Long-Term Prophylaxis in Bipolar Disorder

Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
CNS Drugs (Impact Factor: 5.11). 02/2006; 20(4):303-10. DOI: 10.2165/00023210-200620040-00004
Source: PubMed


Bipolar disorder is a major cause of disability, and the prevention of relapse is a key management goal. Pharmacological interventions, effectively delivered through enhanced clinical care, are central to long-term management. This article summarises the available evidence for a range of pharmacological options, and provides guidance on common issues in clinical management in line with current practice guidelines. The use of medications for long-term prophylaxis should be considered in all patients meeting criteria for bipolar I disorder. Increasing high-quality evidence from randomised trials informs management decisions relating to both novel agents, such as lamotrigine and olanzapine, and longer-established therapies, such as lithium and valproate, in monotherapy. Medications taken long-term in bipolar disorder differ in the extent to which they protect against manic and depressive relapse. Consequently, the emerging challenge is to understand how combination treatments can enhance efficacy and effectiveness based on data from controlled trials rather than random polypharmacy. Clinical care can be enhanced with effective education about the illness, and the use of strategies to improve treatment adherence and the recognition and management of stressors or prodromal symptoms. Where available, a range of specific psychological interventions can be effective as an adjunct to medication. When discontinuation of prophylaxis is necessary, gradual tapering of dose over weeks or months is recommended.

