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Deng F, Fan X, Liao J, Tang R, Sun X, Lin J, Zhang G, Pan J. The effect of neuroendocrine abnormalities on the risk of psychiatric readmission after hospitalization for bipolar disorder: A retrospective study. Prog Neuropsychopharmacol Biol Psychiatry 2024; 130:110922. [PMID: 38114056 DOI: 10.1016/j.pnpbp.2023.110922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND The correlation between the endocrine system and bipolar disorder(BD) has been well recognized, yet the influence of neuroendocrine hormones on readmission risk post-hospitalization for BD remains largely unexplored. This retrospective cohort study was to scrutinize the impact of neuroendocrine functionality on the readmission of patients with BD post-hospitalization for mental disorders. METHODS The dataset was derived from the electronic medical records of the First Affiliated Hospital of Jinan University in Guangzhou, China. Both univariate and multivariate logistic regression analysis were conducted on all patients hospitalized for BD, and from 1 January 2017 to October 2022. RESULTS Of the 1110 eligible patients, 83 and 141 patients experienced psychiatric readmissions within 90 and 180 days post-discharge, respectively. Multivariate analysis revealed that high serum TSH levels (aOR = 1.079; 95%CI = 1.003-1.160) and thyroid disease comorbidities (aOR = 2.899; 95%CI = 1.303-6.452) were independently correlated with the risk of 90-day readmission; while increased serum TSH levels (aOR = 1.179; 95%CI = 1.081-1.287) represented a risk factor for 180-day readmission. These results indicate that high serum TSH levels and thyroid disease comorbidities may contribute to an elevated readmission risk in patients with BD following hospitalization. CONCLUSION Routinely evaluating and intervening in thyroid function is crucial in the treatment of BD, as it may aid in preventing re-hospitalization.
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Affiliation(s)
- Fangyi Deng
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China; Department of Psychiatry, Liyuan Hospital, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei 430077, China
| | - Xiaoxuan Fan
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiwu Liao
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Rui Tang
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xizhe Sun
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jingjing Lin
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Guimei Zhang
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiyang Pan
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Newsome SD, Tian F, Shoemaker T, Fitzgerald KC, Cassard SD, Fiol J, Snoops S, Cooper DS, Mammen JSR, Bhargava P, Mowry EM, Calabresi PA. A Phase 1b, Open-Label Study to Evaluate the Safety and Tolerability of the Putative Remyelinating Agent, Liothyronine, in Individuals with MS. Neurotherapeutics 2023; 20:1263-1274. [PMID: 37460763 PMCID: PMC10480368 DOI: 10.1007/s13311-023-01402-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 09/07/2023] Open
Abstract
Thyroid hormones are essential during developmental myelination and may play a direct role in remyelination and repair in the adult central nervous system by promoting the differentiation of oligodendrocyte precursor cells into mature oligodendrocytes. Since tri-iodothyronine (T3) is believed to mediate the majority of important thyroid hormone actions, liothyronine (synthetic T3) has the potential to induce reparative mechanisms and limit neurodegeneration in multiple sclerosis (MS). We completed a phase 1b clinical trial to determine the safety and tolerability of ascending doses of liothyronine in individuals with relapsing and progressive MS. A total of 20 people with MS were enrolled in this single-center trial of oral liothyronine. Eighteen participants completed the 24-week study. Our study cohort included mostly women (11/20), majority relapsing MS (12/20), mean age of 46, and baseline median EDSS of 3.5. Liothyronine was tolerated well without treatment-related severe/serious adverse events or evidence of disease activation/clinical deterioration. The most common adverse events included gastrointestinal distress and abnormal thyroid function tests. No clinical thyrotoxicosis occurred. Importantly, we did not observe a negative impact on secondary clinical outcome measures. The CSF proteomic changes suggest a biological effect of T3 treatment within the CNS. We noted changes primarily in proteins associated with immune cell function and angiogenesis. Liothyronine appeared safe and was well tolerated in people with MS. A larger clinical trial will help assess whether liothyronine can promote oligodendrogenesis and enhance remyelination in vivo, limit axonal degeneration, or improve function.
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Affiliation(s)
- Scott D Newsome
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA.
| | - Fan Tian
- Department of Mathematics, Tufts University, Medford, USA
| | | | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Sandra D Cassard
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Julie Fiol
- National Multiple Sclerosis Society, New York, NY, USA
| | - Sarah Snoops
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer S R Mammen
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pavan Bhargava
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Baltimore, MD, USA
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Sałaciak K, Koszałka A, Lustyk K, Żmudzka E, Jagielska A, Pytka K. Memory impairments in rodent depression models: A link with depression theories. Prog Neuropsychopharmacol Biol Psychiatry 2023; 125:110774. [PMID: 37088171 DOI: 10.1016/j.pnpbp.2023.110774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 04/25/2023]
Abstract
More than 80% of depressed patients struggle with learning new tasks, remembering positive events, or concentrating on a single topic. These neurocognitive deficits accompanying depression may be linked to functional and structural changes in the prefrontal cortex and hippocampus. However, their mechanisms are not yet completely understood. We conducted a narrative review of articles regarding animal studies to assess the state of knowledge. First, we argue the contribution of changes in neurotransmitters and hormone levels in the pathomechanism of cognitive dysfunction in animal depression models. Then, we used numerous neuroinflammation studies to explore its possible implication in cognitive decline. Encouragingly, we also observed a positive correlation between increased oxidative stress and a depressive-like state with concomitant memory deficits. Finally, we discuss the undeniable role of neurotrophin deficits in developing cognitive decline in animal models of depression. This review reveals the complexity of depression-related memory impairments and highlights the potential clinical importance of gathered findings for developing more reliable animal models and designing novel antidepressants with procognitive properties.
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Affiliation(s)
- Kinga Sałaciak
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Krakow 30-688, Poland
| | - Aleksandra Koszałka
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Krakow 30-688, Poland
| | - Klaudia Lustyk
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Krakow 30-688, Poland
| | - Elżbieta Żmudzka
- Department of Social Pharmacy, Faculty of Pharmacy, Jagiellonian University Medical College Medyczna, 9 Street, Kraków 30-688, Poland
| | - Angelika Jagielska
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Krakow 30-688, Poland
| | - Karolina Pytka
- Department of Pharmacodynamics, Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9, Krakow 30-688, Poland.
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Redei EE, Udell ME, Solberg Woods LC, Chen H. The Wistar Kyoto Rat: A Model of Depression Traits. Curr Neuropharmacol 2023; 21:1884-1905. [PMID: 36453495 PMCID: PMC10514523 DOI: 10.2174/1570159x21666221129120902] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/19/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
There is an ongoing debate about the value of animal research in psychiatry with valid lines of reasoning stating the limits of individual animal models compared to human psychiatric illnesses. Human depression is not a homogenous disorder; therefore, one cannot expect a single animal model to reflect depression heterogeneity. This limited review presents arguments that the Wistar Kyoto (WKY) rats show intrinsic depression traits. The phenotypes of WKY do not completely mirror those of human depression but clearly indicate characteristics that are common with it. WKYs present despair- like behavior, passive coping with stress, comorbid anxiety, and enhanced drug use compared to other routinely used inbred or outbred strains of rats. The commonly used tests identifying these phenotypes reflect exploratory, escape-oriented, and withdrawal-like behaviors. The WKYs consistently choose withdrawal or avoidance in novel environments and freezing behaviors in response to a challenge in these tests. The physiological response to a stressful environment is exaggerated in WKYs. Selective breeding generated two WKY substrains that are nearly isogenic but show clear behavioral differences, including that of depression-like behavior. WKY and its substrains may share characteristics of subgroups of depressed individuals with social withdrawal, low energy, weight loss, sleep disturbances, and specific cognitive dysfunction. The genomes of the WKY and WKY substrains contain variations that impact the function of many genes identified in recent human genetic studies of depression. Thus, these strains of rats share characteristics of human depression at both phenotypic and genetic levels, making them a model of depression traits.
