Treating bipolar depression – antidepressants and alternatives: a critical review of the literature

2011 ◽  
Vol 23 (3) ◽  
pp. 94-105 ◽  
Author(s):  
Antonio Tundo ◽  
Paola Cavalieri ◽  
Serena Navari ◽  
Fulvia Marchetti
Keyword(s):  
Electroconvulsive Therapy ◽  
Dopamine Agonists ◽  
Suicide Risk ◽  
Bipolar Depression ◽  
Scientific Evidence ◽  
Unipolar Depression ◽  
Review Of The Literature ◽  
Acute Response ◽  
Drug Classes

Objective: Although depressive symptoms are preponderant in the course of bipolar (BP) disorders, the treatment of BP depression remains a controversial issue with different clinical approaches available. This review addresses the issues of whether antidepressants (ADs) are effective in treating acute and long-term BP depression, risks linked to ADs and what alternatives to ADs are available.Methods: We searched the MEDLINE databases using the following syntax: [bipolar depression AND unipolar depression AND (antidepressants OR anticonvulsants OR lithium OR antipsychotics OR dopamine-agonists OR psychoeducation OR psychotherapy OR electroconvulsive therapy OR transcranial magnetic stimulation)]. The search included studies published up to 31 May 2009 and conducted on adults.Results: In the acute treatment of BP depression ADs are effective with no differences among drug classes. However, neither the switch into (hypo)mania induction rate nor the suicide risk linked to AD use are definitely established. The effectiveness of long-term AD use is limited to highly selected samples of patients with positive acute response. The risk of long-term ADs causing cycle acceleration and rapid cycling induction concerns a subpopulation of patients. Valid alternatives to ADs in treating acute BP depression are quetiapine, an olanzapine–fluoxetine combination, and electroconvulsive therapy for more severe patients. Lamotrigine is effective and safe in preventing depressive relapses. Psychotherapy and psychoeducation represent effective adjunctive treatments.Conclusion: In the treatment of BP depression there is not a specific effective treatment for all the patients. Interventions should therefore be personalised and the scientific evidence should be adapted to each patient's clinical features.

scholarly journals Bipolar depression: a major unsolved challenge

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Ross J. Baldessarini ◽  
Gustavo H. Vázquez ◽  
Leonardo Tondo
Keyword(s):  
General Population ◽  
Psychiatric Disorders ◽  
Suicide Risk ◽  
Bipolar Depression ◽  
Unipolar Depression ◽  
Short Term ◽  
Term Efficacy ◽  
Medical Disorders ◽  
Mixed Features

AbstractDepression in bipolar disorder (BD) patients presents major clinical challenges. As the predominant psychopathology even in treated BD, depression is associated not only with excess morbidity, but also mortality from co-occurring general-medical disorders and high suicide risk. In BD, risks for medical disorders including diabetes or metabolic syndrome, and cardiovascular disorders, and associated mortality rates are several-times above those for the general population or with other psychiatric disorders. The SMR for suicide with BD reaches 20-times above general-population rates, and exceeds rates with other major psychiatric disorders. In BD, suicide is strongly associated with mixed (agitated-dysphoric) and depressive phases, time depressed, and hospitalization. Lithium may reduce suicide risk in BD; clozapine and ketamine require further testing. Treatment of bipolar depression is far less well investigated than unipolar depression, particularly for long-term prophylaxis. Short-term efficacy of antidepressants for bipolar depression remains controversial and they risk clinical worsening, especially in mixed states and with rapid-cycling. Evidence of efficacy of lithium and anticonvulsants for bipolar depression is very limited; lamotrigine has long-term benefit, but valproate and carbamazepine are inadequately tested and carry high teratogenic risks. Evidence is emerging of short-term efficacy of several modern antipsychotics (including cariprazine, lurasidone, olanzapine-fluoxetine, and quetiapine) for bipolar depression, including with mixed features, though they risk adverse metabolic and neurological effects.

