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| |  DG DISPATCH - APA MEETING: Combination Treatment Often Necessary For Bipolar Disorder By John L. Moore Special to DG News WASHINGTON, DC -- May 27, 1999 -- Bipolar disorder is a severe and complex disease to manage and single-agent management may not guarantee simultaneous control of manic and depressive elements, researchers said at the American Psychiatric Association meeting in Washington, D.C. Consequently, supplementation of mood stabilising medication with other agents can be necessary to achieve the appropriate balance of anti-depressant and anti-manic effects. As many patients with bipolar disorder also manifest a variety of psychotic symptoms, including agitation and violent behaviour, there are potential benefits to controlling these symptoms with additional pharmacological agents. These benefits, however, must be weighed against the potential for negatively impacting on the course of the bipolar disorder and provoking an acute manic or hypomanic episode. "The use of neuroleptics has traditionally been reserved for those patients with a primary diagnosis of schizophrenia because of the potential for causing serious and permanent side effects such as tardive dyskinesia", Dr. Roy Chengappa explained. Significant reductions in Mania Rating Scales (MRS) have been achieved with combination therapy, said Dr. Gary Sachs, M.D., of Massachusetts General Hospital. Combinations of mood stabilisers with atypical neuroleptics have yielded some excellent results in rapid cycling patients, Dr. Sachs added. Olanzapine was far superior to placebo in large-scale trials and clozapine is effective in patients during the manic or mixed phases of bipolar disorder, in treatment-resistant mania and in schizoaffective disorder. In addition, significant improvements in Clinical Global Impression (CGI) have been reported with combination therapy including olanzapine, clozapine or risperidone, Dr. Sachs said. Single-agent therapy with mood stabilisers or neuroleptics is not as effective as therapy combining them with mood stabilisers, he said. There is uncertainty, however, about the benefits of symptom control beyond that provided by single agent therapy and about the potential negative effects on mood stabilisation with atypical neuroleptics. Dr. Nassir Ghaemi, of George Washington University confirmed that, despite the poor reputation previously associated with combination therapy, rational use of more than one agent is now possible. New drug combinations have led to an extension of the treatment algorithm for bipolar disorder, Dr. Ghaemi said. General treatment practices that he recommended included maximising the use of mood stabilisers, emphasising adjuncts such as atypical neuroleptics and anticonvulsants, and using antidepressants only for brief intermittent treatment of acute depressive episodes.
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