双相障碍的锂盐长程治疗循证

本文从循证医学的角度对锂盐长期治疗双相障碍的有关文献进行综述。     

双相障碍的药物治疗

本文以美国2000年版双相障碍药物治疗准则为基础，重点介绍锂盐与抗癫痫药物、非典型抗精神病药物、以及新的心境稳定剂等在双相障碍中的应用。     

双相情感障碍药物治疗规范化程序草案

1　双相情感障碍治疗规范化程序草案制定说明1 .1　自 2 0世纪 80年代以来 ,各类精神药物的研究发展甚快 ,可供临床医师选择的药物品种繁多 ;此外 ,还存在同一类药物可对多种疾病有效 ,而同一疾病又可使用多种不同类别药物单独或联合治疗的复杂情况。临床医师面临着如何合理选择药物及制定治疗方案的问题 ,特别对年轻而又缺乏临床经验的医师及医学文献资料不足的基层医疗机构的医师更是如此。为此 ,早在 2 0世纪 80年代后期 ,国际上已有由精神药物学家及精神病学家开始制定常见精神疾病的治疗规范化程序 ,并不断实践修改 ,目前一些国家已有…     

双相障碍和焦虑障碍共病的药物治疗

在临床实践中,可以发现双相障碍和焦虑障碍常常同时存在,虽然二之间的具体关系尚在进一步的研究探讨阶段,但已有研究显示,双相障碍和焦虑障碍共病是双相障碍患最常见的共病形式。Boylan等研究发现,至少有55．8％的双相障碍患和一种焦虑障碍共病,大约31．8％的双相障碍患与多种焦虑障碍共病。根据DSM-Ⅳ的分类,焦虑障碍包括惊恐障碍（panicdisorder,PD）、广泛性焦虑障碍（generalizedanxiety disorder,GAD）、恐怖障碍（phobia disorder）、强迫障碍（obsessive—compulsive disorder,OCD）和创伤后应激障碍（posttraumtic stress disorder,PTSD）等。Boylan等指出双相障碍与上述几种类型的焦虑障碍的共病率分别为20．8％、30％、7．8％～47．2％、3．2％～35％、40％。有研究指出双相障碍和焦虑障碍共病时焦虑障碍对双相障碍的病程影响很大,具体表现为与焦虑障碍共病的双相障碍患较无焦虑障碍共病的双相障碍患发病年龄会提前3～4年;与焦虑障碍共病增加了双相障碍患的自杀行为和物质滥用的发生率;与焦虑障碍共病降低了双相障碍患的生活质量,对患的家庭、工作和社会功能均造成了一定的损害,加大了治疗难度,也加重了患的经济负担。有献报道双相障碍Ⅰ型较双相障碍Ⅱ型与焦虑障碍共病率高,即双相障碍Ⅰ型患更易伴有焦虑障碍。     

