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Fountoulakis KN, Tohen M, Zarate CA. Lithium treatment of Bipolar disorder in adults: A systematic review of randomized trials and meta-analyses. Eur Neuropsychopharmacol 2022; 54:100-115. [PMID: 34980362 PMCID: PMC8808297 DOI: 10.1016/j.euroneuro.2021.10.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 01/01/2023]
Abstract
The aim of the study was to systematically review the hard evidence alone, concerning lithium efficacy separately for the phases and clinical facets of Bipolar disorder (BD). The PRISMA method was followed to search the MEDLINE for Randomized Controlled trials, Post-hoc analyses and Meta-analyses and review papers up to August 1st 2020, with the combination of the words 'bipolar', 'manic', 'mania', 'manic depression' and 'manic depressive' and 'randomized'. Trials and meta-analyses concerning the use of lithium either as monotherapy or in combination with other agents in adults were identified concerning acute mania (Ν=64), acute bipolar depression (Ν=78), the maintenance treatment (Ν=73) and the treatment of other issues (N = 93). Treatment guidelines were also identified. Lithium is efficacious for the treatment of acute mania including concomitant psychotic symptoms. In acute bipolar depression it is efficacious only in combination with specific agents. For the maintenance phase, it is efficacious as monotherapy mainly in the prevention of manic while its efficacy for the prevention of depressive episodes is unclear. Its combinations increase its therapeutic value. It is equaly efficacious in rapid and non-rapid cycling patients, in concomitant obsessive-compulsive symptoms, alcohol and substance abuse, the neurocognitive deficit, suicidal ideation and fatigue The current systematic review provided support for the usefulness of lithium against a broad spectrum of clinical issues in Bipolar disorder. Its efficacy is comparable to that of more recently developed agents.
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Affiliation(s)
| | - Mauricio Tohen
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, 2400 Tucker Ave NE MSC09 5030, Albuquerque, NM, 87131-0001, USA.
| | - Carlos A Zarate
- Division of Intramural Research Program, National Institute of Mental Health, Bethesda, MD, 20892, USA.
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Naeem A, Aslam M, Mühling KH. Lithium: Perspectives of nutritional beneficence, dietary intake, biogeochemistry, and biofortification of vegetables and mushrooms. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 798:149249. [PMID: 34329936 DOI: 10.1016/j.scitotenv.2021.149249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 06/13/2023]
Abstract
Although lithium (Li) is not an essential nutrient for humans, low Li intakes are associated with increased suicide and homicide rates, aggressive behaviors, unipolar/bipolar disorders, acute mania, etc. On the other hand, Li is one of the most effective psychopharmacological agents used for the treatment of these psycho-behavioral disorders. The beneficial normothymic effect of Li could be achieved at lower doses, therefore, modern psychiatry has called to consider Li biofortification of foods to improve its dietary intake. The concept of agronomic biofortification of crops with Li is juvenile and there exist a limited number of studies, mainly focused on vegetables or mushrooms. This review, first of its kind, discusses the nutritional beneficence and dietary intake of Li, its biogeochemistry, and opportunities and challenges in the Li biofortification of food crops. Literature showed that dietary intake of Li in many countries of the world is insufficient, compared to the provisional recommended dietary allowance (RDA) of 1.0 mg day-1 for a 70 kg adult. Lithium contents of soils are widely variable and the metal has high mobility in soils, making it more prone to leaching, and available for plant uptake. Biofortification studies reveal that plants can accumulate significant quantities of Li in their edible tissues without yield loss and quality associated negative effects. At lower application rates, Li tissue concentration could reach to the level that consuming 100-200 g of Li-biofortified fresh vegetables or mushrooms could support its RDA. It seems impossible to enrich the plants with Li to the levels that allow their application in psychiatric treatments, which requires the dosage of 600-1200 mg day-1. However, there is need to refine the methods of Li biofortification strategies to obtains plant specific concentration of Li in edible parts so that consuming a specific amount could provide the proposed dietary intake requirement.
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Affiliation(s)
- Asif Naeem
- Institute for Plant Nutrition and Soil Science, Kiel University, Hermann Rodewald Strasse 2, D-24118 Kiel, Germany; Nuclear Institute for Agriculture and Biology (NIAB), Jhang Road, 38000 Faisalabad, Pakistan
| | - Muhammad Aslam
- Nuclear Institute for Agriculture and Biology (NIAB), Jhang Road, 38000 Faisalabad, Pakistan
| | - Karl H Mühling
- Institute for Plant Nutrition and Soil Science, Kiel University, Hermann Rodewald Strasse 2, D-24118 Kiel, Germany.
