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Leonardo Tondo

Publications and source records attributed to Leonardo Tondo.

16 recordsLinked to original sources
PubMed2006

Suicide in bipolar disorder: Risks and management.

Bipolar disorders are prevalent, often severe, and disabling illnesses with elevated lethality largely due to suicide. Suicide rates average approximately 1% annually, or perhaps 60 times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in bipolar disorders and in association with severe depressive or mixed states. The high lethality of suicidal acts in bipolar disorders is suggested by a much lower ratio of attempts:suicide (approximately 3:1) than in the general population (approximately 30:1). Risk factors can help to identify patients at increased suicidal risk, but ongoing clinical assessment is essential to limit risk. Empirical short-term interventions to manage acute suicidal risk include close clinical supervision, rapid hospitalization, and electroconvulsive therapy. Remarkably, however, evidence of the long-term effectiveness of most treatments against suicidal behavior is rare. A notable exception is lithium prophylaxis, which is associated with consistent evidence of major (approximately 80%), sustained relative reductions of risk of suicides and attempts, and lower lethality (increased attempts:suicide ratio). Such benefits are unproved for other treatments commonly used to treat bipolar disorder patients, including anticonvulsants, antipsychotics, antidepressants, and psychosocial interventions. Applying available knowledge systematically, with close and sustained clinical supervision, can enhance management of suicidal risk in bipolar disorders patients.

Anticonvulsants↗
PubMed2006

Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review.

OBJECTIVES: To update and extend comparisons of rates of suicides and suicide attempts among patients with major affective disorders with versus without long-term lithium treatment. METHODS: Broad searching yielded 45 studies providing rates of suicidal acts during lithium treatment, including 34 also providing rates without lithium treatment. We scored study quality, tested between-study variance, and examined suicidal rates on versus off lithium by meta-analytic methods to determine risk ratios (RRs) and 95% confidence intervals (CI). RESULTS: In 31 studies suitable for meta-analysis, involving a total of 85,229 person-years of risk-exposure, the overall risk of suicides and attempts was five times less among lithium-treated subjects than among those not treated with lithium (RR = 4.91, 95% CI 3.82-6.31, p < 0.0001). Similar effects were found with other meta-analytic methods, as well as for completed versus attempted suicide, and for bipolar versus major mood disorder patients. Studies with higher quality ratings, including randomized, controlled trials, involved shorter exposures with somewhat lesser lithium superiority. Omitting one very large study or those involving lithium-discontinuation had little effect on the results. The incidence-ratio of attempts-to-suicides increased 2.5 times with lithium-treatment, indicating reduced lethality of suicidal acts. There was no indication of bias toward reporting positive findings, nor were outcomes significantly influenced by publication-year or study size. CONCLUSIONS: Risks of completed and attempted suicide were consistently lower, by approximately 80%, during treatment of bipolar and other major affective disorder patients with lithium for an average of 18 months. These benefits were sustained in randomized as well as open clinical trials.

Bipolar Disorder↗
PubMed2006

Suicide rates in relation to health care access in the United States: an ecological study.

OBJECTIVE: We tested the hypothesis that suicide rates in the United States are associated with indicators of access to health care services. METHOD: With an ecological study design, we compared age-adjusted suicide rates for men and women with demographic, socioeconomic, and other indices of access to health care, by state (N = 51, including the District of Columbia). The most recently available information from the National Statistics Reports at the U.S. Census Bureau, the U.S. Centers for Disease Control and Prevention National Center for Health Statistics, and the American Board of Medical Specialties was used. Data on suicide are from 2001; other measures were matched for the closest available year, except that state-based data on psychiatrists and physicians are from 2004. RESULTS: Positive bivariate associations with state suicide rates (all p < or = .005) are ranked as follows: male sex, Native American ethnicity, and higher proportion of uninsured residents. Negative bivariate associations (all p < or = .002) are ranked as follows: higher population density, higher annual per capita income, higher population density of psychiatrists, higher population density of physicians, higher federal aid for mental health, and higher proportion of African Americans. All factors were associated with state suicide rates in expected directions. In multivariate models of associations between suicide rates and indices of access to health care, the state rate of federal aid for mental health was the strongest indicator, followed by the rate of uninsured persons and population density of psychiatrists and physicians and by population density. DISCUSSION: Such aggregate analyses cannot specify risk indices for individual persons. Nevertheless, the methods employed detected several factors with well-established associations with suicide. They also yielded strong correlations of state-based suicide rates with proposed indicators of access to health care. The findings support the view that clinical intervention is a crucial element in the prevention of suicide.

Black or African American↗
PubMed2005

Secular trends in first hospitalizations for major mood disorders with comorbid substance use.

