Making the Impossible Possible: The Challenges of Practicing Evidence-Based Psychiatry with a Focus on Bipolar Depression*

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Andrew A. Nierenberg, M.D. - brain and behavior research expert on bipolar disorder
Andrew A. Nierenberg, M.D.

From The Quarterly, Winter 2014

The treatment of bipolar disorder, and especially bipolar depression, continues to challenge patients and doctors. Many people with bipolar depression experience difficult-to-treat, recurring depressive episodes.

In his talk, Dr. Nierenberg discussed the challenges clinicians face in treating bipolar depression, and how studies undertaken by his team have informed clinical practice.

Dr. Nierenberg and his colleagues have conducted clinical trials to determine the effects of short- and long-term treatments and what treatments appear to work best. He presented findings from some of the largest studies of bipolar disorder ever conducted: the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and the Lithium Moderate Dose Use Study (LiTMUS). STEP-BD results raised questions as to the efficacy of the use of antidepressants for bipolar depression while LiTMUS showed that low doses of lithium in addition to other medications do not appear to improve outcome.

Dr. Nierenberg also discussed a recently completed study, Bipolar CHOICE, that compares benefits and risks of lithium compared to quetiapine (Seroquel®), a secondgeneration mood-stabilizing antipsychotic. He not only reviewed the available evidence for treatments for bipolar depression, but also critiqued the structure of the evidence and the challenge of practicing and implementing evidence-based psychiatry.

Dr. Nierenberg earned his M.D. from the Albert Einstein College of Medicine of Yeshiva University and completed residency in psychiatry at New York University/ Bellevue Hospital. He studied clinical epidemiology at Yale University as a Robert Wood Johnson Clinical Scholar, then joined the faculty at Harvard Medical School, at McLean Hospital, before assuming his current posts.

Andrew A. Nierenberg, M.D.
Professor of Psychiatry
Harvard Medical School
Director, Bipolar Clinic and Research Program
Associate Director, Depression Clinical and Research Program
Massachusetts General Hospital
2013 Colvin Prize for Outstanding Achievement in Mood Disorders Research
Brain & Behavior Research Foundation Scientific Council Member
2002 NARSAD Independent Investigator Grant

*The 2013 Gloria Neidorf Memorial Lecture
The late Gloria Neidorf struggled with and succumbed to bipolar disorder in 1989. Her family established the Gloria Neidorf Memorial Lecture in hopes to inspire and educate others.

Article comments

For the last six or seven years, i was told by a psych that i had unspecific mood disorder, and was prescribed meds for it. This really got me thinking about my whole life which was full of ups and downs. My doctor eventually changed the mood disorder to bipolar. And now i am just trying to find as much info as i can.

I see what time you're writing this down. If you're not on sleeping pills, perhaps you should be. You may be having a manic episode right now. Give him/her a call ASAP when experiencing extended insomnia and are deep into a project at 3:30 AM.

I WAS TOLD IN 1988 THAT I WAS ADD/BIPOLAR. I HAD TO TAKE BLOOD TEST'S EVERY MONTH BECAUSE MY "JOB AS SECURITY INSPECTOR" REQUIRED US TO CARRY WEAPONS. AND D.O.E. SECURITY DETERMINED THAT "LITHIUM" WAS A CONTROLLED
SUBSTANCE"! I HAD TO GET A "WAVER" FROM D.O.E. WASHINGTON. TO KEEP MY JOB.
I DON'T TAKE LITHIUM ANY MORE I QUIT IN 1998. BECAUSE I BECAME AN OVER THE ROAD TRUCK DRIVER NATION WIDE.
NOW I AM RETIRED AND "MY DAUGHTER SAYS THAT I HAVE THE "SYMPTOM'S" OF "BEING BI-POLAR". MY V.A.DR. SAYS I WAS MISSED DIAGNOSED" YEAR'S AGO. SO WHO IS RIGHT ABOUT WHAT I HAVE? MY DAUGHTER IS UPSET WITH ME BECAUSE I DON'T KNOW WHO TO BELIEVE. CAN YOU CLEAR UP MY CONFUSION? TOMMY JOE WALRATH

If you experience or have experienced: rapid speech, racing thoughts, "pit" in your stomach, no-stop energy, staying up for days in a row, irritability, hostility, aggravation or aggression (especially for no reason at all), unexplained sadness, sleep all day, stay up all night, low energy, major fatigue, thoughts that no one else knows how you feel - then you have Bipolar Disorder. I have ADHD as well, but it's NOTHING compared to Bipolar.

Finally, the correct diagnosis of Bipolar 2. After years of fighting the diagnosis of Borderline Personality, depression meds that didn't work and of the charts mood swings, I am finally getting the treatment and therapy I need to normalize my life for the first time in 45 years. This validation actually feels like a great weight has been lifted and my compass now points in the right direction with the wind at my back. I won't be cured but I will have freedom.

Stop watching TV. Do some or other outdoor activity. Get your ducks in a row.

No time for depression.

Whats really depressing is how people make a living of counseling depressed people.

My wife was diagnosed about 2.5yrs ago and has continued to get worse since. She has been on 20+ different types of meds, involuntarily admitted 2 times, and just keeps cycling. Sometimes she can admitt she is sick, other times, she thinks its everyone else. The hardest part in getting her to co-operate with treatment, and not continue to hurt everyone around her. I met her when she was 19 (now is 35) and she had signs of manic and depression then. I hope there is development some day for early detection and treatment to prevent the condition from taking over lives. She has made attempts on my life and hers, and tried to abduct our son several times. Now I must spend thousands to try to keep my son and myself safe, and there is no guarantee I will win.
I would love to see more early education around mental illness so maybe some can get treatment sooner and live healthy, productive lives.

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