Treatment of acute mania with modafinil monotherapy

Mixed Amphetamine Salts Without a Mood Stabilizer for Treating Comorbid Attention-Deficit Hyperactivity Disorder and Bipolar Disorder: Two Case Reports

Attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) are often comorbid in patients and can have significant overlap in symptoms. Because of this common comorbidity and often overlapping symptoms, accurate diagnoses can be difficult. The standard treatment for these comorbid disorders is a mood stabilizer with the possibility of adding a psychostimulant. However, research suggesting treatment for comorbid disorders with a psychostimulant without a mood stabilizer is lacking. Here, we present two cases where mixed amphetamine salts, which are traditionally avoided in those with BD, were effectively used without a mood stabilizer to treat comorbid BD and ADHD in both patients. The outcome of this case series serves to motivate future investigations which are needed to validate treatment with a psychostimulant without a mood stabilizer for the treatment of comorbid BD and ADHD.

A multi-centre, randomised, double-blind, placebo-controlled clinical trial of methylphenidate in the initial treatment of acute mania (MEMAP study)

Based on many clinical and preclinical findings the 'vigilance regulation model of mania' postulates that an unstable regulation of wakefulness is a pathogenetic factor in both mania and Attention Deficit Hyperactivity Disorder (ADHD) and induces hyperactivity and sensation seeking as an autoregulatory attempt to stabilize wakefulness. Accordingly, stimulant medications with their vigilance stabilizing properties could have rapid antimanic effects similar to their beneficial effects in ADHD. The MEMAP study - a multi-center, double-blind, placebo-controlled and randomized clinical trial (RCT) - assessed the antimanic efficacy and safety of a 2.5-day treatment with methylphenidate (20-40mg/day). Of 157 screened patients with acute mania, 42 were randomly assigned to receive 20-40mg per day of methylphenidate in one or two applications, or placebo. The primary outcome was the change in Young Mania Rating Scale (YMRS) sum scores from baseline to day 2.5 in the methylphenidate group compared to the placebo group. A group sequential design was chosen to justify early RCT termination based on efficacy or futility at an interim analysis after inclusion of 40 patients. In the interim analysis, the change from baseline in the YMRS total score at day 2.5 was not significantly different between both groups (F(1,37)=0.23; p=0.64). Thus, futility was declared for methylphenidate and the RCT was stopped. In summary, although methylphenidate was well tolerated and safe in the full analysis set, it failed to show efficacy in the treatment of acute mania.

TRIAL REGISTRATION

clinicaltrials.gov (URL: http://www.clinicaltrials.gov; registration number: NCT01541605).

Use of Stimulants in Bipolar Disorder

Several international guidelines indicate stimulants, including methylphenidate (MPH), amphetamines and derivatives, modafinil, and armodafinil among the second-third-line choices for bipolar depression. Efficacy of stimulants has been also reported for the management of residual depressive symptoms such as fatigue and sleepiness and for the management of affective, cognitive, and behavioral symptoms in children and adult bipolar patients with comorbid ADHD. Few case reports show positive results with MPH in the treatment of resistant mania. Finally, MPH might be an option in some bipolar forms observed in psychiatric presentations of frontotemporal dementia and traumatic brain injury. In spite of these preliminary observations, the use of stimulants in bipolar patients is still controversial. Potential of misuse and abuse and mood destabilization with induction of (hypo)manic switches, mixed states, and rapid cycling are the concerns most frequently reported. Our aims are to summarize available literature on this topic and discuss practical management implications.

