A systematic review and meta‐analysis of treatments for rapid cycling bipolar disorder

Abstract

Objectives: Rapid cycling is a common and disabling phenomenon in individuals with bipolar disorders. In the absence of a recent literature examination, this systematic review and meta-analysis aimed to synthesise the evidence of efficacy, acceptability and tolerability of treatments for individuals with rapid cycling bipolar disorder (RCBD).Method: A systematic search was conducted to identify randomised controlled trials assigning participants with RCBD to pharmacological and/or non-pharmacological interventions. Study inclusion and data extraction were undertaken by two reviewers independently. The primary outcome was continuous within-subject RCBD illness severity before and after treatment. Pre-post random effects meta-analyses were conducted for each outcome/intervention arm studied, generating a standardised effect size (hedge's g) and 95% confidence interval (CI). Results: A total of 34 articles describing 30 studies were included. A total of 16 separate pharmacological treatments were examined in contrast to 1 psychological therapy study. Only quetiapine and lamotrigine were assessed in >5 studies. By assessing 95% CI overlap of within-subject efficacy effects compared to placebo, the only interventions suggesting significant depression benefits (placebo g = 0.60) were olanzapine (with/without fluoxetine; g = 1.01), citalopram (g = 1.10) and venlafaxine (g = 2.48). For mania, benefits were indicated for quetiapine (g = 1.01), olanzapine (g = 1.19) and aripiprazole (g = 1.09), versus placebo (g = 0.33). Most of these effect sizes were from only one trial per treatment. Heterogeneity between studies was variable, and 20% were rated to have a high risk of bias.Conclusions: While many interventions appeared efficacious, there was a lack of robust evidence for most treatments. Given the limited and heterogeneous Rebecca Strawbridge and Suman Kurana jointly contributed as first author.

Correlation between emotion dysregulation and mood symptoms of bipolar disorder: A systematic review and meta‐analysis

“…This approach would enable a more precise characterization of the phenomenon within specific phases of the disorder. Sixth, it was not possible to control the results for clinically relevant patterns such as rapid‐cycling, 104 atypical and mixed features of depression, 74 lifetime treatment response (including harm) to antidepressants, atypical antipsychotics 105 or lithium, 106 post‐partum, 107 seasonal features, 108 functioning, 109 comorbid eating disorders, 110 borderline personality disorder 111 or substance use disorders 112 as such features may be either relatively frequent among people with BD and likely represent the expression of ED themselves or being modulated (and modulators) of ED anyway. Finally, most of the patients in those studies were on medication, which may influence the findings 113 …”

Variability and efficacy in treatment effects on manic symptoms with lithium, anticonvulsants, and antipsychotics in acute bipolar mania: A systematic review and meta-analysis

“…Second, we focused on acute antimanic outcomes (week 3); therefore, our study findings cannot be generalised to the maintenance treatment phase of bipolar disorder 23 and rapid cycling bipolar disorder. 24 Third, we examined the variability in improvement of manic symptoms of active treatments to control; therefore, we only included placebo-controlled trials. Head-to-head RCTs were not included.…”

The need for establishing optimal treatment strategies for patients with rapid cycling bipolar disorder remains

“…To address this unmet need, Strawbridge et al, for the first time, conducted a systematic review with meta-analysis of treatments for rapid cycling bipolar disorder, published in the current issue of Acta Psychiatrica Scandinavica. 14 They included a total of 30 randomized trials comprising 2266 patients with rapid cycling and analyzed the observed outcomes for each treatment arm separately as pooled estimates across studies, thus providing estimates of the change in illness severity within patients before and after treatment. While such a within-subject approach has the drawback that estimates do not directly reflect the effect of the treatment, because it is not possible to disentangle which proportion of the change was caused by the intervention or other factors, 15 it allowed the authors to include more studies.…”

“…There is unfortunately no clear consensus regarding the optimal treatment for rapid cycling, and the available evidence has not been quantitatively synthesized. To address this unmet need, Strawbridge et al, for the first time, conducted a systematic review with meta‐analysis of treatments for rapid cycling bipolar disorder, published in the current issue of Acta Psychiatrica Scandinavica 14 . They included a total of 30 randomized trials comprising 2266 patients with rapid cycling and analyzed the observed outcomes for each treatment arm separately as pooled estimates across studies, thus providing estimates of the change in illness severity within patients before and after treatment.…”