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Terror in Tenerife: Flights KLM 4805 and PAA 1736. A tragedy impossible

Part

Definition

CATASTROPHE: it is an unfortunate event that alters seriously the regular order of things and is synonymous with catastrophe and disaster.

disasters are classified as:

- NATURAL : geological, climatic, biological and Animals.

- TECHNOLOGY: Fires, Flooding, traffic accidents and rail accidents.

-AIR: Naval and Submarine.

- WAR: bombing, chemical action, Nuclear, invasion of a country and Minefields ...

- SOCIAL : Terrorism social, Hunger, Abductions and Revueltas.


In the different types of disasters are numerous factors that can promote the event (mechanical failures, geology, climatology, etc.), However there is a differential element among all these, and that element is the action of man. May be indirect, for example, in a plane crash, there may be mechanical causes of the aircraft, which has not been properly reviewed by the mechanics, or a misreading of the charts or NOT MEET THE INSTRUCTIONS OF A TOWER CONTROL. Traditionally


disasters are defined by four criteria :

- 1. A grim destructive event (usually sudden and brutal);
- 2. With large numbers of casualties (killed, wounded, shocked, burned, etc.).
- 3. With major property destruction;
- 4. Exceeding (or at least fully occupied) means
local relief - and L. Crocq adds a fifth criterion , perhaps essential, "causing major social disruption."

In any disaster, regardless of the consequences for individuals, society as a whole, is affected in its physiology of great body, injured in their organization and collective life. On the other hand, each individual is affected not only his "personal self", original and unique, but also their sense of belonging to the community in their "social self."

addition to the destruction and somatic injuries, disasters cause a shock and mandatory - though it may be transient - a psychic injury. In this sense, it can be argued that all disaster victims, injured survivors without somatic or physical injury, are "psychological injuries" and should be treated. You can also occur as witnesses, not directly affected by the disaster, families and friends who come to the rescue and even responders, social services, medical staff and organizers, also suffer a shock generator more or less severe symptoms, annoying and durable. Noto proposed the term "involved" to designate this group of families and staff closely involved in the disaster.


In Tenerife radio stations called blood and help, without saying more, and many came without knowing exactly what to do or who to turn, the confusion was total. Still transfers, blood donations and medical aid and individuals were made quickly and efficiently. The 68 survivors, all wounded, were taken to hospitals on the island, of which nine died of wounds. Tenerife village solidarity was remarkable and immediate cooperation of the medical establishment. Physicians still had more work in the reservoirs of the wounded, as though they were taken to hospitals in them almost no one spoke English, and not take any information that there is consistency. The wounded were identified through a plaster on his forehead with a number and were evacuated by the Pan Am before 48 hours back to their country of origin. So much less one would expect such a performance standard speech to a catastrophe.

Very little information comes from the mental condition of the wounded, as we said, no record of it was collected or the psychiatric service intervened, was assumed to be an entirely physical and as such no implications or relevant actions at the level of "crisis intervention" described today.

Although not found in the sources I spoke in libraries and data on air traffic controller, I suspect passed a stress specific responsibility on doctors, nurses and air traffic controllers, or possibly a depression situated. Later due to pressure and suspected that was the victim, she experienced post-traumatic stress syndrome.

After a trauma, and contemplating the human individuality will see the subject get into a series of stages in which it would seem that their vitality after the event has faded, these are:

- Phase shock or stress reaction normal. Mobilizes

biological and physiological processes now well known: the release of endorphins, increases immune defenses, cascading of information and orders - via nervous or humoral pathway - between the sensory organs, the cerebral cortex, midbrain centers, autonomic nervous system, pituitary, adrenal and physiological effectors.

Besides these physiological aspects, the psychiatrist must know even the psychological aspects of stress reaction: stress focuses attention, mobilizes energy and encourages action.
The normal stress response is a useful reaction, adaptive, which inspires the individual decisions and behaviors conducive to shield from danger or to assist others to avoid it.

- phase of inhibition or abnormal stress reaction.

are distinguished four reactions:

The first is the reaction of sideration, leaving the individual perplexed from the cognitive perspective, in a stupor from the standpoint of emotional and paralyzed from the standpoint of motor.

The second is the uncoordinated and sterile agitation.

The third is the flight in panic, in which the individual is also the release of excessive mental tension unbearable impulsive action.

The fourth reaction, less well known but most common is Automatic action: the individual in a state of shock and bewilderment is unable to deliberate to choose the best solution and runs like a robot's gestures and sequences of gestures that happen spontaneously or copies of their neighbors.

- Restoration Phase:

The most common psychopathology, experienced as a reaction to a catastrophic event, is the posttraumatic stress disorder (DSM-IV-TR F 43.1 ) American name, formerly called traumatic neurosis, the most characteristic symptoms of a very didactic summarizes the Professor Alonso-Fernández these being the:

a) Alexithymia (apathy or disinterest, loss of expression of emotions, detachment from others)

b) reliving the trauma (memory-related repetitive trauma , nightmares with the same subject) and

c) sympathicotonia (tachycardia, sweating, insomnia).

Apparently the condition is more serious and lasting when the stressor is of human origin. As
associated symptoms is easy to find symptoms of anxiety, depression. There is an increase in irritability may be associated with sporadic and unpredictable explosions of aggressive behavior under pressure with minimal or even without them.

The handicap may be slight or affect virtually every aspect of your life. Phobic avoidance of situations or activities that resemble or symbolize the original trauma, resulting in a disability employment or recreation. Besides the emotional anesthesia may interfere with family life and partner.

Different countries have created "medical / emergency teams" to act immediately on the site of the disaster, adapting North American debriefing procedures (Or psychological examination of the event) and specialist consultations were held in traumatology. This reflects the interest in specific problems and responding to needs that were not previously covered by health systems.

In the moments that happen in a crisis situation, the proper intervention of medical equipment can help reduce the effects of "trauma" that may occur. The performance of any subject on the stage of the crisis getting mitigate or modulate the consequences of the event. When the patient's physical condition is stable, and emergency relief measures have been accomplished, the act must enter psychosocial measures, which are important for a number of key recommendations:

. Let mourn.
. Give hot drinks.
. Bring blankets.
. Physical contact (hugging, shaking hands).
. Language reassuring.
. Give messages of support and encouragement to those affected, with the intent to influence their mood (without denying the reality or hide).
. Reassure stakeholders on the status of other injured.
. Show understanding.
. Stimulating the talk (despite the crying, screaming, etc..).

