Psikologi Transformatif: Re: [psikologi_transformatif] Bipolar Tipe II

bipolar II itu gejala mau bunuh diri ya?

lamotrigine itu opo? sejenis gado gado kali...

kl mo lihat Link nya di EBSCO aja, asli semua ada.

Treatment of bipolar II disorder

with lamotrigine

E. Vieta, J. M. Goikolea, A. Benabarre, C. Torrent, M. Comes, A. Martínez-Arán, M. Reinares,

F. Colom, G. Parramon, B. Corbella and C. Gastó

Bipolar Disorder Program. Center of the Stanley Medical Research Institute of Barcelona. Hospital Clínico. IDIBAPS. Barcelona

Tratamiento del trastorno bipolar II con lamotrigina

ORIGINALS

Summary

Introduction. This study analyzes the effectiveness and

safety of lamotrigine in the treatment of bipolar II disorder.

Patients and methods. S eventeen patients with DSM-IV

bipolar II disorder with a history of poor response to lithium

or other mood-stab i l i ze rs gave their consent to be tre a t e d

with lamotri gine. Th ey we re fo l l owed-up for 6 months and

assessed with the Young Mania Scale (YMRS), Hamilton

D ep ression Rating Scale (HDRS-17) and the modified ve rs i o n

of the Global Clinic Impresion Scale for Bipolar Disord e r

( C G I - B P - M ) .

Results. Twelve patients completed the study. Three

patients dropped out due to side effects (two because of mild

rash, which vanished after treatment was discontinued and

one because of vomiting) and two due to lack of efficacy.

The mean dose of lamotrigine for patients completing

the study was 202.1±64.4 mg/day. There was a significant

improvement in HDRS-17 scores (p =0.004) and the

depressive (p =0.002) and overall (p=0.002) subscales

of the CGI-BP-M.

Conclusions. This study confirms previous findings

concerning the antidepressant profile of lamotrigine

and its potential effectiveness in bipolar II disorder.

Key words: Bipolar II disorder. Lamotrigine. Depression.

Clinical trial.

INTRODUCTION

On the contra ry to the ge n e ralized opinion that type II

bipolar disorder is simply an attenuated or mild fo rm of

the classical maniac-depre s s i ve psychosis or type I bipolar

disord e r, seve ral studies have demonstrated that its

l o n gitudinal course is ch a ra c t e rized by a greater nu m b e r

of episodes1, part i c u l a r ly depre s s i ve2, greater perc e n t age

of rapid cycl e rs3 and of associated psych i a t ric disease4

and greater risk of suicide5. Consequently, the limited

number of studies focusing on the treatment of this dis

o rder is surprising. A two year fo l l ow-up demonstra t e d

that appro p riate treatment can ra d i c a l ly ch a n ge the pro gn

o s i s6, reducing the number of relapses signifi c a n t ly. The

key would be the use of mood stab i l i z e rs and antidepre ss

i ves, avoiding the use of tri c y clics as mu ch as possibl e7.

Lamotrigine is a drug indicated in the treatment of

partial and generalized epilepsy in both adults and child

re n8. Its fundamental action mechanism is that it

blocks the sodium channels of the neuronal membrane,

reducing the release of excitatory amino acids such as

glutamate, although other mechanisms could also be

METHODOLOGY

A total of 17 patients who complied with the diagnostic

criteria of the DSM-IV for type II bipolar disorder

gave their consent to participate in the study. Mostly

(n=13) the response to lithium or to other anti-epileptic

agents had been unsatisfactory; in other cases, lamotrigine

was chosen due to contraindications to other drugs

or patient preference. The study design was open, observational,

and prospective over 6 months. Response to

treatment was evaluated by the Spanish version of the

Young Mania Scale (YMRS)1 0, the Hamilton Depression Rating

Scale (HDRS)1 1 and the m o d i fied ve rsion of the Global

Clinical I m p ression Scale for Bipolar Disorder (CGI-BP-M)1 2.

In each visit, appearance of adve rse effects and use of conco -

mitant medication were also evaluated. In every case,

lamotrigine was introduced in a stepwise way at a dose

i n c rease rhythm of 25 mg/week gi ven that it has been

d e m o n s t rated that this reduces the risk of the appeara n c e

of exanthema8. The final dose was individualized for

each patient, considering efficacy and tolerability crite -

ria, and the dose of 200 mg/day as target dose based on

that observed in the controlled studies was maintained

as a re fe re n c e1 3. D u ring treatment with lamotri gine, it wa s

attempted to maintain the concomitant medication re c e ived

by the patients unch a n ged. An analysis for intention

to treat was perfo rmed with last observation carried

fo r wa rd analysis to stri c t ly compare the status of the patients

befo re and after the treatment. The statistical analysis

was perfo rmed with non-para m e t ric tests (Wi l c ox o n

RESULTS

The sample composition was made up of 17 bipolar II

patients with depressive symptoms and signs (n = 13),

hypomaniac (n = 2) or in partial remission (n = 2) who

demonstrated unsatisfactory response from any point of

view (inefficacy, intolerability, personal rejection) to

the conventional treatments. Concomitant treatment is

s h own in t able 1. Mean age of the patients was 41.1± 10.7.

