Lamotrigine for treatment of bipolar depression: independent meta-analysis and meta-regression of individual patient data from five randomised trials

New approaches in the treatment of bipolar depression

Patients with bipolar disorder more frequently suffer from depression than from mania. Indeed depressive symptomatology represents the majority of the illness burden experienced by bipolar patients and is also associated with elevated suicide risk. The treatment of bipolar depression differs from that of recurrent major depression in that the efficacy of conventional antidepressant drugs is not well-established. Some evidence-based treatments for bipolar depression are available and include the anticonvulsant drug, lamotrigine, and the atypical antipsychotic, quetiapine. Lithium also has some benefits in the prevention of depression and its use is associated with a significant reduction in suicidal behaviour. Several other treatments are in clinical development including dopamine agonists, glutamatergic modulating drugs and antioxidants. The role of these interventions in management is uncertain. The clinical uncertainties in the pharmacological treatment of bipolar depression mean that treatment has to be individualised and empirical; there is also an important role for psychological therapies, which again need to be tailored to suit the needs of the individual patient and their family.

A critical review of the recent literature and selected therapy guidelines since 2006 on the use of lamotrigine in bipolar disorder

The anticonvulsant drug lamotrigine (LTG), a sodium channel blocker and inhibitor of glutamate release, has been found to have antidepressant effects in the treatment of bipolar disorder. It is recommended by certain therapy guidelines as a first-line agent for acute and maintenance therapy in bipolar depression, but there have been only some promising results of placebo-controlled trials on its acute antidepressant effects, and the recommendation in therapy guidelines has been reconsidered. On the contrary, positive results for maintenance therapy could be confirmed, and LTG is still a well-tolerated option, especially in patients with predominant depressive episodes. Antimanic effects are not shown in the literature, and its use is not advised in any guidelines that were examined. In conclusion, the findings of the present review article on treatment guidelines for bipolar disorder question the role of LTG in acute depressive states, and critically discusses its use, particularly in acute depressive states.

Clinical factors leading to lamotrigine prescription in bipolar outpatients: subanalysis of the SIN-DEPRES study

BACKGROUND

The use of lamotrigine is a point of discrepancy among the diverse guidelines published on the management of bipolar disorder (BD). Evidence supporting the long-term efficacy is reasonably robust. Nonetheless, the effectiveness of lamotrigine in acute treatment is vigorously debated and it is unclear how this drug is used in routine clinical practice. This subanalysis of the SIN-DEPRES study was designed to understand the clinical profile of bipolar patients receiving lamotrigine.

METHODS

In this prospective national multicenter study, 652 patients with clinically stable bipolar I and II disorder were recruited. Clinical assessments included sociodemographic and clinical data, the Modified Clinical Global Impression scale for BD (CGI-BP-M), the Hamilton Depression Rating Scale (HDRS), and prescriptions of psychotropic medications and their doses.

RESULTS

By means of a logistic regression model, an association between receiving treatment with lamotrigine and the following clinical variables was found: number of past depressive episodes (O.R.=2.875, 95% CI: 1.203-6.869, p=0.018), depressive polarity of the most recent episode (O.R.=1.945, 95% CI: 1.267-2.985, p=0.002), severity in CGI-BD-M depression (O.R.=1.850, 95% CI: 1.215-2.817, p=0.004), bipolar II disorder diagnosis (O.R.=1.635, 95% CI: 1.078-2.482, p=0.021) and number of episodes per year (O.R.=1.310, 95% CI: 1.069-1.605, p=0.009).

LIMITATIONS

Subanalysis of the SIN-DEPRES study with a cross-sectional design.

CONCLUSIONS

The use of lamotrigine in clinical practice is in accordance with most of the guidelines, which support its use in patients with depressive predominant polarity and bipolar II disorder.

Targeting the glutamatergic system to treat major depressive disorder: rationale and progress to date

Major depressive disorder (MDD) is a severe, debilitating medical illness that affects millions of individuals worldwide. The young age of onset and chronicity of the disorder has a significant impact on the long-term disability that affected individuals face. Most existing treatments have focused on the 'monoamine hypothesis' for rational design of compounds. However, patients continue to experience low remission rates, residual subsyndromal symptoms, relapses and overall functional impairment. In this context, growing evidence suggests that the glutamatergic system is uniquely central to the neurobiology and treatment of MDD. Here, we review data supporting the involvement of the glutamatergic system in the pathophysiology of MDD, and discuss the efficacy of glutamatergic agents as novel therapeutics. Preliminary clinical evidence has been promising, particularly with regard to the N-methyl-D-aspartate (NMDA) antagonist ketamine as a 'proof-of-concept' agent. The review also highlights potential molecular and inflammatory mechanisms that may contribute to the rapid antidepressant response seen with ketamine. Because existing pharmacological treatments for MDD are often insufficient for many patients, the next generation of treatments needs to be more effective, rapid acting and better tolerated than currently available medications. There is extant evidence that the glutamatergic system holds considerable promise for developing the next generation of novel and mechanistically distinct agents for the treatment of MDD.

An update on antidepressant use in bipolar depression

The effective treatment of depression in people with bipolar disorder remains a clinical challenge. The role of antidepressant medication in treating bipolar depression has been controversial. While early studies and meta-analyses supported a role for antidepressant medication, more recent, high quality randomized controlled trials in bipolar depression have generally not demonstrated efficacy for antidepressant medications. Although the risk of affective switch and long-term de-stabilization remains a concern when using antidepressant medications in bipolar disorder, the magnitude of this risk has been difficult to ascertain with confidence. Maintenance use of antidepressant medication has generally not demonstrated a favorable risk-benefit ratio. Future studies should explore the patient characteristics and response patterns that predict a more favorable response profile to antidepressants amongst patients with bipolar disorder so that the medications can be rationally used in those who are most likely to benefit.

Lamotrigine vs. lamotrigine plus divalproex in randomized, placebo-controlled maintenance treatment for bipolar depression

OBJECTIVE

To compare the maintenance efficacy of lamotrigine (Lam) to combination therapy of Lam+divalproex ER (Div) in recently depressed patients with bipolar disorder (BD).

METHOD

We randomized 86 BD I or II patients in a major depressive episode to 8 months of double-blind treatment with Lam+placebo or Lam+Div. To be eligible for randomization, patients had to achieve control of both depressive and manic symptoms during an open phase that included both Lam and Div.

RESULTS

Time to depressive episode did not differ significantly by Kaplan-Maier survival analysis (χ2=1.82, df=1, P=0.18). However, several secondary outcomes did show significant differences. The proportion of Lam+placebo patients who had at least one Montgomery-Asberg Depression Rating Scale (MADRS) score≥15 during the maintenance phase was 67% (30/45) compared with 44% (18/41) for the Lam+Div group (χ2=4.51, P=0.03). Among BD I patients assigned to Lam+placebo, 71.4% (25/35) had at least one visit with MADRS score≥15 compared with 36.7% (11/30) among Lam+Div patients (χ2=7.89, df=1, P=0.005).

