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Bipolar I (bipolar + i)
Terms modified by Bipolar I Selected AbstractsHierarchical structures of affect and psychopathology and their implications for the classification of emotional disorders,DEPRESSION AND ANXIETY, Issue 4 2008David Watson Abstract The Diagnostic and Statistical Manual of Mental Disorders,IV groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." The current mood and anxiety disorders reflect the logic of older models emphasizing the existence of discrete emotions and, consequently, are based on a fundamental distinction between depressed mood (central to the mood disorders) and anxious mood (a core feature of the anxiety disorders). This distinction, however, ignores subsequent work that has established the existence of a general negative affect dimension that (a) produces strong correlations between anxious and depressed mood and (b) is largely responsible for the substantial comorbidity between the mood and anxiety disorders. More generally, there are now sufficient data to eliminate the current rational system and replace it with an empirically based taxonomy that reflects the actual,not the assumed,similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching superclass of emotional disorders, which can be decomposed into three subclasses: the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia), and the bipolar disorders (bipolar I, bipolar II, cyclothymia). An empirically based system of this type will facilitate differential diagnosis and encourage the ultimate development of an etiologically based taxonomy. Depression and Anxiety 25:282,288, 2008. Published 2008 Wiley-Liss, Inc. [source] Treatment-resistant bipolar depression: towards a new definitionACTA PSYCHIATRICA SCANDINAVICA, Issue 6 2009I. Pacchiarotti Objective:, To summarize the conceptual and operational definitions of treatment-resistant bipolar depression and to review the evidence-based therapeutic options. Method:, Structured searches of PubMed, Index Medicus, Excerpta Medica and Psyclit conducted in December 2008. Results:, Criteria for treatment resistance in bipolar depression are commonly based on concepts stemming from treatment resistance as defined for unipolar depression, an approach that proved to be inadequate. In fact, the addition of an ad hoc criterion based on lithium and other mood stabilizer unresponsiveness after reaching adequate plasma levels appears to be a patch that attempts to take into account the uniqueness of bipolar depression but fails to become operational. Recent data from randomized clinical trials of new anticonvulsants and second-generation antipsychotics should lead to the development of a modern definition of treatment-resistant bipolar depression, and specific therapeutic algorithms. Conclusion:, We suggest a redefinition of resistant bipolar I and II depression. We propose different degrees of severity within bipolar depression in a stepwise manner. [source] Preliminary results of a fine-grain analysis of mood swings and treatment modalities of bipolar I and II patients using the daily prospective life-chart-methodologyACTA PSYCHIATRICA SCANDINAVICA, Issue 6 2009C. Born Objective:, The study aimed to increase the knowledge about the detailed course differences between different forms of bipolar disorder. Method:, Using the prospective life-chart-clinician version, we compared the fine-grain analysis of mood swings and treatment modalities of 18 bipolar II with 31 bipolar I patients. Results:, During an observational period of a mean of 26 months we observed an increase of euthymic days, and a decrease of (sub)depressive and (hypo)manic days. Days in a (sub)depressed state were more frequent than days of (hypo)mania as well as days of subdepression or hypomania in comparison to days of full-blown depression or mania. Bipolar II patients showed an increase in hypomanic days receiving more frequently antidepressants. Bipolar I patients, with a decrease of manic days, were significantly taking more often mood stabilizers. Conclusion:, Treatment in a specialized bipolar clinic improves the overall outcome, but bipolar II disorder seems to be still treated sub-optimally with a possible iatrogenic increase of hypomanic days. [source] Olanzapine monotherapy for acute depression in patients with bipolar I or II disorder: results of an 8-week open label trialHUMAN PSYCHOPHARMACOLOGY: CLINICAL AND EXPERIMENTAL, Issue 1 2010William V. Bobo Abstract We evaluated the efficacy, tolerability, and safety of olanzapine monotherapy in 20 adult patients with bipolar I or II disorder, depressed