Bipolar Disorder: Berk M

Malhi GS, Adams D, Lampe L, Paton M, O'Connor N, Newton LA, Walter G, Taylor A, Porter R, Mulder RT, Berk M, Anonymous00020, Anonymous00021, Anonymous00022. · CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia. · Acta Psychiatr Scand Suppl. · Pubmed #19356155 No free full text.

Abstract: OBJECTIVE: To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making. METHOD: A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives. RESULTS: The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative. CONCLUSION: These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

Berk M, Dodd S, Berk L, Opie J. · No affiliation provided · Br J Gen Pract. · Pubmed #16176731 links to  free full text

This publication has no abstract.

Berk M, Dodd S. · No affiliation provided · Hum Psychopharmacol. · Pubmed #15614839 No free full text.

This publication has no abstract.

Dodd S, Dean O, Copolov DL, Malhi GS, Berk M. · University of Melbourne, Department of Clinical and Biomedical Sciences, Barwon Health, PO Box 281, Geelong 3220, Victoria, Australia. · Expert Opin Biol Ther. · Pubmed #18990082 No free full text.

Abstract: BACKGROUND: Glutathione is an endogenous antioxidant and has a ubiquitous role in many of the body's defences. Treatment with N-acetylcysteine (NAC) has been shown to increase levels of glutathione. NAC has been proposed as a treatment for several illnesses. OBJECTIVES: The efficacy and tolerability of NAC was examined across a range of conditions to evaluate the evidence supporting the use of NAC for each indication. METHODS: A literature search was conducted using PubMed. Information was also collected from other online sources including the websites of the Therapeutic Goods Administration of Australia and the FDA. RESULTS: Reports ranged from case studies to clinical trials. There is strong evidence to support the use of NAC for the treatment of paracetamol overdose and emerging evidence suggesting it has utility in psychiatric disorders, particularly schizophrenia and bipolar disorder. NAC is safe and well tolerated when administered orally but has documented risks with intravenous administration.

Berk M, Malhi GS, Hallam K, Gama CS, Dodd S, Andreazza AC, Frey BN, Kapczinski F. · Department of Clinical and Biomedical Sciences, University of Melbourne, PO Box 281, Geelong, Australia. · J Affect Disord. · Pubmed #18819715 No free full text.

Abstract: In the absence of clear targets for primary prevention of many psychiatric illnesses, secondary prevention becomes the most feasible therapeutic target, and is best encompassed by the concept of early intervention. This construct encompasses the goals of minimising diagnostic delay and the prompt initiation of clinically appropriate therapy. This paper develops the rationale for early intervention in bipolar disorder. Three interrelated themes are discussed; the clinical data supporting the value of prompt diagnosis and treatment in bipolar disorder, the putative biochemical mechanisms underlying the pathophysiological processes, and the parallel concept of neuroprotection, and the developing neuroimaging data that supports early intervention. Early initiation of appropriate therapy may potentially facilitate improved clinical outcomes, and further might allow the secondary prevention of the sequelae of untreated illness, which include the deleterious impact on family relationships, psychosexual and vocational development, identity and self-concept and self-stigma.

Bora E, Yucel M, Fornito A, Berk M, Pantelis C. · Department of Psychiatry, Melbourne Neuropsychiatry Centre, and Melbourne Health, ORYGEN research Centre, The University of Melbourne, Melbourne, Vic, Australia. · Acta Psychiatr Scand. · Pubmed #18699952 No free full text.

Abstract: OBJECTIVE: Evidence related to overlapping clinical and genetic risk factors in schizophrenia and bipolar disorder (BD) have raised concerns about the validity of 'Kraepelinian dichotomy'. As controversies mainly arise in mixed psychoses that occupy the intermediate zone between schizophrenia and BD, investigating neurobiological markers of mixed psychoses may be relevant to understanding the nature of psychotic disorders. METHOD: In this article, we review studies comparing magnetic resonance imaging, neuropsychological and electrophysiological findings in mixed psychoses with each other, as well as with more prototypical cases of schizophrenia and BD. RESULTS: The evidence reviewed suggests that mixed psychoses may be associated with different genetic and neurobiological markers compared with prototypical forms of schizophrenia and BD. CONCLUSION: These findings may be compatible with more sophisticated versions of dimensional and continuum models or, alternatively, they may suggest that there is an intermediate third category between prototypical schizophrenia and BD.

