Thursday, April 30, 2009

What Is Neuropathy? What Causes Neuropathy?

Neuropathy is a collection of disorders that occurs when nerves of the peripheral nervous system (the part of the nervous system outside of the brain and spinal cord) are damaged. The condition is generally referred to as peripheral neuropathy, and it is most commonly due to damage to nerve axons. Neuropathy usually causes pain and numbness in the hands and feet. It can result from traumatic injuries, infections, metabolic disorders, and exposure to toxins. One of the most common causes of neuropathy is diabetes.

Neuropathy can affect nerves that control muscle movement (motor nerves) and those that detect sensations such as coldness or pain (sensory nerves). In some cases - autonomic neuropathy - it can affect internal organs, such as the heart, blood vessels, bladder, or intestines.

READ MORE @ MEDICAL NEWS TODAY

Wednesday, April 29, 2009

Are we cherry picking participants for studies of antidepressants?

People with depression often excluded from clinical studies and tend not to fare as well as study participants

Findings from clinical studies used to gain Food and Drug Administration approval of common antidepressants are not applicable to most patients with depression, according to a report led by the University of Pittsburgh Graduate School of Public Health. Published in the May issue of the American Journal of Psychiatry, the study suggests only a small percentage of people with depression qualify for these studies, and those who do not qualify are often treated with the same medications but may suffer poorer clinical outcomes.

A part of the National Institute of Mental Health-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project – the largest study of the treatment of depression conducted in the United States – researchers compared symptoms and outcomes in depressed patients who met phase III study inclusion criteria to those who did not. Phase III studies for antidepressants determine the effectiveness of the drug in comparison to a placebo. The inclusion criteria for these studies are not standardized nor subject to federal guidelines, resulting in some variation from study to study in the profile of eligible patients. Typically excluded are patients with milder forms of depression, who might be more likely to respond to a placebo drug, and those who may have chronic depression or psychiatric and medical co-morbidities – additional illnesses or conditions.

After assessing 2,855 patients treated with citalopram, a commonly prescribed selective serotonin reuptake inhibitor for mood disorders, study authors concluded that fewer than one in four, or 22.2 percent, of the patients met the usual criteria for inclusion in phase III antidepressant trials.

"Only a small percentage of depressed patients in our study would have qualified for inclusion in phase III efficacy trials of depression drugs," said study lead author, Stephen Wisniewski, Ph.D., professor of epidemiology and co-director of the Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health. "This raises major concerns about whether results from traditional phase III studies can be generalized to most people with depression, who also often suffer from anxiety, substance abuse and other medical and psychiatric problems."

READ MORE @ EUREKALERT

Tuesday, April 28, 2009

No Data Supporting Antipsychotic Drug for Low-IQ Kids With ADHD

A new Cochrane review finds no evidence to support the use of risperidone to treat attention- deficit/hyperactivity disorder (ADHD) in people with intellectual disabilities, even though the review authors say this is a common prescribing pattern.

Risperidone, or Risperdal, is a second-generation antipsychotic drug. Long-term use of these drugs is associated with serious side effects, including weight gain and increased risk for type 2 diabetes.

“People who have intellectual disability are more likely to receive treatment with second- generation antipsychotics for ADHD,” said lead review author Dr. Alex Thomson. “Doctors should be aware that there is no research to demonstrate the effectiveness of risperidone for ADHD in people with intellectual disability, and should carefully monitor each case and consider alternative treatments before trying risperidone.”

Laurel Leslie, M.D., an associate professor at Tufts University School of Medicine whose research centers on pediatric mental health, concurred: “This study demonstrates that we have a gap between what we’re doing clinically and what we have any research evidence for. It’s an important study, as it highlights the need for careful consideration of how we treat children’s mental health issues.” Leslie has no affiliation with the Cochrane review.

Thomson’s research group did not find one study that met their criteria for inclusion among more than 2,000 studies that they initially identified. The group analyzed 15 studies in depth, but ultimately rejected them all.

READ MORE @ NEWSWISE

Monday, April 27, 2009

Medication Errors Could Be Cut: Experts - Two reports show promise of computers, pharmacists for proper prescribing

Medication errors and adverse drug reactions cost lives and dollars each year in the United States, but two new reports suggest ways hospitals and pharmacists can work to reduce these mistakes.

Medication errors are one of the most common medical errors, affecting at least 1.5 million people every year and costing the health-care system between $77 billion and $177 billion annually, researchers point out in the April 27 issue of the Archives of Internal Medicine.