phase. Patients received open-label olanzapine monotherapy (mean modal dose, 15,mg/day) for 8 weeks. Assessments of psychopathology (Montgomery,Asberg Depression Rating Scale [MADRS], Quick Inventory of Depressive Symptomatology [QIDS-SR-16], Young Mania Rating Scale [YMRS]), clinical global state (Clinical Global Impressions [CGI] scale), and safety/tolerability were performed at baseline, and at 1, 2, 4, 6, and 8 weeks. Seventeen patients (85.0%) completed the study. Improvement in MADRS total scores was observed after the first week of treatment, and at all remaining follow-up time points (p,,,0.005). Parallel improvement in QIDS-SR-16 (p,<,0.001) and CGI-Severity (p,<,0.001) was observed between baseline and study endpoint. Nine (45%) subjects achieved positive treatment response, eight of whom (40%) also achieved symptom remission. There were significant increases in weight (+3.2,kg, p,=,0.001) and body mass index (+1.1,kg/m2, p,=,0.001), but not fasting glucose or lipids, with the exception of reduced triglyceride levels in the overall sample, and reduced HDL cholesterol in females. Olanzapine may be an effective, well-tolerated option for treating acute non-psychotic depression across a variety of bipolar disorder subtypes. Copyright © 2009 John Wiley & Sons, Ltd. [source] A Randomized, Double-Blind, Placebo-Controlled Pilot Study of Naltrexone in Outpatients With Bipolar Disorder and Alcohol DependenceALCOHOLISM, Issue 11 2009E. Sherwood Brown Background:, Alcohol dependence is extremely common in patients with bipolar disorder and is associated with unfavorable outcomes including treatment nonadherence, violence, increased hospitalization, and decreased quality of life. While naltrexone is a standard treatment for alcohol dependence, no controlled trials have examined its use in patients with co-morbid bipolar disorder and alcohol dependence. In this pilot study, the efficacy of naltrexone in reducing alcohol use and on mood symptoms was assessed in bipolar disorder and alcohol dependence. Methods:, Fifty adult outpatients with bipolar I or II disorders and current alcohol dependence with active alcohol use were randomized to 12 weeks of naltrexone (50 mg/d) add-on therapy or placebo. Both groups received manual-driven cognitive behavioral therapy designed for patients with bipolar disorder and substance-use disorders. Drinking days and heavy drinking days, alcohol craving, liver enzymes, and manic and depressed mood symptoms were assessed. Results:, The 2 groups were similar in baseline and demographic characteristics. Naltrexone showed trends (p < 0.10) toward a greater decrease in drinking days (binary outcome), alcohol craving, and some liver enzyme levels than placebo. Side effects were similar in the 2 groups. Response to naltrexone was significantly related to medication adherence. Conclusions:, Results suggest the potential value and acceptable tolerability of naltrexone for alcohol dependence in bipolar disorder patients. A larger trial is needed to establish efficacy. [source] Dynamic mapping of cortical development before and after the onset of pediatric bipolar illnessTHE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES, Issue 9 2007Nitin Gogtay Background:, There are, to date, no pre-post onset longitudinal imaging studies of bipolar disorder at any age. We report the first prospective study of cortical brain development in pediatric bipolar illness for 9 male children, visualized before and after illness onset. Method:, We contrast this pattern with that observed in a matched group of healthy children as well as in a matched group of 8 children with ,atypical psychosis' who had similar initial presentation marked by mood dysregulation and transient psychosis (labeled as ,multi-dimensionally impaired' (MDI)) as in the bipolar group, but have not, to date, developed bipolar illness. Results:, Dynamic maps, reconstructed by applying novel cortical pattern matching algorithms, for the children who became bipolar I showed subtle, regionally specific, bilaterally asymmetrical cortical changes. Cortical GM increased over the left temporal cortex and decreased bilaterally in the anterior (and sub genual) cingulate cortex. This was seen most strikingly after the illness onset, and showed a pattern distinct from that seen in childhood onset schizophrenia. The bipolar neurodevelopmental trajectory was generally shared by the children who remained with MDI diagnosis without converting to bipolar I, suggesting that this pattern of cortical development may reflect affective dysregulation (lability) in general. Conclusions:, These dynamic trajectories of cortical development may explain age-related disparate findings from cross-sectional studies of bipolar illness, and suggest the importance of mood disordered non-bipolar control group in future studies. [source] The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility studyBIPOLAR DISORDERS, Issue 3 2010Jedediah M Bopp Bopp JM, Miklowitz DJ, Goodwin GM, Stevens W, Rendell JM, Geddes JR. The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study. Bipolar Disord 2010: 12: 327,334. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objectives:, To examine the feasibility of collecting course of illness data from patients with bipolar I and II disorder, using weekly text-messaged mood ratings, and to examine the time trajectory of symptom ratings based on this method of self-report. Methods:, A total of 62 patients with bipolar I (n = 47) or II (n = 15) disorder provided mood data in response to weekly cell phone text messages (n = 54) or e-mail prompts (n = 8). Participants provided weekly ratings using the Altman Self-Rating Mania Scale and the Quick Inventory of Depressive Symptoms,Self Report. Patients with bipolar I and II disorder, and men and women, were compared on percentages of time in depressive or manic mood states over up to two years. Results:, Participants provided weekly ratings over an average of 36 (range 1,92) weeks. Compliance with the procedure was 75%. Overall, participants reported depressive symptoms 47.7% of the time compared to 7% of entries reflecting manic symptoms, 8.8% reflecting both depressive and manic symptoms, and 36.5% reflecting euthymic mood. Participants with bipolar I disorder reported more days of depression and were less likely to improve with time than participants with bipolar II disorder. Gender differences observed at the beginning of the study were not observed at follow-up. Conclusions:, The results are similar to those of other longitudinal studies of bipolar disorder that use traditional retrospective, clinician-gathered mood data. Text-message-based symptom monitoring during routine follow-up may be a reliable alternative to in-person interviews. [source] Randomized, placebo-controlled trial of flax oil in pediatric bipolar disorderBIPOLAR DISORDERS, Issue 2 2010Barbara L Gracious Gracious BL, Chirieac MC, Costescu S, Finucane TL, Youngstrom EA, Hibbeln JR. Randomized, placebo-controlled trial of flax oil in pediatric bipolar disorder. Bipolar Disord 2010: 12: 142,154. © 2010 The Authors. Journal compilation © 2010 John Wiley & Sons A/S. Objectives:, This clinical trial evaluated whether supplementation with flax oil, containing the omega-3 fatty acid ,-linolenic acid (,-LNA), safely reduced symptom severity in youth with bipolar disorder. Methods:, Children and adolescents aged 6,17 years with symptomatic bipolar I or bipolar II disorder (n = 51), manic, hypomanic, mixed, or depressed, were randomized to either flax oil capsules containing 550 mg ,-LNA per 1 gram or an olive oil placebo adjunctively or as monotherapy. Doses were titrated to 12 capsules per day as tolerated over 16 weeks. Primary outcomes included changes in the Young Mania Rating Scale, Child Depression Rating Scale-Revised, and Clinical Global Impressions-Bipolar ratings using Kaplan-Meier survival analyses. Results:, There were no significant differences in primary outcome measures when compared by treatment assignment. However, clinician-rated Global Symptom Severity was negatively correlated with final serum omega-3 fatty acid compositions: %,-LNA (r = ,0.45, p < 0.007), % eicosapentaenoic acid (EPA) (r = ,0.47, p < 0.005); and positively correlated with final arachidonic acid (AA) (r = 0.36, p < 0.05) and docosapentaenoic acid (DPA) n-6 (r = 0.48, p < 0.004). The mean duration of treatment for ,-LNA was 11.8 weeks versus 8 weeks for placebo; however, the longer treatment duration for ,-LNA was not significant after controlling for baseline variables. Subjects discontinued the study for continued depressive symptoms. Conclusions:, Studies of essential fatty acid supplementation are feasible and well tolerated in the pediatric population. Although flax oil may decrease severity of illness in children and adolescents with bipolar disorder who have meaningful increases in serum EPA percent levels and/or decreased AA and DPA n-6 levels, individual variations in conversion of ,-LNA to EPA and docosahexaenoic acid as well as dosing burden favor the use of fish oil both for clinical trials and clinical practice. Additionally, future research should focus on adherence and analysis of outcome based on changes in essential fatty acid tissue compositions, as