Assessment of Wakefulness and Brain Arousal Regulation in Psychiatric Research

During the last few decades, much knowledge has been gained about sleep being a heterogeneous condition with several distinct sleep stages that represent fundamentally different physiological states. The same applies for the wake state which also comprises distinct global functional states (called vigilance stages). However, various terms and concepts have been introduced describing different aspects of wakefulness, and accordingly several methods of assessment exist, e.g. sleep laboratory assessments (Multiple Sleep Latency Test, Maintenance of Wakefulness Test), questionnaires (Epworth Sleepiness Scale, Karolinska Sleepiness Scale), behavioural tasks (Psychomotor Vigilance Test) or electroencephalography (EEG)-based assessments (Alpha Attenuation Test, Karolinska Drowsiness Test). Furthermore, several theoretical concepts about the regulation of sleep and wakefulness have been put forward, and physiological correlates have been identified. Most relevant for healthy functioning is the regulation of brain arousal and the adaption of wakefulness to the environmental and situational needs so that the optimal balance between energy conservation and responsiveness can be obtained. Since one approach to the assessment of brain arousal regulation is the classification of EEG vigilance stages, a computer-based algorithm (Vigilance Algorithm Leipzig) has been introduced, allowing classification of EEG vigilance stages in EEG recordings under resting conditions. The time course of EEG vigilance stages in EEGs of 15-20 min duration allows estimation of the individual arousal regulation (hyperstable, adaptive, or unstable vigilance pattern). The vigilance model of affective disorders and attention-deficit/hyperactivity disorder links a disturbed arousal regulation to the pathogenesis of psychiatric disorders and accordingly helps to explain and possibly also predict treatment effects of pharmacological and non-pharmacological interventions for these conditions.

Personalized Medicine: Review and Perspectives of Promising Baseline EEG Biomarkers in Major Depressive Disorder and Attention Deficit Hyperactivity Disorder

Personalized medicine in psychiatry is in need of biomarkers that resemble central nervous system function at the level of neuronal activity. Electroencephalography (EEG) during sleep or resting-state conditions and event-related potentials (ERPs) have not only been used to discriminate patients from healthy subjects, but also for the prediction of treatment outcome in various psychiatric diseases, yielding information about tailored therapy approaches for an individual. This review focuses on baseline EEG markers for two psychiatric conditions, namely major depressive disorder and attention deficit hyperactivity disorder. It covers potential biomarkers from EEG sleep research and vigilance regulation, paroxysmal EEG patterns and epileptiform discharges, quantitative EEG features within the EEG main frequency bands, connectivity markers and ERP components that might help to identify favourable treatment outcome. Further, the various markers are discussed in the context of their potential clinical value and as research domain criteria, before giving an outline for future studies that are needed to pave the way to an electrophysiological biomarker-based personalized medicine.

Early report on brain arousal regulation in manic vs depressive episodes in bipolar disorder

OBJECTIVES

The arousal regulation model of affective disorders attributes an important role in the pathophysiology of affective disorders to dysregulation of brain arousal regulation. According to this model, sensation avoidance and withdrawal in depression and sensation seeking and hyperactivity in mania can be explained as auto-regulatory attempts to counteract a tonically high (depression) or unstable (mania) arousal. The aim of this study was to compare brain arousal regulation between manic and depressive bipolar patients and healthy controls. We hypothesized that currently depressed patients with bipolar disorder show hyperstable arousal regulation, while currently manic patients show unstable arousal regulation.

METHODS

Twenty-eight patients with bipolar disorder received a 15-min resting electroencephalogram (EEG) during a depressive episode and 19 patients received the same during a manic/hypomanic episode. Twenty-eight healthy control subjects were matched for age and sex. The Vigilance Algorithm Leipzig (VIGALL), which classifies 1-s EEG segments as one of seven EEG-vigilance substages, was used to measure brain arousal regulation.

RESULTS

Manic patients showed more unstable EEG-vigilance regulation as compared to the control sample (P = .004) and to patients with a depressive episode (P ≤ .001). Depressive patients had significantly higher mean vigilance levels (P = .045) than controls.

CONCLUSIONS

A clear difference was found in the regulation of brain arousal of manic patients vs depressive patients and controls. These data suggest that brain arousal might depend on the current mood state, which would support the arousal regulation model of affective disorders.