CONCLUSION

Lam+Div generally provided greater maintenance efficacy than Lam alone for depressive indices in recently depressed BD patients.

Lamotrigine as add-on treatment to lithium and divalproex: lessons learned from a double-blind, placebo-controlled trial in rapid-cycling bipolar disorder

OBJECTIVES

A substantial portion of the morbidity associated with rapid-cycling bipolar disorder (RCBD) stems from refractory depression. This study assessed the antidepressant effects of lamotrigine as compared with placebo when used as add-on therapy for rapid-cycling bipolar depression non-responsive to the combination of lithium plus divalproex.

METHODS

During Phase 1 of this trial, hypomanic, manic, mixed, and/or depressed outpatients (n = 133) aged 18-65 years with DSM-IV RCBD type I or II were initially treated with the open combination of lithium and divalproex for up to 16 weeks. During Phase 2, subjects who did not meet the criteria for stabilization (n = 49) (i.e., remained in or cycled into the depressed phase) were randomly assigned to double-blind, adjunctive lamotrigine (n = 23) or adjunctive placebo (n = 26). The primary endpoint was the mean change in depression symptom severity from the beginning of Phase 2 to the end of Phase 2 (week 12) on the Montgomery-Åsberg Depression Rating Scale (MADRS) total score. Data were analyzed by analysis of covariance with last observation carried forward and a mixed-models analysis.

RESULTS

  During Phase 1, a high rate of study discontinuations occurred due to intolerable side effects (13/133; 10%) and study non-adherence (22/133; 17%). Only 14% (19/133) stabilized on the open combination of lithium and divalproex. Among the 49 (37%) patients randomized to the double-blind adjunctive treatment phase, mean ± standard error change from baseline on the MADRS total score was -8.5 ± 1.7 points for lamotrigine and -9.1 ± 1.5 points for placebo (p = not significant; mixed-models analysis). No significant differences were observed in the rates of response, remission, or bimodal response between lamotrigine and placebo.

CONCLUSIONS

The poor tolerability, lack of efficacy, and high rate of early discontinuation with the combination of lithium and divalproex suggests this regimen was ineffective for the majority of patients with RCBD. Among patients who did not stabilize on lithium and divalproex, the addition of lamotrigine was no more effective than placebo in reducing depression severity. The findings suggest an opportunity for several design modifications to enhance signal detection in future trials of RCBD. The main limitation is the small number of subjects randomized to double-blind treatment.

Add-on Lamotrigine Treatment for Subsyndromal Depression after Manic or Mixed States in Bipolar Disorder Improved the Quality of Life

Two cases of patients experienced subsyndromal depression after manic or mixed hypomanic and depressive episodes due to bipolar I (case 1) and II (case 2) disorders prior to the use of lamotrigine. Case 1 showed episodes of mood switching induced by antidepressants and seasonal mood instability. Case 2 showed hippocampal atrophy and a persistent dull headache that preceded the use of lamotrigine. Both were successfully treated with add-on lamotrigine therapy, and the dull headache was effectively treated with olanzapine. Both patients improved in social activity and work performance after these add-on treatments. Thus, add-on treatment with lamotrigine alone or in combination with olanzapine was an effective strategy to improve the quality of life in bipolar depression. Subsyndromal depression that present after the disappearance of the manic or mixed state was suggested to be practical indication for the use of lamotrigine.

A randomized, double-blind, placebo-controlled, trial of lamotrigine therapy in bipolar disorder, depressed or mixed phase and cocaine dependence

Bipolar disorder is associated with very high rates of substance dependence. Cocaine use is particularly common. However, limited data are available on the treatment of this population. A 10-week, randomized, double-blind, placebo-controlled trial of lamotrigine was conducted in 120 outpatients with bipolar disorder, depressed or mixed mood state, and cocaine dependence. Other substance use was not exclusionary. Cocaine use was quantified weekly by urine drug screens and participant report using the timeline follow-back method. Mood was assessed with the Hamilton rating scale for depression, quick inventory of depressive symptomatology self-report, and young mania rating scale. Cocaine craving was assessed with the cocaine-craving questionnaire. Data were analyzed using a random regression analysis that used all available data from participants with at least one postbaseline assessment (n=112). Lamotrigine and placebo groups were similar demographically (age 45.1±7.3 vs 43.5±10.0 years, 41.8% vs 38.6% women). Urine drug screens (primary outcome measure) and mood symptoms were not significantly different between groups. However, dollars spent on cocaine showed a significant initial (baseline to week 1, p=0.01) and by-week (weeks 1-10, p=0.05) decrease in dollars spent on cocaine, favoring lamotrigine. Few positive trials of medications for cocaine use, other than stimulant replacement, have been reported, and none have been reported for bipolar disorder. Reduction in amount of cocaine use by self-report with lamotrigine suggests that a standard treatment for bipolar disorder may reduce cocaine use. A study limitation was weekly assessment of urine drug screens that decreased the ability to detect between-group differences.

Effects of the anticonvulsant lacosamide compared to valproate and lamotrigine on cocaine-enhanced reward in rats

Some drugs developed as anticonvulsants (notably, valproate and lamotrigine) have therapeutic effects in bipolar and related disorders. Lacosamide, a recently approved anticonvulsant, has unique effects on sodium channels that may play a role in producing the mood-stabilizing effects of anticonvulsant drugs. We tested whether lacosamide would have effects similar to or different from valproate and lamotrigine in a model of reward and elevated mood. The intracranial self-stimulation (ICSS) test is sensitive to the function of brain reward systems. Changes in ICSS may model aspects of disorders characterized by abnormalities of reward and motivation. Cocaine elevates mood, and reduction of cocaine-induced facilitation of ICSS has been used to predict antimanic-like or mood stabilizing effects of drugs. We tested lacosamide, lamotrigine, and valproate in the rat ICSS test alone or in the presence of cocaine. A high dose of lacosamide (30 mg/kg) significantly elevated ICSS thresholds, indicating that it reduced the rewarding impact of medial forebrain bundle stimulation. Lower doses (3-10 mg/kg) did not alter ICSS, but blocked the cocaine-induced lowering of ICSS thresholds. The highest doses of valproate (300 mg/kg) and lamotrigine (30 mg/kg) also elevated ICSS thresholds, and only these high doses significantly lowered cocaine-induced effects. Of the drugs tested, only lacosamide significantly attenuated the reward-facilitating effects of cocaine at doses that had no effects on ICSS response in the absence of cocaine. Abnormalities of mood and reward are common in psychiatric disorders, and these results suggest that lacosamide deserves further study in models of these disorders.

