Posted by Bill LL on September 27, 2005, at 11:50:39
I thought that this article from Aug 2, 2005 was very interesting. I pasted a snipit from the article below. The article describes bp treatment protocols from the TIMA Bipolar Algorithms,the Canadian Network for Mood and Anxiety Treatment (CANMAT) Guidelines for the Management of Patients with Bipolar, and the Expert Consensus Guideline Series Treatment of Bipolar Disorder published by McGraw Hill in late 2004, led by Paul Keck MD of the University of Cincinnati.
http://www.mcmanweb.com/treating_bipolar_depression.htm
Here is an excerpt:
Ghaemi et al imply that the reward is not worth the risk. Four studies found that the tricyclics did not outperform lithium and another that lithium plus Paxil did no better than lithium alone. Also, discontinuing an antidepressant does not appear to pose the same kind of danger as it does for unipolar depression (17.6 percent of bipolar patients relapsing vs 83.3 percent of unipolar patients, according to one small study). Finally, Prozac poop-out appears to loom much larger for bipolar patients (a 57.5 percent relapse rate vs 18.4 percent for unipolar patients, according to another small study).
The picture may change, however, in the case of bipolar II, where mania by definition is not a feature of this shade of the illness, according to an article in the same issue of Bipolar Disorders by Jay Amsterdam MD and David Brunswick MD of the University of Pennsylvania. Moreover, it may be safe to administer an antidepressant to this population without a mood stabilizer, say the authors. In one small open study, 61 percent of the bipolar II patients and 51 percent of the unipolar patients responded to Prozac alone after 12 weeks. Only 3.8 percent of the bipolar II patients switched into hypomania during that period. The second phase of the study (this time double-blinded) found 78 percent of the bipolar II patients who got well on Prozac stayed well on the med over six months vs 67 percent of unipolar patients, with only 3.6 of the bipolar II patients switching into hypomania. Another small trial involving Effexor produced similar results.
Which antidepressants are the safest? A review article in the same issue by Joseph Goldberg MD of the Zucker Hillside Hospital (Long Island) and Christine Truman of the Payne Whitney Clinic (New York) reports that studies suggest Wellbutrin and Paxil have a lower risk than other antidepressants, but caution that the risk may have more to do with the individual patient than the particular drug. The authors also advise that clinicians should not routinely assume that a concurrent mood stabilizer will prevent antidepressant-induced mania. One study found that lithium or Depakote helped against tricyclic antidepressants, but not against SSRIs and MAOIs. Another study found lithium but not Depakote lowered switch rates while another study still found that mood stabilizers made no difference.
Lori Altshuler MD of UCLA in a grand rounds lecture delivered at UCLA in Jan 2003 suggested that the switch rates into mania attributed to antidepressants may in fact be the result of the natural course of the illness. She also called into question the APA's and TIMA's bias against continuing treatment with antidepressants after full response has been achieved.
In a study published in the July 2003 American Journal of Psychiatry, Dr Altshuler and colleagues examined data from the Stanley Foundation Bipolar Network (comprising six treatment locales in the US and Europe). Of the 549 bipolar patients who received antidepressants (with their mood stabilizers, it goes without saying), only 189 remained on these meds 60 days or more, and only 84 (44 percent) had a successful response, which is not exactly a ringing endorsement for antidepressants. Nevertheless, those who did respond to these meds were far better off staying on them, namely:
Seventy-one percent of those who discontinued their antidepressants before six months had a relapse into depression after 12 months compared to 57 percent who stayed on their antidepressants between six and 12 months, and to 29 percent who at follow-up stayed on their antidepressants for more than a year. Equally as significant, the 18 percent who switched into mania were equally divided among the three groups, suggesting the antidepressants had little or no role.
“Discontinuing people’s antidepressants after they get better,” Dr Altshuler concluded, “puts them at serious risk for depression relapse,” a greater danger, she asserted, than that posed by antidepressant-induced mania.
Nevertheless, it needs to be emphasized that Dr Altshuler is talking about a very small population, about 15 percent of bipolar patients. At a symposium at the 2003 APA meeting, Dr Ghaemi acknowledged there is a small percentage of bipolar patients who would benefit from staying on their antidepressants, so here, at least, there is some form of consensus. The problem, of course, is we don't know which 15 percent of bipolar patients would benefit from antidepressants.
Experimental Meds
An 2004 NIMH double-blind study of 21 depressed bipolar II patients found 60 percent of those taking the dopamine agonist pramipexole (Mirapex), used for treating Parkinson’s, achieved a therapeutic response vs nine percent in the placebo group. One subject on the drug and two on the placebo developed hypomania.
Conclusion
In 2004, Lamictal earned $1 billion in sales worldwide, a rise of 32 percent over the previous year. In the US, sales went up 49 percent, which the manufacturer GSK attributed to the FDA indication. By contrast, Symbyax, barely caused a ripple at $70 million. Part of the explanation could be that Lamictal was seen as unique, with a clearly novel action that gave hope to those who had failed on other meds. Symbyax, by contrast, was cake mix, the packaging of two common ingredients. Perhaps psychiatrists prefer to bake from scratch. Eli Lilly is hardly crying poor, however. Zyprexa earned $4.4 billion in sales in 2004, though how much of this is attributable to bipolar depression is impossible to say.
Lamictal shows all the signs of becoming the equivalent to the next Prozac, with the atypicals in the hunt and no one ready to abandon the antidepressants. But these are all hand-me-down meds intended for different illnesses. CANMAT, TIMA, and the Expert Consensus represent encouraging efforts at getting the most out of what we’ve got, but even a master chef is only as good as his ingredients.
It could be a long wait. In the meantime, establish a good working relationship with your psychiatrist and therapist, learn suitable coping skills, make smart lifestyle choices, and develop a reliable support network. Be well.
For free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.
poster:Bill LL
thread:560188
URL: http://www.dr-bob.org/babble/20050927/msgs/560188.html