[The effects of pharmacological and psychotherapeutic treatment of comorbid anxiety disorders in patients with bipolar disorder]. / De effectiviteit van medicamenteuze en psychotherapeutische behandeling van comorbide angststoornissen bij patiënten met bipolaire stoornis.

BACKGROUND: The co-occurrence of bipolar disorder and anxiety disorder is associated with a worse prognosis. Clinical guidelines do not give clear therapeutic recommendations on this subject.
AIM: To review the evidence on the effectiveness of both psychotherapy and pharmacotherapy for anxiety disorders in patients with a bipolar disorder.
METHOD: A systematic search in PubMed, Embase, Cochrane en Psycinfo and subsequent screening of potential studies resulted in 11 included studies.
RESULTS: Five studies examined the effect of pharmacotherapy on treatment of comorbid anxiety disorders. One of these studies showed that both olanzapine and lamotrigine provided positive results in treating the anxiety disorders, with olanzapine being the more effective of the two. Conflicting results were found for quetiapine and valproic acid. The conclusion of one study was that risperidone was not effective. No studies were found researching the effect of psychotherapy on treatment of comorbid anxiety disorders. However, two case studies and four studies that included patients with mixed diagnoses, including bipolar disorder, proposed evidence that behavioral and cognitive behavioral therapy (cbt) had a positive effect on treatment of the comorbid anxiety disorder.
CONCLUSION: There is little evidence on the treatment of comorbid anxiety disorders in people with bipolar disorder. Psychotherapy is preferred due to the uncertainty of the effects of pharmacotherapy and the associated risk of causing side effects. Pharmacotherapy can be considered in cases where this is insufficiently effective.

[Forcing patients with bipolar disorder to make a financial contribution to secondary psychiatric care may make them forsake care completely]. / Vraaguitval bij poliklinische patiënten met een bipolaire stoornis als gevolg van de eigen bijdrage in de tweedelijns-ggz.

BACKGROUND: In 2012 patients were required to make a personal financial contribution for secondary mental health care over and above their standard insurance fee. According to current guidelines, the majority of patients with bipolar disorder must be treated as outpatients at psychiatric clinics. It was to be expected that some patients would decide to discontinue their outpatient treatment on account of the newly imposed personal financial contribution. AIM: To obtain insight into the size and characteristics of the group of patients with bipolar disorder who were thinking about giving up treatment or had already decided to give it up because of the imposition of the personal financial contribution; also to find out which factors influenced patients' decisions and to discover how patients perceived the role of the GP as the provider of subsequent psychiatric care. METHOD: We conducted an exploratory study by sending a survey to all outpatients receiving treatment at three clinics specialising in the treatment of bipolar disorder. RESULTS: 640 patients responded to the survey (55% response); 15% of these patients were thinking about giving up treatment or had already decided to stop their treatment. They were influenced primarily by financial considerations. Two-thirds of the respondents did not consider that the GP was as a suitable alternative to outpatient care at a clinic. Even patients with moderate to serious symptoms were considering leaving secondary care. CONCLUSION: The obligatory financial contribution for secondary mental health care could have considerable consequences for a small number of patients with severe mood disorder who are currently treated as outpatients in secondary facilities. The increase in the compulsory & squo;own risk' insurance fee as from 2013 could have similar consequences.

[Apathy syndrome: a clinical entity?]. / Apathiesyndroom: een klinische entiteit?

Apathy is defined as a disorder of motivation that expresses itself at an emotional, cognitive and behavioural level. Apathy can occur as a symptom and a syndrome. In the recent years diagnostic criteria and a number of scales for measuring apathy in elderly with psychiatric or neurological disorders have been introduced. Two scales are specifically developed to measure apathy, the Apathy Evaluation Scale (AES) from Marin and the Apathy Scale (AS) from Starkstein. Both scales have been translated into Dutch. The AS is more convenient. The AS in addition can be used when applying the criteria for the apathy syndrome which has been introduced in 2001 by Starkstein. In addition, the Neuropsychiatric Inventory (NPI) and the 'Gedragsobservatieschaal voor de Intramurale Psychogeniatrie' (GIP) (a scale in Dutch) have an apathy domain. Conceptual problems surrounding apathy have only partly been resolved. The criteria for the apathy syndrome can only be used for assessing the extent of the problem. Apathy and depression are strongly correlated. Studies show that apathy as a syndrome can occur without concomitant depression in the elderly, but regularly occurs besides a depressive disorder, in percentages varying between 9% and 53% of the population under study. Especially the varying validity of an apathy syndrome in relation to late life depression needs further clarification.

[Manic state during the addition of lithium in the case of depression resistant to imipramine]. / Ontremming tijdens toevoeging van lithium bij depressie resistent tegen imipramine.

Two women, aged 65 and 43 years, who were suffering from tricyclic-resistant depressions, developed a (hypo)manic state after a few days of lithium addition. In both cases the lithium plasma level was fairly low. For the first woman an increase in the lithium dosage combined with a substitution of the antidepressant resulted in a complete recovery and for the second woman, an increase in the lithium dosage combined with the continued use of the same antidepressant resulted in a recovery to a large extent. In animal experiments lithium addition resulted in a rapid increase in serotonergic neurotransmission, due to an increase in serotonin synthesis and release. This may explain a rapid amelioration of depression as well as the development of (hypo)manic symptoms. Depending on the severity and the persistence of hypomanic symptoms, the antidepressant can be either continued or withdrawn but the lithium dose must be adjusted in order to reach an adequate plasma level of lithium.