Gender differences in oral appliance treatment of obstructive sleep apnea.

PURPOSE: Although overall success rates for treating obstructive sleep apnea (OSA) with an oral appliance (OA) are high, they are significantly higher among females. To verify published data, the study's purpose was to evaluate a participant sample after one year of OA use. The primary outcome was treatment response, with responders defined as having an apnea-hypopnea index (AHI) < 10 at follow-up and/or reduced by ≥50% of baseline. Secondary measures were from standardized questionnaires. METHODS: A sample of 314 participants, predominately with moderate-to-severe OSA, were enrolled and instructed to use an OA every night. At baseline and one-year follow-up, polygraphic recordings and questionnaires, including sleepiness (measured using the Epworth sleepiness scale) and quality-of-life (measured using the Functional Outcomes of Sleep Questionnaire), were collected. RESULTS: Among the 314 participants, 192 completed the one-year evaluation: 51 females (27%) and 141 males (73%). Overall, OA treatment resulted in 78% and 77% responders among females and males, respectively. Neither the difference in improvement nor the absolute change in AHI differed significantly based on gender, at any OSA severity level. There were no significant gender differences in sleepiness or quality of life. Treatment-related adverse reactions were more common among females. CONCLUSION: Both females and males with OSA respond well to OA therapy, with nonsignificant gender differences in outcomes. Thus, the hypothesis that females respond better to OA treatment is rejected.

Oral appliance influence on jaw function in obstructive sleep apnea.

INTRODUCTION: Oral appliance (OA) therapy in obstructive sleep apnea (OSA) could be a risk factor for normal jaw function, given the prolonged effect of an OA in keeping the mandible in a protruded position away from a normal position. This study aimed to assess changes in symptoms and clinical findings related to jaw function after 1 year of treating OSA with an OA. METHODS: In this follow-up clinical trial, 302 patients with OSA were assigned to treatment with either monobloc or bibloc OA. Baseline and 1-year follow-up assessment included using the Jaw Functional Limitation Scale, self-reported symptoms and signs related to jaw function. The clinical examination of jaw function included mandibular mobility, dental occlusion, and tenderness in the temporomandibular joints and masticatory muscles. Descriptive analyses of variables are presented for the per-protocol population. To evaluate differences between the baseline and the 1-year follow-up, paired Student t tests and the McNemar change test was used. RESULTS: One-hundred and ninety-two patients completed the 1-year follow-up (male 73%, mean aged 55 ± 11 years). There was no change in the Jaw Functional Limitation Scale score at the follow-up (nonsignificant). The patients described no change in symptoms at the follow-up, except for improvements in morning headache (P <0.001) and increased frequency of difficulties in opening the mouth or chewing on awakening (P = 0.002). Subjectively reported changes in dental occlusion during biting/chewing increased significantly at the follow-up (P = 0.009). CONCLUSIONS: No changes in measurements of jaw mobility, dental occlusion, or pain on palpation of the temporomandibular joints or masticatory muscles were seen at the follow-up. Thus, using an OA in treating OSA had limited influence on jaw functions and related symptoms. Moreover, the risk of developing pain and functional impairment in the masticatory system was infrequent, indicating that this treatment is safe and can be recommended.

The outcome of oral appliance therapy on position-dependent obstructive sleep apnea: A multicenter randomized controlled trial.

INTRODUCTION: This multicenter trial on patients with obstructive sleep apnea (OSA) treated with an oral appliance aimed to determine the effect of sleeping positions. METHODS: A cohort of 314 patients with OSA were enrolled and evaluated at 8 weeks and 1 year, focusing on treatment effects. At baseline and the 2 follow-ups, new polygraphic registration comparing the proportion of treatment responders without position-dependent OSA (non-position-dependent OSA [non-POSA]) and with POSA was used. RESULTS: At the 8-week and 1-year follow-up, 205 and 139 patients were included, respectively. The proportion of responders (apnea-hypopnea index [AHI] <10 and/or ≥50% reduction in AHI) was 56% for the non-POSA group and 69% for the POSA group (not significant [NS]). The responders increased at the 1-year follow-up: 68% and 77% for the non-POSA and POSA groups (NS), respectively. The absolute change in AHI in all sleeping positions at 8 weeks was -12.9 (interquartile range, -25.0 to -0.5) in the non-POSA group and -10.5 (interquartile range, -19.9 to -5.3; NS) in the POSA group. However, the decrease in supine AHI was significantly greater among subjects with POSA. In contrast, the decrease in nonsupine AHI was significantly greater in the non-POSA group, an effect that remained at the 1-year follow-up. CONCLUSIONS: Our hypothesis that subjects with POSA at baseline would have a higher treatment response rate after oral appliance treatment compared with subjects without POSA was rejected. However, those with POSA had a significantly higher supine AHI decrease, and those without POSA had significantly less nonsupine AHI.

