Are all antidepressants the same? The consumer has a point.

BACKGROUND: Although a large variety of antidepressants agents (AD) with different mechanisms of action are available, no significant differences in efficacy and safety have been shown. However, there have been few attempts to incorporate data on subjective experiences under different AD. METHOD: We conducted a qualitative and quantitative analysis of the posts from the website www.askapatient.com from different AD. We reviewed a random sample of 1000 posts. RESULT: After applying the inclusion and exclusion criteria, we included a final sample of 450 posts, 50 on each of the most used AD: sertraline, citalopram, paroxetine, escitalopram, fluoxetine, venlafaxine, duloxetine, mirtazapine, and bupropion. Bupropion, citalopram, and venlafaxine had the higher overall satisfaction ratings. Sertraline, paroxetine, and fluoxetine had high reports of emotional blunting, while bupropion very few. Overall satisfaction with AD treatment was inversely associated with the presence of the following side-effects: suicidality, irritability, emotional blunting, cognitive disturbances, and withdrawal symptoms. After adjusting for confounders, only emotional blunting was shown to be more frequently reported by users of serotonergic agents, as compared to non-serotoninergic agents. CONCLUSION: This research points out that the subjective experience of patients under treatment should be taken into consideration when selecting an AD as differences between agents were evident. In contrast to the more frequent treatment decisions, users might prefer receiving a non-serotoninergic agent over a serotonergic one due to their lower propensity to produce emotional blunting.

Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report.

OBJECTIVES: Despite the growing numbers and proportion of older adults with bipolar disorder (OABD), there are very limited guidelines for the use of lithium with its double-edged potential for effectiveness and toxicity in this population. The primary aims of this Delphi survey were: (a) To determine the place of lithium among the preferred choices for maintenance treatment of OABD. (b) To provide detailed clinical guidelines for the safe and effective use of lithium in OABD. METHODS: In the face of limited evidence, the Delphi survey method was used to achieve consensus by a group of 25 experts in OABD from nine countries. An oversight committee monitored and analyzed the results of each survey and formulated more focused questions with each subsequent iteration. RESULTS: A 100% response rate was achieved for all three iterations of the survey. Lithium was the preferred choice for maintenance monotherapy in OABD. Serum levels of 0.4-0.8 mmol/L were recommended for ages 60-79 and serum levels of 0.4-0.7 mmol/L were recommended for ages 80 and over. Specific recommendations achieved consensus for second line monotherapy as well as for other drugs to be used in combination with lithium if necessary. Guidelines for routine monitoring of lithium in OABD were provided for laboratory investigations and clinical assessments. CONCLUSIONS: Lithium remains the preferred choice for maintenance monotherapy in OABD. Laboratories should report the therapeutic range for serum levels of lithium separately for older adults.

How Argentina is training their mental health residents to face its Silver Tsunami?

In low- and middle-income countries, there is an increase in the percentage of aging population similar to or greater than that of high-income countries (World Population Ageing 1950-2050, UN, 2001). The emerging health and economical challenges due to these demographic changes will have to be addressed by their health systems. In this context, an adequate training of available human resources in geriatric psychiatry/psychogeriatrics (GP/PG) should be an essential step to meet those challenges.

Longitudinal relationship between clinical course and neurocognitive impairments in bipolar disorder.

BACKGROUND: The aim of this study was to estimate the relationship between clinical course and trajectory of neurocognitive functioning during a follow-up period in a sample of euthymic bipolar patients. METHODS: Fifty-one patients with BD performed two-neurocognitive assessment separated by a period of at least 48 months. The clinical course during the follow-up period was documented by: three measures 1) number of affective episodes, 2) time spent ill, and 3) mood instability. RESULTS: Patients were followed-up for a mean period of 73.21 months. Neurocognitive performance tended to be stable throughout the follow-up. Performance in verbal memory and executive functions at the end of study were related with the number of hypo/manic episodes and time spent with hypo/manic symptoms during the follow-up. None of the clinical measures considered were related to changes in neurocognitive performance over the follow-up period. LIMITATIONS: The relatively small sample size limits the value of subgroup analysis. The study design does not rule out some risk of selection bias. CONCLUSIONS: Although there may be a positive relationship between number of episodes and neurocognitive deficits in patients with bipolar disorder, successive episodes do not seem to modify the trajectory of neurocognitive functioning over time. Theoretical implications of these findings are discussed.

Measurement tools for assessment of older age bipolar disorder: A systematic review of the recent global literature.

