Study Suggests New Treatment Approach May Be Needed For Management Of Depression In Some People With Bipolar Disorder
Main Category: BipolarAlso Included In: Psychology / Psychiatry; Clinical Trials / Drug Trials
Article Date: 12 Feb 2009 - 2:00 PDT
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In a study published in The American Journal of Psychiatry, a team of researchers led by Mayo Clinic psychiatrist Mark Frye, M.D., attempted to identify what factors make some people with bipolar depression more likely to experience treatment-emergent mania (TEM).
Bipolar disorder, also known as manic-depressive illness, is a mental illness characterized by severe mood instability that can be serious and disabling. The deep mood swings from high (mania) to low (depression) may last for weeks or months, causing great disturbances in the lives of the person who has the illness, along with family and friends. Drugs known as mood stabilizers have proven effective at controlling the manic phase of the illness, but treating the depressive phase is more problematic. Antidepressants, although effective for some individuals, can trigger a rapid mood switch from depression to mania, a phenomenon called treatment-emergent mania.
"TEM is a serious and sometimes volatile adverse event, and we wanted to better understand who was at risk for developing this problem," says Dr. Frye. People experiencing mania often exhibit poor judgment and impulsivity that can lead them to engage in highly unsafe or personally damaging behaviors, resulting in hospitalization, arrest and/or incarceration.
Dr. Frye's team did a secondary analysis of data obtained in an earlier study led by Robert Post, M.D., and the Bipolar Collaborative Network. In that earlier study, researchers followed 176 study participants diagnosed with bipolar depression to measure the effectiveness of three different antidepressants. The secondary analysis led by Dr. Frye focused on 44 patients who experienced TEM after starting an antidepressant. Dr. Frye's team compared this TEM group to 84 patients who responded favorably to an antidepressant and 44 patients who stopped taking the antidepressant due to lack of effectiveness or worsening depressive symptoms.
"We found that people who had minimal manic symptoms or a "mixed depression" presentation were at greatest risk for experiencing TEM," says Dr. Frye.
Experts have begun to acknowledge that the common understanding of bipolar illness, once thought to be a disorder with two distinct phases (a manic upswing and a depressive downswing), may be incomplete. A recent study of over 1,300 patients conducted by Joseph Goldberg, M.D., Mount Sinai School of Medicine, reported that two-thirds of the depressed bipolar patients had minimal or mild manic symptoms "mixed" together.
"We're learning that this illness does not occur in two neat, clear-cut phases, but rather a mix of the two," says Dr. Frye. "Our data would suggest that people with mixed depression may need to stay away from antidepressants and work with their health care providers to find alternative treatments, such as mood stabilizers, to help manage the depressive phase of their illness." Further research is encouraged to better understand the best treatment for these mixed presentations.
Other authors for this article include: Gerhard Helleman, Ph.D., David Geffen School of Medicine at UCLA, Los Angeles; Susan McElroy, M.D., University of Cincinnati College of Medicine; Lori Altshuler, M.D., David Geffen School of Medicine at UCLA, Los Angeles; David Black, Ph.D., Pediatric and Developmental Neuropsychiatry, National Institute of Mental Health (NIMH), National Institutes of Health (NIH), Bethesda, Md., and David Geffen School of Medicine at UCLA, Los Angeles; Paul Keck Jr., M.D., University of Cincinnati College of Medicine; Willem Nolen, M.D., Ph.D., University Medical Center Groningen, University of Groningen, the Netherlands; Ralph Kupka, M.D., Ph.D., Altrecht Institute for Mental Health Care and University Medical Centre, Utrecht, the Netherlands; Gabriele Leverich, Biological Psychiatry Branch, NIMH, NIH, Bethesda, Md.; Heinz Grune, M.D., Institute of Neuroscience, Newcastle University, Newcastle, England; Jim Mintz, Ph.D., University of Texas San Antonio; Robert Post, M.D., George Washington School of Medicine, Penn State College School of Medicine and Bipolar Collaborative Network, Bethesda, Md.; and Trisha Suppes, M.D., Ph.D., Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas.
To obtain the latest news releases from Mayo Clinic, go to http:// www.mayoclinic.org/news. MayoClinic.com (http://www.mayoclinic.com) is available as a resource for your health stories.
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Bipolar
posted by Dan on 21 Feb 2009 at 8:04 amBipolar Disorder (manic-depressive illness) has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and embellished elation. These cyclical episodes are a catalyst for noticeable psychosocial impairment
Bipolar Disorder also affect’s one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar by many. Yet Bipolar allows for exceptional abilities when a bipolar person is in their manic phase at times.
The etiology for bipolar disorder is unknown. As many as half of those suspected as having a bipolar are thought to have at least one parent with some sort of mood disorder similar to bipolar disorder, which suggests a genetic predisposition may be present. Because of the complexity associated with bipolar disorder, greater than 50 percent of those afflicted are misdiagnosed as major depression, or perhaps schizophrenia.
It is also believed that bipolar presents itself with symptoms associated with the definition of bipolar when one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980, although bipolar disorder is thought to have existed for quite some time.
Also, those with bipolar are thought to be in possession of heightened creativity during their manic phases, as well as they have accelerated growth of their neurons. This is not necessarily a bad thing, it seems. Conversely, those with bipolar disorder experience up to 3 times the number of depressive episodes as manic ones.
Research has determined that as many as 15 to over 30 percent of bipolar patients commit suicide if they are left untreated, or undertreated. Also, as many as half of those affected with bipolar also have at times severe substance abuse issues along with their bipolar as well. Co-morbid medical conditions should be taken into consideration when evaluating one suspect of, or having bipolar disorder.
Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as a result of these medical issues. The disorder varies as far as severity goes- with some bipolar patients being more severely affected than others. In fact, there are at least 6 classifications of bipolar, according to the DSM.
Bipolar patients are thought to be symptomatic half of their lives. As stated previously, the depressive episodes occur more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some, when in their depressive state in particular. The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar rose from being about 25 per 100 thousand people to being 1000 per 100,000 people.
Most diagnosed with bipolar are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which may include as many as 12 million people in the United States. This is if the diagnostic criteria developed by others were to be fully utilized. An emphasis should be implemented by the health care provider to utilize available clinical evidence, and review this scientific literature.
A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar. Also, there is not any objective diagnostic testing to rely upon for bipolar. There is also a mental diagnosis of what is called mixed depressive disorder, which is one with depression who also has minimal manic episodes.
Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar.
While not recommended, about a half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years.
Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar - with a greater amount of research behind this class of drugs. Furthermore, therapy with any antidepressants has been associated with what is known as treatment-emergent mania. This is when a bipolar disorder that is in a depressive state rapidly enters a manic phase. This occurrence can be unmanageable by the bipolar disorder patient.
The most recognized treatments for bipolar long term are lithium (Ekalith or Lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
Atypical anti-psychotics have been prescribed for bipolar, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well.
As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar who are pregnant, however.
Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago.
Ekalith is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar. As should the health care provider keep in mind that the ultimate goal with this disorder is to stabilize the mood of the one affected.
http://www.dbsalliance.org, http://www.nmha.org
Dan Abshear
Author’s note: What has been annotated is based upon information and belief.
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