Dodd S, Berk M. · Department of Clinical and Biomedical Sciences - Barwon Health, University of Melbourne, Geelong, Australia. · Curr Drug Saf. · Pubmed #18690912 No free full text.

Abstract: Risks associated with pharmacological treatment of bipolar disorder are heightened during reproductive events. Treatments need to be planned with the mutual agreement of both the treating physician and the patient and tailored to the needs of the individual so as to minimise risk while providing adequate treatment. Conventional treatments have all been associated with teratogeny in first trimester exposure, lithium with cardiac malformation and valproate and carbamazepine with neural tube malformations. There have been an insufficient number of first trimester exposures to the newer anticonvulsant mood stabilisers, lamotrigine and oxcarbazepine, to determine whether there is a safety advantage in switching to these agents. Increasingly, atypical antipsychotics are being suggested as useful agents for the treatment of bipolar disorder. While not known to be teratogenic, there are other reproductive safety concerns associated with these agents. Bipolar disorder patients may be prescribed antidepressants, and many of these agents are associated with a low safety risk during reproductive events, however data regarding use of these agents are currently equivocal. Adverse outcomes from inadequate pharmacological prophylaxis have been documented for both the mother and the baby. Risks and benefits need to be carefully balanced based on an accurate review of the evidence.

Conus P, Ward J, Hallam KT, Lucas N, Macneil C, McGorry PD, Berk M. · Treatment and Early Intervention in Psychosis Program (TIPP), Département Universitaire de Psychiatrie CHUV, Lausanne University, Clinique de Cery, Prilly, Switzerland. · Bipolar Disord. · Pubmed #18657240 No free full text.

Abstract: OBJECTIVE: Affective psychoses and bipolar disorders have been neglected in the development of early intervention strategies. This paper aims to gather current knowledge on the early phase of bipolar disorders in order to define new targets for early intervention. METHODS: Literature review based on the main computerized databases (MEDLINE, PUBMED and PSYCHLIT) and hand search of relevant literature. RESULTS: Based on current knowledge, it is likely that an approach aiming at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment. Additionally, various risk factors and markers of vulnerability to bipolar disorders have been identified. CONCLUSIONS: In the few months preceding first-episode mania, patients go through a prodrome phase (proximal prodrome) that could become an important target for early intervention. However, considering the low specificity of the symptoms observed during this phase, criteria defining high-risk profiles to first-episode mania should also include certain risk factors or markers of vulnerability. While more research is needed in high-risk groups (e.g., bipolar offspring), retrospective studies conducted in first-episode mania cohorts could provide valuable information about this critical phase of the illness.

Ng F, Berk M, Dean O, Bush AI. · Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, VIC, Australia. · Int J Neuropsychopharmacol. · Pubmed #18205981 No free full text.

