1. The concept and management of acute episodes of treatment-resistant bipolar disorder: a systematic review and exploratory meta-analysis of randomized controlled trials.
- Author
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Fornaro, Michele, Carvalho, André F., Fusco, Andrea, Anastasia, Annalisa, Solmi, Marco, Berk, Michael, Sim, Kang, Vieta, Eduard, and de Bartolomeis, Andrea
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BIPOLAR disorder , *RANDOMIZED controlled trials , *META-analysis , *MENTAL depression , *ELECTROCONVULSIVE therapy , *ONLINE information services , *PSYCHOLOGY information storage & retrieval systems , *SYSTEMATIC reviews , *KETAMINE , *MEDLINE - Abstract
Background: The definitions of treatment-resistant bipolar disorder (TRBD) have varied across studies. Additionally, its management is clinically challenging. An updated synthesis and appraisal of the available evidence is needed.Methods: A systematic search of major electronic databases from inception up to May 25th, 2020, was conducted to identify randomized controlled trials (RCTs) of pharmacological and non-pharmacological interventions for the management of TRBD. When sufficient evidence was available, a meta-analysis was conducted.Results: Seventeen studies (n = 928 patients) were included in the qualitative synthesis. Fourteen studies (n = 803) assessed treatment-resistant acute bipolar depression (TRBD-De), including five neuromodulatory and nine pharmacological trials. Rapid- vs. standard up-titration of clozapine showed promising efficacy for TRBD mania, without significant adverse events. Electroconvulsive therapy (ECT) was confirmed to be similarly effective for TRBD-De as for treatment-resistant unipolar depression: odd ratio, OR = 0.919 (95%C.I. = 0.44-1.917), I2 = 13.98, p = .822. TRBD-De patients exposed to ketamine at day one post-infusion had high odds of response: OR = 10.682 (95%C.I. = 2.142-53.272), I2 = 0, p = <.005. The pooled drop-out rate in the ketamine trials was 21.2%. Additional evidence is warranted to confirm the potential efficacy of pramipexole or stimulants for TRBD-De.Limitations: Publication/measurement bias; exploratory nature of the meta-analyses for interventions that included participants solely with TRBD-De.Conclusions: Overall, a few interventions are available for TRBD, including pramipexole, ECT, and clozapine, among others. Larger and better-designed trials for TRBD are warranted and should be based on more uniform operational definitions. PROSPERO registration number: CRD42018114567. [ABSTRACT FROM AUTHOR]- Published
- 2020
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