Bipolar Medication Guide

Posted on July 20, 2016 by JmaC

Bipolar Medication Guide

Medications and Drugs for Bipolar Disorder Treatment

Bipolar Medication GuideIf you have bipolar disorder, medication will most likely be a part of your treatment plan. Medication can help bring mania and depression under control and prevent relapse once your mood has stabilized. But taking medication is just one aspect of treatment. Your lifestyle, support system, and other types of therapy are also important in managing symptoms. Finding the right drug can be tricky, so it’s important to work closely with a specialist and re-evaluate your medication regularly as the optimum dose may change over time.

The role of medication in bipolar disorder treatment

If you have bipolar disorder, medication will likely be the foundation of your treatment plan. Medication can bring mania and depression under control and prevent relapse once your mood has stabilized. You may not like the idea of taking bipolar medication long term, especially if you’re struggling with unpleasant side effects. But just as a diabetic needs to take insulin in order to stay healthy, taking medication for bipolar disorder will help you maintain a stable mood.

However, do not expect medication alone to solve all your problems. There are plenty of other steps you can take to manage your symptoms and reduce the amount of medication required. Medication is most effective when used in combination with other bipolar disorder treatments, including therapy, self-help coping strategies, and healthy lifestyle choices.

Tips for getting the most out of medication for bipolar disorder

  • Avoid antidepressants. The treatment for bipolar depression is different than for regular depression. In fact, antidepressants can actually make bipolar disorder worse or trigger a manic episode. Try mood stabilizers first and never take antidepressants without them, as antidepressants can trigger mania and rapid mood cycling when used on their own.
  • Take advantage of natural mood stabilizers. Your lifestyle has an impact on your symptoms. If you make healthy daily choices, you may be able to reduce the amount of medication you need. Mood stabilizers that don’t require a prescription include keeping a strict sleep schedule, exercising regularly, practicing relaxation techniques, and developing a solid support system.
  • Add therapy to your treatment plan. Research shows that people who take medication for bipolar disorder tend to recover much faster and control their moods better if they also get therapy. Therapy gives you the tools to cope with life’s difficulties, monitor your progress, and deal with the problems bipolar disorder is causing in your personal and professional life.
  • Continue taking medication, even after you feel better. The likelihood of having a relapse is very high if you stop taking your bipolar medication. Suddenly stopping medication is especially dangerous. Talk to your doctor before you make any changes, even if you believe you no longer need medication. Your doctor can help you make any adjustments safely.

Finding the right bipolar disorder medication

It can take a while to find the right bipolar medication and dose. Everyone responds to medication differently, so you may have to try several bipolar disorder drugs before you find the one that works for you. Be patient, but don’t settle for a bipolar medication that makes you feel lousy, either.

Once you’ve discovered the right bipolar disorder drug or drug cocktail, it may still take time to determine the optimal dose. In the case of mood stabilizing medications such as lithium, the difference between a beneficial dose and a toxic one is small. Continue taking your medication even after you feel better as the likelihood of having a relapse is very high. Frequent office visits to re-evaluate your bipolar medication needs and careful monitoring of symptoms and side effects will help you stay safe.

Learn about your bipolar disorder medication

When starting a new medication for bipolar disorder, educate yourself about how to take it safely. Questions to ask your doctor about any new prescription include:

  • Are there any medical conditions that could be causing or exacerbating my mood swings?
  • What are the side effects and risks of the medication you are recommending?
  • When and how should I take this medication?
  • Are there any foods or other substances I will need to avoid?
  • How will this drug interact with my other prescriptions?
  • How long will I have to take this medication?
  • Will withdrawing from the drug be difficult if I decide to stop?
  • Will my symptoms return when I stop taking the medication?

How often should I talk with my doctor?

During acute mania or depression, most people talk with their doctor at least once a week, or even every day, to monitor symptoms, medication doses, and side effects. As you recover, you will see your doctor less often; once you are well, you might see your doctor for a quick review every few months. Regardless of scheduled appointments or blood tests, call your doctor if you have:

  • Suicidal or violent feelings
  • Changes in mood, sleep, or energy
  • Changes in medication side effects
  • Need for over-the-counter medication (cold or pain medicine)
  • An acute medical illness or need for surgery, extensive dental care, or changes in other medicines you take
  • A change in your medication situation, such as pregnancy

Source: Treatment of Bipolar Disorder: A Guide for Patients and Families

Generic vs. brand-name drugs

Generic drugs have the same use, dosage, side effects, risks, safety profile, and potency as the original brand-name drug. The main reason why generic drugs are cheaper than brand-name drugs is that the generic drug manufacturer does not need to recoup huge expenses for developing and marketing a drug. Once the patent for the original drug has expired, other manufacturers can produce the same drug with the same ingredients at a markedly lower cost.

Occasionally, brand-name drugs have different coatings or color dyes to change their appearance. In rare cases, these extra ingredients will make the generic form of the drug less tolerable, so if your condition worsens after switching from a brand-name to a generic drug, consult your doctor. In most cases, however, generic drugs are just as safe and effective as brand-name drugs, and a lot easier on your wallet.

Taking medication for bipolar disorder responsibly

All prescription drugs come with risks, but if you take your bipolar disorder medications responsibly and combine them with therapy and healthy lifestyle choices, you can minimize the risks and maximize your chances of treatment success.

Take your bipolar medication as prescribed

You may be tempted to stop taking your bipolar disorder medication if you’re experiencing side effects. Or conversely, you may want to stop taking your pills because you feel great and don’t think you need them anymore. However, stopping maintenance medication comes with a high risk of relapse. Stopping cold turkey is even more risky.

Before you make any bipolar medication changes, talk to you doctor. If you don’t like the way the drug makes you feel or if it’s not working, there may be other options you can try. And if you decide that medication is not for you, your doctor can help you taper off the drugs safely.

Keep track of side effects

Track any side effects you experience. Using a log, keep a record of your symptoms, when they occur, and how bad they are. Bring the worksheet to your doctor. He or she may have suggestions for minimizing the side effects. If side effects are severe, your doctor may switch you to another drug or change your bipolar medication dose.