Respiratory outcomes after a 1-year treatment of obstructive sleep apnoea with bibloc versus monobloc oral appliances: a multicentre, randomized equivalence trial.

Objective: The benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that these types of appliances would be equally effective.Material and methods: In this multicentre, randomized equivalence trial, patients with OSA received one type of bibloc or one type of monobloc treatment. At baseline, a 1-night polygraphy study was done, and this was repeated after 1 year. The outcome was any change in the apnoea-hypopnoea index (AHI) and the limits of equivalence between the two devices were set at ±5 AHI units.Results: Of 302 patients, 146 were randomly assigned to bibloc and 156 to monobloc appliances. In 88 and 104 patients, respectively, there were significant reductions in the AHI (p < .001) with a mean change of -16.7 (95% CI -19.4 to -14.1) in the bibloc and -11.8 (-14.9 to -8.7) in the monobloc groups. The proportions of responders defined as having an AHI <10 were 68% and 65% for the bibloc and monobloc groups, respectively. Treatment-related adverse events were mild, transient and the dropouts were more frequent in the bibloc group.Conclusions: Both types of treatments positively and significantly reduced respiratory disturbances, but at the 1-year follow-up, they were not significantly different in treating OSA, with a numerically greater reduction of the AHI value with the bibloc appliance. However, the higher proportion of treatment-related adverse events and higher proportion of dropouts among bibloc users should be balanced against the advantage of a greater reduction in the AHI.

A prospective 10-year cephalometric follow-up study of patients with obstructive sleep apnea and snoring who used a mandibular protruding device.

INTRODUCTION: This 10-year prospective cephalometric study evaluates the influence of a mandibular protruding device (MPD) in people with obstructive sleep apnea and snoring. METHODS: A baseline study population of 77 people was followed biennially. After 10 years, 65 people (45 MPD users and 20 stopped-MPD users) were reexamined. At baseline and after 10 years, a lateral cephalogram was taken in the upright position. RESULTS: MPD users showed significant changes in all cephalometric variables except for maxillary protrusion. The maxillary incisors were retroclined by a mean -4.2° (standard deviation [SD] 3.95; P <0.001), mandibular incisors were proclined by a mean 3.2° (SD, 5.02; P <0.001), and SNB was reduced by a mean -0.6° (SD 1.41; P = 0.01). In those who had stopped MPD use, these initial cephalometric values were retained. Significant changes in decreased overjet and overbite were seen in the MPD group but not in the MPD-stopped group. The length of the mandible (Cd-Pg) increased by a mean of 5.1 mm (SD 6.78; P <0.001) and 6.1 mm (SD 5.99; P <0.001) in MPD and MPD-stopped groups, respectively. The hyoid bone-mandibular plane distance (hy-ML) increased by a mean of 3.3 mm (SD, 2.90; P <0.001) and 3.8 mm (SD 3.67; P = 0.001) in MPD and MPD-stopped groups, respectively. CONCLUSIONS: Long-term nocturnal MPD use causes retroclination of the maxillary incisors and proclination of the mandibular incisors with consequent decreased overjet and overbite. Both MPD and MPD-stopped users obtained increased mandibular length and lower position of the hyoid bone, which can be a normal physiological change with age.

Selective serotonin re-uptake inhibitors and the risk of violent suicide: a nationwide postmortem study.

