Rapid Cycling bei bipolar-affektiven Störungen: Klinik, Ätiologie und Behandlungsempfehlungen

Abstract

Rapid cycling bipolar disorder is encountered frequently in clinical practice with a lifetime prevalence of up to 31 %. Besides its association with greater illness severity, increased suicide and comorbidity rates, rapid cycling bipolar disorder has been closely associated with a longer and more complicated course of disease and inadequate treatment response compared to non-rapid cycling bipolar disorder. However rapid cycling does not serve as a stable characteristic of bipolar disorder, though its prevalence increases with illness duration. Female gender, hypothyreoidism and antidepressant medications have been suggested as correlates of rapid cycling bipolar disorder; however, the interaction amongst these factors make an interpretation of their causal relations difficult. Only very few data are available from randomized clinical trials that investigated the therapeutic options of rapid cycling bipolar disorder. Based on these trials, the therapeutic outcome of lithium is similar to that of the class of anticonvulsants. Positive treatment outcome reported for atypical neuroleptics is often based on pharmaceutical company-financed, placebo-controlled RCTS. Altogether independent prospective RCTs and head-to-head comparisons are lacking that can provide sufficient information on treatment response. In addition, the role of antidepressant treatment in the course and phase acceleration of bipolar disorder remains insufficiently understood. However, in the light of present empirical evidence, the use of antidepressant medication in the treatment of rapid cycling bipolar disorder has to be looked at highly critically.

Lithium Treatment Over the Lifespan in Bipolar Disorders

“…RC is defined as a course of BD that includes at least four distinct mood episodes (including major depressive, manic, hypomanic, with or without mixed features) occurring within a 12-month period. RC has a lifetime prevalence of 5 to 33 % among BD patients, which emphasizes its clinical relevance (38,39). Patients with RC suffer from a higher burden of symptoms, higher rates of suicide attempts and completed suicides and they are frequently suffering from other psychiatric comorbidities over the lifespan of BD (40,41).…”

Heterogeneity in Bipolar II Disorder Treatments: A Literature Review

“…One factor -which explains this, at least in part, is the fact that the current diagnostic criteria for hypomania, as it is concepted today, -is still quite restrictive and often sensitive only to more exuberant and phasic episodes, that corresponds to mild phasic manias. It explains the BDII prevalence closer to BD I (1%) [12]. In addition to this, the use of antidepressants in the mild cases will hardly aid in a correct diagnosis, because strong mood swings are not enough to permit diagnosis (leading to the emergence of mania or phasic hypomania) and are not common in these settings, although many clinicians think so.…”

“…Although a delay in the diagnosis of bipolar disorder is common, the severe form with episodes of mania, in BD I, is unlikely to go unnoticed and adequate treatment is often and soon implemented. In contrast, mild forms, such as BD II, suffer from an even greater problem, misdiagnosis with MDD and the use of antidepressants for long periods, delaying the use of mood stabilizing drugs that would be better suited to better treatment of BD in long term, preventing recurrence and severe disease presentations such as mixed states and rapid cycling [12]. In addition to this, in contrast to classic forms in which the use of antidepressants in a major depressive episodes (MDE) usually leads to mood swings that lead to the appropriate diagnosis of BD, in mild forms the mood usually does not become polarized to pure (euphoric mood) or hard forms (mania), but usually swings to mixed-states or rapid-cycling conditions that may be missed by the clinician for long years [13].…”

Update – Lithium in der Phasenprophylaxe Bipolarer Störungen

“…Das Vorliegen von negativen Prädiktoren sollte daher nicht dazu führen, Lithium nicht in Betracht zu ziehen, zumal nicht bewiesen ist, dass medikamentöse Alternativen in diesen Fällen wirksamer wären. Exemplarisch wird dies für Rapid Cycling in einer aktuellen Übersichtsarbeit dargestellt [24], die damit die Empfehlung der NICE-Leitlinie untermauert, Patienten mit Rapid Cycling prinzipiell die gleichen Behandlungsoptionen anzubieten wie Patienten ohne Rapid Cycling [5]. Auf Grund der begrenzten Aussagekraft dieser Prädiktoren wurden elektrophysiologische Daten (z.…”