Two 6-week, randomized, double-blind, placebo-controlled studies of ziprasidone in outpatients with bipolar I depression: did baseline characteristics impact trial outcome?

Two randomized, double-blind, placebo-controlled, 6-week studies comparing ziprasidone versus placebo for treatment of bipolar depression (BPD) failed to meet their primary study objectives, indicating that either ziprasidone is ineffective in the treatment of BPD or the study failed. Adult outpatients with bipolar I depression with 17-item Hamilton Rating Scale for Depression total score more than 20 at screening and baseline received either ziprasidone 40 to 80 mg/d, 120 to 160 mg/d, or placebo (study 1), or ziprasidone 40 to 160 mg/d or placebo (study 2). Primary efficacy measure in both studies was change from baseline in Montgomery-Åsberg Depression Rating Scale total scores at week 6 (end of the study). Mixed-model repeated-measures methodology was used to analyze the primary efficacy measure in both studies. Secondary efficacy measures in both studies included Hamilton Rating Scale for Depression total score and Clinical Global Impression-Improvement score. Post hoc analyses were conducted for both studies to examine potential reasons for study failure. In both, ziprasidone treatment groups failed to separate statistically from placebo for change from baseline Montgomery-Åsberg Depression Rating Scale score at week 6. Response rates were 49%, 53%, and 46% for placebo, ziprasidone 40 to 80 mg/d, and ziprasidone 120 to 160 mg/d, respectively (study 1), and 51% and 53% for placebo and ziprasidone 40 to 160 mg/d, respectively (study 2). Ziprasidone 40 to 160 mg/d did not show superiority over placebo at week 6 in the treatment of BPD. Post hoc analyses revealed serious inconsistencies in subject rating that may have limited the ability to detect a difference between drug and placebo response. Rating reliability warrants further investigation to improve clinical trial methodology in psychiatry.

Pharmacokinetic evaluation of armodafinil for the treatment of bipolar depression

INTRODUCTION

Bipolar disorder is a psychiatric illness with recurring episodes of mania and depression. Armodafinil , the R-enantiomer of modafinil, approved for treating excessive sleepiness associated with narcolepsy, obstructive sleep apnea and shift work disorder, is possibly effective as an adjunctive treatment for bipolar depression.

AREAS COVERED

This review covers the pharmacokinetics of armodafinil, with an emphasis on its use in bipolar depression. Its clinical efficacy in the treatment of bipolar depression is evaluated, along with current data regarding its safety and tolerability.

EXPERT OPINION

One placebo-controlled trial is available, in which armodafinil was efficacious as an adjunctive treatment in bipolar depression. Armodafinil shows a linear pharmacokinetic profile over a broad dose range of 50 - 400 mg (maximal plasma concentration and area under concentration-time curve). Compared with modafinil, an equivalent dose of armodafinil attains higher blood concentrations 4 - 6 h post-dose. The possibility of drug interactions is generally low, although interactions have been shown with some drugs used in bipolar disorder, through mild CYP3A4-induction and CYP2C19-inhibition. Armodafinil is well tolerated and presents a possible new treatment option for bipolar depression. However, further investigation is still needed in order to confirm its efficacy and to clarify its role in the treatment of bipolar depression.

Targeting the glutamatergic system to treat major depressive disorder: rationale and progress to date

Major depressive disorder (MDD) is a severe, debilitating medical illness that affects millions of individuals worldwide. The young age of onset and chronicity of the disorder has a significant impact on the long-term disability that affected individuals face. Most existing treatments have focused on the 'monoamine hypothesis' for rational design of compounds. However, patients continue to experience low remission rates, residual subsyndromal symptoms, relapses and overall functional impairment. In this context, growing evidence suggests that the glutamatergic system is uniquely central to the neurobiology and treatment of MDD. Here, we review data supporting the involvement of the glutamatergic system in the pathophysiology of MDD, and discuss the efficacy of glutamatergic agents as novel therapeutics. Preliminary clinical evidence has been promising, particularly with regard to the N-methyl-D-aspartate (NMDA) antagonist ketamine as a 'proof-of-concept' agent. The review also highlights potential molecular and inflammatory mechanisms that may contribute to the rapid antidepressant response seen with ketamine. Because existing pharmacological treatments for MDD are often insufficient for many patients, the next generation of treatments needs to be more effective, rapid acting and better tolerated than currently available medications. There is extant evidence that the glutamatergic system holds considerable promise for developing the next generation of novel and mechanistically distinct agents for the treatment of MDD.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

Aripiprazole in bipolar depression: a pooled, post-hoc analysis by severity of core depressive symptoms

OBJECTIVE

This post-hoc analysis of pooled data from two similarly designed trials assessed the impact of aripiprazole monotherapy vs. placebo on treatment outcomes based on baseline severity of core depressive symptoms in patients with bipolar I disorder.

METHODS

Patients were classified as severely depressed (Bech-6 Total score > 15) or less severely depressed (Bech-6 Total score < 15). Efficacy was assessed by mean changes in Montgomery-Åsberg Depression Rating Scale (MADRS) Total and MADRS-6 subscale scores from baseline to endpoint using a mixed model repeated measures analysis.

RESULTS

A total of 133 patients (n = 62 on active aripiprazole) were classified as severely depressed and 612 patients (n = 309 aripiprazole) as less severely depressed. At endpoint, the mean MADRS Total score reduction for severely depressed patients receiving aripiprazole compared with placebo was -19.4 vs. -15.4 (P = 0.14), whereas MADRS-6 subscale score reduction for patients receiving aripiprazole compared with placebo was -13.8 vs. -10.3 (P = 0.07). Adverse event profiles were similar between the two severity groups.

CONCLUSIONS

Symptomatic improvements assessed here suggest that aripiprazole monotherapy at the doses studied may provide some improvements in core symptoms of depression in patients with bipolar I disorder who were more severely depressed.

How close is evidence to truth in evidence-based treatment of mental disorders?

Given the importance of the term 'evidence' in evidence-based medicine (EBM), the meaning of this term is evaluated, going back to the philosophical tradition and current meaning of the terms 'evidence' and 'truth'. Based on this, current problems in the definition of evidence and in the grading of evidence in EBM are described, taking examples from the field of psychiatry and especially pharmacopsychiatry. These problems underline that the use of the term evidence in EBM is inconsistent and inconclusive. This should be fairly stated in all EBM-related publications, especially in EBM-based guidelines, to avoid severe misunderstandings in and outside the field of psychiatry. Although EBM might have increased empirically driven rational decision-making in psychiatry/medicine, the current limitations should be carefully considered.