PURPOSE: We endeavored to investigate whether previous findings of an association between antemortem exposure to selective serotonin re-uptake inhibitors (SSRI) and method of suicide could be replicated. METHODS: Using the Swedish National Board of Forensic Medicine's toxicology database and the Swedish National Board of Health and Welfare's national registries of causes of death and prescriptions, 10,002 incidents of suicide were retrieved. Risks of violent suicide conferred by SSRIs, expressed as odds ratios (ORs) with 95% confidence intervals (CIs), were estimated using logistic regression. In accordance with previous work, suicide by violent means-cases-were defined as death attributable to causes designated by ICD-10 codes X70-X83 and Y20-Y33; and suicide by non-violent means-controls-by codes X60-X69 and Y10-Y19. RESULTS: Our results imply that SSRI exposure confers a risk of violent suicide for shorter treatment durations; and that antemortem exposure to other substances (including illegal drugs) confounds estimates of risk. After adjustment for age, sex, and other substances, SSRIs treatment not exceeding 28 days conferred an almost fourfold risk of violent suicide (OR 3.6 [95% CI 1.9-6.8]), a finding partly in line with a recent Swedish study that employed a case-crossover design. CONCLUSIONS: Although risks associated with shorter treatment duration may reflect latencies to onset of therapeutic effect, it is unclear how latencies would influence the choice of suicide method, unless conditions for which SSRIs are prescribed are themselves associated with violent suicide. Finally, in the total dataset, SSRIs were not associated with an increased risk of violent suicide; however, by adjusting for other substances, we avoided the spurious conclusion that the effect of medications in this regard is protective.

Pain relief following a single-dose intra-articular injection of methylprednisolone in the temporomandibular joint arthralgia-A multicentre randomised controlled trial.

BACKGROUND: Temporomandibular joint (TMJ) arthralgia is a painful condition assumed to be associated with local inflammation. OBJECTIVE: The objective of the present study was to determine the efficacy for reducing pain of a single-dose intra-articular (IA) injection of methylprednisolone to the TMJ. The hypothesis was that methylprednisolone would effectively reduce TMJ pain. METHODS: This randomised, double-blind, parallel-group, multicentre, controlled study included visits for enrolment, treatment and 4-week follow-up. The study included patients 18 years and older who had been diagnosed with unilateral TMJ arthralgia. All participants were randomly assigned to receive 1 mL IA injections of methylprednisolone or saline. The primary outcome was change in recorded pain intensity on a visual analogue scale (VAS) at maximum jaw opening, analysed in the per protocol population. RESULTS: In total, 54 patients were randomly assigned to single-dose IA injections with methylprednisolone (n = 27) or saline (n = 27). Between baseline and the 4-week follow-up, VAS-rated pain intensity at maximum jaw opening decreased from a mean of 61.0 (95% confidence interval [CI]: 50.1; 70.7) to 33.9 (95% CI: 21.6; 46.2) in the methylprednisolone group and from 59.6 (95% CI: 50.7; 65.9) to 33.9 (95% CI: 23.8; 43.9) in the saline group. The between-group difference was not significant (P = 0.812). Treatment-related adverse events were doubled in the methylprednisolone group. CONCLUSION: Methylprednisolone provided no additional benefit for reducing pain, but caused more harm compared with saline following a single-dose IA injection in patients with TMJ arthralgia.

Use of bibloc and monobloc oral appliances in obstructive sleep apnoea: a multicentre, randomized, blinded, parallel-group equivalence trial.

Background: The clinical benefit of bibloc over monobloc appliances in treating obstructive sleep apnoea (OSA) has not been evaluated in randomized trials. We hypothesized that the two types of appliances are equally effective in treating OSA. Objective: To compare the efficacy of monobloc versus bibloc appliances in a short-term perspective. Patients and methods: In this multicentre, randomized, blinded, controlled, parallel-group equivalence trial, patients with OSA were randomly assigned to use either a bibloc or a monobloc appliance. One-night respiratory polygraphy without respiratory support was performed at baseline, and participants were re-examined with the appliance in place at short-term follow-up. The primary outcome was the change in the apnoea-hypopnea index (AHI). An independent person prepared a randomization list and sealed envelopes. Evaluating dentist and the biomedical analysts who evaluated the polygraphy were blinded to the choice of therapy. Results: Of 302 patients, 146 were randomly assigned to use the bibloc and 156 the monobloc device; 123 and 139 patients, respectively, were analysed as per protocol. The mean changes in AHI were -13.8 (95% confidence interval -16.1 to -11.5) in the bibloc group and -12.5 (-14.8 to -10.3) in the monobloc group. The difference of -1.3 (-4.5 to 1.9) was significant within the equivalence interval (P = 0.011; the greater of the two P values) and was confirmed by the intention-to-treat analysis (P = 0.001). The adverse events were of mild character and were experienced by similar percentages of patients in both groups (39 and 40 per cent for the bibloc and monobloc group, respectively). Limitations: The study shows short-term results with a median time from commencing treatment to the evaluation visit of 56 days and long-term data on efficacy and harm are needed to be fully conclusive. Conclusion: In a short-term perspective, both appliances were equivalent in terms of their positive effects for treating OSA and caused adverse events of similar magnitude. Trial registration: Registered with ClinicalTrials.gov (#NCT02148510).