OBJECTIVES: More than 50% of people with bipolar disorder will be age 60 years or older by 2030. There is a need for more data to guide assessment and treatment in older age bipolar disorder (OABD); however, interpretation of findings from small, single-site studies may not be generalizable and there are few large trials. As a step in the direction of coordinated large-scale OABD data collection, it is critical to identify which measurements are currently used and identify potential gaps in domains typically assessed. METHODS: An international group of OABD experts performed a systematic literature review to identify studies examining OABD in the past 6 years. Relevant articles were assessed to categorize the types of clinical, cognitive, biomarker, and neuroimaging OABD tools routinely used in OABD studies. RESULTS: A total of 53 papers were identified, with a broad range of assessments. Most studies evaluated demographic and clinical domains, with fewer studies assessing cognition. There are relatively few biomarker and neuroimaging data, and data collection methods were less comprehensively covered. CONCLUSION: Assessment tools used in the recent OABD literature may help to identify both a minimum and a comprehensive dataset that should be evaluated in OABD. Our review also highlights gaps where key clinical outcomes have not been routinely assessed. Biomarker and neuroimaging assessment could be further developed and standardized. Clinical data could be combined with neuroimaging, genetic, and other biomarkers in large-scale coordinated data collection to further improve our understanding of OABD phenomenology and biology, thereby contributing to research that advances care.

Neurocognitive heterogeneity in older adults with bipolar disorders.

The aim of this study was to estimate the prevalence of clinically significant cognitive deficits in a sample of euthymic older age bipolar disorder (OABD) patients, and its relationship with functional outcome. Sixty-six outpatients and 30 controls completed a neuropsychological battery and a measure of psychosocial functioning. There were 33.3% (CI95% 22-44%) of patients without clinically significant cognitive deficits, 36.4% (CI95% 24-48%) with selective deficits, and 30.3% (CI95% 19-41%) with global deficits. Patients without cognitive deficits were indistinguishable of healthy controls in terms of psychosocial functioning, while patients with cognitive impairments had lower functional outcome. Neurocognitive and psychosocial functioning might be heterogeneous among patients with OABD.

Claiming the validity of scientific evidence in post-truth times.

This letter is written in response to a review recently published in the journal. The aim is to highlight a potential methodological limitation common to many studies comparing bipolar patients with few previous episodes versus those with multiple episodes, and in which the results are interpreted as indicating the longitudinal course of the illness.

Functional Outcome in the Middle Course of Bipolar Disorder: A Longitudinal Study.

The aim of this study was to assess the long-term functional outcome of patients with bipolar disorder (BD). At baseline and after a follow-up period of at least 48 months, three measures of functioning were administered: psychosocial functioning (GAF), employment status (full-time, part-time, and unemployment/disability), and a self-reported measure of functional recovery. At baseline, patients with more than five previous affective episodes exhibited poorer outcomes on all measures of functioning than patients with less than five previous episodes. However, along a mean follow-up period of 77 months, measures of functioning tended to remain stable or improved slightly. These results highlight the limitation of studies comparing measures of functioning between patients with many and few episodes to evaluate functional outcome. Likewise, these preliminary results do not support the hypothesis that functional outcome deteriorates over the course of BD.

Parkinsonian motor impairment predicts personality domains related to genetic risk and treatment outcomes in schizophrenia.

Identifying endophenotypes of schizophrenia is of critical importance and has profound implications on clinical practice. Here we propose an innovative approach to clarify the mechanims through which temperament and character deviance relates to risk for schizophrenia and predict long-term treatment outcomes. We recruited 61 antipsychotic naïve subjects with chronic schizophrenia, 99 unaffected relatives, and 68 healthy controls from rural communities in the Central Andes. Diagnosis was ascertained with the Schedules of Clinical Assessment in Neuropsychiatry; parkinsonian motor impairment was measured with the Unified Parkinson's Disease Rating Scale; mesencephalic parenchyma was evaluated with transcranial ultrasound; and personality traits were assessed using the Temperament and Character Inventory. Ten-year outcome data was available for ~40% of the index cases. Patients with schizophrenia had higher harm avoidance and self-transcendence (ST), and lower reward dependence (RD), cooperativeness (CO), and self-directedness (SD). Unaffected relatives had higher ST and lower CO and SD. Parkinsonism reliably predicted RD, CO, and SD after correcting for age and sex. The average duration of untreated psychosis (DUP) was over 5 years. Further, SD was anticorrelated with DUP and antipsychotic dosing at follow-up. Baseline DUP was related to antipsychotic dose-years. Further, 'explosive/borderline', 'methodical/obsessive', and 'disorganized/schizotypal' personality profiles were associated with increased risk of schizophrenia. Parkinsonism predicts core personality features and treatment outcomes in schizophrenia. Our study suggests that RD, CO, and SD are endophenotypes of the disease that may, in part, be mediated by dopaminergic function. Further, SD is an important determinant of treatment course and outcome.

The effect of premorbid intelligence on neurocognitive and psychosocial functioning in bipolar disorder.

BACKGROUND: The aim of this study was to assess if premorbid IQ moderates the association between measures of clinical severity and neurocognitive or psychosocial functioning in euthymic patients with bipolar disorder. METHODS: One hundred and nineteen outpatients and forty healthy controls were included. The length of illness, number of previous hypo/manic and depressive episodes, episode density, and history of psychosis assessed clinical severity. Performances in verbal memory, attention, and executive functions, as well as level of psychosocial functioning were used as outcomes. RESULTS: The negative relationship between number of hypo/manic episodes and performance in executive functions decreased as a function of higher values of premorbid IQ. No other influences of premorbid IQ were found in the association between clinical severity measures and neurocognitive and psychosocial functioning. CONCLUSIONS: Premorbid IQ might moderate the relationship between the number of hypo/manic episodes and executive functioning in bipolar disorder. Possible interpretations of this finding are discussed.

