The treatment of bipolar mixed states

2017 ◽  
Author(s):  
Sarah Kittel-Schneider
Keyword(s):  
Mixed States ◽  
Major Depressive ◽  
Randomized Controlled Clinical Trials ◽  
Diagnostic And Statistical Manual ◽  
Dsm 5 ◽  
Bipolar Ii ◽  
Definition Of ◽  
Bipolar Patients ◽  
Major Depressive Episodes ◽  
Depressive Episodes

Definition of mixed episodes has changed in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-5). A mixed feature specifier can be added not only to major depressive episodes and manic episodes in bipolar patients but also to hypomanic episodes in bipolar II patients and major depressive episode in major depressive disorder. Atypical antipsychotics seem to be effective in acute treatment as well as valproate and carbamazepine. Regarding prophylaxis of mixed states, monotherapy with valproate, olanzapine and quetiapine seems to prevent mixed episodes. Adjunctive therapy with valproate or lithium to quetiapine has also proven to be effective in prophylaxis of mixed episodes. In patients who suffer from pharmacotherapy-resistant mixed episodes electroconvulsive therapy can lead to response/remission. There is a lack of randomized controlled clinical trials investigating pharmacological and non-pharmacological treatments with focus on mixed states of bipolar patients, especially according to the DSM-5 definition.

What is the role of conventional antidepressants in the treatment of major depressive episodes with Mixed Features Specifier?

CNS Spectrums ◽  
2016 ◽  
Vol 22 (2) ◽  
pp. 120-125 ◽  
Author(s):  
Gianni L. Faedda ◽  
Ciro Marangoni
Keyword(s):  
Clinical Trials ◽  
Unipolar Depression ◽  
Preliminary Evidence ◽  
Major Depressive ◽  
Pharmacological Management ◽  
Diagnostic And Statistical Manual ◽  
Mixed Features ◽  
Effective Use ◽  
Major Depressive Episodes ◽  
Depressive Episodes

The newly introduced Mixed Features Specifier of Major Depressive Episode and Disorder (MDE/MDD) is especially challenging in terms of pharmacological management. Prior to the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms of the mixed features specifier were intradepressive hypomanic symptoms, always and only associated with bipolar disorder (BD).Intradepressive hypomanic symptoms, mostly referred to as depressive mixed states (DMX), have been poorly characterized, and their treatment offers significant challenges. To understand the diagnostic context of DMX, we trace the nosological changes and collocation of intradepressive hypomanic symptoms, and examine diagnostic and prognostic implications of such mixed features.One of the reasons so little is known about the treatment of DMX is that depressed patients with rapid cycling, substance abuse disorder, and suicidal ideation/attempts are routinely excluded from clinical trials of antidepressants. The exclusion of DMX patients from clinical trials has prevented an assessment of the safety and tolerability of short- and long-term use of antidepressants. Therefore, the generalization of data obtained in clinical trials for unipolar depression to patients with intradepressive hypomanic features is inappropriate and methodologically flawed.A selective review of the literature shows that antidepressants alone have limited efficacy in DMX, but they have the potential to induce, maintain, or worsen mixed features during depressive episodes in BD. On the other hand, preliminary evidence supports the effective use of some atypical antipsychotics in the treatment of DMX.

scholarly journals Short-term venlafaxine v. lithium monotherapy for bipolar type II major depressive episodes: Effectiveness and mood conversion rate

2016 ◽  
Vol 208 (4) ◽  
pp. 359-365 ◽  
Author(s):  
Jay D. Amsterdam ◽  
Lorenzo Lorenzo-Luaces ◽  
Irene Soeller ◽  
Susan Qing Li ◽  
Jun J. Mao ◽  
...  
Keyword(s):  
Type Ii ◽  
Short Term ◽  
Major Depressive ◽  
Bipolar Ii ◽  
Severity Scores ◽  
Bipolar Type ◽  
Antidepressant Use ◽  
Major Depressive Episodes ◽  
Depressive Episodes ◽  
Over Time

