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Combination therapy for bipolar disorder : What to combine and which cautions to take ?
- M. Gardabbou, M. Maalej, R. Feki, I. Gassara, N. Smaoui, L. Zouari, J. Ben Thabet, S. Omri, N. Charfi, M. Maalej
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S83
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Introduction
Bipolar disorder is one of the leading causes of disability among young adults. Given the heterogeneity of the disorder and the complexity of its etiopathogenesis, combination therapy is often considered as part of the treatment regimen.
ObjectivesTo assess the place of non-pharmacological interventions as a co-adjuvant to pharmacological treatment, to discuss the role of polytherapy in the management of bipolar disorder and to underline the drug to drug interactions to keep in mind.
MethodsWe present a critical review of recent international recommendations for the management of bipolar disorder. Two main evidence-based guidelines were included: The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders and The 2018 Canadian Network for Mood and Anxiety Treatment.
ResultsAccording to guidelines, the outcomes in bipolar disorder are improved when medication is combined with evidence-based psychological treatment and lifestyle changes. As to polytherapy, it is often recommended to maximise the treatment efficacy. Studies have shown that combination treatments tend to work faster and more effectively than monotherapy especially in episodes with higher index severity. For the management of agitation, an adjuctive treatment by Haloperidol with midazolam or promethazine can be prescribed. In acute mania, combination therapy with quetiapine, aripiprazole, risperidone or asenapine and lithium or divalproex is recommended as first-line treatment options. Combinations of mood-stabilizing drugs may be more often necessary when rapid cycling is present. In a manic episode with mixed features the use of divalproex with an atypical antipyshcotic is recommended. In bipolar I depression, lurasidone and lamotrigine are often used as adjunctive therapies. When anxious distress is present, the combination of olanzapine and fluoxetine has shown to be effective. In a depression with atypical features, tranylcypromine (IMAO) can be added to lithium, divalproex or a second generation antipsychotic for a better result. Adjunctive treatment of olanzapine with fluoxetine may be necessary in a depression with mixed features. However, in bipolar II depression and for maintenance treatment no adjunctive therapies are recommended. Finally, it is important to consider the adverse effects resulting from polytherapy. Using lithium as an adjunctive medication may increase the risk of tremor and acute dystonic reactions and can be a contributing factor for neuroleptic malignant syndrome, whereas divalproex can be an inducer or an inhibitor of some atypical antipsychotics.
ConclusionsRational polytherapy allows better and faster control over symptoms of bipolar disorder and should be considered after a detailed discussion of risks and benefits.
Disclosure of InterestNone Declared
Combination therapy in patients with acute bipolar mania
- M. Gardabbou, R. Feki, I. Gassara, N. Smaoui, S. Omri, M. Maalej Bouali, N. Charfi, L. Zouari, J. Ben Thabet, M. Maalej
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S704-S705
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Introduction
Numerous guidelines are bending the rule of monotherapy as initial treatment of acute manic episodes and suggest the importance of polytherapy in maximising the treatment efficacy.
ObjectivesTo assess the polytherapy used in the management of acute manic episodes and the degree of conformity of our prescriptions with international guidelines.
MethodsA retrospective study was carried out for descriptive purposes, targeting the drugs prescribed among patients admitted for the first time for a manic episode within the psychiatry « C » department of Sfax, Tunisia between 2019 and 2022. Patients who received ambulatory care prior to the current episode were excluded.
ResultsOur study included 50 male inpatients, with a median age of 31.8 years (min=18, max=62) at the moment of their hospitalisation. Nearly two thirds were single, 82% didn’t get postsecondary education and 65.3% had a profession. The majority (73.5%) belonged to upper-middle class and 67.3% had social security. A quarter of the patients suffered from substance abuse and 14% had a criminal record. Around 89.8% individuals presented a manic episode with psychotic features. The symptoms included mainly heteroaggressiveness in three quarters of cases, agitation in 77.1% and insomnia 76.1%. Insight was good in 79.6% of cases. Polytherapy was preferred to monotherapy in 86% of cases. Bitherapy was used in 74% of cases and tritherapy in only 12%. The most frequent combination was a mood stabilizer plus a second-generation antipsychotic (46%), risperidone plus sodium valproate being used in 34% of cases.