In the first report, researchers led by Dr. Jeffrey L. Schnipper, of Brigham and Women's Hospital and Harvard Medical School, used a computer system to keep track of the medications patients were taking when they were admitted to the hospital and the medications they were taking when they were discharged.

"It turns out that we commit about 1.5 errors per patient either for the admissions orders in the hospital or, much more commonly, in the discharge orders, which is kind of appalling," Schnipper said. "These are errors with potential for patient harm. There are about three times as many errors without potential for patient harm."

READ MORE @ FORBES

Saturday, April 25, 2009

Study: Medicaid patients get wrong drugs

Drugs designed to treat severe mental illnesses are being prescribed to Medicaid patients at inappropriately low doses, at considerable expense and for conditions where their benefits haven't been proven, a team of mostly Oregon researchers reports.

Scientists from the Oregon State University College of Pharmacy, Oregon Health and Science University and Columbia University's psychiatry department reviewed records for 830 Oregon Medicaid patients who had been given antipsychotic medications approved for conditions such as schizophrenia and bipolar disorder. The researchers found the majority of those patients did not have the underlying mental conditions for which the drugs were approved for prescription. Instead, they were given to patients to treat health concerns such as depression, anxiety, post-traumatic stress disorder or insomnia.

READ MORE @ STATESMAN JOURNAL

Friday, April 24, 2009

Depressed and Coping: Treating Depression When Medication Fails

Various lifestyle approaches make drugs more effective or help relieve depression on their own.

James Russo has wrestled for some 60 years with his "black dog" of depression, since the days back in high school when a B left him feeling like an utter failure. He tried Valium, a tricyclic antidepressant, and Prozac before finding some relief in Paxil. Still, says Russo, 74, of Bernville, Pa.: "My disease lives in the corner of my mind, sometimes sleepy enough to let me enjoy a little optimism but ever ready to ruin a day or a week or a year." What has become abundantly clear in the antidepressant age—the drugs are now the most commonly prescribed medications in the country—is that depression is terribly difficult, if not impossible, to cure. Many primary-care doctors, who treat 80 percent of depressed people, labor under the assumption that a prescription is a panacea. But antidepressants completely alleviate symptoms in only about 35 to 40 percent of people compared with 15 to 20 percent of those who take a placebo—a fact not publicized in pharmaceutical ads. And about 70 percent of people who successfully beat one bout can expect to face another.

"We just don't have one magical pill that will do the whole trick," says Madhukar Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. He recently participated in the government-funded "Star*D" trial of more than 4,000 patients with difficult-to-treat depression, which showed that success rates of antidepressants could be increased but that it sometimes took four tries of various drugs plus therapy. Even then, in 30 percent of those who completed the yearlong study, symptoms still lingered. And 5 percent of study participants, according to new Star*D data published last week, actually had a worsening of their symptoms while on an antidepressant. In an effort to better combat treatment-resistant depression, the Food and Drug Administration last month approved a combination pill for those who aren't helped by antidepressants alone. The drug, called Symbyax, combines the antidepressant Prozac and the antipsychotic Zyprexa.

READ MORE @ U.S. NEWS & WORLD REPORT

Thursday, April 23, 2009

A New Way Of Thinking For Schizophrenia Treatment

The effectiveness of psychiatric drugs varies considerably in individuals being treated for depression or schizophrenia. These drugs act on serotonin, a neurotransmitter (chemical messenger) central to the regulation of moods. Scientists from Oxford and Belfast have discovered more about emotional processing and genetic variations that will help to inform treatment strategies.

The long-held view that serotonin levels are low in people with depression has been challenged by Philip Cowen, professor of psychopharmacology at Oxford University. "We asked what evidence is there that the action is abnormal and this stimulated new thinking about how anti-depressants work," he said at the British Neuroscience Association meeting in Liverpool today (21 April).

