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(5/24/00 11:07 pm)
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Lithium Still Top Mood Stabilizer for Manic Phase
Taken from Medscape
But for treatment of a first episode of bipolar depression, the jury is still out.
TUCSON, ARIZ. - Lithium remains the experts' top choice in stabilizing bipolar disorder patients who are in a classic manic phase, according to newly revised information in the Expert Consensus Guideline Series.
For pharmacologic treatment of a first episode of depression, the jury is still out-with venlafaxine, bupropion, paroxetine, sertraline, citalopram, and fluoxetine garnering virtually equal acceptance among the nation's leading authorities on bipolar disorder.
An Expert Consensus Guideline Series document on the treatment of bipolar disorder was first published in 1998 (J. Clin. Psychiatry 59[Suppl 4]:73-79, 199 . Intended to provide a resource to clinicians in the absence of clear data, the original guidelines were devised based on answers to a lengthy questionnaire sent to 61 clinical researchers with extensive experience in treating patients with bipolar disorder or conducting studies on its treatment.
The authors recontacted these researchers so the guidelines could be revised to reflect changes in expert opinion.
Dr. Alan J. Gelenberg, head of psychiatry at the University of Arizona in Tucson, offered a sneak preview of the experts' most current suggestions during a psy- chopharmacology conference sponsored by the university. The official guidelines are in press, to be published in the Journal of Clinical Psychiatry.
Preferred mood stabilizers for mania have not changed materially, he said, with lithium considered first line for classic, euphoric mania.
Valproate edges out lithium for mixed or dysphoric acute mania or rapid-cycling acute mania.
Some experts consider carbamazepine a "next-line" option, but Dr. Gelenberg noted that studies have failed to demonstrate a vigorous response to the drug.
"The data on the efficacy of carbamazepine have never been very strong in acute mania or bipolar disorder in general, and it's unlikely to get any better," he said.
The experts have not rallied around any specific drug for treating a first episode of bipolar depression.
"There really is a horse race here," said Dr. Gelenberg. "Venlafaxine and bupropion edge out an SSRI [selective serotonin reuptake inhibitor] a little bit [for severe melancholic depression], but the experts are going for a variety of drugs."
"Choose as you will," he advised.
For severe atypical depression without psychosis, drugs preferred by the experts included, in order, bupropion, paroxetine, sertraline, venlafaxine, citalopram, fluoxetine, and a MAO inhibitor. But the overlap was considerable and no drug was preferred by a significant margin.
In moderate first-time depression, bupropion held a barely significant edge over paroxetine, citalopram, fluoxetine, and venlafaxine.
The experts also were asked how long to continue medication for a first-time acute episode of bipolar depression. For a severe depression with or without psychotic features, the minimum recommended treatment period was about 9 weeks, while the maximum was 22-23 weeks.
About a quarter of respondents would treat such a patient with an antidepressant indefinitely.
"Most of us tend to pull the drug after a few months to avoid triggering a swing back into mania," said Dr. Gelenberg.
After a first-time episode of psychotic depression, experts would continue an antipsychotic for an average minimum of 7 weeks and a maximum of 22 weeks.
Very few experts would continue an antipsychotic medication indefinitely.
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