Second generation antipsychotics in the treatment of bipolar depression: a systematic review and meta-analysis

Depressive symptoms and episodes dominate the course of bipolar disorder. However, the therapeutic armamentarium for bipolar depression is limited. Recent evidence points to the efficacy of second generation antipsychotics (SGAs) for the treatment of bipolar depression. We conducted a systematic review and meta-analysis of the efficacy and safety of SGAs (randomized, double-blind, placebo-controlled trials; used in monotherapy) in the treatment of adult patients with bipolar depression. Publication bias was corrected for by performing similar searches using the clinical trials register of the respective pharmaceutical companies, the Cochrane Database and ClinicalTrials.gov. Seven published papers were identified on the use of aripiprazole, olanzapine and quetiapine. Internal validity of the trials was fairly good, external validity only moderate. Different outcome measures of efficacy and safety were assessed. When the individual trials were looked at, quetiapine and to a lesser extent olanzapine demonstrated significant improvement in MADRS (Montgomery-Åsberg Depression Rating Scale) total scores. This was not demonstrated for aripiprazole. Efficacy was hampered by adverse events, such as weight gain, akathisia and somnolence/sedation. Both clinical heterogeneity of the included trials and statistical heterogeneity of the meta-analytic data were considerable. The number of quetiapine trials was disproportionate to the number of trials of aripiprazole and olanzapine. Further research is needed to assess differential efficacy of the different SGAs and their use in clinical practice.

The hidden third: improving outcome in treatment-resistant depression

Treatment-resistant depression (TRD) presents many challenges for both patients and physicians. This review aims to evaluate the current status of the field of TRD and reflects the main findings of a consensus meeting held in September 2009. Literature searches were also conducted using PubMed and EMBASE. Abstracts of the retrieved articles were reviewed independently by the authors for inclusion. Evaluation of the clinical evidence in TRD is complicated by the absence of a validated definition, and there is a need to move away from traditional definitions of remission based on severity of symptoms to one that includes normalisation of functioning. One potential way of improving treatment of TRD is through the use of predictive biomarkers and clinical variables. The advent of new treatments may also help by focusing on neurotransmitters other than serotonin. Strategies such as the switching of antidepressants, use of combination therapy with lithium, atypical antipsychotics and other pharmacological agents can improve outcomes, and techniques such as deep brain stimulation and vagus nerve stimulation have shown promising early results. Despite consistent advances in the pharmacotherapy of mood disorders in the last decade, high rates of TRD are still a challenging aspect of overall management.

Balanced efficacy, safety, and tolerability recommendations for the clinical management of bipolar disorder

OBJECTIVE

To provide practical and clinically meaningful treatment recommendations that amalgamate clinical experience and research findings for each phase of bipolar disorder.

METHODS

A comprehensive search of the literature was undertaken using electronic database search engines (Medline, PubMed, Cochrane reviews) using key words (e.g., bipolar depression, mania, treatment). All relevant randomised controlled trials were examined, along with review papers, meta-analyses, and book chapters known to the authors. In addition, the recommendations from accompanying papers in this supplement have been distilled and captured in the form of summary boxes. The findings, in conjunction with the clinical experience of international researchers and clinicians who are practiced in treating mood disorders, formed the basis of the treatment recommendations within this paper.

RESULTS

Balancing clinical experience with evidence informed and lead to the development of practical clinical recommendations that emphasise the importance of safety and tolerability alongside efficacy in the clinical management of bipolar disorder.

CONCLUSIONS

The current paper summarises the treatment recommendations relating to each phase of bipolar disorder while providing additional, evidence-based, practical insights. Medication-related side effects and monitoring strategies highlight the importance of safety and tolerability considerations, which, along with efficacy information, should be given equal merit.

Treatment options for acute depression in bipolar disorder

OBJECTIVE

The burden of depression represents the most debilitating dimension for the majority of patients with bipolar disorder and dominates the long-term course of the illness. The purpose of this manuscript is to review the evidence base of the available treatment options for bipolar depression within two frequent clinical scenarios.

METHODS

The evidence is largely based on a systematic literature search and appraisal that was part of the development of the German Guideline for Bipolar Disorders. All relevant randomized controlled trials were critically evaluated.

RESULTS

Overall, the number of suitably controlled studies for the treatment of bipolar depression is relatively low. There are two common scenarios. Scenario A, if a patient with bipolar depression is currently not being treated with a mood-stabilizing agent (de novo depression, first or subsequent episode), then quetiapine or olanzapine are options, or alternatively, carbamazepine and lamotrigine can be considered. Antidepressants are an option for short-term use, but whether they are best administered as monotherapy or in combination with mood-stabilizing agents is still controversial. In practice, most clinicians use antidepressants in combination with an antimanic agent. Scenario B, if a patient is already being treated optimally with a mood-stabilizing agent (good adherence and appropriate dose) such as lithium, lamotrigine is an option. There is no evidence for additional benefit from antidepressants where a patient is already being treated with a mood stabilizer; however, in practice an antidepressant is often trialled. Efficient psychotherapy is an important part of the treatment regimen and should span all phases of the illness.

CONCLUSIONS

Treatment decisions in bipolar depression involve a range of different pharmacological and non-pharmacological options. Monitoring potential unwanted effects and the appropriateness of treatment can help to effectively balance benefits and risks in individual situations. However, the quality of the assessment and reporting of risks in clinical trials need to be improved to better inform treatment decisions.

An observational nationwide register based cohort study on lamotrigine versus lithium in bipolar disorder

It is not clear whether the effectiveness of lamotrigine versus lithium differs for patients with bipolar disorder treated in clinical practice. We compared rates of switch to, or add on of, another psychotropic, and rates of psychiatric hospitalization for patients treated with lamotrigine or lithium in clinical practice. Using linkage of nationwide Danish registers we identified 730 patients who received lamotrigine and 3518 patients received lithium subsequent to a diagnosis of bipolar disorder in psychiatric hospital settings during a period from 1995 to 2006. The overall rate of switch to or add on of another psychotropic (the opposite drug of interest (lithium or lamotrigine), antidepressants, antipsychotics or other anticonvulsants than lamotrigine) was increased for lamotrigine compared with lithium (HR = 2.60, 95% CI: 2.23-3.04), regardless of whether the index episode was depressive, manic, mixed or remission. In addition, the overall rate of psychiatric hospitalization was increased for lamotrigine compared with lithium (HR = 1.45, 95% CI: 1.28-1.65), as were the rates for patients with a depressive (HR = 1.31, 95% CI: 1.01-1.70) and patients with a manic (HR = 1.65, 95% CI: 1.31-2.09) index episode. Rates did not differ significantly between the drugs for patients with a mixed index episode and for patients in remission. It is concluded that in daily clinical practice, treatment with lithium is in general superior to treatment with lamotrigine.

