Smith et al are to be congratulated in drawing attention to the
possibility that the increased risk of suicide in patients treated with
Venlafaxine may be explained by undiagnosed bipolar disorder in the group
of patients under consideration.[1].Thus the key problem exposed by the
epidemiological facts identified by Rubino et al [2] does not appear to
lie with the medication itself but with the unmasking of occult bipolarity
by Venlafaxine.
It is known that bipolar disorder, of both the type I and Type II sort, is
often underdiagnosed and undertreated.[6]
There is evidence that many patients with bipolar illness have a long
duration of untreated illness analogous with the Duration of Untreated
Psychosis in other psychotic illnesses.[3]
There is evidence that if a series of patients with unipolar
depression are followed up over time, some, at a constant rate, gradually
change to cases of bipolar affective disorder.[4]
The long durations of untreated illness in bipolar affective disorder have
given rise to concern. [3] Attempts are being made to develop a pattern of
early symptoms, analogous to the ‘Prodrome’ of Schizophrenia, to help
identify patients who are developing early bipolar disorder[5].
In practice, early bipolar disorder will be identified and treated if
Primary Care Doctors are effective in identifying and treating early
cases of depression or bipolar disorder which present to them. [6] We
would suggest that care should be taken that , each patient who presents
with major depression, both in primary and secondary care is asked to
identify any period of elated mood which they have experienced, even if
this has lasted for only a few days. A family history of bipolar illness
or suicide, previous episodes of hypomania, at least three recurrent
depressive episodes, cyclothymia, and a seasonal onset [winter in bipolar
II and summer in bipolar I patients], have all been identified as
indicators of the possibility of bipolar illness [7]. Identifying these
markers will enable patients with bipolar illness to be identified,
perhaps earlier than they otherwise would.
The cautions that antidepressant monotherapy for bipolar disorder may
precipitate hypomanic or mixed states, which are strongly associated with
self harm and completed suicide , and that Venlafaxine seems more likely
than other antidepressants to precipitate a switch to mania in bipolar
depression [1] should then lead to a policy that, once bipolar depression
is identified earlier, mood stabilisers , including Lithium, should be
considered to treat the illness [8][9], rather than anti-depessants
[including Venlafaxine] alone.
We would suggest that a policy of early diagnosis and appropriate
treatment of bipolar disorder is likely to be the most effective step that
we can take. Caution regarding the use of Venlafaxine as a first line
treatment in unipolar depression [10] must be seen as secondary to this.
References
[1] Smith D, Walters J [2007] Bipolarity is important during treatment
with antidepressants. BMJ 334;327.
[2] RubinoA, Roskell N, Tennis P, MinesD, Weich S, Andrews E. Risk of
suicide during treatment with Venlafaxine, citalopram, Fluoxetine and
Dothiepin; retrospective cohort study . BMJ 2007;334 242-245.
[3] Vlazquez-Barquero J et al [2006] Early Intervention in Bipolar
Disorders: Rationale for the overdue implementation of a fesable paradigm.
Schizophrenia Research 86 S 36
[4] Angst J, Sellaro R [2000] Historical perspectives and natural history
of Bipolar Disorder. Soc Biol Psychiatry 48; 445-457.
[5] Conus P et al [2006] The prodrome to first episode psychotic mania ;
results of a retrospective study. Schizophrenia Research 86 S 37.
[6] Agius M, Erithrajalu R, Mani B [2006] The diagnosis and treatment of
bipolar and other affective disorders within the model of Early
Intervention Services. The second dual congress on Psychiatry and the
Neurosciences, 1st European Congress of the International Neuropsychiatric
Association ; 2nd Mediterranean congress of the World Federation of
Societies of Biological Psychiatry Athens 2006 Book of Abstracts p 49.
[7] Tavormina G [2006] The approach to Bipolar Spectrum Diagnosis . The
second dual congress on Psychiatry and the Neurosciences, 1st European
Congress of the International Neuropsychiatric Association ; 2nd
Mediterranean congress of the World Federation of Societies of Biological
Psychiatry Athens 2006 Book of Abstracts p 48.
[8]Akiskal H [2006] Bipolar Depression; the long term view. The second
dual congress on Psychiatry and the Neurosciences, 1st European Congress
of the International Neuropsychiatric Association ; 2nd Mediterranean
congress of the World Federation of Societies of Biological Psychiatry
Athens 2006 Book of Abstracts p 30.
[9] Rihmer Z, Gonda X. [2006] Prediction and prevention of suicide in
bipolar illness. The second dual congress on Psychiatry and the
Neurosciences, 1st European Congress of the International Neuropsychiatric
Association ; 2nd Mediterranean congress of the World Federation of
Societies of Biological Psychiatry Athens 2006 Book of Abstracts p 30.
[10] Cipriani A, Geddes J, Barbui C. [2007] Venlafaxine for major
depression. BMJ 334 ;215.
Rapid Response:
Identifying and treating Bipolar Illness Early.