Stimulants for treating bipolar disorder: pro and con

The role of stimulants for treating severe depression remains controversial, especially when it comes to bipolar depression. Potential benefits have to be weighed against risks, including addictive potential and treatment-emergent mania. But not all stimulants are the same. Modafinil and its R-enantiomer armodafinil seem to have positive augmentation effects when coupled with standard treatment of bipolar depression, while also having a relative low risk of addiction and manic switches. A recent hypothesis derived from the observation of hypovigilance in manic patients postulates that modafinil may also have a beneficial effect in reducing manic behaviors. Further controlled studies are needed to clarify the benefits and risks of stimulants, both in bipolar depression and mania.

Hyperactivity and sensation seeking as autoregulatory attempts to stabilize brain arousal in ADHD and mania?

Hypoarousal as indicated by skin conductance and electroencephalography (EEG) has been discussed as a pathogenetic factor in attention-deficit/hyperactivity disorder (ADHD). The aim of this paper was to review these arousal-related pathogenetic concepts and to present the more recently proposed vigilance regulation model of affective disorders and ADHD. The latter builds on methodological advances in classifying short EEG segments into vigilance stages (Vigilance Algorithm Leipzig, VIGALL), indicating different states of global brain function ("brain arousal"). VIGALL allows the objective assessment of vigilance regulation under defined conditions, e.g. how fast vigilance declines to lower vigilance stages associated with drowsiness during 15-20-min EEG recordings under resting conditions with eyes closed. According to the vigilance regulation model, the hyperactivity and sensation seeking observed in overtired children, ADHD and mania may be interpreted as an autoregulatory attempt to create a stimulating environment in order to stabilize vigilance. The unstable regulation of vigilance observed in both mania and ADHD may thus explain the attention deficits, which become especially prominent in monotonous sustained attention tasks. Among the arguments supporting the vigilance regulation model are the facts that destabilizing vigilance (e.g., via sleep deprivation) can trigger or exacerbate symptoms of ADHD or mania, whereas stabilizing vigilance (e.g., via psychostimulants, reducing sleep deficits) alleviates these symptoms. The potential antimanic effects of methylphenidate are presently being studied in an international randomized controlled trial. We propose vigilance regulation as a converging biomarker, which could be useful for identifying treatment responders to psychostimulants and forming pathophysiologically more homogeneous ADHD subgroups for research purposes.

The hypocretin system and psychiatric disorders

The hypocretin system is constituted by a small group of hypothalamic neurons with widespread connections within the entire central nervous system producing two neuropeptides involved in several key physiological functions such as the regulation of sleep and wakefulness, motor control, autonomic functions, metabolism, feeding behavior, and reward. Narcolepsy with cataplexy is a neurological disorder regarded as a disease model for the selective hypocretin system damage, and also shares several psychopatological traits and comorbidities with psychiatric disorders. We reviewed the available literature on the involvement of the hypocretin system in psychiatric nosography. Different evidences such as cerebrospinal hypocretin-1 levels, genetic polymorphisms of the neuropeptides or their receptors, response to treatments, clinical, experimental and functional data directly or indirectly linked the hypocretin system to schizophrenia, mood, anxiety and eating disorders, as well as to addiction. Future genetic and pharmacological studies will disentangle the hypocretin system role in the field of psychiatry.

Personalized Medicine in ADHD and Depression: Use of Pharmaco-EEG

This chapter summarises recent developments on personalised medicine in psychiatry with a focus on ADHD and depression and their associated biomarkers and phenotypes. Several neurophysiological subtypes in ADHD and depression and their relation to treatment outcome are reviewed. The first important subgroup consists of the 'impaired vigilance' subgroup with often-reported excess frontal theta or alpha activity. This EEG subtype explains ADHD symptoms well based on the EEG Vigilance model, and these ADHD patients responds well to stimulant medication. In depression this subtype might be unresponsive to antidepressant treatments, and some studies suggest these depressive patients might respond better to stimulant medication. Further research should investigate whether sleep problems underlie this impaired vigilance subgroup, thereby perhaps providing a route to more specific treatments for this subgroup. Finally, a slow individual alpha peak frequency is an endophenotype associated with treatment resistance in ADHD and depression. Future studies should incorporate this endophenotype in clinical trials to investigate further the efficacy of new treatments in this substantial subgroup of patients.