Antidepressant use in suicides: a case-control study from the Friuli Venezia Giulia Region, Italy, 2005-2014.

PURPOSE: To compare the use of antidepressant (AD) classes and compounds in individuals who committed suicide and in controls from the general population and to assess to what extent adherence and current use of different AD classes can affect the risk of committing suicide. METHODS: Individual data on suicide, diagnoses and AD use in Friuli Venezia Giulia from 2005 to 2014 were obtained from the Regional Social and Health Information System. All suicides that had at least one prescription of AD in the 730 days before death (N = 876) were included as cases. Each case was matched with regard to age and sex with five controls from the general population. The association between suicide and AD use was assessed using conditional logistic regression analysis. RESULTS: Almost 70% of all suicides occurring in the10-year period had been prescribed AD. Selective serotonin reuptake inhibitors (SSRIs) accounted for more than the 90% of the prescriptions, with paroxetine the most prescribed AD. All AD compounds and classes were not associated with a higher suicide risk, with the exception of SSRI (OR = 1.6). A decreasing trend in suicide risk was observed when adherent subjects or current AD users were compared to the others. CONCLUSIONS: AD treatment is an important factor for preventing suicide, since the use of AD at adequate dosage and for a proper duration was associated with a lower suicide risk. The proper use of AD should be ascertained by physicians, particularly in a primary care context.

Obstructive sleep apnea treated with custom-made bibloc and monobloc oral appliances: a retrospective comparative study.

PURPOSE: The primary purpose of this hypothesis-generating retrospective study was to compare the effect of monobloc and bibloc (Narval™) appliances on the apnea-hypopnea index (AHI) and the total cost of treatment during the first year of treatment. METHODS: Obstructive sleep apnea (OSA) subjects treated with a monobloc or bibloc during two different time periods were identified from medical records and data were extracted. Subjects treated with either of the appliances passed the same primary examination, follow-up visits, and follow-up polygraphic examination. A 1-year clinical follow-up was made on the bibloc group. RESULTS: The study analysis included 110 monobloc- and 55 bibloc-treated subjects with baseline mean AHI of 23 and 22, respectively. AHI responders (AHI < 10 and/or a ≥50 % reduction of baseline AHI) were seen at follow-up in 61 % of the monobloc group and 56 % of the bibloc group. The improvement of the AHI value was similar in the two groups, with mean declines of 12.7 and 13.8, respectively. The ODI (oxygen desaturation index), lowest SpO2, longest apnea, and the mean Epworth sleepiness scale (ESS) score were significantly reduced by 3.1 (monobloc) and 2.2 (bibloc), i.e., at the same level for both groups. The total direct cost of treatment for a 1-year treatment was 17 % higher for the bibloc-treated subjects than for the monobloc-treated subjects. CONCLUSIONS: The results indicate that the monobloc and bibloc appliances are equally effective but the cost of treatment over 1 year was higher with the bibloc. However, prospective randomized controlled trials are needed to adequately test the assumption that the two treatment modalities are equally effective.

A prospective 10-year follow-up dental cast study of patients with obstructive sleep apnoea/snoring who use a mandibular protruding device.

