Prominent research scientists working to tease out the relative effectiveness of medical treatments for Bipolar Disorder use evidence based methodologies to provide relevant data for clinicians to use when prescribing medications for their patients. Clinical epidemiology uses evidence based methods and is “a basic science for clinical medicine”, and one that provides an additional approach to traditional medical research methods and to patient care (Sackett et al, 1991).
The Lithium Anticonvulsant Evaluation (BALANCE) study was a large-scale, randomized, and controlled trial that compared the long-term efficacy of lithium alone and valproate alone or in combination with each other. The principal investigator of the study, Dr. John R. Geddes and his research team collaborated internationally to conduct this ground-breaking study. The results are impressive, and of course more studies will need to be conducted to replicate their findings.
Overall:
- Lithium did better than Vaproate for mania.
- Lithium in combination with Valproate did better than Valproate alone.
- Lithium did better for depression.
Sackett, D. L., Haynes, R. B., Guyatt, G. H. & Tugwell, P. (1991) Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown.
Slides leveraged from online slide deck titled: Why we need research: a short history of evidence-based psychiatry. John Geddes
Oxford Clinical Trials Unit for Mental Illness.
I found a couple of recent articles that highlight the importance of exercise and self-management strategies in controlling and maintaining mood stability. The first research study followed a group of high functioning people with Bipolar Disorder to see what strategies they used to control their Bipolar Disorder, and the second study investigated the role of exercise in managing Bipolar Disorder.
In the article, What works for people with bipolar disorder? Tips from the experts. Journal of Affective Disorders, Dec. 2009, the authors acknowledge that there is a large gap in the literature about strategies for managing Bipolar Disorder. Treatments are inadequate and there are few effective self-management strategies that have been studied, validated, and documented for use. In this study, the investigators monitored high functioning people with Bipolar Disorder and recorded the self-management strategies that they used to successfully manage their Bipolar Disorder.
The self-management strategies found to be effective were in the areas of: 1) Sleep, rest, exercise and diet; 2) Ongoing monitoring; 3) Enacting a plan; 4) Reflective and meditative practices; 5) Understanding Bipolar Disorder and educating others; 6) Connecting with others. Hear the authors, “The findings constitute hopeful stories for people affected by the disorder and suggest further research to confirm and refine mechanisms of beneficial effect in Bipolar Disorder.”
In another article, Exercise and bipolar disorder: a review of neurobiological mediators, Neuromoleculcar Medicine, 2009;11(4):328-36, researchers reviewed articles published between 1966 and July of 2008. In their abstract they state, “Individualized exercise interventions are capable of alleviating the severity of affective and cognitive difficulties….”
In order to find appropriate studies to review, they cross referenced the term Bipolar Disorder with the following terms: exercise, neurobiology, brain, cognition, neuroplasticity, etc. They reviewed the literature and found evidence that structured exercise regimens do have positive health effects as well as ”robust anti-depressant effects”. They suggest that structured exercise is capable of “improving psychiatric and somatic health in Bipolar Disorder”.
In summary, these two studies focused on people with Bipolar Disorder. The results of both studies conclude that exercise and other self-management strategies can have significant beneficial effects on Bipolar Disorder.
Traversing through the maze of medications used for managing and stabilizing the debilitating mood swings of bipolar disorder can be daunting and frustrating. It can feel like you are on a never ending merry-go-round. a merry-go-round that leaves you on the edge of spinning in and out of control. When I feel that way, I know that my meds are not right and they need some adjusting. After almost five years and one fairly severe manic episode even when medicated, I think (fingers and toes crossed) I’ve found a combination of meds that work well for me – at least for the time being.
I’m on both Lithium Carbonate and Depakote ER in small doses. After getting used to the Depakote ER there are few if any side effects. For the first three months the Depakote ER really, really upset my stomach. My pdoc suggested that I take 500 mg of a supplement called Acetyl L-Carnitine and that made all the difference in my ability to tolerate the Depakote ER. Depakote depletes L-Carnitine. I have no idea how or why it helps with the side effects caused by Depakote but I’m glad that it minimizes the stomach upset. The combination of Lithium and Depakote ER have made a huge difference in how I feel and function. I am much calmer and less prone to anxiety, panic, and irritability now. My thought processes are clearer and I seem to be much more productive. I realize that not all the same medications work for everyone and it takes a trial and error adjustment period, (maybe several adjustment periods) to find a combination that works well to minimize symptoms with minimal or no side effects.
