Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017)

111 Pages·2017·1.49 MB·English

Copyedited by: oup
International Journal of Neuropsychopharmacology (2017) 20(2): 95–97
doi:10.1093/ijnp/pyx002
Editorial
EDITORIAL
Treatment Guidelines in Bipolar Disorders and the Importance of
Proper Clinical Trial Design
Mauricio Tohen
Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center,
Albuquerque, New Mexico.
Correspondence: Mauricio Tohen, MD, DrPH, MBA, Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center,
2400 Tucker Ave, Albuquerque, NM 87131, USA ([email protected]).
A working group led by Dr. Konstantinos Fountoulakis developed (http://clinicaltrials.gov and http://www.clinicalstudyresults.
the first International College of Neuropsychopharmacology org) as well as web pages of pharmaceutical companies with
(CINP) clinical guidelines for the treatment of Bipolar Disorders compounds used in bipolar disorder up to March 25, 2016.
in adult patients. Their work is very thoroughly described in The authors provide a critical analysis of the existing treat-
four separate papers (parts) included in this issue of the journal. ment grading methods that led them to determine that there
The first article is Background and Methods of the Development was no optimal method to grade treatments for bipolar disorder,
of Guidelines (Fountoulakis et al., 2017d); part 2 is Review, therefore creating their own grading system. Their methodology
Grading of the Evidence, and a Precise Algorithm (Fountoulakis provides 32 different levels of recommendations, starting with
et al., 2017c); part 3 is The Clinical Guidelines (Fountoulakis the optimal: “At least 1 positive 2 active arm RCT vs placebo
et al., 2017a); and Part 4 is Unmet Needs in the Treatment of exists, plus positive 1 active arm RCTs, and no negative RCTs.”
Bipolar Disorder and Recommendations for Future Research Lower level scenarios take into account posthoc reports, meta-
(Fountoulakis et al., 2017b). analyses, and failed trials. Different scenarios are ranked appro-
The background section provides a very comprehensive his- priately, as a different weight is given to the absence of evidence
torical review of bipolar disorder going back 5000 years, including than to the presence of negative data.
its natural course of illness, phenomenology, and development A 5-level composite treatment recommendation was cre-
of treatments. ated that combines efficacy and safety/tolerability, which is a
The CINP guidelines are unique, as they include additional thoughtful approach. An important and reasonable considera-
recommendations for specific clinical characteristics such as tion made by the group was to give a higher weight for safety
agitation, predominant polarity, mixed features, and rapid than for efficacy. For instance, a level 1 recommendation
cycling course. Furthermore, guidelines are also provided for requires level 1 for safety/tolerability but can include level 1 or 2
nonpharmacological treatments. for efficacy. This can lead to treatments of superior efficacy but
The authors clearly describe their approach on grading arti- lower tolerability being ranked lower; level 5 is reserved for “not
cles from the scientific literature, and methods for the devel- recommended.”
opment of guidelines. The guidelines were developed by an Guidelines are provided for each of the major phases of bipo-
evidence-based consensus approach primarily based on placebo lar disorder; a novel approach is emphasizing the importance of
or active comparator randomized controlled trials (RCTs) but considering the maintenance phase when treatments are rec-
also taking into consideration posthoc analysis reports, related ommended during the acute phases.
meta-analyses, and other treatment guidelines as well as the Comparisons with recommendations of other bipolar disor-
research and clinical expert opinion of the authors utilizing a der treatment guidelines (NICE, CANMAT/ISBD, WFSBP, and BAP)
Delphi method to reach final decisions. will be helpful to the reader.
The PRISMA method was used in the literature search Part 4, Needs in the Treatment of Bipolar Disorder and
(Fountoulakis et al., 2017d). The authors based their recom- Recommendations for Future Research, is particularly thought-
mendations on 569 articles containing RCTs, reviews, post- ful. The authors highlight the need to merge guidelines of all
hoc secondary analyses or meta-analyses, and 57 publications phases into a single guideline taking into consideration the
on treatment guidelines. The authors searched MEDLINE course and staging of the condition. Furthermore, the authors
© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected].
95
Copyedited by: oup
96 | International Journal of Neuropsychopharmacology, 2017
emphasize that current treatment guidelines encourage the In the interpretation of clinical trials, issues that need to be
fragmentation of bipolar disorder into phases resulting in the taken into account include potential observation bias (Tohen,
lack of an overall longitudinal therapeutic strategy. They also 1992), the duration of the observation time for maintenance
mention other areas of need for more evidence-based treat- studies (Tohen, 2015), the selection of the patient population
ments, including use of combinations treatment and treatments (Baldessarini et al., 2008; Tohen, 2012), and factors that lead to
for specific conditions such as mixed features or rapid cycling placebo response (Yldiz et al., 2007). Another potential source
course. of bias that needs to be considered is funding source (Paul and
Tohen, 2007; Tohen, 2007).
An area that in general receives little attention in treatment
The Value of Optimal Methodology in the
guidelines are cultural issues or differences in efficacy or tol-
Evaluation of Clinical Trial Results
erability across global populations to specific treatments (Gallo
The authors address a number of research design issues that and Tohen, 2010; Tohen, 2014). Considering that CINP is a global
need to be considered in the future development of treatment organization, for its next version it should consider address-
guidelines in bipolar disorder. A key point raised by the work- ing this important issue as well as expanding the geographical
group is the importance of the release of raw clinical trial data diversity of the authors, as currently only Western Europe and
from industry to the scientific community. The value of this Canada are represented with the omission of any authors from
issue can be exemplified by a recent development of novel developing countries or East Asia.
analyses of exiting longitudinal data such as the Multi-Outcome Another important issue highlighted by the authors is the
Analysis of Treatments that provides more pragmatic informa- need to have more effectiveness studies. Treatment guidelines
tion for clinicians and investigators in guiding maintenance in general do not consider effectiveness comparison studies. An
treatment decisions in bipolar disorder (Bowden et al., 2016; example of a well-designed effectiveness study is a recent head-
Tohen et al., 2016). The development of this methodology was to-head study comparing quetiapine vs lithium in the treatment
possible as 3 major pharmaceutical companies provided the of all phases in bipolar disorder under usual and customary
raw data to independent academic investigators who obtained a clinical care conditions (Nierenberg et al., 2016).
grant from NIMH (RC1MH088431, MTohen [PI]). The methodology In summary, CINP should be commended for the product
is now available to the public (www.moatsofware.com; https:// of this distinguished group of experts that provides clinicians
delta.uthscsa.edu/moat). worldwide an opportunity to make evidence-based treatment
Another important issue raised in the guidelines is the need decisions in the treatment of bipolar disorder that hopefully will
to develop uniform clinical trial standards including uniform result in improving the lives of those who suffer from this dev-
results of outcomes to be reported. The authors provide helpful astating condition.
appendices with recommendations. To address this issue, The
International Society for Bipolar Disorders recently proposed
Statement of Interest
a uniform nomenclature for the definition of commonly used
outcomes such as recovery, relapse, and remission (Tohen et al., Dr. Tohen was a full-time employee at Lilly (1997–2008). He has
2009). In terms of suggested outcomes, the guidelines appro- received honoraria from or consulted for Abbott, Alkermes,
priately highlight the need to focus more on functional rather Allergan, AstraZeneca, Bristol Myers Squibb, Elan, Forest,
than symptomatic outcomes, an issue that has been raised in Geodon Richter Plc, GlaxoSmithKline, Johnson & Johnson, Lilly,
the literature (Dion et al. 1988; Goetz et al. 2007; Tohen et al. Lundbeck, Merck, Minerva, Neurocrine, Otsuka, Pamlab, Pfizer,
1990, 2003). Roche, Shire, Sunovion, Teva, Wyeth, Elsevier Publishing, and
An important recommendation by the workgroup is the need Wiley Publishing. His spouse was a full-time employee at Lilly
to report results on individual items in symptom rating scales (1998–2013).
in addition to overall results, which no doubt provides a better
understanding of the specific benefits of a treatment; for exam-
References
ple, in a patient with bipolar depression, the improvement of
insomnia due to somnolence does not have the same value as Baldessarini RJ, Tohen M, Tondo L (2000) Maintenance treatment
the improvement of depressed mood. in bipolar disorder. Arch Gen Psychiatry 57:490–492.
