The Impact of Antidepressant Discontinuation on Relapse, Remission, and Mood Episode Cycling in Bipolar Disorder - Predicting Relapse in Bipolar Disorder

Written by Martin Korn, MD Robert Glassman

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Predicting Relapse in Bipolar Disorder

Because bipolar disorder is a recurrent and cyclic disease, early prediction of subsequent episodes is essential for optimal treatment. In a study by Tohen and associates,^[15] a post-hoc analysis was conducted based on the pooled data from 2 bipolar maintenance studies. A total of 779 patients who were in a state of remission from manic or mixed episodes were followed for up to 48 weeks. Patients were treated with olanzapine (n = 434), lithium (n = 213), or placebo (n = 132) after completion of an acute open-label treatment study comparing lithium monotherapy with olanzapine-lithium combination therapy. There were several predictors of early relapse, including a history of rapid cycling, a mixed-index episode, frequency of episodes in the previous year, age of onset younger than 20 years, family history of bipolar disorder, female gender, and the lack of a hospitalization in the past year. The strongest predictors were a history of rapid cycling and a mixed-index episode. The identification of risk factors might help the clinician to identify those individuals most at risk for relapse and aid in the development of early intervention strategies.

A Decade of Pharmacologic Trends in Bipolar Disorder

There have been many new treatments for bipolar disorder introduced in the past decade. The most important development has been the introduction of numerous atypical agents and the numerous studies documenting their effectiveness. A study by Cooper and colleagues^[16] looked at the trends in medication use between 1992 and 2002. Data were derived from a pharmacy prescription database of 11,813 patients. The findings were as follows:

The percentage of patients treated with a mood stabilizer has remained stable through the 10-year period at approximately 75%. The percentage of patients on lithium has decreased steadily, a trend paralleled by the increase in valproate (Depakene). In 1999, valproate became the most widely prescribed mood stabilizer. Lamotrigine (Lamictal) and topiramate (Topamax) have been increasing steadily since 1997 to 1998, while the use of carbamazepine (Tegretol) has been decreasing steadily.
Antidepressant use has been relatively stable, varying between 56.9% and 64.3%.
Atypical neuroleptics were utilized in 47.8% of patients in 2002. Olanzapine was the most prescribed atypical medication in 2002, followed by risperidone, quetiapine, and ziprasidone. Clozaril use has decreased dramatically.

The overall trend indicates that mood stabilizing is still the mainstay of treatment; the atypical agents are becoming much more accepted as integral to the treatment of the bipolar patient.

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