Advances in the management of bipolar disorder in children and adolescents: an update on the literature.

INTRODUCTION: Early diagnosis and treatment concerning bipolar disorder (BD) are related to a better functioning over the long-term period. Although pharmacotherapy is indicated for approximately all youths with BD, nearly one-third of patients do not receive adequate medications for their condition. AREAS COVERED: The authors discuss the available scientific evidence from the current literature about the management of BD in both children and adolescents, giving particular focus to the efficacy and tolerability of the available pharmacological agents. Studies were identified searching MEDLINE and retrieved from reference listings of relevant articles and through consultation with experts in the field. EXPERT OPINION: Many D2-blockers, approved by the Food and Drug Administration (FDA) based on their antimanic properties in youths, are related to both short- and long-term side effects. Lurasidone was found to be effective for the treatment of acute juvenile bipolar depression, while lithium for the treatment and recurrence prevention of manic/mixed episodes. The most common anticonvulsants were found to be most useful as adjunctive antimanic agents in non-responders to first-line monotherapies. No data was found to support the use of antidepressants in juvenile BD.

Immunomodulatory Effects of Clozapine: More Than Just a Side Effect in Schizophrenia.

Recent evidence suggests a possible relationship between the immune system and schizophrenia spectrum disorders (SSDs), as neuroinflammation appears to play a role in major psychiatric conditions. Neuroinflammation is as a broad concept representing a physiological protective response to infection or injury, but in some cases, especially if chronic, it may represent an expression of maladaptive processes, potentially driving to clinical dysfunction and neurodegeneration. Several studies are concurrently highlighting the importance of microglia, the resident immune cells of the central nervous system, in a huge number of neurodegenerative diseases, including multiple sclerosis, Alzheimer's and Parkinson's diseases, as well as SSDs. A more fundamental phenomenon of maladaptive coupling of microglia may contribute to the genesis of dysfunctional brain inflammation involved in SSDs, from the onset of their neurophenomenological evolution. Clozapine and other antipsychotic drugs seem to express a provable immunomodulant effect and a more specific action on microglia, while neuroactive steroids and nonsteroidal anti-inflammatory drugs may reduce some SSDs symptoms in add-on therapy. Given these theoretical premises, this article aims to summarize and interpret the available scientific evidence about psychotropic and anti-inflammatory drugs that could express an immunomodulant activity on microglia.

Complex polypharmacy in bipolar disorder: Results from a real-world inpatient psychiatric unit.

BACKGROUND: Multiple medications are frequently prescribed to patients with bipolar disorder (BD). The aim of the present study was to identify sociodemographic and clinical characteristics associated with complex polypharmacy in patients affected by BD. METHODS: 556 patients with BD were included. A semi-structured interview was used to collect sociodemographic and clinical characteristics, as well as pharmacological treatment. Participants were divided in two groups, abased on the use of complex polypharmacy (i.e., a combination of 4 or more psychotropic medications). Differences between the two groups were evaluated with t-test and chi-squared test. A stepwise logistic regression was then applied to identify factors significantly associated with complex polypharmacy. RESULTS: Patients with BD and complex polypharmacy were more likely to be single and unemployed. Moreover, earlier age at onset, longer duration of illness, higher number of hospitalizations, higher prevalence of medical and psychiatric comorbidity, and the use of illicit substances (except heroin) were associated with complex polypharmacy. In the logistic regression model, single status, older age, number of hospitalizations, and the presence of psychiatric comorbidities were regarded as factors significantly associated with complex polypharmacy. CONCLUSIONS: Our findings reflect the need to develop clear guidelines for the long-term management of BD, especially when pharmacological discontinuation is needed.

The efficacy of brief strategic therapy in treating obsessive-compulsive disorder: a case series.

BACKGROUND AND AIM: International guidelines indicate pharmacological therapy and cognitive-behavioral therapy (CBT) as gold standard treatments for obsessive-compulsive disorder (OCD). However, up to 40% patients do not fully respond to CBT, thus manifesting persistent symptomatology. Empirical research reported brief strategic therapy (BST) as a potential treatment for OCD. The aim of the present study is to evaluate the efficacy of BST in treating OCD and to identify the clinical characteristics associated to response. METHODS: BST protocol was administered to patients with OCD. During a 24-weeks observational phase, the following scales have been administered at the baseline and every 4 weeks: Yale Brown Obsessive-Compulsive scale (Y-BOCS), Clinical Global Impression, Global Assessment of Functioning, Quality of Life Index, Medical Outcomes Study Short Form 12-item, Clinical Outcomes in Routine Evaluation-Outcome Measure, Generalized Anxiety Disorder Scale, Patient Health Questionnaire - 9 and Somatic Symptom Scale-8. RESULTS: eight patients completed the treatment and a subgroup of five patients obtained clinical remission, defined as Y-BOCS total score < 25. The repeated measures ANOVA performed showed a significant decreased of the Y-BOCS total scores (p<.001). Comparisons between the two subgroups (remitters vs. non-remitters) highlighted some potential baseline characteristics associated with remission: i.e., higher mean level of anxiety, quality of life, physical health, and lower mean level of somatic symptoms and lower prevalence of personality disorders comorbidity. CONCLUSIONS: BST could be a useful therapeutic strategy in treating OCD patients. Further studies with larger samples and with long-term follow-up are needed to assess the post-treatment maintenance of clinical effects.

Application of a staging model in patients with obsessive-compulsive disorder: cross-sectional and follow-up results.

INTRODUCTION: Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition with frequent chronic course. Staging models applied to psychiatric disorders seek to define their extent of progression at a particular time-point and differentiate early, milder clinical phenomena from those characterizing illness progression and chronicity. In OCD patients, a staging model has been recently proposed but not tested yet. This was the aim of the present study. METHODS: From an overall sample of 198 OCD patients, recruited across two psychiatric clinics in Northern Italy, 70 patients on stable treatment completed a follow-up assessment ranging from 12 to 24 months. At follow-up initiation, patients had been divided into four staging groups, according to the model proposed by Fontenelle and Yucel. At the end of the follow-up, patients were subdivided into three groups (no stage change, improved stage, or worsened stage) compared with statistical analyses. RESULTS: At the end of the follow-up, 67.1% patients showed no stage changes, 24.3% a stage improvement, and 8.6% a stage progression. Worsened patients showed higher rates of comorbid disorders and higher rates of unfavorable employment characteristics compared to the other subgroups (P < .05). Patients with worsened stage showed higher prevalence of somatic obsessions (P < .05), while patients with improved stage showed higher rates of magical thinking and violence/harm obsessions compared to other groups (P < .05). DISCUSSION: The present results provide epidemiologic and clinical correlates of the first application of a staging model in a sample of OCD patients, encouraging further studies to assess the utility of this approach in the field.