The clinical management of bipolar disorder: a review of evidence-based guidelines

OBJECTIVE

To discuss the criteria used to diagnose the mood episodes that constitute bipolar disorder, the approach to the differential diagnosis of these presentations, and the evidence-based treatments that are currently available.

DATA SOURCES

A search for evidence-based guidelines for the diagnosis and treatment of adults with bipolar disorder was performed on May 5, 2010, using the National Guideline Clearinghouse database, the Agency for Healthcare Research and Quality Evidence Reports database, and the Cochrane Database of Systematic Reviews. In addition, a clinical query of the PubMed database (completed March 1, 2010) and searches of drug manufacturers' Web sites (for unpublished trials) were performed to identify randomized, controlled trials and meta-analyses evaluating strategies to treat resistant depression.

STUDY SELECTION

Guidelines were selected based on data from randomized, controlled trials; meta-analyses; and well-conducted naturalistic trials that were published since 2005.

DATA EXTRACTION

Four evidence-based treatment guidelines for bipolar disorder were included. Three were published in 2009: those put forth as part of an Australian project, those of the British Association for Psychopharmacology, and those produced by the International Society for Bipolar Disorders and the Canadian Network for Mood and Anxiety Treatments. The most recent US guidelines are that of the Texas Implementation of Medication Algorithms project, last updated in 2005.

DATA SYNTHESIS

Recommendations from all 4 guidelines were reviewed and are presented with a focus on using them to improve clinical care. The recommendations with the most agreement and highest level of clinical evidence were as follows: (1) mania should be treated first-line with lithium, divalproex, or an atypical antipsychotic medication; (2) mixed episodes should be treated first-line with divalproex or an atypical antipsychotic; (3) bipolar depression should be treated with quetiapine, olanzapine/fluoxetine combination, or lamotrigine; and (4) all patients should be offered group or individual psychoeducation. Additionally, recommendations for therapeutic drug monitoring are presented due to their importance for patient safety, particularly for the primary care physician, although these are based on consensus guidelines.

CONCLUSIONS

Bipolar disorder is a lifelong illness that is complicated by high comorbidity and risk of poor health outcomes, making the primary care physician's role vital in improving patient quality of life. The management of acute mood episodes should focus first on safety, should include psychiatric consultation as soon as possible, and should begin with an evidence-based treatment that may be continued into the maintenance phase. Long-term management focuses on maintenance of euthymia, requires ongoing medication, and may benefit from adjunctive psychotherapy.

Effect of lamotrigine and carbamazepine on corticotropin-releasing factor-associated serotonergic transmission in rat dorsal raphe nucleus

Corticotropin-releasing factor (CRF) and serotonin are important transmitters of the pathophysiology of mood disorder. To clarify the mechanisms of action of lamotrigine (LTG) and carbamazepine (CBZ), we determined their effects on serotonin release associated with CRF in rat dorsal raphe nucleus (DRN) and median prefrontal cortex (mPFC) using dual-probe microdialysis. Neither perfusion with CRF1 nor CRF2 antagonists into DRN-affected serotonin release in DRN and mPFC. Perfusion of 10 μM CRF into DRN increased serotonin release in both regions, whereas 0.1 μM CRF decreased and had no effect on serotonin release in DRN and mPFC, respectively. Pre-perfusion with CRF1 antagonist into DRN inhibited 0.1 μM CRF-induced serotonin reduction, whereas pre-perfusion with CRF2 antagonist in DRN inhibited 10 μM CRF-induced serotonin elevation, without affecting 0.1 μM CRF-induced serotonin reduction. LTG perfusion concentration dependently decreased serotonin releases in DRN and mPFC. Therapeutic and supratherapeutic concentrations of CBZ increased and decreased serotonin releases in both regions, respectively. Pre-perfusion with sub-therapeutic concentration LTG inhibited CRF1-induced serotonin reduction without affecting CRF2-induced serotonin release, whereas pre-perfusion with therapeutic concentration of LTG inhibited both CRF1- and CRF2-actions. In contrast, both therapeutic and supratherapeutic concentrations of CBZ inhibited CRF2-induced serotonin release without affecting CRF1-induced serotonin reduction. Neither LTG nor CBZ affected the CRF-induced cAMP production in cells over-expressing CRF1 and CRF2 receptors. This study demonstrated that inhibition of CRF2-receptor-mediated serotonergic transmission is a mechanism shared by LTG and CBZ, two clinically related compounds, whereas LTG but not CBZ inhibits CRF1-receptor-mediated serotonergic transmission. Therefore, these mechanisms may contribute to the clinical actions of these agents.

Pharmacotherapeutic trends in 2231 psychiatric inpatients with bipolar depression from the International AMSP Project between 1994 and 2009

BACKGROUND

Pharmacological treatment of bipolar depression is a complex and controversial issue, and its real-world practice remains largely unknown.

METHOD

Observational analysis of the pharmacotherapy of 2231 psychiatric inpatients with a current episode of bipolar depression. The study was based on cross-sectional prescription data from European psychiatric hospitals that had been repeatedly collected between 1994 and 2009 through the collaborative Drug Safety in Psychiatry (AMSP) program.

RESULTS

Overall 81.3% of patients received antidepressants (AD) (7.8% monotherapy), 57.9% antipsychotics (AP), 50.1% anticonvulsants (AC), 47.5% tranquilizers, and 34.6% lithium (Li). Use over time was stable for AD, decreased for Li, and increased for AC, AP and tranquilizers. Pronounced increases were specifically observed for quetiapine, lamotrigine and valproate. Use of tricyclic AD decreased but its prevalence was still 11.8% in 2009. Venlafaxine was used by 19.5% in 2009. We also observed an increase of polypharmacy combining AD, AP, AC and Li. From 2006 to 2009 37.0% received concomitant treatment with three, and 6.4% even with all four of those drug classes.

LIMITATIONS

Observational cross-sectional study without follow-up or additional clinical information.

CONCLUSIONS

Monotherapy with antidepressants and any use of tricyclic AD and venlafaxine still has a considerable prevalence in bipolar depression, but this is controversial due to the reported risk of treatment emergent affective switches. Triple and quadruple therapy is not evidence-based but increasingly used in clinical practice. This may reflect an attempt to overcome treatment failure, and further studies should evaluate efficacy and safety of this common practice.

