XI Congresso della Società Italiana di Psicopatologia Psichiatria ...

Depressive Morbidity in Bipolar I Disorder
R.J. Baldessarini
Harvard Medical School, McLean Division of Massachusetts
General Hospital Boston, Massachusetts
Collaborators: Salvatore P, Tohen M, Khalsa HMK, Hennen
J, Gonzalez-Pinto A, Imaz H, Tondo L, Baethge C,
Ghaemi SN, Pompili M, Davis P
Treatment of Bipolar I Disorder (BPD) has advanced greatly
since the introduction of long-term treatment with
lithium a half-century ago, including recent addition of a
growing number of anticonvulsants and antipsychotic
agents with antimanic, and variable mood-stabilizing properties
(Baldessarini & Tarazi, 2005). Recurrences of mania-hypomania
are highly effectively diminished by available
treatments, but the depressive-dysphoric component
of BPD remains a major, unsolved clinical challenge. Our
recent studies document surprisingly high rates of morbidity,
comorbidity, disability, and mortality emerging early
among first-episode BPD patients followed prospectively
from illness-onset (Tohen et al., 2003; Tondo et al., 2003;
Baethge et al., 2005). Despite treatment, unresolved morbidity
was prevalent from illness onset (ca. 40% of followup
time), and depressive-dysphoric illness accounted for
nearly one-third of time-at-risk, as was found in mid-course
in previous studies (Judd et al., 2002; Post et al., 2003;
Joffe et al., 2004). In addition, onset with depressive or
mixed states anticipated an excess of later depressive and
total morbidity, consistent with the concept that course
and treatment response are less favorable when depression
precedes mania as a course characteristic (Faedda et al.,
1991). Moreover, risks of poor functional outcomes and
perhaps substance abuse appear to be associated with depressive
and other dysphoric affective components in BPD
patients. Very importantly, excess depressive morbidity is
a critical risk factor for the very high rates of suicide in
BPD patients (Tondo et al., 2003). Treatment of depressive-dysphoric
components of BPD remains very challenging.
Currently available mood-stabilizers have only limited
short-term and later protective effects vs. bipolar depression,
and antidepressants appear to have a limited range
of efficacy and safety, with or without ongoing moodstabilizing
treatments (Ghaemi et al., 2004). A particularly
important aspect of treating the depressive component
of BPD is to reduce the risk of suicide, risk of which
is at least as high or higher than in any other psychiatric
disorder, and at least 20-times greater than in the general
SABATO 25 FEBBRAIO - ORE 9.15-10.00
SALA CAVALIERI 1
Lettura magistrale
MODERATORE
P. Castrogiovanni (Siena)
13
SESSIONI PLENARIE
population. Our comprehensive meta-analysis of the effects
of long-term treatment with lithium on risks of suicide
and attempts in manic-depressive patients broadly defined
found major protective effects, with reductions in both
suicides and attempts by about 80%, with an increased attempt/completion
ratio that suggests reduced lethality;
supportive data included randomized controlled trials as
well as other clinical studies (Baldessarini et al., 2005).
Overall, the preceding findings strongly indicate that depressive-dysphoric
morbidity in BPD has major clinical
significance and represents an unsolved therapeutic challenge
for which new and improved treatments are urgently
required.
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