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Affiliation(s)
- Eva E. Redei
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mallory E. Udell
- Department of Pharmacology, Addiction Science, and Toxicology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leah C. Solberg Woods
- Section on Molecular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hao Chen
- Department of Pharmacology, Addiction Science, and Toxicology, University of Tennessee Health Science Center, Memphis, TN, USA
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Seshadri A, Sundaresh V, Prokop LJ, Singh B. Thyroid Hormone Augmentation for Bipolar Disorder: A Systematic Review. Brain Sci 2022; 12:1540. [PMID: 36421864 PMCID: PMC9688441 DOI: 10.3390/brainsci12111540] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 07/29/2023] Open
Abstract
Thyroid hormone (TH) augmentation, although commonly used for major depression, is sparingly used for bipolar disorder (BD) after the failure of mood-stabilizing agents. While the exact mechanisms of thyroid hormone action in BD remains unclear, central thyroid hormone deficit has been postulated as a mechanism for rapid cycling. This systematic review-conducted in accordance with the PRISMA guidelines-of eight studies synthesizes the evidence for TH augmentation in BD. A systematic search of the Ovid MEDLINE, Embase, PsycINFO, and Cochrane databases was conducted for randomized controlled trials (RCT), open-label trials, and observational studies of levothyroxine (LT4) and triiodothyronine (T3) for BD. Open-label studies of high dose LT4 augmentation for bipolar depression and rapid cycling showed improvement in depression outcomes and reduction in recurrence, respectively. However, an RCT of high-dose LT4 did not show benefit in contrast to placebo. An RCT comparing LT4, T3, and placebo showed benefit only in rapid-cycling bipolar women. A meta-analysis could not be completed due to significant differences in study designs, interventions, and outcomes. Our systematic review shows mixed evidence and a lack of high-quality studies. The initial promise of supratherapeutic LT4 augmentation from open-label trials has not been consistently replicated in RCTs. Limited data are available for T3. The studies did not report significant thyrotoxicosis, and TH augmentation were well tolerated. Therefore, TH augmentation, especially with supratherapeutic doses, should be reserved for highly treatment-resistant bipolar depression and rapid-cycling BD.
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Affiliation(s)
- Ashok Seshadri
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Department of Psychiatry and Psychology, Mayo Clinic Health System, Austin, MN 55912, USA
| | - Vishnu Sundaresh
- Division of Endocrinology, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Larry J. Prokop
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Balwinder Singh
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Changes in regulators of lipid metabolism in the brain: a study of animal models of depression and hypothyroidism. Pharmacol Rep 2022; 74:859-870. [PMID: 35951260 PMCID: PMC9584974 DOI: 10.1007/s43440-022-00395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/27/2022]
Abstract
Metabolic disturbances in the brain are assumed to be early changes involved in the pathogenesis of depression, and these alterations may be intensified by a deficiency of thyroid hormones. In contrast to glucose metabolism, the link between altered brain lipids and the pathogenesis of depression is poorly understood, therefore in the present study, we determine transcription factors and enzymes regulating cholesterol and fatty acid biosynthesis in the brain structures in an animal model of depression, hypothyroidism and the coexistence of these diseases. In used model of depression, a decrease in the active form of the transcription factor SREBP-2 in the hippocampus was demonstrated, thus suggesting a reduction in cholesterol biosynthesis. In turn, in the hypothyroidism model, the reduction of cholesterol biosynthesis in the frontal cortex was demonstrated by both the reduction of mature SREBP-2 and the concentration of enzymes involved in cholesterol biosynthesis. The lower expression of LDL receptors in the frontal cortex indicates the restriction of cholesterol uptake into the cells in the model of coexistence of depression and hypothyroidism. Moreover, the identified changes in the levels of SNAP-25, GLP-1R and GLP-2R pointed to disturbances in synaptic plasticity and neuroprotection mechanisms in the examined brain structures. In conclusion, a reduction in cholesterol synthesis in the hippocampus in the model of depression may be the reason for the reduction of synaptic plasticity, whereas a lower level of LDL-R occurring in the frontal cortex in rats from the model of depression and hypothyroidism coexistence could be the reason of anxiogenic and depression-like behaviors.
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Levenberg K, Cordner ZA. Bipolar depression: a review of treatment options. Gen Psychiatr 2022; 35:e100760. [PMID: 36035376 PMCID: PMC9358943 DOI: 10.1136/gpsych-2022-100760] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/13/2022] [Indexed: 11/24/2022] Open
Abstract
Bipolar depression (BD-D) is both common and incredibly challenging to treat. Even treated individuals with BD-D experience depression approximately 19% of the time, and subsyndromal depression an additional 18%. This stands in clear contrast to the approximately 10% of time spent in hypomania and 1% of time spent in mania. Despite this high illness burden, there remain relatively few treatment options approved by the US Food and Drug Administration for BD-D. Of the approved medications, four are second-generation antipsychotics (SGAs) and one is an SGA combined with an antidepressant. However, particularly when used long-term, antipsychotics can pose a significant risk of adverse effects, raising the clinical conundrum of weighing the risks associated with long-term antipsychotic use versus the risk of relapse when patients are off medications. Here, we review commonly used treatments for BD-D, including antipsychotics, classic mood stabilisers, electroconvulsive therapy and psychotherapy. We then address the somewhat controversial topic of antidepressant use in BD-D. Finally, we summarise emerging treatment options and highlight ongoing clinical trials. We hope this review will help compare the risks and benefits of several common and novel options for the treatment of patients with BD-D. In doing so, we also hope this review will aid the individualised selection of treatments based on each patient's history and treatment goals.
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Affiliation(s)
- Kate Levenberg
- Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Zachary A Cordner
- Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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George S, Maiti R, Mishra A, Ranjan Mishra B, Jena M. Efficacy and safety of supraphysiologic doses of levothyroxine for patients with bipolar depression in adults: A systematic review. J Psychopharmacol 2022; 36:521-530. [PMID: 35574909 DOI: 10.1177/02698811221078758] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In bipolar disorder (BD), depression is the most difficult-to-treat dimension and available evidence suggests that add-on supraphysiological doses of levothyroxine may be an effective augmenting agent. AIM This systematic review has been conducted to evaluate the efficacy and safety of supraphysiologic doses of levothyroxine in bipolar depression in adults. METHODS After a comprehensive literature search on MEDLINE/PubMed, Scopus, Cochrane databases and International Clinical Trial Registry Platform (ICTRP), reviewers extracted data from eight relevant articles. PRISMA guidelines were followed in the selection, analysis and reporting of findings. Quality assessment was done using the risk of bias assessment and a random effects model was used to estimate effect size. Meta-analysis could not be done due to the lack of randomized, placebo-controlled trials and adequate data. A systematic review was done on eight studies and analysis on the pre-post change in Hamilton depression rating scale score (HDRS) was done for six studies. RESULTS The random model analysis of pooled effects showed a standardized mean difference of HDRS score by 2.62 (95% CI: 2.21-3.04; p < 0.0001). The responder and remission rates were not significant as reported in one study. Markov chain analysis performed in one study revealed that patients in the levothyroxine group had a significantly greater increase in time in the euthymic state and a decrease in the mixed state. In most of the studies, levothyroxine therapy was well tolerated, with no serious adverse events. CONCLUSION Add-on supraphysiological dose of levothyroxine has a potential role in attenuating depressive symptoms in bipolar depression, especially in therapy-resistant BD. PROSPERO REGISTRATION NUMBER CRD42020218456.