Based on the model "crisis intervention" of Slaikeu Kart, highlights the to follow in the psychological intervention:

. Immediacy : As soon as symptoms appear.
. Near : What nearest the scene.
. Expectation : Helping the injured to understand that living a normal reaction to an irregular event.
. Simplicity : short, simple therapeutic methods.

I subtitle this paper as A TRAGEDY IMPOSSIBLE because:

a) Theoretically there DEBIAN BOTH AIRCRAFT HAVE BEEN THERE, BUT IN LAS PALMAS .

b) The PAA 1736 was instructed to move by the runway, leave it to reach the third exit on your left, saw no way out ... due to heavy fog ENTERED IN THE FOURTH PLACE OUT IN THE THIRD .

c) DESPITE WITHDRAWAL ORDER PLAYS AN "OK" COLLOQUIAL LIKE A GREEN LIGHT OUTPUT.

d) All crew, captain, copilot and flight engineer, heed not an INDICATION OF NOT REMOVE, clinging to a pronounced OK by the controller to give the nod to an instruction after takeoff. Y, HEAR, HEAR WHAT YOU WANT.

From this terrible tragedy, one of the most notable consequences of work is changing aviation phraseology used the word off, unless explicit authorization for takeoff.
Tenerife
This catastrophe was not written to the destination. The line, changed the hand of a terrorist act on a sister island ignorant of the consequences of his evil intent.

Once again, we must remember and quote the Roman poet Plautus (third century BC) who wrote "homo homini lupus" Man is wolf to man.

Silió Jaime Velarde, retired pilot of Iberia, was commissioned then to take charge of the official investigation, specialized on behalf of the English pilots' association in the air accident investigation, had studied at the University of Southern California.

In a recent interview (Sunday January 9, 2005) that granted the newspaper El Dia de Tenerife extract:

What were the first steps in research?

That I was very clear. Sketches, photographs, drawings of the main wreckage ... as soon as possible, second, address the situation and respond to what should the international association of pilots to make myself available affected crew, who was in the hospital.


Did hindrance to the investigation or pressure?

The situation in Spain was extremely difficult, because the structure belonged to the Air Force, I actually called the general Franco Iribarne Garai and was very brave, because he ordered the investigation to the U.S., where it took place. I showed my availability and sought the truth. All proud.


And where was the blame?

in a plane crash there is no single cause and no one is to blame, but an accumulation of causes and perpetrators. The truth is that there was a responsibility the KLM pilot. One of the most prestigious and pioneering companies in Europe.


1DR. Miguel Pérez-Camacho Duque . Psychiatrist, Director of the Canary Institute of Psychiatry ( ICAPSI). President of the English Society of Social Psychiatry and Psychopathology ( SEPPS ). BIBLIOGRAPHY



• Alonso-Fernandez, F. The New Addiction. Occupational stress: its types and consequences.
• Alonso-Fernandez, F. Highlights of the Depression.
• Alonso-Fernandez, F. Fundamentals of Current Psychiatry, Volume II, 3 rd Edition.
• DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders. 2002.
• Harold I. Kaplan, Benjamin J. Sadock. Synopsis of Psychiatry.
• L. Crocq, C. Doutheau, P. Louville and D. Cremniter. French Surgical Medical Encyclopedia Psychiatry.
• War Montero, José Manuel. Psychological intervention in war disaster. SOURCES



• Andrada Félix, Claude. Journalist of "THE DAY" in Tenerife.
• Dr. Besada Estévez, Carlos. Head of Anesthesiology at the Hospital Universitario Nuestra Señora de la Candelaria.
• Professor Sierra López, Antonio. Professor of Preventive Medicine at the University of La Laguna and Director General of Health at that time.

Legenda O Orlim Gnieździe

Terror in Tenerife. Flight KLM 4805 and PAA 1736. A tragedy impossible. Burnt out

Terror in Tenerife: Flights KLM 4805 and PAA 1736. A tragedy impossible

Miguel Duque Pérez-Camacho *

Part

The Sunday March 27, 1977, two Boeing 747s collided at Los Rodeos airport, Tenerife North at present north of the island of Tenerife, killing 583 people. Holds the sad record of being the most crash fatalities.

The KLM aircraft were wrecked 4805, charter of the Dutch airline KLM, flying from Schiphol Airport in Amsterdam, heading for Gran Canaria and the PAA flight 1736, flying charter of Royal Cruise Lines, flying from the International Airport, John F. New York Kennedy, who also was heading to the airport of Gran Canaria (Gando).

While the plane was headed Gran Canaria, a bomb planted by the Movement for Self-Determination and Independence the Canary Islands (MPAIAC), exploded in the airport passenger terminal. Later there was a second bomb threat and the airport was closed. Following the closure of the airport, two flights were diverted to Los Rodeos in the neighboring island of Tenerife along with many other flights also diverted. At that time, Los Rodeos was too small to easily support such a congestion, in addition to having at the time of only two air traffic controllers.

When Gran Canaria airport was reopened, the staff of Pan Am flight aircraft (PAA 1736) proceeded to ask permission to take off towards its destination, Gran Canaria, but was forced to wait because the flight of KLM (KLM 4805) blocked the exit to the runway.

Both flights had been instructed to move around the runway instead of the running due to excessive traffic congestion caused by the diversion of flights from the airport of Gran Canaria
.

The KLM 4805 and requested permission to refuel their tanks filled with 55,000 liters of fuel, after which he was instructed to once there, perform a 180 degrees and wait for confirmation of clearing the route. 1736 PAA later received instructions tions to scroll through the runway, leave to reach the third exit on your left and to confirm their departure after completion of the maneuver. But in 1736 PAA did not see the third exit (this was presumably due to heavy fog) and continued into the fourth. Despite not having received permission to take off and due to a misunderstanding of the Dutch pilot and copilot from the KLM sent the message by radio that they were about to take off. By not waiting for takeoff, and yet they were not authorized, the control tower interpreted the message as the plane was in takeoff position and responded by saying they were kept waiting for takeoff.

control tower asked the PAA 1736 to inform him as soon as there Clear the runway. In the KLM cabin 4805, and on takeoff, one confirmed receipt of these messages and PAA 1736 announced that it was still rolling down the track, and report back to clear it. Just after that, the flight engineer and copilot Dutch showed doubt that the landing was really clear, what the Captain Jacob Van Zanten, responded with an emphatic "yes", perhaps influenced by his great prestige, making difficult for a skilled pilot as he made a mistake of this magnitude, as well as the copilot and flight engineer made no further objection. The impact occurred about eight seconds later, at 17 hours 06 minutes 50 seconds GMT, after which the air traffic controllers could not get back in touch with any of the two planes.