The authors recommend statistical analyses of side effects; Bowden CL, Mintz J, Tohen M (2016) Multi-state outcome analy-
however, this has the potential to be misleading. With some sis of treatments (MOAT): application of a new approach to
exceptions (Zajecka et al., 2003), the sample size of the vast evaluate outcomes in longitudinal studies of bipolar disorder.
majority of clinical trials is determined by a power analysis to Mol Psychiatr 21:237–242.
detect a difference (if one exists) for efficacy but not for safety Dion GL, Tohen M, Anthony WA, Waternaux CS (1988) Symp-
(Tohen, 2013). Lack of proper sample size estimation can lead to toms and functioning of patients with bipolar disorder six
a type II error where, due to a small size, the results fail to show months after hospitalization. Hosp Community Psychiatr
that there is a difference in safety of a treatment compared with 39:652–657.
placebo when in reality there is a difference. Such a finding can Fountoulakis KN, Grunze H, Vieta E, Young A, Yatham L, Blier
lead to the dangerous conclusion that a treatment is safe when P, Kasper S, Moeller HJ (2017a) The International College of
in reality it may not be. Neuro-Psychopharmacology (CINP) treatment guidelines for
Adequate sample size estimation is also essential in the Bipolar disorder in adults (CINP-BD-2017), part 3: the clinical
interpretation of comparative studies of active treatments. Low guidelines. Int J Neuropsychopharmacol.
statistical power due to a small sample size can lead to a type Fountoulakis KN, Vieta E, Young A, Yatham L, Grunze H, Blier
II error that concludes that two treatments are equally effec- P, Moeller HJ, Kasper S (2017b) The International College of
tive when in reality one is more effective than the other (Tohen, Neuro-Psychopharmacology (CINP) treatment guidelines
2008, 2015). for Bipolar disorder in adults (CINP-BD-2017), part 4: unmet
Copyedited by: oup
Tohen | 97
needs in the treatment of bipolar disorder and recommenda- Tohen M (2008) Clinical trials in bipolar mania: implications in
tions for future research. Int J Neuropsychopharmacol. study design and drug development. Arch Gen Psychiatry
Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier 65:252–253.
P, Kasper S, Moeller HJ (2017c) The International College of Tohen M (2012) Methodologies to avoid the enrollment of ineli-
Neuro-Psychopharmacology (CINP) treatment guidelines gible patients in clinical trials. J Clin Psychiatry 73:1426–1427.
for Bipolar disorder in adults (CINP-BD-2017), part 2: review, Tohen M (2013) Credibility of industry-funded clinical trials. Int J
grading of the evidence and a precise algorithm. Int J Neu- Neuropsychoparmacol 14:1–6.
ropsychopharmacol. Tohen M (2014) Psychiatric collaborations in the Hispanic world.
Fountoulakis KN, Young A, Yatham L, Grunze H, Vieta E, Blier Rev Psiquiatr Salud Ment 7:155–156.
P, Moeller HJ, Kasper S (2017d) The International College of Tohen M (2015) Clinical trial design of maintenance treatments
Neuro-Psychopharmacology (CINP) treatment guidelines for in bipolar disorder. In: Clinical trial design challenges in
Bipolar disorder in adults (CINP-BD-2017), part 1: background mood disorders, 1st ed (Tohen M, Nierenberg A, Bowden C,
and methods of the development of guidelines. Int J Neu- Geddes J, eds), pp1–17. London, UK: Elsevier.
ropsychopharmacol. Tohen M, Waternaux CM, Tsuang MT (1990) Outcome in mania: a
Gallo C, Tohen M (2010) Current status and future perspectives 4-year prospective follow-up of 75 patients utilizing survival
for psychiatry/mental health research in Latin America. Int analysis. Arch Gen Psychiatry 47:1106–1111.
Rev Psychiatry 22:382–393. Tohen M, Zarate CA Jr, Hennen J, Khalsa HMK, Strakowski SM,
Goetz I, Tohen M, Reed C, Lorenzo M, Vieta E (2007) Functional Gebre-Medhin P, Salvatore P, Baldessarini RJ (2003) The
impairment in patients with mania: baseline results of the McLean-Harvard first-episode mania study: prediction of
EMBLEM study. Bipolar Disord 9:45–52. recovery and first recurrence. Am J Psychiatry 160:2099–2107.
Nierenberg AA, McElroy SL, Friedman ES, Ketter TA, Shelton RC, Tohen M, Frank E, Bowden CL, Colom F, Ghaemi NS, Yatham
Deckersbach T, McInnis MG, Bowden CL, Tohen M, Kocsis JH, LN, Malhi GS, Calabrese JR, Nolen WA, Vieta E, Kapczinski F,
Calabrese JR, Kinrys G, Bobo WV, Singh V, Kamali M, Kemp D, Goodwin GM, Suppes T, Sachs GS, Chengappa KNR, Grunze H,
Brody B, Reilly-Harrington NA, Sylvia LG, Shesler LW, Bern- Mitchell PB, Kanba S, Berk M (2009) The International Society
stein EE, Schoenfeld D, Rabideau DJ, Leon AC, Faraone S, Thase for Bipolar Disorders (ISBD) Task Force report on the nomen-
ME (2016) Bipolar CHOICE (Clinical Health Outcomes Initia- clature of course and outcome in bipolar disorders. Bipolar
tive in Comparative Effectiveness): a pragmatic 6-month trial Disord 11:453–473.
of lithium versus quetiapine for bipolar disorder. J Clin Psy- Tohen M, Mintz J, Bowden CL (2016) Analysis of bipolar main-
chiatry 77:90–99. tenance treatment with lithium versus olanzapine utilizing
Paul SM, Tohen M (2007) Conflicts of interest and the credibility Multi-state Outcome Analysis of Treatments (MOAT). Bipolar
of psychiatric research. World Psychiatry 2007 6:33–34. Disord 18:282–287.
Tohen M (1992) Bias and other methodological issues in follow- Yildiz A, Vieta E, Tohen M, Baldessarini RJ (2011) Factors modify-
up (cohort) studies. In: Research designs and methods in psy- ing drug and placebo responses in randomized trials for bipo-
chiatry (Fava M, Rosenbaum G, eds), pp119–125. Amsterdam: lar mania. Int J Neuropsychopharmacol 14:863–875.
Elsevier. Zajecka JM, R Weisler, G Sachs, AC Swann, P Wozniak, and
Tohen M (2007) Collaborations between academic psychiatry KW Sommerville (2003) A comparison of the efficacy, safety,
and the pharmaceutical industry: a perspective from indus- and tolerability of divalproex sodium and olanzapine in the
try. Epidemiol Psychiatr Soc 16:197–198. treatment of bipolar disorder. J Clin Psychiatr 63:1148.
