Manic switch in bipolar patients treated with electroconvulsive therapy for treatment-resistant depression: The experience at the mood disorder unit of Milan (Italy)

IntroductionDespite appropriate treatment, 30–40% of depressed patients, both unipolar and bipolar, do not achieve improvement, with high morbidity and mortality. For bipolar patients another risk is the switch into mania due to antidepressant treatment. The concern about the switch, suggests to administer antidepressants at lower doses, in combination with mood stabilizers and second generation anti-psychotics.ObjectivesWe performed an observational study on a sample of 23 bipolar patients treated with ECT for severe TRD in last 3 years, in order to evaluate the risk of switch.MethodsTwenty-three bipolar inpatients, undergoing bitemporal ECT twice/week, with MECTA spectrum device. Main demographic and clinical data collected. Hamilton rating scale for depression (HAM-D). Clinical response defined as 50% reduction of HAM-D score at the endpoint from baseline; remission as HAM-D score at the endpoint < 8. Young Mania rating scale (YMRS) weekly in order to assess switch into mania.ResultsThirteen (56.5%) females, 10 (43.5%) males, mean age 60.1 ± 10.3 years. Mean age at onset 35.5 ± 13.6 years. Mean number of episodes: 7.1 ± 3.6. Mean duration of current episode: 33.4 ± 24.9 weeks. Mean HAM-D basal score: 30.0 ± 5. Each patient underwent a cycle of ECT (mean No. 6.7 ± 3.3). Pharmacological treatment was administered upon clinical need. Response rate 87%, remission rate 43.5%. Three out of 23 (13.04%) patients had transient hypomanic switch, spontaneous recovery within 7 days after the last ECT.ConclusionsOur experience confirms that ECT is a powerful antidepressant, especially in patients with severe long-lasting depression, refractory to treatment. ECT is also a safe procedure: no adverse effects were reported. The manic switch rate is comparable with antidepressant drugs.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Impact of modification to DSM-5 criterion A for hypomania/mania in newly diagnosed bipolar patients: findings from the prospective BIO study

International Journal of Bipolar Disorders ◽

10.1186/s40345-020-00219-9 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Mette U. Fredskild ◽

Sharleny Stanislaus ◽

Klara Coello ◽

Sigurd A. Melbye ◽

Hanne Lie Kjærstad ◽

...

Keyword(s):

Rating Scale ◽

Newly Diagnosed ◽

Young Mania ◽

Dsm 5 ◽

Criterion A ◽

Number Of Patients ◽

Bipolar Type ◽

Dsm Iv ◽

Bipolar Patients

Abstract Background DSM-IV states that criterion A for diagnosing hypomania/mania is mood change. The revised DSM-5 now states that increased energy or activity must be present alongside mood changes to diagnose hypomania/mania, thus raising energy/activity to criterion A. We set out to investigate how the change in criterion A affects the diagnosis of hypomanic/manic visits in patients with a newly diagnosed bipolar disorder. Results In this prospective cohort study, 373 patients were included (median age = 32; IQR, 27–40). Women constituted 66% (n = 245) of the cohort and 68% of the cohort (n = 253) met criteria for bipolar type II, the remaining patients were diagnosed bipolar type I. Median number of contributed visits was 2 per subject (IQR, 1–3) and median follow-up time was 3 years (IQR, 2–4). During follow-up, 127 patients had at least one visit with fulfilled DSM-IV criterion A. Applying DSM-5 criterion A reduced the number of patients experiencing a hypomanic/manic visit by 62% at baseline and by 50% during longitudinal follow-up, compared with DSM-IV criterion A. Fulfilling DSM-5 criterion A during follow-up was associated with higher modified young mania rating scale score (OR = 1.51, CL [1.34, 1.71], p < 0.0001) and increased number of visits contributed (OR = 1.86, CL [1.52, 2.29], p < 0.0001). Conclusion Applying the stricter DSM-5 criterion A in a cohort of newly diagnosed bipolar patients reduced the number of patients experiencing a hypomanic/manic visit substantially, and was associated with higher overall young mania rating scale scores, compared with DSM-IV criterion A. Consequently, fewer hypomanic/manic visits may be detected in newly diagnosed bipolar patients with applied DSM-5 criterion A, and the upcoming ICD-11, which may possibly result in longer diagnostic delay of BD as compared with the DSM-IV.