READ MORE @ MEDICAL NEWS TODAY

Tuesday, April 21, 2009

Comorbidity: Psychiatric Comorbidity in Persons With Dementia

The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older. Up to 90% of patients with dementia have psychiatric comorbidities.1,2

Physicians who treat patients with dementia must remember that dementia is not merely a problem with memory. The presence of one or more additional cognitive disturbances, including aphasia, apraxia, or agnosia, is required to make the diagnosis according to DSM-IV-TR criteria. Furthermore, some patients may present with changes in personality or deficits in executive function rather than memory impairment, which complicates the initial diagnosis.3 Additional mental and behavioral disturbances often affect patients and caregivers as much as memory deficits and may influence quality of life, the need for institutionalization, mortality, and caregiver burden.2,4,5

This article emphasizes neuropsychiatric disturbances with the greatest prevalence and morbidity in persons with dementia. It also addresses comorbid depressive and anxiety disorders, as well as psychological and behavioral disturbances associated with dementia—psychosis and agitation/aggression.3,6

READ MORE @ PSYCHIATRIC TIMES

Monday, April 20, 2009

F.D.A. Rules on Drug Ads Sow Confusion as Applied to Web

WHEN the Food and Drug Administration sent letters to 14 major pharmaceutical companies late last month, the warning was strong. The companies’ search advertisements — the short text ads that run beside Google results — had to start including risk information about each drug or else be rewritten or removed.

Just how the companies were supposed to comply was not so clear. In the 95 characters that Google allowed for search ads, there was no way to include all the required information, the companies argued.

Now, as the companies change their search ads to comply with the letters, industry executives say the solution is worse than the problem: their ads are even more confusing and misleading now, they say. And they worry that regulators will enforce standards that were created for magazines and television, rather than making new rules that acknowledge how Internet ads have evolved.

The letters were sent to almost all of the major pharmaceutical companies, including GlaxoSmithKline, Pfizer, Merck and Eli Lilly. The letters said ads for widely prescribed drugs, including Celebrex, Propecia and Yaz, did not include the paragraphs of precautions the agency required.

READ MORE @ NY TIMES

Sunday, April 19, 2009

Alzheimer’s Patients on Atypical Antipsychotics Experience “Significant” Weight Gain

Some newer, atypical, or second-generation, antipsychotic medications have been found to have two serious adverse reactions. The drugs both lower so-called “good” cholesterol and cause weight gain in older Alzheimer patients.

HealthDay News reports that in a study of over 400 elderly patients, medications such as Zyprexa (olanzapine) and Seroquel (quetiapine) were both linked to “significant” weight gain, saying that those patients specifically taking Zyprexa “experienced increases in waist circumference and declines in HDL cholesterol,” as well. The study also revealed that the weight gain correlated to the amount of time the patient was on the medication; the longer the patient was taking the drug, the more weight gained, said HealthDay News.

The findings from the Clinical Antipsychotic Trials of Intervention Effectiveness—Alzheimer’s Disease (CATIE-AD) study, were funded by the U.S. National Institute of Mental Health (NIMH), said HealthDay News, and appear in the April 15 issue of the American Journal of Psychiatry. “These findings are especially troubling, because antipsychotics are associated with a higher risk of death and cerebrovascular adverse events in patients with dementia. They’re often used to minimize disruptive symptoms (such as psychosis or agitation), but patients should be monitored more closely,” said lead investigator Dr. Lon S. Schneider, in an American Psychiatric Association news release, quoted HealthDay News. The team noted that similar “metabolic side effects” have been seen in schizophrenia patients taking the newer antipsychotics, said HealthDay News.

READ MORE @ NEWS INFERNO

Friday, April 17, 2009

What Should Count as a Mental Disorder in DSM-V?

If sick men fared just as well eating and drinking and living exactly as healthy men do . . . there would be little need for the science [of medicine].
attributed to Hippocrates

Well, while I’m here, I’ll do the work—and what’s the work? To ease the pain of living. . . .
Allen Ginsberg

What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”? Is “disease” something like an oak tree—a physical object you can bump into or put your arms around? Or are terms like “disease” and “disorder” merely abstract, value-laden constructs, akin to “injustice” and “immorality”? Are categories of disease and disorder fundamentally different in psychiatry than in other medical specialties? And—by the way—how do the terms “disease,” “disorder,” “syndrome,” “malady,” “sickness,” and “illness” differ?

Anyone who believes there are easy or certain answers to these questions is either in touch with the Divine Mind, or out of touch with reality. To appreciate the complexity and ambiguity in this conceptual arena, consider this quote from the venerable Oxford Textbook of Philosophy and Psychiatry:



The term “mental illness” is probably best used for those disorders that are intuitively most like bodily illness (or disease) and, yet, mental rather than bodily. This of course implies everything that is built into the mind-brain problem!1(p11)

In a single sentence, we are already grappling with the terms “illness,” “disorder,” and “disease,” not to mention Cartesian psychology! And yet—daunting though these issues are—they are central to the practical task now before the DSM-V committees: figuring out what conditions ought to be included as psychiatric disorders.

