Double-blind comparison of addition of a second mood stabilizer versus an antidepressant to an initial mood stabilizer for treatment of patients with bipolar depression.

OBJECTIVE: This study's purpose was to clarify the appropriate treatment of bipolar depression by comparing the addition of an antidepressant versus a second mood stabilizer for inpatients being treated with lithium carbonate or divalproex sodium. METHOD: Twenty-seven patients were randomly assigned to groups that received double-blind treatment with paroxetine or a second mood stabilizer (lithium carbonate or divalproex sodium) for 6 weeks. RESULTS: Both groups showed significant improvement in depressive symptoms during the 6-week trial. There were significantly more noncompleters in the group being treated with the two mood stabilizers than in the group being treated with a mood stabilizer and paroxetine. CONCLUSIONS: Both treatments appeared to be effective; however, the addition of an antidepressant may have greater clinical utility in the treatment of bipolar depression.

Quality of life and lifestyle disruption in euthymic bipolar disorder.

The objective was to assess the extent and pattern of illness intrusiveness, one measure of quality of life, in subjects with bipolar disorder (BD) and to determine whether specific illness variables had influenced the degree of intrusiveness experienced. To compare findings from BD subjects relative to published findings for subjects with chronic medical conditions. The study involved the administration of a self-report assessment tool to euthymic outpatients with BD attending a university based hospital clinic. Of the 155 eligible participants, 112 completed a standardized psychiatric interview (SADS-L) and 87 of these met study criteria for euthymia and were approached to participate in the study. Sixty-eight completed self-report measures were returned. The main outcome measure was the Illness Intrusiveness Rating Scale (IIRS) which was analysed along with a composite measure of life events. It resulted that individuals' with BD experience significant illness intrusiveness into a number of life domains even after controlling for negative life events. Factors such as type of BD, the presence of a depressive episode in the preceding year and current Hamilton depression rating scale score contributed to the total illness intrusiveness. The degree of total illness intrusiveness experienced by individuals with BD was similar to that of subjects with multiple sclerosis and greater than subjects with end stage renal disease and rheumatoid arthritis. It seems apparent that quality of life, as determined by illness intrusiveness, is compromised in subjects with BD even during periods of euthymia. BD is at least as intrusive as several chronic medical conditions. Those with a type II BD report greater impairment in all domains compared with type I. Future research should determine specific psychosocial interventions aimed at reducing the impact of BD.

Hybrid myocardial revascularization after previous left pneumonectomy.

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.

Anxious and non-anxious bipolar disorder.

Eighty-one outpatients with bipolar disorder (BD) were grouped by SADS anxiety symptom scores (high vs. low) or diagnosis of generalized anxiety disorder, and/or panic disorder. BD patients with high anxiety scores were more likely to have suicidal behaviour (44% vs. 19%), alcohol abuse (28% vs. 6%), cyclothymia (44% vs. 21%) and an anxiety disorder (56% vs. 25%) with a trend toward lithium non-responsiveness. Diagnosis of an anxiety disorder was related only to high anxiety and lower GAS scores. Thus, anxiety may have similar clinical relevance in BD as it does in unipolar patients.

Well-being and functioning in patients with bipolar disorder assessed using the MOS 20-ITEM short form (SF-20).

Sixty-eight euthymic outpatients diagnosed with bipolar disorder according to Research Diagnostic Criteria, based on structured assessment, completed the 20-item short form of the Medical Outcomes Study (MOS) questionnaire (SF-20). Patients' mean scores on the 6 SF-20 subscales fell within or below the range of mean scores reported for patients with chronic medical illness and major depression in the MOS. Thus, BD, even in clinical remission, is associated with marked reductions in self-reported functioning and well-being, confirming the importance of the disorder as a major public health problem, meriting substantial resources for research and treatment.

Levels of functioning and well-being in recovered psychotic versus nonpsychotic mania.

The aim of the study was to compare psychotic and nonpsychotic bipolar patients on demographic and outcome measures. Sixty two patients with bipolar disorder were divided into groups on the basis of psychosis during an index episode of mania. Groups were compared on demographic, clinical and outcome measures. Psychotic patients were more symptomatic during the index episode, but they did not differ from nonpsychotic patients on ratings of function and well being when euthymic. Psychosis occurring within the context of an exacerbation of mania does not seem to predict a poorer outcome when patients return to the euthymic state. A limitation of the present study is that it involves short-term outcome, but the data can be used to inform patients and family about the possibility of full recovery even in the psychotic form of mania.

Gender differences in patients with bipolar disorder influence outcome in the medical outcomes survey (SF-20) subscale scores.

BACKGROUND: The importance of gender on the course and outcome in bipolar disorder (BD) has been widely acknowledged. The limited data suggest that the prevalence is similar between sexes but that the course of illness may be different. This study investigated gender differences in a clinic sample of patients with BD including a measure of subjects' perception of well-being and functioning. METHODS: Euthymic outpatients attending a mood disorders clinic were systematically assessed. Measurements obtained included SADS-LV, Hamilton Depression Ratings scores, Young Mania Rating scores, and Medical Outcome Survey Short Form 20 items and Global Assessment of Functioning. RESULTS: Women with BD have a later onset of mania, are more likely to have a rapid cycling course, experience mixed episodes, experience more depressive episodes and report more overall impairment in all MOS subscale scores with significant impairment in physical health and pain. CONCLUSIONS: Further investigation and replication of these differences need to be addressed including non-euthymic patients and during a longer period of systematic follow-up.