BackgroundControversy exists over antidepressant use in bipolar II depression.AimsTo compare the safety and effectiveness of antidepressant v. mood stabiliser monotherapy for bipolar type II major depressive episodes.MethodRandomised, double-blind, parallel-group, 12-week comparison of venlafaxine (n = 65) v. lithium (n = 64) monotherapy in adult out-patients (trial registration number NCT00602537).ResultsPrimary outcome – venlafaxine produced a greater response rate (67.7%) v. lithium (34.4%, P<0.001). Secondary outcomes – venlafaxine produced a greater remission rate (58.5% v. 28.1%, P<0.001); greater decline in depression symptom scores over time (β=–5.32, s.e. = 1.16, χ2 = 21.19, P<0.001); greater reduction in global severity scores over time (β=–1.05, s.e. = 0.22, χ2 = 22.33, P<0.001); and greater improvement in global change scores (β=–1.31, s.e. = 0.32, χ2 = 16.95, P<0.001) relative to lithium. No statistically significant or clinically meaningful differences in hypomanic symptoms were observed between treatments.ConclusionsThese findings suggest that short-term venlafaxine monotherapy may provide effective antidepressant treatment for bipolar II depression without a statistically significant increase in hypomanic symptoms relative to lithium.

Exclusion of overlapping symptoms in DSM-5 mixed features specifier: heuristic diagnostic and treatment implications

CNS Spectrums ◽  
2016 ◽  
Vol 22 (2) ◽  
pp. 126-133 ◽  
Author(s):  
Gin S Malhi ◽  
Yulisha Byrow ◽  
Tim Outhred ◽  
Kristina Fritz
Keyword(s):  
Future Research ◽  
Mixed States ◽  
Statistical Manual ◽  
Diagnostic And Statistical Manual ◽  
Dsm 5 ◽  
Mixed Features ◽  
Definition Of ◽  
Compare And Contrast ◽  
Current Classification System

This article focuses on the controversial decision to exclude the overlapping symptoms of distractibility, irritability, and psychomotor agitation (DIP) with the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier. In order to understand the placement of mixed states within the current classification system, we first review the evolution of mixed states. Then, using Kraepelin’s original classification of mixed states, we compare and contrast his conceptualization with modern day definitions. The DSM-5 workgroup excluded DIP symptoms, arguing that they lack the ability to differentiate between manic and depressive states; however, accumulating evidence suggests that DIP symptoms may be core features of mixed states. We suggest a return to a Kraepelinian approach to classification—with mood, ideation, and activity as key axes—and reintegration of DIP symptoms as features that are expressed across presentations. An inclusive definition of mixed states is urgently needed to resolve confusion in clinical practice and to redirect future research efforts.

Bipolar II illness: course and outcome over a five-year period

1989 ◽  
Vol 19 (1) ◽  
pp. 129-141 ◽  
Author(s):  
William Coryell ◽  
Martin Keller ◽  
Jean Endicott ◽  
Nancy Andreasen ◽  
Paula Clayton ◽  
...  
Keyword(s):  
Major Depression ◽  
Family Study ◽  
Study Data ◽  
Major Depressive ◽  
Bipolar Ii Disorder ◽  
Bipolar Ii ◽  
Major Depressive Episodes ◽  
Depressive Episodes ◽  
Relapse Rates

SynopsisA five year semi-annual follow-up of patients with non-bipolar (N = 442), bipolar II (N = 64) and bipolar I (N = 53) major depression tracked the courses of prospectively observed major depressive, hypomanic and manic syndromes. In all three groups, depression was much more likely in any given week than was hypomania or mania. However, during the majority of weeks, no full syndrome was present and none of the groups exhibited evidence of continuing psychosocial deterioration. Though all three groups exhibited similar times to recovery from index and subsequent major depressive episodes, both bipolar groups had substantially higher relapse rates and developed more episodes of major depression, hypomania and mania. The two bipolar groups, in turn, differed by the severity of manic-like syndromes and thus remained diagnostically stable; the bipolar II patients were much less likely to develop full manic syndromes or to be hospitalized during follow-up. In conjunction with family study data showing that bipolar II disorder breeds true, these data support the separation of bipolar I and bipolar II affective disorder.

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