory task ( ß = − 0.314, t = − 2.144, p = 0.041), accounting for 36% of the variance. Specific predictors of occupational functioning were, again, subthreshold depression ( ß = 0.435, t = 2.8, p = 0.009) and a measure of executive function, digits backwards ( ß = − 0.347, t = − 2.23, p = 0.034). This model explained around 28% of the variance (corrected R2 = 0.28; F = 6.38, gl = 2, p = 0.004). Conclusions Subdepressive symptomatology together with neurocognitive impairments related to verbal memory and executive functions are predictor variables of long-term functional outcome in bipolar disorder.
To determine the clinical and therapeutic relevance of longitudinally predominant polarity for bipolar disorders long-term outcome.
Two hundred twenty-four patients (n=224) were enrolled for the ...study in the Bipolar Disorders Program of Barcelona, which provides integrated care for difficult-to-treat bipolar patients derived from all over Spain, but also provides clinical care to all bipolar patients coming from a specific catchment area (Eixample Esquerre) in Barcelona. Data collection regarding predominant polarity started on October 1994 and lasted for the following ten years. Patients were divided according to the predominance of depressive or manic/hypomanic episodes. The two groups were compared regarding clinical and sociodemographic variables.
135 patients (60.3%) were classified as Depressive Polarity, whilst 89 (39.7%) were considered as Manic Polarity. Manic Polarity was more prevalent amongst bipolar I patients than bipolar II. Depressive Polarity was strongly associated with depressive onset of bipolar disorder. Lifetime history of attempted suicide was strongly associated with Depressive Polarity, who also had a higher mean number of suicide attempts. As for therapeutic issues, acute and maintenance use of atypical antipsychotics and conventional neuroleptics were more common amongst Manic Polarity whilst antidepressants and lamotrigine use was highly prevalent amongst Depressive Polarity.
Prevention of depression is crucial for the maintenance treatment of bipolar II patients, whilst prevention of mania and depression would be equally important in the case of bipolar I patients. Predominant polarity is a valid prognostic parameter with therapeutic implications.
The coronavirus disease 2019 (COVID-19) outbreak is putting healthcare professionals, especially those in the frontline, under extreme pressures, with a high risk of experiencing physical exhaustion, ...psychological disturbances, stigmatization, insomnia, depression and anxiety. We report the case of a general practitioner, without relevant somatic or psychiatric history that experienced a “brief reactive psychosis (298.8)” under stressful circumstances derived from COVID-19. She presented with delusional ideas of catastrophe regarding the current pandemic situation, delusions of self-reference, surveillance and persecution, with high affective and behavioural involvement. Physical examination and all further additional investigations did not reveal any secondary causes. She was administered olanzapine 10 mg with significant psychopathological improvement being later discharged with indications to maintain the treatment. To our knowledge this is the first reported case of severe mental illness in a healthcare professional without previous psychiatric history due to COVID-19 outbreak. Around 85% of patients presenting a brief psychotic disorder will develop a potentially disabling serious psychotic illness in the long-term. This case represents the potentially serious mental health consequences on healthcare professionals throughout the COVID-19 crisis and emphasizes the need to implement urgent measures to maintain staff mental health during the current pandemic.
Sleep alterations are frequent occurrence in Bipolar Disorder (BD), both in acute and interepisodic phases. Sleep alterations have been also described both long before BD onset, as aspecific risk ...syndromes, or as immediate prodromes of BD onset. The aim of the present study is to systematically review the relationship between sleep alterations anticipating for the full-blown onset of BD, both in general and according to specific polarities of onset.
A systematic literature research according to PRISMA statement and considering: 1. prospective studies about BD patients' offspring with sleep alterations who later developed BD. 2. prospective studies assessing patients with sleep disorders who later developed BD. 3. retrospective studies on BD patients where sleep alterations before BD onset of the disease were reported.
A total of 16 studies were included in this review. Sleep disturbances may frequently appear 1 year before the onset of BD or more, often during childhood or adolescence. A decreased need for sleep may precede the onset of the illness, specially a manic episode, while insomnia appears to anticipate either a manic or a depressive episode. Hypersomnia seems to precede bipolar depressive episodes.
Sleep alterations frequently appear long before the onset of BD, and appear to be related specifically to the polarity of the index episode. The detection and treatment of sleep alterations in special high risk populations may help achieving an earlier detection of the illness.
Introduction
Pramipexole is a dopaminergic agonist used in the treatment of Parkinson’s disease and restless leg syndrome. Although there is a lack of pharmacological options to treat drug-induced ...parkinsonism, not many studies have been made on the use of pramipexole in its management. There is also evidence on pramipexole effectiveness on major depressive episodes, particularly for bipolar and treatment-resistant depression.
Objectives
To describe a case of drug-induced parkinsonism treated with pramipexole in a complex patient with bipolar disorder type I and obsessive-compulsive disorder, long-term treated with antipsychotics and valproate.
Methods
We present the case of a 51-year-old woman admitted in our psychiatric inpatient unit mainly to treat a bipolar depression. She also presented a parkinsonian syndrome, and a neurological study was conducted. As a negative DaTSCAN concluded its cause to be pharmacological, we decided to stop lurasidone and initiated pramipexole.
Results
Guidelines suggest that drug-induced parkinsonism should be managed by discontinuing causative drugs or switching to another agent. However, we decided to use pramipexole with the aim of not only treating the parkinsonian syndrome but helping manage the depressive episode. We observed a remission of the depressive symptoms and an improvement in the parkinsonian symptoms.
Conclusions
Although the best way to treat drug-induced parkinsonism is to avoid its causative agents, in clinical practice it is not always possible as some patients have resistant and complex psychiatric syndromes. We suggest considering pramipexole in its management, especially when dealing with a patient with a comorbid unipolar or bipolar depression. Further research is necessary to clarify its utility.
Disclosure
No significant relationships.