J.M. Montes

New treatment guidelines for acute bipolar mania: A critical review

A number of treatment guidelines for bipolar disorder have been published and updated in the last few years. They are aimed at providing a synthesis of the best available scientific knowledge, and their application to every-day work should be helpful to clinicians. The aim of this report is to critically review recent guidelines focusing on the treatment of manic/hypomanic and mixed episodes. Guidelines are quite heterogeneous in methodology and conclusions, but they all agree that the treatment of manic/hypomanic and mixed episodes should generally be initiated with a medication such as lithium (Li), valproate (VPA) or atypical antipsychotics (AAP), including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone as monotherapy. All guidelines agree on stopping ongoing antidepressant medication during mania. Combination therapy including Li or VPA with an AAP is suggested usually as second-line choice, sometimes as first-choice treatment for severe mania. Carbamazepine is mostly suggested as second line and not recommended in combination. Other antiepileptic drugs are not recommended for the treatment of mania, although lamotrigine may be maintained if it was prescribed previously for the prevention of depressive episodes. Main sources of discrepancies among guidelines include benefit-risk ratio issues (how much priority is given to efficacy over safety and tolerability), starting with combination versus monotherapy, and how to deal with treatments which are more experience-based than evidence-based (i.e.: electroconvulsive therapy).

Theory of mind deficit in bipolar disorder: Is it related to aprevious history of psychotic symptoms?

It has been hypothesized that a Theory of Mind (ToM) deficit could be a vulnerability marker for psychosis. Recent studies, however, have shown ToM deficits in affective relapses of bipolar disorder as well as in the euthymic phase. This study analyzes the relationship between ToM and a previous history of psychotic symptoms in bipolar disorder. ToM, sustained attention and executive functions were analyzed in 75 bipolar euthymic patients with three or more previous relapses (42 of them had a history of psychotic symptoms and 33 did not) and 48 healthy subjects. ToM was assessed with the Advanced Test by Happé. ToM performance was similar in bipolar patients with or without a history of psychotic symptoms, and in both cases it was significantly reduced as compared with the healthy control group. Similarly, both bipolar groups showed impaired sustained attention and executive functions. This general cognitive deficit partially explains the differences obtained in ToM. The ToM instrument used shows low sensitivity for assessing ToM in bipolar patients and it could partially reflect general cognitive functioning rather than a specific deficit in psychosis. ToM deficit is not a trait marker for psychosis, given that it is present in bipolar disorder regardless of a previous history of psychotic symptoms.

A short message service (SMS)-based strategy for enhancing adherence to antipsychotic medication in schizophrenia

BACKGROUND The aim of this study was to assess the impact of a short message service (SMS)-based strategy on adherence to antipsychotic treatment. METHODS A multicentre, randomised, open-label, controlled, 6-month study with clinically stabilised outpatients with schizophrenia was conducted. The patients assigned to the intervention received daily SMS reminders to take their medication for 3 months. Self-reported medication adherence was determined using the Morisky Green Adherence Questionnaire (MAQ). Secondary outcomes were severity of illness, attitude towards medication, insight into illness and health-related quality of life. RESULTS A total of 254 patients were analysed. A significantly greater improvement in adherence was observed among patients receiving SMS text messages compared with the control group. The mean change in MAQ total score from baseline to month 3 was -1.0 (95% confidence interval (CI) -1.02, -0.98) and -0.7 (95%CI -0.72, -0.68), respectively (P=0.02). Greater improvement in negative, cognitive and global clinical symptoms at month 3 was observed. Attitude towards medication also significantly improved across the study in the intervention group versus the controls. CONCLUSIONS An SMS-based intervention seems feasible and acceptable for enhancing medication adherence. Further studies are needed to confirm whether this kind of intervention could be a complementary strategy to optimise adherence in schizophrenia.

