مالك المطرودي

Psychopathology, Exhaustion, and Identity Diagnostic manuals cannot tell us who we “really” are

“Clinicians are—by training, by temperament, by context—biased towards offering treatment. Often the only corrective to this bias in the clinic is hesitancy on part of the patient.”

www.psychiatrymargins.com/p/psychopath...

William James on Psychology as a Science

Last but not least

📌Manual based therapies (Interpersonal Social Rhythm therapy, CBT, Mindfulness)

📌 Lithium monotherapy (Evidenced for superiority in prevention of Manic episodes)

📌Lamotrigine (evidence strongest for prevention of Depressive episodes)

📌 if stable on Divalproex, then, maintain.

*A very interesting note: “be aware that there are limited data on longterm efficacy of Divalproex.”

💊 Maintenance/Continuation treatment of Bipolar Disorder (Algorithm)

📌 due to the many choices in maintenance phase of BD Continue with the effective regimen used in acute mania. (However, be vigilant for adverse effects and patient needs and adjust accordingly)

📌 Severe episode (requiring hospitalization)
- Lithium or Divalproex + Aripiprazole, Asenapine, Quetiapine or Risperidone.

📌 If none of the above works

Consider Haloperidol or Olanzapine.

📌 If still no benefit move to Level 2 then Level 3 then Level 4 as indicated by the algorithm.

😆Acute Bipolar Mania (Algorithm)

📌 If Mild to moderate severity (not requiring hospitalization)

- Lithium (The GOAT) still holds sway as first line agent.

- Aripiprazole, Asenapine, Divalproex, Risperidone, Ziprasidone, or Cariprazine. (Also good choices as Monotherapy)

📌 In both BD-I and BD-II, if the patient was already started on a mood stabilizer previously then consider augmenting with Lirasidone or Lamotrigine.

(Cariprazine doesn’t have enough evidence with it comes down to augmentation with mood stabilizer)

📌 Bipolar Type II — Quetiapine still holds sway as first line here.

📌 In both BD-I and BD-II, if the patient was already started on a mood stabilizer previously then consider augmenting with Lirasidone or Lamotrigine.

📌 Bipolar Type II — Quetiapine still holds sway as first line here.

☹️ Acute Bipolar Depression (Algorithm)

📌 Bipolar Type I — Lurasidone and Cariprazine as first line (due to their favorable metabolic profile)

🔴 A change from their 2017 guidelines where Quetiapine or Lurasidone were their first line agents.

📌 DUE (Duration of untreated Episode)
is strongly associated with increasein depression-related disability

The earlier you intervene the better the outcome (much like in Early Psychosis prevention programs)

(take history again as treatment resistance sometimes point to a faulty diagnosis)

📌 Treatment success prediction:
best available evidence points to a period of around 2-4 weeks (3 on average).

be vigilant in non-responders as the longer they remain on current medication the less likelihood that they will respond to other agents.

STAR-D trial outcome- see second picture)

📌first off, some bullet points

1) Duration of Episode is strongly correlated with treatment response.

2) Treatment selection is the most important step in the management of any psychiatric patient, as this will determine the future tolerance and response to other mediactions (as evidenced by…

🧠Management Of Mood Disorders (Based on the 2017 Florida Medicaid guideline as expounded on by Prof @rogersmcintyre)

I have updated the changes within above mentioned guidelines with their 2019-2020 update.

and dishonest – but the myth – persistent, persuasive and unrealistic. Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought.
(Commencement address at Yale Uni,1962)

👴🏼 Professor Gin Malhi Stance

“Professor Malhi’s 2021 editorial on lithium mythology opens with a quote from former US President John F. Kennedy that aptly describes why certain ideas take root and are difficult to eradicate:
The great enemy of truth is very often not the lie - deliberate, contrived

YouTube video by CityOfDarebin Dr John Cade | Bundoora Homestead Heritage Film Series

youtu.be/JH3Xsswhe58?si…

John Cade and the discovery Lithium

Lithium treatment of Bipolar disorder in adults: A systematic review of randomized trials and meta-analyses The aim of the study was to systematically review the hard evidence alone, concerning lithium efficacy separately for the phases and clinical facets of Bipolar disorder (BD). The PRISMA method was fol...

(2022) Meta Analysis in question

pmc.ncbi.nlm.nih.gov/articles/PMC...

episodes.
As of 2022, leading BD experts comment about lithium: “It is equally efficacious in rapid and non-rapid cycling patients”

#Lithium #Psychopharmacology #Psychiatry

examine this issue.
The current impression that lithium is not inferior to other mood stabilizers for RC-BD maintenance therapy is based on almost 50 years of research that characterized RC-BD as a difficult group to treat with any mood stabilizer monotherapy due to the frequency of depressive…

👁️ Excerpt from Stahl’s The Lithium Handbook:

As noted in the 2022 meta-analysis of adult lithium BD trials, “the widely believed concept among clinicians that divalproex is more effective than lithium in the long-term management of rapid-cycling BD was not supported” by the only clinical trial to

“The refined message from two decades
of research is that the limitations of lithium relate to the neurobiology of RC-BD itself and not a failure of lithium per se, and that no mood stabilizer monotherapy will be sufficient to manage mood recurrence in many of these individuals.”

*Stahl (LHB,2024)

👁️👁️ However, when the analysis was confined to data from high-quality studies (11 trials out of 31 trials originally included)

Only Higher lifetime number of hospitalization admissions remained.

(Alcohol Use Disorder, Personality Disorders, Higher lifetime number of Hospital admissions, rapid cycling)

👀 in 2020 meta-analysis on Predictors of long-term clinical outcomes.

Two important conclusions of this study:
1) There is marked heterogeneity in the quality of outcomes data in this area.

2) among the 4 predictors of poor lithium outcome initially identified in the 31 relevant data sets —>

All excerpts taken from (The American Psychiatric Association Publishing Textbook of Psychopharmacology, 5th edition) ☕️

📊 - (Calabrese et al. 2005) Evaluated Lithium vs Divalproex monotherapy for maintenance in Rapid cycling patients who had been stabilized on Lithium and Divalproex Combination therapy; The rates of relapse were similar for lithium and divalproex treated patients.

📊 (Kupka et al. 2003) a meta analysis of clinical trials comparing subjects with rapid cycling vs non-rapid-cycling bipolar showed that Lithium was less effective in preventing relapses but it did have a beneficial effect on severity and duration of episodes.