International Journal of Neuropsychopharmacology (2017) 20(2): 98–120
doi:10.1093/ijnp/pyw091
Advance Access Publication: November 4, 2016
Review
review
The International College of Neuropsychopharmacology
(CINP) Treatment Guidelines for Bipolar Disorder
in Adults (CINP-BD-2017), Part 1: Background and
Methods of the Development of Guidelines
Konstantinos N. Fountoulakis, MD; Allan Young, MD; Lakshmi Yatham, MD;
Heinz Grunze, MD; Eduard Vieta, MD; Pierre Blier, MD; Hans Jurgen Moeller,
MD; Siegfried Kasper, MD
3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
(Dr Fountoulakis); Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King’s
College, London, UK (Dr Young); Department of Psychiatry, University of British Columbia, Mood Disorders
Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Vancouver, Canada (Dr Yatham); Paracelsus
Medical University, Salzburg, Austria (Dr Grunze); Hospital Clinic, Institute of Neuroscience, University of
Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain (Dr Vieta); The Royal Institute of Mental Health
Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada (Dr Blier); Psychiatric Department,
Ludwig Maximilians University, Munich, Germany (Dr Moeller); Department of Psychiatry and Psychotherapy,
Medical University Vienna, MUV, AKH, Vienna, Austria (Dr Kasper).
Correspondence: Konstantinos N. Fountoulakis, MD, 6, Odysseos str (1st Parodos Ampelonon str.), 55535 Pylaia Thessaloniki, Greece ([email protected]).
Abstract
Background: This paper includes a short description of the important clinical aspects of Bipolar Disorder with emphasis on
issues that are important for the therapeutic considerations, including mixed and psychotic features, predominant polarity,
and rapid cycling as well as comorbidity.
Methods: The workgroup performed a review and critical analysis of the literature concerning grading methods and methods
for the development of guidelines.
Results: The workgroup arrived at a consensus to base the development of the guideline on randomized controlled trials and
related meta-analyses alone in order to follow a strict evidence-based approach. A critical analysis of the existing methods
for the grading of treatment options was followed by the development of a new grading method to arrive at efficacy and
recommendation levels after the analysis of 32 distinct scenarios of available data for a given treatment option.
Conclusion: The current paper reports details on the design, method, and process for the development of CINP guidelines for the
treatment of Bipolar Disorder. The rationale and the method with which all data and opinions are combined in order to produce
an evidence-based operationalized but also user-friendly guideline and a specific algorithm are described in detail in this paper.
Keywords: Bipolar Disorder; anticonvulsants; antidepressants; antipsychotics; evidence-based guidelines; lithium; mania;
bipolar depression; mood stabilizers; treatment
Received: June 29, 2016; Revised: September 17, 2016; Accepted: October 20, 2016
© The Author 2016. Published by Oxford University Press on behalf of CINP.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
98
creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,
provided the original work is properly cited. For commercial re-use, please contact [email protected]
Copyedited by: oup
Fountoulakis et al. | 99
International Journal of Neuropsychopharmacology (2017) 20(2): 98–120
Introduction Historical Perspective
doi:10.1093/ijnp/pyw091
Advance Access Publication: November 4, 2016 General Background, Disclosure, and Aim Depression and bipolarity were mentioned in Eber’s papyrus
Review in ancient Egypt around 3000 BC (Okasha and Okasha, 2000)
Treatment guidelines are becoming an ever more important part
and in the Hippocratic texts. Plato (424–348 BC) and Aristotles
of medical reality, especially since the translation of research
(384–322 BC) further elaborated on the concept and Aristotle was
findings to everyday clinical practice is becoming increasingly
the first to describe accurately the affections of desire, anger,
difficult with the accumulation of complex and often con-
fear, courage, envy, joy, hatred, and pity. Later, Galen (131–201
flicting research findings that are thereafter also included in
AD), Themison of Laodicea (1st century BC) and Aretaeus of
metaanalysis. Guidelines aim to assist clinicians but also poli-
Cappadocia (2nd century AD) as well as Arab scholars and espe-
cymakers to arrive at decisions concerning the treatment and
cially Avicenna (980–1037) further elaborated on the concept of
care of patients. They set the standard of care and training for
mood disorders (Fountoulakis, 2015b).
health professionals and they also identify priority areas for fur-
Jean-Philippe Esquirol (1772–1840) was the first to clearly
ther research, since they are based primarily on the available
point out that melancholia was a disorder of the mood with
evidence, but also in areas where evidence is not available, on
“partial insanity” (monomania) and used the word “lypemania.”
expert opinion (Fountoulakis, 2015i).
Finally, Jean-Pierre Falret (1794–1870) and Jules Gabriel Francois
In the field of Bipolar Disorder (BD), accumulated knowledge
Baillarger (1809–1890) established the connection between
is often complex, confusing, and in many instances contrasts
depression and mania and gave it the name of “folie circulaire”
with the beliefs and pracices that appear to have been set in
or “folie à double forme,” but it was Emil Kraepelin (1856–1926)
stone in psychiatric culture and training for the last few decades.
who established manic-depressive illness as a distinct nosologi-
To fulfil this need for expert translation of research findings
cal entity and separated it from schizophrenia on the basis of
into clinical practice for the benefit of patients, the International
heredity, longitudinal follow-up, and a supposed favorable out-
College of Neuropsychopharmacology (CINP) launched an effort
come (Kraepelin, 1921). His pupil Wilhelm Weygandt (1870–1939)
to critically appraise the literature and provide guidance to clini-
published the first textbook on mixed clinical states (Weygandt,
cians in the form of a precise treatment algorithm. It is hoped
1899). Following a similar line of thinking, and in spite of some
that this algorithm for the treatment of BD will help the clini-
major objections to the Kraepelinian approach, Karl Jaspers
cian to follow the state-of-the-art evidence, thus enabling their
(1883–1969) described aspects of mixed depressive states that
clinical practice to be based on an informed decision-making
he named “querulant mania,” “nagging depression,” or “wailing
process. This guideline has been commissioned by the CINP,
melancholia” (Jaspers, 1913), while Eugene Bleuler coined the
and the workgroup consisted of experts with extensive research
term “affective illness” and by this he broadened the concept of
and clinical experience in the field of BDs. There was no funding
manic-depression.
from any source for the development of the guidelines and the
In 1957 Karl Leonhard (1902–1988) proposed that the term
activities of the workgroup.
“bipolar disorder” should replace manic-depression, and he also
All the members of the workgroup were psychiatrists who
made a distinction between monopolar (unipolar depression)
are in active clinical practice and were selected according to
and bipolar illness (Leonhard, 1957a, 1957b; Leonhard, 1979).
their expertise and with the aim to cover a multitude of some
In 1870, Silas Weir Mitchell (1829–1914) was the first to rec-
different cultures. All of them were involved in research and
ommend lithium as an anticonvulsant, hypnotic, and as medi-
other academic activities, and therefore it is is possible that
cation for “general nervousness” (Mitchell, 1870, 1877). In 1871,
through such activities some contributors have received income
William Alexander Hammond (1828–1900) was probably the first
related to medicines discussed in this guideline. All conflicts of
to prescribe a modern and effective psychotropic agent, and
interest are mentioned at the end of this paper, which is the
this was lithium (Mitchell and Hadzi-Pavlovic, 2000). Carl Lange
introductory paper to the CINP BD guidelines. It should also be
(1834–1900) and Frederik Lange (1842–1907) had used lithium
noted that some drugs recommended in the guideline may not
in the treatment of depression since 1886 (Lenox and Watson,
be available in all countries, and labeling and dosing might vary.