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Driving ability in bipolar patients receiving lithium or lamotrigine

European Psychiatry ◽

10.1016/s0924-9338(11)71904-6 ◽

2011 ◽

Vol 26 (S2) ◽

pp. 194-194

Author(s):

A. Brunnauer ◽

F. Segmiller ◽

I. Hermisson ◽

F. Seemüller ◽

M. Riedel ◽

...

Keyword(s):

Visual Perception ◽

Stress Tolerance ◽

Traffic Safety ◽

Test Performance ◽

Rating Scale ◽

Safety Data ◽

Developed Countries ◽

Driving Ability ◽

Young Mania ◽

Bipolar Patients

ObjectivesDriving is a daily activity for most people in developed countries and is important in maintaining independence. Bipolar patients may have an impaired driving behavior because of the pathology itself, with psychomotor and cognitive disturbances. Additionally, adverse effects of pharmacologic treatment may be detrimental.Methods24 remitted bipolar outpatients diagnosed according to ICD-10 criteria were enrolled in the study, receiving either lithium (n = 12) or lamotrigine (n = 12). Participants were investigated under steady state plasma level conditions. According to the German Guidelines for road and traffic safety data were collected with the Wiener Testsystem (WTS) measuring visual perception, reactivity, stress tolerance, concentration and vigilance.Psychopathologic symptoms were rated with the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale - Clinician rated (YMRS-C).ResultsAbout 40% of patients were without clinically relevant psychomotor disturbances. In 40% of cases mild to moderate impairments could be seen, and 20% of the patients were considered as severely impaired. Data show that patients under lamotrigine had an altogether better test performance than patients treated with lithium. Especially in visual perception and stress tolerance differences were most pronounced.ConclusionsAbout 20% of remitted bipolar outpatients treated with lithium or lamotrigine must be considered unfit to drive. In 40% of the cases it seems justified to counsel patients individually, taking into account compensational factors. Analysis of our data point to an advantage for bipolar patients treated with lamotrigine when compared with lithium. However causal relationships can not be drawn from our data.

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Depressive Mixed States: Symptomatology, Prevalence and Principles of Treatment

European Psychiatry ◽

10.1016/s0924-9338(09)70808-9 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

W. Drozdz ◽

A. Borkowska

Keyword(s):

Affective Disorders ◽

Rating Scale ◽

Depressive Symptomatology ◽

Depression Scale ◽

Assessment Tools ◽

The Other ◽

Mood Stabilizers ◽

Hamilton Depression Scale ◽

Principles Of Treatment ◽

Bipolar Patients

Current diagnostic systems (DSM-IV-TR and ICD-10) do not include depressive mixed state (DMS) as a separate category. However, both historical descriptions and data from recent research clearly indicate that cooccurrence of (hypo)maniacal and depressive symptoms is standard in clinical picture of affective disorders. Most frequently employed criterion for DMS is the presence of at least three symptoms of (hypo)mania for 7 days during a major depressive episode. Not only formal diagnostic criteria for DMS are lacking but also psychometric assessment tools (for example the Hamilton Depression Scale or the MADRS) were designed around the features of “classical” depression. The other obstacles to recognize DMS could be lack of insight into the (hypo)maniacal symptoms in patients and cognitive dysfunctions present during an episode. On the other hand, newly created instrument, the Bipolar Depression Rating Scale, may assist clinical evaluation of DMS. Despite predominating depressive symptomatology, the principles of treatment of DMS suggest avoidance of antidepressant monotherapy in favor of mood stabilizers' administration. Actually DMS may emerge as a complication of antidepressant monotherapy in some bipolar patients or may be induced with interferon-alpha treatment in some chronic hepatitis C patients. Important consequences of both spontaneous and drug-induced DMS could be the roughening of affective symptomatology, resistance to antidepressants and the increase of suicidality. Thorough appraisal of symptoms seen in patients with affective disorders for indicators of DMS could have critical consequences for functional outcomes.

