Group psycho-education for bipolar disorder.

Psycho-education is an established intervention for various physical and mental health conditions. This article describes a psycho-education programme developed for people with bipolar disorder. The courses appear to have been beneficial to participants and appraisal of the intervention is ongoing. One area that needs further consideration is whether courses should be run by a person who has bipolar disorder; the advantages and disadvantages of this are discussed.

A cross-sectional and a prospective study of thyroid disorders in lithium-treated patients.

BACKGROUND: The effects of lithium treatment on the thyroid gland have been demonstrated in a number of studies. Most of this research is based on cross-sectional studies and prospective studies are required to confirm these observations. METHOD: During our genetic association studies, we recruited 115 males and 159 females suffering with affective disorders who had received lithium treatment. We observed longitudinally 57 of these patients, who attended our clinic for between 1 and 7 years and had no thyroid abnormalities at baseline. We performed regular checks of thyroid antibodies, thyroid function tests and lithium levels. RESULTS: Hypo- and hyperthyroidism, including cases that developed prior to lithium treatment, were more common in women (25.8%) than in men (8.7%) and increased with age. By the age of 65, the risk in women increased to 50%. Hypothyroidism was induced by lithium in 17% women. In the prospective study, 4 out of 33 women developed hypothyroidism (an incidence of 27.4 cases per 1000 years). One woman developed thyrotoxicosis. CONCLUSIONS: The risk for hypothyroidism induced by lithium is especially increased in women over the age of 50. Women should be warned of the risks involved when offered lithium treatment. The frequency of lithium-induced thyrotoxicosis is very low.

Add-on topiramate reduces weight in overweight patients with affective disorders: a clinical case series.

BACKGROUND: The weight-gain caused by many psychotropic drugs is a major cause for poor compliance with such medications and could also increase cardio-vascular morbidity among psychiatric patients. Recent reports have shown that the anticonvulsant topiramate causes weight loss in various patient groups. The drug has also shown effectiveness in open trials as a mood stabilizer in patients with affective disorders, but not in controlled trials in the acute treatment of mania. We used topiramate to treat 12 patients with affective disorders who had a body-mass index > 30 kg/m2. METHODS: Topiramate was prescribed as part of our routine clinical practice, as an add-on medication, or as a replacement of a mood stabilizer. Patients' weight was recorded in 1 to 2 monthly intervals. Patients were followed up for between 6 and 12 months. The final dose of topiramate varied from 200 to 600 mg/day. RESULTS: Topiramate was effective in reducing the weight in 10 out of the 12 patients. At six months the 12 patients had lost a mean of 7.75 kg (SD = 6.9 kg, p < 0.001) and at 12 months 9 patients had lost a mean of 9.61 kg (SD = 6.7 kg, p = 0.003). Three patients stopped the treatment: one due to side effects, one due to possible side effects, and one suffered a manic relapse and showed no sustained weight loss. There were no other clear changes in the course of illness of the patients. CONCLUSION: The evidence of a strong weight-reducing potential of topiramate is indisputable and clinically significant. Topiramate could be considered in the treatment of bipolar patients who are overweight, or whose concerns about weight gain compromise their compliance with long-term prophylactic medication. So far there is no evidence that topiramate has anti-manic effect and it should not be used as monotherapy.

Transcranial magnetic stimulation for patients with depression.

Transcranial magnetic stimulation (TMS) is a relatively new technique which has been used to treat depression. It delivers magnetic radiation to the head using a hand-held coil. Some studies have indicated clinical remission of depressive symptomatology with use of TMS. Methodological limitations remain, however, and more studies are recommended to determine its efficacy.

Effects of chronic lithium treatment on renal function.