opposed to group randomization alone. [source] Clinical predictors of unrecognized bipolar I and II disordersBIPOLAR DISORDERS, Issue 2 2008Outi Mantere Objectives:, Bipolar disorder (BD) is correctly diagnosed in only 40,50% of patients. No previous study has investigated the characteristics of bipolar patients in psychiatric care with or without clinical diagnoses of BD. We investigated the demographic and clinical predictors of the absence of a clinical diagnosis of BD I and II among psychiatric patients. Methods:, In the Jorvi Bipolar Study, 1,630 psychiatric in- and outpatients were screened with the Mood Disorder Questionnaire. Suspected cases were diagnosed with the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient version (SCID-I/P) for BD. Patients with no preceding clinical diagnosis of BD, despite previous manic, hypomanic or mixed phases and treatment in psychiatric care, were classified as undiagnosed. The clinical characteristics of unrecognized BD I patients (23 of 90 BD I patients) and BD II patients (47 of 93 BD II patients) were compared to those of patients who had been correctly diagnosed. Results:, No previous hospitalizations [odds ratio (OR) = 10.6, p = 0.001] or psychotic symptoms (OR = 4.4, p = 0.045), and the presence of rapid cycling (OR = 11.6, p = 0.001) predicted lack of BD I diagnosis. No psychotic symptoms (OR = 3.3, p = 0.01), female gender (OR = 3.0, p = 0.03), and shorter time in treatment (OR = 1.1, p = 0.03) predicted the lack of a BD II diagnosis. Conclusions:, Correct diagnosis of BD I is related to the severe phases of illness leading to hospitalizations. In BD II, the illness factors may not be as important as time elapsed in treatment, a factor that often leads to a delay in diagnosis or none at all. Excessive reliance on typical and cross-sectional presentations of illness likely explain the non-recognition of BD. The challenge for correctly diagnosing bipolar patients is in outpatient settings. [source] Neurocognitive profiles in bipolar I and bipolar II disorder: differences in pattern and magnitude of dysfunctionBIPOLAR DISORDERS, Issue 2 2008Carmen Simonsen Objectives:, Studies on neurocognitive functioning in bipolar disorder, reporting deficits in memory, attention, and executive functioning, have primarily focused on bipolar I disorder. The aim of this study was to examine whether patients with bipolar I and bipolar II disorder have different neurocognitive profiles. Methods:, Forty-two patients with bipolar I disorder, 31 patients with bipolar II and 124 healthy controls, from a large ongoing study on psychotic disorders, were included. Neurocognitive function was measured with a comprehensive neuropsychological test battery. Results:, The bipolar I group performed significantly poorer than the healthy control group and the bipolar II group on all measures of memory. Compared with the control group, the bipolar I group also had significantly reduced performance on most measures of attention and executive functioning, while the bipolar II group only had a significantly reduced performance on a subset of these measures. On average, 24% of the bipolar I group had clinically significant cognitive impairment (,1.5 SD below the control group mean) across measures, compared with 13% of the bipolar II group. Conclusions:, Patients with bipolar I and bipolar II disorder in this study have different neurocognitive profiles. Bipolar I patients have more widespread cognitive dysfunction both in pattern and magnitude, and a higher proportion has clinically significant cognitive impairments compared with patients with bipolar II. This may suggest neurobiological differences between the two bipolar subgroups. [source] Lamotrigine in the acute treatment of bipolar depression: results of five double-blind, placebo-controlled clinical trialsBIPOLAR DISORDERS, Issue 2 2008Joseph R Calabrese Objectives:, The efficacy of lamotrigine as maintenance treatment for bipolar disorder (BD), particularly for delaying depressive episodes, is well established, but its efficacy in the acute treatment of bipolar depression is less clear. This paper reports the results of five randomized, double-blind, placebo-controlled trials of lamotrigine monotherapy for the acute treatment of bipolar depression. Methods:, Adult subjects with bipolar I or II disorder experiencing a depressive episode were randomized to placebo or lamotrigine monotherapy (after titration, at a fixed dose of 50 mg or 200 mg daily in Study 1; a flexible dose of 100,400 mg daily in Study 2; or a fixed dose of 200 mg daily in Studies 3, 4 and 5) for 7,10 weeks. Results:, Lamotrigine