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Affiliation(s)
- Seena George
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Biswa Ranjan Mishra
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Monalisa Jena
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Zamar A, Lulsegged A, Kouimtsidis C. A new approach for the treatment of subthreshold bipolar disorders: Targeted high dose levothyroxine and repetitive transcranial magnetic stimulation for mitochondrial treatment. Front Psychiatry 2022; 13:976544. [PMID: 36311500 PMCID: PMC9606762 DOI: 10.3389/fpsyt.2022.976544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
Bipolar spectrum disorder includes Bipolar I, Bipolar II and subthreshold bipolar disorders (BD). The condition is highly prevalent, disabling and associated with high mortality. Failure of diagnosis is high. Subthreshold presentations present as 4 or more changes in polarity, are generally less responsive to standard treatment and as a result, drug combinations are often needed. High Dose Levothyroxine (HDT) has been reported to be safe and effective with this condition. Treatment response has been associated with mutations in thyroid activating enzymes and intra cerebral transporter protein carrier. Repetitive Transcranial Magnetic Stimulation (rTMS) has been shown to be effective in bipolar depression and has been proved to have neuroplastic effect. Present authors had reported clinical evidence of safe and effective use of a combination treatment protocol. Potential mechanisms of action of the combined treatment protocol and the role of mitochondria function are discussed.
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Affiliation(s)
- Andy Zamar
- Consultant Psychiatrist, The London Psychiatry Centre, London, United Kingdom
| | - Abbi Lulsegged
- Consultant Endocrinologist Health 121 Ltd., London, United Kingdom
| | - Christos Kouimtsidis
- Consultant Psychiatrist, The London Psychiatry Centre, London, United Kingdom.,Honorary Senior Lecturer Imperial College London, London, United Kingdom
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Elsayed OH, Ercis M, Pahwa M, Singh B. Treatment-Resistant Bipolar Depression: Therapeutic Trends, Challenges and Future Directions. Neuropsychiatr Dis Treat 2022; 18:2927-2943. [PMID: 36561896 PMCID: PMC9767030 DOI: 10.2147/ndt.s273503] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Bipolar disorder (BD) is a chronic mental illness impacting 1-2% of the population worldwide and causing high rates of functional impairment. Patients with BD spend most of their time in depressive episodes and up to one-third of patients do not respond to adequate doses of medications. Although no consensus exists for definition of treatment-resistant bipolar depression (TRBD), failure of symptoms improvement despite an adequate trial of two therapeutic agents is a common theme of TRBD. In this paper, we review the evidence base of therapeutic interventions, challenges, and potential future directions for TRBD. METHODS We conducted a literature search for randomized controlled trials on PubMed for the treatment of TRBD and ongoing trials for the treatment of TRBD/bipolar depression on clinicaltrials.gov. RESULTS Several therapeutic agents have been investigated for TRBD. Adjunctive pramipexole and modafinil have data supporting short-term efficacy in TRBD, along with limited data for racemic intravenous ketamine. Celecoxib augmentation of escitalopram and treatment with metformin in patients with insulin resistance showed promising results. Right unilateral electroconvulsive therapy displayed statistically significant response rate and improvement, but not remission compared to pharmacotherapy. Trials for transcranial magnetic stimulation (TMS) have failed to show a significant difference from sham treatment in TRBD. FUTURE TRENDS Pharmacological treatments with novel mechanisms of actions like brexpiprazole and vortioxetine are being investigated following successes in unipolar depression. Modified TMS protocols such as accelerated TMS are under investigation. Innovative approaches like psychedelic-assisted psychotherapy, interleukin-2, fecal microbiota transplantation and multipotent stromal cells are being studied. CONCLUSION Evidence on current treatment modalities for TRBD is limited with low efficacy. More research is needed for successful treatment of TRBD. Effective therapies and innovative approaches to treatment are being investigated and could show promise.
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Affiliation(s)
- Omar H Elsayed
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY, USA
| | - Mete Ercis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Mehak Pahwa
- Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY, USA
| | - Balwinder Singh
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Abstract
PURPOSE The close association among thyroid metabolism, mood disorders and behavior has long been known. The old and modern uses of thyroid hormones to modulate the expression of depression and bipolar disorder and to improve clinical outcome when used in conjunction with psychotropic medications. METHODS A literature search was performed to identify studies investigating the effects of thyroid hormone treatment in patient s with mood disorders. RESULTS The successful modification of mood disorders with thyroid hormone underscores the association between endocrine and cerebral systems in these disorders. Thyroid hormones have a profound influence on behavior and appear to be capable of modulating the phenotypic expression of major mood disorders. In fact, there is evidence that triiodothyronine (LT3) may accelerate the antidepressant response to antidepressants, and studies suggest that LT3 also may augment the response to antidepressants in refractory depression. Add-on treatment with supraphysiologic doses of levothyroxine (LT4) has shown efficacy in open-label and in placebo-controlled studies, including in rapid cycling and prophylaxis-resistant bipolar disorder, and with acute refractory uni- or bipolar depression. Functional brain-imaging studies (PET) demonstrated that administration of supraphysiologic LT4 improves depressive symptoms in patients with bipolar depression by modulating cerebral activity in the anterior limbic network. CONCLUSION The add-on administration of supraphysiologic doses of LT4 is a promising strategy in patients with refractory bipolar and depressive mood disorders.
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Affiliation(s)
- M Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - P C Whybrow
- Department of Psychiatry and Biobehavioral Sciences, The Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), Los Angeles, CA, USA
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Patterns of Thyroid Hormone Prescription in Patients with Bipolar or Schizoaffective Disorder: Findings from the LiSIE Retrospective Cohort Study. J Clin Med 2021; 10:jcm10215062. [PMID: 34768582 PMCID: PMC8584539 DOI: 10.3390/jcm10215062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
The prescription of thyroid hormone replacement therapy (THRT) has increased in the general population; the thyroid stimulating hormone (TSH) threshold to initiate THRT has decreased. It remains unclear whether a similar trend has occurred in patients with bipolar disorder (BD). In this work we explore patterns and trends of prescribing THRT in patients with BD or schizoaffective disorder (SZD) with an observational study and time-trend analysis in the framework of the LiSIE (Lithium-Study into Effects and Side Effects) retrospective cohort study. In most patients, THRT was initiated for subclinical hypothyroidism. The median TSH at which THRT was started was 6.0 (IQR 4.0) mIU/L and the median free serum thyroxine (fT4) at which THRT was started was 11.8 (IQR 3.9) pmol/L. The median TSH concentration at the start of THRT decreased annually with 0.10 mIU/L (p = 0.047) and was higher in patients treated with lithium than in patients treated with other mood stabilisers (p = 0.02). In conclusion, THRT was typically initiated in the context of mild or absent alterations of thyroid function tests with a decreasing TSH threshold. As THRT is rarely reversed once initiated, clinicians need to weigh up potential benefits and risks when prescribing THRT for subclinical hypothyroidism in patients with BD or SZD.