Be aware of potential drug interactions

You should always check for drug interactions before taking another prescription medication, over-the-counter drug, or herbal supplement. Drug interactions can cause unexpected side effects or make your bipolar disorder medication less effective or even dangerous. Mixing certain foods and beverages with your bipolar medication can also cause problems.

Talk to your doctor about special precautions for the bipolar medication or medications you’re taking. You can also learn about potential interactions by reading drug labels or talking to your pharmacist.

Tips for managing bipolar disorder medications

  • Use a daily reminder/medication saver system to make sure you are taking all of the necessary medications.
  • Throw away old medications or those you are no longer taking.
  • Realize that medications work best when you are making other healthy choices. Don’t expect a pill to fix a bad diet, lack of exercise, or an abusive or chaotic lifestyle.
  • Reduce or discontinue the use of alcohol. Alcohol is a depressant and makes recovery even more difficult. It can also interfere with the way your medication works.

Source: Depression and Bipolar Support Alliance

Lithium: The first mood stabilizer for bipolar disorder

Mood stabilizers are medications that help control the highs and lows of bipolar disorder. They are the cornerstone of treatment, both for mania and depression. Lithium is the oldest and most well-known mood stabilizer. It is highly effective for treating mania.

Lithium can also help bipolar depression. However, it is not as effective for mixed episodes or rapid cycling forms of bipolar disorder. Lithium takes from one to two weeks to reach its full effect.

Common side effects of lithium

The following side effects are common on lithium. Some may go away as your body adapts to the medication.

  • Weight gain
  • Drowsiness
  • Tremor
  • Weakness or fatigue
  • Excessive thirst; increased urination
  • Stomach pain
  • Thyroid problems
  • Memory and concentration problems
  • Nausea, vertigo
  • Diarrhea

The importance of regular blood tests

If you take lithium, it’s important to have regular blood tests to make sure your dose is in the effective range. Doses that are too high can be toxic. When you first start taking it, your doctor may check your blood levels once or twice a week. Once the right dose has been determined and your levels are steady, blood tests will be less frequent.

However, it’s still important to get blood tests every two to three months, since many things can cause your lithium levels to change. Even taking a different brand of lithium can lead to different blood levels.

Other factors that influence your lithium levels

  • Weight loss or gain
  • The amount of sodium in your diet
  • Seasonal changes (lithium levels may be higher in the summer)
  • Many prescription and over-the-counter drugs (e.g. ibuprofen, diuretics, and heart and blood pressure medication)
  • Caffeine, tea, and coffee
  • Dehydration
  • Hormonal fluctuations during the menstrual cycle and pregnancy
  • Changes in your health (for example, heart disease and kidney disease increase the risk of lithium toxicity)

What can I do to avoid toxic lithium levels from developing?

  • Make sure that you go for the blood tests whenever they are needed.
  • Don’t suddenly change the amount of salt in your diet; it is especially important not to suddenly reduce your salt intake.
  • Make sure that you drink enough fluids, especially if you are exercising heavily or in hot weather when you will sweat more.
  • Remember that alcoholic drinks can make you lose water overall. This is particularly important to bear in mind if you are on vacation in the sun: you may feel like drinking more alcohol, and the weather may be hot so you sweat more.
  • See a doctor straight away if you get any of the physical illnesses or symptoms listed above. Always tell any doctor or pharmacist that you are taking lithium before you are prescribed, or buy, any new medicines.

Source: Netdoctor.co.uk

Anticonvulsant mood stabilizers for bipolar disorder

Anticonvulsants are used in the treatment of bipolar disorder as mood stabilizers. Originally developed for the treatment of epilepsy, they have been shown to relieve the symptoms of mania and reduce mood swings.

Valproic acid (Depakote)

Valproic acid, also known as divalproex or valproate, is a highly effective mood stabilizer. Common brand names include Depakote and Depakene. Valproic acid is often the first choice for rapid cycling, mixed mania, or mania with hallucinations or delusions. It is a good bipolar medication option if you can’t tolerate the side effects of lithium.

Common side effects include:

  • Drowsiness
  • Weight gain
  • Dizziness
  • Tremor
  • Diarrhea
  • Nausea

Other anticonvulsant medications for bipolar disorder

  • Carbamazepine (Tegretol)
  • Lamotrigine (Lamictal)
  • Topiramate (Topamax)

Antidepressant medications for bipolar disorder

Although antidepressants have traditionally been used to treat episodes of bipolar depression, their use is becoming more and more controversial. A growing body of research calls their safety and efficacy into question.

Antidepressants should be used with caution

  • Antidepressants don’t work very well for bipolar depression. Mounting evidence suggests that antidepressants aren’t effective in the treatment of bipolar depression. A major study funded by the National Institute of Mental Health showed that adding an antidepressant to a mood stabilizer was no more effective in treating bipolar depression than using a mood stabilizer alone. Another NIHM study found that antidepressants work no better than placebo.
  • Antidepressants can trigger mania in people with bipolar disorder. If antidepressants are used at all, they should be combined with a mood stabilizer such as lithium or valproic acid. Taking an antidepressant without a mood stabilizer is likely to trigger a manic episode.
  • Antidepressants can increase mood cycling. Many experts believe that over time, antidepressant use in people with bipolar disorder has a mood destabilizing effect, increasing the frequency of manic and depressive episodes.

Treating bipolar depression with mood stabilizers

The new focus in bipolar depression treatment is on optimizing the dose of mood stabilizers. If you can stop your mood cycling, you might stop having depressive episodes entirely. If you are able to stop the mood cycling, but symptoms of depression remain, the following medications may help:

  • Lamictal (lamotrigine)
  • Seroquel (quetiapine)
  • Zyprexa (olanzapine)
  • Symbyax (a pill that combines olanzapine with the antidepressant fluoxetine)

What should I do if I’m currently taking an antidepressant?