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Losenkov IS, Plotnikov EV, Epimakhova EV, Bokhan NA. [Lithium in the psychopharmacology of affective disorders and mechanisms of its effects on cellular physiology]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:108-115. [PMID: 33340305 DOI: 10.17116/jnevro2020120111108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
However, despite successful use of lithium in the treatment of affective disorders for almost 40 years, the mechanisms of its therapeutic action are still poorly understood. This review presents and summarizes the current literature about the use of lithium in treatment of affective disorders, as well as its effects on cellular physiology, with a separate description of the effect of this ion on the functioning of nerve tissue and ion-molecular mechanisms.
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Affiliation(s)
- I S Losenkov
- Mental Health Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - E V Plotnikov
- Mental Health Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - E V Epimakhova
- Mental Health Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - N A Bokhan
- Mental Health Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
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McKnight RF, de La Motte de Broöns de Vauvert SJ, Chesney E, Amit BH, Geddes J, Cipriani A. Lithium for acute mania. Cochrane Database Syst Rev 2019; 6:CD004048. [PMID: 31152444 PMCID: PMC6544558 DOI: 10.1002/14651858.cd004048.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Bipolar disorder is a common condition associated with high morbidity; developing efficacious, safe treatments is therefore essential. Lithium is an effective maintenance treatment for bipolar disorder. It acts as mood stabiliser and reduces the risk of suicide. However, evidence assessing the efficacy of lithium in the treatment of acute mania is less robust. Current evidence-based guidelines cite multiple anti-dopaminergic and mood-stabilising agents as initial treatments: more definite evidence is needed to decide if lithium should be the first-line therapy. OBJECTIVES 1. To assess the effects of lithium in comparison with placebo or other active treatment in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder.2. To review the acceptability and tolerability of treatment with lithium in comparison with placebo or other active treatments in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, and PsycINFO. We also searched the World Health Organization trials portal (ICTRP) and ClinicalTrials.gov. We checked the reference lists of all included studies and relevant systematic reviews. We have incorporated studies from searches to 18 May 2018 into the current analyses. SELECTION CRITERIA Prospective randomised controlled studies comparing lithium with placebo or alternative drug treatment in treatment of acute mania. We included anyone with bipolar disorder, male and female, of any age. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data and assessed methodological quality. We used odds ratios (ORs) to analyse binary efficacy outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuously distributed outcomes. We used a fixed-effect model unless heterogeneity was moderate or substantial, in which case we used a random-effects model. We used Review Manager 5 to analyse data. We assessed the certainty of evidence for individual outcomes using the GRADE approach. MAIN RESULTS We found 36 randomised controlled studies comparing lithium with placebo, one of 12 drugs, or electroconvulsive therapy for treatment of acute mania. Studies included male and female participants (n = 4220), of all ages, who all fitted criteria for a manic episode within the context of a diagnosis of bipolar disorder.Risk of bias was variable; 12 studies had a high risk of bias in one domain and 27 gave inadequate information on randomisation leading to an 'unclear' rating for selection bias.Lithium versus placeboHigh-certainty evidence found that lithium was an effective treatment for acute mania and was more effective than placebo at inducing a response (OR 2.13, 95% confidence interval (CI) 1.73 to 2.63; participants = 1707; studies = 6; I2 = 16%; high-certainty evidence), or remission (OR 2.16, 95% CI 1.73 to 2.69; participants = 1597; studies = 5; I2 = 21%; high-certainty evidence).Lithium was more likely than placebo to cause tremor (OR 3.25, 95% CI 2.10 to 5.04; participants = 1241; studies = 6; I2 = 0%; high-certainty evidence), and somnolence (OR 2.28, 95% CI 1.46 to 3.58; participants = 1351; studies = 7; I2 = 0%; high-certainty evidence).There was insufficient evidence to determine the effect of lithium for all-cause dropouts (OR 0.76; 95% CI 0.46 to 1.25; participants = 1353; studies = 7; I2 = 75%; moderate-certainty evidence), and weight gain (OR 1.48, 95% CI 0.56 to 3.92; participants = 735, studies = 3; I2= 51%; moderate-certainty evidence).Lithium versus antipsychotics or mood stabilisersFor the outcome of inducing a response, there was only very low-certainty evidence regarding lithium compared to haloperidol (MD -2.40, 95% CI -6.31 to 1.50; participants = 80; studies = 3; I2 = 95%), quetiapine (OR 0.66, 95% CI 0.28 to 1.55; participants = 335; studies = 2; I2 = 71%), and carbamazepine (SMD 0.21, 95% CI -0.18 to 0.60; participants = 102; studies = 3; I2 = 0%).Lithium was probably less likely to induce a response than olanzapine (OR 0.44, 95% CI 0.20 to 0.94; participants = 180; studies = 2; I2 = 0%; moderate-certainty evidence).Lithium may be less likely to induce a response than risperidone (MD 7.28, 95% CI 5.22 to 9.34; participants = 241; studies = 3; I2 = 49%; low-certainty evidence).There was no evidence of a difference between lithium and valproate (OR 1.22, 95% CI 0.87 to 1.70; participants = 607; studies = 5; I2 = 22%; moderate-certainty evidence).There was moderate-certainty evidence that lithium was more effective than topiramate at treating acute mania (OR 2.28, 95% CI 1.63 to 3.20; participants = 660; studies = 1).Data on adverse events for these comparisons contained too few studies to provide high-certainty evidence. AUTHORS' CONCLUSIONS This systematic review indicates that lithium is more effective than placebo as a treatment for acute mania but increases the risk for somnolence and tremor. Limited evidence suggests little or no difference between lithium and other mood stabilisers (valproate, carbamazepine) or antipsychotics (risperidone, quetiapine, haloperidol). Olanzapine may be an exception, as it is probably slightly more effective than lithium. There is uncertain evidence that risperidone may also be more effective than lithium. Lithium is probably more effective at treating acute mania than topiramate. When compared to placebo, lithium was more likely to cause adverse events. However, when compared to other drugs, too few studies provided data on adverse effects to provide high-certainty evidence. More, rigorously designed, large-scale studies are needed to definitively conclude if lithium is superior to other interventions in treating acute mania.
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Affiliation(s)
- Rebecca F McKnight
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
| | | | - Edward Chesney
- Institute of Psychiatry, Psychology and Neuroscience, King's College LondonDepartment of Psychosis StudiesDe Crespigny ParkLondonUKSE5 8AF
| | - Ben H Amit
- Tel Aviv UniversityDepartment of Psychiatry, Sackler Faculty of MedicineTel AvivIsrael
| | - John Geddes
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
- Oxford Health NHS Foundation TrustWarneford HospitalOxfordUK
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalWarneford LaneOxfordUKOX3 7JX
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Shoja Shafti S, Kaviani H. Extended-release carbamazepine versus lithium in management of acute mania in male inpatients with bipolar I disorder. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1449181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Saeed Shoja Shafti
- Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences (USWR), Razi Psychiatric Hospital, Tehran, Iran
| | - Hamid Kaviani
- Department of Psychiatry, University of Azad, Tehran, Iran
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Morsel AM, Morrens M, Sabbe B. An overview of pharmacotherapy for bipolar I disorder. Expert Opin Pharmacother 2018; 19:203-222. [PMID: 29361880 DOI: 10.1080/14656566.2018.1426746] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Bipolar I disorder (BD I) is complex with a chronic course that significantly impacts a sufferer's quality of life. As of right now, there are many available treatments that aim to rapidly treat manic or depressive episodes and stabilize mood. The purpose of this report is to provide an up-to-date comprehensive review of the available evidence-based trials of pharmacotherapy for the treatment of BD I. AREAS COVERED This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of current pharmacotherapy in adults with BD I from phase III to clinical practice. Monotherapy and combination therapy for acute and long-term treatment were reviewed for this purpose. EXPERT OPINION There are many treatments available for BD mania; however, the depressive and stabilization phases of the illness remain a clinical challenge. Unfortunately, randomized controlled trials do not represent 'real world' patients, as their strict inclusion and exclusion criteria do not allow for different features sometimes present in patients to be considered. Research efforts must also focus on treating cognitive deficits, which adds to lower functional outcome. The authors believe that there is dire need for new, more targeted treatments in BD I, with a critical view of the side effects.