Modulation of ion channels in clinical psychopharmacology: adults and younger people

This review focuses on the use of Na(+), Ca(2+) and Cl(-) channel modulators in psychiatric disease. Drugs that modulate ion channels have been used in psychiatry for more than a century, and in this review we critically evaluate clinical research that reports the therapeutic effects of drugs acting on GABA(A), voltage-gated Na(+) and voltage-gated Ca(2+) channels in pediatric and adult patients. As in other fields, the evidence underpinning the use of medicines in younger people is far less robust than for adults. In addition, we discuss some current developments and highlight clinical disorders in which current molecules could be further tested. Notable success stories, such as benzodiazepines (in sleep and anxiety disorders) and antiepileptics (in bipolar disorder), have been the result of serendipitous discoveries or refinements of serendipitous discoveries, as in all other major treatments in psychiatry. Genomic, high-throughput screening and molecular pharmacology discoveries may, however, guide further developments in the future. This could include increased research in promising targets that have been perceived as commercially risky, such as selective α-subunit GABA(A) receptors.

Review of pharmacological treatment in mood disorders and future directions for drug development

After a series of serendipitous discoveries of pharmacological treatments for mania and depression several decades ago, relatively little progress has been made for novel hypothesis-driven drug development in mood disorders. Multifactorial etiologies of, and lack of a full understanding of, the core neurobiology of these conditions clearly have contributed to these development challenges. There are, however, relatively novel targets that have raised opportunities for progress in the field, such as glutamate and cholinergic receptor modulators, circadian regulators, and enzyme inhibitors, for alternative treatment. This review will discuss these promising new treatments in mood disorders, the underlying mechanisms of action, and critical issues of their clinical application. For these new treatments to be successful in clinical practice, it is also important to design innovative clinical trials that identify the specific actions of new drugs, and, ideally, to develop biomarkers for monitoring individualized treatment response. It is predicted that future drug development will identify new agents targeting the molecular mechanisms involved in the pathophysiology of mood disorders.

Bipolar depression: an evidence-based approach

Bipolar disorder is a complex, multidimensional illness that is often difficult to treat. Unfortunately, bipolar patients are much more likely to experience depression, which is all too often severe and a potentially lethal phase of the illness. In addition, pharmacotherapies with strong evidence for bipolar depression are limited. Most treatments are based on unsupported extrapolation from the treatment of unipolar depression or are derived largely from the clinical practice experience. In this article, we focus on the treatment of bipolar depression, with particular focus on evidence from the existing literature, to help guide readers in clinical practice.

Genetic approaches to a better understanding of bipolar disorder

Bipolar disorder is a disease which causes major disability. The disease has both a manic and depressive component. Current standard of care consists of atypical antipsychotics for the treatment of mania, antidepressants for the treatment of depression, and mood stabilizers for the maintenance of euthymia. The molecular mechanisms which cause the disease are not well understood. Genome wide association studies have provided a set of genes which are linked to the disease. These genes show linkage to physiological and neuroanatomical alterations which are also seen in bipolar disorder.

Lamotrigine: when and where does it act in affective disorders? A systematic review

Recent published data and treatment guidelines have created uncertainty about the use of lamotrigine in affective disorders, especially in acute bipolar depression. Furthermore, unpublished data on lamotrigine in mania, mixed episodes, unipolar depression and rapid cycling are still waiting to be integrated into the literature. Therefore, we critically reviewed the position of lamotrigine in the acute and long-term treatment of affective disorders. Studies were identified by searching English language articles published in MEDLINE using the key words: lamotrigine, bipolar depression, unipolar depression, mania, mixed episode, long-term treatment, rapid-cycling. Results of unpublished trials were obtained from the GlaxoSmithKline website. Lamotrigine showed efficacy in the prophylaxis of bipolar disorder, more so in depressive than manic episodes. There was no evidence of effectiveness in the acute treatment of mania, mixed episodes, unipolar depression or rapid-cycling bipolar I disorder. Its effect in the acute treatment of bipolar depression is at most small. Based on current evidence, lamotrigine is indicated for the prophylaxis of bipolar disorder with predominantly depressive episodes. Its effectiveness in the acute treatment of bipolar depression is open to debate, and practical considerations limit its usefulness here. There are no grounds for recommending its use in manic or mixed states, in rapidly-cycling bipolar I or in unipolar depression.

Bipolar depression: clinically missed, pharmacologically mismanaged

Bipolar affective disorders are common and frequently debilitating mental illnesses. Diagnostic criteria mean they are defined by the presence of pathological mood elevation, but research shows greater disease burden is inflicted by depressive phases (bipolar depression) both in terms of duration and impact of symptoms. Despite this there is consistent evidence for the underdiagnosis of bipolar depression and its misdiagnosis as a unipolar disorder, with significant subsequent impact on medication management. There is currently less robust evidence for the appropriate pharmacological approach in such individuals than in unipolar depression, and fewer guidelines for clinicians. Despite this there is clear and growing evidence that 'treatment as usual' of depressive symptomatology is ineffective at best, harmful at worst, and that there is little role for the use of antidepressants. Both mood stabilizers and antipsychotics demonstrate efficacy, and whilst there are emerging data on intraclass differences, more research is needed, particularly concerning bipolar II disorder. Present treatment strategies are limited by insufficient large randomized control trials, an inadequate understanding of the neuropathology of bipolar illnesses and a lack of tailored medications. Better clinical training, understanding and recognition of this common condition are essential.

Aripiprazole monotherapy in the treatment of bipolar disorder: a meta-analysis

INTRODUCTION

Aripiprazole is approved for the acute and maintenance treatment of manic and mixed episodes associated with bipolar I disorder. The aim of the present work was to review and meta-analyze the findings of all the available randomized double-blind controlled trials (RCTs) on the efficacy of aripiprazole in the treatment of bipolar disorder.

MATERIAL AND METHODS

Aripiprazole RCTs were identified with a systematic search of MEDLINE and repositories. Standard meta-analytic techniques were applied.

RESULTS

Two thousand three hundred and three patients took part in the aripiprazole acute mania RCTs. At week 3 the pooled aripiprazole vs. placebo effect size was 0.34 and the NNT was 6 for response and 14 for remission. On average, response started at day 3. Suicide rates were negligible for all groups in mania but they were not reported in the acute depression trials. The meta-analysis of acute bipolar depression RCTs revealed a significant difference at week 8 with a weak effect size equal to 0.17. The analysis of maintenance data suggest that the median survival time for the aripiprazole group was not evaluable (very long), while the median survival time for placebo was 118-203 days depending on the clinical subpopulation.

DISCUSSION

The current meta-analysis supports the usefulness of aripiprazole during all phases of bipolar illness. Its effect against acute bipolar depression is weak and the efficacy during the maintenance phase is proven only against new manic episodes in patients with an index manic episode who had previously responded to aripiprazole during the acute phase.

A case series of lamotrigine increased to 300mg daily in patients with bipolar depression

Bipolar depression is a condition lacking sufficient treatment options. While lamotrigine appears effective, clinical trials and prescribing guidelines address only daily doses below 300mg.

