Lithium salts in bipolar disorder: a prospective naturalistic study on 234 outpatients

Bipolar disorder (BD) is a chronic mood disorder characterized by recurrent manic, hypomanic, depressive and mixed episodes. The main goal of maintenance treatment of bipolar disorder is stabilizing mood and reducing inter-episodic symptoms. Lithium salts are the gold standard for acute and long-term management of bipolar disorder because of its prophylactic and antisuicidal properties. The aim of our prospective naturalistic study was to examine the clinical characteristics and the course of illness in a sample of 234 BD-I or BD-II outpatients treated with lithium salts or anti-epileptics drugs or with a combination of both. We studied a possible relationship between the kind of stabilization utilized and the characteristics of illness. Patients have been followed for a period of at least 8 months at Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa and at the Istituto di Psicopatologia in Rome. Patient enrollment criteria were age 18-65 years and meeting DSM IV criteria for BD-I or BD-II or Koukopoulos’s criteria for mixed attenuated episodes. We used the SCID-I / P, SIMD and the LIFE scale to evaluate the diagnostic, clinical and therapeutic aspects. We divided the 234 patients into three groups according to the different treatments utilized for long term stabilization of Bipolar disorder: 51 patients with Lithium only, 56 patients stabilized with anticonvulsant drugs and 127 patients stabilized with a combination of Lithium and anticonvulsant drugs. Our study highlights that Lithium and antiepileptic drugs combination was the most common treatment strategy used to stabilize patients in the sample. From our findings, patients taking lithium and anti-epileptics combination were more frequently affected by BD-I, had higher rates of mixed episodes in retrospective and prospective course, higher rates of lifetime psychotic symptoms, and showed higher rates of concomitant atypical antipsychotic prescription. Patients stabilized with anti-epileptics or lithium alone were more frequently BD-II, had higher rate of comorbidity and higher antidepressants concomitant prescription. No significant difference emerged according to the duration of the follow up period among the three groups of treatment, so that we could suppose the long-term tolerance of lithium associated with anti-epileptic drugs was similar to the tolerability expected by using a single mood stabilizer. Overall, in our study, patients on a combination therapy, had evidenced the major improvement measured as the difference between the medium frequency of relapses in retrospective and prospective course, rather than the other patients treated on a single mood stabilizer. Several limitations in the present study should be considered. The most important are its small sample, the lack of randomization and the absence of a placebo group which not permitted to evaluate and draw conclusions about the efficacy of the treatments. Further investigations are required to confirm the present study's results

Eating behaviours in bipolar patients and in 200 candidates for bariatric surgery: the role of mood disorders.

Background: Obesity is one of the most important multifactorial diseases of our time; it can be associated with many psychiatric disorders, one of the main is bipolar disorder (BD). Some of the elements that mediate the role of BD and obesity are problematic eating behaviours (PEB) such as emotional eating (EE), food addiction (FA), grazing (GZ) and night eating (NE). They are also studied in samples of candidates for bariatric surgery where they may affect their severe obesity. The main goal of the study is to investigate the presence of eating behaviours, in a sample of bipolar patients and in a sample of candidates for bariatric surgery, searching a correlation among them, the presence of impulsivity and BMI and analyzing the possible role of mood disorders. The secondary objective is to evaluate whether these features also occur in subjects who do not have a full-blown mood disorder but subthreshold symptoms of the mood spectrum. Methods: 50 euthymic bipolar patients (BD) and 200 subjects undergoing psychiatric evaluation before bariatric surgery (BS) were recruited at the University Hospital of Pisa. Patients were clinically interviewed and diagnoses were made according to DSM-5 criteria by means of structured clinical interview (SCID-5). Anamnestic informations were collected and a battery of psychometric tests was administered: Emotional Eating Scale (EES), Yale Food Addiction Scale (YFAS), Eating Disorder Inventory (EDI-2), Eating Disorder Questionnaire (EDE-Q), Night Eating Scale (NES), Grazing Questionnaire (GQ), Mood Spectrum Self-Report (MOOD-SR), Barratt Impulsive Scale (BIS). Results: The only PEB that correlated with BMI and with impulsivity was GZ. GQ correlated more strongly than the others with EDI-2 and EDE-Q. We divided BS in those with a mood disorder (MD, n=48) and those without (w/o MD, n=152), comparing scales between BD vs MD, BD vs w/o MD and MD vs w/o MD. We observed no difference for EE, FA, GZ in the three groups. Impulsivity was significantly greater in BD and MD vs w/o MD; NE was greater in BD and MD vs w/o MD while EDI-2 and EDE-Q were significantly greater in MD vs the other two groups. The correlation with MOOD-SR in the w/o MDs confirmed the connection of PEBs also with subthreshold symptoms of the mood spectrum, especially for the depressive or rhythmicity domains. Conclusions: These evidences show that bipolar and severely obese people have a high prevalence of PEB. In BD, GZ and impulsivity have the greatest relevance while in BS the presence of a mood disorder led to higher scores in all scales. PEB could have a major influence on obesity in patients with mood disorders and aggravate their psychopathology. On the contrary, the presence of a mood disorder (even if subthreshold) in obese subjects is an element to be carefully researched in so far as it worsens the seriousness and the post-surgical bariatric course, mainly because of its greater susceptibility to elements such as emotional eating, food addiction, high impulsivity, grazing and night eating, which can worsen the seriousness of the clinical picture, affect the response to bariatric surgery and the subsequent prognosis

Predictors of recurrence during long-term treatment of bipolar I and II disorders. A 4 year prospective naturalistic study

Background Despite the large number of treatments available for bipolar disorder (BD), more than one half of patients have a recurrence within 2 years, and over 90% experience at least one additional affective episode during their lifetime. Methods The aim of this study was to test the impact of a number of demographic and clinical features on the risk to recurrence in a real- word representative sample of 266 outpatients with BD-I or II treated in a naturalistic setting during a 4-years-follow-up period. Results We found that the number of episodes per year after study entry, compared to the number of episodes per year before study entry,significantly decreased and that about one third of patients had no recurrences during the observation period. The length of follow-up and the number of previous episodes, mainly depressive, predicted the risk of recurrence, while female gender, higher age at intake, and a higher frequency of past mixed episodes predicted a higher frequency of recurrences. Limitations The study had some limitations to consider: i.e. the risk of poor reliability of information on the previous course of illness or the naturalistic treatment during the follow-up. Conclusions Our study suggests that (a) an evidence-based long-term treatment, with regular follow-up visits could improve the course of disease and prognosis; (b) clinicians should carefully consider the presence of a high number of mixed episodes, to provide more targeted treatment strategies; (c) an appropriate use of antidepressants in selected patients did not worsen the course of illness