There was a predominance of women (12.71%).

Twelve patients (71%) completed the 6 months of

follow-up. There were three drop outs due to secondary

effects (two due to exanthema, that disappeared when

the treatment was discontinued, and one due to vomiting)

and two due to lack of efficacy. The mean dose of

lamotrigine at 6 months was 160.3± 86.6 mg/day for all

the sample and 202.1±64.4 mg/day for the patients who

completed the study.

To evaluate the treatment efficacy, the scores of the

HDRS and YMRS scales with the subscales of the CGIBP-

M (mania, depression, and longitudinal course) were

compared between the baseline and final visit, carrying

forward the values of the patients who dropped out.

This analysis was also performed in the subgroup of patients

who initiated the treatment during a depressive

episode, these being the majority.

For all the sample, statistically significant differences

were obtained between the initial and final scores of the

HDRS scale (p = 0.004) and the subscales of the CGIBP-

M of depression (p = 0.002) and longitudinal course

(p = 0.002) as is shown in figure 1. There were no differences

in the YMRS scale and the CGI-BP-M mania subscale.

Ten of the 13 patients who initiated the treatment

during a depressive phase showed improvements superior

to 50% of the baseline score in the HDRS scale,

which implies a 76.9 % percentage of responders. However,

since one of the responder patients really presented

a shift towards hypomania, with a score of 17

points in the YMRS, the real value of responders would

be 9/13, that is 69.2%. Applying the strict remission criterion

of presenting a score of 8 points or less on both

the YMRS and HDRS, there were 7 patients in remission

(41.2%) at the end of the follow-up, 6 of whom had initiated

the treatment during a depressive phase and 1

while euthymic. Figure 2 shows these data.

The adverse effects occurring during the study are

shown in table 2. Ten patients (58.8%) showed some

side effect, the most frequent being headache. Two

patients presented exanthema that was resolved without

complications when the treatment was discontinued.

Besides these two interruptions, a third patient discontinued

the medication due to intolerability related with

nausea and vomiting. One patient presented a shift towards

hypomania and was withdrawn from the study,

although this was considered as lack of response to

treatment. The shift, however, has been added to the table

as a possible side effect or as drug related.

CONCLUSIONS

The results of this study confirm the observation of

Calabrese et al. (1999a and 2000) that lamotrigine could

have antidepressive and mood stabilizer properties in

bipolar patients, although these studies specifically observe

an antidepressive effect in depressed bipolar I patients

and a preventive effect on the depressive phases

in bipolar II patients with rapid cycling, respectively.

Thus, our study provides data on the efficacy and safety

of lamotrigine in an indication that has still not been studied

strictly, although the results are clearly concordant

with those of the previous study.

However, there are important limitations that make it

necessary to be extremely cautious in the conclusions

that can be made from our study. The first and fundamental

one is the open and non-controlled design that

prevents intra-trial sensitivity from being known and

opens the door to a possible placebo effect. The second,

and no less important, one is simultaneity with other

treatments, which, although they were practically not

m o d i fied during the study, could contribute to the results.

The third obvious limitation is the sample size, with

more manifestation in patients who initiated the study

d u ring a hypomaniac phase or in partial remission. Finally,

compliance with the medication was not verified by any

laboratory technique, but rather was based on the information

provided by the patient and their family.

In spite of the limitations mentioned, we consider that

our study provides relevant information from the clinical

point of view. Although drug efficacy is shown much

better when compared with a placebo, the simple existence

of the placebo in the design of a study automatically

biases the study population, indirectly selecting the

patients with the most predisposition and generally,

the least serious. Controlled clinical trials also systematic

a l ly ex clude patients with a risk of suicide, with com o r b i d

disorders or polymedicated. In this sense, our study is

closer to the clinical reality and its results may possibly

be more generalized.

It seems that two conclusions regarding the efficacy

of lamotrigine in bipolar II patients can be deduced in

our study: lamotrigine seems to improve the depressive

symptoms of patients who initiated the treatment during

a depressive phase and the benefits of treatment seem to

extend beyond the acute phase with an improvement of

the disease course evaluated by the specific subscale

CGI-BP-M at 6 months. Our data are insufficient to draw

any conclusion in hypomaniac patients, given their limited

number. It can be deduced that the investigators were

more prone to enroll depressed patients than hypomaniacs,

probably as a consequence of the previous negative

data on the efficacy of lamotrigine in mania, that

have not been published, and the positive data in depression9.