OBJECTIVES: This 10-year prospective study aimed to measure and evaluate the teeth position and occlusion following 10-year nocturnal use of a mandibular protruding device (MPD) in subjects with obstructive sleep apnoea (OSA) or snoring. MATERIALS AND METHODS: Seventy-seven consecutive patients diagnosed with OSA/snoring were treated with an MPD. Fabrication of dental casts with jaw registration indexes in the intercuspal position was carried out at baseline and at follow-up, a construction bite was made, and an MPD was fitted. At the 10-year follow-up, all subjects (n = 74) were invited to participate. The dental casts were analysed in a series of measurements. RESULTS: Sixty subjects were included in the follow-up examination-41 were still using the device and 19 had ceased using the MPD. The MPD users showed significant changes in all analysed variables-decrease of overjet (-1.8 mm), overbite (-1.5 mm)-except the mandibular intercanine width and the maxillary anteroposterior relationship. Subjects who had ceased using their MPD retained their initial values, with the exception of a decreased overbite. The MPD users also showed an increased number of subjects with mesio-occlusion and posterior infra-occlusion; those who had ceased using their MPD mostly retained their initial status. CONCLUSIONS: Long-term nocturnal use of an MPD may cause both favourable and unfavourable occlusion changes, such as a decrease of the overjet and overbite or posterior infra-occlusion, and these changes may continue to develop during treatment with an MPD. Subjects with a Class III relationship may not be a suitable group for treatment with an MPD due to the mesial drift of the mandibular teeth.

Relationship of suicide rates with climate and economic variables in Europe during 2000-2012.

BACKGROUND: It is well known that suicidal rates vary considerably among European countries and the reasons for this are unknown, although several theories have been proposed. The effect of economic variables has been extensively studied but not that of climate. METHODS: Data from 29 European countries covering the years 2000-2012 and concerning male and female standardized suicidal rates (according to WHO), economic variables (according World Bank) and climate variables were gathered. The statistical analysis included cluster and principal component analysis and categorical regression. RESULTS: The derived models explained 62.4 % of the variability of male suicidal rates. Economic variables alone explained 26.9 % and climate variables 37.6 %. For females, the respective figures were 41.7, 11.5 and 28.1 %. Male suicides correlated with high unemployment rate in the frame of high growth rate and high inflation and low GDP per capita, while female suicides correlated negatively with inflation. Both male and female suicides correlated with low temperature. DISCUSSION: The current study reports that the climatic effect (cold climate) is stronger than the economic one, but both are present. It seems that in Europe suicidality follows the climate/temperature cline which interestingly is not from south to north but from south to north-east. This raises concerns that climate change could lead to an increase in suicide rates. The current study is essentially the first successful attempt to explain the differences across countries in Europe; however, it is an observational analysis based on aggregate data and thus there is a lack of control for confounders.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008.

OBJECTIVE: To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals. METHODS: Case-control study based on a health register. RESULTS: Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide. CONCLUSIONS: Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

A prospective 10-year follow-up polygraphic study of patients treated with a mandibular protruding device.

PURPOSE: This 10-year follow-up prospective study aimed to evaluate the effects of treatment with a mandibular protruding device (MPD) on respiratory parameters and subjective symptoms in patients with obstructive sleep apnea (OSA) or snoring. METHODS: Seventy-seven consecutive patients diagnosed with OSA or snoring were treated with an MPD. At baseline and the 10-year follow-up, a polygraphic examination and questionnaires on sleep quality were administrated and weight, and neck size was measured. RESULTS: At the 10-year follow-up, we examined 64 of the 77 patients and recorded their current treatment (45 MPD, 9 continuous positive airway pressure (CPAP), and 10 no treatment). For MPD patients, 89 % reported MPD use every night and 9 % several nights a week. Compared to baseline, MPD users with OSA had a significantly decreased oxygen desaturation index (ODI) (p = 0.006) and increased lowest arterial oxygen saturation, SaO2 nadir (p = 0.007) after 10 years. MPD treatment was successful for 70 % of OSA patients, yet 89 % subjectively considered themselves cured, indicating overestimation of the treatment effect. OSA patients who responded to treatment maintained baseline weight and neck size, while these increased for non-responders. Of the baseline snorers still using an MPD, 93 % maintained an ODI value of <5. All CPAP users had an ODI value of <5. Both OSA and snorers using an MPD had significantly fewer self- and relative reports of snoring, apnea, daytime tiredness, and poor night sleep quality (p < 0.001). CONCLUSIONS: MPD treatment is well tolerated and effective in a long-term, 10-year perspective. Weight gain may jeopardize MPD effects. Both patients and relatives reported significantly less snoring and fewer periods of apnea.

Relationship of suicide rates to economic variables in Europe: 2000-2011.