Taxiway at Los Rodeos.

Due to the heavy fog, the KLM jet pilots could not see the Pam Am plane in front. KLM flight 4805 was visible from PAA 1736 approximately 8 seconds and a half before the collision, but despite having tried to accelerate out of the track, the clash was inevitable.


The KLM was completely in the air when the impact occurred, about 250 kilometers per hour. The front hit the top of another Boeing, ripping the roof of the cabin and upper deck passengers while the two other struck the Pan Am plane, killing most of the rear passengers instantly.

continued flying after the collision, hitting the ground about 150 meters from the crash site, and sliding down the track about 300 meters. There was a violent fire immediately and although the impact to the Pan Am and soil were extremely violent, all 248 people aboard died in the fire KLM and 321 of the 380 people aboard the Pan Am including 9 people who died later from his injuries.

weather conditions also made it possible for the accident was seen from the control tower immediately, where there was only one explosion followed another, without being clear their situation or causes. Moments later

the collision, an aircraft located on the apron tower alerted the fire he had seen. The tower sounded the fire alarm, and even without knowing the status of the firefighters reported fire. They went to the area as quickly as possible, which due to heavy fog was still too slow, even without seeing the fire, until they could see the light of the flames and feel the strong radiation of heat. The fog cleared a bit, they could see for the first time that a plane had completely engulfed in flames. After extinguishing the fire has started, the fog continued to clear and could see another light, they thought would be part of the burning plane that had fallen. Split the trucks and close to what they thought was a second outbreak of the fire, they discovered a second plane in flames. Concentrated their efforts in this second plane and that the former was completely unrecoverable.

As a result, despite the powerful flames on the second plane, could save the left side from which later were taken between fifteen and twenty thousand kilos of fuel.

Meanwhile, the control tower, still covered in a dense fog, still could not find the exact location of the fire and if it was one or two aircraft involved in the accident.

According to survivors of Pan Am flight, including flight captain Victor Grubbs, the impact was not so terribly violent, which made them believe that there had been an explosion. A few at the front door and jumped into the openings on the left side as he produced several explosions. The evacuation, however, was quickly wounded were taken and offered numerous donations of blood. Firetrucks

neighboring cities of La Laguna and Santa Cruz had to be employed and the fire was not completely extinguished until 0330 on 28 March.

A number of factors likely contributed to the accident include, among others, fatigue after long hours of waiting and the growing tension of the situation. The KLM captain, due to the rigidity of the Dutch rules on limitations of length of service, had only three hours to take off from the airport of Gran Canaria back to Amsterdam airport or have to suspend the flight, with the consequent chain delays related thereto. In addition, airport weather conditions were worsening rapidly, which could cause the flight was further delayed.

Another factor was the transmission tower to wait for indicating to KLM and Pan Am was still reporting that rolling down the runway, which were not received with all the clarity that would have been desirable. The technical language used in communication between the three parties also was proper. For example, the Dutch co-pilot did not use appropriate language to indicate they were about to take off and the flight controller OK added a call just before the KLM flight to wait for authorization for takeoff. The Pan Am

not left the track at the third intersection, as he had indicated. The plane should have been, in fact, talking to the tower, but this could not have been a direct cause of the accident, because he never reported that the runway was clear and informed twice that she was rolling. Excessive traffic congestion also affected, forcing the tower to take action, though regulations, in some cases it can be taken as potentially dangerous as having aircraft taxiing down the runway.

should also be borne in mind that the flight from Tenerife to Gran Canaria is only 25 minutes long so that the refueling 55500 liters of fuel, which caused the fire was later produced even greater, suggests that the captain of the KLM flight 4805 proposed the save further delay in Gran Canaria by air traffic problems. Being a charter flight should take off from Gran Canaria Airport to Amsterdam and this amount would have enough fuel.

The transcript of conversations between the Pan American Boeing, La Torre de Los Rodeos Airport and KLM Boeing you can see, the tragedy was hatched in 6 minutes and 49 seconds of haste, constraints, forward and misunderstandings

17,00:43,5 : Ground Control to

PAA Clipper one seven three six is \u200b\u200bcleared to taxi to the runway following the seven four seven from KLM

17,00:51,1 : Second

PAA Clipper one seven three

17,01:19,5 : Ground Control

Clipper one seven three six, leave the door (...) three a (...) to (her, me) left.

17,01:28,6 : PAA Second

Please repeat

17,01:31,6 : Ground Control

Leave the track for the third (your) left.

17,01:37,7 : Second
PAA
OK, roll down the runway and (...) to leave the runway at the first intersection on the left.

17,01:45,6 : Ground Control

Negative. The third, third and switch to one one nine point seven.

17,01:51,1 : PAA Second

OK, the first and switching to a nineteen seven

17,01:54,2 : Commander of PAA (Cockpit Voice Recorder)

let us wait here.

17,01:57,0 : PAA Second

Tenerife, this is Clipper one seven three six.

17,02:01,8 : Approach Control

Clipper one seven three six, Tenerife here.

17,02:03,6 : Second

PAA (...) We have been instructed to contact you and also the track rodemos correct?

17,02:08,4 :

Affirmative Approach. Roll down the runway and (...) take the third, third to your left, third.

17,02:16,4 : PAA

Second Third on the left, OK.

(There was some confusion in the cockpit of Pan Am The commander still believed that the driver had said "first." The second says that it asked again. You can not do so immediately, since the control approach is following the departure of flight 282, Sunjet).

17,02:49,8 : Approach

KLM four eight zero how many intersections has already passed?.

17,02:55,6 : Second
KLM
I think Charlie just spent four.

17,02:59,9 : Approach Received

... At the end of the runway turn one eighty and report for the approval of the CTA.

(PAA crew discusses the intersection to take and not pay much attention to the road between KLM and control approach).

17,03:14,2 : Second

KLM (...) are central runway lights available for the four eight zero five?

17,03:19,8 : Approach

hope. I think not, sir: I think not. Wait. Check it.

17,03:22,9 : Second
KLM
OK

17,03:25,0 : Approach

We are looking (...) We'll check.

17,03:29,3 : PAA Second

I confirm that it is expected that the Clipper one seven three six to turn left at the third intersection.

17,03:36,4 : Approach

The third, sir. One, two, three, third, third.

17,03:39,2 : Second

Thank PAA.

17,03:47,6 :

approach (...) er seven one three six report when leaving the track.

17,03:55,0 : Second

PAA Clipper one seven three six.

