1
|
Tundo A, Musetti L, Betrò S, Cambiali E, de Filippis R, Marazziti D, Mucci F, Proietti L, Dell’Osso L. Are anxious and mixed depression two sides of the same coin? Similarities and differences in patients with bipolar I, II and unipolar disorders. Eur Psychiatry 2023; 66:e75. [PMID: 37697671 PMCID: PMC10594275 DOI: 10.1192/j.eurpsy.2023.2445] [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: 12/27/2022] [Revised: 03/28/2023] [Accepted: 05/13/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Diagnostic criteria are not always useful to discriminate major depression with anxious distress (ADS-D; Diagnostic and Statistical Manual for Mental Disorders, version-5 [DSM-5] criteria) from mixed depression (Koukopoulos' criteria; KMX-D). So, clinicians need alternative tools to improve their diagnostic ability and to choose the most appropriate treatment. The aim of the present study is to identify socio-demographic and clinical features that discriminate patients with ADS-D from those with KMX-D. METHODS Two hundred and forty-one consecutive outpatients with unipolar (51%) and bipolar (49%) disorder, fulfilling DSM-5 criteria for a current major depressive episode (MDE) and with a 21-item Hamilton Depression Rating Scale score ≥ 14, were recruited and treated in a prospective observational study. RESULTS Ten percent of patients met criteria for KMX-D, 22% ADS-D, and 37% for both. Irritable premorbid temperament, mixed depression polarity at onset, mixed depression recurrence, and a high number of mania symptoms at intake were typical features of patients with KMX-D. Depressive polarity at onset, a low number of mania symptoms at intake, and generalized anxiety disorder comorbidity were typical features of patients with ADS-D. Multinomial logistic regression confirmed that higher rate of irritable temperament and higher Young Mania Rating Scale total score differentiated patients with KMX-D from patients with pure MDE. CONCLUSION Our findings suggest some clinical features that could help differentiate between ADS-D and KMX-D in patients meeting both conditions and to select the appropriate treatment. However, the small sample size may have limited the power to detect differences between the groups. Further research is needed to confirm the results of present study.
Collapse
Affiliation(s)
| | - Laura Musetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Erika Cambiali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Donatella Marazziti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Mucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | | | - Liliana Dell’Osso
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
2
|
Tundo A, Betro' S, de Filippis R, Marchetti F, Nacca D, Necci R, Iommi M. Pramipexole Augmentation for Treatment-Resistant Unipolar and Bipolar Depression in the Real World: A Systematic Review and Meta-Analysis. Life (Basel) 2023; 13:life13041043. [PMID: 37109571 PMCID: PMC10141126 DOI: 10.3390/life13041043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/12/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Pramipexole is a dopamine full agonist approved for the treatment of Parkinson's disease and restless legs syndrome. Its high affinity for the D3 receptor and neuroprotective, antioxidant, and anti-inflammatory activity provides a rationale for the treatment of depression. In this paper, we review studies on the effectiveness and safety of antidepressant pramipexole augmentation in treatment-resistant depression. METHODS This comprehensive systematic review and meta-analysis of observational studies on pramipexole-antidepressant augmentation included patients with resistant unipolar and bipolar depression. The primary outcome measure was the treatment response, measured at the study endpoint. RESULTS We identified 8 studies including 281 patients overall, 57% women and 39.5% with bipolar disorder and 60.5% with major depressive disorder. The mean follow-up duration was 27.3 weeks (range 8-69). The pooled estimate of treatment response was 62.5%, without significant differences between unipolar and bipolar depression. Safety was good, with nausea and somnolence the most frequent side effects. CONCLUSIONS The findings of this systematic review, needing further confirmation, show that off-label use of pramipexole as augmentation of antidepressant treatment could be a useful and safe strategy for unipolar and bipolar treatment-resistant depression.
Collapse
Affiliation(s)
- Antonio Tundo
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Sophia Betro'
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Rocco de Filippis
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Fulvia Marchetti
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Daniele Nacca
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Roberta Necci
- Istituto di Psicopatologia, Via Girolamo da Carpi, 1, 00196 Rome, Italy
| | - Marica Iommi
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40126 Bologna, Italy
| |
Collapse
|
3
|
Which patients with bipolar depression receive antidepressant augmentation? Results from an observational multicenter study. CNS Spectr 2022; 27:731-739. [PMID: 34505564 DOI: 10.1017/s109285292100078x] [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] [Indexed: 01/29/2023]
Abstract
BACKGROUND To identify demographic and clinical characteristics of bipolar depressed patients who require antidepressant (AD) augmentation, and to evaluate the short- and long-term effectiveness and safety of this therapeutic strategy. METHODS One hundred twenty-two bipolar depressed patients were consecutively recruited, 71.7% of them received mood stabilizers (MS)/second-generation antipsychotics (SGA) with AD-augmentation and 28.3% did not. Patients were evaluated at baseline, and after 12 weeks and 15 months of treatment. RESULTS The AD-augmentation was significantly higher in patients with bipolar II compared with bipolar I diagnosis. Patients with MS/SGA + AD had often a seasonal pattern, depressive polarity onset, depressive index episode with anxious features, a low number of previous psychotic and (hypo)manic episodes and of switch. They had a low irritable premorbid temperament, a low risk of suicide attempts, and a low number of manic symptoms at baseline. After 12 weeks of treatment, 82% of patients receiving ADs improved, 58% responded and 51% remitted, 3.8% had suicidal thoughts or projects, 6.1% had (hypo)manic switch, and 4.1% needed hospitalization. During the following 12 months, 92% of them remitted from index episode, 25.5% did not relapse, and 11% needed hospitalization. Although at the start advantaged, patients with AD-augmentation, compared with those without AD-augmentation, did not significantly differ on any outcome as well on adverse events in the short- and long-term treatment. CONCLUSION Our findings indicate that ADs, combined with MS and/or SGA, are short and long term effective and safe in a specific subgroup for bipolar depressed patients.