Smith et al are to be congratulated in drawing attention to the
possibility that the increased risk of suicide in patients treated with
Venlafaxine may be explained by undiagnosed bipolar disorder in the group
of patients under consideration.[1].Thus the key problem exposed by the
epidemiological facts identified by Rubino et al [2] does not appear to
lie with the medication itself but with the unmasking of occult bipolarity
by Venlafaxine.
It is known that bipolar disorder, of both the type I and Type II sort, is
often underdiagnosed and undertreated.[6]
There is evidence that many patients with bipolar illness have a long
duration of untreated illness analogous with the Duration of Untreated
Psychosis in other psychotic illnesses.[3]
There is evidence that if a series of patients with unipolar
depression are followed up over time, some, at a constant rate, gradually
change to cases of bipolar affective disorder.[4]
The long durations of untreated illness in bipolar affective disorder have
given rise to concern. [3] Attempts are being made to develop a pattern of
early symptoms, analogous to the ‘Prodrome’ of Schizophrenia, to help
identify patients who are developing early bipolar disorder[5].
In practice, early bipolar disorder will be identified and treated if
Primary Care Doctors are effective in identifying and treating early
cases of depression or bipolar disorder which present to them. [6] We
would suggest that care should be taken that , each patient who presents
with major depression, both in primary and secondary care is asked to
identify any period of elated mood which they have experienced, even if
this has lasted for only a few days. A family history of bipolar illness
or suicide, previous episodes of hypomania, at least three recurrent
depressive episodes, cyclothymia, and a seasonal onset [winter in bipolar
II and summer in bipolar I patients], have all been identified as
indicators of the possibility of bipolar illness [7]. Identifying these
markers will enable patients with bipolar illness to be identified,
perhaps earlier than they otherwise would.
The cautions that antidepressant monotherapy for bipolar disorder may
precipitate hypomanic or mixed states, which are strongly associated with
self harm and completed suicide , and that Venlafaxine seems more likely
than other antidepressants to precipitate a switch to mania in bipolar
depression [1] should then lead to a policy that, once bipolar depression
is identified earlier, mood stabilisers , including Lithium, should be
considered to treat the illness [8][9], rather than anti-depessants
[including Venlafaxine] alone.
We would suggest that a policy of early diagnosis and appropriate
treatment of bipolar disorder is likely to be the most effective step that
we can take. Caution regarding the use of Venlafaxine as a first line
treatment in unipolar depression [10] must be seen as secondary to this.
References
[1] Smith D, Walters J [2007] Bipolarity is important during treatment
with antidepressants. BMJ 334;327.
[2] RubinoA, Roskell N, Tennis P, MinesD, Weich S, Andrews E. Risk of
suicide during treatment with Venlafaxine, citalopram, Fluoxetine and
Dothiepin; retrospective cohort study . BMJ 2007;334 242-245.
[3] Vlazquez-Barquero J et al [2006] Early Intervention in Bipolar
Disorders: Rationale for the overdue implementation of a fesable paradigm.
Schizophrenia Research 86 S 36
[4] Angst J, Sellaro R [2000] Historical perspectives and natural history
of Bipolar Disorder. Soc Biol Psychiatry 48; 445-457.
[5] Conus P et al [2006] The prodrome to first episode psychotic mania ;
results of a retrospective study. Schizophrenia Research 86 S 37.
[6] Agius M, Erithrajalu R, Mani B [2006] The diagnosis and treatment of
bipolar and other affective disorders within the model of Early
Intervention Services. The second dual congress on Psychiatry and the
Neurosciences, 1st European Congress of the International Neuropsychiatric
Association ; 2nd Mediterranean congress of the World Federation of
Societies of Biological Psychiatry Athens 2006 Book of Abstracts p 49.
[7] Tavormina G [2006] The approach to Bipolar Spectrum Diagnosis . The
second dual congress on Psychiatry and the Neurosciences, 1st European
Congress of the International Neuropsychiatric Association ; 2nd
Mediterranean congress of the World Federation of Societies of Biological
Psychiatry Athens 2006 Book of Abstracts p 48.
[8]Akiskal H [2006] Bipolar Depression; the long term view. The second
dual congress on Psychiatry and the Neurosciences, 1st European Congress
of the International Neuropsychiatric Association ; 2nd Mediterranean
congress of the World Federation of Societies of Biological Psychiatry
Athens 2006 Book of Abstracts p 30.
[9] Rihmer Z, Gonda X. [2006] Prediction and prevention of suicide in
bipolar illness. The second dual congress on Psychiatry and the
Neurosciences, 1st European Congress of the International Neuropsychiatric
Association ; 2nd Mediterranean congress of the World Federation of
Societies of Biological Psychiatry Athens 2006 Book of Abstracts p 30.
[10] Cipriani A, Geddes J, Barbui C. [2007] Venlafaxine for major
depression. BMJ 334 ;215.
Competing interests:
None declared
Competing interests: No competing interests