Abstract: Oxidative stress has been implicated in the pathogenesis of diverse disease states, and may be a common pathogenic mechanism underlying many major psychiatric disorders, as the brain has comparatively greater vulnerability to oxidative damage. This review aims to examine the current evidence for the role of oxidative stress in psychiatric disorders, and its academic and clinical implications. A literature search was conducted using the Medline, Pubmed, PsycINFO, CINAHL PLUS, BIOSIS Preview, and Cochrane databases, with a time-frame extending to September 2007. The broadest data for oxidative stress mechanisms have been derived from studies conducted in schizophrenia, where evidence is available from different areas of oxidative research, including oxidative marker assays, psychopharmacology studies, and clinical trials of antioxidants. For bipolar disorder and depression, a solid foundation for oxidative stress hypotheses has been provided by biochemical, genetic, pharmacological, preclinical therapeutic studies and one clinical trial. Oxidative pathophysiology in anxiety disorders is strongly supported by animal models, and also by human biochemical data. Pilot studies have suggested efficacy of N-acetylcysteine in cocaine dependence, while early evidence is accumulating for oxidative mechanisms in autism and attention deficit hyperactivity disorder. In conclusion, multi-dimensional data support the role of oxidative stress in diverse psychiatric disorders. These data not only suggest that oxidative mechanisms may form unifying common pathogenic pathways in psychiatric disorders, but also introduce new targets for the development of therapeutic interventions.

Cassidy F, Yatham LN, Berk M, Grof P. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA. · Bipolar Disord. · Pubmed #18199232 No free full text.

Abstract: OBJECTIVE: To review issues surrounding the diagnosis and validity of bipolar manic states. METHODS: Studies of the manic syndrome and its diagnostic subtypes were reviewed emphasizing historical development, conceptualizations, formal diagnostic proposals, and validation. RESULTS: Definitions delineating mixed and pure manic states derive some validity from external measures. DSM-IV and ICD-10 diagnosis of bipolar mixed states are too rigid and less restrictive definitions can be validated. Anxiety is a symptom often overlooked in diagnosis of manic subtypes and may be relevant to the mixed manic state. The boundary for separation of mixed mania and depression remains unclear. A 'pure' non-psychotic manic state similar to Kraepelin's 'hypomania' has been observed in several independent studies. CONCLUSIONS: Issues surrounding diagnostic subtyping of manic states remain complex and the debates surrounding categorical versus dimensional approaches continue. To the extent that categorical approaches for mixed mania diagnosis are adopted, both DSM-IV and ICD-10 are too rigid. Inclusion of non-specific symptoms in definitions of mixed mania, such as psychomotor agitation, does not facilitate and may hinder the diagnostic separation of pure and mixed mania. The inclusion of a diagnostic seasonal specifier for DSM-IV, which is currently based on seasonal patterns for depression might be expanded to include seasonal patterns for mania. Boundaries between subtypes may be 'fuzzy' rather than crisp, and graded approaches could be considered. With the continued development of new tools, such as imaging and genetics, alternative approaches to diagnosis other than the purely symptom-centric paradigms might be considered.

Berk M, Conus P, Lucas N, Hallam K, Malhi GS, Dodd S, Yatham LN, Yung A, McGorry P. · Barwon Health and The Geelong Clinic, Geelong, Victoria, Australia. · Bipolar Disord. · Pubmed #17988356 No free full text.

Abstract: Bipolar disorder is common, and both difficult to detect and diagnose. Treatment is contingent on clinical needs, which differ according to phase and stage of the illness. A staging model could allow examination of the longitudinal course of the illness and the temporal impact of interventions and events. It could allow for a structured examination of the illness, which could set the stage for algorithms that are tailored to the individuals needs. A staging model could further provide as structure for assessment, gauging treatment and outcomes. The model incorporates prodromal stages and emphasizes early detection and algorithm appropriate intervention where possible. At the other end of the spectrum, the model attempts to operationalize treatment resistance. The utility of the model will need to be validated by empirical research.

Berk M, Hallam K, Lucas N, Hasty M, McNeil CA, Conus P, Kader L, McGorry PD. · Barwon Health, University of Melbourne, Geelong, VIC, Australia. · Med J Aust. · Pubmed #17908017 links to  free full text

Abstract: The early phases of bipolar disorders are difficult to diagnose and have specific treatment issues. The initial polarity of the illness is more commonly depressive, yet in counterpoint, mania is required for diagnosis; consequently, there is often a substantial delay in the initiation of appropriate therapy. There is good evidence that lithium in particular is most effective early in the illness course, and that its efficacy declines after multiple episodes. The notion of neuroprotection reflects this, and furthermore suggests that appropriate therapy may prevent the neurostructural and neurocognitive changes seen in the disorder. Inappropriate therapy may worsen the course of the illness. Patients with a first episode have specific psychosocial needs, and adherence to medication is relatively poor. There is a need for early identification, and to develop treatments and services applicable to the specific needs of this population.

