Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

81 Rapid-cycling bipolar disorderTable 3.2 Baseline characteristics and outcome of subjects in two ongoing rapid-cycling,6-month combined lithium and divalproex maintenance treatmentWithoutADA (n ¼ 215)WithADA (n ¼ 84)CharacteristicsFemale 64 38Bipolar I 31 66Bipolar II 69 34Circular continuous 92 98CyclingOutcomeMood stabilization 25 17Early full remission of ADA NA 25Premature discontinuationPoor compliance 29 44Refractory depression 20 16Refractory hypomania/mania/mixed states 6 9Values are percentage unless otherwise specified.ADA, alcohol and drug abuse; NA, not applicable.Inclusion criteria included the presence of rapid cycling and an episode of hypomaniaor mania within the 3 months prior to study entry, along with the absence ofcomorbid substance abuse. Patients were mostly women with BP-II disorderpresenting in the depressed phase of their illness. The median number of affectiveepisodes meeting DSM-IV criteria in the 12 months prior to study entry was eight.Patients were required to have minimum therapeutic concentrations of 0.8 mmol/lof lithium and 50 mg/ml of valproate. Both intent-to-treat analyses and responderanalyses on completers were carried out. Of the 55 patients who failed to berandomly assigned because they were non-responsive to combined treatment,76% were experiencing refractory depression and 24% were experiencing refractoryhypomania/mania/mixed states. Of the completers, only one-half met criteriafor a marked bimodal response and were randomly assigned to the maintenancephase of the study; 61% of patients met criteria for a marked antidepressantresponse, and 88% met criteria for a marked antimanic response (Tables 3.2and 3.3).The second study evaluated the spectrum of efficacy of combined treatmentwith lithium and divalproex in a cohort of 84 patients with rapid-cycling BP-I orBP-II disorder comorbid with a current history of either abuse of, or dependenceon, alcohol, cannabis, and/or cocaine. Data are derived from the open stabilization