1994). However, in spite of encouraging results, by the turn of the
The aim of the current endeavor was to develop a guideline
20th century, the “brain gout” theory of mood disorders disap-
and precise algorithm for treatment of BD in adults for use in
peared as a medical entity and the use of lithium in psychiatry
primary and secondary care. Children, adolescents, and the
was abandoned.
elderly are not the focus of this guidance. The guideline and
In 1949 John Cade (1912–1980) reported positive results from
algorithm have been developed after a complete review of the
the treatment of 10 acutely manic patients (Cade, 1949, 2000);
literature and with the use of stringent criteria. Both the guide-
however, 2 years later he reported the first death caused by
line and the precise algorithm try to balance research vs clinical
lithium toxicity in a patient whose bipolar illness otherwise
wisdom but give primacy to the available evidence.
responded extremely well to treatment. Later, Mogens Schou
To comply with the journal’s word limit for manuscripts and
(1918–2005) undertook a randomized controlled trial of lithium
for easy readability, the CINP guidelines have been organized
in mania (Schou et al., 1954; Bech, 2006), and eventually the the
and presented as a series of 4 distinct papers. This paper is the
efficacy of lithium during the maintenance phase was estab-
first of this series and will cover the general background of the
lished (Gershon and Yuwiler, 1960; Baastrup, 1964; Baastrup and
guideline and algorithm, that is, the historical perspective and
Schou, 1967; Angst et al., 1969, 1970; Baastrup et al., 1970; Schou
general clinical and treatment issues followed for the devel-
et al., 1970; Johnstone et al., 1988; Schioldann, 1999; Mitchell and
opment of the guideline and the algorithm. The second paper
Hadzi-Pavlovic, 2000; Bech, 2006; Schioldann, 2006; Schioldann,
summarizes, classifies, and grades the treatment data on BD
2011).
while the third paper includes the guideline and the treatment
Valproate was introduced in 1966 as an anticonvulsant
algorithm themselves. The fourth and final paper addresses the
(Lambert et al., 1966) and later carbamazepine (Okuma et al.,
unmet needs and areas that should be the focus of attention
1979) followed. Neuroleptics were introduced by Jean Delay
and specific research in the future.
Copyedited by: oup
100 | International Journal of Neuropsychopharmacology, 2017
(1907–1987) and Pierre Deniker (1917–1999) in 1955, and prob- In terms of individual symptoms, fatigue and psychomotor
ably many of their patients were suffering from acute mania retardation dominate the clinical picture in 75% of patients dur-
or schizoaffective disorder (Delay and Deniker, 1955). In 1958 ing acute bipolar depression. Irritability is present in almost 75%
Roland Kuhn (1912–2005) reported on the efficacy of the first of patients (Winokur et al., 1969), delusions are present in 12 to
antidepressant, imipramine (Kuhn, 1958). 66% (Winokur et al., 1969; Carlson and Strober, 1978; Rosenthal
There were several reports in the 1970s suggesting that in et al., 1980; Black and Nasrallah, 1989), and hallucinations in 8 to
bipolar depression the use of antidepressants might induce 50% (Winokur et al., 1969; Carlson and Strober, 1978; Rosenthal
mania, mixed episodes, and rapid cycling (Wehr and Goodwin, et al., 1980; Black and Nasrallah, 1989; Baethge et al., 2005).
1987; Wehr et al., 1988). In 1994 the first detailed operational treat- Psychotic features seem to constitute a stable trait that tends
ment guidelines were published by the American Psychiatric to repeat itself across episodes (Helms and Smith, 1983; Nelson
Association and after 2000, systematic industry-sponsored et al., 1984; Aronson et al., 1988a, 1988b). Depending of the study
studies of second generation antipsychotics and haloperidol sample composition, changes in appetite for food are seen in
were performed. Also, during this period the first meta-analytic almost all patients (Winokur et al., 1969), with one-fourth mani-
studies emerged, and the evidence-based medicine principles festing overeating and one-fourth losing significant weight
gained ground in treatment recommendations. (Casper et al., 1985). Almost all bipolar depressed patients expe-
rience some kind of sleep problem (Winokur et al., 1969; Casper
Clinical Description et al., 1985). Α subgroup of bipolar depressed patients (up to 25%)
often exhibit excessive sleep and have difficulty getting up in
While the basic conception of BD suggested that it is charac- the morning (Winokur et al., 1969). Decreased sexual desire is
terized by the alternation of manic and depressive episodes seen in more than 75% of patients (Winokur et al., 1969; Casper
with a return to the premorbid level of functioning between the et al., 1985) and concerns both sexes. Approximately two-thirds
episodes and to favorable outcome compared with schizophre- of bipolar depressed patients present with multiple physical
nia (Kraepelin, 1921), today we know that this is not always the pains and complaints (e.g., headache, epigastric pain, precordial
case (Tohen et al., 1990; Grande et al., 2016). Not only BD is a distress, etc.) in the absence of any physical illness, especially in
much more complex disorder than this, but also the outcome primary care (Winokur et al., 1969).
varies. The most prominent clinical facets are shown in Table 1 Euphoria is observed in 30 ot 97% of acutely manic patients
(Fountoulakis, 2015a, 2015c, 2015d, 2015e, 2015j, 2015n). (Clayton and Pitts, 1965; Winokur et al., 1969; Beigel and Murphy,
The fact that often the correct diagnosis is made only after 1971; Carlson and Goodwin, 1973; Taylor and Abrams, 1973;
8 to 10 years have passed because the first episode is psychotic- Winokur and Tsuang, 1975; Abrams and Taylor, 1976; Leff et al.,
like or depressive and the correct diagnosis can be made only 1976; Loudon et al., 1977; Taylor and Abrams, 1977; Cassidy et al.,
after a manic or a mixed episode emerges (Angst, 2007) is espe- 1998a), while unrestrained and expansive mood is seen in 44 to
cially problematic. It has been estimated that more than one- 66% (Taylor and Abrams, 1973, 1977; Loudon et al., 1977). Patients
half of hospitalized patients originally manifesting a depressive are dissatisfied and intolerant and the vast majority manifest
episode will turn out to be bipolars in the next 20 years (Angst mood lability and instability (42 to 95%) (Winokur et al., 1969;
et al., 2005a). It is of utmost importance for both clinicians and Carlson and Goodwin, 1973; Abrams and Taylor, 1976; Loudon
researchers to create a biographical chart with the patient’s et al., 1977; Taylor and Abrams, 1977; Cassidy et al., 1998a).
course over time and including any important event in the Irritability is also very frequent (51–100%) (Winokur et al., 1969;
developmental history of the patient and emphasizing the main Carlson and Goodwin, 1973; Taylor and Abrams, 1973, 1977;
events and hallmarks of his/her life and his/her full psychiatric Winokur and Tsuang, 1975; Abrams and Taylor, 1976; Loudon
and medical history. Such a chart clarifies both the diagnosis et al., 1977; Cassidy et al., 1998a; Serretti and Olgiati, 2005).
and the course of the disease and also the response to therapeu- However, even significant depressive symptoms are experienced
tic interventions, since any delay in the proper diagnosis also by as many as 29 to 100% of acutely manic patients (Winokur
delays proper treatment (Altamura et al., 2010; Drancourt et al., et al., 1969; Beigel and Murphy, 1971; Kotin and Goodwin, 1972;
2013). Carlson and Goodwin, 1973; Murphy and Beigel, 1974; Loudon
et al., 1977; Prien et al., 1988; Cassidy et al., 1998a; Bauer et al.,
2005).