17,04:58,2 :

approach (...) ... M eight seven zero five and clipper one seven three six ... for information, the lights are out of service stations.

17,05:05,8 : Second
KLM
Received

17,05:07,7 : Second

PAA Clipper one seven three six.

17,05:44,8 : Second

KLM (...) the KLM four eight zero five is ready to take off and ... (...) await the approval of the CTA.

17,05:53,4 : Approach

KLM eight seven zero five (...) is authorized to mark Pope. Climb and maintain flight level nine zero ... turn right after takeoff. Proceed with heading zero four zero until intercepting the three two five radial from Las VOR Palmas.

17,06:09,6 : Second

KLM (...) received. We are entitled to (...) the mark Pope. Flight level nine zero. Turn right to zero four zero until intercepting the three two five and we (...) (take off) (in DT).

17,06:18,5 : Approach ... K



17,06:19,3 : Commander of PAA

No (...) ...

17,06:20,3 : Second
And
PAA Clipper one seven three six is \u200b\u200bstill rolling down the runway.

17,06:25,6 : Approach Received

, Papa Alpha one seven three six report when leaving the track.

17,06:29,6 : PAA Second

OK, I will report when no longer.

17,06:32,1 : Approach

Thanks.

What now follows is a transcript of cockpit voice recorder of the PAA during the eighteen seconds before the collision.

17,06:32,1 : Commander


Apart from the (...) Get out of here ... (...) from here.

17,06:34,9 : Second

Yes, it seems that now has come the rush.

17,06:36,2 : Mechanical

Yes, after having us for an hour and a half this (...)

17,06:38,4 : Second

Yes, this (...)

17,06:39,8 : Mechanical

Now hurry.

17,06:40,6 : Commander

There is ... look at that (...) ... that (...) is upon us.

17,06:45,9 : Second

Out! Turn away! Turn away!

17,06:48,7 : Sound of takeoff warning horn. Sound of approaching engines.

17,06:50,1 : Noise impact.

Following is the transcript of the cockpit voice recorder from
KLM 17,06:32,43 to the collision.

17,06:32,4 : Voice unidentifiable

Still not out?

17,06:34,1 : Commander

What?

17,06:34,7 unidentifiable

Voice Has not gone out that Pan American?

17,06:35,7 : Commander

Yes

17,06:43,5 : Second



V1 17,06:47,4 : Commander

Ah! (...)

17,06:49,3 : Noise impact.

Trivia

legend circulating in Tenerife during World War II, Hitler urge the English regime of Franco in the construction of an airport in Tenerife to cover his troops North Africa. German technical design studies began at the airport, later presenting the project to the English authorities. They decided to postpone the construction, but kept all the studies done by Germans, who in those days were regarded as true experts in the design and construction of airports.

Years later, and after the war, the English authorities decided it was time to build the airport in Tenerife, so they decided to use the valuable documentation provided by the Germans. In it, presented a map which clearly had a large red cross marked. The English "assumed" that this was the perfect location for the airport, beginning with its construction based on the German maps. Little did they know, is that the large red cross indicates the location never had to build an airport.

Samantha 38g Filmographie

NEW mood stabilizers in bipolar disorders

(second part)

Miguel Pérez-Camacho Duque

The schizoaffective disorder, included in the group of so-called " atypical psychosis," answered the asymptomatic group and both a patient's own psychopathology of schizophrenia and mood disorder mood.

in DSM III-R (1988), we first provide diagnostic criteria for this table, requiring the presence of acute symptoms of mania or depression and schizophrenia, and the existence of delusions and hallucinations for at least 2 weeks in the absence of affective symptoms. The DSM IV (1994) only brings changes, distinguishing, as does the DSM III-R, a subtype schizoaffective bipolar and other depressive. For its part, the ICD-10 (WHO, 1992) includes schizoaffective mixed subtype.

Regarding the age of onset, it is early in the tables in the schizo-affective disorders (unipolar and bipolar) and slightly Late in schizophrenia.

is often an association between life stressors and subsequent clinical episode schizoaffective and greater socio-cultural level in these patients than observed in schizophrenia. Angst maintains that the risk of suicide in patients with schizoaffective disorder (15%) is higher than schizophrenic patients (10% of the study by Caldwell and Gottesman, 1990). It

consider three types of tables:

1. Bipolar (more frequent in young adults and closer to the emotional side of the spectrum)
2. Depressive (more common in adults older and seemingly closer to schizophrenia)
3. And mixed that are more difficult to diagnose and that would correspond to what Leonhard called "cycloid psychosis anxious."

In schizoaffective disorder, bipolar type (esquizomanía ), in principle, there is a good response to therapy of type antimanic drugs, including lithium salts, classic antipsychotics (haloperidol, chlorpromazine), benzodiazepines (clonazepam ) and anticonvulsants (carbamazepine, valproic acid, gabapentin, lamotrigine), which are generally used in partnership.

Studies with atypical antipsychotics offer new hope for the future. The effect of low dose risperidone and half (less than 6mg/día) with mood stabilizers has been successful.

On the olanzapine, because of its mechanism of action, this drug appears to possess antidepressant-like properties and possibly antimanic. Few data are taken from other atypical antipsychotic sertindole type (retired prematurely from the market due to its effect of lengthening the QT interval of the electrocardiogram), amisulpiride, quetiapine or ziprasidone.

The bipolar type schizoaffective disorder (bipolar esquizodepresivo ), preferably selective serotonin reuptake of serotonin, norepinephrine, or both together with antipsychotic drugs and mood stabilizers appear to be more reasonable therapeutic opinion.

In the unipolar type schizoaffective disorder (unipolar esquizodepresivo), treatment of patients esquizodepresivo unipolar subtype is more controversial, whereas some authors discourage the use of antidepressants and in many cases only the symptoms improve with treatment antipsychotics.

Where mixed episodes, treatment is comparable to that used in mixed bipolar disorders, so that greater emphasis should in antipsychotic treatment and, more specifically, the use of clozapine and probably the newer atypical antipsychotics (risperidone, olanzapine, quetiapine, amisulpiride, ziprasidone) in association with standard mood stabilizers.

As for the maintenance treatment , we encounter similar difficulties objectified for schizophrenia or bipolar disorders. After a first episode, in principle, maintain the treatment that has proved effective in the acute phase, at least for a year and a half, and indefinitely if we are faced with two or more episodes of the disease.

schizoaffective patients bipolar should be treated similarly to pure bipolar, so after a manic phase may be appropriate to reduce the doses of antipsychotics but without removing them completely and keep mood stabilizers. Since these patients (as well as bipolar) are at increased risk of extrapyramidal side effects before taking antipsychotic drugs should be administered in combination antiparkinsonian. In this sense, it is noted that the new atypical antipsychotics appears to be reduced substantially the risk of onset of tardive dyskinesia.