METHODOLOGY

Thirteen consecutive outpatients with bipolar depression and taking 200mg of daily lamotrigine were openly administered a dose increased to 300mg and naturalistically followed. Study outcome was assessed by comparison of pre- and post-treatment Beck Depression Inventory (BDI) and Global Assessment of Functioning (GAF) scores. Stastical analysis applied the paired t-test.

RESULTS

Increasing daily lamotrigine dose to 300mg was associated with good tolerability and significant improvement in BDI and GAF scores.

Current and emerging therapies for the management of bipolar disorders

Bipolar disorder is a complex condition to treat because agents that may be effective for a specific phase may not be effective for other phases, or may even worsen the overall course of the illness. Over the last decade there has been an increase in research activity in the treatment of bipolar illness. There are now several agents that are well established for the treatment of acute mania (lithium, divalproex, carbamazepine, nearly all antipsychotics), acute bipolar depression (lamotrigine, quetiapine, olanzapine/fluoxetine combination), and relapse prevention (lithium, lamotrigine, divalproex, most second generation antipsychotics). There are also novel treatments that are being studied for all three phases. These include eslicarbazepine, cariprazine, MEM-1003, memantine, tamoxifen and pentazocine for acute mania; pramipexole, modafinil, armodafinil, divalproex, lurasidone, agomelatine, cariprazine, lisedexamfetamine, riluzole, RG-2417, bifeprunox, ropinirole, GSK1014802, and magnetic stimulation for bipolar depression; and asenapine, lurasidone, and cariprazine for relapse prevention. Additionally, there are accumulating data that antidepressants, particularly serotoninergic ones, are not particularly effective in acute bipolar depression and may worsen the course of the illness.

Fronto-limbic dysfunction in mania pre-treatment and persistent amygdala over-activity post-treatment in pediatric bipolar disorder

RATIONALE

Neural deficits at the interface of affect and cognition may improve with pharmacotherapy in pediatric bipolar disorder (PBD).

OBJECTIVES

We examined lamotrigine treatment impact on the neural interface of working memory and affect in PBD.

METHODS

Un-medicated, acutely ill, patients with mania and hypomania (n = 17), and healthy controls (HC; n = 13; mean age = 13.36 ± 2.55) performed an affective two-back functional magnetic resonance imaging task with blocks of angry vs neutral faces (i.e., angry face condition) or happy vs neutral faces (i.e., happy face condition) before treatment and at follow-up, after 8-week treatment with second-generation antipsychotics followed by 6 weeks of lamotrigine monotherapy.

RESULTS

At baseline, for the angry face condition, PBD, relative to HC, showed reduced activation in the left ventrolateral prefrontal cortex (VLPFC) and right caudate; for the happy face condition, PBD showed increased activation in bilateral PFC and right amygdala and middle temporal gyrus. Post-treatment, PBD showed greater activation in right amygdala relative to HC for both conditions. Patients, relative to HC, exhibited greater changes over time in the right VLPFC and amygdala, left subgenual anterior cingulate cortex and left caudate for the angry face condition, and in right middle temporal gyrus for the happy face condition.

CONCLUSIONS

Pharmacotherapy resulted in symptom improvement and normalization of higher cortical emotional and cognitive regions in patients relative to HC, suggesting that the VLPFC dysfunction may be state-specific in PBD. Amygdala was overactive in PBD, relative to HC, regardless of reduction in manic symptoms, and may be a trait marker of PBD.

State of the art: treatment of bipolar disorders

Bipolar disorders are lifelong lasting affective disorders, with an episodic course of the illness in most cases. The lifetime prevalence is around 2-5%, the illness usually appears in early adulthood and causes significant impairment in psychosocial functioning. This is a selective review focusing on recent developments and issues of interest in the psychopharmacological treatment of bipolar disorders. It is based primarily on the results of adequately powered, randomised, controlled trials (RCTs). These studies were systematically retrieved by means of a Medline search. The past 10 years have led to a broadening of the psychopharmacological treatment options for bipolar disorders. The proof of efficacy for the combination of fluoxetine/olanzapine as well as quetiapine in the acute treatment of bipolar I depression were important steps. While lithium remains the gold standard in the maintenance treatment of bipolar disorders, valproate, olanzapine, lamotrigine, aripiprazole, and quetiapine have been shown efficacious for this indication, with quetiapine possessing the broadest approval status of all drugs for the different treatment phases of this illness. Despite this progress there remains a huge demand regarding new compounds for nearly every area in the psychopharmacological treatment of bipolar disorders. In addition new methodological approaches regarding the proof of effectiveness in clinical practice are urgently needed.

Topiramate augmentation in patients with resistant major depressive disorder: a double-blind placebo-controlled clinical trial

BACKGROUND

Despite evolution of new antidepressant treatment, clinicians still encounter challenges in the treatment of depressed patients. Looking for new medications that can potentiate the effects of current antidepressants seems to be necessary. Our objective is to survey the efficacy of topiramate augmentation in resistant major depressive disorder (MDD).

METHOD

This augmentation trial was designed as an 8-week randomized, placebo-controlled, double-blind study. Fifty three patients with DSM-IV diagnosis of MDD who had failed to respond to at least 8 weeks of treatment with an adequate dose of one of the SSRIs (fluoxetine, citalopram or serteraline) were included in the study. Patients were randomized to receive a flexible dose of topiramate (100-200 mg/day) or placebo beside their current antidepressant medication for a period of eight weeks. Outcome measures were Hamilton Depression Scale (HAM-D) and Clinical Global Impression (CGI).

RESULTS

42 patients completed the study and there were 6 and 5 dropouts in topiramate and placebo groups, respectively. The topiramate group demonstrated significant improvement over the study period based on mean HAM-D score at week 8 compared to baseline (P = .000, Z = 3.699). Those receiving topiramate demonstrated to have a mean decrease of 32.0% in HAM-D score, compared to only 5.5% for those receiving placebo. Depressed mood, suicidality, insomnia (early, middle and late), agitation and anxiety symptoms were significantly improved in the topiramate group.

CONCLUSION

Our double-blind placebo-controlled study demonstrated that topiramate augmentation potentiate the efficacy of selective serotonin reuptake inhibitors (SSRIs) in treatment of resistant major depressive disorder. Of note is that our study is preliminary and larger double-blind studies are needed to confirm the results.

Treating bipolar depression - antidepressants and alternatives: a critical review of the literature

OBJECTIVE

Although depressive symptoms are preponderant in the course of bipolar (BP) disorders, the treatment of BP depression remains a controversial issue with different clinical approaches available. This review addresses the issues of whether antidepressants (ADs) are effective in treating acute and long-term BP depression, risks linked to ADs and what alternatives to ADs are available.