scholarly journals Overview of antidepressant treatment of bipolar depression

2013 ◽  
Vol 16 (7) ◽  
pp. 1673-1685 ◽  
Author(s):  
Gustavo H. Vázquez ◽  
Leonardo Tondo ◽  
Juan Undurraga ◽  
Ross J. Baldessarini
Keyword(s):  
Bipolar Depression ◽  
Antidepressant Treatment ◽  
Meta Analysis ◽  
Unipolar Depression ◽  
Placebo Treatment ◽  
Research Literature ◽  
Therapeutic Trials ◽  
Significant Disability ◽  
Short And Long Term

Abstract Bipolar depression remains a major unresolved challenge for psychiatric therapeutics. It is associated with significant disability and mortality and represents the major proportion of the approximately half of follow-up time spent in morbid states despite use of available treatments. Evidence regarding effectiveness of standard treatments, particularly with antidepressants, remains limited and inconsistent. We reviewed available clinical and research literature concerning treatment with antidepressants in bipolar depression and its comparison with unipolar depression. Research evidence concerning efficacy and safety of commonly used antidepressant treatments for acute bipolar depression is very limited. Nevertheless, an updated meta-analysis indicated that overall efficacy was significantly greater with antidepressants than with placebo-treatment and not less than was found in trials for unipolar major depression. Moreover, risks of non-spontaneous mood-switching specifically associated with antidepressant treatment are less than appears to be widely believed. The findings encourage additional efforts to test antidepressants adequately in bipolar depression, and to consider options for depression in types I vs. II bipolar disorder, depression with subsyndromal hypomania and optimal treatment of mixed agitated-dysphoric states – both short- and long-term. Many therapeutic trials considered were small, varied in design, often involved co-treatments, or lacked adequate controls.

Electroconvulsive therapy in elderly - a preliminary study

2016 ◽  
Vol 33 (S1) ◽  
pp. s230-s230
Author(s):  
C. Agostinho ◽  
M. Duarte ◽  
R. Alves ◽  
I. Cunha ◽  
A.M. Batista
Keyword(s):  
Electroconvulsive Therapy ◽  
Rating Scale ◽  
Bipolar Depression ◽  
Severe Depression ◽  
Unipolar Depression ◽  
Normal Range ◽  
Significant Difference ◽  
The Mean ◽  
Preliminary Study ◽  
Competing Interest

IntroductionStudies with electroconvulsive therapy (ECT) in elderly focus mainly on the assessment of possible side effects on the cognitive functioning; there are few studies that evaluate the effectiveness.ObjectiveEvaluate the effectiveness of this treatment in the population over 65 years.AimsPerform a preliminary study to evaluate the response to ECT of ≥ 65 years patients with depression.MethodsWe carry out a descriptive study based on patients treated in the last 10 years in the ECT Unit of Centro Hospitalar Psiquiátrico de Lisboa.ResultsOur initial sample consisted of 457 patients. We select patients aged ≥ 65 years with depression, and with complete data, including electroconvulsive parameters, and initial and final Hamilton Rating Scale for Depression (HRSD) scores (n = 59). Of this, 81.36% (n = 48) had unipolar depression, and 18.64% (n = 11) had bipolar depression. In the first group, the mean variation between the initial and final scores in HRSD was 13.88 points, and 27.10% (n = 13) of the patients ended the treatment in the normal range of HRSD score. In the second group, the mean variation was 12.82, and 63.60% (n = 7) ended the treatment in the normal range of HRSD. Considering the initial and final HRSD scores, it appears that unipolar depression group presents higher values (severe depression) (P < 0.05). When we compare the mean variation between the initial and final HRSD scores, we didn’t observe a statistically significant difference between the two groups. There was a clinical improvement in both.ConclusionsThe acute treatment with ECT appears to improve depressive symptoms in bipolar and unipolar depression, when considering an elderly population.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Long-Term Naturalistic Follow-Up of Patients With Bipolar Depression and Mixed State Treated With Electroconvulsive Therapy