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Kuś A, Kjaergaard AD, Marouli E, Fabiola Del Greco M, Sterenborg RB, Chaker L, Peeters RP, Bednarczuk T, Åsvold BO, Burgess S, Deloukas P, Teumer A, Ellervik C, Medici M. Thyroid Function and Mood Disorders: A Mendelian Randomization Study. Thyroid 2021; 31:1171-1181. [PMID: 33899528 PMCID: PMC7612998 DOI: 10.1089/thy.2020.0884] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Observational studies suggest that even minor variations in thyroid function are associated with the risk of mood disorders, including major depressive disorder (MDD) and bipolar disorder (BD). However, it is unknown whether these associations are causal or not. We used a Mendelian randomization (MR) approach to investigate causal effects of minor variations in thyrotropin (TSH) and free thyroxine (fT4) levels on MDD and BD risk. Materials and Methods: We performed two-sample MR analyses using data from the largest publicly available genome-wide association studies on normal-range TSH (n = 54,288) and fT4 (n = 49,269) levels, MDD (170,756 cases, 329,443 controls) and BD (20,352 cases, 31,358 controls). Secondary MR analyses investigated the effects of TSH and fT4 levels on specific MDD and BD subtypes. Reverse MR was also performed to assess the effects of MDD and BD on TSH and fT4 levels. Results: There were no associations between genetically predicted TSH and fT4 levels and MDD risk, nor MDD subtypes and minor depressive symptoms. A one standard deviation increase in fT4 levels was nominally associated with an 11% decrease in the overall BD risk (odds ratio [OR] = 0.89, 95% confidence interval [CI] = 0.80-0.98, p = 0.022) and a 13% decrease in the BD type 1 risk (OR = 0.87, CI = 0.75-1.00, p = 0.047). In the reverse direction, genetic predisposition to MDD and BD was not associated with TSH nor fT4 levels. Conclusions: Variations in normal-range TSH and fT4 levels have no effects on the risk of MDD and its subtypes, and neither on minor depressive symptoms. This indicates that depressive symptoms should not be attributed to minor variations in thyroid function. Borderline associations with BD and BD type 1 risks suggest that further clinical studies should investigate the effect of thyroid hormone treatment in BD.
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Affiliation(s)
- Aleksander Kuś
- Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 CE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Alisa D. Kjaergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Hedeager 3, 8000 Aarhus, Denmark
| | - Eirini Marouli
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, EC1M 6BQ London, UK
- Centre for Genomic Health, Life Sciences, Queen Mary University of London, EC1M 6BQ London, UK
| | - M. Fabiola Del Greco
- Institute for Biomedicine, Eurac Research, Affiliated Institute of the University of Lubeck, Via Galvani 31, 39100 Bolzano, Italy
| | - Rosalie B.T.M. Sterenborg
- Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 CE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Layal Chaker
- Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 CE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| | - Robin P. Peeters
- Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 CE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Bjørn O. Åsvold
- K.G. Jebsen Center for Genetic Epidemiology, NTNU, Norwegian University of Science and Technology, Post box 8905, 7491 Trondheim, Norway
- Department of Endocrinology, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030 Trondheim, Norway
| | - Stephen Burgess
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - Panos Deloukas
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, EC1M 6BQ London, UK
- Centre for Genomic Health, Life Sciences, Queen Mary University of London, EC1M 6BQ London, UK
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Alexander Teumer
- Institute for Community Medicine, University Medicine Greifswald, W.-Rathenau-Str. 48, 17475 Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), partner site Greifswald, Fleischmannstr. 8, 17475 Greifswald, Germany
| | - Christina Ellervik
- Department of Laboratory Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, 02115 MA, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Alle 41, 2200 Copenhagen, Denmark
| | - Marco Medici
- Academic Center for Thyroid Diseases, Department of Internal Medicine, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 CE Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Dr. Molewaterplein 50, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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14
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Głombik K, Detka J, Budziszewska B. Venlafaxine and L-Thyroxine Treatment Combination: Impact on Metabolic and Synaptic Plasticity Changes in an Animal Model of Coexisting Depression and Hypothyroidism. Cells 2021; 10:cells10061394. [PMID: 34198731 PMCID: PMC8227539 DOI: 10.3390/cells10061394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/23/2022] Open
Abstract
The clinical effectiveness of supportive therapy with thyroid hormones in drug-resistant depression is well-known; however, the mechanisms of action of these hormones in the adult brain have not been fully elucidated to date. We determined the effects of venlafaxine and/or L-thyroxine on metabolic parameters and markers involved in the regulation of synaptic plasticity and cell damage in an animal model of coexisting depression and hypothyroidism, namely, Wistar Kyoto rats treated with propylthiouracil. In this model, in relation to the depression model itself, the glycolysis process in the brain was weakened, and a reduction in pyruvate dehydrogenase in the frontal cortex was normalized only by the combined treatment with L-thyroxine and venlafaxine, whereas changes in pyruvate and lactate levels were affected by all applied therapies. None of the drugs improved the decrease in the expression of mitochondrial respiratory chain enzymes. No intensification of glucocorticoid action was shown, while an unfavorable change caused by the lack of thyroid hormones was an increase in the caspase-1 level, which was not reversed by venlafaxine alone. The results indicated that the combined administration of drugs was more effective in normalizing glycolysis and the transition to the Krebs cycle than the use of venlafaxine or L-thyroxine alone.
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Affiliation(s)
- Katarzyna Głombik
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna 12, 31-343 Kraków, Poland; (J.D.); (B.B.)
- Correspondence: ; Tel.: +48-12-662-33-94
| | - Jan Detka
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna 12, 31-343 Kraków, Poland; (J.D.); (B.B.)
| | - Bogusława Budziszewska
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Smętna 12, 31-343 Kraków, Poland; (J.D.); (B.B.)
- Department of Biochemical Toxicology, Medical College, Jagiellonian University, Medyczna 9, 30-688 Kraków, Poland
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15
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Głombik K, Detka J, Kurek A, Budziszewska B. Impaired Brain Energy Metabolism: Involvement in Depression and Hypothyroidism. Front Neurosci 2020; 14:586939. [PMID: 33343282 PMCID: PMC7746780 DOI: 10.3389/fnins.2020.586939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/09/2020] [Indexed: 12/14/2022] Open
Abstract
Although hypothyroidism appears to be an important factor in the pathogenesis of depression, the impact of thyroid hormones on the bioenergetics of the adult brain is still poorly known. Since metabolic changes are reported to be a key player in the manifestation of depressive disorder, we investigated whether there are differences in selected metabolic markers in the frontal cortex and hippocampus of Wistar Kyoto rats (WKY; an animal model of depression) compared to those of control Wistar rats and whether the induction of hypothyroidism by propylthiouracil (PTU) elicits similar effects in these animals or intensifies some parameters in the WKY rats. In our study, we used WKY rats as a model of depression since this strain exhibits lower levels of monoamines in the brain than control rats and exhibits behavioral and hormonal alterations resembling those of depression, including increased reactivity to stress. The findings indicate a decrease in glycolysis intensity in both brain structures in the WKY rats as well as in both strains under hypothyroidism conditions. Furthermore, hypothyroidism disrupted the connection between glycolysis and the Krebs cycle in the frontal cortex and hippocampus in the depression model used in this study. Decreased thyroid hormone action was also shown to attenuate oxidative phosphorylation, and this change was greater in the WKY rats. Our results suggest that both the depression and hypothyroidism models are characterized by similar impairments in brain energy metabolism and mitochondrial function and, additionally, that the co-occurrence of hypothyroidism and depression may exacerbate some of the metabolic changes observed in depression.