Regarding the mechanism of action of anticonvulsants in treating bipolar disorder, it has not yet been well established. They have different mechanisms of action, including the following:

• Modulation of gene expression through control of the enzyme protein kinase.
• Inhibition of the enzyme carbonic anhydrase.
• Action on ion channels (sodium, potassium, calcium) in the producing cell membarana neuronal voltage changes.
• Performance on second messenger enzyme inhibition on inositol monophosphatase involved in inositol fofatidil system, modulating the synthesis of protein G.
• Acting on the inhibitory neurotransmitter GABA, or by increasing its synthesis, release, inhibiting their metabolism or reuptake by GABA neurons.
• Performance in second messenger enzyme inhibition phosphokinase C.
• Reduced synthesis or release.

With the appearance in the clinic of the new antiepileptic opens a door of hope to this, above all, the future treatment of bipolar affective disorder and schizoaffective disorder probably due to its good tolerance, safety, profile interactions and their relative lack of serious adverse effects.

Among the new anticonvulsants, lamotrigine outside are the following:
Gabapentin
: This is a structural analogue of GABA. Its mechanism of action is complex and currently unknown, although it points to a reversal of the neuronal GABA transporter, thereby increasing the latter extracellularly. Something similar happens with the effective dose, for which there is a wide range (600-3600 mg / day), recommended for use by installment.

Its main adverse effects include sedation, ataxia, dizziness and gastrointestinal upset. Other less common side effects are headache, weight gain, nystagmus, diplopia, and tremor. Among its main interactions include antacids oral phenytoin.

It appears from several studies carried out, gabapentin possesses anxiolytic and antimanic effect, either alone or preferably in combination with other mood stabilizers. It also has some antidepressant effect and derivative thereof, a risk of inducing hypomanic desocmpensaciones. Its main clinical utility appears in social phobia and anxiety disorder, bipolar depression and dysphoric mania and refractory. Also you may have a useful role in treating disorders of impulse control.

Topiramate: Its mechanism of action derived from glutamatergic receptor blockade. Power, therefore, the action of GABA. It also acts as a calcium antagonist and inhibits the enzyme carbonic anhydrase. The optimal dose to achieve, in ascending and progressive, is 200-400 mg / day.

Side effects include sedation, numbness, gastrointestinal distress, difficulties in concentration, Memoir and verbal fluency and kidney stones. One of its main advantages is that unlike other drugs does not increase (even decreased) body weight by a mechanism of action remains desonocido. Presents a small number of interactions, including which include carbamazepine and phenytoin decrease the values \u200b\u200bof topiramate Induction your metabolism, and conversely decreases topiramate plasma levels of digoxin and oral contraceptives.
Topiramate has an antimanic effect in the acute phase, either as monotherapy or in combination and also in the acute phase antidepressant. Its main clinical utility found in refractory mania and dysphoric mania. Oxcarbazepine

: Presents a structure and a clinical profile similar to that of the carbmacepina, but with fewer side effects. The starting dose is 600 mg weekly. The therapeutic range is between 600-2400 mg / day.
Among its advantages are you do not have the toxic metabolites and present few drug interactions. The carbmacepina, phenytoin, phenobarbital and valproic acid plasma concentrations and reduce their vouchers, in turn, decreases the values \u200b\u200boxcabacepina oral contraceptives. The main adverse effects are nausea, vomiting, diarrhea and abdominal pain. Other less common side are sedation, drowsiness, headache, difficulty in concentration, amnesic disorders, dermatological disorders, increase in transaminases and alkaline phosphatase and hyponatremia, among others.

Its main use is in particular epilepsy and partial seizures with or without secondarily generalized tonic-clonic seizures. Although the effect has been attributed antimanic, its possible role in bipolar affective disorder and schizoaffective disorder, from the point of view, mood stabilizer, is to be determined. Tiagabine

: although its efficacy in manic phase seems doubtful, could tiagbina resultr ocmo HERAPY useful adjunctive bipolar I and schizoaffective disorder refractory. However, further studies are needed to support its therapeutic potential in these disorders. In Spain there is little use, like the three below.
Zonisamide: This is an anticonvulsant structurally similar to serotonin and a clinical profile similar to carbamazepine, with possible antimanic and mood stabilizer efficacy maintenance therapy.

levetiracetam and pregabalin : missing data regarding their role in bipolar disorder or schizoaffective.

Among the group of new antiepileptic drugs used in the treatment of bipolar disorder and schizoaffective disorder, lamotrigine is the one that seems to have a greater number of controlled clinical data supporting its efficacy, especially in bipolar depression in fast and cicladotes in bipolar disorder type II.

The mechanism of action of lamotrigine , although it is still unknown in many respects, it seems will guide through the blockade of serotonin 5HT3 and presynaptic inhibition of glutamate release.

Different studies seem to show that this drug could be useful not only in the stabilization of manic and / or mixed (including cicladotes fast) but also in the treatment of bipolar and unipolar depression. In fact lamotrigine seems to have a regulatory role of monoamine reuptake and especially serotonin, which can become clinically translated into an increase in serotonergic neurotransmission. Among

spontaneous reports of clinical cases, in which the association of lamotrigine in bipolar patients previously treated with other anticonvulsants (Lithium salts, valproate, carbamazepine) was satisfactory for clinical improvement and reduction in side effects attributable to drug treatment, notably with Walden (1996), Weisler (1994), Calíbrese (1996) , Labatte (1997), Maxoutova (1997) and Kotler (1998), among others.

found that, in general, describes an improvement in patients Bipolars type I and II, both as being manic depressive, hypomanic or mixed episode during and in rapid cyclers using lamotrigine as monotherapy or associated to other drugs, mood stabilizers, antipsychotics, benzodiazepines). To this effect should review the work of Calíbrese (2001 and 1999), Walden (2000), Fogelson (1997), Pinto (1997), Sport and Sachs (1997), as well as of Mandoki (1997), performed with bipolar children and adolescents, in which lamotrigine was associated with valproate. Work done

double-blind, placebo-controlled, in general we can say that lamotrigine has demonstrated clinical efficacy in the treatment of the following entities or processes:

bipolar depression, both studies short period of 7 weeks duration with lamotrigine as monotherapy in studies of one year follow up of bipolar type I and II. Lamotrigine is the only one of which used the new antiepileptic drugs has shown in clinical trials as authoritative a clear therapeutic potential in bipolar depression.

unipolar depression

affective disorders, both unipolar bipolar ocmo refractory to other drug treatments.
As prophylaxis maintenance monotherapy in bipolar rapid cycling.
As apparently effective treatment of mania.

