Vol 1 n° 1 - Bipolar Disorders
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Although much progress has been made in success- fully treating bipolar disorder, there is increasing awareness of the limitations of traditional treat- ment regimens such as lithium and neuroleptics. The large family of anticonvulsant drugs, however, appears to be capable of providing new treatment options, not only as medication of second choice in patients  refractory  to  treatment,  but  often  as  a treatment standard with high efficacy and low inci- dence of side effects. Besides established mood sta- bilizers such as carbamazepine and valproate, new antiepileptic  drugs  are  entering  the  field  with promising initial results in the treatment of bipolar patients. Furthermore, bringing to light the mecha- nisms of action of anticonvulsants and the similari- ties between anticonvulsants effective in bipolar disorder may also deepen our understanding of the pathophysiological basis of the disorder.

Keywords: anticonvulsant; bipolar disorder; mania; depression; prophylaxis; carbamazepine; valproate

From: the Department of Psychiatry, University of Munich, Germany (Drs Grunze, Schlösser, and Amann); and the Department of Psychiatry, University of Freiburg, Germany (Dr Walden)
Address for correspondence: Heinz Grunze, MD, Dept of Psychiatry, Lud-wig- Maximilians University, Nussbaumstr. 7, 80336 Munich, Germany
E-mail: grunze@psy.med.uni-muenchen.de

 ecent  epidemiological  studies  on  the  preva- lence of bipolar disorder (BD), as defined by the  Diag- nostic and Statistical Manual of Mental Disorders, IVth edition (DSM IV),1  have revealed a lifetime preva- lence of 0.3% to 1.5% across countries.2  However, there is increasing awareness that this may be only the tip of the iceberg.3  Two  large  ongoing  French  studies  on  the  epi- demiology of mania and depression (EPIMAN and EPI- DEP,  respectively),4   seek  to  characterize  possible  sub- groups  of  the  bipolar  spectrum.  One  of  the  preliminary findings in the EPIMAN study is the relatively high inci- dence of dysphoric mania (38%). On the other hand, the EPIDEP  study showed that careful screening of patients revealed in 20% to 30% of the patients, previously diag- nosed as unipolar depression, a short hypomanic episode, thus classifying them as bipolar II disorder (BD II) (ie, BD with hypomanic and depressive episodes) in the Inter- national Classification of Diseases, Tenth Revision (ICD 10),5 but not necessarily in DSM IV, where a cutoff point of  four  hypomanic  days  is  defined.  Inclusion  of  these forms of BD is likely to increase the prevalence to 3% to 6 %, which has also been estimated from the studies of Angst.6 A  meta-analysis  of  studies  published  so  far  reveals  that lithium is only effective in approximately 60% of acutely manic  patients,  and  probably  even  less  in  prophylaxis.7,8 Lithium appears especially helpful in euphoric mania, but with  atypical  forms  such  as  dysphoric  mania  or  mania within a rapid cycling course, its efficacy rapidly declines. However, as the epidemiological study of Bourgeois et al pointed  out,4  these  forms  of  mania,  despite  being  called atypical, are quite frequent. In contrast, the antiepileptic drugs carbamazepine (CBZ) and valproate (VPA) appear more able to cover a broader spectrum  of  BD.  Their  acute  antimanic  as  well  as  their prophylactic  efficacy  appear  to  be  relatively  uniform across subtypes of the disease, with an estimated efficacy of 50% to 60%. New antiepileptic drugs such as lamotri- gine (LTG) may add another valuable aspect as an effec- C l i n i c a l   r e s e a r c h Anticonvulsant drugs in bipolar disorder Heinz Grunze, MD, PhD; Sandra Schlösser, MA; Benedikt Amann, MD; Jörg Walden, MD, PhD R 2 4 Heinz GRUNZE