Berk M, Dodd S, Kauer-Sant'anna M, Malhi GS, Bourin M, Kapczinski F, Norman T. · Department of Clinical and Biomedical Sciences, Barwon Health and The Geelong Clinic, University of Melbourne, Geelong, Victoria, Australia. · Acta Psychiatr Scand Suppl. · Pubmed #17688462 No free full text.

Abstract: OBJECTIVE: Rational therapeutic development in bipolar is hampered by a lack of pathophysiological model. However, there is a wealth of converging data on the role of dopamine in bipolar disorder. This paper therefore examines the possibility of a dopamine hypothesis for bipolar disorder. METHOD: A literature search was conducted using standard search engines Embase, PyschLIT, PubMed and MEDLINE. In addition, papers and book chapters known to the authors were retrieved and examined for further relevant articles. RESULTS: Collectively, in excess of 100 articles were reviewed from which approximately 75% were relevant to the focus of this paper. CONCLUSION: Pharmacological models suggest a role of increased dopaminergic drive in mania and the converse in depression. In Parkinson's disease, administration of high-dose dopamine precursors can produce a 'maniform' picture, which switches into a depressive analogue on withdrawal. It is possible that in bipolar disorder there is a cyclical process, where increased dopaminergic transmission in mania leads to a secondary down regulation of dopaminergic receptor sensitivity over time. This may lead to a period of decreased dopaminergic transmission, corresponding with the depressive phase, and the repetition of the cycle. This model, if verified, may have implications for rational drug development.

Malhi GS, Berk M. · Psychological Medicine, Northern Clinical School, University of Sydney, NSW, Australia. · Acta Psychiatr Scand Suppl. · Pubmed #17280577 No free full text.

Abstract: OBJECTIVE: To examine the evidence that dopamine (DA) dysfunction contributes to melancholic depression. METHOD: Database (EMBASE, PsychLit and MEDLINE) searches using relevant key words were conducted and citations were scrutinized. RESULTS: In this paper, we assume that the definition of melancholia is contingent upon the presence of psychomotor disturbance (PMD). In melancholic depression PMD comprises both a cognitive and motor component and DA is found to be important in both. DA neurotransmission modulates cognition in particular in attention, adaptation and motivational processes and has a pivotal role in motor function. CONCLUSION: DA is a credible aetiological candidate for the PMD in melancholic depression. However, melancholia needs first to be characterized both clinically and in terms of its pathophysiology. In this regard, illnesses such as bipolar depression and Parkinson's disease warrant consideration as they provide suitable models of both the cognitive and motor aspects of PMD, and hold the necessary markers to better define melancholia.

Conus P, Berk M, McGorry PD. · Département Universitaire de Psychiatrie CHUV, Université de Lausanne, Treatment and Early Intervention Program for Psychosis (TIPP), Clinique de Cery, Prilly, Switzerland. · Aust N Z J Psychiatry. · Pubmed #16476146 No free full text.

Abstract: OBJECTIVE: To review available guidelines, explore treatment strategies currently applied, identify critical issues and propose direction for new developments. METHOD: Literature review based on Medline search and hand search of relevant literature. RESULTS: Pharmacological treatment of the early phase of bipolar disorders lacks specific guidelines. Mood stabilizers are often prescribed after many years of illness, antipsychotic medications are frequently prescribed and often for extensive periods of time, and adherence to medication is relatively poor. In addition, mania is frequently misdiagnosed, and there is limited knowledge on which to base identification of bipolar depression and identification of the initial prodrome to bipolar disorders. CONCLUSIONS: There is an urgent need for more research in the early phases of bipolar disorders to develop means to identify patients earlier and to develop approaches that would address the specific needs of this population in a more adequate manner.