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Affiliation(s)
- Anne Michal Morsel
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium
| | - Manuel Morrens
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium.,b Psychiatric University Hospital Duffel - University Hospital Antwerp , Duffel , Belgium
| | - Bernard Sabbe
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium.,b Psychiatric University Hospital Duffel - University Hospital Antwerp , Duffel , Belgium
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An Oldie but Goodie: Lithium in the Treatment of Bipolar Disorder through Neuroprotective and Neurotrophic Mechanisms. Int J Mol Sci 2017; 18:ijms18122679. [PMID: 29232923 PMCID: PMC5751281 DOI: 10.3390/ijms18122679] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/04/2017] [Accepted: 12/07/2017] [Indexed: 12/21/2022] Open
Abstract
Lithium has been used for the treatment of bipolar disorder (BD) for the last sixty or more years, and recent studies with more reliable designs and updated guidelines have recommended lithium to be the treatment of choice for acute manic, mixed and depressive episodes of BD, along with long-term prophylaxis. Lithium’s specific mechanism of action in mood regulation is progressively being clarified, such as the direct inhibition on glycogen synthase kinase 3β, and its various effects on neurotrophic factors, neurotransmitters, oxidative metabolism, apoptosis, second messenger systems, and biological systems are also being revealed. Furthermore, lithium has been proposed to exert its treatment effects through mechanisms associated with neuronal plasticity. In this review, we have overviewed the clinical aspects of lithium use for BD, and have focused on the neuroprotective and neurotrophic effects of lithium.
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Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, Kasper S, Moeller HJ. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 2: Review, Grading of the Evidence, and a Precise Algorithm. Int J Neuropsychopharmacol 2017; 20:121-179. [PMID: 27816941 PMCID: PMC5409012 DOI: 10.1093/ijnp/pyw100] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 02/05/2023] Open
Abstract
Background The current paper includes a systematic search of the literature, a detailed presentation of the results, and a grading of treatment options in terms of efficacy and tolerability/safety. Material and Methods The PRISMA method was used in the literature search with the combination of the words 'bipolar,' 'manic,' 'mania,' 'manic depression,' and 'manic depressive' with 'randomized,' and 'algorithms' with 'mania,' 'manic,' 'bipolar,' 'manic-depressive,' or 'manic depression.' Relevant web pages and review articles were also reviewed. Results The current report is based on the analysis of 57 guideline papers and 531 published papers related to RCTs, reviews, posthoc, or meta-analysis papers to March 25, 2016. The specific treatment options for acute mania, mixed episodes, acute bipolar depression, maintenance phase, psychotic and mixed features, anxiety, and rapid cycling were evaluated with regards to efficacy. Existing treatment guidelines were also reviewed. Finally, Tables reflecting efficacy and recommendation levels were created that led to the development of a precise algorithm that still has to prove its feasibility in everyday clinical practice. Conclusions A systematic literature search was conducted on the pharmacological treatment of bipolar disorder to identify all relevant random controlled trials pertaining to all aspects of bipolar disorder and graded the data according to a predetermined method to develop a precise treatment algorithm for management of various phases of bipolar disorder. It is important to note that the some of the recommendations in the treatment algorithm were based on the secondary outcome data from posthoc analyses.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Lakshmi Yatham
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Heinz Grunze
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Eduard Vieta
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Allan Young
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Pierre Blier
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Siegfried Kasper
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Hans Jurgen Moeller
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
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Yildiz A, Nikodem M, Vieta E, Correll CU, Baldessarini RJ. A network meta-analysis on comparative efficacy and all-cause discontinuation of antimanic treatments in acute bipolar mania. Psychol Med 2015; 45:299-317. [PMID: 25036226 DOI: 10.1017/s0033291714001305] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence synthesis methods enabling direct and indirect comparisons over the entire set of relevant clinical data produce quantitative point estimates for the treatments contrasts between competing interventions, and provide a hierarchical rank ordering between them. We aimed to provide evidence-based guidance on the efficacy and all-cause discontinuation of antimanic treatments. METHOD We conducted a network meta-analysis within a Bayesian framework. We searched all standard literature databases without language restrictions up to 15 January 2014 to identify reports of short-term, randomized, blinded trials of putative antimanic drugs as monotherapy for adults with bipolar-I mania. RESULTS Altogether, 14256 manic patients randomized to one of 18 active treatments or placebo provided 95 direct comparisons on 128 data points. For the primary outcome, standardized mean difference as Hedges' g (standardized mean difference; SMD), the hierarchies indicated by surface under the cumulative ranking (SUCRA) probabilities were in agreement with the point estimates for all antimanic drugs identified as effective. For the 12 effective antimanic drugs on clinical use, SMDs against placebo ranged from 0.32 to 0.66 without superiority of one over another, except for risperidone v. aripiprazole and valproate. Aripiprazole, olanzapine, quetiapine, risperidone, and valproate had less all-cause discontinuation rates than placebo. Sensitivity analysis by drug class indicated similar efficacy profiles for haloperidol, second-generation antipsychotics, and mood stabilizers. CONCLUSIONS Hierarchical rank ordering by comparative efficacy and risk of all-cause discontinuations should help to guide antimanic treatment choices by clinicians, healthcare policy makers, and guideline developers.