In the past half-century, the incidence of major mood disorders reportedly has risen, and onset age, diminished. Substance-use disorders (SUDs) are commonly comorbid with mood disorders and may influence their course and outcome. Since secular relationships of these disorders remain unknown, we evaluated medical records of 421 patients (233 men, 188 women) at first-lifetime admissions for major depression, mania or mixed bipolar episodes at a public hospital in Italy during 1978-2002, updated diagnoses to DSM-IV criteria, and compared selected factors between subjects with vs. without SUDs, seeking evidence of secular trends in SUDs in association with early mood disorders. SUD was diagnosed in 122 patients (29.0%). SUD risk was greatest in young males. Relative risk (RR) of diagnostic association with SUDs ranked: mixed states (RR 1.80), mania (RR 1.06), depression (RR 0.55). Annual rates of comorbid SUD and mood disorders increased continuously over the 25-yr epoch for all substances (r=0.640, p<0.001). Age at onset of illness and at first hospitalization (averaging 36 yr and 38 yr) were unrelated to year of hospitalization in this relatively brief sampling, but patients with SUD were younger at onset and admission, overall. Clinical Global Impression (CGI) ratings of illness severity at hospitalization and discharge were stable across years. These findings indicate a secular increase of comorbid SUD among first admissions for mood disorder, especially in young males, with a parallel increase in the proportion of bipolar disorder diagnoses over the past quarter of a century.

Adult↗
PubMed2003

Treatment-latency and previous episodes: relationships to pretreatment morbidity and response to maintenance treatment in bipolar I and II disorders.

OBJECTIVE: To clarify relationships of treatment delay and pretreatment episode count with pretreatment morbidity and responses to maintenance treatments in bipolar disorders. METHODS: In 450 DSM-IV bipolar I (n = 293) or II (n = 157) patients (280 women, 170 men), we evaluated correlations of latency from illness-onset to starting maintenance treatment and pretreatment episode counts with pretreatment morbidity and treatment response. We considered morbidity measures before and during treatment, and their differences. RESULTS: Latency averaged 7.8 years, with 9.0 episodes per patient, before various maintenance treatments started. Morbidity (percentage of time-ill, episodes per year, first wellness-interval, or proportion of subjects hospitalized or having no recurrences) during maintenance treatment averaging 4.2 years was unrelated to treatment latency or pretreatment episode count. However, pretreatment morbidity was greater with shorter latency, resulting in larger relative reduction of morbidity after earlier treatment. CONCLUSIONS: Greater treatment latency and pretreatment episode count were not followed by greater morbidity during treatment, although longer delay yielded smaller during-versus-before treatment reduction in morbidity. Predictions that longer treatment delay or more pretreatment episodes lead to poorer responses to various maintenance treatments in bipolar I or II disorder were not supported.

Adult↗
PubMed2003

Prophylaxis latency and outcome in bipolar disorders.

OBJECTIVE: To analyze new and reviewed findings to evaluate relations between treatment response and latency from onset of bipolar disorder (BD) to the start of mood-stabilizer prophylaxis. METHOD: We analyzed our own new data and added findings from research reports identified by computerized searching. RESULTS: We found 11 relevant studies, involving 1485 adult patients diagnosed primarily with BD. Reported latency to prophylaxis averaged 9.6 years (SD 1.3), and follow-up in treatment averaged 5.4 years (SD 3.1). Greater illness intensity and shorter treatment latency were closely associated, resulting in a greater apparent reduction in morbidity with earlier treatment. However, this finding was not sustained after correction for pretreatment morbidity, and treatment latency did not predict morbidity during treatment. Therefore, assessments based on improvement with treatment, or without correction for pretreatment morbidity, can be misleading. CONCLUSIONS: Available evidence does not support the proposal that delayed prophylaxis may limit response to prophylactic treatment in BD and related disorders.

Anticonvulsants↗
PubMed2003

Suicidal behaviour in bipolar disorder: risk and prevention.

Bipolar (manic-depressive) disorder is a common and severe illness. It is also potentially fatal as a result of accidents and increased mortality associated with comorbid substance use and medical illnesses, but its highest lethality results from suicide. Suicide rates, averaging 0.4% per year in men and women diagnosed with bipolar disorder, are >20-fold higher than in the general population. Suicidal acts often occur early in the illness course and in association with severe depressive and dysphoric-agitated mixed phases of illness, especially following repeated, severe depressions. Systematic consideration of risk and protective factors enhances assessment of potentially suicidal patients. Short-term interventions employed empirically to manage acute suicidality include close clinical supervision, rapid hospitalisation and use of electroconvulsive treatment. Several plausible therapeutic interventions have limited evidence of long-term effectiveness against mortality risks associated with any psychiatric disorder, including antidepressant, antimanic, antipsychotic and electroconvulsive, as well as psychosocial, treatments. However, in bipolar disorder and other major affective disorders, lithium maintenance treatment is a notable exception, with strong and consistent evidence that it reduces suicidal risk. The growing range of drugs being introduced to treat acute and long-term phases of bipolar disorder, including antiepileptic drugs, atypical antipsychotics and relatively safe, modern antidepressants, require research assessment for their ability to limit premature mortality from suicide and other causes. For now, however, more can be done to improve treatment in major affective illnesses by application of current knowledge in a systematic fashion, with close and sustained clinical follow-up of patients at risk, hopefully with a resulting reduction of mortality rates.