BACKGROUND: It is unclear whether there is a direct link between economic crises and changes in suicide rates. AIMS: The Lopez-Ibor Foundation launched an initiative to study the possible impact of the economic crisis on European suicide rates. METHOD: Data was gathered and analysed from 29 European countries and included the number of deaths by suicide in men and women, the unemployment rate, the gross domestic product (GDP) per capita, the annual economic growth rate and inflation. RESULTS: There was a strong correlation between suicide rates and all economic indices except GPD per capita in men but only a correlation with unemployment in women. However, the increase in suicide rates occurred several months before the economic crisis emerged. CONCLUSIONS: Overall, this study confirms a general relationship between the economic environment and suicide rates; however, it does not support there being a clear causal relationship between the current economic crisis and an increase in the suicide rate.

An item response theory evaluation of three depression assessment instruments in a clinical sample.

BACKGROUND: This study investigates whether an analysis, based on Item Response Theory (IRT), can be used for initial evaluations of depression assessment instruments in a limited patient sample from an affective disorder outpatient clinic, with the aim to finding major advantages and deficiencies of the instruments. METHODS: Three depression assessment instruments, the depression module from the Patient Health Questionnaire (PHQ9), the depression subscale of Affective Self Rating Scale (AS-18-D) and the Montgomery-Åsberg Depression Rating Scale (MADRS) were evaluated in a sample of 61 patients with affective disorder diagnoses, mainly bipolar disorder. A '3- step IRT strategy' was used. RESULTS: In a first step, the Mokken non-parametric analysis showed that PHQ9 and AS-18-D had strong overall scalabilities of 0.510 [C.I. 0.42, 0.61] and 0,513 [C.I. 0.41, 0.63] respectively, while MADRS had a weak scalability of 0.339 [C.I. 0.25, 0.43]. In a second step, a Rasch model analysis indicated large differences concerning the item discriminating capacity and was therefore considered not suitable for the data. In third step, applying a more flexible two parameter model, all three instruments showed large differences in item information and items had a low capacity to reliably measure respondents at low levels of depression severity. CONCLUSIONS: We conclude that a stepwise IRT-approach, as performed in this study, is a suitable tool for studying assessment instruments at early stages of development. Such an analysis can give useful information, even in small samples, in order to construct more precise measurements or to evaluate existing assessment instruments. The study suggests that the PHQ9 and AS-18-D can be useful for measurement of depression severity in an outpatient clinic for affective disorder, while the MADRS shows weak measurement properties for this type of patients.

The increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

Numerous ecological studies have shown an inverse association between antidepressant use and suicide rates and a smaller number of individual-based studies have shown an association between current antidepressant use and reduced suicide risk. Such evidence is often cited in support of the notion that antidepressants prevent suicide. However, more recently, the premises underlying this proposition, namely that suicide is caused by depression and that antidepressants relieve depression, have been challenged and the potential harm caused by antidepressants has been highlighted. In this article, Goran Isacsson and Charles Rich debate with Jon Jureidini and Melissa Raven the motion that the increased use of antidepressants has contributed to the worldwide reduction in suicide rates.

Identifying predictors for good lithium response - a retrospective analysis of 100 patients with bipolar disorder using a life-charting method.

PURPOSE: Our aim was to investigate bipolar patients in order to test the validity of various outcome measures and to identify prognostic predictors for pharmacological treatment. MATERIAL AND METHOD: One hundred patients were interviewed using a computerized life-charting program in a descriptive, retrospective analysis. The concept "Burden of illness" was defined as a combination of severity and duration of episodes. Response to treatment was defined as the difference in burden before and after treatment, a low burden during treatment, and freedom of episodes for at least 3 years after insertion of treatment. RESULTS: The absence of mixed episodes and a high initial burden predicted a good response measured as the difference in burden. If remission for 3 years or a low burden during lithium treatment was used, the absence of rapid cycling and of mixed episodes were the most important predictors. The severity of illness before treatment had no impact. DISCUSSION AND CONCLUSION: We suggest the use of absolute measures of severity during treatment as the most appropriate measure of the outcome. Furthermore, our data provide corroboration that treatment with lithium ameliorates the prognosis of the illness, but that mixed episodes and rapid cycling predict a poorer response to lithium.