Lamotrigine in pregnancy and lactation

Lamotrigine should not be used during pregnancy and / or breast, anus, be that in the opinion of the physician the potential benefit for use to the mother outweigh any possible risks to the developing fetus.

The data obtained so far removed from the registry and open by Glaxo-Wellcome laboratories purpose (Lamotriguine Pregnancy Registry) can say that:

At present there is no experience on the effect of lamotrigine on human fertility.

Lamotrigine is a weak inhibitor of the enzyme dihydrofolate reductase, and in this sense, it could have some teratogenic potential. The experience gained in the proportion of children born with birth defects after exposure to lamotrigine during the first trimester of pregnancy is no different to that provided to women affected by epilepsy undergoing anticonvulsant treatment.

Lamotrigine passes into breast milk during lactation at a rate of 40-60% in serum. In this sense, it seems advisable in these patients pose an artificial feeding.

Dosage and concomitant

In adult patients the mean daily dose of lamotrigine recomdada is between 100 and 400 mg / day at the beginning of treatment and then tapering down to a maintenance dose of 200 mg / day.

escalation is recommended before treatment to minimize's the risk of rash, the major side effect attributable to the drug.

lamotrigine monotherapy: 25 mg / day dose the first 2 weeks, 50 mg / day dose of Weeks 3 and 4 from there, increases between 59 and 100 mg every 1-2 weeks until dose maintenance.
This guideline also recommended that lamotrigine is combined with other drugs such as lithium and clonazepam. Lamotrigine

+ Valproate, 12.5 mg / day dose the first 2 weeks, 25 mg / day dose weeks 3 and 4, increases between 25 and 50 every 1-2 weeks until the maintenance dose and then decrease valproate. Lamotrigine + anticomicales

enzyme inducers: 50 mg / day dose the first 2 weeks, 100 mg / day dose of Weeks 3 and 4 from there, increments of 100 mg every 1-2 weeks until dose maintenance.

side effects

Major side effects associated with the clinical use of lamotrigine include skin rash maculopapular, apparently closely related to the initial drug dose administered, with the speed in climbing therapeutics, with the concomitant use of valproate (increases the mean half-life of lamotrigine) or sun exposure. In this case, should remain vigilant, because in a small per cent (less than 1%) of them could see a Steven-Johnson syndrome or toxic epidermal necrolysis.

Other less common side effects are: fatigue, headache, nausea, pain and itching. They have also been isolated reports of neutropenia and agranulocyte.

Lamotrigine has not gone directly related to increased concentrations hepatic transaminases and a incremetno in the final weight of the individual. If you have to come to an eventual withdrawal of the drug, recommended phasing in a period of not less than 1-2 weeks before stopping it completely.

Drug Interactions

Among the drugs that produce an induction of lamotrigine metabolism by decreasing their serum, and thus are clinical efficacy of carbamazepine, phenytoin, primidone, phenobarbital and acetaminophen.

By contrast, drugs such as sertraline or valproic acid inhibits lamotrigine metabolism, increase their plasma and thereby promote a greater presence of side effects and a consequent risk of poisoning by this drug. Conclusions



With the release of new antiepileptic drugs (lamotrigine, gabapertina, topiramate, oxcarbazepine, etc). , As has happened before in other areas such as psychosis or depression, it opens a wide range of possibilities for the treatment of bipolar and schizoaffective patients both in the search for a prophylactic effect on recurrence of each disorder in question as address when and to minimize both manic and depressive symptoms in the acute phase and monitor those patients resistant to conventional therapies. Bibliography



F. Alonso Fernández Fundamentals of psychiatry. Volume II Editorial Paz Montalvo 3 rd Edition, 1977

M. Berk, S. Dodd Bipolar Disorders Internatcional an Journal of Psychiatry and Neurosciences. Volume 4, Number 1, 2006.

Bobes García, J. Et al. Psychiatry in schemas. Bipolar disorders. Ars Medica. Novartis Neuroscience. Psychiatric Publishing, SL, 2005.

Michel G. Gelder, JJ Lopez Ibor, Nancy Andersen. Textbook of psychiatry. Volume I. Ars Medical Publishing, 2003

Gregory, I. Psychiatry Clinic, 2 nd Edition. Editorial Interamericana, SA, 1970.

Kalinowsky, Lothr, Hippius Hanus. Official treatment of the English Society of Biological Psychiatry. Volume 9, Number 1, January-February 2002.

Vandel P,, rebiere V., Sechter D. Surgical Medical Encyclopedia EMC (Eservier SAS), number 121. April-May-June 2005.

Good Roulette Numbers

NEW mood stabilizers in bipolar disorders.

(Part One)

Miguel Pérez Camacho Duque

Background

Mood Disorders magnify everyday human experiences, they acquire a larger dimension. Its symptoms are exaggerations of sadness and exhaustion, joy and happiness, sensuality and sexuality, irritability and anger, energy and creativity that can happen in normal life. In the first descriptions found in a wide variety of cultures for thousands of years and is considered the manic-depressive mood disorder as the prototype.

What are depression and mania?

Ideally, we should first describe the mood or state of mind "normal." Despite the difficulty that entails, an operational definition may be that the humor "normal" is the state of not feeling particularly elated or sad, except in certain circumstances.
For example, if something is wrong, we feel sad and dejected at the time. The vast majority of people can be included in this definition. Superficially, depression and hypomania can be seen as ends of these normal fluctuations of mood. But clinical depression or mania are more than extremes of normal mood, represent syndromes in which, in addition to affecting mood, there are abnormal thinking, psychomotor status, behavior, motivation, physiology and psychosocial functioning.

The Hippocratic School an essential contribution to the scientific psychiatry: it was argued that diseases of the body, not related to magical or supernatural spirits. Hippocrates described the melancholy as a condition "associated with aversion to eating, depression, insomnia, irritability and restlessness, and mania as a state of high energy and euphoria.

Hippocrates also located the etiology of disorders mood in the brain:

Men should know that the brain and the brain only come our pleasures, joys, laughter and jokes, as well as our sorrows, grief, sorrow and tears ... so I say that the brain is the interpreter of consciousness. Hippocratic

This awareness was buried for two millennia under the humoral theory, established in medicine for Galen (second century AD), which held that melancholy was an excess of black bile and mania of an excess of yellow bile . The heart, rather than the brain, was also considered the organ of mood disorders for a long time.