Neuropsychological profiles of major depressive disorder and bipolar disorder during euthymia. A systematic literature review of comparative studies.

Bipolar disorder and major depressive disorder have been shown to be associated with neurocognitive abnormalities during periods of clinical remission. However, at present, there is no consensus on whether these disorders have distinctive cognitive profiles. The aim of this study was to provide an updated systematic review of studies comparing neuropsychological functioning between bipolar disorder and major depressive disorder during remission. Main findings included the following: 1) no differences regarding performances in measures of attention and processing speed, executive functions and theory of mind were found between both patient groups and 2) regarding verbal memory, preliminary evidence points towards a more defective performance in patients with bipolar disorder than those with major depressive disorder. However, several variables with negative impact on cognition (medication status, age at onset, premorbid IQ, bipolar subtype, among others) were not adequately controlled in most studies. In conclusion, evidence from studies exploring neuropsychological profiles in bipolar disorder and major depressive disorder could not provide clues to differentiate these mood disorders. Larger studies with adequate control of confounding variables would be necessary to elucidate if the finding of more defective verbal memory performance in bipolar disorder is truly explained by distinct underlying mechanisms.

Stability of facial emotion recognition performance in bipolar disorder.

The aim of this study was to assess the performance in emotional processing over time in a sample of euthymic patients with bipolar disorder (BD). Performance in the facial recognition of the six basic emotions (surprise, anger, sadness, happiness, disgust, and fear) did not change during a follow-up period of almost 7 years. These preliminary results suggest that performance in facial emotion recognition might be stable over time in BD.

Do current national and international guidelines have specific recommendations for older adults with bipolar disorder? A brief report.

OBJECTIVE: Older adults with bipolar disorder (OABD) are a growing segment of patients with bipolar disorder (BD) for which specific guidelines are warranted. Although, OABD are frequently excluded from randomized controlled trials due to their age or somatic comorbidity, more treatment data from a variety of sources have become available in recent years. It is expected that at least some of this emerging information on OABD would be incorporated into treatment guidelines available to clinicians around the world. METHODS: The International Society of Bipolar Disorders OABD task force compiled and compared recommendations from current national and international guidelines that specifically address geriatric or older individuals with BD (from year 2005 onwards). RESULTS: There were 34 guidelines, representing six continents and 19 countries. The majority of guidelines had no separate section on OABD. General principles for treating OABD with medication are recommended to be similar to those for younger adults, with special caution for side effects due to somatic comorbidity and concomitant medications. Therapeutic lithium serum levels are suggested to be lower but recommendations are very general and mostly not informed by specific research evidence. CONCLUSIONS: There is a lack of emphasis of OABD-specific issues in existing guidelines. Given the substantial clinical heterogeneity in BD across the life span, along with the rapidly expanding population of older individuals worldwide, and limited mental health workforce with geriatric expertise, it is critical that additional effort and resources be devoted to studying treatment interventions specific to OABD and that treatment guidelines reflect research findings. Copyright © 2016 John Wiley & Sons, Ltd.

Behavioral and emotional adverse events of drugs frequently used in the treatment of bipolar disorders: clinical and theoretical implications.

BACKGROUND: Behavioral and emotional adverse events induced by drugs commonly prescribed to patients with bipolar disorders are of paramount importance to clinical practice and research. However, no reviews on the topic have been published so far. METHODS: An extensive search was performed. Reports were reviewed if they described behavioral side effects related to pharmacological treatments for bipolar disorders in healthy subjects or patients with different neuropsychiatric disorders. For this review, lithium, antipsychotics, anticonvulsants and selective serotonin reuptake inhibitors were included. RESULTS: Apathy or emotional blunting, diminished sexual desire, and inability to cry were reported to be associated with exposure to selective serotonin reuptake inhibitors. Neuroleptic-induced deficit syndrome/emotional detachment and obsessive-compulsive symptomatology and decision-making modifications. A lithium-related amotivational syndrome was also reported in the literature. Furthermore, hypersexuality and obsessive-compulsive symptoms have been noted in subjects treated with lamotrigine. LIMITATIONS: Primary studies on drug-related adverse events are scant so far and most of the data currently available derive from case reports. Moreover, most of the evidence reviewed is based on studies performed on healthy subjects and patients with neuropsychiatric conditions other than bipolar disorders. DISCUSSION: There is a remarkable dearth of data on behavioral adverse events of pharmacological treatment for bipolar disorders. However, the pieces of evidence available at present, though scant and scattered, suggest that different behavioral adverse events may be related to pharmacological treatment for these disorders. The implications of these findings for research and management of patients with mood disorders are discussed.