Bipolar disorder treatment decisions

The evidence base for clinical decisions based on cost-effectiveness for the affective disorders is less clear than for schizophrenia. In bipolar disorder the primary effectiveness of the mainstay treatments, lithium and anticonvulsant pharmacotherapy, is undergoing considerable revision (Bowden et al, 2000). Until this is clarified, cost-effectiveness studies are probably premature. Nevertheless the cost burden in bipolar disorder is qualitatively similar to that in schizophrenia, with in-patient costs being the primary burden and associated social costs in treated patients. The drug costs are even less than those for schizophrenia. In Chapter 5 John Cookson suggests there is little economic evidence to drive prescribing decisions. The in-patient burden does not seem to have altered with the introduction of lithium. The only drug-related study (Keck et al, 1996) showed an obvious difference in treatment costs only when lithium was compared with sodium valproate. Since these are both cheap drugs this is unlikely to influence clinical decisions. The main question is what impact... 

Sachs GS. Decision tree for the treatment of bipolar disorder. J Clin Psychiatry 2003 64(Supplement 8) 35-40. 

Given the available data, it is extremely important that clinicians evaluate patients with major depression for features of psychosis, because the failure to do so may result in inadequate treatment for the patient. A practical problem encountered by clinicians, however, is the subtlety of delusions. For example, it is not unusual in geriatric depression for patients to present with a somatic preoccupation that borders on delusional. These so-called near delusions may put the patient into the arena of psychotic depression. Some evidence exists that patients with depression with near delusions may respond more favorably to combinations of antidepressants and antipsychotics or ECT. Once the presence of both major depression and psychosis is determined, other psychotic disorders including bipolar disorder and schizophrenic spectrum illness must also be ruled out because this may influence long-term treatment decisions. 

Dr. J. F. J. Cade, an Australian psychiatrist, first reported on the beneficial use of a lithium compound for a psychiatric disorder, namely, manic behavior in 1949. The early human trials were undertaken after initial experiments on rats, which became quite lethargic after treatment with lithium urate. Fairly large doses were required for treating manic behavior and its use for this disorder has been displaced by organic drugs that carry less risk. His report, however, led to its current nse as a treatment for bipolar affective disorder (also known as manic-depressive disorder). Its use in the United States was curtailed for a decade and a half by the US. Food and Dmg Administration (FDA), which based its decision on incidental poisonings due to overuse of a lithium-based table salt substitute, despite a safe record of controlled psychiatric apphcations in Europe. It has been estimated that by 1985... 

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