Bipolar Disorder Carlat Reports

Clinical Update

From The Carlat Psychiatry Report, Bipolar Disorder

Topics: | | | | | | | | | | | | | | | | | | ADHD Alpha Agonists Amphetamines ArModafinil Atomoxetine Attention Deficit Hyperactivity Disorder Bipolar Disorder Bipolar II Comorbidity Guanfacine methylphenidate Modafinil Nuvigil Pharmacology Provigil Psychopharmacology Psychopharmacology Tips stimulant Stimulants

Patients with bipolar disorder often present with cognitive complaints. Our October 2021 issue laid out a diagnostic plan for these symptoms, and in this article, I’ll cover some treatment approaches for patients with a DSM-based ADHD-bipolar comorbidity (ie, the ADHD symptoms began in childhood and persist after the mood episodes have stabilized).

Clinical Update

How to Diagnose ADHD in Bipolar Disorder

From The Carlat Psychiatry Report, Mood Disorders

Hailey is a 24-year-old woman with bipolar II disorder who has recently come out of a mixed episode. Although her mood symptoms have resolved, she is distracted easily, has difficulty organizing her work, and often forgets important tasks. She read about ADHD online and asks if she can have a stimulant to help her focus. ADHD and hypomania share many

Research Update

Maintenance Pharmacotherapy of Bipolar Disorder: How Long Is Long Enough?

From The Carlat Psychiatry Report, Problems with Generics

Review of: Kishi T et al, Psychol Med 2020 Oct 13:1–9; PMID: 33046156 Type of study: Meta-analysis of double-blind, randomized placebo-controlled trials Bipolar disorder is a lifelong illness whose treatment is an ongoing challenge, complicated not least by difficulties in treatment adherence. What do we know and what can we tell our patients about

Research Update

Antidepressants Harm Some With Bipolar Depression

From The Carlat Psychiatry Report, Metabolism and Mental Health

Topics: Antidepressants | Bipolar Depression | Bipolar Disorder

REVIEW OF: Ghaemi SN et al, J Clin Psychiatry 2021;82(1):19m13136 Study TYPE: Randomized, double-blind, placebo-controlled trial Antidepressants are controversial in bipolar depression, in part because we don’t have enough well-designed studies to clarify their role. The most rigorous trials have come up negative, and many of the positive ones s

Clinical Update

How to Use Lamotrigine

From The Carlat Psychiatry Report, Mind-Gut Connection

Lamotrigine is FDA approved as maintenance treatment for bipolar disorder—that is, for delaying episodes of depression, hypomania, or mania. However, it is not approved for active depression or mania—which has given it a reputation as a “light” mood stabilizer. For patients who appreciate tolerability, that’s a good thing, but it isn’t the f

Research Update

Mood Stabilizers: What You Don’t Know Can Hurt Them

From The Carlat Psychiatry Report, Mood and Menopause

Review of: Bai Y et al, J Clin Psychopharmacol 2020;40(2):167–179 STUDY TYPE: Combined meta-analysis and literature review of placebo-controlled trials Medication adherence is an ongoing struggle in bipolar disorder, and it’s compounded by the fact that our patients often don’t advertise their non-adherence. While numbers vary, reviews general

Expert Q&A

Who Should Get Lithium?

From The Carlat Psychiatry Report, When to Use Lithium

TCPR: Lithium has been called the gold-standard treatment in bipolar disorder. Why is it not used more often? Dr. Rybakowski: That is a paradox. On the one hand, lithium is accepted as a first-line treatment for bipolar disorder, but it is also greatly underutilized. And I think there are two main reasons. One is aggressive promotion of branded mood st

Research Update

Two Augmentation Strategies Compared in Bipolar I

From The Carlat Psychiatry Report, When to Use Lithium

Review of: Missio G et al, Trials 2019;20(1):608 STUDY TYPE: Randomized, open-label controlled trial It’s rare to see full recovery in bipolar I disorder with a single medicine, so we often depend on some combination of mood stabilizers and/or antipsychotics. Even then, weight gain and metabolic problems are deal-breakers. Some experts favor the c

Research Update

A New Antipsychotic for Bipolar Depression

From The Carlat Psychiatry Report, Traumatic Brain Injury

Lumateperone (Caplyta) just hit the pharmacy shelves with FDA approval in schizophrenia (see TCPR March 2020), and its manufacturer is pursuing further approval for bipolar depression. So far they’ve completed two phase III trials—one negative and one positive—and the positive one was presented in poster form by Suresh Durgam and colleagues at the

Clinical Update

The Modafinils in Bipolar Depression

From The Carlat Psychiatry Report, Borderline Personality Disorder

Your patient has recovered enough from bipolar depression to leave the hospital, but not enough to return to work. He is inactive, he can’t concentrate, and it takes him 4 hours to wake up in the morning. What can you add to his regimen of lithium, lamotrigine, and lurasidone? Modafinil (Provigil) and armodafinil (Nuvigil) are wakefulness-promoting