Chengappa KN, Suppes T, Berk M. · Western Psychiatric Institute and Clinic, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213-2593, USA. · Expert Rev Neurother. · Pubmed #16279862 No free full text.

Abstract: Acute manic episodes in bipolar disorder require rapid and effective relief. Pharmacotherapy has traditionally involved mood stabilizers such as lithium or divalproex. Evidence for the efficacy of atypical antipsychotics to treat bipolar mania, either as monotherapy or in combination with traditional mood-stabilizing agents, has increased in recent years. Since the combination of an atypical agent and a traditional mood stabilizer is generally well tolerated, it represents a first-line approach for the treatment of severe and treatment-resistant mania. Atypical antipsychotics have a superior neurological tolerability profile compared with typical antipsychotics and are preferentially recommended in most treatment guidelines. The atypical agents, olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole, have demonstrated efficacy in bipolar mania in large randomized, controlled studies, and offer efficacy across a broader range of symptoms than typical antipsychotics, and may even have mood-stabilizing properties traditionally associated with lithium and divalproex. Olanzapine, risperidone and quetiapine have been shown to be effective for manic episodes both as monotherapy and in combination with other agents such as lithium and divalproex. Although the tolerability profiles of atypicals as a class are superior to those of conventional antipsychotics, there are differences among the atypical agents in their propensity to cause certain adverse events such as extrapyramidal symptoms (EPS) and weight gain, particularly in the long-term. The ultimate choice of the atypical agent will depend on the patient's individual needs, but atypical antipsychotics are clinically effective options for achieving mood stabilization in the treatment of acute bipolar mania.

Malhi GS, Berk M, Bourin M, Ivanovski B, Dodd S, Lagopoulos J, Mitchell PB. · Mood Disorder Unit, Black Dog Institute, Prince of Wales Hospital, Sydney, Australia. · Acta Psychiatr Scand Suppl. · Pubmed #16104066 No free full text.

Abstract: OBJECTIVE: To assess the potential role of atypical antipsychotics as mood stabilizers.METHOD: A MedLine, PsychLIT, PubMed, and EMBASE literature search of papers published up to December 2004 was conducted using the names of atypical antipsychotics and a number of key terms relevant to bipolar disorder. Additional articles were retrieved by scrutinizing the bibliographies of review papers and literature known to the authors. Data pertinent to the objective was reviewed according to the various phases of bipolar disorder.RESULTS: The data is most substantive for the use of atypical antipsychotics in mania, to the extent that an argument for a class effect of significant efficacy can be made. This does not extend to bipolar depression, however, good data is now emerging for some agents and will need to be considered for each individual agent as it accumulates. As regards mixed states and rapid cycling the evidence is thus far sparse and too few maintenance studies have been conducted to make any firm assertions. However, with respect to long-term therapy the atypical antipsychotics do have clinically significant side-effects of which clinicians need to be aware.CONCLUSION: Based on the evidence thus far it is perhaps premature to describe the atypical antipsychotics as mood stabilizers. Individual agents may eventually be able to claim this label, however, much further research is needed especially with respect to maintenance and relapse prevention.

Berk M, Dodd S, Berk L. · Department of Clinical and Biomedical Sciences, Barwon Health, University of Melbourne, Geelong, Victoria, Australia. · Psychiatry Clin Neurosci. · Pubmed #15896214 No free full text.

Abstract: Recent evidence suggests that the prevalence of bipolar disorder is as much as fivefold higher than previously believed, and may amount to nearly 5% of the population, making it almost as common as unipolar major depression. It is, therefore, not unrealistic to assume that primary care or family physicians will frequently encounter bipolar patients in their practice. Such patients may present with a depressive episode, for a variety of medical reasons, for longer-term maintenance after stabilization, and even with an acute manic episode. Whatever the reason, a working knowledge of current trends in the acute and longer-term management of bipolar disorder would be helpful to the primary care physician. In addition, an understanding of important side-effects and drug interactions that occur with drugs used to treat bipolar disorder, which may be encountered in the medical setting, are paramount. This paper will attempt to review existing and emerging therapies in bipolar disorder, as well as their common drug interactions and side-effects.

