Zusammenfassung
Hintergrund: Manisch-depressive Mischzustände kommen in 40 % aller akuten bipolaren Episoden vor. Es handelt sich um komplexe, schwer zu behandelnde klinische Bilder. In diesem Beitrag soll ein Überblick über die Literatur zur Therapie der Mischzustände gegeben werden. Methode: Die Literatur wurde anhand von Medline-, Embase- und dem Cochrane-Controlled-Trials-Register-Suche identifiziert. Stichwörter waren „mixed mania”, „mixed state/(s)”, „mixed episode/(s)”, „treatment”, „therapy”, „study” und „trial”. Ergebnisse: Es fanden sich sehr wenige doppelblinde, plazebokontrollierte Studien, die sich speziell mit der Therapie manisch-depressiver Mischzustände beschäftigen. Stattdessen sind Patienten mit Mischzuständen oftmals eine Untergruppe der untersuchten Gesamtkohorte. Die verfügbaren Daten zeigen, dass akute Mischzustände nicht günstig auf Lithium ansprechen. Stattdessen sind Valproat und Olanzapin die Medikamente der ersten Wahl. Antidepressiva sollten vermieden werden, weil sie das intraepisodische Switching dieser Episoden verstärken können. Lamotrigin kann bei Mischzuständen mit überwiegend depressiven Symptomen eingesetzt werden. Schlussfolgerungen: Es sind mehr Studien nötig, die sich speziell mit der Therapie manisch-depressiver Mischzustände befassen. Behandlungsempfehlungen können nur vorläufig sein, weil die Datenlage eine definitive Therapieempfehlung zum jetzigen Zeitpunkt nicht zulässt.
Abstract
Objective: Mixed episodes comprise up to 40 % of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options. Method: Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state (s), mixed episode (s), treatment, therapy, study or trial. Results: Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a subgroup of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms. Conclusions: More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target selected aspects of these episodes.
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Priv.-Doz. Dr. med. Stephanie Krüger
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