Table 1. List of the Multiple Clinical Aspects of Manic-Depressive Accelerated psychomotor activity is observed in the vast
Illness majority of patients (56–100%) (Winokur et al., 1969; Carlson
and Goodwin, 1973; Taylor and Abrams, 1973; Abrams and
1. Manic episodes
Taylor, 1976; Leff et al., 1976; Loudon et al., 1977; Carlson and
2. Depressive episodes
Strober, 1978; Cassidy et al., 1998a, 1988b; Cassidy et al., 1998a;
3. Mixed episodes
Serretti and Olgiati, 2005) and pressured speech in almost all
4. Subthreshold manic symptoms
patients (Clayton and Pitts, 1965; Winokur et al., 1969; Carlson
5. Subthreshold depressive symptoms
and Goodwin, 1973; Taylor and Abrams, 1973; Abrams and Taylor,
6. ‘Mixed’ states and ‘roughening’
1976; Leff et al., 1976; Loudon et al., 1977; Carlson and Strober,
7. Mood lability/cyclothymia/’personality-like’ behavior
8. Predominant polarity 1978; Cassidy et al., 1998b; Serretti and Olgiati, 2005); hyper-
9. Frequency of episodes/rapid cycling sexuality is present in 25 to 80% of patients with 23 to 33% of
10. Psychotic features them having significant sexual exposure (Allison and Wilson,
11. Neurocognitive disorder 1960; Clayton and Pitts, 1965; Winokur et al., 1969; Carlson and
12. Functional deficit and disability Goodwin, 1973; Taylor and Abrams, 1973, 1977; Abrams and Taylor,
13. Drug/alcohol abuse 1976; Leff et al., 1976; Loudon et al., 1977; Carlson and Strober,
14. Comorbid anxiety and other mental disorders 1978). Decreased need for sleep (hyposomnia) is present in 63 to
15. Self-destructive behavior and suicidality 100% of patients (Clayton and Pitts, 1965; Winokur et al., 1969;
Leff et al., 1976; Loudon et al., 1977; Carlson and Strober, 1978;
Copyedited by: oup
Fountoulakis et al. | 101
Cassidy et al., 1998b; Serretti and Olgiati, 2005) and psychotic Table 2. Summary of the Frequencies of Appearance of Various
features in 33 to 96% of patients (Winokur et al., 1969; Carlson Symptoms during the Two Different Acute Phases of BD
and Strober, 1978; Rosenthal et al., 1980; Black and Nasrallah,
Episodes
1989).
Overall, psychotic features are so common that acute mania Symptom Manic Depressive
should be considered primarily a psychotic state (Koukopoulos,
2006). Delusions are present in 24 to 96% of manic patients, and Euphoria 30–97%
it is interesting that persecutory ideas are equally frequent with Expansive mood 44–66
delusions of grandiose (Bowman and Raymond, 1932; Rennie, Depressive symptoms 29–100% 100%
1942; Astrup et al., 1959; Clayton and Pitts, 1965; Winokur et al., Mood lability 42–95%
1969; Beigel and Murphy, 1971; Carlson and Goodwin, 1973; Irritability 51–100% 75%
Psychomotor retardation 75%
Taylor and Abrams, 1973, 1977; Murphy and Beigel, 1974; Abrams
Psychomotor acceleration 56–100%
and Taylor, 1976; Leff et al., 1976; Loudon et al., 1977; Carlson and
Pressured speech 100%
Strober, 1978; Rosenthal et al., 1980; Winokur, 1984; Black and
Psychotic features 33–96%
Nasrallah, 1989; Serretti et al., 2002; Keck et al., 2003; Goodwin
Delusions 24–96% 12–66%
and Jamison, 2007). Hallucinations are less frequent and present
Hallucinations 13–66% 8–50%
in 13 to 66% of cases; they can either be congruent or noncon-
Weight loss 25%
gruent, with auditory, visual, and olfactory ones being almost
Weight gain 25%
equally frequent (Lange, 1922; Bowman and Raymond, 1932;
Hyposomnia 63–100%
Astrup et al., 1959; Winokur et al., 1969; Taylor and Abrams, Oversleeping 25%
1973, 1977; Abrams and Taylor, 1976; Carlson and Strober, 1978; Loss of libido 25%
Rosenthal et al., 1980; Winokur, 1984; Black and Nasrallah, 1989; Hypersexuality 25–80%
Serretti et al., 2002; Keck et al., 2003; Goodwin and Jamison, 2007). Significant sexual exposure 23–33%
Psychotic symptoms in BD are predictive of a more detrimen- Confused 33%
tal course, including a higher rate of rehospitalizations (Caetano Violent 46–75%
et al., 2006; Ozyildirim et al., 2010). Regression, catatonia etc. 14–56%
Almost one-third of acutely manic patients are “confused” Fecal incontinence 10–20%
and 46 to 75% are violent (Carlson and Goodwin, 1973; Taylor Physical complains 66%
and Abrams, 1973, 1977; Abrams and Taylor, 1976; Cassidy et al.,
1998b). The term confused refers to manic disorganization and Karl Leonhard was the first to report the presence of a pre-
not to organic drop in the level of consciousness. As many as dominant polarity with 17.9% of patients having a manic- and
14 to 56% of patients manifest severe regression, catatonia, 25.6% having a depressive-predominant polarity (Leonhard,
posturing, and negativism, often making differential diagnosis 1963). The concept was further formulated by Jules Angst (1978)
from schizophrenia difficult (Lange, 1922; Carlson and Goodwin, and Carlo Perris (Perris and d’Elia, 1966a, 1966b) and has recently
1973; Taylor and Abrams, 1973, 1977; Carlson and Strober, 1978; been utilized for long-term prognosis and to assist clinicians in
Abrams and Taylor, 1981; Braunig et al., 1998; Kruger et al., 2003), long-term therapeutic design (Quitkin et al., 1986; Judd et al.,
and 10 to 20% have fecal incontinence (Taylor and Abrams, 1973, 2003; Colom et al., 2006). The most reliable definition of pre-
1977; Abrams and Taylor, 1976). A summary of the frequencies of dominant polarity demands that at least two-thirds of episodes
appearance of various symptoms during the two different acute belong to one of the poles (Colom et al., 2006; Rosa et al., 2008;
phases of the illness is shown in Table 2. Garcia-Lopez et al., 2009; Mazzarini et al., 2009; Tohen et al.,
Formally, those episodes with manic symptoms but less pro- 2009; Vieta et al., 2009; Nivoli et al., 2011; Baldessarini et al., 2012;
nounced in terms of severity and with a shorter duration are Pacchiarotti et al., 2013a; Carvalho et al., 2014a, 2014b).
labeled hypomanic. Hypomania is much more common than Somewhere between 15% and 50% of BD patients are
mania (Angst, 1998), but its recognition is mostly achieved reported to manifest some type of seasonal variation of symp-
mainly by interviewing significant others and not the patient. tomatology (Hunt et al., 1992; Faedda et al., 1993; Goikolea et al.,
Hypomanic episodes cause mild or no impairment at all, and 2007; Shand et al., 2011). Two opposing seasonal variations have
on the contrary, in some cases, they may even contribute to suc- been described: fall-winter depression with or without spring-
cess in business, leadership roles, and the arts. Psychotic symp- summer mania or hypomania; and spring-summer depres-
toms are less frequent (around 20%) in comparison to full-blown sion with or without fall-winter mania or hypomania (Faedda
manic episodes, but they do occur (Mazzarini et al., 2010). et al., 1993). Most studies support the first subtype (Walter, 1977;
Mixed episodes are defined as the coexistence of both Parker and Walter, 1982; Mulder et al., 1990; Peck, 1990; Partonen
depressive and manic symptoms; however, the term was aban- and Lonnqvist, 1996; Clarke et al., 1999; Lee et al., 2007; Murray
doned with DSM-5, which includes mixed features as a specifier et al., 2011).