Psychostimulants in moderate to severe affective disorder: a systematic review of randomized controlled trials

BACKGROUND

Despite antidepressant therapy of appropriate trial duration and dose optimization, 50-60% of depressed patients have an adequate treatment response, whereas only 35-40% achieve remission. Psychostimulants have been suggested as potential candidates to promote acceleration of response and to alleviate residual symptoms of depression.

AIMS

In this review results from randomized clinical trials (RCTs) exploring the efficacy of psychostimulants in the treatment of major depressive disorder (MDD) were analyzed to clarify the current empirically founded evidence for clinical approaches involving psychostimulants.

METHOD

Literature research via PubMed retrieved 846 articles. 18 RCTs reporting on the use of psychostimulants in the treatment of adult patient populations, suffering from moderate-severe depression and having no other concomitant medical illnesses, were included in this review. 14 articles provided results for unipolar depression, two for bipolar depression, whereas two articles presented mixed samples of unipolar and bipolar patients.

RESULTS

Five different psychostimulants were evaluated: modafinil, methylphenidate, dexamphetamine, methylamphetamine and pemoline. Two studies examining modafinil demonstrated significant ameliorating characteristics pertaining to symptoms of depression. No clear evidence for the effectiveness of traditional psychostimulants in the therapeutic management of MDD was found. In general the quality of included trials was poor since the majority was of short-term duration, comprising relatively small sample sizes and some, especially older studies, were methodologically flawed.

CONCLUSION

Clearly larger well designed placebo-controlled studies with longer follow-up accompanied by evaluations of tolerance/dependence are warranted before psychostimulants can be recommended in routine clinical practice for the treatment of MDD.

Diffusion imaging-based subdivision of the human hypothalamus: a magnetic resonance study with clinical implications

The hypothalamus and its subdivisions are involved in many neuropsychiatric conditions such as affective disorders, schizophrenia, or narcolepsy, but parcellations of hypothalamic subnuclei have hitherto been feasible only with histological techniques in postmortem brains. In an attempt to map subdivisions of the hypothalamus in vivo, we analyzed the directionality information from high-resolution diffusion-weighted magnetic resonance images of healthy volunteers. We acquired T1-weighted and diffusion-weighted scans in ten healthy subjects at 3 T. In the T1-weighted images, we manually delineated an individual mask of the hypothalamus in each subject and computed in the co-registered diffusion-weighted images the similarity of the principal diffusion direction for each pair of mask voxels. By clustering the similarity matrix into three regions with a k-means algorithm, we obtained an anatomically coherent arrangement of subdivisions across hemispheres and subjects. In each hypothalamus mask, we found an anterior region with dorsoventral principal diffusion direction, a posteromedial region with rostro-caudal direction, and a lateral region with mediolateral direction. A comparative analysis with microstructural hypothalamus parcellations from the literature reveals that each of these regions corresponds to a specific group of hypothalamic subnuclei as defined in postmortem brains. This is to our best knowledge the first in vivo study that attempts a delineation of hypothalamic subdivisions by clustering diffusion-weighted magnetic resonance imaging data. When applied in a larger sample of neuropsychiatric patients, a structural analysis of hypothalamic subnuclei should contribute to a better understanding of the pathogenesis of neuropsychiatric conditions such as affective disorders.

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate

BACKGROUND

Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the 'vigilance regulation model of mania' which postulates that vigilance is unstable in manic patients. Accordingly, vigilance-stabilising psychostimulants could be more useful than conventional treatment in acute mania. We present here the study protocol of a trial intended to study the efficacy and safety of methylphenidate in the initial treatment of acute mania.