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Studies of Carbamazepine Extended-Release Capsules in Bipolar Disorder

CNS Spectrums ◽

10.1017/s1092852900023075 ◽

2005 ◽

Vol 10 (6) ◽

pp. 3-5

Author(s):

Richard H. Weisler

Keyword(s):

Extended Release ◽

Rating Scale ◽

Controlled Trial ◽

Controlled Study ◽

Mixed States ◽

Open Label ◽

Young Mania ◽

Double Blind ◽

Double Blind Placebo ◽

Bipolar Patients

This discussion reviews data from two 3-week, double-blind, placebo-controlled pivotal trials of carbamazepine extended release capsules (CBZ ERC; SPD417.301 and SPD417.304); pooled results from these trials; data from a 3-week, double-blind, placebo-controlled trial in lithium non-responders or non-tolerators (SPD417.302); and additional supportive data from a 6-month, open-label, extension trial (SPD417.303). In addition, information on a retrospective chart review of 600 adolescent and adult bipolar patients on CBZ ERC is presented.In the first large double-blind, placebo-controlled study assessing CBZ ERC in acute mania, manic and mixed bipolar patients from multiple centers were hospitalized and all medications were discontinued. After reaching a stable baseline 2–5 days later, the patients were randomized to CBZ ERC (n=101; 59% with mixed states) or placebo (n=103; 47% with mixed states) for 3 weeks. An aggressive initial titration schedule was implemented, beginning with 200 mg BID and increased by 200 mg/day until good clinical response was achieved or the patient could not tolerate the dosage. Many patients were taking 1,200–1,600 mg/day by the end of week 1. Efficacy was assessed using the Young Mania Rating Scale (YMRS). The Clinical Global Impressions (CGI) scale and the Hamilton Rating Scale for Depression (HAM-D) were also followed.

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Comparison of efficacy between risperidone and aripiprazole in combination with sodium valproate in patients with acute manic or mixed episodes

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.1390 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S749-S749

Author(s):

N. Amanat ◽

A. Nazeri Astane ◽

B. Dieji ◽

O. Rezaie ◽

A. Biglarian

Keyword(s):

Weight Gain ◽

Sodium Valproate ◽

Rating Scale ◽

Analysis Of Covariance ◽

Young Mania ◽

Double Blind ◽

Measurement Evaluation ◽

Significant Difference ◽

Competing Interest ◽

Bipolar Patients

Today, despite of the improvement in the psychological therapeutic approach, mania still remains as a challenging problem for health system. The aim of this study is comparison efficacy of risperidone and aripiprazole in combination with sodium valproate in bipolar patients with acute manic or mixed episodes who hospitalized in Razi psychiatric hospital in Tehran. This study was conducted as a double blind randomized clinical trial in two groups of bipolar disorder patients with manic or mixed episodes (18–65 age). Patients randomly set in two groups who received valproate with aripiprazole or risperidone. Clinical response was assessed with young mania rating scale (YMRS) and weight gain at 3 and 6 weeks. Data was analyzed with Chi2 test, paired t-test and analysis of covariance and repeated measurement. Evaluation of treatment response after 3 and 6 weeks (50% reduction in Young's scale) in both groups did not show any significant difference between the two therapeutic combinations. The combination of sodium valproate and risperidone showed higher weight gain in comparison with the combination of valproate and aripiprazole at the end of week 6 (P < 0.001). The mentioned combination in bipolar I disorder with manic or mixed episode has similar therapeutic effect, so that both of them are effective and usable. There was no difference in their efficacy, and both treatments can be used. Due to the less weight gain, the combination of valproate and aripiprazole in patients who prone to weight gain, this approach is recommended as more safe and effective therapy.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Studies of Carbamazepine Extended-Release Capsules in Bipolar Disorder

CNS Spectrums ◽

10.1017/s1092852900024500 ◽

2005 ◽

Vol 10 (S1) ◽

pp. 3-5

Author(s):

Richard H. Weisler

Keyword(s):

Extended Release ◽

Rating Scale ◽

Controlled Trial ◽

Controlled Study ◽

Mixed States ◽

Open Label ◽

Young Mania ◽

Double Blind ◽

Double Blind Placebo ◽

Bipolar Patients

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Role of Age at Onset in the Clinical Presentation of Bipolar Disorder

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/24770.14692 ◽

2021 ◽

Author(s):

Ajitabh Soni ◽

Paramjeet Singh ◽

Raghav Shah ◽

Sunil Kumar ◽

Lalit Batra

Keyword(s):