In the first century BC, Greek doctors initially suggested a connection between melancholia and mania.

clinical acuity of this period culminated in Cappadocia Areteo :

According to Areteo , the classic form of bipolar mania was the way: the patient who previously was elated, happy, hyperactive, suddenly experienced tendency to melancholy, at the end of the crisis, going to feel listless, sad, silent, expressing concerns about their future, feeling ashamed. " When the depressive phase is complete, these patients return to be happy, laugh, joke, sing. In a severe form of mania, called the furor, the patient "sometimes kills and slaughters the servants", in milder forms, it exalts itself frequently, "without being cultivated, said to be a philosopher ... and the incompetent (say be them) ... others are good craftsmen suspicious and they feel persecuted, why are irascible. "

Age Media

clinical-empirical tradition survived in Greek early Middle Ages in the midst of Islam and Christianity , but later succumbed to religious intolerance. In the twelfth century, this tradition led to a more theological than empirical. So Roger Bacon , arguing that empirical observation was necessary to obtain the knowledge and mental illness had natural etiologies, was censured by the Church and condemned by his colleagues at the University of Oxford .
yours
A similar tension in the Middle East instead. The Hippocratic tradition was exemplified by the Persian Rhazes , who represents the equivalent of Roger Bacon . Avicenna took a more diplomatic stance and prospered as a synthesizer moderate traditions of Greek, Roman and religious. Its synthesis care, the Canon of Medicine, raised suedogalénica consideration for centuries, conveying this vision in mood disorders: "undoubtedly, the substrate is produced by the mania of the same nature than that produced the blues.

At the beginning of the sixteenth and seventeenth centuries, the Enlightenment gave impetus to medical progress in Europe. The eighteenth century witnessed the resurgence of clinical and empirical tradition in medicine, with descriptions advanced on the mania and melancholy.

The turning of the nineteenth century French clinical psychiatry

In 1845, Jean Falret described cyclic disorder (folie circulaire) who first explicitly defined a disease that "the succession of mania and melancholia manifests itself continuously and almost regular." In the same year, Baillarger described essentially the same concept (folie a double forme), emphasizing that the manic and depressive episodes were not different access, but rather different phases of the same access. For the first time, the manic-depressive disorder was conceived as a single, clearly anticipating the subsequent synthesis of Kraepelin .

Mendel was the first to define hypomania, a "form of mania that typically only shown in the mild stages, abort, so to speak." At the same time, Kahlbaum described cyclic disorders and cyclothymia, characterized by episodes of depression and excitement, but that would permit a dementia, such as occurred with chronic mania or melancholia.

The twentieth century and the synthesis Kraepelinian

Emil Kraepelin in the twentieth century, distinguished from other psychoses diseases and clearly delineated manic-depressive.
emphasize those aspects of manic-depressive that most clearly differentiated from dementia praecox: the periodic or episodic course, more benign prognosis and a family history of manic-depressive illness. Karl Jaspers

argued that the clinical data collected need to be neutral, free of underlying theories, such as Freud free specific diagnostic paradigms, such as Kraepelin . The influence of Jaspers resulted in more thorough descriptions of the syndromes of humor, as exemplified in the highly influential textbook Fish's Clinical Psychopathology .

First twentieth century

In Europe, in the midst of academicians psychiatrist, Eugen Bleuler Kraepelin left to conceptualize the relationship between illness (affective) manic-depressive and demntia praecox (schizophrenia) as a continuous without a clear line marking. Bleuler

grew that the location of a patient in the spectrum depended on the number of schizophrenic features presented. In that sense, he believed that mood symptoms were not specific.

In 1933, Kasanin identified a number of patients with manic-depressive but also showed psychotic symptoms outside of affective episodes. These conditions appeared to be outside the dichotomy of Kraepelin, and led to the concept of schizoaffective disorder .

Bipolar-unipolar distinction

In 1957, Karl Leonhard noted that within the broad category of manic-depressive illness, some patients had a history of depression and mania, while others had only depression. He then pointed out that patients with a history of mania (which he called "bipolar") had a higher incidence of mania in their families when compared with those with depression alone (which he called "monopole"). Alonso Fernández

proposed in 1968 Fasotímicas Psychosis terminology and concept and I quote:

"In the mid-nineteenth century, French psychiatrists and Farlet Baillarger described the" la folie circulaire "and" folie double forme ", respectively, an entity that is characterized by an alternate course between the poles of exaltation and depression, with more or less prolonged periods of emotional stability.

corresponds to Kraepelin merit have grouped this set of circular psychosis or manic depressive psychosis exclusively a disease entity which he called manic-depressive insanity. Specht includes developments here too paranoid. Although this attempt did not prosper, it should be noted that there are many boxes mounted on a sad paranoid (especially self-referential delusions of persecution and jealousy) or vital exuberance (especially delusions litigants).
studies Dreyfus Kraepelin forced to finally including involutional depression in the "manic-depressive insanity." Piquer

Arrufat , illustrious English doctor eighteenth century, the English Hippocrates by some fans of his, describes in detail the condition of the English king Fernando VI and diagnosed as manic-melancholic. Diagnosis has been confirmed by modern psychiatrists. The first is to have established a link between mania nosological and melancholy, is a English psychiatric contribution truly exceptional and very little known, which anticipates the release of manic-depressive insanity by Kraepelin in more than one hundred years and Farlet circular insanity and madness double Baillarger formed by more than seventy-five years.

Any designation of the disease in containing the word "madness" I find it unacceptable. I base my position on two grounds: First

: this word is overloaded with derogatory meanings, so that should be excluded from psychiatric gazetteer.

Second, precisely because of the nature of the semantic burden, gives a wrong idea of \u200b\u200bwhat most of these patients are essentially emotional.

Moreover, the terms "circular", "dual form" and "manic depression" only encompass the patients at least once, have had a manic phase and a depressive. These names are inapplicable to the large contingent in one step (single) or several (multi). Unipolar depressive courses are much more common than bipolar courses (manic and depressive phases).

should therefore be reserved for the names "manic-depressive" and "psychosis circular" exclusively for bipolar affective psychotic disorders.

To Kretschmer, cyclothymia is one form of fluctuating temper, for his share diathetic, between joy and sadness, this temperamental type, as is familiar, is correlated positively with the fleshy body architecture. Alonso Fernández

means can only be resolved by appealing to the two basic characteristics apply to all the manic and depressive mood disorders: to be a vital dysthymia sad or elated, as primary and fundamental psychological symptoms, and the follow a phasic course.

faso thymic The term psychosis, I would propose, means etymologically "during phasic affective psychoses, in whose sector includes essentially forms affective (depressive, manic and manic-depressive).

