The comparative efficacy of carbamazepine low and high serum level and lithium carbonate in the prophylaxis of affective disorders
University Clinic of Vienna, Department of Psychiatry, Austria. Journal of Affective Disorders
(Impact Factor: 3.38).
09/1993; 28(4):221-31. DOI: 10.1016/0165-0327(93)90057-Q
The prophylactic efficacy of carbamazepine slow release (CBZ) at ke different blood levels and lithium carbonate slow release (LI) was compared in a retrospective/prospective, randomized, 2-year open trial. 84 patients with a DSM-III-R diagnosis of recurrent affective disorder who had no prophylactic medication in the 2 years preceding the trial (no LI nonresponders), were randomly allocated to three treatment groups: CBZ low (15-25 mumol/l), CBZ high (28-40 mumol/l) and LI (0.6-0.8 mumol/l). Fifty-eight patients completed the full observation period of 2 years, 26 patients dropped out. There were no statistically significant differences in the efficacy of the prophylactic treatment for bipolar patients. For the unipolar patients, the group with a low CBZ serum level showed no reduction in the duration of episodes. The two other treatment groups seem to be equal in attenuation of a unipolar course of an affective disorder.
Available from: John R Geddes
- "The seven RCTs which compared carbamazepine versus lithium were: Lerer et al. (1987), Okuma et al. (1990), Small et al. (1991), Coxhead et al. (1992), Greil et al. (1997), Berky et al. (1998), Hartong et al. (2003). From the identified RCTs that compared carbamazepine with lithium, the following studies were excluded for the following reasons: cross over design with no separate data from the first phase (Denicoff et al., 1997); inclusion of patients with other diagnosis than bipolar as unipolar depression or schizoaffective disorder with no separated data for the bipolar subgroups (Lenzi et al., 1986; Placidi et al., 1986; Watkins et al., 1987; Lusznat et al., 1988; Simhandl et al., 1993; Rybakowski et al., 1999); medications used in augmentation scheme (Gangadhar et al., 1987; Small et al., 1995). All seven studies included in this analysis were randomized. "
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ABSTRACT: To review data from randomized controlled trials (RCTs) assessing the comparative efficacy of carbamazepine and lithium in treatment of acute manic and maintenance phase of bipolar disorder (BD).
RCTs were identified through a search strategy that included: electronic databases, reference cross-checking, hand search of non-indexed publications, and book chapters on the treatment of BD comparing carbamazepine with lithium. Outcomes investigated were antimanic effect, trial withdrawal, relapse, hospitalization, need for rescue medication, and presence of adverse effects. Selection of studies and data analysis were performed independently by authors. Whenever possible, data from trials were combined through meta-analyses. Relative risks (RR) were estimated for dichotomous data.
In acute mania, carbamazepine was similar to lithium on the following outcomes: trial withdrawal due to adverse effects, number of participants with at least one adverse effect, improvement in the Clinical Global Impression (CGI). In acute mania, carbamazepine was associated with fewer trial withdrawals. In maintenance treatment, carbamazepine was similar to lithium in relapses and hospitalization, but there were fewer trial withdrawals due to adverse effects on lithium.
This review suggests that carbamazepine might be comparable to lithium in terms of efficacy and safety, and therefore a valuable option in the treatment of both manic and maintenance phases.
Available from: Eduard Vieta
- "Several studies suggest carbamazepine is equivalent to lithium although in some of them there is a trend for lithium to perform slightly but not significantly better (Coxhead et al., 1992; Denicoff et al., 1997; Greil and Kleindienst, 1999a,b; Greil et al., 1997; Kleindienst and Greil, 2002; Lusznat et al., 1988; Placidi et al., 1986; Simhandl et al., 1993; Small et al., 1991; Stoll et al., 1989; Watkins et al., 1987). However, the most important studies comparing carbamazepine with lithium were the MAP study in 1997 (Greil et al., 1997; Kleindienst and Greil, 2000) and a replication in 2003 (Hartong et al., 2003). "
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ABSTRACT: This paper is a systematic review of the available data concerning the treatment of bipolar disorder: a systematic Medline search concerning treatment guidelines and clinical trials. The search for treatment guidelines returned 583 articles and 913 papers for RCTs. The search was last performed on 1 March 2008. An additional search included repositories of clinical trials and previous systematic reviews in order to trace especially older trials. The literature suggests that lithium is useful during the acute manic and the maintenance phase. Both first- and second-generation antipsychotics are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also effective for treating bipolar depression, while olanzapine, quetiapine and aripiprazole are effective during the maintenance phase. Anticonvulsants, particularly valproate and carbamazepine have antimanic properties, whereas lamotrigine may be preferably effective in the treatment of depression but not mania. Antidepressants should always be used in combination with an antimanic agent because they were reported to induce switching to mania or hypomania, mixed episodes, and rapid cycling when given as monotherapy. The best evidence-based psychosocial interventions for bipolar disorder are group- and family-focused psychoeducation. Electroconvulsive therapy is an option for refractory patients. Although a variety of treatment options for bipolar disorder is currently available, their effectiveness is far from satisfactory, especially against bipolar depression and maintenance. Combination therapy may improve treatment outcome but it also carries the burden of more side-effects. Further research as well as the development of better guidelines and algorithms for step-by-step rational treatment are necessary.
Available from: Paolo Brambilla
- "Carbamazepine was also reported to have therapeutic effects in schizoaffective (Lusznat et al., 1988 ; Placidi et al., 1986 ; Post et al., 1990) and unipolar patients (Coxhead et al., 1992 ; Placidi et al., 1986 ; Post et al., 1990 ; Watkins et al., 1987). Three open studies found comparable long-term efficacy of carbamazepine and lithium in bipolar and unipolar patients (Bellaire et al., 1990 ; Cabrera et al., 1986 ; Simhandl et al., 1993) (Table 5). Greil and colleagues (Greil and Kleindienst, 1999a,b ; Greil et al., 1998), on the contrary, found a 50 % higher risk of prophylaxis failure with carbamazepine compared to lithium in bipolar type I patients, while patients with non-classical features (BP II\NOS, with mood incongruent delusions or with comorbidity) responded better to carbamazepine than to lithium. "
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ABSTRACT: The authors reviewed the available literature on the efficacy of carbamazepine, valproate, and other newer anticonvulsants for the treatment of bipolar disorder. A comprehensive Medline search was conducted, and all uncontrolled and controlled reports on anticonvulsants used for the treatment of bipolar patients were identified. Carbamazepine and valproate have been shown to be effective in the acute treatment of bipolar disorder, and are the first-choice treatments for lithium-refractory patients. While the efficacy of these drugs in the acute treatment of the illness has been satisfactorily documented, double-blind randomized studies are still necessary to evaluate the long-term effectiveness of both anticonvulsants. Patients on a mixed state and rapid cyclers seem to respond better to valproate and carbamazepine than to lithium. The preliminary data evaluating the efficacy of newer anticonvulsants, such as gabapentin, lamotrigine, and topiramate in bipolar patients is still limited, but some of the available findings are promising, and these new agents may represent appropriate third choices for refractory bipolar individuals. Double-blind, controlled studies with the newer anticonvulsants are still largely unavailable, and it will be necessary to evaluate their acute and prophylactic mood-stabilizing effects. The prospects for future therapeutic advances in this area are also discussed.
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