The first speaker of the session was Professor Andreas Erfurth, whose presentation was on Epidemiology and assessment of suicide risk in bipolar disorder. He opened with the hard facts: that 30–40% of patients with bipolar disorder will attempt suicide at least once in their lifetime, and that 7–19% will succeed.
Suicide has been an important topic in many of the symposia that this correspondent has attended, but Prof Erfurth was the first speaker to highlight the impact suicide has not just on the deceased patient’s family, but also on their therapist.
While the risk of suicide is a factor to be aware of in all bipolar patients, those with depressive symptoms during an episode of mania are at particular risk. In fact, suicidality was seen in 57.9% of patients with mania with depressive symptoms (two or more prominent depressive features) compared to 1.3% in patients with pure mania.
Prof Erfurth then talked about the updated DSM-5 ‘with mixed features’ specifiers for manic or depressive episodes, which allows bipolar I diagnosis to move from a categorical to a dimensional approach.
But new guidelines are only useful if they can be applied in clinical practice, and Prof Erfurth’s presentation of the M.I.N.I. patient-report module for DSM-5 gave clinicians an effective, practical and validated tool to evaluate depressive symptoms in mania.
Prof Erfurth was followed by Professor Eduard Vieta, who presented data on Suicide risk in bipolar disorder related to mania with depressive symptoms, and implications for treatment.
Prof Vieta began his presentation by highlighting the impact that mania with depressive symptoms can have on both the patient and on healthcare systems. Patients suffering from mania with depressive symptoms spend an average of 42 days in hospital, compared to those with unipolar states who spend approximately 29 days.
Building on Prof Erfurth’s focus on assessing depressive symptoms in mania (through the M.I.N.I.), Prof Vieta highlighted the symptoms of anxiety, irritability and agitation (AIA) as “gateway symptoms” for identifying these patients.
72% of patients who experienced mania with depressive symptoms also had symptoms of anxiety and irritability/agitation, and in patients with more than three depressive symptoms this rises to more than 90%, so Prof Vieta considered them highly important to look out for.
Prof Vieta then moved into the role of antipsychotics in treating patients with mania with depressive symptoms. Results of a recent study on drug use in pure mania and mania with depressive symptoms showed that some types of antipsychotics are used relatively more frequently in manic patients that have concurrent depressive symptoms. Prof Vieta then moved on to show results from post-hoc analyses of trials that were completed before the DSM-5 was published. Interestingly, the data suggests that antipsychotics in general work on the manic symptoms, whereas the effect on the depressive symptoms may differ between antipsychotics.
The final speaker of the symposium was Professor Andrea Fagiolini, who presented two case studies in which he invited the audience to participate, through the magic of the internet.
For this correspondent this was a real highlight of the conference. Not only was this a chance to see the practical applications of the data presented by Profs Erfurth and Vieta, but also it was a fascinating chance to compare and contrast the treatment strategies of Prof Fagiolini and the audience.
It was particularly interesting to see how closely the approaches of Prof Fagiolini and the audience matched up, showing (at least to this correspondent) that the methodologies and approaches to mania with depressive symptoms that have come out of DSM-5 already have a strong clinical following.
For patients suffering from mania with depressive symptoms, bipolar I continues to be a heavy burden. However, the expertise and dedication on display at this symposium give this correspondent hope for these patients’ futures.
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