Antidepressants in bipolar disorder

Joseph F. Goldberg, MD Associate clinical professor, Department of psychiatry, Mount Sinai School of Medicine, New York, NY, Affective Disorders Research Program, Silver Hill Hospital, New Canaan, CT

Few topics are as controversial as the role of antidepressants for patients with bipolar disorder. Although depression usually is the predominant, most enduring mood state in bipolar disorder, clinicians often face uncertainty about using antidepressants because of concerns about safety and efficacy. Whether and when to use antidepressants for bipolar depression hinges on complex parameters that preclude any single, simple rule.

Rather than asking if antidepressants are useful or detrimental for depressed patients with bipolar disorder, a more practical question might be: Under what circumstances are antidepressants likely to be beneficial, deleterious, or ineffective for an individual patient? Because “real world” patients often have idiosyncrasies that defy practice guidelines’ generic treatment recommendations, clinicians who practice in the proverbial trenches need strategies to tailor treatments to each patient that are informed—but not dictated—by evidence-based research.

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Women's response to antidepressants

Wendy K. Marsh, MD, Assistant professor, Department of psychiatry, University of Massachusetts Medical School, Worcester, MA

Kristina M. Deligiannidis, MD, Assistant professor of psychiatry, Director, Depression Specialty Clinic, Center for Psychopharmacologic Research and Treatment, University of Massachusetts Medical School, Worcester, MA

Both men and women respond well to antidepressants, yet there are notable differences between the 2. Understanding why men and women may differ in response to antidepressants helps clinicians better tailor their treatment choice and dosing.

This article outlines some of differences—and lack thereof—in response rates to antidepressants. Our discussion of why these differences may occur is framed in the context of pharmacokinetics, pharmacodynamics, and the influence of gonadal hormones on antidepressant-related neurotransmitter systems. The second section focuses on major reproductive phases of adult women (the menstrual cycle, pregnancy, postpartum, and menopause) and how antidepressant response rates can influence clinical decision making, such as antidepressant timing, dose, and choice of potential adjunct treatments.

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Combination therapy is here to stay

Henry A. Nasrallah, MD
Editor-in-Chief

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses.

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2010 Psychopharmacology Update

A one-day psychopharmacology symposium

Save the date!

Saturday, October 23, 2010, 7:45 am – 5:00 pm
Kingsgate Marriott Conference Hotel*
Cincinnati, Ohio

Join us for this interactive, live symposium where nationally renowned faculty will address:

• Treatment Resistant Depression: A Multi-Functional Pharmacologic Approach
• The Philosophy, Process, and Application of Evidence-Based Psychopharmacology

Symposium Director
Henry Nasrallah, MD
Professor of Psychiatry and Neuroscience
University of Cincinnati College of Medicine

Faculty
Stephen M. Stahl, MD, PhD
Adjunct Professor of Psychiatry
University of California, San Diego

Leslie Citrome, MD, MPH
Professor of Psychiatry
New York University School of Medicine

*A discounted room rate will be available for participants of the Psychopharmacology Update.

Email Updates
To receive email updates about this conference directly to your inbox, please contact: kathy.wenzler@qhc.com

To receive a copy of the invitation to this conference please send your full name and address to: kathy.wenzler@qhc.com

Adjunctive anticonvulsants in alcohol withdrawal

David R. Spiegel, MD, Associate professor, Department of psychiatry and behavioral sciences, Director of consultation-liaison services, Eastern Virginia Medical School, Norfolk, VA

Daiana Radac, MD, Resident, Eastern Virginia Medical School, Norfolk, VA

Benzodiazepines are the mainstay of alcohol detoxification treatment, with extensive evidence supporting their efficacy and relative safety. The risk of benzodiazepine-alcohol interaction, however, and psychomotor and cognitive impairments associated with benzodiazepine use may limit early rehabilitation efforts in hospitalized patients. Cross-tolerance with alcohol also limits benzodiazepines’ potential benefit in outpatients with substance use disorders.

Adding anticonvulsants to acute benzodiazepine therapy has been shown to decrease alcohol withdrawal symptom severity, reduce seizure risk, and support recovery, particularly in patients with multiple alcohol withdrawal episodes. After detoxification, long-term anticonvulsant use may reduce relapse risk by decreasing post-cessation craving, without abuse liability.

Although not all studies endorse adding anticonvulsants to benzodiazepines for managing alcohol withdrawal syndrome (AWS), we present 3 cases in which anticonvulsants were used successfully as adjuncts to lorazepam. Valproic acid, levetiracetam, and gabapentin offer advantages in acute and long-term therapy of alcohol dependence with efficacy in AWS, low abuse potential, benign safety profile, and mood-stabilizing properties.

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PTSD and mood disorders

Steven C. Dilsaver, MD, Comprehensive Doctors Medical Group, Inc., Arcadia, CA

Major depressive disorder (MDD) and bipolar spectrum disorders are associated with some symptoms of—and fully defined—posttraumatic stress disorder (PTSD). Many traumatic experiences can lead to this comorbidity, the most common being exposure to or witnessing combat for men and rape and sexual molestation for women.Trauma has major prognostic and treatment implications for affectively ill patients, including those whose symptoms do not meet PTSD’s full diagnostic criteria.

This article aims to help clinicians by:

• presenting evidence characterizing the overlap between affective disorders and PTSD
• reviewing evidence that the bipolar spectrum may be broader than generally thought, an insight that affects PTSD treatment
• making a case for routine PTSD screening for all patients with affective illnesses
• recommending PTSD treatments tailored to the patient’s comorbid affective disorder

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A psychiatric manifesto

Henry A. Nasrallah, MD
Editor-in-Chief

Psychiatry is one of the most rapidly evolving medical disciplines. Its scientific foundation is neuroscience, which is growing at the most explosive pace in science. Yet the public and even other medical specialists still envision psychiatrists sitting behind a couch scribbling Freudian jargon on a yellow pad. For that reason, I propose that we create a manifesto that promulgates the basic tenets of psychiatry and make it a permanent, living document on CurrentPsychiatry.com.

So I present my initial iteration of a psychiatric manifesto here. I invite all readers and CurrentPsychiatry.com visitors to suggest valid additions and/or modifications. I will serve as the custodian and editor of the manifesto, in charge of its continuous update as a living document

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