did not differ significantly from placebo on primary efficacy endpoints [17-item Hamilton Depression Rating Scale in Studies 1 and 2; Montgomery,Asberg Depression Rating Scale (MADRS) in Studies 3, 4 and 5]. In Study 1, lamotrigine significantly separated from placebo on some secondary measures of efficacy, including the MADRS, the Clinical Global Impressions-Severity (CGI-S) and the CGI-Improvement (CGI-I), but seldom differed on secondary efficacy endpoints for the other studies. Conclusions:, Lamotrigine monotherapy did not demonstrate efficacy in the acute treatment of bipolar depression in four out of five placebo-controlled clinical studies. Lamotrigine was well tolerated in the acute treatment of bipolar depression. [source] Familial aggregation of postpartum mood symptoms in bipolar disorder pedigreesBIPOLAR DISORDERS, Issue 1 2008Jennifer L Payne Objectives:, We sought to determine if postpartum mood symptoms and depressive episodes exhibit familial aggregation in bipolar I pedigrees. Methods:, A total of 1,130 women were interviewed with the Diagnostic Interview for Genetic Studies as part of the National Institute of Mental Health (NIMH) Genetics Initiative Bipolar Disorder Collaborative Study and were asked whether they had ever experienced mood symptoms within four weeks postpartum. Women were also asked whether either of two major depressive episodes described in detail occurred postpartum. We examined the odds of postpartum mood symptoms in female siblings, who had previously been pregnant and had a diagnosis of bipolar I, bipolar II, or schizoaffective (bipolar type) disorders (n = 303), given one or more relatives with postpartum mood symptoms. Results:, The odds ratio for familial aggregation of postpartum mood symptoms was 2.31 (p = 0.011) in an Any Mood Symptoms analysis (n = 304) and increased to 2.71 (p = 0.005) when manic symptoms were excluded, though this was not significantly different from the Any Mood Symptoms analysis. We also examined familial aggregation of postpartum major depressive episodes; however, the number of subjects was small. Conclusions:, Limitations of the study include the retrospective interview, the fact that the data were collected for other purposes and the inability to control for such factors as medication use. Taken together with previous studies, these data provide support for the hypothesis that there may be a genetic basis for the trait of postpartum mood symptoms generally and postpartum depressive symptoms in particular in women with bipolar disorder. Genetic linkage and association studies incorporating this trait are warranted. [source] Three times more days depressed than manic or hypomanic in both bipolar I and bipolar II disorder,BIPOLAR DISORDERS, Issue 5 2007Ralph W Kupka Objectives:, To assess the proportion of time spent in mania, depression and euthymia in a large cohort of bipolar subjects studied longitudinally, and to investigate depression/mania ratios in patients with bipolar I versus bipolar II disorder. Methods:, Clinician-adjusted self-ratings of mood were completed daily for one year for naturalistically treated outpatients with bipolar I (n = 405) or bipolar II (n = 102) disorder. Ratings were analyzed for mean time spent euthymic, depressed, manic, hypomanic, and cycling, and the percentages of time spent ill were compared between the two groups. Results:, Percentages of time spent ill for bipolar I versus II patients were: euthymia 47.7% versus 50.2%; depression 36.0% versus 37.0%; hypomania 11.5% versus 9.8%; mania 1.0% versus 0.2%; and cycling 3.7% versus 2.8%. The depression/mania ratio was 2.9 in the bipolar I and 3.8 in bipolar II sub-groups. Conclusions:, Depression represents the predominant abnormal mood state for treated outpatients with bipolar I and II disorder. In contrast to other studies, we found that depression/mania ratios were of a similar magnitude, suggesting the same tendency towards mood instability in both sub-groups. [source] Manic symptoms and impulsivity during bipolar depressive episodesBIPOLAR DISORDERS, Issue 3 2007Alan C Swann Objectives:, In contrast to the extensive literature on the frequent occurrence of depressive symptoms in manic patients, there is little information about manic symptoms in bipolar depressions. Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior. Therefore, we investigated the prevalence of manic symptoms and their relationships to impulsivity and clinical characteristics in patients with bipolar depressive episodes. Methods:, In 56 bipolar I or II depressed subjects, we investigated the presence of manic symptoms, using Mania Rating Scale (MRS) scores from the Schedule for Affective Disorders and Schizophrenia (SADS), and examined its association with other psychiatric symptoms (depression, anxiety, and psychosis), age of onset, history of alcohol and/or other substance abuse and of suicidal behavior, and measures of impulsivity. Results:, MRS ranged from 0 to 29 (25th,75th percentile, range 4,13), and correlated significantly with anxiety and psychosis, but not with depression, suggesting the superimposition of a separate psychopathological mechanism. Impulsivity and history of substance abuse, head trauma, or suicide attempt increased with increasing MRS. Receiver-operating curve analysis showed that MRS could divide patients into two groups based on history of alcohol abuse and suicide attempt, with an inflection point corresponding to an MRS score of 6. Discussion:, Even modest manic symptoms during bipolar depressive episodes were associated with greater impulsivity, and with histories of alcohol abuse and suicide attempts. Manic symptoms during depressive episodes suggest the presence of a potentially dangerous combination of depression and impulsivity. [source] Acute treatment of bipolar depression with adjunctive zonisamide: a retrospective chart reviewBIPOLAR DISORDERS, Issue 5 2004Claudia F Baldassano Background:, This retrospective chart review evaluated the use of zonisamide as adjunctive treatment in patients with bipolar depression. Method:, The charts of outpatients with bipolar I or II disorder treated with adjunctive zonisamide were reviewed. The efficacy of zonisamide was assessed via comparison of physician-rated Global Assessment of Functioning (GAF) and Clinical Global Impression of Severity (CGI-S) Scale scores at baseline and after 6 weeks of therapy using paired t -tests. Patients who scored ,2 on the CGI-S after 6 weeks of zonisamide therapy were considered good responders to zonisamide. Results:, Charts for 12 patients (four men and eight women) with a mean (±SD) age of 39.6 (±7.6) years were evaluated. Patients received a mean (±SD) zonisamide dosage of 236 (±68) mg/day. Mean GAF scores significantly improved from 44.0 at baseline to 59.3 at week 6 (P = 0.05). Mean CGI-S scores improved from 4.54 at baseline to 3.42 at week 6, but the change was not statistically significant. Six patients (50.0%) were considered responders to zonisamide. Four patients discontinued zonisamide therapy, two for an adverse event (sedation) and two for lack of efficacy. Conclusions:, Zonisamide may be a useful adjunctive treatment for some patients with bipolar depression. Conclusions from this study are limited due to its retrospective design. Further investigation of zonisamide in the treatment of bipolar depression is warranted. [source] Ketoconazole in bipolar patients with depressive symptoms: a case series and literature reviewBIPOLAR DISORDERS, Issue 1 2001E Sherwood Brown Background: Data from several studies suggest that medications, such as ketoconazole, which lower cortisol levels, may be effective for major depressive disorder (MDD). As with MDD, the manic, depressive, and mixed phases of bipolar disorder are frequently associated with elevated cortisol levels. The literature on the use of cortisol-lowering strategies in mood disorders is reviewed, and a case series illustrating the use of ketoconazole in bipolar depression is presented. Methods: For the review, the MEDLINE and PSYCHINFO databases were searched, as were the bibliographies of pertinent articles to find papers on the use of cortisol-lowering agents in patients with mood disorders. In our open-label case series (n=6), ketoconazole (up to 800 mg/day) as an add-on therapy was given to patients with treatment-resistant or intolerant bipolar I or II disorders with current symptoms of depression. Results: Several case reports and small open studies suggest that cortisol-lowering agents may be useful for patients with depression. Two recent placebo-controlled trials of ketoconazole on patients with MDD report conflicting results. In our case series, all three patients who received a dose of at least 400 mg/day had substantial reductions in depressive symptoms. None had significant increases in mania. However, cortisol levels were not lowered in any of the subjects. Conclusions: The literature suggests that cortisol-lowering medications may be effective for a subset of depressed patients. Our preliminary findings suggest that ketoconazole may be useful in some patients with bipolar depression. Larger clinical trials are needed to confirm our observations. 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