Clinical practice study supports ISBD recommendations

By Eleanor McDermid, Senior medwireNews Reporter

Findings in patients with bipolar disorder given short-term antidepressant treatment support the recent International Society for Bipolar Disorder’s (ISBD) task force recommendations.

However, Antonio Tundo (Istituto di Psicopatologia, Roma, Italy) and co-workers propose two modifications to the consensus recommendations, to potentially increase the number of treatable patients and improve safety.

The first is to treat patients irrespective of their history of response to antidepressants. “Our impression is that the exclusion of patients with a previous history of nonresponse to [antidepressants] is not justifiable”, they say.

They found that treatment was at least as effective in patients with bipolar disorder, despite the inclusion of previous nonresponders, as in those with unipolar depression. Considering the “mediocre evidence base” for the exclusion of nonresponders, the team believes this recommendation should be reconsidered.

Tundo et al treated 154 patients with unipolar depression, 49 with bipolar I disorder and 52 with bipolar II disorder according to the ISBD recommendations. At 12 weeks, treatment response was similar in all three groups, with 64.9% of patients with unipolar depression and 75.5% and 75.0% of those with bipolar I and II disorder, respectively, achieving at least a 50% reduction in baseline 21-item Hamilton Depression Rating Scale (HDRS) scores.

Likewise, remission, defined as a HDRS score below 7, was achieved by 51.3%, 61.2% and 65.4% of patients with unipolar, bipolar I and bipolar II depression, respectively, with no difference between the groups.

The second variance from the ISBD guidelines is to use adjunctive mood stabilisers in patients with bipolar II disorder, as well as those with bipolar I disorder.

“This modification was intended to protect against antidepressant-induced switching”, Tundo et al write in the Journal of Affective Disorders, noting evidence that the strategy reduces the risk of treatment-emergent mania and suicidality.

They found that two patients with bipolar I disorder displayed signs of treatment-emergent mania, but so did one with bipolar II disorder. One bipolar I disorder patient attempted suicide during antidepressant treatment.

The researchers stress that their findings are applicable only to patients with “pure” bipolar depression, because, in accordance with ISBD advice, they excluded patients with mixed states, who comprised about a quarter of the initial sample. They add that their proposed modifications warrant further study.

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