First, and most importantly, don’t panic! DO NOT stop taking your antidepressant suddenly, as this can be dangerous. Talk to your doctor about slowly tapering off the antidepressant. The tapering process should be done very slowly, usually over the course of several months, in order to reduce adverse withdrawal effects. Only stop taking antidepressants immediately if any symptoms of mania or hypomania develop.

Antipsychotic medications for bipolar disorder

If you lose touch with reality during a manic or depressive episode, an antipsychotic drug may be prescribed. They have also been found to help with regular manic episodes. Antipsychotic medications may be helpful if you have tried mood stabilizers without success. Often, antipsychotic medications are combined with a mood stabilizer such as lithium or valproic acid.

Antipsychotic medications used for bipolar disorder include:

  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Risperidone (Risperdal)
  • Ariprazole (Abilify)
  • Ziprasidone (Geodon)
  • Clozapine (Clozaril)

Common side effects of antipsychotic medications for bipolar disorder

  • Drowsiness
  • Weight gain
  • Sexual dysfunction
  • Dry mouth
  • Constipation
  • Blurred vision

Dealing with antipsychotic-induced erectile dysfunction

Sexual and erectile dysfunction is a common side effect of antipsychotic medications, one that often deters bipolar disorder patients from continuing medication. However, a recent study has shown that the medication Sildenafil citrate (Viagra) is both safe and effective in the treatment of antipsychotic-induced erectile dysfunction in men.

Source: The American Journal of Psychiatry

Other medications for bipolar disorder

Benzodiazepines

Mood stabilizers can take up to several weeks to reach their full effect. While you’re waiting for the medication to kick in, your doctor may prescribe a benzodiazepine to relieve any symptoms of anxiety, agitation, or insomnia. Benzodiazepines are fast-acting sedatives that work within 30 minutes to an hour. Because of their high addictive potential, however, benzodiazepines should only be used until your mood stabilizer or antidepressant begins to work. Those with a history of substance abuse should be particularly cautious.

Calcium channel blockers

Traditionally used to treat heart problems and high blood pressure, they also have a mood stabilizing effect. They have fewer side effects than traditional mood stabilizers, but they are also less effective. However, they may be an option for people who can’t tolerate lithium or anticonvulsants.

Thyroid medication

People with bipolar disorder often have abnormal levels of thyroid hormone. Thyroid dysfunction is particularly prevalent in rapid cyclers. Lithium treatment can also cause low thyroid levels. In these cases, thyroid medication is added to the drug treatment regimen. While research is still ongoing, thyroid medication also shows promise as a treatment for bipolar depression with minimal side effects.

Bipolar disorder medication alone is not enough

Bipolar medication is most effective when used in combination with other bipolar disorder treatments, including therapy, self-help coping strategies, natural mood stabilizers, and healthy lifestyle choices.

  • Therapy. People who take medication for bipolar disorder tend to recover much faster and control their moods much better if they also get therapy. Therapy gives you the tools to cope with life’s difficulties, monitor your progress, and deal with the problems bipolar disorder is causing in your personal and professional life.
  • Exercise. Getting regular exercise can reduce bipolar disorder symptoms and help stabilize mood swings. Exercise is also a safe and effective way to release the pent-up energy associated with the manic episodes of bipolar disorder.
  • Stable sleep schedule. Studies have found that insufficient sleep can precipitate manic episodes in bipolar patients. To keep symptoms and mood episodes to a minimum maintain a stable sleep schedule. It is also important to regulate darkness and light exposure as these throw off sleep-wake cycles and upset the sensitive biological clock in people with bipolar disorder.
  • Healthy diet. Omega-3 fatty acids may lessen the symptoms of bipolar disorder. Weight gain is a common side effect of many bipolar medications, so it’s important to adopt healthy eating habits to manage your weight. Avoid caffeine, alcohol, and drugs as they can adversely interact with bipolar medications.
  • Social support network. Living with bipolar disorder can be challenging, and having a solid support system in place can make all the difference in your outlook and motivation. Participating in a bipolar disorder support group can give you the opportunity to share your experiences and learn from others. Support from loved ones also makes a huge difference, so reach out to your family and friends. They care about you and want to help.
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Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis

Posted on July 20, 2016 by JmaC
CCBYNC Open access
Research

Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6019 (Published 08 December 2015)Cite this as: BMJ 2015;351:h6019

  1. Halle R Amick, research associate1,
  2. Gerald Gartlehner, associate director2, department chair and professor3,
  3. Bradley N Gaynes, professor and associate chair of research training4,
  4. Catherine Forneris, professor4,
  5. Gary N Asher, assistant professor5,
  6. Laura C Morgan, research public health analyst2,
  7. Emmanuel Coker-Schwimmer, research assistant1,
  8. Erin Boland, public health analyst2,
  9. Linda J Lux, senior health analyst2,
  10. Susan Gaylord, associate professor and director of the program on integrative medicine6,
  11. Carla Bann, fellow (statistics and psychometrics)2,
  12. Christiane Barbara Pierl, fellow (epidemiology)3,
  13. Kathleen N Lohr, distinguished fellow (health care services)2

Author affiliations

  1. Correspondence to: H R Amick amick@med.unc.edu
  • Accepted 24 October 2015

Abstract

Study question What are the benefits and harms of second generation antidepressants and cognitive behavioral therapies (CBTs) in the initial treatment of a current episode of major depressive disorder in adults?

Methods This was a systematic review including qualitative assessment and meta-analyses using random and fixed effects models. Medline, Embase, the Cochrane Library, the Allied and Complementary Medicine Database, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from January1990 through January 2015. The 11 randomized controlled trials included compared a second generation antidepressant CBT. Ten trials compared antidepressant monotherapy with CBT alone; three compared antidepressant monotherapy with antidepressant plus CBT.