Berk M, Dodd S, Malhi GS. · Barwon Health and The Geewong Clinic, Swanston Centre, PO Box 281, Geelong, Victoria 3220, Australia. · Aust N Z J Psychiatry. · Pubmed #15777356 No free full text.

Abstract: OBJECTIVE: To explore diagnostic and treatment issues concerning bipolar mixed states. METHOD: Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed. RESULT: Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression. CONCLUSIONS: The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.

Berk M, Dodd S. · Department of Clinical and Biomedical Sciences, University of Melbourne, Swanston Centre, Geelong, Victoria, Australia. · Bipolar Disord. · Pubmed #15654928 No free full text.

Abstract: OBJECTIVES: To review the current knowledge of bipolar II disorder. METHODS: Literature was reviewed after conducting a Medline search and a hand search of relevant literature. RESULTS: Bipolar II disorder is a common disorder, with a prevalence of approximately 3-5%. Distinct clinical features of bipolar II disorder have been described. The key to diagnosis is the recognition of past hypomania, while depression is the typical presenting feature of the illness. This is responsible for a significant rate of missed diagnosis, and consequent management according to unipolar guidelines. It is unclear if bipolar II disorder is over-represented amongst resistant depression populations and if abrupt offset of antidepressant action is a phenomenon over represented in bipolar II disorder, reflecting induction of predominantly depressive cycling. A few mood-stabilizer studies available provide provisional suggestion of utility. A supportive role for psychosocial therapies is suggested, however, there is a sparsity of published studies specific to bipolar II disorder cohorts. A small number of short-term antidepressant trials have suggested efficacy, however, compelling long-term maintenance data is absent. CONCLUSIONS: An emerging literature on the specific clinical signature and management of the disorder exists, however, this is disproportionately small relative to the epidemiology and clinical significance of the disorder.

Berk M, Dodd S. · Department of Clinical and Biomedical Sciences, The University of Melbourne, Swanston Centre, PO Box 281, Geelong, VIC 3220, Australia. · Drugs. · Pubmed #15631544 No free full text.

Abstract: Bipolar disorder is a severe and recurrent disorder. Atypical antipsychotics have emerged as both an alternative and adjunct to conventional mood stabilisers. The manic phase of the illness is the best studied, and it appears that a class effect with regards to efficacy is present in both monotherapy and augmentation studies.Evidence for efficacy of atypical antipsychotics in depression is emerging. At this stage controlled data are available for both olanzapine and quetiapine. Maintenance data demonstrating efficacy are available for olanzapine. Atypical antipsychotics have utility in treating acute agitation and aggression in manic episodes of bipolar disorder. Subgroup analyses from trials treating manic phase bipolar disorder, and an open-label study of rapid cycling, have suggested that atypical antipsychotics may be useful for the treatment of mixed states and rapid cycling. Several studies have suggested that atypical antipsychotics may be useful in treatment-refractory episodes of bipolar disorder.The current available data suggest greater efficacy of the atypical antipsychotics in mania than in depression, although the data are fairly clear that induction of depression is not an issue with the atypical antipsychotics. A number of trials are underway that will hopefully address many of the questions still pending.

Berk M, Berk L, Castle D. · Department of Clinical and Biomedical Sciences, University of Melbourne, Melbourne, Victoria, Australia. · Bipolar Disord. · Pubmed #15541066 No free full text.

