The management of individuals with bipolar disorder : a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify difterences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps besl bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder, Anticonvulsants, such as lamotrigine. have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when

Atypical antipsychotics for bipolar disorder : overblown or blown over?

Objective：Developments in the pharmacological treatment of bipolar disorder are of much interest, as the chronicity and disability of the disorder become better understood, and as treatment goals have shifted to emphasise early control of illness course and maintenance of euthymia in addition to acute episodic remission. Atypical antipsychotics have emerged as treatment options, and this paper aims to review the evidence for their role in bipolar disorder.

Methods：A MEDLINE search was conducted for publications up till October 2006.

Results：The search yielded a number of randomised, controlled clinical trials of various atypical antipsychotics as monotherapy or adjunctive therapy in bipolar disorder. The majority of such trials have investigated their efficacy in acute mania, with fewer studies devoted to acute bipolar depression or maintenance treatment. There are no specific trials on mixed states, which have mainly been studied together with bipolar mania. The most robust evidence supports a class effect of atypical agents in the treatment of mania.

Conclusions：There are placebo-controlled trials that support the efficacy of olanzapine and quetiapine in bipolar depression, and of olanzapine and aripiprazole as maintenance treatment. There is strong support for the role of atypical antipsychotics in bipolar disorder management despite a relatively narrow literature base, chiefly for the treatment of mania. However, these findings need to be replicated, and further investigation is warranted to clarify their spectrum of efficacy in bipolar disorder.

Bipolar disorder and adiposity : a study using whole body dual energy X-ray absorptiometry scans

Objective: Previous research has demonstrated a relationship between adiposity and bipolar disorder, although data are derived predominantly from patient samples and use indirect methods of assessing adiposity. This study investigated the association between bipolar disorder and several indices of adiposity, including body fat mass as measured by dual energy X-ray absorptiometry (DXA), in a community-based sample.

Methods: In this study, 21 women with bipolar disorder and 523 healthy controls were drawn from an age-stratified, random, community-based sample of women (20–93 years) participating in the Geelong Osteoporosis Study. Bipolar disorder was diagnosed utilising a semi-structured clinical interview. Anthropometric measurements (weight, height, waist and hip circumference) were taken and fat mass was determined from whole body DXA scans (Lunar DPX-L).

Results: Those with bipolar disorder tended to have greater adiposity. Age-adjusted mean (95% CI) values for bipolar versus controls according to adiposity indices were weight 75.6 (68.9–82.3) versus 72.6 (71.3–74.0) kg, waist circumference 89.8 (84.1–95.6) versus 87.3 (86.1–88.5) cm, waist:hip ratio 0.85 (0.82–0.87) versus 0.84 (0.83–0.84), body mass index 27.6 (25.1–30.1) versus 27.5 (27.0–28.0) kg/m2, fat mass 31.4 (26.5–36.3) versus 28.6 (27.5–29.5) kg and %body fat 40.4 (36.9–43.9) versus 38.0 (37.3–38.7)%; all p > 0.05. Further adjustment for height, smoking, alcohol, psychotropic medication, energy intake or physical activity did not influence these patterns.

Conclusion: Although a pattern suggestive of greater adiposity among those with bipolar disorder was observed, no significant differences were detected. We cannot exclude the possibility of a type II error. Further research with a larger sample may produce more conclusive results.

Caring for individuals with an eating disorder

A longitudinal study indicated that carers experienced long-term moderate levels of psychological distress and burden. High levels of negative expressed emotion, use of maladaptive coping strategies and unmet needs predicted burden longitudinally. Further, eating disorder sufferers underestimate the burden experienced by carers. The results support the use of carer-based intervention.

Association between abnormal psychosocial situations in childhood, generalised anxiety disorder and oppositional defiant disorder

Objective: Psychosocial stressors are important in the pathogenesis of most mental disorders. However, little is known about the way psychosocial stressors uniquely combine to create risk for different expressions of child and adolescent psychopathology. The purpose of this study was to determine whether core dimensions of stressful psychosocial situations are differentially associated with childhood generalized anxiety disorder and oppositional defi ant disorder.

Method: A case-control design conducted in Trondheim (Norway) from 2002 to 2004 comparing exposure to ICD-10-defi ned abnormal psychosocial situations (Z-codes) among 21 children with oppositional defi ant disorder (ODD) and 22 children with generalized anxiety disorder (GAD) recruited from a university outpatient clinic with 42 non-patient school controls.

Results: Multigroup discriminant analysis extracted two signifi cant dimensions within the psychosocial variables assessed. Function 1 was characterized by overprotection, parental pressures and acute life events and was associated with GAD. Function 2 was characterized by parental abuse/hostility and interpersonal stress and was associated with ODD. Both dimensions were able to correctly classify 89.7% of the cases, compared to 35.9% by chance.

Conclusions: The results indicate that specifi c psychosocial dimensions are differentially related to childhood GAD and ODD. This may be useful in targeting at-risk populations for preventive intervention as well as informing more accurate alignment of psychosocial resources for treatment.