Social cognition and interaction training (SCIT) for outpatients with bipolar disorder

INTRODUCTION Patients with bipolar disorder show social cognition deficits during both symptomatic and euthymic phases of the illness, partially independent of other cognitive dysfunctions and current mood. Previous studies in schizophrenia have revealed that social cognition is a modifiable domain. Social cognition and interaction training (SCIT) is an 18-week, manual-based, group treatment designed to improve social functioning by way of social cognition. METHOD 37 outpatients with DSM-IV-TR bipolar and schizoaffective disorders were randomly assigned to treatment as usual (TAU)+SCIT (n=21) or TAU (n=16). Independent, blind evaluators assessed subjects before and after the intervention on Face Emotion Identification Task (FEIT), Face Emotion Discrimination (FEDT), Emotion Recognition (ER40), Theory of Mind (Hinting Task) and Hostility Bias (AIHQ). RESULTS Analysis of covariance revealed significant group effects for emotion perception, theory of mind, and depressive symptoms. The SCIT group showed a small within-group decrease on the AIHQ Blame subscale, a moderate decrease in AIHQ Hostility Bias, a small increase in scores on the Hinting Task, a moderate increase on the ER40, and large increases on the FEDT and FEIT. There was no evidence of effects on aggressive attributional biases or on global functioning. LIMITATION No follow up assessment was conducted, so it is unknown whether the effects of SCIT persist over time. CONCLUSION This trial provides preliminary evidence that SCIT is feasible and may improve social cognition for bipolar and schizoaffective outpatients.

Cardiovascular risk in patients with bipolar disorder.

BACKGROUND To date, little is known about cardiovascular risk (CVR) in terms of coronary heart disease (CHD) and cardiovascular mortality risk (CMR) in patients with bipolar disorder. This study provides data on the overall risk of any fatal or non-fatal coronary heart disease (CHD) and on the cardiovascular mortality risk (CMR) within 10 years in these patients. METHODS Naturalistic, cross-sectional, multicenter study conducted in Spain. Patients were evaluated for cardiovascular risk using the Framinghan function (CHD) and the Systematic COronary Risk Evaluation (SCORE) function (CMR). RESULTS The mean age was 46.6 years and 49% were male. Forty-six percent were in remission. Ten-year CHD risk was 7.6% (males 10.2% versus females 4.7%, p<0.001) and 10-year CMR was 1.8% (males 2.2% versus females 1.3%, p 0.161). Fifty-one percent smoked and 34% was obese. Metabolic syndrome was present in 22.4% of the sample (35.6% according to AHA and NHLBI criteria). Cardiovascular risk significantly increases with age, body mass index and presence of metabolic syndrome. LIMITATIONS The cross-sectional design of the study. CONCLUSIONS Cardiovascular risk is high in patients with bipolar disorder. It is associated with age, body mass index and metabolic syndrome. Psychiatrists should be aware of this issue and carefully monitor these patients for cardiovascular risk factors, including cigarette smoking, as part of the standard of care when treating them.

Risk factors for suicide in schizophrenia: systematic review and clinical recommendations.

To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence.

Social cognition and global functioning in bipolar disorder.

Abstract The purpose of this study was to assess the role of social cognition, together with other relevant clinical variables and measures of general cognition, in the global functioning of euthymic bipolar patients. Thirty-nine euthymic outpatients fulfilling DSM-IV-TR criteria for bipolar disorder type I or II were recruited and were divided in two groups: high (n = 19) and low (n = 20) global functioning. Both groups’ performance was compared in verbal and nonverbal social cognition (Faux pas test and Facial Emotion Recognition test), sustained attention and executive function. The low-functioning group showed a significant impairment in both verbal and nonverbal measurements of social cognition compared with the high-functioning group. Globally, both bipolar groups showed a significant impairment in facial emotion recognition compared with a similar sample of healthy volunteers. Social cognition may play a significant role in the clinical-functional gap of bipolar patients.