ConclusionsOverall, our prescriptions were in line with the international guidelines and the choice of polytherapy was well argued. Combination therapy is the suggested way to increase treatment efficacy, however, vigilance is required because of the increased risk of side effects.
Disclosure of InterestNone Declared
Homosexual Obsessive–compulsive Disorder Comorbid with Bipolar Disorder: A Rare Case report
- M. Gardabbou, R. Feki, N. Smaoui, I. Gassara, S. Omri, M. Maalej Bouali, N. Charfi, J. Ben Thabet, L. Zouari, M. Maalej
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S927-S928
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Introduction
While bipolar disorder–obsessive compulsive disorder overlap is quite common, sexuality remains a largely unexplored area of this clinical entity.
ObjectivesIllustrate through a clinical vignette the case of a patient with diagnosed homosexual obsessive –compulsive disorder (OCD) comorbid with bipolar disorder (BD).
MethodsThe clinical case report was prepared through the review of the patient´s clinical record.
ResultsWe report a rare case of a 22 year-old man who was diagnosed with Homosexual Obsessive–compulsive Disorder comorbid with Bipolar Disorder, admitted to our department for a suicide attempt. He came from a religious and conservative background and suffered from intrusive, unwanted mental images of homosexual behaviour since the age of 17. He presented periods of remission from his obsessive thoughts, while showing signs of elevated mood, talkativeness, restlessness, agitation and hyperactivity that would last for a few days, with recrudescence of obsessive and depressive symptoms again afterwards. The present case showed a significant reduction in depressive symptoms and in the impact of his obsessive intrusive thoughts after prescription of Risperidone and Sodium Valproate along with Exposure and Response Prevention Therapy conducted over a period of 6 weeks.
ConclusionsThe homosexual OCD comorbid with bipolar disorder can cause important distress and impairment and severely impact a person’s life in multifaceted ways. Correct diagnosis, adequate medication and psychotherapy provide the effective treatment.
Disclosure of InterestNone Declared
Clinical characteristics and sociodemographic profile of patients with First Bipolar Mania
- M. Gardabbou, R. Feki, I. Gassara, N. Smaoui, M. Maalej Bouali, N. Charfi, L. Zouari, J. Ben Thabet, S. Omri, M. Maalej
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S705
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- Article
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- You have access Access
- Open access
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Introduction
Mania is a serious psychiatric condition, characterized by high rates of relapse and significant dysfunction. An early understanding of the factors involved with the manifestations of this disease is critical as to help estimate impact and plan appropriate treatment modalities.
ObjectivesTo assess demographic and clinical characteristics in a first bipolar mania and describe the associations between these factors.
MethodsA retrospective study was carried out for descriptive and analytical purposes targeting the demographic and clinical characteristics of patients admitted for the first time for a mania within the psychiatry « C » department of Sfax, Tunisia between 2019 and 2022.
ResultsOur study included 50 male inpatients, with a median age of 31.8 years (min=18, max=62) at the moment of their hospitalisation. One third of the patients was married. Only 18% got postsecondary education and 65.3% had a profession. A total of 26.5% had a low socioeconomic status. Twenty-four percent suffered from substance abuse and 14% had a criminal record. Personal psychiatric history was noted in 32% of cases and a personal medical history in 16% of cases. Psychotic features were found in 89.8% of patients. Heteroaggressiveness was present in three quarters of cases, whereas an expansive mood was found in half the population. Twenty percent of patients had a poor insight. A statistically significant association was found between being employed and the absence of personal psychiatric history (p=0.017), whereas personal medical history was associated with a poor insight (p=0.049). Substance abuse was correlated with having a criminal record (p=0.006) and heteroagressiveness (p=0.012). The presence of psychotic features was positively associated with expansive mood (p=0.022).
ConclusionsThis study confirms that some epidemiological factors are strongly associated with clinical characteristics of the bipolar mania. Early interventions over these factors may contribute to a potential reduction in morbidity and mortality of this disease.
Disclosure of InterestNone Declared