One piece of data which, from our point of

view, instills certain optimism, is the finding of 41.2% of

the patients who are in remission at 6 months. Considering

that the patients enrolled were mostly resistant or

i n t o l e rant to the conventional treatment, this value seems

to be quite promising.

The mean dose of lamotri gine was 202 mg/day, in re l ationship

with the mean dose used in previous studies3,13.

Slow titration of 25 mg/week was performed in most of

the cases to avoid or reduce the risk of exanthematic

reactions as much as possible. After the titration period,

most of the patients took lamotrigine as a single morning

dose of 200 mg/day. The dose ra n ge used with 25 to 325 mg

if the patients who prematurely withdrew from the

study are included and from 100 to 325 if we refer exclusively

to those who reached 6 months of follow-up.

Lamotrigine was shown to be a well tolerated drug,

although three drop outs occurred due to side effects. In

two cases, interruption occurred due to the appearance

of a cutaneous exanthema that spontaneously abated at

48 hours of withdrawing the drug, and which, in both

cases, had limited seriousness. Although appearance of

exanthema has been described in approximately 10% of

the patients treated with lamotrigine (which coincides

with our study), this result of extreme seriousness rarely

occurs8. The cases of serious exanthema are extremely

rare and have been related with high and sudden doses,

combinations with valproate, and more frequently in

children. In any case, in our study, we follow the guideline

of discontinuing treatment when any form of skin

reaction appears. Regarding other side effects, their incidence

was also comparable to that observed in samples

of epileptic8 and bipolar3,13 patients. Another relevant

question in the treatment of depressed bipolar patients

is the risk of hypomaniac change associated to the

t reatment. This risk has been associated with certain antidepressant

treatments14, but it was not superior to that

of the placebo in the Calabrese et al. (1999) study. In our

sample, there was only one case (5.9%), which means a

value similar to that observed in the mentioned study,

which was 8% of the patients treated with 200 mg/day.

As a conclusion, we believe that, in spite of its limitations,

this study provides sufficient data on short and

long term efficacy of lamotrigine in bipolar II patients,

especially for those who initiate treatment during a depressive

phase. Up to the present date, few studies have

focused on analyzing the treatment of the bipolar II

disorder15. If verified in randomized clinical trials, the

results of our study would indicate that lamotrigine is a

very interesting alternative in short and long term treatment

of bipolar II disorder. Other features that should be

studied are up to what point a combined treatment

(with lithium, for example) would be convenient and up

to what point the efficacy of lamotrigine in bipolar depression

extends to the prevention of the suicide behavior

as seems to occur in the case of lithium16.

REFERENCES

1. Vieta E, Gastó C, Otero A, Nieto E, Vallejo J. Differential

features between bipolar I and bipolar II disorder. Compr

Psychiatry 1997;38(2):98-101.

2. Ayuso-Gutiérrez JL, Ramos Brieva JA. The course of manicdepressive

illness. A comparative study of bipolar I and bipolar

II patients. J Af fect Disord 1982;4:9-14.

3. Calabrese JR, Suppes T, Bowden CL, Sachs GS, Swann AC,

McElroy SL, et al. A double-blind, placebo-controlled,

prophylaxis study of lamotrigine in rapid-cycling bipolar

disorder. Lamictal 614 study group. J Clin Psychiatry

2000;61(11):841-50.

4. Vieta E, Colom F, Martínez-Arán A, Benab a rre A, Reinares M,

Gastó C. Bipolar II disorder and comorbidity. Compr Psychiatry

2000;41(5):339-43.

5 . Rihmer Z, Rutz W, Pihlgren H. Depression and suicide

on Gotland. An intensive study. An intensive study of

all suicides before and after a depression-training programme

for general practitioners. J Affect Disord 1995;

35(4):147-52.

6 . Vieta E. Diagnosis and classification of psychiatric disorders.

En: Sussman N, editor. Anticonvulsivants in Psychiatry.

Worcester: Royal Society of Medicine Press Limited,

1999; p. 3-16.

7. Vieta E. Abordaje actual de los trastornos bipolares. Barcelona:

Masson, 1999b.

8. Messenheimer J, Mullens EL, Giorgi L, Young F. Safety review

of adult clinical trial experience with lamotrigine.

Drug Saf 1998;18(4):281-96.

9. C a l ab rese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E,

Rudd GD, for the Lamictal 602 Study Group. A doubleblind

placebo-controlled study of lamotrigine monotherapy

in outpatients with bipolar I depression. J Clin Psychiatry

1999a;60:79-88.

10. Colom F, Vieta E, Martínez-Arán A, García M, Reinares M,

To rrent C, et al. Ve rsión española de una escala de evaluación

de la manía: validez y fi abilidad de la escala de

Young. Med Clin 2002;119:366-71.