READ MORE @ PSYCHIATRIC TIMES

Wednesday, April 15, 2009

Comorbidity: Schizophrenia With Obsessive-Compulsive Disorder

The co-occurrence of obsessive-compulsive symptoms (OCS) and psychotic illness has been a challenge for clinicians and investigators for more than a century.1 Over the past decade, interest in this area has burgeoned because of recognition of higher-than-chance comorbidity rates of schizophrenia and obsessive-compulsive disorder (OCD), and observations of appearance or exacerbation of OCS during treatment of schizophrenia with atypical antipsychotics.2-6 Emerging neurobiological and genetic evidence suggests that persons with comorbid OCD and schizophrenia may represent a spe­cial category of the schizophrenic population.

The evidence for a putative schizo-obsessive disorder is examined and practical treatment suggestions for this subgroup of patients are outlined in this article.7-9

Comorbidity between OCD and schizophrenia
The lifetime prevalence for schizophrenia is 1% and for OCD it is 2% to 3%.10 Comorbidity rates for OCD in the schizophrenia population are substantially higher than what would be expected to occur randomly. In the schizophrenic population, the reported prevalence of clinically significant OCS and of OCD ranges from 10% to 52% and from 7.8% to 26%, respectively.11-23

The higher-than-expected comorbidity rate for OCD and schizophre­nia suggests a nonrandom association and possibly an integral relation between these 2 conditions.9 The question is whether this comorbid group with schizo-obsessive disorder represents a more severely ill group with greater brain dysfunction that could, in part, be caused by common neuro­developmental predisposing factors, or whether the 2 conditions are part of a more complex syndrome that rep­resents a distinct diagnostic entity. The answer could be clarified in part if neurobiological studies were to dem­­onstrate a distinct neuroanatomical substrate in this comorbid group rather than the summation or superimposition of neurobiological lesions observed in the separate disorders.9

READ MORE @ PSYCHIATRIC TIMES

Tuesday, April 14, 2009

Heart Disease and Depression Up Heart Failure Risk Use of antidepressants makes little difference, study finds

Depression increases the risk that people with heart disease caused by blockage of coronary arteries will develop heart failure, a new study finds.

That finding was to be expected, said Heidi May, an epidemiologist at the Intermountain Medical Center in Murray, Utah, and lead author of the study, because earlier research had found that depression increases the risk of heart failure in otherwise healthy people. Heart failure is a progressive loss of the ability to pump blood.

What was not expected was the finding that treatment with antidepressant drugs did not reduce the risk of heart failure among people with depression in the group May studied -- 13,708 people who were diagnosed with coronary artery disease.

READ MORE @ FORBES

Sunday, April 12, 2009

Atypical antipsychotics: too hard a sell?

Use of drugs such as Abilify, Seroquel and Zyprexa for treatment-resistant depression is gaining ground. Some see an 'unmet need' for medication. Others worry about side effects.

About a year ago, patients began trooping into the office of UCLA psychiatrist Andrew Leuchter, asking whether an antipsychotic drug called Abilify "might be right for them." Few appeared to be delusional, plagued by hallucinations or suffering fearsome mood swings. Mostly, they were depressed or anxious, and frustrated by the pace of their recovery.

Leuchter wondered what was up: Depressed patients didn't usually seek out drugs used to quell psychiatry's most disturbing symptoms.

What was up, he soon discovered, was spending on a new advertising campaign touting Abilify as an "add-on" treatment for depression. For the first time since the arrival of a new generation of antipsychotic medications -- six drugs called the "atypicals" because they work differently from the earlier generation of antipsychotic drugs -- the makers of one, Abilify, had been granted the legal right to market to a vast new population of patients beyond those with schizophrenia or bipolar disorder.

This week, a Food and Drug Administration advisory panel recommended that the agency should grant the makers of a second atypical antipsychotic drug -- Seroquel XR -- similar latitude. The drug giant AstraZeneca wants permission to market the drug as a treatment for depression or anxiety that has not yielded to antidepressants alone.


READ MORE @ LOS ANGELES TIMES

Saturday, April 11, 2009

When to Avoid Antidepressants in Bipolar Patients

Patients with bipolar depression who exhibit even minimal manic symptoms are at heightened risk for switching into mania if they receive antidepressant medication, according to a new report from the Bipolar Collaborative Network.1

This finding from the multinational sites of the former Stanley Foundation Bipolar Network emerged in a post hoc analysis of 176 patients who participated in a 10-week controlled trial of adjunctive antidepressant medication for bipolar I or II depression. The investigators sought to identify clinical correlates for the development of treatment-emergent affective switching from patient demographics and baseline symptoms.

