Why Do Clinicians Maintain Antidepressants in Some Patients With Acute Mania? Hints From the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a Large Naturalistic Study
ABSTRACT Antidepressants are supposed to be withdrawn during a manic episode. The aim of this study was to analyze the characteristics of manic patients who received antidepressants during a manic phase in a large, naturalistic study.
The European Mania in Bipolar Longitudinal Evaluation of Medication was a 2-year prospective observational study of inpatients and outpatients with acute mania/mixed mania (DSM-IV or ICD-10 criteria) conducted in 14 European countries. Of 2,416 manic patients who continued into the maintenance phase of the study, 345 (14%) were taking an antidepressant and 2,071 (86%) were not taking an antidepressant at baseline, week 1, and/or week 2 postbaseline. Demographic and clinical variables were collected at baseline and each study visit up to 24 months. Outcome measures included the Clinical Global Impressions-Bipolar Disorder scale (CGI-BP overall, mania, and depression scores) at 12 weeks and 24 months, the 5-item Hamilton Depression Rating Scale (HDRS-5), and the Young Mania Rating Scale (YMRS) at 12 weeks only. The present study was conducted from December 2002 to June 2004.
More antidepressant maintenance use was seen in patients with mixed episodes (P < .001), rapid cyclers (P < .02), patients with more previous depressive episodes (P < .001), and patients with higher mean HDRS-5 score at baseline (P < .001)-specifically patients with anxiety (P = .013). Patients in the antidepressant group had significantly higher CGI-BP depression scores (P < .001) and a significantly higher rate of depression relapse (P < .001) at both 12 weeks and 24 months.
Patients with mania receiving antidepressants are more likely to be outpatients with mixed episodes, anxiety, or rapid cycling and have a higher risk of depression relapse during follow-up.
- SourceAvailable from: Yiru Fang
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- "The third reason, possibly as a main reason, is that treatment with antidepressant administered during episodes of depression or for purposes of preventing further episodes in patients with a recent depressive or mixed episode or a depressive episode at first onset, is not suspended in time during maintenance treatment phase (Paterniti and Bisserbe, 2013). Finally, there is agreement on the discontinuance of treatment with antidepressant during manic episodes in both different guidelines and clinical practice (Dennehy et al., 2005; Rosa et al., 2010). Thus, the patients with a hospitalization history due to manic episode were less likely to be prescribed with antidepressant in our sample. "
ABSTRACT: Although the treatment guidelines of bipolar disorders (BPD) have spread more than a decade, the concordance with evidence-based guidelines was typically low in routine clinical practice. This study is to present the data on the maintenance treatment of BPD in mainland China. One thousand and twenty-three patients who had experienced a euthymia were eligible for entry into this survey on the maintenance treatment of BPD. Guidelines disconcordance was determined by comparing the medication(s) that patients were prescribed with the recommendations in the guidelines of the Canadian Network for Mood and Anxiety Treatments. Three hundred and sixty-four patients (35.6%) had not been prescribed with the maintenance treatment as guidelines recommendations, and 208 patients (20.3%) were prescribed with the antidepressants. A longer duration of BPD, a depressive episode at first onset, and a recent depressive or mixed episode significantly increased the risk for guidelines disconcordance and prescribing antidepressant. In contrast, a hospitalization history due to manic episode was associated with a significant decrease in the risk for guidelines disconcordance and prescribing antidepressant. This study was a cross-sectional and retrospective investigation based on medical records. Considering the potentially hazardous effects of inappropriate treatment, individualized psychoeducational strategies for subjects with BPD are necessary to enhance treatment adherence and close the gap between guidelines and clinical practice in mainland China. Copyright © 2015 Elsevier B.V. All rights reserved.Journal of Affective Disorders 04/2015; 182. DOI:10.1016/j.jad.2015.04.028 · 3.71 Impact Factor