Bipolar Disorder ◽

Family History ◽

Rating Scale ◽

Clinical Presentation ◽

Late Onset ◽

Age At Onset ◽

P Value ◽

Young Mania ◽

Thought Disorders ◽

History Of

Introduction: There is considerable evidence to suggest that the clinical expression of Bipolar Disorder (BD) differs according to Age at Onset (AAO) that has therefore been identified as a potential specifier of interest. Aim: To compare the clinical presentation of BD and also to compare the presence of family history of illness in three subgroups made on the basis of AAO. Materials and Methods: A cross-sectional hospital based observational study was carried out on 162 patients having a diagnosis of BD current episode manic. Three subgroups were made according to AAO viz., Early Onset Bipolar Disorder (EOBD; AAO ≤21 years; 67 patients), Intermediate Onset Bipolar Disorder (IOBD; AAO=22-34 years; 59 patients) and Late Onset Bipolar Disorder (LOBD; AAO ≥35 years; 36 patients). The subgroups were compared on clinical variables, items of the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HAM-D) and Scale for Assessment of Positive Symptoms (SAPS) scales and family history of illness. Results: The EOBD subgroup had significantly more episodes per year (p-value <0.001 and partial eta squared value=0.17) than IOBD and LOBD subgroups (mean episodes per year, respectively in EOBD, IOBD and LOBD were 1.8, 0.8 and 0.6). The prevalence of family history of mood disorder was also significantly higher in the EOBD (present in 35 out of 67; χ2 value=22.8 and p-value <0.001) than both the other subgroups (present in 10 out of 59 in IOBD and 6 out of 36 in LOBD). Significant differences were found on different items of YMRS, HAM-D and SAPS scales among the subgroups EOBD subgroup had higher rating on irritability, motor activity energy, sexual interest, depressed mood, delusions, thought disorders, while LOBD subgroup had higher rating on elevated mood. Conclusion: EOBD subgroup can be considered as a specific phenotype of BD patients, which is more homogenous, severe and heritable form of illness.

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Breathing-focused Yoga as Augmentation for Unipolar and Bipolar Depression: A Randomized Controlled Trial: Le yoga axé sur la respiration comme traitement d’appoint pour la dépression unipolaire et bipolaire: Un essai randomisé contrôlé

The Canadian Journal of Psychiatry ◽

10.1177/0706743720940535 ◽

2020 ◽

pp. 070674372094053

Author(s):

Arun V. Ravindran ◽

Martha S. McKay ◽

Tricia da Silva ◽

Claudia Tindall ◽

Tiffany Garfinkel ◽

...

Keyword(s):

Depressive Symptoms ◽

Rating Scale ◽

Bipolar Depression ◽

Controlled Trial ◽

Well Being ◽

Mood Stabilizers ◽

Adjunctive Treatment ◽

Residual Symptoms ◽

Significant Difference ◽

Bipolar Patients

Objective: Patients with depression frequently experience persistent residual symptoms even with optimal interventions. These patients often use complementary treatments, including yoga, as a preferred alternative or adjunctive treatment. There is evidence for the benefit of yoga for depression, but this has not been rigorously evaluated, particularly in bipolar depression. We aimed to determine the feasibility and benefit of manualized breathing-focused yoga in comparison to psychoeducation as augmentation to pharmacotherapy for improving residual symptoms of depression in unipolar and bipolar patients. Methods: Using a randomized single-blind crossover design, 72 outpatients with unipolar or bipolar depression were augmented with the two 8-week interventions at separate times, as add-ons to current first-line antidepressants and mood stabilizers. The primary outcome measure was the Montgomery-Åsberg Depression Rating Scale (MADRS). Due to the high dropout of participants after crossover at Week 8, analysis focused on between-group comparisons of yoga and psychoeducation during the initial 8 weeks of the study. Results: There was a significant decline in depressive symptoms, as measured by the MADRS, following 8 weeks of yoga. However, there was no significant difference in MADRS ratings between intervention groups. Similar improvements in self-rated depressive symptoms and well-being were also observed across time. Conclusions: Both yoga and psychoeducation may improve residual symptoms of unipolar and bipolar depression as add-on to medications. In-class group sessions and long study durations may reduce feasibility for this population. Larger trials with parallel group design and shorter duration may be more feasible.