双相情感障碍药物治疗进展

双相情感障碍是精神科常见疾病，病程复杂，治疗棘手，本文综述了双相情感障碍药物治疗的近期进展。     

难治性双相情感障碍的药物治疗

本文介绍了难治性双相情感障碍的诊断概念及药物治疗现状。     

2006年我国十省市双相障碍患者药物使用的横断面调查

目的 调查2006年我国10省市双相障碍患者药物治疗现况.方法 根据经济发展水平,按照方便取样原则,在我国10省市41所精神疾病专科医院或综合医院精神科,选择760例年龄16～65岁,符合国际疾病分类第10版精神和行为障碍分类双相情感障碍诊断标准,接受精神药物治疗的双相障碍门诊和住院患者,于2006年5月22-28日使用自制修订的调查问卷调查双相障碍患者药物治疗的处方方式.结果 (1)760例患者中,门诊患者为329例(43.3％);住院患者为431例(56.7％);男436例(57.4％),女318例(41.8％),缺失6例(0.8％)数据.(2) ＞2/3的患者表现为情感高涨(481例,63.3％)、活动增多(513例,67.5％)及思维奔逸(436例,57.4％),162例(21.3％)患者以抑郁表现为主,60例(7.9％)患者伴有精神病性症状,48例(6.3％)患者有自杀观念或行为.住院患者处于急性治疗期、伴精神病性症状的患者比例显著高于门诊患者,并且功能损害更严重.(3)671例(88.3％)患者接受心境稳定剂治疗,主要是碳酸锂和丙戊酸盐;593例(78.0％)患者接受了抗精神病药治疗,按照使用频率高低前5种药物分别是:氯氮平、利培酮、氯丙嗪、奎硫平和氟哌啶醇;142例(18.7％)患者接受了抗抑郁药治疗,其中78例(63.4％)选择新型抗抑郁药选择性5-羟色胺再摄取抑制剂.(4)住院患者使用抗精神病药的比例明显高于门诊患者(87.0％vs 66.3％,x2=46.835,P=0.000),门诊患者接受抗抑郁药治疗的比例显著高于住院患者(22.5％ vs 15.8％,x2=5.538,P=0.019).(5)606例(79.8％)的患者联合2种或3种药物治疗,主要治疗方案是心境稳定剂联合抗精神病药,双相抑郁发作以心境稳定剂联合抗抑郁药治疗为主.(6)患者对治疗药物(抗精神病药、心境稳定剂或抗抑郁药)的选择受不同临床症状的影响(P＜0.05).结论 临床实践中,双相障碍以联合治疗为主,心境稳定剂联合抗精神病药及联合抗抑郁药分别是双相躁狂和双相抑郁患者的主要治疗方案,治疗药物选择主要受患者临床症状的影响.     

双相情感障碍药物治疗进展

双相情感障碍是精神科常见疾病 ,病程复杂 ,治疗棘手 ,本文综述了双相情感障碍药物治疗的近期进展     

双相障碍患者伴发焦虑症状的药物治疗的研究进展

双相障碍患伴发焦虑症状十分常见,这已经引起精神科医生的高度重视。双相障碍患伴发焦虑症状通常与下列因素相关：（1）发病年龄早,抑郁发作次数多,症状严重,出现自杀行为;（2）高致残率和隐匿型抑郁;（3）精力和体力的明显下降;（4）物质滥用以及进食障碍。因此,伴发焦虑症状的双相障碍患通常在急性期和维持治疗阶段疗效欠佳,且预后不良。另外,伴发惊恐障碍和广泛性焦虑的患对锂盐或抗惊厥药物的疗效欠佳。近期,有的学提出一种假设,即双相障碍患伴发惊恐障碍和／或广泛性焦虑,或伴发社交焦虑障碍,可能是双相障碍的一种特殊类型。对于双相障碍与焦虑障碍共病患,药物治疗的目的应该是要致力于使二种精神障碍都得以缓解,而不是在治疗一种精神障碍的同时造成另一种精神障碍病情恶化,这也是目前临床治疗上的一个挑战。     

双相障碍抑郁发作药物治疗的研究进展

以抑郁为首发的双相障碍患者往往进行抗抑郁治疗,很少联合应用心境稳定剂[1],致使很多患者转躁.重性抑郁障碍(MDD)和双相障碍在最新的DSM-5中是两种并列的主要心境障碍,近年来随着新的抗抑郁药不断出现,使大家对MDD的关注相对较多,国外有资料显示,双相障碍被误诊为单相抑郁多达40%,平均延误诊断7.5年,约1/3患者因为未使用心境稳定剂而影响疗效.MDD和双相障碍抑郁发作是两种完全不同的疾病,后者的临床表现和病程变化更为复杂,增加了治疗的难度,预后效果更差,抗抑郁治疗易转相,故而有效治疗双相障碍抑郁发作受到越来越多的关注[2].本文对双相障碍抑郁发作药物治疗的新发展进行综述如下.     

An evidence-based medicine strategy for achieving remission in bipolar disorder

Controlled trials have demonstrated the efficacy of several classes of drugs for achieving acute response in bipolar mania and depression. For many years, clinical response has been the primary outcome in the majority of short-term efficacy studies. However, there is a growing consensus that the optimal goal in the long-term management of bipolar disorder is remission. The purpose of this article is to briefly summarize the clinical importance of remission in bipolar disorder and to review data on the effectiveness of available treatments for achieving and sustaining remission.     

