A systematic review of the efficacy and safety of second generation antipsychotics in the treatment of mania

Intracellular pathways of antipsychotic combined therapies: implication for psychiatric disorders treatment

Dysfunctions in the interplay among multiple neurotransmitter systems have been implicated in the wide range of behavioral, emotional and cognitive symptoms displayed by major psychiatric disorders, such as schizophrenia, bipolar disorder or major depression. The complex clinical presentation of these pathologies often needs the use of multiple pharmacological treatments, in particular (1) when monotherapy provides insufficient improvement of the core symptoms; (2) when there are concurrent additional symptoms requiring more than one class of medication and (3) in order to improve tolerability, by using two compounds below their individual dose thresholds to limit side effects. To date, the choice of drug combinations is based on empirical paradigm guided by clinical response. Nonetheless, several preclinical studies have demonstrated that drugs commonly used to treat psychiatric disorders may impact common intracellular target molecules (e.g. Akt/GSK-3 pathway, MAP kinases pathway, postsynaptic density proteins). These findings support the hypothesis that convergence at crucial steps of transductional pathways could be responsible for synergistic effects obtained in clinical practice by the co-administration of those apparently heterogeneous pharmacological compounds. Here we review the most recent evidence on the molecular crossroads in antipsychotic combined therapies with antidepressants, mood stabilizers, and benzodiazepines, as well as with antipsychotics. We first discuss clinical clues and efficacy of such combinations. Then we focus on the pharmacodynamics and on the intracellular pathways underpinning the synergistic, or concurrent, effects of each therapeutic add-on strategy, as well as we also critically appraise how pharmacological research may provide new insights on the putative molecular mechanisms underlying major psychiatric disorders.

Mania and attention-deficit/hyperactivity disorder: common symptomatology, common pathophysiology and common treatment?

PURPOSE OF REVIEW

Attention-deficit/hyperactivity disorder (ADHD) and mania show broad symptom overlap, and high comorbidity exists between ADHD and bipolar disorder. This raises the question concerning common neurobiological pathomechanisms and concerning common treatments.

RECENT FINDINGS

On genetic, biochemical, electrophysiological, brain morphological and neuropsychological levels, the commonalities of ADHD and mania and the commonalities between ADHD and bipolar disorder (independent of manic state) are outlined. An intriguing finding is that both ADHD and mania are characterized by an unstable wakefulness regulation assessed by EEG measures of vigilance, by ratings of sleepiness and by deficits in sustained attention tasks. In both mania and ADHD, this unstable wakefulness regulation is supposed to be a central pathogenetic factor leading to attention deficits and inducing the hyperactive, impulsive and sensation-seeking behavior as an autoregulatory attempt to stabilize wakefulness by increasing external stimulation. Evidence is accumulating to suggest that psychostimulants do not have a high risk of triggering or aggravating mania, but might even be a treatment option in acute mania.

SUMMARY

ADHD and mania share many symptoms and several pathogenetic aspects. The common belief that stimulants are contraindicated in mania has been challenged, and controlled trials to study the possible antimanic effects of vigilance-stabilizing drugs such as stimulants are justified and necessary.

Longer-term treatment of patients with bipolar disorder: a 9-month observational study in Central and Eastern Europe, the Middle East and Africa

OBJECTIVE

To compare the longer-term outcomes of pharmacological treatment of patients with a diagnosis of bipolar affective disorder currently suffering a manic or hypomanic episode prescribed olanzapine or non-olanzapine medication in naturalistic, clinical practice settings in Bosnia-Herzegovina, Slovakia, Slovenia, Turkey, Saudi Arabia and Egypt.

RESEARCH DESIGN AND METHODS

Prospective, observational, non-interventional study conducted over 9 months. Inpatients or outpatients who initiated or changed oral bipolar mania medication were grouped into (1) those prescribed olanzapine at baseline (n = 569) and (2) those not prescribed olanzapine (n = 325).

MAIN OUTCOME MEASURE(S)

The change from baseline in the Clinical Global Impression Severity scale for bipolar disorder (CGI-BP-S), the rates of symptomatic response and remission (based on CGI-BP-S) and the frequency and nature of treatment-emergent adverse events. Analyses included (1) linear or logistic regression, with adjustment for confounders, based on the last observation carried forward and (2) weighted repeated measures models that adjusted for treatment switching and patient drop-out.