Summary answer and limitations Meta-analyses found no statistically significant difference in effectiveness between second generation antidepressants and CBT for response (risk ratio 0.91, 0.77 to 1.07), remission (0.98, 0.73 to 1.32), or change in 17 item Hamilton Rating Scale for Depression score (weighted mean difference, −0.38, −2.87 to 2.10). Similarly, no significant differences were found in rates of overall study discontinuation (risk ratio 0.90, 0.49 to 1.65) or discontinuation attributable to lack of efficacy (0.40, 0.05 to 2.91). Although more patients treated with a second generation antidepressant than receiving CBT withdrew from studies because of adverse events, the difference was not statistically significant (risk ratio 3.29, 0.42 to 25.72). No conclusions could be drawn about other outcomes because of lack of evidence. Results should be interpreted cautiously given the low strength of evidence for most outcomes. The scope of this review was limited to trials that enrolled adult patients with major depressive disorder and compared a second generation antidepressant with CBT, and many of the included trials had methodological shortcomings that may limit confidence in some of the findings.

What this study adds Second generation antidepressants and CBT have evidence bases of benefits and harms in major depressive disorder. Available evidence suggests no difference in treatment effects of second generation antidepressants and CBT, either alone or in combination, although small numbers may preclude detection of small but clinically meaningful differences.

Funding, competing interests, data sharing This project was funded under contract from the Agency for Healthcare Research and Quality by the RTI-UNC Evidence-based Practice Center. Detailed methods and additional information are available in the full report, available at http://effectivehealthcare.ahrq.gov/.

Introduction

Major depressive disorder is the most prevalent and disabling form of depression, affecting more than 32 million Americans.1 In any given year, nearly 7% of the American adult population has an episode of major depressive disorder, but only about half of these people seek care.1 For patients who do obtain care, only 20% receive adequate treatment.1 Based on available evidence based guidelines, this would include either drug therapy (at least two months of an appropriate drug for major depressive disorder plus more than four visits to any type of physician) or psychotherapy (at least eight visits with any healthcare professional lasting an average of at least 30 minutes).2 3 4

Treatment for major depressive disorder is often started in a primary care setting,5 and patients generally receive drugs as the standard treatment.6 Of the available antidepressants, second generation antidepressants are the most commonly prescribed agents.6 These drugs include selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and other drugs with related mechanisms of action that target specific neurotransmitters. Although these drugs have different mechanisms of action, evidence suggests that no substantial differences in benefits exist among them as a class.7

Although drug therapy is the treatment most frequently offered to depressed primary care patients, data from studies of antidepressant drugs show that approximately 20% of patients do not fill their prescriptions. Moreover, even if they start a course of treatment, they may discontinue early before receiving an adequate course.8 One reason for lack of adherence to second generation antidepressants is the frequency and severity of side effects. More than 60% of patients have at least one adverse effect during treatment with a second generation antidepressant. Although most adverse effects are minor (for example, constipation, diarrhea, and dizziness), they frequently lead to discontinuation of treatment.9

Patients’ preferences for starting or switching treatment may also play a key role in acceptance and continuation of treatment for major depressive disorder. Some research suggests that patients might prefer treatment with psychotherapy over drugs.10 11 12 13 14 Reasons for preferring psychotherapy over drugs include concerns about side effects and perceived “addictiveness” of drugs.12 15 16 17 18 In addition, women and ethnic minorities may be more likely to prefer psychotherapies over drugs.12 13 19 20 Regardless of which treatment patients prefer, some evidence suggests that patients who receive their treatment of choice fare better than those whose treatment is incongruous with their preferences.11 21

In general, psychotherapeutic interventions aim to help patients to identify how past and present factors may contribute to their depression and to teach them how to deal effectively with them.22 23 24 25 Cognitive behavioral therapy is based on a combination of basic behavioral and cognitive principles. Briefly, it helps patients to understand and examine how their thoughts, moods, and behaviors interact in a way that can result in or worsen depression. Patients are taught how to replace dysfunctional thoughts and behaviors with more adaptive ones, which can reduce distress and improve mood.

Given the range of available treatments for patients with major depressive disorder, each with its own evidence base of benefits and harms, primary care physicians require high quality evidence of the comparative effectiveness of the available treatments to select and manage the best options for their patients. This paper focuses on the comparative benefits of second generation antidepressants and cognitive behavioral therapies as an initial treatment of a current episode of major depressive disorder in adults. Our results come from a larger comparative effectiveness review of benefits and harms of second generation antidepressants, psychotherapies (including psychotherapies other than cognitive behavioral therapy), complementary and alternative medicine treatments, and exercise interventions for major depressive disorder funded by the US Agency for Healthcare Research and Quality.26

Methods

Detailed methods are available in the full report.26 The full search strategy is available in web appendix A. In brief, we searched Medline, Embase, the Cochrane Library, the Allied and Complementary Medicine Database, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature for randomized and non-randomized controlled trials published from January1990 through January 2015. For drugs, we searched for individual generic drug names and broader second generation antidepressant related terms; for cognitive behavioral therapy studies, we used the terms “psychotherapy,” “cognitive therapy,” and “cognitive behavioral therapy” in titles or abstracts. To detect unpublished studies, we searched ClinicalTrials.gov, the World Health Organization’s International Clinical Trials Registry Platform, Drugs@FDA, the European Medicines Agency, the National Institute of Mental Health website, the American Psychological Association website, Scopus, the Conference Proceedings Citation Index, and reference lists of pertinent reviews and included trials.

Table 1⇓ contains the eligibility criteria that we applied to search results. Briefly, we included studies that compared a second generation antidepressant with cognitive behavioral therapy for the initial treatment of a current episode of major depressive disorder in adults. Cognitive behavioral therapy is the umbrella “class” with which we compared second generation antidepressants. However, we recognize the challenge in organizing and categorizing psychological interventions in systematic reviews. In an effort to enhance the consistency of categorization of psychotherapies in this review and our ability to compare our findings with those of other large reviews, we have used the Cochrane Collaborative Depression, Anxiety and Neurosis Group’s framework for categorizing psychological interventions.27 In addition to the umbrella term cognitive behavioral therapy, the framework’s cognitive behavioral therapy category includes problem solving therapy, rational emotive therapy, reality therapy, restructuring, role play, schemas, self control, and stress management. If the authors of an included trial specified the particular form of the behavioral intervention, we mention it; if they did not, we use the term cognitive behavioral therapy.