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Affiliation(s)
- Katarzyna Głombik
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Jan Detka
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Anna Kurek
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
| | - Bogusława Budziszewska
- Laboratory of Immunoendocrinology, Department of Experimental Neuroendocrinology, Maj Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland
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16
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Vancamp P, Butruille L, Demeneix BA, Remaud S. Thyroid Hormone and Neural Stem Cells: Repair Potential Following Brain and Spinal Cord Injury. Front Neurosci 2020; 14:875. [PMID: 32982671 PMCID: PMC7479247 DOI: 10.3389/fnins.2020.00875] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/28/2020] [Indexed: 12/22/2022] Open
Abstract
Neurodegenerative diseases are characterized by chronic neuronal and/or glial cell loss, while traumatic injury is often accompanied by the acute loss of both. Multipotent neural stem cells (NSCs) in the adult mammalian brain spontaneously proliferate, forming neuronal and glial progenitors that migrate toward lesion sites upon injury. However, they fail to replace neurons and glial cells due to molecular inhibition and the lack of pro-regenerative cues. A major challenge in regenerative biology therefore is to unveil signaling pathways that could override molecular brakes and boost endogenous repair. In physiological conditions, thyroid hormone (TH) acts on NSC commitment in the subventricular zone, and the subgranular zone, the two largest NSC niches in mammals, including humans. Here, we discuss whether TH could have beneficial actions in various pathological contexts too, by evaluating recent data obtained in mammalian models of multiple sclerosis (MS; loss of oligodendroglial cells), Alzheimer’s disease (loss of neuronal cells), stroke and spinal cord injury (neuroglial cell loss). So far, TH has shown promising effects as a stimulator of remyelination in MS models, while its role in NSC-mediated repair in other diseases remains elusive. Disentangling the spatiotemporal aspects of the injury-driven repair response as well as the molecular and cellular mechanisms by which TH acts, could unveil new ways to further exploit its pro-regenerative potential, while TH (ant)agonists with cell type-specific action could provide safer and more target-directed approaches that translate easier to clinical settings.
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Affiliation(s)
- Pieter Vancamp
- Laboratory Molecular Physiology and Adaptation, CNRS UMR 7221, Muséum National d'Histoire Naturelle, Department Adaptations of Life, Paris, France
| | - Lucile Butruille
- Laboratory Molecular Physiology and Adaptation, CNRS UMR 7221, Muséum National d'Histoire Naturelle, Department Adaptations of Life, Paris, France
| | - Barbara A Demeneix
- Laboratory Molecular Physiology and Adaptation, CNRS UMR 7221, Muséum National d'Histoire Naturelle, Department Adaptations of Life, Paris, France
| | - Sylvie Remaud
- Laboratory Molecular Physiology and Adaptation, CNRS UMR 7221, Muséum National d'Histoire Naturelle, Department Adaptations of Life, Paris, France
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17
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Wang D, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on bipolar depression. Bipolar Disord 2020; 22:472-489. [PMID: 31650675 DOI: 10.1111/bdi.12860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Psychopharmacology Algorithm Project at the Harvard South Shore Program (PAPHSS) published algorithms for bipolar depression in 1999 and 2010. Developments over the past 9 years suggest that another update is needed. METHODS The 2010 algorithm and associated references were reevaluated. A literature search was conducted on PubMed for recent studies and review articles to see what changes in the recommendations were justified. Exceptions to the main algorithm for special patient populations, including those with attention-deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), substance use disorders, anxiety disorders, and women of childbearing potential, and those with common medical comorbidities were considered. RESULTS Electroconvulsive therapy (ECT) is still the first-line option for patients in need of urgent treatment. Five medications are recommended for early usage in acute bipolar depression, singly or in combinations when monotherapy fails, the order to be determined by considerations such as side effect vulnerability and patient preference. The five are lamotrigine, lurasidone, lithium, quetiapine, and cariprazine. After trials of these, possible options include antidepressants (bupropion and selective serotonin reuptake inhibitors are preferred) or valproate (very small evidence-base). In bipolar II depression, the support for antidepressants is a little stronger but depression with mixed features and rapid cycling would usually lead to further postponement of antidepressants. Olanzapine+fluoxetine, though Food and Drug Administration (FDA) approved for bipolar depression, is not considered until beyond this point, due to metabolic side effects. The algorithm concludes with a table of other possible treatments that have some evidence. CONCLUSIONS This revision incorporates the latest FDA-approved treatments (lurasidone and cariprazine) and important new studies and organizes the evidence systematically.
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Affiliation(s)
- Dana Wang
- Rivia Medical PLLC, New York, NY, USA
| | - David N Osser
- Department of Psychiatry, Harvard Medical School, VA Boston Healthcare System, Brockton Division, Brockton, MA, USA
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18
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Yalin N, Young AH. Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatr Dis Treat 2020; 16:1459-1472. [PMID: 32606699 PMCID: PMC7294105 DOI: 10.2147/ndt.s245166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Depression accounts for the predominant burden associated with bipolar disorder. The identification and management of bipolar depression are challenging, since bipolar depression differs from unipolar depression, responding poorly to traditional antidepressants, which may also induce a switch to hypomania/mania, mixed states and/or cause rapid cycling. Current treatment options for bipolar depression are limited and guidelines vary greatly in their recommendations, reflecting gaps and inconsistencies in the current evidence base. Moreover, some treatment options, such as quetiapine and olanzapine-fluoxetine, although clearly efficacious, may be associated with adverse cardiometabolic side effects, which can be detrimental to the long-term physical health and well-being of patients, increasing the likelihood of treatment non-adherence and relapse. Evidence for some more recent therapeutic options, including lurasidone and cariprazine, suggests that patients' symptoms can be effectively managed without compromising their physical health. In addition, novel agents targeting alternative neurotransmitter pathways and inflammatory processes (such as ketamine and N-acetyl cysteine) are emerging as promising potential options for the treatment of bipolar depression in the future.
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Affiliation(s)
- Nefize Yalin
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Allan H Young
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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19
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Pilhatsch M, J Stamm T, Stahl P, Lewitzka U, Berghöfer A, Sauer C, Gitlin M, Frye MA, Whybrow PC, Bauer M. Treatment of bipolar depression with supraphysiologic doses of levothyroxine: a randomized, placebo-controlled study of comorbid anxiety symptoms. Int J Bipolar Disord 2019; 7:21. [PMID: 31583561 PMCID: PMC6776578 DOI: 10.1186/s40345-019-0155-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/24/2019] [Indexed: 11/25/2022] Open
Abstract
Background Symptoms of anxiety co-occur in a variety of disorders including in depressive episodes of bipolar disorder and in patients with thyrotoxicosis. Treatment of refractory bipolar disorder with supraphysiologic doses of levothyroxine (L-T4) has been shown to improve the phenotypic expression of the disorder and is associated with an increase of circulating thyroid hormones. However, it might be associated with somatic and mental adverse effects. Here we report the investigation of the influence of treatment with supraphysiologic doses of L-T4 on symptoms of anxiety in patients with refractory bipolar depression. Methods Post-hoc analysis from a 6-week, multi-center, randomized, double-blind, placebo-controlled study of the effects of supraphysiologic L-T4 treatment on anxiety symptoms in bipolar depression. Anxiety symptoms were measured weekly with the Hamilton anxiety/somatization factor (HASF) score of the Hamilton Depression Rating Scale (HAMD) and the State- and Trait Anxiety Inventory (STAI). Results Treatment of both groups was associated with a significant reduction in anxiety symptoms (p < 0.001) with no statistical difference between groups (LT-4: from 5.9 (SD = 2.0) at baseline to 3.7 (SD = 2.4) at study end; placebo: from 6.1 (SD = 2.4) at baseline to 4.4 (SD = 2.8) at study end; p = 0.717). Severity of anxiety at baseline did not show a statistically significant correlation to the antidepressive effect of treatment with supraphysiologic doses of L-T4 (p = 0.811). Gender did not show an influence on the reduction of anxiety symptoms (females: from 5.6 (SD = 1.7) at baseline to 3.5 (SD = 2.4) at study end; males: from 6.1 (SD = 2.3) at baseline to 4.0 (SD = 2.4) at study end; p = 0.877). Conclusions This study failed to detect a difference in change of anxiety between bipolar depressed patients treated with supraphysiologic doses of L-T4 or placebo. Comorbid anxiety symptoms should not be considered a limitation for the administration of supraphysiologic doses of L-T4 refractory bipolar depressed patients. Trial registration ClinicalTrials, ClinicalTrials.gov identifier: NCT01528839. Registered 2 June 2012—Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT01528839
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Affiliation(s)