Bipolar Disorder↗
PubMed2003

Lithium treatment and suicide risk in major affective disorders: update and new findings.

BACKGROUND: Evidence that therapeutic benefits of psychiatric treatments include reduction of suicide risk is remarkably limited and poorly studied. An exception is growing evidence for such suicidal risk reduction with long-term lithium maintenance. This report updates and extends analyses of lithium treatment and suicides and attempts. METHOD: We pooled data from studies providing data on suicidal acts, patients at risk, and average exposure times with or without lithium maintenance therapy, and considered effects of lithium on selected subgroups. RESULTS: Data from 34 reported studies involved 42 groups with lithium maintenance averaging 3.36 years, and 25 groups without lithium followed for 5.88 years, representing 16,221 patients in a total experience of 64,233 person-years. Risks for all suicidal acts/100 person-years averaged 3.10 without lithium versus 0.210 during treatment (93% difference) versus approximately 0.315 for the general population. For attempts, corresponding rates were 4.65 versus 0.312 (93% difference), and for completed suicides, 0.942 versus 0.174 (82% difference). Subjects with bipolar versus various recurrent major affective disorders showed similar benefits (95% vs. 91% sparing of all suicidal acts). Risk reductions for unipolar depressive, bipolar II, and bipolar I cases ranked 100%, 82%, and 67%. Suicide risk without lithium tended to increase from 1970 to 2002, with no loss of effectiveness of lithium treatment. CONCLUSION: The findings indicate major reductions of suicidal risks (attempts > suicides) with lithium maintenance therapy in unipolar >/= bipolar II >/= bipolar I disorder, to overall levels close to general population rates. These major benefits in syndromes mainly involving depression encourage evaluation of other treatments aimed at reducing mortality in the depressive and mixed phases of bipolar disorder and in unipolar major depression.

Bipolar Disorder↗
PubMed1996

Lithium Withdrawal in Bipolar Disorder: Implications for Clinical Practice and Experimental Therapeutics Research.

Recent clinical research strongly suggests that there is a period of elevated risk of morbidity in the several months following abrupt discontinuation or reduction of doses in maintenance treatments commonly used in the contemporary management of chronic or recurring major psychiatric disorders. This risk is best quantified for the discontinuation of lithium therapy in bipolar disorders, in which risk of mania, depression, and suicidal behavior may rise. Similar symptomatic risks are well known after stopping antianxiety agents, and probably also follow rapid removal of oral neuroleptics in schizophenia and antidepressants in major depression. Morbid risk probably can be limited by slowing the rate of removal of medication. Such responses probably reflect interactions of individual illness diatheses with physiological adaptations to long-term drug treatments. The findings appear to have broad scientific, clinical, and ethical implications for clinical pharmacology in psychiatry as well as in general medicine.

Journal Article↗
PubMedDate not supplied

Is lithium still worth using? An update of selected recent research.

The treatment of bipolar disorder has seen greater innovation in the past decade than at any other time since the introduction of lithium and the neuroleptics a half-century ago. The place of lithium in contemporary psychiatric therapeutics has become controversial, calling for the present overview of research findings pertaining to its use in treating patients with bipolar disorder. Lithium, by itself, typically is inadequate for rapid control of acute mania; antipsychotics, divalproex, or potent sedatives are commonly used, with or without lithium, for this purpose. The special usefulness of lithium lies in long-term prevention of recurrences of mania and bipolar depression and in reducing risk of suicidal behavior. Lithium also may be beneficial in recurrent unipolar depression and is an effective adjunct for treatment-resistant depression. Expectations that prolonged untreated bipolar illness, multiple episodes, rapid cycling, or retreatment following discontinuation might routinely lead to lithium nonresponsiveness, and the belief that lithium is too toxic for use during pregnancy, have not been borne out by research. Lithium retains a substantial share of prescriptions for bipolar disorder and is inexpensive. No other treatment has performed as well as lithium in as many aspects of long-term care of bipolar disorder patients, and despite some risks and limitations, lithium remains the standard against which all proposed alternatives are compared.

Antimanic Agents↗
PubMedDate not supplied

Pretreatment episode count and response to lithium treatment in manic-depressive illness.

Factors that reliably predict treatment response in bipolar disorder are much needed, particularly since no available treatment routinely affords complete protection from future illness. The number of pretreatment episodes (PTEs) is a proposed predictor, but its value remains uncertain. We therefore reviewed available research on this topic. Based on a computer-assisted search of the literature, we identified 28 reports providing data on response to lithium treatment and on history of past illness. We evaluated their methods and findings to test the hypothesis that greater PTE count predicts inferior clinical response to lithium. Most studies (68%) found no support for the predicted relationship, and those that did or did not find the hypothesized relationship differed nonsignificantly in ratings of overall study quality and individual factors, including study size, previous lithium use, diagnostic criteria, and outcome measures. The concept that PTE count strongly and consistently predicts inferior clinical response to lithium treatment in manic-depressive disorders is not supported by available research, thus adding to emerging uncertainties about the relationship of past history and later course of these often severe, disabling, and life-threatening illnesses.

Bipolar Disorder↗