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In recent years, several controlled studies could show that psychoeducational interventions have been effective for relapse prevention in bipolar disorders. We therefore established a cognitive-psychoeducational group intervention with 14 sessions providing information about the illness, early warning signs, cognitive and behavioural strategies for stress management and social rhythm. Additionally we offered a group intervention for the patients' relatives. The objective of this study was to describe the outcome associated with our psychoeducational intervention in bipolar patients and their relatives.
Sixty-two bipolar patients attended 14 sessions (à 90 min) of cognitive-psychoeducational group therapy. Patients' knowledge of bipolar disorder and their satisfaction with the treatment were assessed using self-developed questionnaires before and after the group intervention. Additionally, 49 relatives of bipolar patients received two psychoeducational workshops of 4 hours each. We assessed demographic variables, burden, high expressed emotion and depressive symptoms of the relatives before and after the two workshops and at 1-year follow-up.
Patients significantly improved their knowledge of bipolar disorder. They also have benefited from the discussions and the exchange of useful coping strategies. Burden and high expressed emotions showed no significant reductions at post-assessment, however they were significantly reduced at 1-year follow-up. Relatives also felt significantly better informed about the illness.
These findings show that psychoeducational interventions in bipolar patients and their relatives improve patients' and their relatives' knowledge of the illness and the burden of the disorder as well as high expressed emotions are reduced in relatives at 1-year follow-up.
Most people with bipolar disorder spend a significant percentage of their lifetime experiencing either subsyndromal depressive symptoms or major depressive episodes, which contribute greatly to the high levels of disability and mortality associated with the disorder. Despite the importance of bipolar depression, there are only a small number of recognised treatment options available. Consecutive treatment failures can quickly exhaust these options leading to treatment-resistant bipolar depression (TRBD). Remarkably few studies have evaluated TRBD and those available lack a comprehensive definition of multi-therapy-resistant bipolar depression (MTRBD).
To reach consensus regarding threshold definitions criteria for TRBD and MTRBD.
Based on the evidence of standard treatments available in the latest bipolar disorder treatment guidelines, TRBD and MTRBD criteria were agreed by a representative panel of bipolar disorder experts using a modified Delphi method.
TRBD criteria in bipolar depression was defined as failure to reach sustained symptomatic remission for 8 consecutive weeks after two different treatment trials, at adequate therapeutic doses, with at least two recommended monotherapy treatments or at least one monotherapy treatment and another combination treatment. MTRBD included the same initial definition as TRBD, with the addition of failure of at least one trial with an antidepressant, a psychological treatment and a course of electroconvulsive therapy.
The proposed TRBD and MTRBD criteria may provide an important signpost to help clinicians, researchers and stakeholders in judging how and when to consider new non-standard treatments. However, some challenging diagnostic and therapeutic issues were identified in the consensus process that need further evaluation and research.
