OBJECTIVES While clinical guidelines exist for the management of bipolar disorder (BD), there are... more OBJECTIVES While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. METHODS C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/ video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. RESULTS Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point- of- care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p=0.0001). CONCLUSIONS Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.
Objectives: Safety monitoring is an important aspect of bipolar disorder treatment, as mood‐stab... more Objectives: Safety monitoring is an important aspect of bipolar disorder treatment, as mood‐stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost‐effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.Methods: These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus‐based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.Results: General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.Conclusions: These guidelines are derived from evolving and often indirect data, with minimal empirical cost‐effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.
Bilateral lesions of the amygdaloid central nucleus (ACE) significantly diminished the secretion ... more Bilateral lesions of the amygdaloid central nucleus (ACE) significantly diminished the secretion of ACTH in response to immobilization stress. Stress is associated with increased noradrenergic activity in the ACE and in the anterior and lateral hypothalamic areas. In comparison with intact stressed animals, lesion of the ACE reduced the noradrenergic activity in response to stress within the anterior and lateral hypothalamic areas, the arcuate and paraventricular nuclei of the hypothalamus and the bed nucleus of the stria terminalis. These results support the hypothesis of a stimulatory role for the noradrenergic system in the ACE on ACTH secretion. Stress decreased dopaminergic activity in the ACE, the cortical nucleus of the amygdala, the dorsomedial and ventromedial nuclei of the hypothalamus and the ventral tegmental area. In comparison with intact stressed rats, lesion of the ACE reduced dopaminergic activity in the anterior and lateral hypothalamic areas. Our results support the hypothesis of an inhibitory role of the dopaminergic system, particularly in the ACE, on ACTH secretion. This study also indicates that, in the control of ACTH secretion in response to immobilization stress, the noradrenergic and dopaminergic systems act in opposition to one another in certain brain structures such as the anterior and lateral hypothalamic areas and the ACE.
Excessive body weight gain (BWG), hyperglycemia and dyslipidemia are important side effects of ol... more Excessive body weight gain (BWG), hyperglycemia and dyslipidemia are important side effects of olanzapine. We assessed the effects of rosiglitazone on BWG, the insulin resistance index (HOMA-IR), lipids, glycated hemoglobin and fibrinogen in olanzapine-treated schizophrenia patients. Thirty patients taking olanzapine (10-20 mg daily for 8 months) were randomly allocated to rosiglitazone (n=15; 4 to 8 mg daily) or placebo (n=15) in a 12-week double-blind protocol. Anthropometric and biochemical variables were evaluated at baseline, weeks 6 and 12. The rosiglitazone and placebo groups gained 3.2+/-4.5 and 2.2+/-2.3 kg, respectively (p=0.65). Insulin and the HOMA-IR significantly decreased after rosiglitazone (p<0.05). Rosiglitazone did not improve the lipid profile, fibrinogen and Hb1c levels. The positive impact of rosiglitazone was limited to improved glycemic control. It cannot be recommended for metabolic control during olanzapine treatment.
Background: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience ad... more Background: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience adult attention-deficit/hyperactivity disorder (ADHD) at rates substantially greater than the general population. Nonetheless, ADHD frequently goes untreated in this population. Methods: We reviewed the literature regarding the management of adult ADHD in patients with mood disorders. Because a limited number of studies have been conducted in adults, our treatment recommendations also are partly informed by research in children and adolescents with BD+ADHD or MDD+ADHD, adults with ADHD, and our clinical experience. Results: In individuals with mood disorders, ADHD is best diagnosed when typical symptoms persist during periods of sustained euthymia. Individuals with BD+ADHD, particularly those with bipolar I disorder (BD I), are at risk for mood destabilization with many ADHD treatments, and should be prescribed mood-stabilizing medications before initiating ADHD therapies. Bupropion is a reasonable first-line treatment for BD+ADHD, while mixed amphetamine salts and methylphenidate also may be considered in patients determined to be at low risk for manic switch. Modafinil and cognitive-behavioral therapy (CBT) are second-line choices. In patients with MDD+ADHD and moderate to severe depression, MDD should be the treatment priority, whereas in mildly depressed or euthymic patients the order may be reversed. First-line treatments for MDD+ADHD include bupropion, an antidepressant plus a long-acting stimulant, or an antidepressant plus CBT. Desipramine, nortriptyline, and venlafaxine are second-line options. Conclusions: Clinicians should be vigilant in screening for comorbid ADHD in mood disorder patients. ADHD symptoms can respond to appropriately chosen treatments.