- Maximilian Pilhatsch
- Department of Psychiatry and Psychotherapy, Medical Faculty, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Thomas J Stamm
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, Brandenburg Medical School, Neuruppin, Germany
| | - Petra Stahl
- Psychiatrische Universitätsklinik der Charité, St. Hedwig-Krankenhaus, Berlin, Germany
| | - Ute Lewitzka
- Department of Psychiatry and Psychotherapy, Medical Faculty, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Anne Berghöfer
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Cathrin Sauer
- Department of Psychiatry and Psychotherapy, Medical Faculty, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Michael Gitlin
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Mark A Frye
- Department of Psychiatry & Psychology, Mayo Clinic Depression Center, Mayo Clinic, Rochester, MN, USA
| | - Peter C Whybrow
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Medical Faculty, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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20
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Walshaw PD, Gyulai L, Bauer M, Bauer MS, Calimlim B, Sugar CA, Whybrow PC. Adjunctive thyroid hormone treatment in rapid cycling bipolar disorder: A double-blind placebo-controlled trial of levothyroxine (L-T 4 ) and triiodothyronine (T 3 ). Bipolar Disord 2018; 20:594-603. [PMID: 29869405 PMCID: PMC6323302 DOI: 10.1111/bdi.12657] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES This report describes the first comparative double-blind, placebo-controlled trial of levothyroxine (L-T4 ) and triiodothyronine (T3 ) as adjunctive treatments in rapid cycling bipolar disorder. METHODS Thirty-two treatment-resistant, rapid cycling patients who had failed a trial of lithium were randomized into three treatment arms: L-T4 , T3 , or placebo. They were followed for ≥4 months with weekly clinical and endocrine assessments. RESULTS There were no statistically significant differences between the groups in age, gender, duration of illness, or thyroid status. Markov chain analyses were employed to assess treatment effects on cycling patterns among mood states (euthymia, depression, mania, and mixed). Within groups, post-treatment the L-T4 group spent significantly less time depressed or in a mixed state and greater time euthymic. The T3 and placebo groups did not differ significantly pre- and post-treatment in any mood state, although the pattern of effects was the same for the T3 group as for the L-T4 group. Between groups, the L-T4 group had a significantly greater increase in time euthymic and decrease in time in the mixed state than the placebo group. Other group differences were not significant, although they were in the expected direction. CONCLUSIONS The findings in this first double-blind study directly comparing the effects of L-T4 and T3 therapy against placebo provide evidence for the benefit of adjunctive L-T4 in alleviating resistant depression, reducing time in mixed states and increasing time euthymic. Adjunctive T3 did not show statistically significant evidence of benefit over placebo in reducing the time spent in disturbed mood states.
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Affiliation(s)
- Patricia D. Walshaw
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Laszlo Gyulai
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA and Corporate Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mark S. Bauer
- Department of Psychiatry, Harvard Medical School & the Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Brian Calimlim
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles (UCLA), Los Angeles, CA, USA,Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Catherine A. Sugar
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles (UCLA), Los Angeles, CA, USA,Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Peter C. Whybrow
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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21
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Long-term treatment with supraphysiologic doses of levothyroxine in treatment-refractory mood disorders - A prospective study of cardiovascular tolerability. J Affect Disord 2018; 238:213-217. [PMID: 29886201 DOI: 10.1016/j.jad.2018.05.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/24/2018] [Accepted: 05/25/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND To investigate long-term effects of adjunctive prophylactic treatment with supraphysiologic doses of levothyroxine (L-T4) on cardiovascular tolerability in 23 patients with treatment-refractory mood disorders. METHODS Starting point for a comprehensive cardiovascular assessment in patients was the indication for long-term maintenance treatment with L-T4 (mean dose 463 mcg/day). Prospective longitudinal assessment of the cardiovascular risk profile included in addition to a physical examination and blood pressure measurement, several technical investigations: resting electrocardiogram, transthoracic echocardiogram, cardiac stress test, and holter electrocardiogram. Statistical analysis was performed by linear mixed effects models (LMM) for evaluation of longitudinal changes in various heart measures. RESULTS During the mean observational period of 20.4 months none of the heart measures reached statistical significance in change over time. None of the assessed cardiac parameters of each single patient was in a range predictive for cardiac dysfunction. LIMITATIONS Small sample size, no technical cardiac investigations prior to L-T4 initiation, no patient control group with mood disorders who did not receive L-T4. CONCLUSIONS Results of this study indicated no increased risk for cardiovascular disorders during treatment with supraphysiologic L-T4 doses in patients with refractory mood disorders.
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22
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Parmentier T, Sienaert P. The use of triiodothyronine (T3) in the treatment of bipolar depression: A review of the literature. J Affect Disord 2018; 229:410-414. [PMID: 29331701 DOI: 10.1016/j.jad.2017.12.071] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/18/2017] [Accepted: 12/31/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a paucity of treatment options for bipolar depression. The use of triiodothyronine (T3) has been suggested as adjunctive treatment. METHODS A search on Medline, Limo and ScienceDirect was performed using the search terms bipolar disorder, bipolar depression, treatment resistant, treatment refractory, thyroid hormones, triiodothyronine, T3, acceleration and augmentation. RESULTS We retrieved three open studies, one comparative study, two double blind and one retrospective chart review. The three open studies observed improvement in respectively 56%, 75% and 79% of patients, the retrospective chart review noted improvement in 89% of cases and the mirror design showed improvement in 66%. In the comparative study T3 performed significantly better than placebo. The only randomized double blind study could not prove any substantial difference between T3 and placebo. LIMITATIONS Available studies are scarce and flawed. All have (very) low number of subjects: overall, only 353 subjects and only 194 of which in prospective trials. In only two of the prospective trials bipolar patients were analyzed separately. Comparing the studies is hampered by a high variability in assessment tools, baseline medication and degree of treatment-resistance. CONCLUSIONS The few available studies are small and flawed. They do show promising results. We found many clues suggesting that T3 could augment and accelerate treatment response not only with antidepressants, but also with lithium and perhaps with other treatment options, that it might protect against rapid cycling bipolar disorder, as well as against relapse during the first few years of treatment.
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Affiliation(s)
- T Parmentier
- KU Leuven, University of Leuven, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium
| | - P Sienaert
- KU Leuven, University of Leuven, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium; KU Leuven, Department of Neurosciences, Psychiatry, Herestraat 49, 3000 Leuven, Belgium.
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Kelly T. A hypothesis on the mechanism of action of high-dose thyroid in refractory mood disorders. Med Hypotheses 2016; 97:16-21. [PMID: 27876122 DOI: 10.1016/j.mehy.2016.09.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/24/2016] [Accepted: 09/27/2016] [Indexed: 12/21/2022]
Abstract
Multiple lines of evidence suggest the hypothesis that high dose thyroid therapy corrects for cellular hypothyroidism found in bipolar disorders. Evidence indicates that bipolar disorders are associated with mitochondrial dysfunction which results in low cellular adenosine 5'-triphosphate (ATP) levels. Transport of thyroid hormones into cells is energy intensive and dependent on ATP except in the pituitary gland. Inadequate ATP levels makes it difficult to get thyroid hormone into cells leading to cellular hypothyroidism. This creates a condition where the blood and pituitary levels of thyroid hormone are normal but low in other tissues. High dose thyroid therapy produces a gradient that is sufficient for thyroid hormone to diffuse into cells correcting cellular hypothyroidism. If this hypothesis is correct there are number of implications. The two most important are: On average patients suffering from a bipolar disorder die 10-20years earlier than the general population. The medical sequelae associated with bipolar disorders cause far more deaths than suicide. If high dose thyroid corrects for cellular hypothyroidism it could well decrease the medical morbidity and mortality associated with bipolar disorders that are the result of cellular hypothyroidism. Thus high dose thyroid would be a first treatment that decreases the considerable medical morbidity and mortality associated with the bipolar disorders. This would stand in stark contrast to most psychiatric medications that can that increase morbidity and mortality. It would also reinforce the safety of HDT. The second implication is thyroid hormone blood levels in patients suffering from a bipolar disorder do not accurately reflect the true thyroid status.