Refractoriness in bipolar disorder: definitions and evidence-based treatment

Defining refractoriness in bipolar disorder is complex and should concern and include either every phase and pole or the disorder as a whole. The data on the treatment of refractory bipolar patients are sparse. Combination and add-on studies suggest that in acutely manic patients partial responders to lithium, valproate, or carbamazepine, a good strategy would be to add haloperidol, risperidone, olanzapine, quetiapine, or aripiprazole. Adding oxcarbazepine to lithium is also a choice. There are no reliable data concerning the treatment of refractory bipolar depressives and also there is no compelling data for the maintenance treatment of refractory patients. It seems that patients stabilized on combination treatment might do worse if shifted from combination. Conclusively there are only limited and sometimes confusing data on the treatment of refractory bipolar patients. Further focused research is necessary on this group of patients.     

Asenapine in bipolar disorder: efficacy, safety and place in clinical practice

Asenapine is a new second-generation antipsychotic (SGA) approved in September 2010 by the European Medicines Agency for the treatment of bipolar disorder. It was significantly more effective than placebo in acute mania or mixed episodes as monotherapy or adjunctive therapy to mood stabilizers (lithium or valproate). Early improvement was seen at day-2 (significant difference with placebo) and was strongly associated with week-3 response and remission. These suggest that the observation of an early improvement in the first week may be clinically an useful tool for individual treatment adjustment during the early course of treatment. Post-hoc analyses of asenapine studies showed significantly better effects on improving depressive symptoms associated with manic symptoms, and physical health related quality of life dimensions as compared to placebo. Asenapine differs from the other SGAs by a good tolerability profile, in particular in terms of metabolic profile. However, it seems to have a significant though moderate link with the occurrence of sedation. This new tolerance profile greatly broadens the scope of SGAs and supports the view of some authors that the term SGA is now outdated. Other therapeutic perspectives of asenapine are being assessed, in particular in specific population (pediatric and elderly patients).     

Lamotrigine in bipolar disorder: efficacy during pregnancy

Objective:  Clinical management of bipolar disorder (BPD) patients during pregnancy is a major challenge. The high risk of bipolar depression during pregnancy encourages consideration of lamotrigine (LTG). We therefore compared recurrence risks among pregnant women with BPD treated with LTG to those discontinuing mood stabilizer therapies.
Methods:  We compared risks and weeks to new DSM-IV illness-episodes among 26 initially clinically stable pregnant women diagnosed with DSM-IV BPD who continued LTG treatment to those discontinuing all mood stabilizer treatment during pregnancy.
Results:  The risk of new illness-episodes with LTG was 30% versus 100% after discontinuing mood stabilizers, and survival-computed time-to-25%-recurrence was 28.0 versus 2.0 weeks (χ² = 17.3, p < 0.0001; hazard ratio = 12.1; 95% confidence interval = 1.6–91.7).
Conclusions:  Discontinuing mood stabilizer treatment presents high risks of illness-recurrence among pregnant women diagnosed with BPD. LTG may afford protective effects in pregnancy, and its reported fetal safety compares favorably to other agents used to manage BPD.     

Third generation anticonvulsants in bipolar disorder: a review of efficacy and summary of clinical recommendations