METHODS/DESIGN

A multi-centre, randomised, double-blind, placebo-controlled clinical trial will be conducted in 88 bipolar inpatients with acute mania. Male and female patients older than 18 years will be randomised to treatment with either methylphenidate (20 to 40 mg/day) or placebo for 2.5 days, given once or twice daily. The main outcome measure is the reduction in the Young Mania Rating Scale (YMRS) after 2.5 days of treatment. Other outcome measures include the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) the Clinical Global Impression-Bipolar Scale (CGI-BP), the Screen for Cognitive Impairment in Psychiatry (SCIP), actigraphy and the EEG-'Vigilance Algorithm Leipzig' (VIGALL).

DISCUSSION

A positive study outcome of the proposed study could substantially impact our understanding of the etiopathogenesis of mania and open new treatment perspectives.

Use of adjunctive stimulants in adult bipolar depression

Bipolar depression represents a high priority research field, due to its pervasiveness, and high economic and personal (suicidality, impaired function, quality of life) costs, and the limited evidence base to inform therapeutics. Mood stabilizers and second-generation antipsychotics for bipolar depression are commonly only partially effective, and their side-effects may overlap with depressive symptoms such as hypersomnia, daytime drowsiness, fatigue, psychomotor retardation, and weight gain. Moreover, the use of antidepressants in bipolar depression is controversial due to concerns regarding the risks of inefficacy or switching to mood elevation. Stimulants and related compounds such as modafinil and armodafinil have on occasion been used as adjuncts in bipolar depressed patients with encouraging results, but their use is limited by the paucity of systematic evidence of efficacy and safety. The present review aims to provide an updated perspective on the use of stimulants and stimulant-like medications in adult bipolar depression, considering not only recent randomized controlled trials, but also open naturalistic studies, in order to clarify the strengths and limitations of using these agents.

Evidence-based treatment strategies for treatment-resistant bipolar depression: a systematic review

OBJECTIVES

Treatment resistance in bipolar depression is a common clinical problem that constitutes a major challenge for the treating clinician as there is a paucity of treatment options. The objective of this paper was to review the evidence for treatment options in treatment-resistant bipolar depression, as found in randomized controlled trials and with special attention to the definition and assessment of treatment resistance.

METHODS

A Medline search (from database inception to May 2012) was performed using the search terms treatment resistance or treatment refractory, and bipolar depression or bipolar disorder, supplemented with 43 separate searches using the various pharmacologic agents or technical interventions as search terms.

RESULTS

Only seven studies met our inclusion criteria. These studies examined the effects of ketamine (n = 1), (ar)modafinil (n = 2), pramipexole (n = 1), lamotrigine (n = 1), inositol (n = 1), risperidone (n = 1), and electroconvulsive therapy (ECT) (n = 2).

CONCLUSIONS

The available level I evidence for treatment strategies in resistant bipolar depression is extremely scarce, and although the response rates reported are reassuring, most of the strategies remain experimental. There is an urgent need for further study in homogeneous patient samples using a clear concept of treatment resistance.

The vigilance regulation model of affective disorders and ADHD

According to the recently proposed vigilance model of affective disorders (vigilance in the sense of "brain arousal"), manic behaviour is partly interpreted as an autoregulatory attempt to stabilise vigilance by creating a stimulating environment, and the sensation avoidance and withdrawal in Major Depressive Disorder (MDD) is seen as an autoregulatory reaction to tonically increased vigilance. Indeed, using a newly developed EEG-based algorithm, hyperstable vigilance was found in MDD, and the contrary, with rapid drops to sleep stages, in mania. Furthermore, destabilising vigilance (e.g. by sleep deprivation) triggers (hypo)mania and improves depression, whereas stabilising vigilance, e.g. by prolonged sleep, improves mania. ADHD and mania have common symptoms, and the unstable vigilance might be a common pathophysiology. There is even evidence that psychostimulants might ameliorate both ADHD and mania. Hyperactivity of the noradrenergic system could explain both the high vigilance level in MDD and, as recently argued, anhedonia and behavioural inhibition. Interestingly, antidepressants and electroconvulsions decrease the firing rate of neurons in the noradrenergic locus coeruleus, whereas many antimanic drugs have opposite effects.