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Affiliation(s)
- Tammas Kelly
- George Washington University, GWU MFA Department of Psychiatry and Behavioral Sciences, 2120 L St NW, Suite 600, Washington DC 20037, United States; The Depression & Bipolar Clinic of Colorado, 400 East Horsetooth Road, Suite 300, Fort Collins, Colorado 80525, United States.
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Hui Poon S, Sim K, Baldessarini RJ. Pharmacological Approaches for Treatment-resistant Bipolar Disorder. Curr Neuropharmacol 2016; 13:592-604. [PMID: 26467409 PMCID: PMC4761631 DOI: 10.2174/1570159x13666150630171954] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 12/06/2014] [Accepted: 12/06/2014] [Indexed: 01/11/2023] Open
Abstract
Bipolar disorder is prevalent, with high risks of disability, substance abuse and premature
mortality. Treatment responses typically are incomplete, especially for depressive components, so that
many cases can be considered “treatment resistant.” We reviewed reports on experimental treatments
for such patients: there is a striking paucity of such research, mainly involving small incompletely
controlled trials of add-on treatment, and findings remain preliminary. Encouraging results have been reported by adding
aripiprazole, bupropion, clozapine, ketamine, memantine, pramipexole, pregabalin, and perhaps tri-iodothyronine in
resistant manic or depressive phases. The urgency of incomplete responses in such a severe illness underscores the need
for more systematic, simpler, and better controlled studies in more homogeneous samples of patients.
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Affiliation(s)
| | | | - Ross J Baldessarini
- Department of General Psychiatry, Institute of Mental Health, 10, Buangkok View, Singapore 539747
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An examination of myth: a favorable cardiovascular risk-benefit analysis of high-dose thyroid for affective disorders. J Affect Disord 2015; 177:49-58. [PMID: 25745835 DOI: 10.1016/j.jad.2015.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 01/14/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION High dose thyroid (HDT) is included in major treatment guidelines for the treatment of bipolar disorders. Yet it is seldom used partly based on perceived cardiovascular risks. The cardiovascular risks of HDT are examined. METHODS A literature search was conducted for the cardiovascular risks of HDT and for comparisons sake psychiatric medications. Case reports of atrial fibrillation (afib) associated with HDT are reported. RESULTS While hyperthyroidism is a significant cardiovascular risk factor causing a 20% premature death rate, HDT treatment does not appear to be of significant cardiovascular risk. HDT differs from hyperthyroidism in significant ways. The sequela of hyperthyroidism are increasingly tied to autoimmune complications which are absent with HDT. Equating hyperthyroidism with HDT is incorrect. The five case reports of HDT treatment associated with afib were potentially caused by other factors. If HDT increases the risks of afib, monitoring for afib would minimizes the risk. Even in overt hyperthyroidism the risk of other arrhythmias are minimal. When compared to many psychiatric medications HDT is as safe or safer. LIMITATIONS There are no direct studies of cardiovascular risks of HDT for affective patients. High tolerance of a medication does not necessarily imply lack of risk. The five case reports were spontaneous, other cases may not have been reported. CONCLUSION The cardiovascular risks of HDT appear to be low. HDT is at least as safe as or safer than many psychiatric medications. It is effective and well tolerated.
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26
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Kelly T. A favorable risk-benefit analysis of high dose thyroid for treatment of bipolar disorders with regard to osteoporosis. J Affect Disord 2014; 166:353-8. [PMID: 24981132 DOI: 10.1016/j.jad.2014.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/11/2014] [Indexed: 12/14/2022]
Abstract
High dose thyroid hormone has been in use since the 1930s for the treatment of affective disorders. Despite numerous papers showing benefit, the lack of negative trials and its inclusion in multiple treatment guidelines, high dose thyroid has yet to find wide spread use. The major objection to the use of high dose thyroid is the myth that it causes osteoporosis. This paper reviews the literature surrounding the use of high dose thyroid, both in endocrinology and in psychiatry. High dose thyroid does not appear to be a significant risk factor for osteoporosis while other widely employed psychiatric medications do pose a risk. Psychiatrists are uniquely qualified to do the risk-benefit analyses of high dose thyroid for the treatment of the bipolar I, bipolar II and bipolar NOS. Other specialties do not have the requisite knowledge of the risks of alterative medications or of the mortality and morbidity of the bipolar disorders to do a full risk benefit analysis.
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Affiliation(s)
- Tammas Kelly
- Psychiatry and Behavioral Sciences George Washington University, The Depression & Bipolar Clinic of Colorado, USA.
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27
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Abstract
Bipolar disorders of types I and II, even when treated by currently standard options, show a marked excess of depressive morbidity. Treated, type I patients in mid-course or from the onset of illness are ill, overall, 50 % of weeks of follow-up, and 75 % of that unresolved morbidity is depressive. Currently widely held impressions are that bipolar depression typically is poorly responsive to antidepressants, that treatment-resistant depression (TRD) is characteristic of the disorder, and that risk of mania with antidepressant treatment is very high. However, none of these views is supported consistently by available research. TRD may be more prevalent in bipolar than unipolar mood disorders. Relatively intense research attention is directed toward characteristics and treatments of TRD in unipolar depression, but studies of bipolar TRD are uncommon. We found only five controlled trials, plus 10 uncontrolled trials, providing data on a total of 13 drug treatments, all of which involved one or two trials, in 87 % as add-ons to complex, uncontrolled regimens. In two controlled trials, ketamine was superior to placebo but it is short-acting and not orally active; pramipexole was weakly superior to placebo in one controlled trial; three other drugs failed to outperform controls. Other pharmacotherapies are inadequately evaluated and nonpharmacological options are virtually untested in bipolar TRD. The available research supports the view that antidepressants may be effective in bipolar depression provided that currently agitated patients are excluded, that risk of mania with antidepressants is only moderately greater than risk of spontaneous mania, and that bipolar TRD is not necessarily resistant to all treatments.
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Abstract
BACKGROUND A relationship between hypothyroidism and depression has been assumed for many years; however, the true nature of this association has been difficult to define with many conflicting studies. In recent years, our knowledge in this area has increased significantly with large cohort studies and genetically driven studies being published. OBJECTIVES We reviewed the literature on thyroid function and depression to determine if this relationship has been clarified. METHODS We performed a search on the Pubmed database using the terms 'thyroid
' and 'mental health
', 'depression
' and 'well-being
'. RESULTS Large epidemiological studies generally suggest no association between thyroid function and depression in subjects without thyroid disease. Subjects on thyroxine have poorer psychological well-being than subjects with no thyroid disease even if biochemically euthyroid, they also show an association between thyroid function and well-being. Whilst there is some early evidence that genetic factors can influence well-being on thyroxine and response to combination therapy, there is also evidence to suggest that much morbidity on thyroxine may be due to initial misdiagnosis and mis-attribution of symptoms. CONCLUSION Despite the large number of studies, the relationship between thyroid function and depression remains poorly defined. Clarification of the proportion of subjects on thyroxine incorrectly may assist the large (perhaps genetically driven) studies needed to move forward in this area, as it is expected that they cloud the results.