2013 ◽  
Vol 29 (3) ◽  
pp. 179-188 ◽  
Author(s):  
Pierpaolo Medda ◽  
Mauro Mauri ◽  
Sara Fratta ◽  
Benedetta Ciaponi ◽  
Mario Miniati ◽  
...  
Keyword(s):  
Electroconvulsive Therapy ◽  
Mixed State ◽  
Bipolar Depression

The influence of treatment modality on long-term neurocognitive functioning in treatment resistant bipolar depressed inpatients treated with pharmacotherapy or electroconvulsive therapy

2016 ◽  
Vol 33 (S1) ◽  
pp. S329-S329
Author(s):  
J. Bjorke-Bertheussen ◽  
B. Auestad ◽  
U. Kessler ◽  
H. Schoyen
Keyword(s):  
Autobiographical Memory ◽  
Electroconvulsive Therapy ◽  
Bipolar Depression ◽  
Short Form ◽  
Controlled Trial ◽  
Long Term Effects ◽  
Treatment Resistant ◽  
Neurocognitive Functions ◽  
Multicenter Randomized Controlled Trial

IntroductionBipolar depression is difficult to manage, and causes considerable disability and distress for patients and their surroundings. Electroconvulsive therapy (ECT) is an effective treatment, but there are concerns regarding long-term neurocognitive impairment, and in particular autobiographical memory.ObjectivesTo compare the long-term effects of algorithm-based pharmacologic treatment (APT) and ECT in treatment-resistant bipolar depression as measured with standard neurocognitive tests and autobiographical memory interview.AimsTo examine the long-term neurocognitive effects of ECT.MethodsIn this multicenter randomized controlled trial 73 in-patients with treatment resistant bipolar depression were randomized to either APT or unilateral ECT. Patients were assessed at baseline and at 6 months. Neurocognitive functions were assessed with the MATRICS Consensus Cognitive Battery (MCCB), Wechsler Abbreviated Scale of Intelligence (WASI) and the Autobiographical Memory Inventory - Short form (AMI-SF). At 6 months, neurocognitive data were available for 26 patients (APT n = 11, ECT n = 15).ResultsThere were no group-differences at baseline.At 6 months, there was no group-difference in MCCB-score (APT 44.9 vs. ECT 46.0, P-value: 0.707), or WASI total IQ-score (APT 103.9 vs. ECT 107.2, P-value: 0.535). There were indications of (P-value: 0.109) poorer AMI-SF consistency score in the ECT group (APT 72.3% vs. ECT 64.3%).ConclusionsThis study does not find that ECT causes long-term impairment in neurocognitive function as measured with standard neuropsychological tests. We find a trend towards poorer autobiographical memory in the ECT-group, and there needs to be further research regarding this.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Analysis of treatment results in the electroconvulsive therapy unit of centro hospitalar psiquiatrico de lisboa (CHPL)

2011 ◽  
Vol 26 (S2) ◽  
pp. 1158-1158
Author(s):  
F. Silva-Carvalho ◽  
A. Moutinho ◽  
L. Mendonça ◽  
I. Cunha
Keyword(s):  
Clinical Outcome ◽  
Electroconvulsive Therapy ◽  
Bipolar Depression ◽  
Psychiatric Patients ◽  
Unipolar Depression ◽  
Response Rates ◽  
Treatment Results ◽  
Depressed Patients ◽  
Remission Rates ◽  
Schizophrenic Patients

