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Current p SYCHIATRY

From the editor

Henry A. Nasrallah, MD Editor-in-Chief, CURRENT PSYCHIATRY [email protected]

Bipolar disorder Clinical questions beg for answers ® Dowden Health Media distinguished speaker at a recent national con- Long-term follow-up studies indicate that depres- A ference was describingCopyright his classification of sion dominates in >75% of bipolar patients’ symp- bipolar disorder, and his slides listedFor subtypes personal I, II, tomatic use days. only Even so, (inexplicably) 8 drugs are 1 1 II /2, III, IV, and IV /2. During the question-and- approved in monotherapy for bipolar mania and answer session, a perplexed attendee announced— only 1 for bipolar depression. [Quetiapine mono- 1 with tongue in cheek—that he had 4 /2 questions and therapy was FDA-approved in October, joining the 1 2 /2 comments about the bipolar presentation. . . . combination of olanzapine/fluoxetine with this Let’s face it, bipolar disorder is a fascinating labeling.] neuropsychiatric condition that tests every clini- No antidepressants are indicated for bipolar cian’s diagnostic acumen and treatment skills. depression, yet they have been widely used despite Many questions about its diagnosis and treatment remain unanswered. Diagnosis. Bipolar disorder can pre- Astonishingly few large controlled trials sent with many different symptoms guide bipolar disorder pharmacotherapy and with phases that cycle sponta- neously or in response to treatment. And with its many mood states and multiple their inherent risk of inducing switches to mania, comorbidities, bipolar disorder is replete with red hypomania, mixed states, and rapid cycling. herrings. Many of its sufferers are misdiagnosed Winging it. Most clinicians improvise when treating with alcoholism, anxiety, borderline personality dis- rapid cycling, hypomania, cyclothymia, or bipolar order, attention-deficit/hyperactivity disorder (child II. No medications have been approved for these or adult), or—the most frequent misdiagnosis— bipolar states, which commonly are seen in outpa- major depression. tient settings. Treatment. Despite a rich literature, astonishingly Three mood stabilizers and five atypical few large controlled clinical trials have been con- antipsychotics are approved for mania in bipolar I ducted to guide bipolar disorder pharmacotherapy. disorder, but hardly a shred of controlled evidence

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From the editor Current p SYCHIATRY

exists to help you decide which drug to try first. based on opinion or clinical experience. No con- Without controlled head-to-head trials, clinicians trolled clinical trials have compared various combi- must choose treatment based on available data: nations, and little is known about: • Some may use quetiapine as first-line thera- • optimal dosing of agents in combinations py because of evidence showing efficacy in • which combinations are safest in patients both bipolar mania and bipolar depression. with coexisting medical conditions. Much remains to be learned about diagnosis and treatment of bipo- Most clinicians improvise when treating rapid lar disorder’s subtypes. Our tal- cycling, hypomania, cyclothymia, or bipolar II ented and productive patients with bipolar disorder look to us to provide the safest, most effective • Others may select ziprasidone or valproate ER, treatments that improve functioning without com- the only agents approved for all three types of promising quality of life. For this, we need a mania (euphoric, mixed, and psychotic). National Institute of Mental Health-sponsored • Still others—cognizant of high nonadher- study of bipolar disorder, similar to the Clinical ence and the relapse-inducing risk of sub- Antipsychotic Trials of Intervention Effectiveness stance abuse in bipolar patients—may choose (CATIE) studies of schizophrenia and Alzheimer’s parenteral long-acting risperidone for long- disease (see page 49). term maintenance. In the meantime, good luck managing the next 1 Combination therapy. Most bipolar disorder patients bipolar II /2 patient you see! eventually receive two or more medications, but the evidence is anemic (at best) for combination thera- py as well. What is the optimal combination for mania with severe anxiety or for bipolar II disorder with mixed features or irritable depression? Dozens of iterations are possible, with nothing for prescribers Henry A. Nasrallah, MD to rely on except “expert consensus” guidelines Editor-in-Chief

Dear Readers,

In this issue, CURRENT PSYCHIATRY recognizes the contributions of those who have served as peer reviewers of articles published in our journal in 2006. The list of reviewers spans pages 19 and 20 and testifies to psychiatric practitioners’ strong commitment to continuing education and intellectual integrity.

We invite you to send us suggestions of topics you would like to see CURRENT PSYCHIATRY cover in 2007. If you wish to serve as a reviewer or submit an article for peer review, contact me at [email protected].

12 VOL. 5, NO. 12 / DECEMBER 2006 Currentp SYCHIATRY