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Affiliation(s)
- Colin M. Dayan
- Cardiff University School of Medicine, Heath Park, Cardiff, UK
- *Colin M. Dayan, MA, FRCP, PhD, Cardiff University School of Medicine, Heath Park, Cardiff CF14 4XN (UK), E-Mail
| | - Vijay Panicker
- Department of Endocrinology, Sir Charles Gairdner Hospital, Nedlands, W.A., Australia
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29
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Is methoxydine a new rapid acting antidepressant for the treatment of depression in alcoholics? Med Hypotheses 2013; 81:10-4. [DOI: 10.1016/j.mehy.2013.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 03/21/2013] [Indexed: 12/31/2022]
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30
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Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, O'Donovan C, Macqueen G, McIntyre RS, Sharma V, Ravindran A, Young LT, Milev R, Bond DJ, Frey BN, Goldstein BI, Lafer B, Birmaher B, Ha K, Nolen WA, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013; 15:1-44. [PMID: 23237061 DOI: 10.1111/bdi.12025] [Citation(s) in RCA: 540] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.
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Affiliation(s)
- Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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Sienaert P, Lambrichts L, Dols A, De Fruyt J. Evidence-based treatment strategies for treatment-resistant bipolar depression: a systematic review. Bipolar Disord 2013. [PMID: 23190379 DOI: 10.1111/bdi.12026] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Pascal Sienaert
- Department of Mood Disorders, University Psychiatric Center, Catholic University Leuven, Campus Kortenberg, Kortenberg, Belgium.
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32
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Poon SH, Sim K, Sum MY, Kuswanto CN, Baldessarini RJ. Evidence-based options for treatment-resistant adult bipolar disorder patients. Bipolar Disord 2012; 14:573-84. [PMID: 22938165 DOI: 10.1111/j.1399-5618.2012.01042.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Many patients diagnosed with bipolar disorder (BD) respond incompletely or unsatisfactorily to available treatments. Given the potentially devastating nature of this prevalent disorder, there is a pressing need to improve clinical care of such patients. METHODS We performed a literature review of the research findings related to treatment-resistant BD reported through February 2012. RESULTS Therapeutic trials for treatment-resistant bipolar mania are uncommon, and provide few promising leads other than the use of clozapine. Far more pressing challenges are the depressive-dysthymic-dysphoric-mixed phases of BD and long-term prophylaxis. Therapeutic trials for treatment-resistant bipolar depression have assessed anticonvulsants, modern antipsychotics, glutamate [N-methyl-D-aspartate (NMDA)] antagonists, dopamine agonists, calcium-channel blockers, and thyroid hormones, as well as behavioral therapy, sleep deprivation, light therapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation, and deep brain stimulation-all of which are promising but limited in effectiveness. Several innovative pharmacological treatments (an anticholinesterase, a glutamine antagonist, a calcium-channel blocker, triiodothyronine, olanzapine and topiramate), ECT, and cognitive-behavior therapy have some support for long-term treatment of resistant BD patients, but most of trials of these treatments have been methodologically limited. CONCLUSIONS Most studies identified were small, involved supplementation of typically complex ongoing treatments, varied in controls, randomization, and blinding, usually involved brief follow-up, and lacked replication. Clearer criteria for defining and predicting treatment resistance in BD are needed, as well as improved trial design with better controls, assessment of specific clinical subgroups, and longer follow-up.
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Affiliation(s)
- Shi Hui Poon
- Department of General Psychiatry, Institute of Mental Health, 10 Buangkok ViewSingapore 539747
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Abstract
The phenomenon of treatment-resistant depression (TRD), described as the occurrence of an inadequate response after an adequate treatment with antidepressant agents (in terms of dose, duration, and adherence), is very common in clinical practice. It has been broadly defined in the context of unipolar major depression, but alternative definitions for bipolar depression have also been suggested. In both cases, there is a remarkable lack of consensus amongst professionals concerning its operative definition. A relatively wide variety of treatment options for unipolar TRD are available, whilst the evidence is very scanty for bipolar TRD. TRD is associated to poor clinical, functional, and social outcomes. Several novel therapeutic options are currently being investigated as promising alternatives, targeting the neurotransmitter system outside of the standard monoamine hypothesis. Augmentation or combination with lithium or atypical antipsychotics appears as a valid option for both conditions, and the same occurs with electroconvulsive therapy. Other non-pharmacological strategies such as deep brain stimulation may be promising alternatives for the future. The use of cognitive behaviour therapy is recommended for unipolar TRD, but there is no evidence supporting its use in bipolar TRD.
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Affiliation(s)
- Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona , Catalonia, Spain.
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Chakrabarti S. Thyroid functions and bipolar affective disorder. J Thyroid Res 2011; 2011:306367. [PMID: 21808723 PMCID: PMC3144691 DOI: 10.4061/2011/306367] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 04/23/2011] [Accepted: 05/29/2011] [Indexed: 02/05/2023] Open
Abstract
Accumulating evidence suggests that hypothalamo-pituitary-thyroid (HPT) axis dysfunction is relevant to the pathophysiology and clinical course of bipolar affective disorder. Hypothyroidism, either overt or more commonly subclinical, appears to the commonest abnormality found in bipolar disorder. The prevalence of thyroid dysfunction is also likely to be greater among patients with rapid cycling and other refractory forms of the disorder. Lithium-treatment has potent antithyroid effects and can induce hypothyroidism or exacerbate a preexisting hypothyroid state. Even minor perturbations of the HPT axis may affect the outcome of bipolar disorder, necessitating careful monitoring of thyroid functions of patients on treatment. Supplementation with high dose thyroxine can be considered in some patients with treatment-refractory bipolar disorder. Neurotransmitter, neuroimaging, and genetic studies have begun to provide clues, which could lead to an improved understanding of the thyroid-bipolar disorder connection, and more optimal ways of managing this potentially disabling condition.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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35
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Abstract
The management of long-term mental illness in women requires a number of specialized approaches in order to optimize their quality of life and health outcomes. This selective review addresses the latest key issues related to hospitalization, life cycle, hormonal and other reproductive issues that impact on the treatment of women with mental illness. A particular focus is given to the management of women with schizophrenia, bipolar disorder and depression. Novel treatment approaches such as oestrogen augmentation and gender-specific medication prescription are detailed.
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Affiliation(s)
- Jayashri Kulkarni
- Monash Alfred Psychiatry Research Centre, Alfred Hospital and School of Psychology and Psychiatry, Monash University, Melbourne, Australia.
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36
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Kansagra SM, McCudden CR, Willis MS. The Challenges and Complexities of Thyroid Hormone Replacement. Lab Med 2010. [DOI: 10.1309/lmb39th2fzgndgim] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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37
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Kaplan RM. Freud's excellent adventure Down Under: the only publication in Australia by the founder of psychoanalysis. Australas Psychiatry 2010; 18:205-9. [PMID: 20482424 DOI: 10.3109/10398561003682952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this paper is to describe the circumstances surrounding the only paper published in Australia by Sigmund Freud--his only publication in the Southern Hemisphere--in 1911. CONCLUSIONS The invitations in 1911 from a Sydney psychoanalysis study group to Sigmund Freud, Carl Jung and Havelock Ellis to present papers at the Australasian Medical Congress, came at a time when the world was barely aware of Freud's new psychology, and well in advance of many other countries. Sparring by Freud and Jung over a joint presentation was evident in the respective papers they sent, and they soon parted. A review of other papers presented at the congress indicates that Australian psychiatry, notwithstanding its slow progress, was well informed on recent developments, which was to manifest with biological treatments, as well as with the establishment of psychoanalysis. Despite its distance from Vienna, Australia seemed to have a special place in Freud's mind that was to surface in various ways over the years, not least in Totem and Taboo.
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Affiliation(s)
- Robert M Kaplan
- Graduate School of Medicine, University of Wollongong, NSW, Australia.
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