Declaration of interest
In the past 3 years, M.B. has received grant/research support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Grunbiotics, Glaxo SmithKline, Janssen Cilag, LivaNova, Lundbeck, Merck, Mylan, Otsuka, Pfizer and Servier. A.J.C. has in the past 3 years received honoraria for speaking from Astra Zeneca and Lundbeck, honoraria for consulting from Allergan, Janssen, Lundbeck and LivaNova and research grant support from Lundbeck. G.M.G. holds shares in P1Vital and has served as consultant, advisor or CME speaker for Allergan, Angelini, Compass pathways, MSD, Lundbeck, Otsuka, Takeda, Medscape, Minervra, P1Vital, Pfizer, Servier, Shire and Sun Pharma. J.G. has received research funding from National Institute for Health Research, Medical Research Council, Stanley Medical Research Institute and Wellcome. H.G. received grants/research support, consulting fees or honoraria from Gedeon Richter, Genericon, Janssen Cilag, Lundbeck, Otsuka, Pfizer and Servier. R.H.M.-W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, Liva Nova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. R.M. has received research support from Big White Wall, Electromedical Products, Johnson and Johnson, Magstim and P1Vital. S.N. received honoraria from Lundbeck, Jensen and Otsuka. J.C.S. has received funds for research from Alkermes, Pfizer, Allergan, J&J, BMS and been a speaker or consultant for Astellas, Abbott, Sunovion, Sanofi. S.W has, within the past 3 years, attended advisory boards for Sunovion and LivaNova and has undertaken paid lectures for Lundbeck. D.J.S. has received honoraria from Lundbeck. T.S. has reported grants from Pathway Genomics, Stanley Medical Research Institute and Palo Alto Health Sciences; consulting fees from Sunovion Pharamaceuticals Inc.; honoraria from Medscape Education, Global Medical Education and CMEology; and royalties from Jones and Bartlett, UpToDate and Hogrefe Publishing. S.P. has served as a consultant or speaker for Janssen, and Sunovion. P.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. E.V. received grants/ research support, consulting fees or honoraria from Abbott, AB-Biotics, Allergan, Angelini, Dainippon Sumitomo, Ferrer, Gedeon Richter, Janssen, Lundbeck, Otsuka and Sunovion. L.N.Y. has received grants/research support, consulting fees or honoraria from Allergan, Alkermes, Dainippon Sumitomo, Janssen, Lundbeck, Otsuka, Sanofi, Servier, Sunovion, Teva and Valeant. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has also previously received funding for investigator-initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth. P.R.A.S. has received research funding support from Corcept Therapeutics Inc. Corcept Therapeutics Inc fully funded attendance at their internal conference in California USA and all related expenses. He has received grant funding from the Medical Research Council UK for a collaborative study with Janssen Research and Development LLC. Janssen Research and Development LLC are providing non-financial contributions to support this study. P.R.A.S. has received a presentation fee from Indivior and an advisory board fee from LivaNova.
Antidepressants constitute a central cornerstone in the treatment of depressive syndromes. In bipolar patients, however, there is an ongoing controversy about their usefulness for at least 3 decades. Early reports, mainly concerning tricyclic antidepressants, have repeatedly pointed toward unfavorable side effects on the course of the disorder, namely switching into (hypo)mania, induction of rapid cycling, and increased risk of suicide. Most evidence for both unfavorable and favorable effects has been deducted, thus far, from small studies with methodological flaws. More substantiated evidence only recently became available. From this it appears that, at least, the switch risk, and perhaps also the risk for rapid cycling and new-onset suicidality have been overinterpreted. At the same time, these new data raise doubt about the efficacy of anti-depressants as a primary-treatment choice in bipolar depression.
The relative incidence of childhood-onset bipolar illness in the USA compared with that in Europe is controversial. We examined this issue in more than 500 out-patients (average age 42 years) with bipolar illness who reported age at onset of first episode, family history, and childhood physical or sexual abuse. Childhood or adolescent onset of bipolar illness was reported by 61% of those in the US cohort but by only 30% of those in The Netherlands or Germany. In the USA there was also twice the incidence of childhood adversity and genetic/familial risk for affective disorder. The findings deserve replication and further exploration.
Sub-syndromal symptoms in bipolar disorder impair functioning and
diminish quality of life.
To examine factors associated with time spent with sub-syndromal symptoms
and to characterise how these symptoms influence outcomes.
In a double-blind randomised maintenance trial, patients received either
olanzapine or lithium monotherapy for 1 year. Stepwise logistic
regression models were used to identify factors that were significant
predictors of percentage time spent with sub-syndromal symptoms. The
presence of sub-syndromal symptoms during the first 8 weeks was examined
as a predictor of subsequent relapse.
Presence of sub-syndromal depressive symptoms during the first 8 weeks
significantly increased the likelihood of depressive relapse (relative
risk 4.67, P<0.001). Patients with psychotic features
and those with a greater number of previous depressive episodes were more
likely to experience sub-syndromal depressive symptoms (RR=2.51,
P<0.001 and RR=2.35, P=0.03
These findings help to identify patients at increased risk of affective
relapse and suggest that appropriate therapeutic interventions should be
considered even when syndromal-level symptoms are absent.