11. Hamilton M. A rating score for depression. J Neurol Neurosurg

Psychiatry 1960;23:56-62.

12. Vieta E, Torrent C, Martínez-Arán A, Colom F, Reinares M,

B e n ab a rre A, et al. Una escala sencilla de evaluación del curso

del tra s t o rno bipolar: la CGI-BP-M. Actas Esp Psiquiatr

2 0 0 2 ; 3 0 : 3 0 1 - 4 .

1 3 . C a l ab rese JR, Bowden CL, McElroy SL, Cookson J, Andersen J,

Ke ck PE Jr, et al. Spectrum of activity of lamotri gina in tre a tment-

refractory bipolar disorder. Am J Psychiatry 1999b;

156(7):1019-23.

14. Peet M. Induction of mania with selective serotonin reuptake

inhibitors and tricyclic antidepressants. Br J Psychiatry

1994;164(4):549-50.

15. Vieta E, Gastó C, Colom F, Reinares M, Martínez-Arán A,

Benabarre A, et al. Role of risperidone in bipolar II: an

open 6-month study. J Affect Disord 2001;67:213-9.

1 6 . Tondo L, Hennen J, Baldessasrini RJ. Lower suicide risk with

l o n g - t e rm lithium treatment in major affe c t i ve illness: a metaa

n a lysis. Acta Psychiatr Scand 2001;104(3):163-72.

(sumber:

Correspondence:

Eduard Vieta

Director Programa de Trastornos Bipolares

Departamento de Psiquiatría

Hospital Clínico de Barcelona

Villarroel, 170

08036 Barcelona (Spain)

E-mail: EVIETA@clinic.ub.es)

Web: EBSCO

tomy

----- Original Message ----
From: ratih ibrahim <personalgrowth@gmail.com>
To: psikologi_transformatif@yahoogroups.com
Sent: Monday, November 5, 2007 11:55:39 AM
Subject: Re: [psikologi_transformatif] Bipolar Tipe II

ini kata seorang bude-bude.

si dia,

memang ga bakal mau diajak ketemu psikolog apalagi psikiater.

mengapa?

karena yang bersangkutan tidak merasa terganggu.

siapa sih yang merasa terganggu (oleh dia) orang-orang lain di sekitarnya.. .

dan para penderita psikotik tidak akan merasa dirinya terganggu... .

orang lain yang merasa terganggu...

karena dia memang mengganggu.. .

dan sangat mungkin untuk bertemu dengan psikolog maupun psikiater bisa diinterpretasikan sebagai "penghinaan" untuk dia..

karena bisa jadi dalam benaknya dia bilang, "memangnya saya gila apa????'"

apakah bisa di"obati" dengan konseling?

tergantung tingkat "keparahan"nya tentu...

semakin parah yang dikonseling sampai dower yang memberi konseling ga bakalan ada perbaikan...

bisa2 yang jadi stress dan harus dikonseling adalah si konselornya, hahahaha

nah,

apa yang harus dilakukan?

bila HARUS, angkutlah si dia ke RS terdekat yang ada psikiaternya.

memang harus janjian dulu...

------------ --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- --------- -

mas Goen,

Vincent?

hahahahahahahaaaaaa ......... .

bapaknya juga tuhhhhhhhhh, yang musti disuntik obat...

ga bisa cuma disuruh minum obat aja

bude Tih

On 11/4/07, Carmelita Renatha <carmelita_renatha@ yahoo.com> wrote:

Rekan rekan,
perkenalkan saya Ita, awam psikologi.
Apakah ada yang bisa memberi masukan mengenai Bipolar Tipe II?
Mengenai perkembangannya di Indonesia? Apakah penyakit ini hanya
bisa diselesaikan dengan obat antidepresan? Apakah konseling
psikologi tidak mampu banyak membantu? jika konseling membantu,
bagaimana meyakinkan seseorang yang meyakini dirinya mengidap
Bipolar II untuk berkonsultasi dengan psikolog di saat dia hanya
menginginkan antidepresan? Beliau menolak untuk diajak ke psikolog
namun untuk ke psikiater juga sulit. Terus menerus mengajukan
pertanyaan seputar antidepresan. Ajakan saya untuk bertemu psikolog
sepertinya berujung kekecewaan pada dirinya, merasa tidak di-
mengerti bahwa yang dideritanya adalah sakit dan hanya butuh obat.

Saya sangat memerlukan informasinya karena beberapa artikel tentang
bipolar II yang saya temukan hanya berbicara bahwa sakit ini seakan2
hanya butuh obat antidepresan dan dipergunakan rekan saya sebagai
semacam pembenarannya.

Terima kasih sebelumnya.

salam hangat,
Ita