RESULTS

When results were adjusted for treatment switching and patient drop-out, patients prescribed olanzapine had significantly better CGI-BP-S scores (mean difference = -0.24; 95% confidence interval [CI] -0.33, -0.16; p < 0.001) and significantly greater odds of treatment response (odds ratio [OR] = 1.86; 95% CI 1.31, 2.65; p < 0.001) and symptom remission (OR = 1.65; 95% CI 1.18-2.32; p = 0.003) than those not prescribed olanzapine. The frequency of most adverse events decreased in both groups. Patients prescribed olanzapine had significantly greater weight gain from baseline (mean increase = 2.66 kg; 95% CI 2.35, 2.98) compared with those not prescribed olanzapine (mean increase = 1.85 kg; 95% CI 1.51, 2.19; p < 0.001).

CONCLUSIONS

Inclusion of olanzapine is of benefit for pharmacological treatment of patients with bipolar disorder. However, the favourable outcomes observed cannot be directly attributed to olanzapine alone because of the high prevalence of polypharmacy in the patient population.

Pharmacogenetics of risperidone response and induced side effects

Risperidone is an atypical antipsychotic that has been effectively used to treat several psychiatric diseases. Atypical antipsychotics present some advantages over conventional antipsychotics, primarily because they offer effective treatment alternatives that are relatively free of extrapyramidal symptoms. However, as with all antipsychotics, there are wide individual differences in response to risperidone, both regarding therapeutic effects and adverse effects, imposing some limitations with respect to the therapeutic use of the drug. Genetic factors are thought to play an important role in determining the variability to drug response. A growing number of studies are investigating how genetic polymorphisms of enzymes involved in drug metabolism or of receptors targeted by antipsychotic agents influence drug treatment of several neuropsychiatric diseases. In this article we will review the genetic variability in both the pharmacokinetics of risperidone action and in pharmacodynamic structures mediating risperidone effects, as well as the pharmacogenetic studies performed for these genes.

An analysis of safety and tolerability data from controlled, comparative studies of quetiapine in patients with schizophrenia, focusing on extrapyramidal symptoms

AIM

This analysis evaluated the tolerability profile of quetiapine using data from all comparative controlled studies in patients with schizophrenia or related disorders in the AstraZeneca clinical trials database, focusing on extrapyramidal symptoms (EPS).

METHODS

Adverse event (AE) data from randomised, double-blind, controlled studies in the AstraZeneca clinical trials database were pooled, allowing comparison of quetiapine (mean daily doses 357-496 mg/day) with placebo, haloperidol (10.4 mg/day), risperidone (5.5 mg/day) or chlorpromazine (552 mg/day). Incidence of EPS-related AEs in relation to quetiapine dose was also analysed using a subset of data from fixed-dose studies.

RESULTS

Data from 4956 patients were analysed. Quetiapine was well tolerated, and did not increase EPS-related AEs when compared with placebo (9.6 vs. 10.6%, respectively). The incidence of EPS-related AEs with quetiapine was consistent across the dose range (4.2-13.2% vs. 11.1% with placebo). Patients receiving haloperidol, risperidone and chlorpromazine experienced significantly higher levels of EPS-related AEs than those on quetiapine. The most common quetiapine- associated AEs, with significantly higher incidence than placebo, were sedation, somnolence and orthostatic hypotension.

CONCLUSION

Quetiapine is generally well tolerated in patients with schizophrenia or related disorders, with placebo-level EPS-related AEs. Quetiapine has a more favourable EPS profile than haloperidol, chlorpromazine or risperidone.

Atypical antipsychotics in the treatment of mood disorders

PURPOSE OF REVIEW

The aim of the present study is to evaluate the use and the usefulness of atypical antipsychotics in patients with affective symptomatology. Recent literature has been reviewed to show the potential use and usefulness of the atypical medications in patients suffering from depression or mania.

RECENT FINDINGS

The use of amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone in depression (both bipolar I and II) as well as in manic states has been evaluated. Preference was given to well designed randomized clinical trials. The effectiveness of the atypical antipsychotics in manic states has been shown. It is suggested that when an antipsychotic agent is needed, preference should be given to an atypical antipsychotic over the classic drug.

SUMMARY

The potential benefit from the use of atypical antipsychotics in both depression and mania seems to be clinically justified.