Functional cerebral asymmetry in affective disorders: new facts contributed by transcranial magnetic stimulation

A growing body of experimental data usually finds a slightly lower activation in the left hemisphere than in the right in depressive syndromes, whereas the opposite occurs in mania. Transcranial magnetic stimulation (TMS) seems to have a distinctive lateralized effect with manic or depressed patients. These clinical findings provide new elements for discussion of the significance of unbalanced hemispherical activation as a biological substrate in affective disorders. Based on these data and on the theories of chaos and complexity, a hypothesis for the physiopathology of affective disorders and the functional mechanism of TMS is proposed. This hypothesis is in agreement with valence theory.

Consenso Español de Salud Física del Paciente con Trastorno Bipolar

Resumen Introduccion y objetivos Los pacientes con trastorno bipolar presentan una morbilidad fisica y una mortalidad muy superior a la de la poblacion general. Ademas de una mayor mortalidad por suicidio, tienen tambien una mayor prevalencia de enfermedades fisicas. El objetivo de este consenso, promovido por las Sociedades Espanolas de Psiquiatria y Psiquiatria Biologica, en colaboracion con las sociedades de medicos de asistencia primaria, es establecer recomendaciones practicas sobre los procedimientos de deteccion, prevencion e intervencion en las enfermedades somaticas que coexisten con el trastorno bipolar para mejorar la calidad y esperanza de vida de estos pacientes. Metodo Las Sociedades Espanolas de Psiquiatria y Psiquiatria Biologica eligieron un Comite Cientifico que selecciono a su vez a 32 psiquiatras expertos y 10 medicos expertos en otras especialidades medicas. Se crearon grupos de trabajo para cada especialidad con la finalidad de adaptar las guias aplicadas en la poblacion general a pacientes con trastorno bipolar. Partiendo de una revision sistematica sobre la comorbilidad medica y la mortalidad en el trastorno bipolar se realizaron dos reuniones para acordar el consenso. Resultados En la revision bibliografica se detecto un riesgo aumentado, entre los pacientes con trastorno bipolar, de presentar hipertension arterial, obesidad, tabaquismo, enfermedades pulmonares, migrana e infeccion por virus de la inmunodeficiencia humana (VIH). Tambien se encontro evidencia de un aumento de mortalidad por enfermedades cardiovasculares, respiratorias e infecciones, ademas del suicidio. El grupo de expertos alcanzo el consenso en una serie de medidas basicas para la deteccion de comorbilidad medica aplicables a la monitorizacion de estos pacientes. Las recomendaciones resultantes seran asumidas y divulgadas por las sociedades promotoras. Conclusiones El decalogo generado en el Consenso Espanol de Salud Fisica del Paciente con Trastorno Bipolar recoge los aspectos mas relevantes para la mejora del funcionamiento psicosocial, la calidad y la esperanza de vida en los pacientes con esta patologia.

Suboptimal treatment adherence in bipolar disorder: impact on clinical outcomes and functioning

Background The primary aim of this study was to assess drug treatment adherence in patients with bipolar disorder and to identify factors associated with adherence. The secondary aim was to analyze the impact of suboptimal adherence on clinical and functional outcomes. Methods A cross-sectional study was conducted in a sample of outpatients receiving an oral antipsychotic drug. Medication adherence was assessed combining the 10-item Drug Attitude Inventory, the Morisky Green Adherence Questionnaire, and the Compliance Rating Scale. Logistic regression was used to determine significant variables associated with suboptimal adherence to medication. Results Three hundred and three patients were enrolled into the study. The mean age was 45.9 ± 12.8 years, and 59.7% were females. Sixty-nine percent of patients showed suboptimal adherence. Disease severity and functioning were significantly worse in the suboptimal group than in the adherent group. Multivariate analysis showed depressive polarity of the last acute episode, presence of subsyndromal symptoms, and substance abuse/dependence to be significantly associated with suboptimal treatment adherence (odds ratios 3.41, 2.13, and 1.95, respectively). Conclusion A high prevalence of nonadherence was found in an outpatient sample with bipolar disorder. Identification of factors related to treatment adherence would give clinicians the opportunity to select more adequately patients who are eligible for potential adherence-focused interventions.