Table 1

 Inclusion criteria for studies comparing second generation antidepressant with cognitive behavioral therapy

Two trained team members independently reviewed all abstracts and full text articles against predefined inclusion/exclusion criteria. Investigators resolved disagreements about inclusion or exclusion by consensus or by involving a third reviewer. We designed, pilot tested, and used a structured data abstraction form to ensure consistency of data abstraction. Trained reviewers initially abstracted data from each study; a senior reviewer evaluated the completeness and accuracy of the data abstraction.

We rated the risk of bias for each relevant outcome of a study as low, moderate, or high. To determine risk of bias in a standardized way, we used the Cochrane Risk of Bias tool to appraise randomized controlled trials.28 Two independent reviewers assigned ratings for risk of bias. They resolved any disagreements by discussion and consensus or by consulting a third member of the team. We included all eligible studies in this review regardless of risk of bias, but we used studies rated as at high risk of bias only in sensitivity analyses. Risk of bias assessments are shown in appendix B.

We graded the strength of evidence on the basis of guidance established by the US Agency for Healthcare Research and Quality for the Evidence-based Practice Center program.29 This approach, which is based largely on the approach developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group, incorporates five domains: study limitations, consistency, directness, precision, and reporting bias. Grades (high, moderate, low, insufficient) reflect the confidence we had about the evidence for a specific outcome on the comparative benefits and harms of the interventions.

Evidence suggests that no substantial differences in benefits exist among the different types of second generation antidepressants7; therefore, in all meta-analyses we compared second generation antidepressants as a class with cognitive behavioral therapies. When we did meta-analyses, we assessed statistical heterogeneity in effects between studies by calculating the χ2 statistic and Cochran’s q. We used the I2 statistic (the proportion of variation in study estimates attributable to heterogeneity) to estimate the magnitude of heterogeneity. We examined potential sources of heterogeneity by using sensitivity and subgroup analyses.

For all analyses, we used random effects and fixed effects models to estimate comparative effects. We used DerSimonian and Laird models for random effects analyses. For studies with attrition, we used a “worst case” assumption that non-completers failed to respond or remit. We used funnel plots to assess publication bias, but given the small number of studies in our meta-analyses, these tests have low sensitivity to detect publication bias. We used Comprehensive Meta-analysis, version 3.2 (Biostat; Englewood, NJ, USA) for all meta-analyses.

Patient involvement

A representative of the National (US) Board of Directors of the National Alliance on Mental Illness participated in the refinement of the research topic and the development of the preliminary research questions and review criteria. The research question and a draft version of the report were posted online for input from all members of the public, including patients and their advocates. Dissemination of results will include a translation of the results into short, easy to read summaries and tools that can be used by patients, caregivers, and others who use healthcare services.

Results

Literature searches and evidence base

Our searches for the full report identified 7813 citations, of which we included 11 primary randomized controlled trials (reported in 14 articles) that compared a second generation antidepressant with cognitive behavioral therapy and provided data relevant to this paper (fig 1⇓).30 31 32 33 34 35 36 37 38 39 40 41 42 43 Those studies provided information on 1511 patients with major depressive disorder.

Figure1

Fig 1 PRISMA diagram for second generation antidepressants versus cognitive behavioral therapy in treatment of major depressive disorders

Two trials were conducted in primary care settings38 39; the remainder took place in outpatient mental healthcare locations. Four trials took place solely in the United States30 35 37 38; other countries included Canada,33 36 42England,39 Germany,40 Iran,43 and Romania.32

Generally, patients were aged between 18 and 65 years; most trials reported a mean age between 35 and 45 years. In all trials, most patients were female. One trial enrolled only women.38 In the few trials that reported race or ethnicity, a quarter of patients were non-white. All trials reported mean baseline severity of depression of at least a moderate degree; most trials reported mean baseline scores on the 17 item Hamilton Rating Scale for Depression between 16 (moderate depression) and 23 (severe). The total daily dose of each second generation antidepressant drug was within the usual ranges prescribed for adults.

Table 2⇓ describes the 11 included trials (14 publications) of a second generation antidepressant compared with cognitive behavioral therapy. Second generation antidepressants used in the trials were fluoxetine,32 fluvoxamine,39paroxetine,35 36 37 39 sertraline,36 40 venlafaxine,33 36 citalopram,43 and escitalopram.30 42 Because of the inherent heterogeneity in delivery of psychotherapies, even for those under the umbrella of cognitive behavioral therapy, we used the individual studies’ definitions of the cognitive therapies provided. Six trials used cognitive behavioral therapy,30 33 36 38 40 42 four used the specific cognitive therapy modality,32 35 37 43 and one each used problem solving therapy and rational emotive therapy modalities.32 39 Trial counts exceed 11 because one trial had both cognitive therapy and rational emotive therapy arms.32 All but one trial compared second generation antidepressant monotherapy with cognitive behavioral therapy alone; Lam and colleagues compared second generation antidepressant monotherapy with second generation antidepressant plus cognitive behavioral therapy.42 Two trials included an additional comparison of second generation antidepressant monotherapy with a combination of second generation antidepressant and cognitive behavioral therapy.39 43 Treatment duration ranged from eight weeks to one year; some trials also reported follow-up results once patients were no longer receiving active treatments.

Table 2

 Second generation antidepressants versus cognitive behavioral therapy: trial characteristics, main outcomes, and risk of bias ratings

We present our findings first by treatment comparison (monotherapy comparisons followed by combination therapy comparisons). Within each comparison, we present the benefits followed by the harms. Table 3⇓summarizes the findings and respective strength of evidence ratings for all comparisons and outcomes.

