Tuesday, January 16, 2007
Let’s review some of the main points from my two previous blogs:
On one hand, bipolar depression appears to be a different animal from unipolar depression. On the other, some unipolar depressions have a cycling pattern that resembles bipolar. Accordingly, treating bipolar depressions as if they were unipolar depression can lead to disaster. Ironically, treating certain unipolar depressions as if they were unipolar depression can also lead to disaster.
In terms of both efficacy and safety, antidepressants (the go-to med for unipolar depression) tend to be problematic for treating bipolar depression. Bipolar patients on antidepressants are at risk of switching into mania or rapid-cycling. There may be a time and a place for an antidepressant, but it is advisable to use them only in conjunction with a mood stabilizer, the American Psychiatric Association strongly recommends in its 2002 practice guideline for bipolar disorder.
Because of the cycling nature of bipolar (and some unipolar) depressions, there is a growing consensus that clinicians should have regard for treating the cycle rather than merely the symptom. Even in the early phase of treatment, when depression (or for that matter mania) may be raging fierce, clinicians need to be thinking ahead toward keeping the patient stable, and thus avoiding cycles back down into depression (which are far more common than cycles back up into mania).
Until recently, only lithium was regarded as having utility for treating bipolar depression (though it is considered stronger against mania). Mood stabilizers (such as Depakote) and antipsychotics (such as Risperdal) earned their stripes battling mania.
Lately, however, one antipsychotic and one mood stabilizer, plus an antipsychotic-antidepressant combo pill, have been pressed into service for bipolar depression.
Before proceeding, once again the reminder that my MD stands for manic depression and not doctor of medicine. Please fully discuss matters with your psychiatrist before reaching any conclusions.
Lamictal
Lamictal’s FDA indication is for bipolar maintenance treatment, not bipolar depression. The 2003 indication is based on two trials lasting 18 months (an eternity by meds trial standards). Lamictal proved superior to lithium at delaying relapses into depression in patients with bipolar I with recently occurring manic or hypomanic episodes, while lithium proved superior at staving off relapses into mania. The FDA did allow GSK to put on its labeling that the findings were more robust for bipolar depression treatment.
Lamictal’s manufacturer, GSK, also tested Lamictal for treating depression in the short-term (what is called the acute phase), and achieved encouraging results in one published 1999 trial. But, according to trial data listed on GSK’s web-based clinical trial register, the drug failed to outperform the placebo in seven unpublished trials ranging from seven to ten weeks. One of these trials involved unipolar depression. Two were for recurring unipolar depression, the type of cycling depression considered by many a close cousin of bipolar depression. The other four trials involved populations with bipolar I and bipolar II depression.
On one hand, bipolar depression appears to be a different animal from unipolar depression. On the other, some unipolar depressions have a cycling pattern that resembles bipolar. Accordingly, treating bipolar depressions as if they were unipolar depression can lead to disaster. Ironically, treating certain unipolar depressions as if they were unipolar depression can also lead to disaster.
In terms of both efficacy and safety, antidepressants (the go-to med for unipolar depression) tend to be problematic for treating bipolar depression. Bipolar patients on antidepressants are at risk of switching into mania or rapid-cycling. There may be a time and a place for an antidepressant, but it is advisable to use them only in conjunction with a mood stabilizer, the American Psychiatric Association strongly recommends in its 2002 practice guideline for bipolar disorder.
Because of the cycling nature of bipolar (and some unipolar) depressions, there is a growing consensus that clinicians should have regard for treating the cycle rather than merely the symptom. Even in the early phase of treatment, when depression (or for that matter mania) may be raging fierce, clinicians need to be thinking ahead toward keeping the patient stable, and thus avoiding cycles back down into depression (which are far more common than cycles back up into mania).
Until recently, only lithium was regarded as having utility for treating bipolar depression (though it is considered stronger against mania). Mood stabilizers (such as Depakote) and antipsychotics (such as Risperdal) earned their stripes battling mania.
Lately, however, one antipsychotic and one mood stabilizer, plus an antipsychotic-antidepressant combo pill, have been pressed into service for bipolar depression.
Before proceeding, once again the reminder that my MD stands for manic depression and not doctor of medicine. Please fully discuss matters with your psychiatrist before reaching any conclusions.
Lamictal
Lamictal’s FDA indication is for bipolar maintenance treatment, not bipolar depression. The 2003 indication is based on two trials lasting 18 months (an eternity by meds trial standards). Lamictal proved superior to lithium at delaying relapses into depression in patients with bipolar I with recently occurring manic or hypomanic episodes, while lithium proved superior at staving off relapses into mania. The FDA did allow GSK to put on its labeling that the findings were more robust for bipolar depression treatment.
Lamictal’s manufacturer, GSK, also tested Lamictal for treating depression in the short-term (what is called the acute phase), and achieved encouraging results in one published 1999 trial. But, according to trial data listed on GSK’s web-based clinical trial register, the drug failed to outperform the placebo in seven unpublished trials ranging from seven to ten weeks. One of these trials involved unipolar depression. Two were for recurring unipolar depression, the type of cycling depression considered by many a close cousin of bipolar depression. The other four trials involved populations with bipolar I and bipolar II depression.