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- "Accordingly, colleagues at the present study-site recently evaluated factors associated with responsiveness to ADtreatment in BPD patients (Pacchiarotti et al., 2011a), those associated with manic-switching during AD-treatment (Valentí et al., 2011), use of AD in mixed states (Valentí et al., in press), comparisons of AD alone or combined with mood-stabilizers (Pacchiarotti et al., 2011b), and factors that explain why clinicians maintain AD-treatment even during acute manic episodes (Rosa et al., 2010). We now report on an independent study involving 290 adult, currently depressed BPD patients at the University of Barcelona to distinguish characteristics of those who did or did not receive AD treatment during acute episodes of major depression. "
ABSTRACT: The efficacy and tolerability of antidepressants (ADs) to treat or avoid episodes of depression in bipolar disorder (BPD) patients as well as reasons for using them remain unresolved. We analyzed patient-characteristics and outcomes of episodes of acute major depression among 290 adult, DSM-IV BPD patients (71% type-I, 52% women) at the Hospital Clinic of Barcelona; 80% were given an AD and 20% were not; 80% of both groups also received mood-stabilizers. We evaluated factors associated with AD-treatment using bivariate analyses and multiple logistic-regression modeling. Factors associated with AD-use by multivariate modeling ranked: [a] more years ill, [b] depressive first-lifetime episode, [c] more depressions/year, [d] melancholic index episode, and [e] less affective illness in first-degree relatives. Within 8weeks, depression improved by ≥50%, less often among BPD patients given an AD (64.4%; 38.6% without switching into hypo/mania) than not (82.1%; 78.6% without switching). Use of ADs to treat acute BP-depression was very common and associated with a more severe clinical history. Mood-switching was prevalent with AD-treatment even with mood-stabilizers present.Journal of Affective Disorders 03/2012; 139(1):89-93. DOI:10.1016/j.jad.2012.01.027 · 3.71 Impact Factor
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- "During the acute manic phase, the treatment with antidepressant drugs was associated with a higher rate of depressive relapse at 12 week (26.6% vs 15.6%, p = 0.001) and 24 month (31.3% vs 19.3%, p = 0.001) follow-ups compared to subjects not taking antidepressants (Rosa et al., 2010). Gao et al. (2008) showed that, in rapid cyclers, about 50% of subjects experienced manic episodes during monotherapy with antidepressant medications, with the higher rates of manic episodes reported for fluoxetine (42%), bupropione (35.71%) and venlafaxine (30.56%). "
ABSTRACT: There is increasing awareness that, in some cases, long-term use of antidepressant drugs (AD) may enhance the biochemical vulnerability to depression and worsen its long-term outcome and symptomatic expression, decreasing both the likelihood of subsequent response to pharmacological treatment and the duration of symptom-free periods. A review of literature suggesting potential side effects during long treatment with antidepressant drugs was performed. Studies were identified electronically using the following databases: Medline, Cinahl, PsychInfo, Web of Science and the Cochrane Library. Each database was searched from its inception date to April 2010 using "tolerance", "withdrawal", "sensitization", "antidepressants" and "switching" as key words. Further, a manual search of the psychiatric literature has been performed looking for articles pointing to paradoxical effects of antidepressant medications. Clinical evidence has been found indicating that even though antidepressant drugs are effective in treating depressive episodes, they are less efficacious in recurrent depression and in preventing relapse. In some cases, antidepressants have been described inducing adverse events such as withdrawal symptoms at discontinuation, onset of tolerance and resistance phenomena and switch and cycle acceleration in bipolar patients. Unfavorable long-term outcomes and paradoxical effects (depression inducing and symptomatic worsening) have also been reported. All these phenomena may be explained on the basis of the oppositional model of tolerance. Continued drug treatment may recruit processes that oppose the initial acute effect of a drug. When drug treatment ends, these processes may operate unopposed, at least for some time and increase vulnerability to relapse. Antidepressant drugs are crucial in the treatment of major depressive episodes. However, appraisal and testing of the oppositional model of tolerance may yield important insights as to long-term treatment and achievement of enduring effects.Progress in Neuro-Psychopharmacology and Biological Psychiatry 08/2011; 35(7):1593-602. DOI:10.1016/j.pnpbp.2010.07.026 · 4.03 Impact Factor