Table 3

 Strength of evidence and summary of findings

Second generation antidepressant versus cognitive behavioral therapy: monotherapy comparisons

We did random effects meta-analyses of trials rated as at low or medium risk of bias for remission, response, and change in 17 item Hamilton Rating Scale for Depression score. We also did sensitivity analyses for those outcomes including additional trials rated as at high risk of bias.30 33 36

For remission, we included three trials (four comparisons) with a total of 432 patients.32 35 39 We analyzed results measured between 12 and 16 weeks. The three trials defined remission on the basis of a 17 item Hamilton Rating Scale for Depression score of either less than 732 or less than or equal to 7.35 39 One trial also required a score less than or equal to 10 on the Beck Depression Inventory for remission.35 Patients treated with second generation antidepressants had numerically lower but not significantly different remission rates than patients receiving cognitive behavioral therapy (40.7% v 47.9%; risk ratio 0.98, 95% confidence interval 0.73 to 1.32; fig 2⇓; low strength of evidence). Our sensitivity analysis including three trials at high risk of bias yielded a similar, non-significant difference (risk ratio 1.08, 0.90 to 1.29).30 33 36

Figure2

Fig 2 Second generation antidepressants (SGA) versus cognitive behavioral therapy (CBT): remission

For response, we included results from 660 patients studied in five trials (six comparisons).32 35 37 39 40 We analyzed results measured between eight and 16 weeks. The five trials defined response as a 50% or greater reduction from baseline in 17 item Hamilton Rating Scale for Depression score. Treatment effects were similar for second generation antidepressants and cognitive behavioral therapies (44.2% v 45.5%; risk ratio 0.91, 0.77 to 1.07; fig 3⇓; moderate strength of evidence). The sensitivity analysis including three studies at high risk of bias yielded a similarly non-statistically significant difference in response between second generation antidepressants and cognitive behavioral therapies (risk ratio 1.02, 0.83 to 1.25).30 33 36

Figure3

Fig 3 Second generation antidepressants (SGA) versus cognitive behavioral therapy (CBT): response

Our analysis of the two trials (three comparisons; 249 patients)32 39 that reported change in 17 item Hamilton Rating Scale for Depression scores at eight weeks or longer found no statistically significant difference between second generation antidepressants and cognitive behavioral therapies (weighted mean difference −0.38, −2.87 to 2.10; fig 4⇓). Adding the trials at high risk of bias to the model yielded no difference in comparative effectiveness (−0.27, −2.44 to 1.90).33 40

Figure4

Fig 4 Second generation antidepressants (SGA) versus cognitive behavioral therapy (CBT): change in 17 item Hamilton Rating Scale for Depression

Two trials, both rated as at medium risk of bias, reported response, remission, or change in 17 item Hamilton Rating Scale for Depression score at time points beyond 16 weeks. In one,32 patients receiving either rational emotive therapy or cognitive therapy reported higher rates of remission and response at six months than patients taking a second generation antidepressant, although neither difference was statistically significant. At six months, patients receiving rational emotive therapy or cognitive therapy reported significantly lower 17 item Hamilton Rating Scale for Depression scores than did the patients taking the second generation antidepressant. In the trial that compared second generation antidepressants with problem solving therapy,39 the rate of remission at one year was higher in the problem solving therapy arm, although rate of response at one year was higher in the second generation antidepressant arm. In that trial, patients’ 17 item Hamilton Rating Scale for Depression scores continued to decline, with one year scores being lower in the problem solving therapy arm than the second generation antidepressant arm. Again, these differences failed to reach statistical significance.

With respect to other health outcomes, three trials reported relapse rates during off treatment follow-up.32 35 36 45Two trials defined relapse as symptom levels meeting criteria for major depressive disorder; the third defined relapse as either a 17 item Hamilton Rating Scale for Depression score of 14 or greater or a psychiatric status rating of 5 or greater during the first year of follow-up.35 During the follow-up period of that trial,35 patients who had initially received cognitive therapy did not receive any treatment, and patients who had received second generation antidepressant were randomized to continue second generation antidepressant or switched to a placebo pill.

In one trial at medium risk of bias,32 10.6% of patients treated with second generation antidepressant relapsed within six months, compared with 2.1% and 6.1% of patients treated with rational emotive therapy and cognitive therapy, respectively (statistical significance not reported). In the other trial at medium risk of bias,35 45 the rates of relapse within the first year of follow-up were 39% for previous cognitive therapy, 53% for patients who were in the second generation antidepressant arm and continued to receive it during follow-up, and 59% for patients who received second generation antidepressants during the acute phase but were switched to placebo during follow-up. Previous cognitive therapy was significantly different from previous second generation antidepressant switched to placebo (P=0.02). In the trial rated as at high risk of bias,36 47% of patients treated with a second generation antidepressant who achieved remission and 39% of those treated with cognitive behavioral therapies who achieved remission relapsed within 18 months (P=0.40).

Finally, one trial at medium risk of bias reported recurrence during the second year of follow-up, defined as either a 17 item Hamilton Rating Scale for Depression score of 14 or greater or a psychiatric status rating of 5 or greater among those who did not relapse during year 1 of follow-up.35 The rates of recurrence during year 2 were 24% for previous cognitive therapy and 52% for patients who were taking second generation antidepressants during the acute phase (P=0.06). Owing largely to small numbers of patients in each group (17 in each group), the difference was not statistically significant. The single trial (also at medium risk of bias) that reported measures of functional capacity used the Social Adjustment Scale39; second generation antidepressant and problem solving therapy did not differ at end of treatment or at 40 week off-treatment follow-up (P>0.05 at both times).

With regard to adverse events, reporting was generally poor, particularly for serious adverse events and specific adverse events. As a result, we analyzed rates of discontinuation as proxies for adverse events. Overall discontinuation from the four studies at medium risk of bias did not differ significantly between second generation antidepressants and cognitive behavioral therapies (risk ratio 1.00, 0.55 to 1.81; I2=47%; moderate strength of evidence).32 35 37 39 Adding three studies at high risk of bias did not change the result (risk ratio 0.92, 0.69 to 1.23).3033 40 More patients treated with a second generation antidepressant than receiving cognitive behavioral therapy withdrew from studies owing to adverse events (risk ratio 2.54, 0.39 to 16.47; three studies35 37 39; I2=62%), but the difference was not statistically significant (low strength of evidence). Again, including a trial at high risk of bias did not affect the results (risk ratio 2.97, 0.69 to 12.81).40 Finally, second generation antidepressants and cognitive behavioral therapies did not differ significantly in terms of dropouts attributed to lack of efficacy in the main analysis (risk ratio 0.36, 0.06 to 2.21; three studies35 37 39; I2=51%).

