Eduard Vieta

Predictores clínicos del funcionamiento interpersonal en pacientes bipolares

OBJECTIVE Functional impairment has been repeatedly reported in patients with bipolar disorder even during clinical remission. Less is known about specific domains, such as interpersonal relationships. The aim of this study was to identify clinical predictors of poor interpersonal relationships. METHODS Using a specific subscale of the Functioning Assessment Short Test (FAST), we assessed the interpersonal relationships of a sample of 71 euthymic bipolar (Hamilton Depression Rating Scale [HAM-D] < 8; Young Mania Rating Scale [YMRS] < 5) patients. The sample was divided into two categories: low vs. high level functioning in interpersonal relationships according to the median of the sample. Multivariate analyses were applied to identify significant predictors of interpersonal functioning. RESULTS Age (p=0.026), the number of previous depressive and mixed episodes and HAM-D scores differed significantly between the two groups (p<0.05). For manic episodes, only a tendency was detected (p=0.064). After running multivariate analyses, age (p=0.026), depressive symptoms (p=0.055) and the number of previous manic episodes (p=0.033) could be considered predictors of poor interpersonal functioning. The model predicted 83.3% of the variance (R=0.59; gl=1; p<0.001). DISCUSSION Our results indicate a link between greater impairment in interpersonal relationships and being older and having more residual symptoms and a higher number of previous manic episodes. Patients with these features should be carefully monitored and specific psychosocial interventions should be implemented to improve their outcome.

Los costos y consumo de recursos sanitarios asociados a episodios maníacos en la práctica clínica diaria: el estudio MANACOR

INTRODUCTION Bipolar disorder is a relapsing-remitting condition affecting approximately 1-2% of the population. Even when the treatments available are effective, relapses are still very frequent. Therefore, the burden and cost associated to every new episode of the disorder have relevant implications in public health. The main objective of this study was to estimate the associated health resource consumption and direct costs of manic episodes in a real world clinical setting, taking into consideration clinical variables. METHODS Bipolar I disorder patients who recently presented an acute manic episode based on DSM-IV criteria were consecutively included. Sociodemographic variables were retrospectively collected and during the 6 following months clinical variables were prospectively assessed (YMRS,HDRS-17,FAST and CGI-BP-M). The health resource consumption and associate cost were estimated based on hospitalization days, pharmacological treatment, emergency department and outpatient consultations. RESULTS One hundred sixty-nine patients patients from 4 different university hospitals in Catalonia (Spain) were included. The mean direct cost of the manic episodes was €4,771. The 77% (€3,651) was attributable to hospitalization costs while 14% (€684) was related to pharmacological treatment, 8% (€386) to outpatient visits and only 1% (€50) to emergency room visits. The hospitalization days were the main cost driver. An initial FAST score>41 significantly predicted a higher direct cost. CONCLUSIONS Our results show the high cost and burden associated with BD and the need to design more cost-efficient strategies in the prevention and management of manic relapses in order to avoid hospital admissions. Poor baseline functioning predicted high costs, indicating the importance of functional assessment in bipolar disorder.

Eficacia y seguridad de la ketamina en depresión bipolar: una revisión sistemática

The depression is the most prevalent state throughout the life of the bipolar patient. Ketamine has been shown to be an effective and rapid treatment for depression. The objective of the present work is to perform a systematic review on the efficacy and safety of ketamine as treatment of bipolar depression, as well as its different patterns of administration. The search found 10 relevant manuscripts that met the inclusion criteria: one clinical trial, 5 cohort studies, and 4 case reports. Intravenous infusion was used in 60% of the studies. According to data, ketamine seems to be an effective and safe treatment for bipolar depression, although the length of its effect is short. Adverse effects observed generally occurred at the time of infusion, and tended to completely disappear within 1-2h. Therefore, more studies are necessary to explore new patterns of administration, as well as on its safety and adverse effects.

Vortioxetina: una nueva alternativa en el trastorno depresivo mayor

Major Depressive Disorder (MDD) is a serious psychiatric condition. Its treatment remains a challenge nowadays. Vortioxetine is a novel antidepressant with a unique profile, as it acts as a multimodal serotoninergic agent. Its efficacy in MDD has been established in many short- and long-term studies, with 7 positive, 4 negative and 1 failed randomized controlled trials. Moreover, its ability to modulate a wide range of neurotransmitters (serotonin, dopamine, norepinephrine, histamine, glutamate or GABA) confers vortioxetine pro-cognitive effects. Side effects are also different from conventional antidepressants, according to its low incidence of sexual dysfunction, weight gain or cardiovascular alterations. The aim of this systematic review is to describe the pharmacology, clinical efficacy and safety profile of vortioxetine, as well as its potential effectiveness in improving cognitive symptoms.