IntroductionElectroconvulsive therapy is widely used for treatment-resistant psychiatric patients, with remission rates close to 50% and response rates between 60–70%. Post ictal suppression index (PISI) has been positively correlated with clinical outcome.ObjectivesCharacterize the treatment results of the electroconvulsive therapy unit of CHPL; find a correlation between improvement on HAM-D, PANSS and PSAS and PISI.MethodsThe patient data was collected and divided according to ICD-10 diagnosis. Evaluation scales were applied at the beginning and end of treatment: depressed patients (F31.3–5; F33; F20.4; F25.1) - HAM-D; schizophrenic/ schizoaffective/ bipolar-manic or mixed patients (F20.X, F25.X, F31.0, F31.6) - PANSS; with any of these diagnosis - PSAS. A correlation between the points of improvement on each scale and PISI was investigated using the Pearson product-moment correlation coefficient.ResultsOf 101 depressed patients, 33,7% showed remission and 49,5% showed response, over 11 sessions (average). The reduction on HAM-D score was significantly greater for patients with initial HAM-D score > 18 versus HAM-D ≤ 18 (52,9% versus 37,75%). Patients with unipolar depression (N = 72) and bipolar depression (N = 22) showed comparable results (response:47,2% versus 52,4%; remission: 30,6% versus 40,1%). Schizophrenic patients (N = 43) had higher response rates: 88%. No correlation was found between PISI and HAM-D, PANSS or PSAS improvement (r = -0,1;-0,01;-0,07).ConclusionResponse and remission rates in depressed patients were inferior to other ECT studies, except in patients with higher severity. Those rates were comparable for schizophrenic patients. PISI did not correlate with clinical outcome.

Treatment of Affective Illnesses

2018 ◽  
pp. 231-272
Author(s):  
S. Nassir Ghaemi
Keyword(s):  
Bipolar Depression ◽  
Unipolar Depression ◽  
Depressive Illness ◽  
Manic Depressive Illness ◽  
Bipolar Illness ◽  
Manic Depressive ◽  
Antidepressant Efficacy ◽  
The Common ◽  
Term Benefit

The diagnosis and treatment of affective illnesses are examined. Depressive conditions are characterized in their subtypes, as opposed to the DSM-based broad and heterogeneous “major depressive disorder” (MDD) concept (which includes melancholia, mixed depression, neurotic depression, and vascular depression). Bipolar illness is seen as a subgroup of the larger manic-depressive illness (MDI) concept, which also included unipolar depression. MDI was seen as mania or depression, not mania and depression, as in bipolar illness. The treatment implications of this broader concept of MDI are explored, including: limited antidepressant efficacy in “MDD” and in bipolar depression, leading to the common report of “treatment-resistant” depression; worsening of bipolar illness with antidepressants; limited long-term benefit with dopamine blockers in bipolar illness; and good efficacy with dopamine blockers in mixed depressive states.

Lithium and Suicide Risk in Bipolar Disorder

CNS Spectrums ◽  
2000 ◽  
Vol 5 (S1) ◽  
pp. 6-11
Author(s):  
Leonardo Tondo ◽  
Ross J. Baldessarini ◽  
John Hennen
Keyword(s):  
Suicide Risk ◽  
Suicide Attempts ◽  
Bipolar Depression ◽  
Close Association ◽  
Bipolar Disorders ◽  
Term Treatment ◽  
Diagnosis And Treatment ◽  
Timely Diagnosis ◽  
Long Term Treatment

AbstractCan timely diagnosis and treatment of depression reduce the risk of suicide? Studies of treatment effects on mortality in major mood disorders remain rare and are widely considered difficult to carry out ethically. Despite close associations of suicide with major affective disorders and related comorbidity, the available evidence provides little support for sustained reductions of suicide risk by most mood-altering treatments, including antidepressants. Studies designed to evaluate clinical benefits of mood-stabilizing treatments in bipolar disorders, however, provide comparisons of suicidal rates with and without treatment or under different treatment conditions. This emerging body of research provides consistent evidence of reduced rates of suicides and attempts during long-term treatment with lithium. This effect may not generalize to proposed alternatives, particularly carbamazepine. Our recent international collaborative studies found compelling evidence for prolonged reduction of suicidal risks during treatment with lithium, as well as sharp increases soon after its discontinuation, all in close association with depressive recurrences. Depression was markedly reduced, and suicide attempts were less frequent, when lithium was discontinued gradually. These findings indicate that studies of the effects of long-term treatment on suicide risk are feasible and that more timely diagnosis and treatment for all forms of major depression, but particularly for bipolar depression, should further reduce suicide risk.

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