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PSYCHIATRY SYMPOSIUM
PSYCHIATRY IN THE 21st CENTURY: FROM MOLECULE TO CLINIC
In the continuation phase of treatment for acute mania, knowledge of the
Wednesday 13th March 2013
Royal College of Physicians,
Regents Park, London
natural duration of an untreated episode and the recognition of mixed states
are key issues. Steve Titmarsh reports on Professor Allan Youngs lecture on
this important topic given at a satellite symposium organised by Lundbeck at
A collaboration between Progress and the
Psychopharmacology Special Interest Group of the Royal College of Psychiatrists
four (Q1) and eight to ten A distinct period of abnormally and persistently elevated, expansive or
months (Q3).10 irritable mood, lasting at least one week (or any duration if hospitalisation
So what might have been is needed
thought of as episode recurrence Three or more of the following symptoms are present to a significant
just a few weeks after an initial degree and persist:
episode has been treated is likely - Increased self-esteem or grandiosity
to be a relapse of the initial - Decreased need for sleep
episode. It is probably not a true - More talkative than usual or pressure to keep talking
recurrence at all, rather a break- - Flight of ideas or subjective experience that thoughts are racing
through of the initial episode. - Distractibility
- Increased goal-directed activity or psychomotor agitation
Therefore recurrence should
- Excessive involvement in pleasurable activities with a high potential for
only be thought of as occurring painful consequences
after the period of spontaneous
natural recover y which could Table 1. DSM-IV symptoms in a manic episode3
even be a year or more after the
initial episode, Professor Young continuation and maintenance 2009;166:173-81.
5. Salvadore G, Quiroz JA, Machado-Vieira R,
explained. treatment is supported by trials of et al. The neurobiology of the switch process
up to around 52 weeks.13,14 In con- in bipolar disorder: a review. J Clin Psychiatry
Implications for continuation trast, a continuation trial of 2010;71:1488-501.
6. Mander AJ, Loudon JB. The rapid recurrence
treatment haloperidol lasted only nine
of mania following abrupt discontinuation of
Understanding the natural weeks.15 lithium. Lancet 1988;2(8601):15-7.
course of mania has significant Professor Young concluded by 7. Strakowski SM, DelBello MP, Fleck DE, et al.
The impact of substance abuse on the course
implications for continuation emphasising that the continua-
of bipolar disorder. Biol Psychiatry 2000;
treatment. Following an acute tion phase of treatment covers a 48:477-85.
manic episode, the duration of period of ongoing vulnerability to 8. www.rcpsych.ac.uk/expertadvice/problems/
the hypothetical untreated relapse following acute mania, bipolardisorder /bipolardisorder.aspx (accessed
3 April 2013).
episode represents a period of commensurate with the estimated 9. Angst J, Sellaro R. Historical perspectives
ongoing vulnerability to episode duration of an untreated manic and natural history of bipolar disorder. Biol
relapse, hence the recommenda- episode. In mixed states, this Psychiatry 2000;48:445-57.
10. Wertham FI. A group of benign chronic
tion that continuation treatment phase of vulnerability may be psychoses: prolonged manic excitements with
should be for 6-12 months after even more prolonged. Current a statistical study of age, duration and fre-
remission.1 guidelines recommend that con- quency in 2000 manic attacks. Am J Psychiatry
1929;86:17-78.
Data on the natural duration of tinuation treatment should last 11. Keller MB, Lavori PW, Coryell W, et al .
mixed episodes are rare. However, for 6-12 months after symptom Differential outcome of pure manic,
in treating mixed mania, it is remission. mixed/cycling and pure depressive episodes in
patients with bipolar illness. JAMA 1986;225
important to consider that 3138-42.
episodes of mixed or rapid cycling References 12. Angst J, Preisig M. Course of a clinical
may well have a longer duration 1. Grunze H, Vieta E, Goodwin GM, et al. The cohort of unipolar, bipolar and schizoaffective
World Federation of Societies of Biological patients. Results of a prospective study from
than pure mania11,12 and a med- Psychiatry (WFSBP) guidelines for the 1959 to 1985. Schweiz Arch Neurol Psychiatr
ication that is effective in pure biological treatment of bipolar disorders: 1995;146:5-16.
mania may not be the treatment update 2009 on the treatment of acute 13. McIntyre RS, Cohen M, Zhao J, et al .
mania. World J Biol Psychiatry 2009;10: Asenapine for long-term treatment of
of choice for a mixed episode. For 85-116. bipolar disorder: a double-blind 40-week
instance, most efficacy data on the 2. Goodwin FK, Jamison KR. Manic-Depressive extension study. J Affect Disord 2010;126:
treatment of mixed mania comes Illness: Bipolar Disorder and Recurrent 358-65.
Depression. 2nd edition. New York: Oxford 14. Quiroz JA, Yatham LN, Palumbo JM, et al.
from the post hoc analysis of ran- University Press, 2007. Part V: Treatment. Risperidone long-acting injectable
domised controlled trials. These Chapter 17: Fundamentals of treatment. monotherapy in the maintenance treatment
data suggest that lithium may not Stages of treatment, pp702-3. of bipolar I disorder. Biol Psychiatry 2010;
3. American Psychiatric Association. Diagnostic 68:156-62.
be so efficacious in mixed states as
and Statistical Manual of Mental Disorders, 15. Smulevich AB, Khanna S, Eerdekens M, et
valproate, risperidone or olanzap- 4th edition (DSM-IV). Washington DC: al . Acute and continuation risperidone
ine.1 However, these data are not American Psychiatric Association, 1994. monotherapy in bipolar mania: a 3-week
conclusive. 4. Goldberg JF, Perlis RH, Bowden CL, et al. placebo-controlled trial followed by a 9-week
Manic symptoms during depressive episodes double-blind trial of risperidone and haloperi-
Professor Young added that the in 1,380 patients with bipolar disorder: find- dol. Eur Neuropsychopharmacol 2005;15:
use of newer anti-manic agents in ings from the STEP-BD. Am J Psychiatry 75-84.