BACKGROUND: To review the literature on efficacy of third generation anticonvulsants for treatment of bipolar disorder and provide clinical recommendations. METHOD: Open and controlled studies, case reports, and case series on the efficacy of lamotrigine, gabapentin, topiramate, tiagabine, and zonisamide were located through electronic searches of several databases, by manual search of proceedings of international meetings, and through contacting authors of recent reports. RESULTS: Lamotrigine is the best studied anticonvulsant and has efficacy in acute bipolar depression and in longer term treatment of bipolar depression as well as rapid-cycling bipolar II disorder but not in acute mania. Open reports suggest usefulness of gabapentin as an adjunct in bipolar disorder, but double-blind trials failed to confirm efficacy in acute mania and treatment-resistant rapid-cycling bipolar disorder. Topiramate is reported to be effective in acute mania and rapid-cycling bipolar disorder in several open studies, but methodological problems in a double-blind study led to a failed study in acute mania. However, topiramate may lead to weight loss in some patients. Zonisamide deserves further investigation, but tiagabine does not appear to be useful in acute mania. CONCLUSION: Lamotrigine clearly fills an unmet need in treating bipolar depression and rapid-cycling bipolar disorder. Other third generation anticonvulsants with the exception of tiagabine offer promise but require confirmation of their efficacy from double-blind studies.     

Atypical antipsychotics: efficacy across bipolar disorder subpopulations

Atypical antipsychotic medications, used as monotherapy or as adjunctive therapy with mood stabilizers, have shown efficacy and tolerability for 4 subpopulations of patients with bipolar disorder: patients with mixed mania, patients with psychotic episodes, children and adolescents, and the elderly. Patients experiencing mixed mania generally respond poorly to lithium therapy and are more difficult to treat than patients with pure mania. Atypical antipsychotics are increasingly being considered for this bipolar subpopulation because of their efficacy as antimanic agents, and because they are less likely to cause as many or as severe adverse events as conventional antipsychotics. Atypical antipsychotics have also demonstrated beneficial effects as monotherapy and adjunctive therapy for bipolar I disorder patients experiencing psychotic states. In addition, they have shown effectiveness and tolerability in small-scale and open-label trials and case studies with pediatric and geriatric bipolar patients.     

Development of evidence-based performance measures for bipolar disorder: overview of methodology

The STAndards for BipoLar Excellence (STABLE) Project was organized in 2005 to improve quality of care for bipolar disorder by developing and testing a set of evidence-based clinical process performance measures related to identifying, assessing, managing, and coordinating care for bipolar disorder. This article first briefly reviews the literature on the science of performance measurement and the use of performance measures as a tool for quality improvement. It then presents a detailed overview of the methodology used to develop the STABLE performance measures. Steps included choosing a clinical area to be measured, selecting key aspects of care for measurement, designing specifications for the measures, developing a data collection strategy, testing the scientific strength (validity, reliability, feasibility) of the measures, and obtaining, analyzing, and reporting conformance findings for the measures. Five of the STABLE measures have been endorsed by the National Quality Forum as part of their Standardizing Ambulatory Care Performance Measures project: screening for bipolar mania/hypomania in patients diagnosed with depression, assessment for risk of suicide, assessment for substance use, screening for hyperglycemia when atypical antipsychotic agents are prescribed, and monitoring change in level of functioning in response to treatment. Additional STABLE measures will be submitted to appropriate national organizations in the future. It is hoped that these measures will be used in quality assessment activities and that the results will inform efforts to improve care for individuals with bipolar disorder.     

Psychological interventions in bipolar disorder: From wishful thinking to an evidence-based approach

OBJECTIVE: We aimed to examine the historical and current relevance of psychosocial approaches to bipolar illness by conducting a systematic review of prospective studies assessing the effectiveness of psychological interventions for bipolar disorder. METHOD: A systematic literature search was conducted using EMBASE, MedLine and PsychLIT and reference sections of papers were scrutinized for further relevant reports. Only four trials met the criteria of a prospective study and achieved the necessary methodological standards. RESULTS: The studies showed benefits for patients in terms of relapse prevention and the reduction of hospitalization rates. Psychoeducation (delivered in groups or as part of a family intervention) and cognitive behavioural therapy were also found to be effective prophylactic treatments for bipolar disorder in medicated patients. Other interventions do not appear to be supported by sufficient evidence. CONCLUSION: Psychological approaches, and particularly psychoeducation and cognitive-behavioural therapies, are evidence-based prophylactic therapies for bipolar patients receiving pharmacotherapy. They should be used as adjuncts to medication where possible in the prevention of bipolar disorder.