INTRODUCTION: Lithium treatment is associated with renal side effects which vary from mild nephrogenic diabetes insipidus to end stage renal disease (ESRD). A review of the literature suggests that ESRD is a very rare side effect, caused after very long-term lithium treatment, and that it might be preventable if lithium is stopped early. METHODS: Sixty-one patients were treated with lithium for a mean of 15.6 years (range 3-32, SD=6.4). Their kidney function was monitored at an Affective Disorders Clinic for a mean of 11.5 years (range 2-29, SD=5.4). We estimated their glomerular filtration rate (eGFR) at the end of monitoring. As a control group we used 53 patients who received ECT at our hospital, and had not taken lithium, and nine patients from the same clinic who were taking other mood-stabilisers. RESULTS: Lithium patients had lower eGFR compared to controls: 66.1 vs. 75.0 mL/min/1.73 m2, p=0.0006 after controlling for age and gender. The percentage of patients with an eGFR<60 ml/min/1.73 m2 (grade 3 chronic kidney disease) was 34.4%, vs. 13.1% in the controls, and was much increased compared to the general population in the respective age ranges. There was a modest but non-significant correlation between the number of years that patients had taken lithium and their eGFR, (beta=-0.177, B=-0.43, p=0.1). One patient reached an eGFR of 28 mL/min/1.73 m2 and her lithium was stopped. One patient required dialysis 6 years after leaving the clinic. CONCLUSIONS: Lithium causes a modest decline in renal function. However the available research suggests that ESRD is a very rare complication of long-term lithium treatment, affecting ∼1% of patients who have taken lithium for over 15 years.

Age-at-onset in bipolar-I disorder: mixture analysis of 1369 cases identifies three distinct clinical sub-groups.

BACKGROUND: To assess whether bipolar disorder type I segregates into three clinically distinct sub-groups defined by age-at-onset. METHODS: Clinical data were available on 1369 individuals with DSM-IV bipolar I disorder. Mixture analysis was performed on the age-at-onset (AAO) data to determine whether they were composed of more than one normal distribution. Individuals were allocated to groups according to the results of the mixture analysis. Categorical logistic regression was then used to investigate relationships between AAO and nine clinical characteristics. RESULTS: The distribution of AAOs in our sample comprised a mixture of three normal distributions with means of 18.7 (SD=3.7), 28.3 (SD=5.5) and 43.3 (SD=9.1) years, with relative proportions of 0.47, 0.39 and 0.14 respectively. Individuals were allocated into three groups dependent on their AAO: < or = 22; 25-37; and > or = 40 years, producing a sample of 1225 individuals (144 with borderline values were excluded). Eight out of the nine clinical characteristics showed evidence for a statistical association with AAO group. LIMITATIONS: Systematic and non-systematic recruitment of participants. Some data relied on retrospective recall. CONCLUSIONS: Our results provide further robust evidence to suggest that the AAO distribution of individuals affected with bipolar disorder is composed of three normal distributions. Substantial clinical heterogeneity between the three AAO groups may reflect genetic heterogeneity within bipolar I disorder. Future genetic studies should consider AAO grouping as potential sub-phenotypes.

The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study.

OBJECTIVES: Electroconvulsive therapy (ECT) is a very effective treatment of major depressive disorder. However, its use has been declining over the years in the United Kingdom, where it is now reserved for cases where all other treatment options have failed. We wanted to assess whether ECT is still highly effective in such a severely treatment-resistant population. METHODS: We report results from an ongoing, prospectively conducted, naturalistic study examining the effectiveness of ECT at a general psychiatric hospital in Cardiff, United Kingdom. We present results on every patient who received ECT between March 2004 and August 2006 for major depressive episodes, had a baseline 24-item Hamilton Rating Scale for Depression (HRSD24) score of greater than or equal to 18 and consented for participation. RESULTS: We analyzed the results of 38 patients who had at least 6 ECT sessions or achieved remission earlier. They had spent on average 14.6 months in their current episodes and 6.2 years of their lifetime in depression. They had failed to respond to an average of 5.4 different pharmacological treatments. Twenty-five patients (65.8%) responded (improvement in HDRS24 of >or=50%) and 21 (53.3%) achieved remission (end point HDRS24 score or=60%). There was no correlation between the number of unsuccessful antidepressant trials and improvement (r = -0.04, P = 0.8). CONCLUSIONS: The ECT is still highly effective in severely treatment-resistant patients with major depressive disorder, with more than half of such patients achieving remission.