Also, in 1968 Ian Gregory considered psychotic affective disorders characterized by serious deviations affect, mood or emotional tone. Affectivity may be predominant at the lower end of the scale (depression) or top (euphoria). Associated with severe depression or euphoria, may have also significant problems of perception, thinking or behavior, including hallucinations, delusions and suicidal or homicidal.
subtypes of mood disorders in DSM-IV

1. Disorder (unipolar) major depression is characterized by depressive episodes without manic or hypomanic states.
2. Affective disorder characterized by bipolar manic or mixed episodes of major depressive type (bipolar I according to DSM IV ) or hypomanic episodes and major depressive type (bipolar II), is now one of the psychiatric disorders that enjoy increased research interest both in its etiopathogenesis, pathological physiological, evolutionary, nosological and therapeutic.

The current diagnostic classification systems bipolar disorder face fairly similar. For the DSM IV ( APA, 1994) there are two forms of bipolar affective disorder differentiated by the intensity of manic symptoms (Bipolar I mania or mixed pure "dysphoric mania" more bipolar depression, bipolar II, hypomania, bipolar depression more), within which one can distinguish a subgroup of cicladotes too fast (four or more episodes per year of illness), more frequent young women and sometimes associated with subclinical hypothyroidism, and organic brain factors itself caused this farmacógne mania by antidepressants, particularly poor prognosis Give your poor response to conventional treatment, mood stabilizers and especially lithium carbonate. The DSM IV also recognizes another disorder called cyclothymia, characterized by episodes with depressive hypomanic phases that do not meet criteria for major depression.
In type II bipolar disorder tends to start in adolescence, ua times, in preadolescence. The average age of onset is 18 years. At first, it is common that misdiagnosed as unipolar depression as adjustment disorder or personality disorder, especially the limit. The fact that the disease starts with mild fluctuations in mood and its amplitude or frequency will increase over time until they reach the threshold is a common pattern. Keller et al., in a ten-year follow-up of childhood depression, observed that ultimately 33% met the criteria for bipolar I disorder and 15.3% for bipolar disorder type II.

The gender distribution appears to be midway between the patterns observed in unipolar disorder (preponderance of females) and bipolar disorder type I (equal sex ratios), although some studies support the non-existence of gender differences.

3. Dysthymia refers to more clinically significant depressive symptoms are present for 2 years or more but do not reach the threshold for major depressive disorder. Cyclothymia is a condition in which, as in dysthymia, depressive symptoms did not reach the threshold for a diagnosis of major depressive episode, and is present hypomania. The "hyperthymia" sometimes described chronic mild hypomania (decrease in sleep needs, expansive behavior, extraversion checked).

Regarding treatment, the mainstay is still the psychopharmacological, based on lithium carbonate in both manic and depressive mood stabilizer as maintenance therapy.

lithium salts enjoyed popularity in the nineteenth century to treat gout and other disorders, but fell into disuse by the alarming reports of toxicity. Its use in psychiatric disorders was first suggested by Cade in Australia in 1949. This author developed the idea of \u200b\u200busing lithium in the treatment of psychotic excitement, based on the experimental fact that lithium carbonate caused or short period of lethargy and lack of response to stimuli in guinea pigs, on the other hand, remained conscious. Cade

reported favorable response in manic without hypnotic effect, and from this first study have been published many others point to the efficacy of lithium salts in manic states. Schou et al., in Denmark, addressed a series of manic, alternatively, with lithium and a placebo. Rice, in a trial with a mixed group of patients, found a special sedative when the manic and schizophrenic patients were improved affective elements which influenced.

is generally agreed that the drug is effective only in manic states. Noack and Trautner found that the best responses were in acute cases and do not consider value in chronic. Schoou , in a review of the literature indicates that 80 100 of cures and improvements relating to manic. Andreani reported improvement in 10 of 24 depressed patients. However, recently it has been recognized the value of lithium for prophylactic use in the manic and depressive episodes (1950).

The therapeutic dose for an acute attack would be 600mg. three times a day, although a slow increase may be advised daily to avoid side effects. The maintenance or preventive dose of 300mg can be. three times daily. The lithium concentration in serum is an indicator of the effect of lithium. Using the criterion of Kalinowsky should not be less than 0.6 mEq. / L. not more than 1.6 mEq. / l. Increasingly

are the authors who advocate an indefinite treatment with this substance to the risk of relapse and resistance to lithium after deletion especially if it is done in a rough manner. Lithium has proved effective in both manic and depressive phase of bipolar disorder and prophylaxis of new affective decompensation. However, their efficiency is lower in dysphoric mania in the cicladotes fast and those individuals who attend organic disorders such as thyroid dysfunction, epilepsy or brain damage.

as alternatives to lithium we find the antiepileptic drugs, mainly carbamazepine and valproate, alone or in combination with the first. These drugs are apparently more effective than lithium in rapid cycling, dysphoric mania in the patients and epilepsy, although its use in bipolar disorder type I is associated with worse outcomes. In addition, follow-up studies to 5 years up to 70% speaks of relapses in patients treated with a combination of these drugs and their effect on maintenance therapy is more questionable in the case of lithium.

Other associations would be recommended for atypical antipsychotics in the manic phases of the disease because of its speed of action, preferably the newer atypical antipsychotics (olanzapine, risperidone, quetiapine, ziprasidone) or classical antipsychotic, perphenazine, before reaching atypical, solved many problems bipolar.

New antipsychotics:

conclusions are an alternative first-line treatment for acute mania ( Texas Consensus Conference Panel, 2002).

Data suggest its effectiveness in preventing new episodes.

Its use in prophylaxis can and should be done in combination with mood stabilizers such as lithium, lamotrigine or others.

In its continued use should choose those with better tolerability profile.

During the depressive phase, although this aspect is controversial because in principle it is recommended monotherapy with mood stabilizers may be used concomitantly antidepressant drugs recommended for this purpose reuptake inhibitors of serotonin by their lower risk of inducing a change manic, hypomanic or rapid cycling. The new atypical antipsychotics (olanzapine, risperidone) on their mechanism of action is less dependent on dopaminergic blockade and among their properties with serotonergic stimulation could also be used as a treatment for bipolar depression coadyudante.

Other pharmacological approaches (inhibitors of inositol, omega 3) are in the studio waiting for consistent results.