It has taken me several years to get to this point, and I’m glad I kept working at it. Stability makes life much less uncomfortable than it would be if I were unmedicated. If you are struggling with mood swings, anxiety, and that gripping pressure that seems to dwell inside you when your bipolar disorder is untreated, I urge you to consider seeking treatment or continuing to pursue your current treatment and making treatment adjustment with your doctor if you are not content with how you are feeling and doing at this time in your life.
Here’s a link to a great site all about psych medications: http://www.crazymeds.us/
This article was written by Anne Harding for Reuters Health. I found it interesting because I’ve been using ketamine 10 mg once or twice per day as needed in a nasal spray form for both pain and mood regulation. My psychiatrist and his partner are writing an article about the effectiveness of ketamine with their patients and I’m looking forward to reading their article.
Ketamine lifts mood quickly in bipolar disorder
Tue, Aug 3 2010
“An infusion of the anesthetic ketamine can lift mood within minutes in patients suffering from severe bipolar depression, according to a small study out this month in the Archives of General Psychiatry.
The 18 patients in the study had tried an average of seven different drugs for treating their bipolar illness, and were still severely depressed; 55 percent had failed electroconvulsive therapy (ECT), or shock treatment. But within 40 minutes of receiving a ketamine injection, their depressive symptoms improved; the effect persisted for at least three days.
Right now, medications available for treating either major depression or bipolar illness can take weeks, or even months, to work, notes Dr. Carlos A. Zarate Jr. of the National Institutes of Health in Bethesda, Maryland, one of the researchers on the study.
And as a person waits for their medications to kick in, he added, they will continue to have difficulty working and coping with social and family life; they may even be having thoughts of suicide. “We want to alleviate the suffering and get them back to their life,” he said.
Zarate and his colleagues had previously demonstrated that ketamine shots helped some patients with treatment-resistant unipolar depression, meaning they did not cycle through manic episodes. In the new study, they gave patients with bipolar illness ketamine or a placebo on two test days two weeks apart.
All of the patients were on lithium or valproate – two drugs commonly used for bipolar illness – but had not responded to treatment. Nearly all were unemployed, Zarate and his team note, and two-thirds were on psychiatric disability.
Compared to placebo, patients showed significant improvement in mood within 40 minutes of receiving the ketamine infusion, using a common depression rating scale. Symptom improvement peaked two days after the injection, but remained significantly greater than for placebo for three days.
Seventy-one percent of the patients responded to ketamine, meaning they had at least a 50 percent improvement in their depressive symptoms. Six percent responded to placebo.
Side effects included anxiety, “feeling woozy or loopy,” headache, and dissociative symptoms, meaning a temporary sense of disconnection from reality, although there were no serious adverse events. By developing more specifically targeted drugs, Zarate noted, it may be possible to treat patients effectively while avoiding these symptoms.
Ketamine appears to work by “resetting” the way nerve cells process glutamate, a brain chemical key for learning, memory, and other functions, according to Zarate. The problem in bipolar illness and depression, he explains, doesn’t appear to be that a person has too much or too little glutamate; instead, it’s likely that the way their neurons release and take up the chemical is out of whack.
First introduced in 1962, ketamine is used legally in both human and veterinary medicine as an anesthetic. It’s also a drug of abuse, at much higher doses than those used in Zarate’s research; while patients in the current study received about 50 milligrams during a 40-minute period, a dose too low to induce anesthesia, recreational users of ketamine, known as “Special K,” may take hundreds of milligrams per week.
In 1999, US regulators classified ketamine as a Schedule III controlled substance, meaning it has the potential for abuse but is also useful medically.
Ketamine could improve treatment of bipolar illness and depression in a variety of ways, Zarate said; for example, as a means to jump-start standard drug treatment, or as an anesthetic before ECT. “It’s opened the floodgate of many different directions of research, and all of them are quite encouraging,” said Zarate, who along with a co-author has filed for a patent on the use of ketamine in depression. Those rights would be assigned to his employer, the National Institutes of Health.
Efforts are already underway in Europe to develop guidelines for how ketamine should be used and prescribed to treat bipolar illness and depression, the researcher said.
In the US, research is continuing on the drug, he added, and some physicians are likely trying the drug in their patients with bipolar illness or depression who aren’t helped by standard treatments. But, according to Zarate, more research is needed on how to use the drug in the safest and most effective way.
SOURCE: link.reuters.com/wek23n Archives of General Psychiatry, August 2010.”
Recent Comments