Abstract: OBJECTIVES: The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes. METHODS: A literature search was undertaken using Medline, Ovid, Psychinfo and Science Direct from 1975 to 2004. The following key words were used: bipolar disorder, patient adherence, non-adherence to medication, compliance, doctor-patient relationship, doctor-patient communication, treatment alliance, therapeutic alliance, chronic illness management, collaborative care, self-management, health beliefs, self-efficacy, self-determination, autonomy support, motivational interviewing. RESULTS: Psychosocial interventions have demonstrated positive effects on adherence problems. Studies of the impact of the treatment alliance on outcomes in mental illness highlight the possibilities of fruitful research in this area in bipolar disorder. Different theoretical models of changing health related behaviour may inform approaches to the treatment alliance. CONCLUSIONS: Results suggest the usefulness of a collaborative approach to the treatment alliance. Attention needs to be given to developing intervention models that target modifiable risk factors for non-adherence and address patient, clinician and illness related variables to enhance medication adherence in the treatment alliance. Refinement of these models through controlled evaluation in real world settings may lead to integration in health care delivery systems.

Berk M, Malhi GS, Mitchell PB, Cahill CM, Carman AC, Hadzi-Pavlovic D, Hawkins MT, Tohen M. · Barwon Health and The Geelong Clinic, Geelong, Australia. · Acta Psychiatr Scand Suppl. · Pubmed #15330937 No free full text.

Abstract: OBJECTIVE: To briefly review the clinical and biological distinctions between unipolar and bipolar depression critiquing in particular currently available depression rating scales and discuss the need for a new observer-rated scale tailored to bipolar depression. METHOD: Relevant literature pertaining to the symptomatic differences between bipolar disorder and unipolar disorder as well as their measurement using existing assessment scales was identified by computerized searches and reviews of scientific journals known to the authors. RESULTS: Bipolar depression is distinct from unipolar depression in terms of phenomenology and clinical characteristics. These distinguishing features can be used to identify bipolarity in patients that present with recurrent depressive episodes. This is important because current self-report and observer-rated scales are optimized for unipolar depression, and hence limited in their ability to accurately assess bipolar depression. CONCLUSION: The development of a specific bipolar depression rating scale will improve the assessment of bipolar depression in both research and clinical settings and assist the development of better treatments and interventions.

Dodd S, Berk M. · Department of Clinical and Biomedical Sciences, University of Melbourne, Community and Mental Health, Barwon Health, Swanston Centre, Geelong, Victoria, Australia. · Expert Opin Drug Saf. · Pubmed #15155150 No free full text.

Abstract: Treating bipolar disorder in women during reproduction presents a significant challenge to the physician. The pharmaceutical agents most commonly used for treating bipolar disorder have been associated with adverse effects when used during pregnancy and breastfeeding. Of particular concern has been the association of lithium with cardiac malformations, and the association of carbamazepine and valproate with neural tube defects including spina bifida. Toxicity in neonates has also been reported for the most commonly used mood-stabilising agents. Treatment options for mood stabilisation are either associated with risks of adverse events, have been used less frequently and their associated risks are unknown, or may not provide effective prophylaxis against recurrences of bipolar episodes. However, strategies are available that minimise the risk to the fetus and infant whilst still providing effective prophylaxis against bipolar disorder in the mother. Ideally, a treatment regimen tailored to suit the individual should consider both mother and baby and should be planned prior to conception.

Berk M, Berk L. · Barwon Health and Geelong Clinic, University of Melbourne, Geelong, Victoria, Australia. · Ann Clin Psychiatry. · Pubmed #14971867 No free full text.

Abstract: Adverse events associated with lithium and anticonvulsant use in patients with bipolar disorder have been determined to decrease rates of treatment adherence; however, research that explores how adverse events influence treatment adherence, and which events have the greatest impact, is sparse and limited. This paper reviews the existing literature regarding common side effects encountered with lithium and anticonvulsant use in patients with bipolar disorder and presents data regarding their impact on treatment adherence. Guidelines for reducing and limiting adverse events are highlighted, as are recommendations for improving compliance associated with the experience of adverse events in the bipolar disorder population.