Possible risk factors for affective switch, which have been previously suggested, include comorbid substance abuse, younger age, decreased thyroid-stimulating hormone, and rapid cycling. Although none of these factors were predictive in this study, the investigators acknowledged that their modest effect size precluded ruling these out in other populations. They characterize this study, however, as the first controlled assessment of antidepressant treatment in bipolar depression to correlate a specific phenomenological presentation at baseline with affective switching in subsequent antidepressant treatment.

READ MORE @ PSYCHIATRIC TIMES

Friday, April 10, 2009

FDA Approves Pioneering Treatment for Obsessive- Compulsive Disorder

Psychiatrists will have to take the lead in ensuring that deep-brain stimulation (DBS)—approved by the FDA in February for the first time for use in obsessive-compulsive disorder (OCD)—is used appropriately.

Medtronic Inc’s Reclaim DBS therapy was approved under a humanitarian device exemption, which means that the system will be used on a relatively small number of adults (no more than 4000 and probably considerably fewer) with recalcitrant OCD.

The DBS device offers an adjustable, reversible, and nondrug therapy. This surgically implanted device- similar to a pacemaker- delivers carefully controlled electrical pulses to precisely targeted areas of the brain.

Only one other medical device has been approved for treatment of a psychiatric condition: the vagus nerve stimulation (VNS) implantation device made by Cyberonics. In 1997, the FDA approved the use of VNS as an adjunctive therapy for partialonset epilepsy; in 2005, its use in treatment-resistant depression was also approved. But Benjamin D. Greenberg, MD, PhD, told Psychiatric Times that VNS has been somewhat controversial, and insurance reimbursement remains an issue. Greenberg, who is associate professor of psychiatry at Brown University Medical School in Providence, RI, noted, however, that VNS does not involve brain surgery, as DBS does. Thus, the potential adverse effects from DBS, while relatively rare, can be more serious.

READ MORE @ PSYCHIATRIC TIMES

Wednesday, April 8, 2009

FDA Review Questions Cardiac, Suicide Risks for Investigational Antipsychotic

Investigational antipsychotic drug sertindole (Serdolect) is effective at treating schizophrenia, but it may lead to sudden cardiac death, according to an FDA review.

The agency released its review in advance of Tuesday's meeting of the Psychopharmacologic Drugs Advisory Committee, which will decide if the drug's cardiovascular risk is an obstacle to FDA approval.

The advisory panel will also consider the sponsor's suicide prevention claim, and whether to recommend to the FDA that the drug is safe and effective. The vote will effectively amount to a recommendation of approval or denial.

Sertindole is already used in other countries to treat schizophrenia.

According to the FDA review, led by psychiatrist Phillip Kronstein, M.D., sertindole is effective in treating schizophrenia, but concerns remain about the drug's potential to prolong the heart's QT interval, which can lead to sudden cardiac death. That same cardiac risk has been seen in other antipsychotic drugs similar to sertindole.

Sertindole is a so-called atypical antipsychotic drug, Its specific mechanism appears to be to inhibit spontaneously active dopamine neurons in the mesolimbic ventral tegmental area without affecting dopamine neurons in the substantial nigra compacta.

READ MORE @ MADPAGE TODAY

Tuesday, April 7, 2009

Several Factors Predict Response to Treatment in Depressed Teens

Research findings answer many clinical questions on how to tailor interventions to varying adolescent patient characteristics based on individual and family factors.

Teenagers who suffer from antidepressant-resistant depression and have a concurrent history of family conflict, nonsuicidal self injury, or more severe symptoms of depression will likely have a poorer response to a new course of treatment, according to a study published in the March Journal of the American Academy of Child and Adolescent Psychiatry.

The study also found that adding cognitive-behavioral therapy (CBT) to antidepressant medications produces the most benefit for patients who have comorbidities such as anxiety disorders.

The study's findings can help clinicians individualize treatment plans for adolescents with more chronic and complicated forms of depression.

Analyzing the data from the Treatment-Resistant Depression in Adolescents (TORDIA) study, Joan Asarnow, Ph.D., a professor of psychiatry and behavioral sciences at the University of California at Los Angeles (UCLA) and the principal investigator of TORDIA at UCLA, and coauthors identified a number of patient characteristics that are associated with the likelihood of response to treatment and the benefit of medication—CBT combination therapy versus medication alone in this hard-to-treat population.

