Department of Psychiatry, Pharmacology, Neurobiology and Bio-technology,
University of Pisa, via Roma 67, 56100 Pisa, Italy. s.pini@psico.med.unipi.it
BACKGROUND: The present study examined whether specific types of comorbid
anxiety disorders, namely panic disorder (PD), social phobia (SP) and
obsessive-compulsive disorder (OCD) are differentially associated with course
variables and insight into bipolar illness. METHOD: The sample consisted of 151
consecutively hospitalized patients with bipolar I disorder. They were assessed
in the week prior to discharge using the Structured Clinical Interview for
DSM-III-R (SCID-P), the Brief Psychiatric Rating Scale (BPRS), the Global
Assessment of Functioning Scale (GAF) and the Hopkins Symptom Checklist
(HSCL-90). Level of insight was assessed with the Scale to assess Unawareness of
Mental Disorders (SUMD). RESULTS: Of the 151 bipolar subjects, 92 had no PD, SP
and OCD comorbidity, 35 had PD and 24 had SP and/or OCD. The three groups
differed significantly on the current awareness of illness and treatment
response scores and the retrospective awareness of illness and treatment
response scores. Post-hoc analyses revealed that, compared with bipolar patients
without PD/SD/OCD and those with comorbid PD, patients with comorbid SP and/or
OCD had better insight on current awareness of illness, current awareness of
treatment response, retrospective awareness of illness and retrospective
awareness of treatment response. The regression analysis showed that the
presence of no panic type anxiety comorbidity was a predictor of good insight.
CONCLUSIONS: These data indicate the value of identifying comorbid anxiety
disorders in patients with bipolar illness. The results could be interpreted as
evidence of discrete disorders within the bipolar spectrum, one that is
characterized by, among other things, SP and/or OCD with good insight, another
characterized by PD with poor insight.
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Monday, November 5, 2007
Antidepressants in bipolar disorder: the case for caution
Bipolar Disorder Research Program, Cambridge Hospital, Cambridge, MA and Harvard Medical School, Boston, MA 02139, USA. ghaemi@hms.harvard.edu
The 2002 American Psychiatric Association (APA) guidelines for the treatment of bipolar disorder recommended more conservative use of antidepressants. This change in comparison with previous APA guidelines has been criticized, especially from some groups in Europe. The Munich group in particular has published a critique of assumptions underlying the conservative recommendations of the recent APA treatment guidelines. In this paper, we re-examine the argument put forward by the Munich group, and we demonstrate that indeed, conceptually and empirically, there is a strong rationale for a cautious approach to antidepressant use in bipolar disorder, consistent with, and perhaps even more strongly than, the APA guidelines. This rationale is based on support for the following four propositions: (i) The risk of antidepressant induced mood-cycling is high, (ii) Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, whereas lithium has, (iii) Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression and have been shown to be less effective than mood stabilizers in preventing depressive relapse in bipolar disorder and (iv) Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. We therefore draw three conclusions from this interpretation of the evidence: (i) There are significant risks of mania and long-term worsening of bipolar illness with antidepressants, (ii) Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases and (iii) Antidepressants should be discontinued after recovery from the depressive episode, and maintained only in those who repeatedly relapse after antidepressant discontinuation (a minority we judge to represent only about 15-20% of bipolar depressed patients).
The 2002 American Psychiatric Association (APA) guidelines for the treatment of bipolar disorder recommended more conservative use of antidepressants. This change in comparison with previous APA guidelines has been criticized, especially from some groups in Europe. The Munich group in particular has published a critique of assumptions underlying the conservative recommendations of the recent APA treatment guidelines. In this paper, we re-examine the argument put forward by the Munich group, and we demonstrate that indeed, conceptually and empirically, there is a strong rationale for a cautious approach to antidepressant use in bipolar disorder, consistent with, and perhaps even more strongly than, the APA guidelines. This rationale is based on support for the following four propositions: (i) The risk of antidepressant induced mood-cycling is high, (ii) Antidepressants have not been shown to definitively prevent completed suicides and reduce mortality, whereas lithium has, (iii) Antidepressants have not been shown to be more effective than mood stabilizers in acute bipolar depression and have been shown to be less effective than mood stabilizers in preventing depressive relapse in bipolar disorder and (iv) Mood stabilizers, especially lithium and lamotrigine, have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes. We therefore draw three conclusions from this interpretation of the evidence: (i) There are significant risks of mania and long-term worsening of bipolar illness with antidepressants, (ii) Antidepressants should generally be reserved for severe cases of acute bipolar depression and not routinely used in mild to moderate cases and (iii) Antidepressants should be discontinued after recovery from the depressive episode, and maintained only in those who repeatedly relapse after antidepressant discontinuation (a minority we judge to represent only about 15-20% of bipolar depressed patients).
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