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Affiliation(s)
- A Yildiz
- Department of Psychiatry,Dokuz Eylül University,Izmir,Turkey
| | - M Nikodem
- Faculty of Applied Mathematics,AGH University of Science and Technology,Krakow,Poland
| | - E Vieta
- International Consortium for Bipolar Disorder Research & Psychopharmacology Program, McLean Division of Massachusetts General Hospital,Boston, MA,USA
| | - C U Correll
- Division of Psychiatry Research, Department of Psychiatry,Zucker Hillside Hospital,New York, NY,USA
| | - R J Baldessarini
- International Consortium for Bipolar Disorder Research & Psychopharmacology Program, McLean Division of Massachusetts General Hospital,Boston, MA,USA
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The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania. Harv Rev Psychiatry 2014; 22:274-94. [PMID: 25188733 DOI: 10.1097/hrp.0000000000000018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This new algorithm for the pharmacotherapy of acute mania was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The authors conducted a literature search in PubMed and reviewed key studies, other algorithms and guidelines, and their references. Treatments were prioritized considering three main considerations: (1) effectiveness in treating the current episode, (2) preventing potential relapses to depression, and (3) minimizing side effects over the short and long term. The algorithm presupposes that clinicians have made an accurate diagnosis, decided how to manage contributing medical causes (including substance misuse), discontinued antidepressants, and considered the patient's childbearing potential. We propose different algorithms for mixed and nonmixed mania. Patients with mixed mania may be treated first with a second-generation antipsychotic, of which the first choice is quetiapine because of its greater efficacy for depressive symptoms and episodes in bipolar disorder. Valproate and then either lithium or carbamazepine may be added. For nonmixed mania, lithium is the first-line recommendation. A second-generation antipsychotic can be added. Again, quetiapine is favored, but if quetiapine is unacceptable, risperidone is the next choice. Olanzapine is not considered a first-line treatment due to its long-term side effects, but it could be second-line. If the patient, whether mixed or nonmixed, is still refractory to the above medications, then depending on what has already been tried, consider carbamazepine, haloperidol, olanzapine, risperidone, and valproate first tier; aripiprazole, asenapine, and ziprasidone second tier; and clozapine third tier (because of its weaker evidence base and greater side effects). Electroconvulsive therapy may be considered at any point in the algorithm if the patient has a history of positive response or is intolerant of medications.
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Curran G, Ravindran A. Lithium for bipolar disorder: a review of the recent literature. Expert Rev Neurother 2014; 14:1079-98. [DOI: 10.1586/14737175.2014.947965] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Lithium has been used for the treatment of mood disorders for over 60 years, yet the exact mechanisms by which it exerts its therapeutic effects remain unclear. Two enzymatic chains or pathways emerge as targets for lithium: inositol monophosphatase within the phosphatidylinositol signalling pathway and the protein kinase glycogen synthase kinase 3. Lithium inhibits these enzymes through displacing the normal cofactor magnesium, a vital regulator of numerous signalling pathways. Here we provide an overview of evidence, supporting a role for the inhibition of glycogen synthase kinase 3 and inositol monophosphatase in the pharmacodynamic actions of lithium. We also explore how inhibition of these enzymes by lithium can lead to downstream effects of clinical relevance, both for mood disorders and neurodegenerative diseases. Establishing a better understanding of lithium's mechanisms of action may allow the development of more effective and more tolerable pharmacological agents for the treatment of a range of mental illnesses, and provide clearer insight into the pathophysiology of such disorders.