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    • "Les auteurs insistent de plus en plus sur l'intérêt des techniques psychoéducatives lors de la prise en charge. Ils insistent aussi sur l'importance de la détection précoce des symptômes annonciateurs de rechutes pour justement prévenir l'installation d'un handicap préjudiciable au patient et a ` la collectivité [20]. Lors des phases intercritiques, le praticien reste fortement dépendant de la qualité de reconnaissance de la maladie par les patients et/ou leurs familles et de leurs capacités a ` reconnaıˆtre les symptômes e ´vocateurs, afin de détecter les rechutes. "
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    ABSTRACT: Bipolar disorder is a disease that affects 1% of the general population. It is a great social burden due mostly to temporal disability and to the medical care it entrains. The management of bipolar disorder is both curative on relapse phases, and preventive on remission ones. Researchers have insisted on the importance of preventive treatment on the management of bipolar disorders and therefore on the detection of prodromic symptoms and then on the treatment of relapses before they create functional disability. In their opinion, relapses are a result of an imperfect management of remissions. In practice, it is difficult to detect prodromic relapse signs, as the practitioner's diagnosis depends greatly on the patient's insight. Thus, a patient may forget to indicate signs that have a pathologic signification. In such a situation, any instrument detecting the insidious beginning of relapse will be helpful. The aim of this study is to create a scale to detect relapses in bipolar disorders and to proceed to its preliminary validation. The scale was created based on the visual analogical model. It consisted in nine faces showing emotions grading from sadness to extreme joy. The patients were invited to choose the face that corresponded to their best mood in the preceding week. In this logic, detection of relapses is based on detection of pathologic mood variations.The validation was made on a sample of 77 patients suffering mostly from bipolar disorder subtype I. Two thirds were primary school graduates and 84% were men. Patients were evaluated by the Montgomery Asberg Depression Rate Scale (MADRS) for those suffering from depression, and the Young Manic Rate Scale (YMRS) for those suffering from manic episodes. The patients on remitted phases were evaluated by both scales. A total of 94 evaluations were computerized. Twenty four concerning depressed patients, 26 concerning patients in manic episodes and 44 concerning patients on a remission phase. Reliability was tested using the “test–retest” method. The results showed no statistical difference between the different subgroups. The Gold Standard chosen to assess validation was the DSM-IV diagnosis and the concordance rate between the MGRS and the DSM-IV diagnosis was 0,79. The sensibility of the MGRS on diagnosis of “abnormal mood variation” was 94%. Its specificity on the diagnosis of “normal mood variation” was 91,9%. The sensibility to mood variation was tested on a small sample and patients were evaluated at admission and at discharge. The result showed that the MGRS patients were more sensible to mood change than the MADRS patients and less sensible than YMRS patients. The analysis of responses relative to gender showed a significant difference between men and women in the depressed group. That difference may be due to the gender difference in emotion recognition. The analysis of responses regarding educational level showed no statistical differences. The primary validation shows an encouraging result. The authors think, however, that a validation on a larger and more homogenous sample is necessary to confirm the results.
    Annales Médico-psychologiques revue psychiatrique 03/2010; 168(2):120-126. DOI:10.1016/j.amp.2007.11.019 · 0.22 Impact Factor
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    • ", 2005 ; Baldessar - ini and Tarazi , 2005 ; Lin et al . , 2006 ; Taylor and Goodwin , 2006 ) . It is , therefore , important to evaluate further the potential impact of this widespread practice on treatment - adherence . "
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    ABSTRACT: Since sustained treatment-adherence is often problematic and may limit clinical outcomes among bipolar disorder (BPD) patients, we sought risk factors to guide clinical prediction of nonadherence. Data were from a 2005 US national sample providing questionnaire responses by 131 randomly selected prescribing psychiatrists and their adult BPD patients. We contrasted demographic and clinical factors in treatment-adherent versus nonadherent patients (strictly defined as missing > or =1 dose within 10 days) in univariate analyses followed by multivariate logistic-regression modeling. Of 429 DSM-IV BPD patients (79% type-I; 62% women; 17% minorities), 34% reported missing > or = 1 dose of psychotropic medication within 10 days, 20% missed entire daily doses at least once, and only 2.5% missed all doses for 10 days. However, their prescribing psychiatrists considered only 6% as treatment-nonadherent. Factors significantly associated with nonadherence in multivariate modeling ranked: alcohol-dependence > youth > greater affective morbidity > various side effects > or = comorbid obsessive-compulsive disorder > or = recovering from mania-hypomania. Unrelated were sex, diagnostic subtype, and other comorbidities. Since most patients received > or = 2 psychotropics, potential relationships between treatment-complexity and adherence were obscured. Prevalent treatment-nonadherence among American BPD patients, and striking underestimation of the problem by prescribing clinicians may encourage increasingly complex treatment-regimens of untested value, but added expense, risk of adverse effects, and uncertain impact on treatment-adherence itself.
    Human Psychopharmacology Clinical and Experimental 03/2008; 23(2):95-105. DOI:10.1002/hup.908 · 2.19 Impact Factor
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    • "The disease states where evidence based guidelines support the use of valproate as a first-line choice include: acute manic exacerbations, euphoric mania, dysphoric or mixed mania, and in patients being treated for rapid cycling bipolar disorder (see Table 2) (Bowden et al 2002; Keck et al 2004; Suppes et al 2005). Valproate is also considered an appropriate agent for maintenance therapy, though it lacks the FDA maintenance indication (Taylor and Goodwin 2006). Other FDA approved indications for DR include the treatment of complex partial, simple absence, and complex absence seizures in addition to prophylaxis of migraine headaches (Abbott Laboratories 2006). "
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    ABSTRACT: Bipolar disorder can be a devastating disease state for individuals with the disease and also for family members. Proper recognition and treatment is vital to the successful management of this disease state. Through increased community and practitioner awareness, along with efforts to increase awareness for proper assessment, the rate of diagnosed bipolar disorder is increasing. Recent years have brought about the introduction of several new medications with approved indications for the treatment of bipolar disorder. In addition to new agents, traditional mood stabilizing medications have also been released in different formulations to better enhance tolerability without jeopardizing efficacy. One particular product is extended-release divalproex sodium. In the following article, we review the clinical presentation of bipolar disorder, its epidemiology, and the pharmacokinetics and mechanism of action for divalproex. In addition, we specifically review the role of extended-release divalproex in bipolar disorder through a critical analysis of the currently available published primary literature.
    Neuropsychiatric Disease and Treatment 01/2008; 3(6):839-46. · 1.74 Impact Factor
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