only. The DSM-5 demands the presence of a full-blown episode Τhe concept of rapid cycling appeared for the first time in the
of either pole together with at least 3 symptoms of the opposite 70s in a landmark paper by Dunner and Fieve (1974). In general
pole being present in order to allow the label of “mixed features” the classic rapid-cycling includes cycles with duration of weeks
specifier. to months. Ultra-rapid cycling is reported when mood cycling
It is reported that in 69.6% of cases the course resembles that has frequency of weeks to days, and ultradian cycling when
of a recurrent episodic illness, while in 25% of cases there is a there is significant mood variation within a 24-hours period
chronic course without clear remissions between episodes. In (Kramlinger and Post, 1996). Other terms include ultra-ultra
only 5.4% is there a single episode of mania. Suicidal ideation rapid and ultradian rapid and refer to weekly or daily cycling,
is present in 78.6% of patients at some time in their life. Only which is not uncommon in BD patients (Kramlinger and Post,
around 5% of BD patients have chronic mania (Akiskal, 2000). 1996). Most studies suggest a 5 to 33.3% up-to-1-year prevalence
Copyedited by: oup
102 | International Journal of Neuropsychopharmacology, 2017
(Kukopulos et al., 1980; Nurnberger et al., 1988; Coryell et al., depressive episodes simultaneously. Although such a coexist-
1992; Schneck et al., 2004, 2008; Azorin et al., 2008; Cruz et al., ence is rather rare, almost one-third of patients recruited in
2008; Garcia-Amador et al., 2009; Lee et al., 2010) and 25.8 to 43% pharmaceutical trials of acute mania were diagnosed as mixed.
lifetime prevalence (Dittmann et al., 2002; Coryell et al., 2003; Thus there exists ample data, although neither properly ana-
Yildiz and Sachs, 2004; Hajek et al., 2008; Lee et al., 2010). lyzed nor published. Instead of the diagnosis of mixed epi-
In terms of neurocognitive function, the literature suggests sodes, DSM-5 introduced the mixed features specifier concept.
that the neurocognitive deficit in BD patients concerns almost According to this, a mood episode (either manic or depressed)
all domains and phases of the illness with only a few exceptions. has mixed features if at least 3 criteria of the opposite pole
Its magnitude is at the severe range during the acute episodes (from a specific list) coexist. It is important to note that accord-
and at the medium range during euthymia, while the origin of ing to DSM-5, mixed features can also be attributed to a unipolar
the deficit remains unclear. In terms of neurocognitive function, major depressive episode without changing the diagnosis to BD.
BD patients do quantitatively better than patients with schizo- Another important change in the DSM-5 is the introduction
phrenia, but the qualitative pattern of the deficit is similar in of the anxious distress specifier, which demands the presence of
the 2 disorders. There are no clear differences between BD sub- at least 2 criteria from a list of 5 (tension, restlessness, concen-
types. The deficit is present early in the course of the disorder. tration difficulties, worry, fear of losing control).
At least in some patients it might emerge before the onset of the The ICD-10 classification accepts the presence of “somatic
first mood episode, and in the majority of patients it progresses syndrome,” which sems analogous but it is not identical to “mel-
probably in relationship with the manifestation of psychotic acholic features” of DSM-5 (Fountoulakis et al., 1999). The atypi-
symptoms. The verbal memory and executive function deficit cal features, rapid cycling, and anxious distress are described
probably constitute endophenotypes, while the role of medica- in DSM-5 but not in ICD-10. Also, ICD-10 does not differentiate
tion as a causative factor is limited (Tsitsipa and Fountoulakis, psychotic symptoms into mood congruent vs mood incongru-
2015; Cullen et al., 2016). ent. The other specifiers, catatonia, peripartum onset, and sea-
Finally, in contrast to the original conceptualization of BD by sonal pattern, are not included in the ICD-10 either. It is also
Emil Kraepelin a century ago, unfortunately it seems that only important to note that ICD-10 recognizes catatonia only in the
a minority of BD patients achieve complete functional recovery frame of schizophrenia, while DSM-5 uses this specifier also in
(Goldberg et al., 1995a, 1995b; Keck et al., 1998; Strakowski et al., affective disorders.
1998; Daban et al., 2006; Martinez-Aran et al., 2007; Mur et al., There is an issue concerning the diagnosis of cases with sub-
2007). threshold manic symptoms or long-lasting hyperthymia. While
the traditional bipolar vs unipolar distinction is widely used and
adopted by classification systems, it is doubtful whether it can
Classification
capture the essence of the huge heterogeneity observed in mood
ICD and DSM include BD as a diagnostic entity but with signifi- disorders and their dynamic nature with frequent switches and
cant differences between them (Fountoulakis, 2015h). It is impor- changes in the clinical profile. The greatest disadvantage of both
tant to note that almost all the research literature follows the classification systems is that they perform better (and focus)
DSM classification, while almost all countries worldwide have when interepisodic remission is present; instead, the everyday
the obligation to use the ICD in their official documents, includ- real-life patient is more likely to suffer from a chronic disorder
ing hospital records, etc. The ICD-10-CM helps to bridge these with residual and mixed symptoms. The term spectrum was
2 different classification systems for administration purposes. first used in psychiatry in 1968 for the schizophrenia spectrum
In ICD-10 (WHO, 1992, 1994), BD is included in the chapter on (Kety et al., 1968).
mood (affective) disorders (F30-F39). While in previous editions The proposed mood spectrum models unify categorical clas-
of the DSM, both unipolar and bipolar disorders were grouped sification, which is essential, with a dimensional view, which is
under the chapter on mood disorders, on the contrary in DSM-5 true to nature; both are needed and both are empirically test-
(American Psychiatric Association, 2013), BDs were separated able. Today the term bipolar spectrum is mainly used in 2 com-
from unipolar depression. The “bipolar” chapter includes BD and plementary senses: (1) a spectrum of severity, which embraces
cyclothymic disorder, while the “depression” chapter includes psychotic and nonpsychotic major and minor BDs (including
disruptive mood dysregulation disorder, major depressive dis- bipolar dysthymia, recurrent brief and minor depressions),
order, persistent depressive disorder (dysthymia), and premen- cyclothymic disorders, hypomania and, at its broadest, even
strual dysphoric disorder. Both chapters include “unspecified,” borderline disorders and cyclothymic temperament; (2) a pro-
“other,” and “due to” categories. portional mood spectrum, which considers the 2 components,
Another important difference between the 2 classification mania and depression, on the level of major and minor mood
systems is that ICD requires the presence of at least 2 episodes disorders. This proportional model is an extension of Kleist’s
of pathological disturbance of mood while DSM does not. DSM concept of BD as a combination of the 2 monopolar disorders of
recognizes the presence of 2 subtypes of BD, that is, of BD-I (BD depression and mania (Kleist, 1937). Thus these 2 approaches to
with manic episodes) and BD-II (BD with hypomanic but not spectrum reflect 2 distinct continua: from normal to pathologi-
manic episodes). BD-II is not part of the ICD-10 diagnostic list, cal and from unipolar to bipolar.
which accepts hypomania as a diagnostic entity (F30.0), but it is An important part of the bipolar spectrum is cyclothymic
considered simply a low-severity mania. disorder, which is considered to be an attenuated form of BD.