Gabapentin as an adjunctive treatment in bipolar disorder.

OBJECTIVE: To evaluate the efficacy of gabapentin as an adjunctive treatment for bipolar disorder in both depressed and manic phases. METHOD: Thirty seven patients with bipolar type I or II with or without a rapid cycling course were openly treated with gabapentin added to current treatment for up to six months. Mood symptoms were rated weekly for 12 weeks then monthly for 3 months utilizing the HamD and YMS. RESULTS: Participants experienced a significant reduction in both depressive and manic symptoms. CONCLUSIONS: These findings are consistent with others in establishing the efficacy of gabapentin in both phases of bipolar disorder. LIMITATIONS: Small sample size and the use of an open uncontrolled design limit interpretation of results.

Group cognitive behavioral therapy for bipolar disorder: a feasibility and effectiveness study.

BACKGROUND: Bipolar disorder (BD) is a common disorder that results in significant psychosocial impairment, including diminished quality of life and functioning, despite aggressive pharmacotherapy. Psychosocial interventions that target functional factors could be beneficial for this population, and we hypothesized that the addition of group cognitive behavioral therapy (CBT) to maintenance pharmacotherapy would improve functioning and quality of life. METHODS: Patients diagnosed (by SCID) with bipolar disorder attending an outpatient clinic of a mood disorders program participated in the study. All patients were on maintenance mood stabilizers, and were required to have controlled symptoms before entering the study. Mood symptoms were assessed with the Hamilton Depression Rating scale and Young Mania scale at baseline and 14 weeks. Objective and subjective functioning was rated at the same interval using the Global Assessment of Functioning scale and the Medical Outcomes Survey SF-36. Treatment was provided via a specific manual based on CBT principles that could be applied to this population. RESULTS: Forty nine patients participated in this open trial, and 38 patients completed treatment. Objective and subjective indices of impairment showed improvement after 14 weeks. Both GAF and MOS scores increased significantly by the end of treatment. LIMITATIONS: This study was an open trial, and lack of control groups limits the interpretation of results. Because the study concerned effectiveness, the results do not clarify whether the improvement represents the normal course of illness or whether it is the result of the CBT intervention. CONCLUSIONS: The addition of group CBT to standard pharmacological treatment was acceptable to patients, and nearly 80% of patients complied with treatment. Despite the fact that mood symptoms were controlled at entry into the study, psychosocial functioning increased significantly at the end of treatment. Adjunctive CBT should be further investigated in this population.

Platelet protein kinase C alpha levels in drug-free and lithium-treated subjects with bipolar disorder.

Recent studies suggest that protein kinase C (PKC), particularly the alpha isoform, plays an important role in the action of lithium. There is, however, little evidence from patients with bipolar disorder (BD) to support this effect. The present investigation carried out comparative studies of PKC levels in platelets obtained from BD subjects including those with and without lithium treatment. All subjects met DSM-IV criteria for BD type I confirmed by structured interview (SCID-IV). Levels of PKC-alpha isoform in platelets from controls and from BD subjects were measured with immunoblotting analysis. No significant differences were found between controls, drug-free or lithium-treated BD subjects on membrane or cytosolic levels of PKC-alpha or in the membrane-to-cytosol ratio of this protein. The present study suggests that levels of PKC-alpha do not change in the peripheral tissues of BD subjects with or without lithium treatment.

Serum Mg2+ and Ca2+/Mg2+ ratio in major depressive disorder.

Serum Mg2+ has been implicated in the symptom severity and pathophysiology of mood disorders. Furthermore, the recent findings of blunted signalling through the G-protein-coupled adenylyl cyclase (AC) pathway in major depressive disorder (MDD) and the importance of Mg2+ in G-protein/AC function led us to reexamine in a large sample whether serum Mg2+ concentrations were decreased in MDD patients. In 145 drug-free MDD patients compared with 2 control groups: (a) patients with bipolar disorder (n = 33) and (b) non-mood-disordered patients (n = 47), there were no differences in Mg2+ levels or Ca2+/Mg2+ ratios. Neither of these measures differed when comparing responders and nonresponders to antidepressant treatment.

Effect of number of episodes on wellbeing and functioning of patients with bipolar disorder.

OBJECTIVE: To examine the relationship between number of episodes and inter-episode functioning in bipolar disorder. METHOD: Sixty-four euthymic subjects with bipolar affective disorder completed the Medical Outcomes Questionnaire Short Form and the Global Assessment of Functioning Scale. Goodness-of-fit models were used to define the relation between episode number and level of function. RESULTS: Non-linear logarithmic and power relations best described the association between number of episodes and outcome. Number of past depressions was a stronger determinant of outcome than past manias. CONCLUSION: Strategies to minimize the number of episodes experienced by patients with bipolar illness must be pursued aggressively if function is to be maintained, with particular attention given to minimizing episodes of depression.