SYMPOSIA

Abstracts of the Invited Speakers
episode is not a common occurrence. The Cincinnati criterion has a more flexible approach in terms of diagnosis; a complete manic states
together with at least three depression symptoms is enough to diagnose the case as mixed mania. There are studies that identify mixed
mania as “a severe form related to mania,” “a transition period between manic and depressive episodes,” or “a separate emotional state.”
15-20% of all manic episodes have characteristics that belong to the mixed mania. In comparison to a classic manic episode, the mixed
mania has a more severe psychopathology. Episodes of dysphoria are observed more frequently, and it is frequently reported that
dysphoria is an important part of mixed states. In comparison to a classic manic episode, the duration of hospitalization is longer, the
number of attacks is higher, and the good periods are shorter during mixed episode. In addition, the psychotic characteristics and
catatonic symptoms are more, and the rate of suicide is higher.
The most important element of treating the mixed episode is making the right diagnosis. The basis used to determine the treatment
method is the same as those recommended for treating manic episodes. Unfortunately, there are no comprehensive studies that address
treating mixed mania. There are limited data related to the efficacy of medications on mixed mania or which medication is better than
the other. In general, combining drugs and clinical experiments are required for the short-term and long-term treatment of mixed mania
patients. According to the Turkish Psychiatric Association (TPA), the treatment for mixed episodes of bipolar disorder is as follows: The
treatment starts with valproate, lithium is added if the decrease in symptoms is not >25% within 4-5 days; in the event that the degree of
symptoms do not get better by 50% at the end of three weeks, an alternative is using an atypical antipsychotic and stopping the lithium-
valproate combination by gradually reducing the amount given to the patient, or moving on to a lithium – carbamazepine combination,
and if >50% progress is not reached at the end of Week 6, it is recommended that patients receive ECT.
In comparison to classic manic episodes, the rate of response to mood stabilizers for mixed episodes is lower. Antidepressants should also
not be used to treat symptoms of depression during this period. This situation proves the need for other treatment options. Olanzapine
can be used effectively in acute and preventative treatment of mixed mania; however, its disadvantages are weight gain, diabetes, and
metabolic syndrome risk. Ziprasidone has a high level of effectiveness that incorporated psychotic and mixed mania. There is evidence
that risperidone is effective in treating manic episodes; however, the amount of information related to its efficacy in mixed episodes is
limited. The number of studies about the efficacy of quetiapine on mixed episodes is also limited. The efficacy of aripiprazole on manic
and mixed episodes is addressed by some studies.
In conclusion, mixed states in bipolar disorder are common clinical reflections. Mood stabilizer treatment strategies are the form of
treatment that gives the best results. Mood stabilizer and antipsychotics can be used in the form of monotherapy or combination. Among
these mood stabilizers, valproate is the one that has been studied most and is the most recommended. Aripiprazole, ziprasidone, and
olanzapine are the antipsychotics that should be utilized first and foremost.
Key words: Bipolar disorder, mixed mania
Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S97-8
How are the guidelines prepared? Are they necessary? How to use them?
Their benefits and limitations?
Yasin Bez
Dicle University School of Medicine, Department of Psychiatry, Diyarbakir, Turkey
E-mail: yasinbez@gmail.com
Some important points when preparing guidelines are search strategies and methods to assess evidence and the criteria for rating the
strenght of evidence and making a clinical recommendation. The development of treatment guidelines mostly aims to standardize
treatment and to provide clinicians with algorithms, which would be able to carry research findings to everyday clinical practice, by
organizing information from diverse sources into an easily accessible format (1). From this point of view, treatment guidelines may be useful
to avoid non-evidence-based treatment decisions. Thus, their common use should be supported. On the other hand, they get quickly outof-date
and may interfere with following the most recent treatment approaches. Besides, they may not fully apply to the everyday clinical
setting. Besides the benefits and limitations of guidelines another important point is the adherence of the clinicians to these guidelines (1).
Despite considerable efforts to develop them, adherence to the treatment guidelines for bipolar disorders are not enough yet. For
example a study from United States demostrated adherence of 64.1% of the psychiatrists to the treatment guidelines (2). Another study
conducted in France reported a 40% non-adherence rate to treatment guidelines of bipolar disorder among psychiatrists (3).
Current and more detailed data about preparation, use, benefits, and limitations of treatment guidelines will be further discussed in this
presentation.
Key words: Bipolar disorders, guidelines
S98 Bulletin of Clinical Psychopharmacology, Vol: 21, Supplement: 2, 2011 - www.psikofarmakoloji.org