In ICD-10 a mixed affective episode (F38.0) is defined as an Their behavior is characterized by the alternation of extremes
affective episode of at least 2 weeks duration that is character- (Akiskal et al., 1977). Depending on the threshold of traits used in
ized by either a mixture or a rapid alternation (usually within determining the presence of hyperthymia, cyclothymic patients
a few hours) of hypomanic, manic, and depressive symptoms. may constitute 10 to 20% of those with major depressive disor-
In DSM-5 a radical change was the abolishment of the concept der. Also, cyclothymia is often a prodromal of BD (Akiskal et al.,
of mixed episodes. In previous versions of the DSM, mixed epi- 1979). Another important part of the bipolar spectrum are those
sodes were defined as the coexistence of full-blown manic and patients who experience an antidepressant-induced switch.
Copyedited by: oup
Fountoulakis et al. | 103
Thus, many patients with so-called unipolar depression are with the addition of subthreshold bipolarity produced a total
actually pseudounipolar. lifetime prevalence of 6.4% with 0.5% being a lifetime preva-
Some authors suggest that a significant part of the literature lence of BD-II (Judd and Akiskal, 2003). The National Comorbidity
consists mostly of expert opinion overemphasizing various links Survey (NCS) (Kessler et al., 1993, 1994a, 1994b, 1995, 1996,
between bipolar and unipolar mood disorders and personality 1997b; Blazer et al., 1994; Wittchen et al., 1994; Warner et al.,
disorders (Paris et al., 2007; Patten and Paris, 2008). Recently, the 1995; Kendler et al., 1996; Magee et al., 1996) reported a lifetime
first solid international epidemiological data in support of the prevalence of 1.7% for BD-I and an annual prevalence of 1.3%
bipolar spectrum have been published (Merikangas et al., 2007, with similar prevalence for males and females. The median age
2011; Angst et al., 2010). According to these authors there is a at onset was 21 years. The NCS-R (Kessler et al., 2004, 2005a,
direct association between increasingly restrictive definitions of 2005b, 2012a, 2012b; Kessler and Merikangas, 2004; Merikangas
BD and indicators of clinical severity, including symptom sever- et al., 2007; Angst et al., 2010; Nierenberg et al., 2010) reported a
ity, role impairment, comorbidity, suicidality, and treatment. For lifetime prevalence of 1.0% for BD-I and an annual prevalence
example, the proportion of mood episodes rated as clinically of 0.6% with again similar prevalence for males and females.
severe increased from 42.5% for subthreshold BD to 68.8% for The median age at onset was 19 years. For BD-II the lifetime
BD-II to 74.5% for BD-I. However, since clinical diagnosis and prevalence was 1.1% and the annual prevalence was 0.8% with
severity share confounding factors and definitions overlap, it similar prevalence for males and females. The median age at
is also important to note that these studies also showed that onset was 20 years. There was a small difference between males
the proportion of cases reporting severe role impairment ranged and females in the BD-II rates, with female rates being slightly
from 46.3% for subthreshold BD to 57.1% for BD-I (Merikangas higher. The Cross National Collaboration Group study included
et al., 2011). data from 7 countries (US, Canada, Puerto Rico, Germany,
On the basis of both epidemiological data and clinical wis- Taiwan, South Korea and New Zealand) (Weissman et al., 1996)
dom, a limited number of models reflecting the structure of and reported variable rates for different countries, but overall
the bipolar spectrum have been proposed. The first effort was the rates seemed moderately consistent cross-nationally. The
a dimensional concept (from normal to pathological) proposed Zurich study (Angst et al., 1984, 2005b; Wicki and Angst, 1991)
by Kretschmer in 1921 for schizophrenia (schizothymic-schiz- reported an annual prevalence of BD-I of 0.7% and a lifetime
oid-schizophrenic) and for affective disorders (cyclothymic prevalence for the bipolar spectrum of 5.5%. The Nottingham
temperament-cycloid ‘psychopathy’-manic-depressive disor- study (Brewin et al., 1997) reported the 2-year incidence rate
der). Bleuler suggested a similar concept in 1922. In 1977 Akiskal reported for BD was 0.005%, which corresponds to an annual
proposed a cyclothymic-bipolar spectrum (Akiskal et al., 1977). incidence of 2.5/100 000. The Netherlands study (Bijl et al., 2002;
A simple model system was introduced in 1978 by Jules Angst Regeer et al., 2002; ten Have et al., 2002) suggested a lifetime
(1978; Angst et al., 1978), who used the the following codes: M for prevalence of BD equal to 2.0%. The annual incidence was equal
severe mania, D for severe depression (unipolar depression), m to 2.7/100 000. There was no significant difference between
for less severe mania (hypomania), and d for less severe depres- males and females. The Australian National Survey reported
sion. In 1981 Gerald Klerman suggested a mania spectrum the year prevalence of euphoric BD (combined BD-I and BD-II)
(Klerman, 1981, 1987) and in the late 1990s Akiskal proposed 6 was 0.5% (Mitchell et al., 2004). The Butajira study from Ethiopia
subtypes, some of which are further subdivided according to reported a lifetime prevalence of BD-I disorder of 0.5%, with the
their unique clinical features. A summary of his proposed sub- rate being 0.6% for males and 0.3% for females. The mean age
type schema is as follows (Akiskal and Pinto, 1999; Akiskal and of cases was 29.5 years, with no significant sex difference. The
Benazzi, 2005; Ng et al., 2007; Fountoulakis, 2008). mean age of first recognition of illness was 22 years. There was
no significant sex difference in the age at onset of manic or
Epidemiology depressive phases (Negash et al., 2005). A more recent cross-
sectional, face-to-face, household survey in 11 countries in the
In the last few decades there has been an increasing interest Americas, Europe, and Asia reported that the lifetime preva-
in psychiatric epidemiology. For BD, a point that plays a major lence was 0.6% for BD-I and 0.4% for BD-II, while the year preva-
role in the estimation of the prevalence rates is the definition of lence was 0.4% and 0.3%, respectively (Merikangas et al., 2011).
hypomania and of mixed, irritable, or dysphoric forms of manic A few studies report on the epidemiology of bipolar spectrum
episodes. This is further complicated by the presence of inaccu- and suggest that in the adult population the lifetime preva-
rate recall and the low sensitivity of the interview instruments lence of the bipolar spectrum is between 3 and 8.3% (Weissman
concerning subthreshold symptomatology and nonclassical and Myers, 1978; Angst et al., 1984, 2005b; Oliver and Simmons,
clinical pictures (Kessler et al., 1997a). 1985; Wicki and Angst, 1991; Heun and Maier, 1993; Angst, 1998;
A number of important studies exist and provide impor- Szadoczky et al., 1998; Hirschfeld et al., 2003a, 2003b; Judd and
tant but inconclusive information. The Amish study (Egeland Akiskal, 2003; Moreno and Andrade, 2005; Faravelli et al., 2006;
and Hostetter, 1983; Egeland et al., 1983; Hostetter et al., 1983) Kessler et al., 2006).