Hyperstable regulation of vigilance in patients with major depressive disorder

OBJECTIVES

This study tested the hypothesis that patients with depression show less and later declines into lower EEG vigilance stages (different global functional brain states) under resting conditions than healthy controls, as proposed by the vigilance theory of affective disorders.

METHODS

Thirty patients with Major Depressive Disorder (19 female; mean age: 37.2 years, SD: 12.6) without psychotropic medication and 30 carefully age- and sex-matched controls (19 female; mean age: 37.3 years, SD: 12.8) without past or present mental disorders underwent a 15-min resting EEG. EEG-vigilance regulation was determined with a computer-based vigilance classification algorithm (VIGALL, Vigilance Algorithm Leipzig), allowing a classification of vigilance stages A (with substages A1, A2 and A3), B (with substages B1 and B2/3) and C.

RESULTS

Depressive patients spent significantly more time in the highest EEG vigilance substage A1, and less time in substages A2, A3 and B2/3 than controls. In depressive patients, a significantly longer latency until the occurrence of substages A2, A3 and B2/3 was observed. No significant group differences in the percentage of B1 segments or the latency until occurrence of B1 were found.

CONCLUSIONS

The results confirm the hypothesis that patients with depression show less (and later) declines into lower EEG vigilance stages under resting conditions than healthy controls, and support the vigilance theory of affective disorders linking a hyperstable vigilance regulation to depression.

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.

EEG vigilance regulation patterns and their discriminative power to separate patients with major depression from healthy controls

BACKGROUND/AIM

Recently, a framework has been presented that links vigilance regulation, i.e. tonic brain arousal, with clinical symptoms of affective disorders. Against this background, the aim of this study was to deepen the knowledge of vigilance regulation by (1) identifying different patterns of vigilance regulation at rest in healthy subjects (n = 141) and (2) comparing the frequency distribution of these patterns between unmedicated patients with major depression (MD; n = 30) and healthy controls (HCs; n = 30).

METHOD

Each 1-second segment of 15-min resting EEGs from 141 healthy subjects was classified as 1 of 7 different vigilance stages using the Vigilance Algorithm Leipzig. K-means clustering was used to distinguish different patterns of EEG vigilance regulation. The frequency distribution of these patterns was analyzed in independent data of 30 unmedicated MD patients and 30 matched HCs using a χ² test.

RESULTS

The 3-cluster solution with a stable, a slowly declining and an unstable vigilance regulation pattern yielded the highest mathematical quality and performed best for separation of MD patients and HCs (χ² = 13.34; p < 0.001). Patterns with stable vigilance regulation were found significantly more often in patients with MD than in HCs.

CONCLUSION

A stable vigilance regulation pattern, derived from a large sample of HCs, characterizes most patients with MD and separates them from matched HCs with a sensitivity between 67 and 73% and a specificity between 67 and 80%. The pattern of vigilance regulation might be a useful biomarker for delineating MD subgroups, e.g. for treatment prediction.

Potential novel therapeutics for bipolar disorders

Existing pharmacological treatments for bipolar disorder (BPD), a severe recurrent mood disorder, are in general insufficient for many patients. Despite adequate doses and treatment duration, many individuals with this disease continue to experience mood episode relapses, residual symptoms, and functional impairment. This chapter reviews a number of targets/compounds that could result in putative novel treatments for BPD, including the dynorphin opioid neuropeptide system, the glutamatergic system, the purinergic system, the cholinergic system (muscarinic and nicotinic systems), the oxidative stress system, and the melatonergic system. The arachidonic acid cascade and intracellular signaling cascades (including glycogen synthase kinase 3 and protein kinase C) are also reviewed, as are agents that affect multiple targets (e.g., modafinil, Uridine RG2417). Further study of these and similar agents may improve our understanding of relevant drug targets and their clinical utility as potential therapeutics for this devastating disorder.