OBJECTIVES While clinical guidelines exist for the management of bipolar disorder (BD), there are... more OBJECTIVES While clinical guidelines exist for the management of bipolar disorder (BD), there are significant challenges to their widespread dissemination and implementation in clinical practice. The Canadian Network of Mood and Anxiety Treatment Improving Patient Care and Outcomes in the Treatment of Bipolar Disorder (C-IMPACT BD) web-based application was developed for use at the point-of-care to improve adherence to guidelines for evidence-based pharmacological management of BD. METHODS C-IMPACT BD uses a point-of-care practice assessment which, via adaptive questioning of patient-specific information, text/ video descriptions of the guidelines, and pop-up prompts delivers personalized, evidence-based treatment recommendations for patients with BD. In order to inform quality improvement of the newly developed tool, a sample of Canadian physicians were invited to use the application and record its influence on their prescribing behavior. RESULTS Of 375 patients with bipolar I (BD-I) or bipolar II (BD-II) disorder for whom a point- of- care practice assessment was completed, a change in therapy was considered for 225 (60.0%). Prior to completing the assessment, 59.6% of these patients were receiving first-line therapy recommended for their phase of illness. Following the assessment, the overall number of patients for whom a first-line recommended therapy was being considered increased significantly to 76.9% (p=0.0001). CONCLUSIONS Outcomes suggest that the C-IMPACT BD web-based application has the potential to improve physician adherence to clinical treatment guidelines. Formal research investigations are warranted to explore the impact of this tool on physician prescribing behavior and patient outcomes.
Objectives: Safety monitoring is an important aspect of bipolar disorder treatment, as mood‐stab... more Objectives: Safety monitoring is an important aspect of bipolar disorder treatment, as mood‐stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost‐effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.Methods: These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus‐based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.Results: General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.Conclusions: These guidelines are derived from evolving and often indirect data, with minimal empirical cost‐effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.
Bilateral lesions of the amygdaloid central nucleus (ACE) significantly diminished the secretion ... more Bilateral lesions of the amygdaloid central nucleus (ACE) significantly diminished the secretion of ACTH in response to immobilization stress. Stress is associated with increased noradrenergic activity in the ACE and in the anterior and lateral hypothalamic areas. In comparison with intact stressed animals, lesion of the ACE reduced the noradrenergic activity in response to stress within the anterior and lateral hypothalamic areas, the arcuate and paraventricular nuclei of the hypothalamus and the bed nucleus of the stria terminalis. These results support the hypothesis of a stimulatory role for the noradrenergic system in the ACE on ACTH secretion. Stress decreased dopaminergic activity in the ACE, the cortical nucleus of the amygdala, the dorsomedial and ventromedial nuclei of the hypothalamus and the ventral tegmental area. In comparison with intact stressed rats, lesion of the ACE reduced dopaminergic activity in the anterior and lateral hypothalamic areas. Our results support the hypothesis of an inhibitory role of the dopaminergic system, particularly in the ACE, on ACTH secretion. This study also indicates that, in the control of ACTH secretion in response to immobilization stress, the noradrenergic and dopaminergic systems act in opposition to one another in certain brain structures such as the anterior and lateral hypothalamic areas and the ACE.
Excessive body weight gain (BWG), hyperglycemia and dyslipidemia are important side effects of ol... more Excessive body weight gain (BWG), hyperglycemia and dyslipidemia are important side effects of olanzapine. We assessed the effects of rosiglitazone on BWG, the insulin resistance index (HOMA-IR), lipids, glycated hemoglobin and fibrinogen in olanzapine-treated schizophrenia patients. Thirty patients taking olanzapine (10-20 mg daily for 8 months) were randomly allocated to rosiglitazone (n=15; 4 to 8 mg daily) or placebo (n=15) in a 12-week double-blind protocol. Anthropometric and biochemical variables were evaluated at baseline, weeks 6 and 12. The rosiglitazone and placebo groups gained 3.2+/-4.5 and 2.2+/-2.3 kg, respectively (p=0.65). Insulin and the HOMA-IR significantly decreased after rosiglitazone (p<0.05). Rosiglitazone did not improve the lipid profile, fibrinogen and Hb1c levels. The positive impact of rosiglitazone was limited to improved glycemic control. It cannot be recommended for metabolic control during olanzapine treatment.
Background: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience ad... more Background: Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience adult attention-deficit/hyperactivity disorder (ADHD) at rates substantially greater than the general population. Nonetheless, ADHD frequently goes untreated in this population. Methods: We reviewed the literature regarding the management of adult ADHD in patients with mood disorders. Because a limited number of studies have been conducted in adults, our treatment recommendations also are partly informed by research in children and adolescents with BD+ADHD or MDD+ADHD, adults with ADHD, and our clinical experience. Results: In individuals with mood disorders, ADHD is best diagnosed when typical symptoms persist during periods of sustained euthymia. Individuals with BD+ADHD, particularly those with bipolar I disorder (BD I), are at risk for mood destabilization with many ADHD treatments, and should be prescribed mood-stabilizing medications before initiating ADHD therapies. Bupropion is a reasonable first-line treatment for BD+ADHD, while mixed amphetamine salts and methylphenidate also may be considered in patients determined to be at low risk for manic switch. Modafinil and cognitive-behavioral therapy (CBT) are second-line choices. In patients with MDD+ADHD and moderate to severe depression, MDD should be the treatment priority, whereas in mildly depressed or euthymic patients the order may be reversed. First-line treatments for MDD+ADHD include bupropion, an antidepressant plus a long-acting stimulant, or an antidepressant plus CBT. Desipramine, nortriptyline, and venlafaxine are second-line options. Conclusions: Clinicians should be vigilant in screening for comorbid ADHD in mood disorder patients. ADHD symptoms can respond to appropriately chosen treatments.
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Papers by Serge Beaulieu