READ MORE @ PSYCHIATRIC NEWS

Monday, April 6, 2009

Does Antipsychotic Treatment Impact Pediatric Health Care Costs?

Declining health care costs in pediatric patients treated with antipsychotic agents are being offset by the health care costs associated with the development of adverse events related to these medications.

Using retrospective data from South Carolina's Medicaid medical and pharmacy claims between January, 1996 and December, 2005, researchers Jeanette Jerrell, Ph.D., and Roger McIntyre, M.D., identified 4140 children and adolescents prescribed antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications. Their main outcome measures were total health care costs and emergency, inpatient, and outpatient services use over time, but they included pre-existing medical conditions, receipt of multiple psychotropic medications, and individual risk factor differences for gender, age group, and ethnicity in the analyses.

READ MORE @ MEDICAL NEWS TODAY

Saturday, April 4, 2009

Cognitive Impairments Found With Attention-Deficit/Hyperactivity Disorder

Over the past century, the syndrome currently referred to as attention-deficit/hyperactivity disorder (ADHD) has been conceptualized in relation to varying cognitive problems including attention, reward response, executive functioning, and other cognitive processes.1 More recently, it has become clear that whereas ADHD is associated at the group level with a range of cognitive impairments, no single cognitive dysfunction characterizes all children with ADHD.2,3 In other words, ADHD is not a one-size-fits-all phenomenon. Patients with this syndrome do not fit into any one category and present with widely differing co-occurring disorders—including varying cognitive profiles.

Thus, ADHD represents not a single disease entity but a heterogeneous group of patients who require differentiated analysis, assessment, and treatment. This article focuses on the cognitive presentation of children (and, to a lesser extent, adults) with ADHD.

READ MORE @ PSYCHIATRIC TIMES

Thursday, April 2, 2009

Schizophrenia - Novel Treatment May Provide Relief

A compound that naturally occurs in the brain and other areas of the body may be a promising new treatment for the most severe and disruptive symptoms of schizophrenia, according to researchers from Durham Veterans Affairs Medical Center and Duke University Medical Center.

Researchers conducted a pilot study that suggests the neurosteroid pregnenolone targets symptoms of schizophrenia for which no treatment options are available. The findings are published online in journal Neuropsychopharmacology.

While antipsychotic medications can help reduce hallucinations and delusions associated with schizophrenia for some patients, the other two categories of symptoms often continue to significantly disable patients -- negative symptoms, such as apathy, lack of emotion and poor social functioning, and cognitive symptoms, which include memory impairment and difficulty concentrating and completing tasks.

READ MORE @ HEALTH NEWS DIGEST

Wednesday, April 1, 2009

Comorbidity in Bipolar Disorder The Complexity of Diagnosis and Treatment

The central tenet of clinical comorbidity, the occurrence of 2 syndromes in the same patient, presupposes that they are distinct categorical entities. By this definition, 2 or more coexisting syndromes do not negate one another, nor paradoxically does this coexistence negate the potential for one to influence the course, outcome, and treatment response of the other. Isolating a syndrome by characterizing it through a unique pathogenic process allows for diagnostic fidelity even while acknowledging overlapping phenotypes.

Bipolar disorder (BPD) is highly prevalent and heterogeneous. Its increasing complexity is often caused by the presence of comorbid conditions, which have become the rule rather than the exception. Lifetime prevalence of psychiatric comorbidity has been reported in community and clinical studies. Most (95%) of the respondents with BPD in the National Comorbidity Survey met criteria for 3 or more lifetime psychiatric disorders.1 In a Stanley Foundation Bipolar Treatment Outcome Network study of almost 300 patients, 65% met DSM-IV criteria for at least 1 comorbid Axis I disorder.2

Analogous to models in medicine (eg, cardiovascular disease), BPD incorporates psychiatric and medical comorbidities (Table) whose simultaneous treatment is equally pressing to the core mood disturbance.3 Checks and balances must be used to address the distressing comorbid condition (eg, anxiety) whose treatment with an SSRI or serotonin norepinephrine reuptake inhibitor (SNRI) may catalyze a round of mood cycling in an otherwise stable patient; a greater degree of protection via mood stabilizers may be warranted in such an individual to reduce this possibility.

Overall, the presence of comorbidities in BPD has negative prognostic implications for psychological health and for medical well-being and longevity.4-6 The most common comorbid conditions are reviewed below to help guide the clinician through this diagnostic maze and associated treatment considerations.

READ MORE @ PSYCHIATRIC TIMES