Second generation antidepressant versus cognitive behavioral therapy: combination comparisons

The three trials that compared second generation antidepressant monotherapy with a combination of second generation antidepressant and cognitive behavioral therapy reported no statistically significant between group differences in rates of either remission or response (low strength of evidence).39 42 43 All reported change in depression scale score between baseline and endpoint; one reported a significant between group difference—namely, a smaller decrease in scores on the Montgomery-Åsberg Depression Rating Scale for patients taking second generation antidepressant alone than for patients treated with second generation antidepressant plus cognitive therapy.43 That trial, however, was rated as at high risk of bias, whereas the other two were rated as at low42 and medium39 risk of bias.

The trial that compared second generation antidepressant alone with second generation antidepressant plus telephone cognitive behavioral therapy measured several work related outcomes.42 Patients receiving the combination of second generation antidepressant and telephone cognitive behavioral therapy reported greater improvement on three of four work functioning measures. The authors found no between group differences in reduction of hours of work missed, although both groups reported a decrease at the end of treatment. In the trial that compared second generation antidepressant alone with the combination of second generation antidepressant and problem solving therapy, groups did not differ in the Social Adjustment Scale at end of treatment or at 40 week off-treatment follow-up.39

Two of the three trials reported adverse events.39 42 In the trial rated as at low risk of bias, more patients withdrew for any reason from the combination arm than from the second generation antidepressant alone arm (23% v 13%; significance not reported).42 However, slightly more patients withdrew owing to adverse events from the second generation antidepressant alone arm (6%) compared with the combination arm (4%). In the other trial, rated as at medium risk of bias, discontinuation rates were similar between the second generation antidepressant alone and combination arms (17% in each arm).39 Eleven per cent and 6% of patients in the combination and second generation antidepressant arms, respectively, withdrew because of adverse events. No patients in either arm withdrew because of lack of treatment efficacy. The low number events in each of these outcomes results in a low strength of evidence rating.

Discussion

For second generation antidepressants compared with cognitive behavioral therapies, the available evidence based on 11 randomized controlled trials with 1511 patients suggests no difference in treatment effects of second generation antidepressants and cognitive behavioral therapies, either alone or in combination, although our conclusions are tempered by small numbers and mostly low strength of evidence. Relative risks of remission and response were nearly identical for monotherapy comparisons (0.98 and 0.91, respectively) and for second generation antidepressant alone versus combination (1.06 and 1.03, respectively). Adverse event outcomes were also clinically and statistically similar for all comparisons.

Comparison with other studies and guidelines

Our findings are relatively consistent with similar meta-analyses by Cuijpers and colleagues that compared second generation antidepressants with cognitive behavioral therapy.25 46 47 48 In addition to containing several more recent studies, our analyses have some key methodological differences that make them more relevant for the primary care population. Cuijpers and colleagues did meta-analyses of second generation antidepressants compared with any psychotherapy and of cognitive behavioral therapy compared with any drug, but they did not report results from a specific comparison between second generation antidepressant and cognitive behavioral therapy for adults with major depressive disorder. They found that only selective serotonin reuptake inhibitors, rather than second generation antidepressants as a class, were more effective than any type of psychotherapy in treating patients with major depressive disorder; however, the effect was small and potentially clinically insignificant. Furthermore, they did not require the use of evidence based psychotherapy (for example, non-directive supportive counseling was eligible for their analyses), they did not limit studies to those in which patients had not already failed a previous antidepressant treatment (who would be more likely to be seen in primary care). Finally, their analyses did not report on comparative harms, which we have done in this report.

Spielmans and colleagues found that bona fide cognitive behavioral therapy (based on their included studies’ descriptions of therapist training, therapist-client relationship, and therapy components) resulted in better outcomes that second generation antidepressant, but the effect sizes were small and heterogeneity was high.25Although we considered treatment fidelity in our risk of bias assessment, we did not attempt to determine whether the cognitive behavioral therapy offered in the included trials was “bona fide.” Because primary care clinicians are unlikely to have the information necessary to determine whether the cognitive behavioral therapy to which they refer patients is bona fide, our results may be more relevant to primary care providers.

Our results are also consistent with the recommendations of the American Psychiatric Association,3 the US Department of Veterans Affairs/Department of Defense,49 and the UK National Institute for Health and Care Excellence.50 Those groups consider both drugs and psychotherapy to be appropriate individual initial treatments for patients with mild to moderate major depressive disorder. Furthermore, they state that drugs plus psychotherapy may be a useful initial treatment for patients with a current episode of moderate to severe major depressive disorder and for those with major depressive disorder and coexisting conditions.

Limitations

This review, and the evidence that informed it, does have limitations. The scope of this review was limited to trials that enrolled adult patients with major depressive disorder and compared a second generation antidepressant with cognitive behavioral therapy (alone or in combination with a second generation antidepressant). We did not attempt to review the literature on interventions for major depressive disorder in children or for patients with subthreshold depression, dysthymia, or perinatal depression. The included trials enrolled mostly patients with moderate to severe major depressive disorder; therefore, results may not be applicable to patients with milder major depressive disorder. Most trials excluded patients with medical comorbidities or suicidal ideation; few trials included elderly patients. We found insufficient evidence to confirm or refute whether treatments are more or less efficacious for various subgroups (patients characterized by sex, race, or ethnicity or those with coexisting psychiatric conditions).

Many of the included trials, even those rated as at medium risk of bias, had methodological shortcomings that may limit confidence in some of our findings. Several studies reported very high attrition, although rates were usually similar between treatment groups. Our “worst case” assumption of withdrawals as failures to respond or remit should alleviate some of that concern. Most of the included trials provided data only for acute phase treatment; information to help providers to manage ongoing depression or prevent relapse and recurrence is lacking.