Expert Q&A

The Psychopharmacology Algorithm Project

From The Carlat Psychiatry Report, Psychopharmacology Algorithms

TCPR: What would be the biggest change in practice if psychiatrists followed your algorithms?Dr. Osser: One area is bipolar depression. This is a disorder where there is an exceptionally large deviation between what the evidence says and what people are doing, especially when it comes to antidepressants. They are still being used rampantly, even in pati

Clinical Update

Oxcarbazepine: Close, but no Cigar

From The Carlat Psychiatry Report, Bipolar II

You are selecting a mood stabilizer for a 29-year-old woman with mania. If it works, she’ll need to take it long term, but with adherence rates hovering around 50% in this illness, that’s not a likely prospect. The FDA-approved options are not very high on tolerability, but what about oxcarbazepine? Oxcarbazepine (Trileptal) is often used in bipo

Expert Q&A

Psychopharmacology in Bipolar II

From The Carlat Psychiatry Report, Bipolar II

Topics: Bipolar Disorder | Hypomania | Mania | Mixed Features | Mood Stabilizers

TCPR: You’ve carved out a unique practice with difficult-to-treat bipolar disorders. Tell us about the patients you see. Dr. Kelly: I see a lot of bipolar II and “softer bipolar.” Clinically these patients have chronic depression, often mixed with hypomanic symptoms. Nearly all have tried multiple antidepressants that didn’t work, stopped worki

Highlights

Highlight From This Issue

From The Carlat Psychiatry Report, Bipolar II

In bipolar disorder, oxcarbazepine is slightly better tolerated than carbamazepine, but less effective. While its medical risks are different, they are by no means safer than carbamazepine’s. Its drug interactions can be a problem as well. On average, higher doses of second-generation antidepressants do not bring greater recoveries in major depress

Clinical Update

A Practical Guide to Light Therapy

From The Carlat Psychiatry Report, Adult ADHD

Outdoor living, morning light, evening darkness, and regular rhythms of sleep and waking all have one thing in common: They prevent depression. That’s the conclusion of many large epidemiologic studies, but for people who work indoors and wake up to dark winter mornings, this isn’t good news (Asai Y et al, J Affect Disord 2018;241:235–240). Here�

News of Note

A New Treatment for Bipolar Depression

From The Carlat Psychiatry Report, Side Effects Part II

On May 28, 2019, cariprazine (Vraylar) became the fourth atypical antipsychotic to receive FDA approval for bipolar depression. The approval was based on two randomized controlled trials involving 1,051 patients and lasting 6–8 weeks. These studies grouped patients into fixed doses from 0.75–3 mg/day. The sweet spot seems to be 1.5 mg/day, which was

Research Update

Mood Stabilizers and Stroke Risk in Bipolar Disorder

From The Carlat Psychiatry Report, Side Effects Part I

Topics: Bipolar Disorder | Lithium | Medical Comorbidities | Mood Stabilizers | Pharmacology

Review of: Chen PH et al, Br J Psychiatry 2018;1–6. doi:10.1192/bjp.2018.203 Study Type: Case-crossover study People living with bipolar disorder already have a decreased life expectancy of 10+ years compared to the general population (Crump C et al, JAMA Psychiatry 2013;70:931–939). Most of these years of lost life have been attributed to cardiov

Expert Q&A

Light and Darkness in Bipolar Disorder

From The Carlat Psychiatry Report, Dark and Light Therapy

Topics: Bipolar Disorder

Dr. Jim Phelps is the author of a textbook on bipolar spectrum disorders, A Spectrum Approach to Mood Disorders: Not Fully Bipolar But Not Unipolar—Practical Management (W. W. Norton & Company) as well as two self-help books on bipolar disorder. He conducted some of the early studies on dark therapy out of his private practice in Oregon, and we ca

Article

Does Mania Follow the Sun?

From The Carlat Psychiatry Report, Dark and Light Therapy

Topics: Bipolar Disorder | Free Articles | Mania

TABLE : SPRINGTIME MANIA Click here for the full PDF table showing sunlight peaks. If dark nights can treat mania, can too much sunshine destabilize it? Yes and no. Mania is linked to rapid changes in sunlight, but not to the amount of light itself. Mania peaks in early spring when there’s a steep rise in sunlight. By the time the longe

Article

Evaluating and Treating Co-Occurring ADHD and Bipolar Disorder

From The Carlat Child Psychiatry Report, ADHD in Children and Adolescents

Topics: ADHD | Bipolar Disorder | Child Psychiatry

Early into the evaluation of a 10-year-old boy, you note the following symptoms: inattention, hyperactivity, impulsivity, sleep problems, racing thoughts, and moodiness. The boy’s parents came to your office convinced that their son has ADHD, but thinking through the case, you recognize that the same symptoms could signal bipolar disorder (BD). You ha