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Psychosocial functioning impairment in euthymic patients with bipolar disorder II: The role of clinical factors

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1164 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S333-S333

Author(s):

R.S. Ilhan ◽

V. Senturk-Cankorur

Keyword(s):

Bipolar Disorder ◽

Psychosocial Functioning ◽

Rating Scale ◽

Healthy Individuals ◽

Young Mania ◽

Clinical Variables ◽

Hamilton Anxiety Rating Scale ◽

Short Test ◽

Competing Interest ◽

Bipolar Patients

IntroductionGrowing body of evidence have showed that euthymic bipolar patients have poor psychosocial functioning. Most of the studies have focused on the psychosocial functioning in euthymic bipolar disorder (BD)-I patients. On the contrary, there have been limited researches investigating psychosocial functioning in euthymic BD-II patients. Moreover, the factors associated with psychosocial functioning in euthymic patients with BD II have been also understudied.Objectives/aimsAim of our study was to investigate the association between clinical variables and poor psychosocial functioning in euthymic BD-II patients. Hypothesis of this study was that euthymic BD-II patients would have low level of psychosocial functioning compared with healthy individuals.MethodsBD-II (n = 37) and healthy subjects (n = 35) were compared in terms of their psychosocial functioning which were assessed by Functional Assessment Short Test (FAST). The euthymic state was confirmed by low scores both on the Hamilton Depression Rating Scale (HDRS) and the Young Mania Rating Scale (YMRS). Anxiety symptoms were also assessed by Hamilton Anxiety Rating Scale (HARS) in both groups. Clinical variables were taken as independent variables and FAST scores were taken as dependent variable in order to run correlation analysis in BD-II group.ResultsNo socio-demographic differences were found between two groups. Euthymic BD-II patients had significantly higher FAST, HARS, HDRS YMRS scores compared with healthy individuals. Only HDRS scores correlated with FAST scores of BD-II patients.ConclusionsThis study indicated that euthymic BD-II patients had poorer psychosocial functioning. And subclinical depressive symptoms were associated with poor psychosocial functioning.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Discontinuation of antipsychotic therapy in severe mania: A six months follow-up study

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1143 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S329-S330

Author(s):

S. Brioschi ◽

D. Delmonte ◽

C. De Santis ◽

L. Franchini ◽

C. Colombo

Keyword(s):

Rating Scale ◽

Remission Rate ◽

Mood Stabilizer ◽

Manic Episode ◽

Young Mania ◽

Antipsychotic Therapy ◽

Course Of Illness ◽

Follow Up Study ◽

Continuation Therapy

IntroductionIndependently of the drug choice, antimaniac treatment has to be continued at least until full remission. Most guidelines recommend continuation therapy for 6–12 months but controlled studies are lacking.ObjectivesA six months follow-up study on a sample of 57 inpatients affected by mania at Mood Disorder Unit.AimsTo evaluate a timeframe for the discontinuation of the antipsychotic therapy.MethodsFifty-seven bipolar inpatients affected by a manic episode according to DSM-5 criteria. Patients treated according to our pharmacological protocol with a mood stabilizer (lithium or valproate) and an antipsychotic (haloperidol or risperidone). Course of illness assessed with Young Mania Rating Scale (YMRS) scored at week 0, 1, 2, 4, 8, 24. Remission defined as YMRS < 12.ResultsTwenty men (35.09%) and 37 women (64.91%); mean age 43.18 ± 12.71 years. Mean YMRS basal score 38.55 ± 8.08. At 4th week, remission rate was 54.39% (31 patients); at 8th week was 80.70% (46 patients). At 8th week, 39/57 patients (68.42%) discontinued the antipsychotic. Relapse rate after 6 months was 26.32% (12 depressed, 3 manic). Multiple regression, t-test and Chi2 analysis were performed: older patients (P = 0.01) and with higher number of episodes (P = 0.04) tend to relapse earlier. Neither severity of the episode (P = 0.3), nor delusional symptoms (P = 0.6) nor discontinuation of the antipsychotic (P = 0.3) correlate with relapse time.ConclusionsOur experience suggests that an early discontinuation of antipsychotics, usually 4–8 weeks after remission, does not worsen the short-term course of illness. This approach could minimize the risk of side effects. Evidence is lacking about the duration of this therapy, long-term studies are still necessary.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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