Although studies of psychotherapy contain some inherent heterogeneity of the content and delivery, the included trials used treatment manuals with prescribed goals and techniques to minimize variability between therapists. The type, training, and experience of the clinicians who render these various interventions were also quite diverse. Unlike the case with second generation antidepressants, which are broadly equivalent and have standardized dosing, the cumulative effect of the various sources of heterogeneity within and across psychological interventions may limit the applicability of our findings. Clinician type, training, experience, and degree of treatment fidelity are likely to be even less consistent in routine clinical practice than in the trials in this review. Along with availability of psychotherapists, these are important factors for clinicians to consider when recommending psychological treatment and interventions.

Finally, comparative effectiveness at a group level did not detect a difference between second generation antidepressants and cognitive behavioral therapies, but how best to tailor this information to an individual patient is still not clear, especially given the low strength of evidence for most of the included outcomes. Preliminary evidence suggests that biomarkers may have a role in predicting response to cognitive behavioral therapy compared with second generation antidepressants, but these findings have yet to be replicated or implemented in clinical practice.30 Analyses of individual patient level data are best suited to answer that question and should be done in the future. Although we searched for unpublished literature, publication bias and selective outcome reporting may still be potential limiting factors. Finally, because we did not compare active treatment with placebo or no treatment, we cannot rule out the possibility that cognitive behavioral therapy and second generation antidepressants may be similarly ineffective. However, because evidence of benefit from both treatments exists, a provider would be unlikely recommend no treatment instead.

Conclusions and policy implications

In clinical decision making, providers should consider not only the efficacy of second generation antidepressants and cognitive behavioral therapy interventions but also patients’ preferences about potential adverse events, the costs and availability of each treatment, and expected treatment effects. Currently, the biggest barrier to offering psychotherapy either alone or in combination with drugs may be how well patients can gain access to such mental healthcare clinicians. Given that the benefits of second generation antidepressants and cognitive behavioral therapy do not seem to differ significantly in treating major depressive disorder and that primary care patients may have personal preferences for one first line treatment over the other, both treatments should be made accessible, either alone or in combination, to primary care patients with major depressive disorder.8

Having access to psychotherapeutic interventions in the primary care setting might improve treatment outcomes for patients with major depressive disorder. It has the potential to improve use of psychiatric consultations and therapy and to enhance coordination of care between primary care clinicians and mental health professionals. It may also have additional downstream effects of reducing the stigma associated with mental illness in general, empowering patients to tackle the symptoms and problems associated not only with depression but also with other mental health related concerns and encouraging them to seek and maintain treatment more quickly at an earlier stage of their illness.

What is already known on this topic

  • Second generation antidepressants and cognitive behavioral therapy have evidence bases of benefits and harms in major depressive disorder

  • However, primary care physicians require high quality evidence of the comparative effectiveness of the available treatments to select and manage the best options for their patients

What this study adds

  • The available evidence suggests no difference in treatment effects of second generation antidepressants and cognitive behavioral therapies, either alone or in combination, in major depressive disorder

  • Given that patients may have personal preferences for one first line treatment over the other, both treatments should be made accessible, either alone or in combination, to primary care patients with major depressive disorder

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Depressive and Bipolar Disorders: Crash Course Psychology #30 Depressive and Bipolar Disorders: Crash Course Psychology #30 Video

Posted on July 20, 2016 by JmaC

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Bipolar Disorder & Manic Depression- History, Classification, Treatment & Healing | The Truth Talks

Posted on July 20, 2016 by JmaC

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Genetics and Borderline personality

Posted on July 20, 2016 by JmaC

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Sadness

Posted on July 20, 2016 by JmaC

SADNESS

 

Everyone experiences sadness at some point in life. It’s intensity may differ from person to person. Though a perfection of happiness everyone prays for our lives are not complete without experiencing sadness. It helps us to accept as well as appreciate things that we may have taken for granted in our life. Even though sadness is not a desirable thing it teaches us values of hope, self belief, patience and humility. Trying times also help us to strengthen the bonds of true friendships.

 

JmaC

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Wonder Wish

Posted on July 18, 2016 by JmaC

Wonder & wish
Sometimes I wonder, how did I get like this.
Sometimes I wish for a quick fix.
Sometimes I wonder if ill ever get better.
Sometimes I wish I was a bit more clever.
Sometimes I wonder why so much pain?
Sometimes I wish I didn’t get the blame. 
Sometimes I wonder why all I see is grey.
Sometimes I wish for the sun to brighten up my day.
Sometimes I wonder if there is a god at all.
Sometimes I wish there is in hope to fix it all. 
Sometimes I wonder does everyone feel like this?
Sometimes I wish I was still only a kid.
Sometimes I wonder if ill ever succeed?
Sometimes I wish for that lotto ticket win.
Sometimes I wonder if money would bring a grin. 
Sometimes I wish for that dream to come true. 
Sometimes I wonder why all I do is think.
Sometimes I wish to one day stay afloat and not sink.

 

JmaC

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Mentalization

Posted on July 18, 2016 by JmaC

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Mindfulness video

Posted on July 18, 2016 by JmaC

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Positive self talk

Posted on July 18, 2016 by JmaC
Present Tense Affirmations
I encourage myself
I am fully confident in myself
I see only the good things in myself
I destroy negative self talk
I am immune to negative thinking
I utilize positive self talk to my advantage
I talk to my mind as needed
I am a strong individual
Positive self talk ensures my independence
I use positive self talk regularly

 

Future Tense Affirmations
I will get rid of internal negativeness
I will tell myself only positive things
I will stop seeing the bad things in me
I will repeat positive affirmations on a regular basis
I will focus on the positive moments of my life
I will stop comparing myself to others
I will stop putting myself down
My self-image will improve with positive self talk
I am becoming more upbeat
I will stop saying “I can’t”

 

Natural Affirmations
I naturally talk myself up
I was born a positive person
My awareness of negative talk helps me to eliminate it
I see myself for what I truly am
I constantly remind myself of the good things in my life
I concentrate on my positive attributes
I am naturally my own life coach
I avoid personal doubts
I naturally overcome personal challenges
I know that I am a beautiful person
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