reported similar prevalence rates between unipolar depression Overall and according to the WHO, BD affected an estimated
and bipolar illness and also similar rates between genders. It is 29.5 million persons worldwide in 2004 (WHO, 2008). The avail-
impressive that 79% of patients with BD-I were previously diag- able data suggest that the life prevalence of BD-I is around 1%,
nosed as suffering from schizophrenia. The Epidemiological with probably a similar rate concerning BD-II. The full bipolar
Catchment Area study (ECA) (Eaton et al., 1981; Regier et al., spectrum probably has lifetime prevalence around 5%. There
1984, 1988, 1993; Bourdon et al., 1992) reported a lifetime preva- are no striking differences between genders. However these fig-
lence of 0.8% for BD-I (0.3–1.2%) and an annual prevalence of ures should be considered as only indicative, since important
0.6% (0.2–1%) with similar prevalence for males and females. discrepancies exist among studies and countries, as mentioned
The annual incidence was 0.4% (0.1–0.6%) of cases, which corre- above. The rather small difference between annual and lifetime
sponds to approximately 3.2 (0.8–4.8) per 100 000 residents. The rates suggests that BD is both an episodic but also a chronic
median age at onset was 18 years. A reanalysis of the ECA data mental disorder with high recurrence rates.
Copyedited by: oup
104 | International Journal of Neuropsychopharmacology, 2017
The various studies from around the world suggest that the the concept of mood stabilizers. This term was originally used
age at onset is late adolescence or early adulthood, around the age during the 1950s to refer to a combination of amphetamine and
of 18 to 20 years, but also they suggest that approximately one- a barbiturate to treat patients with neurotic instability but not
fourth of BD patients have the onset before the age of 13 (Perlis patients with BD. The term mood normalizer was proposed by
et al., 2004; Post et al., 2008; Stringaris et al., 2010; Merikangas Mogens Schou for lithium (Schou, 1963), but eventually the sta-
et al., 2012), and among other things this suggests caution in the bilizer concept prevailed, probably because the focus of research
use of stimulants for the treatment of children with ADHD and with lithium was on the long-term prophylaxis.
worse overall outcome (Agnew-Blais and Danese, 2016). During the last decade, however, there was a plethora of data,
mainly because of the introduction of atypical antipsychotics
Staging as possible treatment options. However, this gave the chance
also for older substances to be tested under rigorously defined
After the introduction of operationalized diagnostic criteria for research conditions. These studies revealed that the treatment
all contemporary classification systems, the need to define and could be more complex than previously believed and several
rate seriousness, progression, changes in physiology, and dam- issues exist. The clinician should be aware of many specific
age made and the extent and the specific characteristics of the indications, contraindications, details, and traps (Fountoulakis
disease emerged. Staging is the term that defines this procedure et al., 2005, 2007a, 2007b, 2008, 2015m; Gonda et al., 2009).
(Fountoulakis, 2015k). The field in medicine where staging is most The concept of mood stabilizers is disputed, since the data
successful and enjoys great importance is that of clinical oncol- do not support an equally wide efficacy for different compounds
ogy. Since 1993 there were many attempts to arrive at a staging like lithium, valproate, or carbamazepine to warrant such a
model for psychiatry (Fava and Kellner, 1993; Yung and McGorry, label. On the contrary, there are negative data concerning spe-
1996, 2007; McGorry et al., 2006, 2007, 2010; McGorry, 2007, 2010b; cific areas, while our knowledge is quite limited concerning
Vieta et al., 2011; Cosci and Fava, 2013). The concept of staging other areas. One particular problem, which only recently has
if and when applied has a number of implications. Almost by been awknowledged, is that probably some facets of the dis-
definition it suggests that early stages are easier to treat, while order are refractory to treatment. Another important problem
later stages are rather refractory to treatment. Thus these later is that not only is the evidence limited concerning the treat-
stages might need the application of treatment options with ment of specific facets and issues of BD (Fountoulakis, 2010;
more adverse events, higher risk, and less overall benefit (Post Fountoulakis et al., 2012, 2013), but also continued scientific
et al., 2010) or some kind of palliative care should be considered. training and reading is inadequate. Thus, research findings are
The earliest research contribution to the effort of staging BD not making it to everyday clinical practice. Focused educational
was the description of the stages of mania in the early 1970s when intervention might be nessessary to change this attitude. Part of
Carlson and Goodwin not only described discrete stages in the this problem is reflected in the common practice among clini-
development and course of acute mania, but also they described cians to use medication on the basis of a class effect. This means
a rollback phenomenon that is the clinical condition improves by that they consider that a whole class of medications possesses a
manifesting the same stages but at a reverse order (Carlson and specific action. This class effect is often considered in combina-
Goodwin, 1973). Up to n, 5 major staging models have been pro- tion with a syndromal approach, which means that irrespective
posed for BD (Berk et al., 2007a, 2007b; Kapczinski et al., 2009; Post, of the nosological entity, a specific kind of symptoms respond to
2010; Post et al., 2012; Cosci and Fava, 2013; Frank et al., 2014). a specific class of medication.
Although there is some support for the proposed staging models, For example, according to this combined approach all antip-
the research base is thin, the heterogeneity of the data is significant, sychotics are equally effective against psychotic symptoms
and the studies include small sample sizes. A number of vicious irrespective of disorder diagnosis, and the same holds for all
logical cycles could be in place. Most of the data are cross-sectional antidepressants against depressive symptoms. This is the most
(Kapczinski et al., 2014), and the need for a transdiagnostic and lon- commonly used approach in everyday clinical practice and has
gitudinal research approach is prominent (Lin et al., 2013). a huge impact on public mental health. Its significant advan-
The data so far support the presence of an asymptomatic tage is that it provides the clinician with fast and simple rules to
at-risk phase and a nonspecific prodromal phase. This prodro- determine treatment. On the other hand, its greatest problem is
mal phase seems to be common for a number of mental disor- that this approach has been proven false, especially in the case
ders, and prediction is extremely difficult on the basis of current of BD where it is specifically combined with a very broad mood
knowledge. The literature is also supportive of the presence of stabilizers concept (Fountoulakis et al., 2011). The extent to
an early stage of the full-blown illness, during which the epi- which this truly influences the everyday clinical practice world-
sodes are well defined and there are no or very few inter-episode wide is unknown but is probably significant. The extent to which
residual symptoms, good response to treatment, and little dis- this concept influences the outcome of BD is similarly unknown,
ability. It also supports the presence of a late stage that is associ- although theoretically a more evidence-based approach should
ated with a more chronic and refractory disease, probably with improve the overall outcome of BD patients.
depressive predominant polarity, psychotic features, and sig- It is important to note that with the introduction of the
nificant disability. It is disappointing that there is little research second-generation antipsychotics, antipsychotics became a
on the treatment effect at late stages (Berk et al., 2012), with cornerstone for the treatment of BP also according to treatment
only a few exceptions (Torrent et al., 2013). The use of biomark- guidelines. On the contrary, a number of studies showed that
ers might, in the near future, facilitate the validation of staging the usefulness of antidepressants that were traditionally seen
systems and their therapeutic utility (Vieta, 2015). in Europe as a meaningful treatment option for bipolar depres-
sion is questionable (Pacchiarotti et al., 2013b). Additionally, the
maintenance/long-term treatment became more complex, since
Therapeutic Issues
it has proven that agents previously considered to be mood sta-
The treatment of BD is complex (Fountoulakis, 2008) and for bilizers were essentially more effective for one pole than the
several decades the treatment of BD was theoretically based on other (Popovic et al., 2012). This is definitely a fast-moving field,