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Affiliation(s)
- Kayleigh M Brown
- Institute of Psychiatry, King's College London, PO Box 63, De Crespigny Park, Denmark Hill, London SE5 8AF, UK
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Malhi GS, Tanious M, Das P, Coulston CM, Berk M. Potential mechanisms of action of lithium in bipolar disorder. Current understanding. CNS Drugs 2013; 27:135-53. [PMID: 23371914 DOI: 10.1007/s40263-013-0039-0] [Citation(s) in RCA: 256] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lithium has been used for over half a century for the treatment of bipolar disorder as the archetypal mood stabilizer, and has a wealth of empirical evidence supporting its efficacy in this role. Despite this, the specific mechanisms by which lithium exerts its mood-stabilizing effects are not well understood. Given the inherently complex nature of the pathophysiology of bipolar disorder, this paper aims to capture what is known about the actions of lithium ranging from macroscopic changes in mood, cognition and brain structure, to its effects at the microscopic level on neurotransmission and intracellular and molecular pathways. A comprehensive literature search of databases including MEDLINE, EMBASE and PsycINFO was conducted using relevant keywords and the findings from the literature were then reviewed and synthesized. Numerous studies report that lithium is effective in the treatment of acute mania and for the long-term maintenance of mood and prophylaxis; in comparison, evidence for its efficacy in depression is modest. However, lithium possesses unique anti-suicidal properties that set it apart from other agents. With respect to cognition, studies suggest that lithium may reduce cognitive decline in patients; however, these findings require further investigation using both neuropsychological and functional neuroimaging probes. Interestingly, lithium appears to preserve or increase the volume of brain structures involved in emotional regulation such as the prefrontal cortex, hippocampus and amygdala, possibly reflecting its neuroprotective effects. At a neuronal level, lithium reduces excitatory (dopamine and glutamate) but increases inhibitory (GABA) neurotransmission; however, these broad effects are underpinned by complex neurotransmitter systems that strive to achieve homeostasis by way of compensatory changes. For example, at an intracellular and molecular level, lithium targets second-messenger systems that further modulate neurotransmission. For instance, the effects of lithium on the adenyl cyclase and phospho-inositide pathways, as well as protein kinase C, may serve to dampen excessive excitatory neurotransmission. In addition to these many putative mechanisms, it has also been proposed that the neuroprotective effects of lithium are key to its therapeutic actions. In this regard, lithium has been shown to reduce the oxidative stress that occurs with multiple episodes of mania and depression. Further, it increases protective proteins such as brain-derived neurotrophic factor and B-cell lymphoma 2, and reduces apoptotic processes through inhibition of glycogen synthase kinase 3 and autophagy. Overall, it is clear that the processes which underpin the therapeutic actions of lithium are sophisticated and most likely inter-related.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Sydney Medical School, University of Sydney, and Department of Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia.
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Fountoulakis KN, Kasper S, Andreassen O, Blier P, Okasha A, Severus E, Versiani M, Tandon R, Möller HJ, Vieta E. Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry. Eur Arch Psychiatry Clin Neurosci 2012; 262 Suppl 1:1-48. [PMID: 22622948 DOI: 10.1007/s00406-012-0323-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, 6 Odysseos str./1st Parodos Ampelonon str., Pylaia, Thessaloniki, Greece.
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Abstract
INTRODUCTION Despite more that 60 years of clinical experience, the effective use of lithium for the treatment of mood disorder, in particular bipolarity, is in danger of becoming obsolete. In part, this is because of exaggerated fears surrounding lithium toxicity, acute and long-term tolerability and the encumbrance of life-long plasma monitoring. Recent research has once again positioned lithium centre stage and amplified the importance of understanding its science and how this translates to clinical practice. OBJECTIVE The aim of this paper is to provide a sound knowledge base as regards the science and practice of lithium therapy. METHOD A comprehensive literature search using electronic databases was conducted along with a detailed review of articles known to the authors pertaining to the use of lithium. Studies were limited to English publications and those dealing with the management of psychiatric disorders in humans. The literature was synthesized and organized according to relevance to clinical practice and understanding. RESULTS Lithium has simple pharmacokinetics that require regular dosing and monitoring. Its mechanisms of action are complex and its effects are multi-faceted, extending beyond mood stability to neuroprotective and anti-suicidal properties. Its use in bipolar disorder is under-appreciated, particularly as it has the best evidence for prophylaxis, qualifying it perhaps as the only true mood stabilizer currently available. In practice, its risks and tolerability are exaggerated and can be readily minimized with knowledge of its clinical profile and judicious application. CONCLUSION Lithium is a safe and effective agent that should, whenever indicated, be used first-line for the treatment of bipolar disorder. A better understanding of its science alongside strategic management of its plasma levels will ensure both wider utility and improved outcomes.
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Affiliation(s)
- Gin S Malhi
- CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, Australia.
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