P.1.003 Brain-derived neurotrophic factor as a biomarker of clinical response in bipolar disorder: 16-week follow-up study

Simultaneous infusion of the selective 5-HT2A-receptor antagonist M100907, as well as asenapine, completely blocked the DOI-induced increase in dopamine and serotonin release and partially the increased noradrenaline release, indicating a similar mechanism by M100907 and asenapine. When given alone, infusion of M100907 or asenapine, in the concentrations used, did not affect monoamine release. Intracortical administration of the selective a2adrenoceptor agonist clonidine significantly decreased dopamine, noradrenaline and serotonin release in the mPFC (maximal effects; 61.0±8.0, 50.4±7.6, and 67.0±4.1% of baseline, respectively; p< 0.01–0.001). Simultaneous infusion of the a2-adrenoceptor antagonist idazoxan blocked the clonidine-induced reduction of dopamine and noradrenaline release. The effect of idazoxan on serotonin was less pronounced and not statistically significant. Simultaneous infusion of asenapine did not acutely block the clonidine-induced decrease in transmitter release. However, following termination of the clonidine infusion the transmitter release remained at a low level. During this interval, i.e. the following hour after the clonidine infusion, intracortical infusion of asenapine restored the catecholamine release to baseline level, indicating an a2-adrenoceptor blocking effect of asenapine which was somewhat delayed. When given alone, the infusion of idazoxan or asenapine, in the concentrations used, did not affect monoamine release. Our results propose that local application of asenapine in the mPFC indeed exhibits a pharmacological significant 5-HT2Aand, to a weaker extent, a2-receptor antagonistic activity. Whereas its 5-HT2A blocking property preferentially influenced the release of serotonin and dopamine but only to a lesser extent noradrenaline, blockage of a2-adrenoceptors preferentially influenced dopamine and noradrenaline release, albeit the effect was somewhat delayed. Thus, 5-HT2A-receptor antagonism and a2-adrenoceptor blockage induced by asenapine in the mPFC may contribute to enhance prefrontal monoamine release in vivo and, secondarily, its effect on positive and negative symptoms as well as pro-cognitive and antidepressant effects [1,2].

PMH53 PREDICTIVE FACTORS OF RECURRENCE AND BIPOLAR DISORDER MANAGEMENT IN SPAIN: A PROSPECTIVE COHORT STUDY BASELINE ASSESSMENT

PMH51 DECLINE IN DEPRESSIONTREATMENT PERSISTS AFTER FDA ANTIDEPRESSANTWARNINGS Libby AM, Orton HD,Valuck RJ University of Colorado Denver, Aurora, CO, USA OBJECTIVES: To measure the persistence over time of intended and unintended effects on community based depression treatment in the U.S. associated with the FDA warnings on antidepressants and suicidality. In October 2003 the U.S. FDA issued a Public Health Advisory about the risk of suicidality for pediatric patients on SSRI antidepressants; a boxed warning and medication guide were implemented in February 2005, and later extended to young adults aged 19–24. Unintended declines in diagnosis and non-SSRI substitute treatment have been shown immediately following the advisory both for pediatric patients, and for adult patients not targeted by the warnings. Whether those changes persisted is unknown. METHODS: Pediatric, young adult, and adult cohorts with newly diagnosed episodes of depression were created using a national, integrated managed care claims (commercially available from PHARMetrics®, a Unit of IMS, Inc.) from July 1999-June 2006 (n = 55,218 youth; 44,141 young adults; 394,524 adults patients with new episodes). Time series analyses compared post-FDA advisory trends to expected trends based on pre-advisory patterns. RESULTS: Young adult and adult populations mirrored changes in pediatric depression care after the FDA advisory. Reductions in national rates of depression treatment were substantial, returning national diagnosing rates to 1999 levels for pediatric patients and to 2003 levels for adults. Primary care providers continued significant reductions in new diagnoses of depression (50% lower for pediatric, 40% lower for young adult, 30% lower for adult). Substitute care by psychiatrists or psychologists, psychotherapy, and anxiolytic and atypical antipsychotic medication use did not significantly change from pre-advisory trends. CONCLUSIONS: Declines in depression diagnosis continued after the advisory. Substitute care did not compensate. Spillover to adults continued. Results suggest that the unintended effects were substantial, diffuse, and non-transitory in a large national population. Policy actions are required to counter the unintended consequences of reduced depression treatment.