METHODS

We searched the MEDLINE databases using the following syntax: [bipolar depression AND unipolar depression AND (antidepressants OR anticonvulsants OR lithium OR antipsychotics OR dopamine-agonists OR psychoeducation OR psychotherapy OR electroconvulsive therapy OR transcranial magnetic stimulation)]. The search included studies published up to 31 May 2009 and conducted on adults.

RESULTS

In the acute treatment of BP depression ADs are effective with no differences among drug classes. However, neither the switch into (hypo)mania induction rate nor the suicide risk linked to AD use are definitely established. The effectiveness of long-term AD use is limited to highly selected samples of patients with positive acute response. The risk of long-term ADs causing cycle acceleration and rapid cycling induction concerns a subpopulation of patients. Valid alternatives to ADs in treating acute BP depression are quetiapine, an olanzapine-fluoxetine combination, and electroconvulsive therapy for more severe patients. Lamotrigine is effective and safe in preventing depressive relapses. Psychotherapy and psychoeducation represent effective adjunctive treatments.

CONCLUSION

In the treatment of BP depression there is not a specific effective treatment for all the patients. Interventions should therefore be personalised and the scientific evidence should be adapted to each patient's clinical features.

Multisite, open-label, prospective trial of lamotrigine for geriatric bipolar depression: a preliminary report

AIMS

This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression.

METHODS

Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects.

RESULTS

A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed.

CONCLUSIONS

In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

Clozapine-related EEG changes and seizures: dose and plasma-level relationships

Clozapine is a widely used atypical antipsychotic with a unique effectiveness in treatment-resistant schizophrenia. An important adverse effect is seizures, which have been observed at all stages of clozapine treatment. Valproate has traditionally been considered the drug of choice for the prophylaxis of clozapine seizures, however it may not be the most suitable choice for all patients. There is disagreement as to the best point to prescribe valproate or a suitable antiepileptic: as seizure prophylaxis at a certain clozapine dose or level, or only as remedial treatment. In this review, we examine the relevant literature with an aim to evaluate the following relationships: clozapine dose and electroencephalogram (EEG) abnormalities, plasma levels and EEG abnormalities, dose and occurrence of seizures and plasma levels and occurrence of seizures. Weighted linear regression models were fitted to investigate these relationships. There was a strong relationship between clozapine dose and plasma level and occurrence of clozapine-induced EEG abnormalities. However, a statistically significant relationship between dose and occurrence of seizures was not found. A relationship between clozapine plasma level and occurrence of seizures was not established because of the scarcity of useful data although our review found three case reports which suggested that there is a very substantial risk of seizures with clozapine plasma levels exceeding 1300 μg/l. Seizures are more common during the initiation phase of clozapine treatment, suggesting a slow titration to target plasma levels is desirable. An antiepileptic drug should be considered when the clozapine plasma level exceeds 500 μg/l, if the EEG shows clear epileptiform discharges, if seizures, myoclonic jerks or speech difficulties occur and when there is concurrent use of epileptogenic medication. The antiepileptics of choice for the treatment and prophylaxis of clozapine-induced seizures are valproate (particularly where there is mood disturbance) and lamotrigine (where there is resistance to clozapine).

Meta-analysis: fact or fiction? How to interpret meta-analyses

OBJECTIVES

Widespread use of increasingly complex statistical methods makes it ever more challenging to adequately assess the results reported and conclusions drawn in meta-analytic research. This paper aims to identify potential fallacies by in-depth examination of recent publications on mood disorders.

METHODS

Three meta-analyses were selected based on availability of data and representativeness of methods employed. By means of detailed re-analysis, several widespread methodological problems were identified, and the example data were used to illustrate and discuss them.

RESULTS

General points addressed include clear formulation of the research question, choice of effect size measures, and general choice of model. Data quality problems like missing data and publication bias are discussed along with methods to deal with them. Furthermore, aspects of meta-analytic modelling like the use of fixed or random effects, data aggregation, as well as the use of subgroups are explained, and issues of excessive complexity and data dredging pointed out. Finally, the benefit of diagnostic tools like confidence bands and the importance of transparency regarding data and methodology for the interpretation of meta-analytic results are highlighted.

CONCLUSIONS

Practically relevant quality criteria for readers to bear in mind when dealing with meta-analytic publications are summarized in a ten point checklist.

Proof of concept trials in bipolar disorder and major depressive disorder: a translational perspective in the search for improved treatments

A better understanding of the neurobiology of mood disorders, informed by preclinical research and bi-directionally translated to clinical research, is critical for the future development of new and effective treatments. Recently, diverse new targets/compounds have been specifically tested in preclinical models and in proof-of-concept studies, with potential relevance as treatments for mood disorders. Most of the evidence comes from case reports, case series, or controlled proof-of-concept studies, some with small sample sizes. These include (1) the opioid neuropeptide system, (2) the purinergic system, (3) the glutamatergic system, (4) the tachykinin neuropeptide system, (5) the cholinergic system (muscarinic system), and (6) intracellular signaling pathways. These targets may be of substantial interest in defining future directions in drug development, as well as in developing the next generation of therapeutic agents for the treatment of mood disorders. Overall, further study of these and similar drugs may lead to a better understanding of relevant and clinically useful drug targets in the treatment of these devastating illnesses.

Pharmacotherapy for the treatment of acute bipolar II depression: current evidence

OBJECTIVE

Bipolar II disorder is a common, recurrent, and disabling psychiatric illness, and yet little is known about how best to treat it. The pressing clinical need for evidence-based approaches to the treatment of bipolar II disorder, coupled with recent publication of pertinent studies, calls for an updated review of this literature. This review focuses on a critical examination of the evidence supporting the efficacy of treatments for acute depressive episodes in bipolar II disorder.

DATA SOURCES

A MEDLINE (via Ovid) search of journals, covering the period from January 1950 to January 2009, was performed to identify relevant studies. Keywords used were bipolar II disorder, bipolar disorder, bipolar depression, and pharmacotherapy. Studies were further limited to those that were in adult samples, published in peer-reviewed journals, and written in English.

STUDY SELECTION

We examined all randomized trials evaluating the use of pharmacotherapy in the treatment of acute bipolar II depression. Studies with mixed samples of bipolar I and II or bipolar II and unipolar depression were examined as well. Twenty-one randomized trials were identified and reviewed.

DATA EXTRACTION

Therapeutic agents were rated according to the quality of evidence supporting their efficacy as treatments for bipolar II depression.

DATA SYNTHESIS

Ninety percent of relevant trials were published after 2005. Quetiapine was judged as having compelling evidence supporting its efficacy. Lithium, antidepressants, and pramipexole were judged as having preliminary support for efficacy. Lamotrigine was considered to have mixed support.

CONCLUSIONS

Although progress has been made, further research on bipolar II depression is warranted.