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Gao K, Arnold JG, Prihoda TJ, Quinones M, Singh V, Schinagle M, Conroy C, D'Arcangelo N, Bai Y, Calabrese JR, Bowden CL. Sequential Multiple Assignment Randomized Treatment (SMART) for Bipolar Disorder at Any Phase of Illness and at least Mild Symptom Severity. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:8-25. [PMID: 32508363 PMCID: PMC7255841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To sequentially study the effectiveness of lithium and divalproex monotherapy and adjunctive therapy with quetiapine or lamotrigine in the acute and continuation treatment of bipolar I or II disorder at any phase of illness and at least mild symptom severity. METHODS From June 2011 to December 2016, patients with bipolar I or II disorder (using DSM-IV diagnostic criteria) and CGI-S (Clinical Global Impression-Severity) ⩾ 3 were randomized to receive lithium or divalproex monotherapy for 2 weeks. Patients who had CGI-S-depression ⩾ 3 for 2 weeks at any time after 2-week monotherapy were randomly assigned to receive quetiapine or lamotrigine, or remaining on monotherapy for a total of 26 weeks. RESULTS The rates of early termination due to lack of efficacy and side effects and changes in BISS (Bipolar Inventory of Symptoms Scale) and CGI-S total score were not significantly different between lithium and divalproex. The completion rate was significantly higher with adjunctive therapy than with monotherapy. BISS and CGI-S total scores, and their sub-scores were significantly reduced with adjunctive therapy compared to monotherapy. Adjunctive therapy significantly increased survival times compared to monotherapy (hazard ratio = 6.8), and the monotherapy group had a significantly increased risk for not reaching sustained recovery from depression (hazard ratio = 12.7). Patients who did not need the 2nd randomization and remained on monotherapy had a significantly reduced hazard for discontinuation (hazard ratio = 3.8). CONCLUSIONS The efficacy of lithium and divalproex as monotherapy was modest. Adjunctive lamotrigine and quetiapine to either one was well-tolerated and equally effective in reducing bipolar symptomatology, but adjunctive therapy should be initiated as early as possible when depression symptoms are present.
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Affiliation(s)
- Keming Gao
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Jodi G Arnold
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Thomas J Prihoda
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Marlon Quinones
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Vivek Singh
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Martha Schinagle
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Carla Conroy
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Nicole D'Arcangelo
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Yuanhan Bai
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Joseph R Calabrese
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
| | - Charles L Bowden
- Gao, MD, PhD, Schinagle, MD, Calabrese, MD, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Case Western Reserve University School of Medicine, Cleveland, Ohio. Arnold, PhD, Bowden, MD, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Prihoda, PhD, Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Quinones, MD, IKARE Mood, Trauma, and Recovery Clinic, San Antonio, Texas. Singh, MD, Department of Psychiatry, Texas Tech University Health Sciences Center at El Paso, El Paso, Texas. Conroy, MPH, D'Arcangelo, MSW, Case Western Reserve University School of Medicine. Cleveland, Ohio. Bai, MD, MS, Mood and Anxiety Clinic in the Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Shenzhen Kangning Hospital, Shenzhen, Guandong Province, China
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Aftab A, Kemp DE, Ganocy SJ, Schinagle M, Conroy C, Brownrigg B, D'Arcangelo N, Goto T, Woods N, Serrano MB, Han H, Calabrese JR, Gao K. Double-blind, placebo-controlled trial of pioglitazone for bipolar depression. J Affect Disord 2019; 245:957-964. [PMID: 30699881 DOI: 10.1016/j.jad.2018.11.090] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/07/2018] [Accepted: 11/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Objective of the present study was to conduct an 8-week double-blind, randomized, placebo-controlled trial to test the efficacy of pioglitazone in the treatment of bipolar depression. METHODS 38 outpatients with bipolar disorder and current major depressive episode were randomized to pioglitazone (15-45 mg/day) or placebo. The use of concomitant mood stabilizers, antipsychotics, and antidepressants was permitted. The primary outcome measure was the 30-item Inventory of Depressive Symptomatology, Clinician Rated (IDS-C30) total score change from baseline to endpoint. Laboratory evaluations, including serum level of inflammatory and metabolic biomarkers, were conducted. RESULTS 37 subjects were analyzed for efficacy (1 subject had no follow-up data). Mean reduction from baseline to week 8 in IDS-C30 score was-6.59 for pioglitazone and -11.63 for placebo. Mixed effects modeling indicated borderline statistically significant difference between the two groups (p = 0.056) in favor of placebo. On analysis of inflammatory and metabolic markers, a statistically significant negative correlation was noted between change in leptin levels and change in depression scores in the pioglitazone group (r = -0.61, p = 0.047) but not in the placebo group, the significance of which is unclear as the study failed to demonstrate antidepressant efficacy of pioglitazone over placebo. No serious adverse effects were reported, and pioglitazone was well-tolerated. LIMITATIONS small sample size with inadequate power, concomitant use of other psychotropic medications, and lack of statistical adjustment for multiple testing. CONCLUSION Current study does not support the antidepressant efficacy of pioglitazone in the treatment of bipolar depression. (240 words).
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Affiliation(s)
- Awais Aftab
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, MC0664, La Jolla, CA, 92093, United States.
| | - David E Kemp
- Advocate Health Care, 4440W 95th Street, Oak Lawn, IL 60453, United States.
| | - Stephen J Ganocy
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Martha Schinagle
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Carla Conroy
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Brittany Brownrigg
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Nicole D'Arcangelo
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States. Nicole.D'
| | - Toyomi Goto
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Nicole Woods
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Mary Beth Serrano
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Huiqin Han
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Joseph R Calabrese
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
| | - Keming Gao
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, 10524 Euclid Avenue, 12th Floor, Cleveland, OH, 44106, United States.
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