En ãnos recientes, varios estudios controlados pudieron demostrar que las intervenciones psicoeducativas han sido eficaces para prevenir la recaída en los trastornos bipolares. Así, establecimos una intervención de grupo psicoeducativo cognitivo con 14 sesiones que suministraban información sobre la enfermedad, las señales tempranas de aviso, las estrategias cognitivas y conductuales para el tratamiento del estrés y el ritmo social. Además, ofrecimos una intervención de grupo para los familiares de los pacientes. El objetivo de este estudio era describir el desenlace clínico asociado con nuestra intervención psicoeducativa en los pacientes bipolares y sus familiares.
Sesenta y dos pacientes bipolares asistieron a 14 sesiones (de unos 90 minutos) de terapia de grupo psicoeducativa cognitiva. Se evaluó el conocimiento de los pacientes del trastorno bipolar y su satisfacción con el tratamiento utilizando cuestionarios desarrollados por nosotros antes y después de la intervención de grupo. Además, 49 familiares de pacientes bipolares recibieron dos talleres psicoeducativos de 4 horas cada uno. Evaluamos las variables demográficas, la carga, la emoción expresada elevada y los síntomas depresivos de los familiares antes y después de los dos talleres y en el seguimiento al año.
Los pacientes mejoraron significativamente su conocimiento del trastorno bipolar. Se beneficiaron también de los debates y del intercambio de estrategias de afrontamiento útiles. La carga y la emoción expresada elevada no mostraron reducciones significativas en la evaluación posterior; sin embargo, se redujeron significativamente en el seguimiento al año. Los familiares se sintieron también significativamente mejor informados sobre la enfermedad.
Estos hallazgos muestran que las intervenciones psicoeducativas en los pacientes bipolares y sus familiares mejoran su conocimiento de la enfermedad y la carga del trastorno, y además las emociones expresadas elevadas se reducen en los familiares en el seguimiento al año.
Rapid cycling includes some rare manifestations which appear to have a highly biological background, probably coupled to the circadian rhythm and Zeitgeber. Increased cortical norepinephrine (noradrenaline) and decreased 5-hydroxytryptamine and dopamine turnover has been described in bipolar patients. Concerning an impact of the serotonergic system, a very high and, compared to bipolar disorder in general, increased comorbidity has been described between mixed states, obsessive-compulsive disorder, and anxiety disorders, which are generally considered as serotonergic disorders. Besides acting on different neurotransmitters, antiepileptic drugs mainly target transmembranous ion fluxes. Mobilization of calcium is a key event in presynaptic and postsynaptic signalling and also in lasting neuronal changes, as long-term potentiation. The effects of antiepileptic drugs that are efficacious in mixed states and rapid cycling also include a variety of intracellular action targeting the protein kinase activity, the inositol phosphate metabolism, and finally the expression of early genes and cytoprotective proteins.
The Stanley Foundation Bipolar Network (SFBN) was created to address the paucity of help studies in bipolar illness.
To describe the rationale and methods of the SFBN.
The SFBN includes five core sites and a number of affiliated sites that have adopted consistent methodology for continuous longitudinal monitoring of patients. Open and controlled studies are performed as patients' symptomatology dictates.
The reliability of SFBN raters and the validity of the rating instruments have been established. More than 500 patients are in continuous daily longitudinal follow-up. More than 125 have been randomised to one of three of the newer antidepressants (bupropion, sertraline and venlafaxine) as adjuncts in a study of mood stabilisers and 93 to omega-3 fatty acids. A number of open clinical case series have been published.
Well-characterised patients are followed in a detailed continuous longitudinal fashion in both opportunistic case series and double-blind, randomised controlled trials with reliable and validated measures.
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