Psychoeducation Manual for Bipolar Disorder: Awareness of the disorder

Unit 1 is fundamental, because its objective is to give the patient the basic information about bipolar disorders. We, the professionals, must not fall into the trap of considering that our patients obviously know all the information concerning the causes and symptoms of the disorder, since most of them ignore the biological, clinical and recurrent nature of their disorder. This unit must always be the first, because it will introduce concepts that will later be absolutely necessary during the group program. For example, we do not believe that it makes sense to carry out the brief intervention merely designed to identify the symptoms early, if we have not first correctly defined what the bipolar disorder is and why its symptoms appear. Consequently, we dedicate a very large number of sessions to this matter (the first five) for two main reasons: (1) on the one hand, because we believe that this is the point that warrants more specific work, as demonstrated by the high rates of lack of illness insight, which are associated to poor adherence, and (2) because, in a way, it is a manner of “refocusing” the patient included in a psychoeducation group in the fundamental aspect of their treatment: its biological nature and the need for drugs. Quite a large number of patients misunderstand their joining the therapy group as the beginning of their “depsychiatrization” or, in other words, the first step toward becoming medication free, and they so declare in the first session. At least, this is what happened in one of our groups.

What is bipolar disorder

Goal The goal of Session 2 is to introduce patients to the concept of bipolar disorders and to dispel the numerous myths about it, stressing the biological nature of the disorder and attempting to overcome its social stigma. From the point of view of a hospital-based practice, we tend to think that our own opinion regarding mental illness, in this case bipolar disorder, is probably the one most widely held by society as a whole. Nothing could be further from the truth. Generally speaking, the general public is extremely unaware of the origins and natures of psychiatric disorders. For many of our patients, what we will say in this session is going to be rather surprising. It will revolutionize their lives and change the way they understand their disorder and, consequently, the way they understand themselves as individuals. Session 2 is often very effective in combating the feelings of guilt that a lot of our patients feel, especially the ones that arise from a strictly psychologistic focus or come directly from dynamic orientation treatments. Procedure We begin the session, as we always do, with a warm-up phase, where we can simply ask patients how their week was, go over any questions they might have about the guidelines given in Session 1, joke around (“Are you up for this?”), and repeat the name game (see p. 59). This way the mood in the room will be pleasant when we begin the session. […]

Psychoeducation Manual for Bipolar Disorder: Psychoeducation program: sessions and contents

Although the mainstay of bipolar therapy is drug treatment, psychoeducation is a technique that has proven to be very effective as an add-on to medication, helping to reduce the number of all types of bipolar recurrences and hospitalization. The object is to improve patients’ understanding of the disorder and therefore their adherence to pharmacotherapy. Based on the highly successful, evidence-based Barcelona Program, this book is a pragmatic, therapist’s guide for how to implement psychoeducation for bipolar patients. It gives practical guidance for how to conduct a psychoeducation group, using sessions and cases drawn from the Barcelona Psychoeducation Program. Moreover, it provides the reader with a great amount of practical tips and tricks, and specific techniques to maximize the benefits of bipolar psychoeducation. The authors formed the first group to show the efficacy of psychoeducation as a maintenance treatment and have a long history of performing bipolar psychoeducation.

Psychoeducation Manual for Bipolar Disorder: Index

Although the mainstay of bipolar therapy is drug treatment, psychoeducation is a technique that has proven to be very effective as an add-on to medication, helping to reduce the number of all types of bipolar recurrences and hospitalization. The object is to improve patients’ understanding of the disorder and therefore their adherence to pharmacotherapy. Based on the highly successful, evidence-based Barcelona Program, this book is a pragmatic, therapist’s guide for how to implement psychoeducation for bipolar patients. It gives practical guidance for how to conduct a psychoeducation group, using sessions and cases drawn from the Barcelona Psychoeducation Program. Moreover, it provides the reader with a great amount of practical tips and tricks, and specific techniques to maximize the benefits of bipolar psychoeducation. The authors formed the first group to show the efficacy of psychoeducation as a maintenance treatment and have a long history of performing bipolar psychoeducation.