Treatments for bipolar disorder: can number needed to treat/harm help inform clinical decisions?

OBJECTIVE: To compare bipolar treatment interventions, using number needed to treat (NNT) and number needed to harm (NNH). METHOD: Results of randomized controlled clinical trials were used to assess efficacy (NNT for response and relapse/recurrence prevention vs. placebo) and tolerability (e.g. NNH for weight gain and sedation vs. placebo). RESULTS: United States Food and Drug Administration-approved bipolar disorder pharmacotherapies all have single-digit NNTs (i.e. > 10% advantage over placebo), but NNHs for adverse effects that vary widely. Some highly efficacious agents are as likely to yield adverse effects as therapeutic benefit, but may be interventions of choice in more acute severe illness. In contrast, some less efficacious agents with better tolerability may be interventions of choice in more chronic mild-moderate illness. CONCLUSION: Clinical trials can help inform clinical decision making by quantifying the likelihood of benefit vs. harm. Integrating such data with individual patient circumstances, values, and preferences can help optimize treatment choices.

Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer.

The authors tested effects of a 10-week group cognitive-behavioral stress management intervention among 100 women newly treated for Stage 0-II breast cancer. The intervention reduced prevalence of moderate depression (which remained relatively stable in the control condition) but did not affect other measures of emotional distress. The intervention also increased participants' reports that having breast cancer had made positive contributions to their lives, and it increased generalized optimism. Both remained significantly elevated at a 3-month follow-up of the intervention. Further analysis revealed that the intervention had its greatest impact on these 2 variables among women who were lowest in optimism at baseline. Discussion centers on the importance of examining positive responses to traumatic events--growth, appreciation of life, shift in priorities, and positive affect-as well as negative responses.

Religiosity, Religious Coping, and Distress: A Prospective Study of Catholic and Evangelical Hispanic Women in Treatment for Early-stage Breast Cancer.

Religious involvement was measured in a sample of 49 lower socio-economic status Hispanic women who were newly diagnosed with early-stage breast cancer. Religious coping and emotional distress were assessed at pre-surgery, post-surgery, and at 3-, 6-, and 12-month follow-ups. Among Catholic women, greater religiosity tended to be associated with more distress throughout the year; among Evangelical women, in contrast, greater religiosity tended to be associated with less distress throughout the year. These correlations were significantly different at two measurement points. Similarly, religious coping tended to have divergent effects in the two groups. Among Catholics, church attendance at 6 months predicted greater distress at 12 months; among Evangelical women, obtaining emotional support from church members at 6 months predicted less distress at 12 months. These various differences are interpreted in terms of differences in the ideologies of the two religious groups.

Divalproex extended-release in acute bipolar II depression.

BACKGROUND: Divalproex extended-release (divalproex-ER) is effective in acute mania, and limited data suggest divalproex may have efficacy in acute bipolar depression. METHODS: A 7-week, open-label trial of divalproex-ER monotherapy or adjunctive therapy was conducted in 28 outpatients (15 female, mean age 36.7+/-9.1, and mean duration of illness 22.1+/-11.1 years) with bipolar II depression (39% with rapid cycling course of illness within the prior year). Divalproex-ER was generally given as a single dose at bedtime, starting at 250mg and increased by 250mg every 4 days to symptom relief or adverse effects. Efficacy was assessed using weekly prospective Montgomery Asberg Depression Rating Scale (MADRS) scores. RESULTS: Overall, mean divalproex-ER final doses and serum concentrations were 1469mg/day and 80.1microg/mL, respectively. Mean MADRS scores (last observation carried forward) decreased significantly from baseline in patients in the overall group (from 30.1 to 15.2, p<.00001). The overall response rate was 54%. Divalproex-ER therapy was generally well tolerated, with no early discontinuations due to adverse events. LIMITATIONS: This study is limited by a small sample size and an open-label study design with no placebo control. CONCLUSIONS: Divalproex-ER as monotherapy and adjunctive therapy was well tolerated and yielded an overall response rate of 54% in bipolar II depression. Based on the results of this pilot study, randomized, double-blind, placebo-controlled studies of divalproex-ER in bipolar II depression are warranted.

Bipolar disorder: improving diagnosis and optimizing integrated care.

Bipolar disorder is a chronic, severe condition commonly causing substantial mortality and psychosocial morbidity. Challenges in recognition can delay the institution of appropriate management, whereas misdiagnosis may initiate pharmacologic interventions that adversely affect the condition's course. Pharmacotherapy remains the foundation of treatment. In addition to efficacy, tolerability is an important consideration in medication choice, particularly for long-term maintenance because of its impact on adherence. Mood stabilizers are the classic treatments for bipolar disorder. Newer agents such as atypical antipsychotics may offer efficacy and/or tolerability advantages compared with other medications. The role of antidepressants in bipolar disorder remains controversial. Growing evidence indicates that adjunctive psychosocial interventions improve long-term functioning; consequently, psychologists are becoming increasingly involved in the long-term care of patients with bipolar disorder. This review seeks to update psychologists and related healthcare professionals on recent advances and the current limitations in the diagnosis and treatment of bipolar disorder.

Anesthetic implications of illicit drug use.

Individuals who abuse illicit drugs have an increased incidence of traumatic injury, medical illness, and drug overdose. Subsequently, many of these drug abusers will require perianesthesia care. The health care professionals responsible for their care must have an understanding of the prevalence, the pharmacology, and medical complications of illicit drug use, including the potential interactions with anesthetic agents.