Collapse
|
4
|
Distinct Effects of Antidepressants in Association With Mood Stabilizers and/or Antipsychotics in Unipolar and Bipolar Depression. J Clin Psychopharmacol 2022; 42:118-124. [PMID: 35067518 DOI: 10.1097/jcp.0000000000001500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND There is a dearth of studies comparing the clinical outcomes of patients with treatment-resistant unipolar (TRD) depression and depression in bipolar disorder (BD) despite similar treatment strategies. We aimed to evaluate the effects of the pharmacological combinations (antidepressants [AD], mood stabilizers [MS], and/or antipsychotics [AP]) used for TRD and BD at the McGill University Health Center. METHODS/PROCEDURES We reviewed health records of 206 patients (76 TRD 130 BD) with TRD and BD treated with similar augmentation strategies including AD with MS (AD+MS) or AP (AD+AP) or combination (AD+AP+MS). Clinical outcomes were determined by comparing changes on the 17-time Hamilton Depression Rating Scale (HAMD-17), Quick Inventory of Depressive Symptomatology, and Clinical Global Impression-Severity of Illness at the beginning (T0) and after 3 months of an unchanged treatment (T3). FINDINGS/RESULTS Baseline HAMD-17 scores in TRD were higher than in BD (P < 0.001), but TRD patients had a greater improvement at end point (P = 0.003). Antidepressants with AP generated greater reductions in HAMD-17 in TRD compared with BD (P = 0.02). Importantly, in BD patients, the addition of AD compared with other treatment strategies failed to improve the outcome. The limitations of this study include possibly unrepresentative subjects from tertiary care settings, incomplete matching of BD and TRD subjects, nonrandomized treatment with unmatched agents, doses, and times, unknown treatment adherence, and nonblinded retrospective outcome assessments. Nevertheless, the findings may reflect real-world interactions of clinically selected pharmacotherapies. IMPLICATIONS/CONCLUSIONS Combination of augmentation strategies such as AD+AP and/or MS showed a better clinical improvement in patients with TRD compared with BD suggesting a limited evidence for AD potentiation in BD.
Collapse
|
5
|
Efficacy and safety of 24-week pramipexole augmentation in patients with treatment resistant depression. A retrospective cohort study. Prog Neuropsychopharmacol Biol Psychiatry 2022; 112:110425. [PMID: 34375683 DOI: 10.1016/j.pnpbp.2021.110425] [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] [Received: 02/28/2021] [Revised: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 12/13/2022]
Abstract
Pramipexole is a dopamine agonist with potential antidepressant, neuroprotective, antioxidant and anti-inflammatory activity. In the present study we investigated the 24 weeks effect and safety of traditional AD augmentation with pramipexole for treatment-resistant depression. The study includes 116 patients, 37 (32%) with bipolar disorders and 79 (68%) with major depressive disorder, who failed to respond to at least 2 ADs trials of different classes and that were treated with AD augmented with pramipexole. Mood stabilizers and/or second-generation antipsychotics were added in patients with bipolar or mixed depression. Exclusion criteria were psychotic depression, rapid cycling bipolar course and previous unsuccessful treatment with pramipexole. After 24 weeks of pramipexole augmentation (median max dose 1.05 mg/day, IQR 0.72-1.08) 74.1% of patients responded (≥50% reduction of baseline Hamilton Depression Rating Scale21 total score) and 66.4% remitted (Hamilton Depression Rating Scale21 total score < 7). Global Assessment of Functioning score significantly increase from 53 (50-60) at baseline to 80 (71-81) at 24 weeks (Wilcoxon signed rank test = 8.174, p < 0.001]. Ten patients (8.6%) dropped out (8 due to side effects and 2 for lack of efficacy) and 1 experienced an induced hypomanic switch. No patient committed a suicide attempt, had suicidal ideation, needed hospitalization, reported lethargy, gambling, hypersexuality and compulsive shopping. The limitations of the study are the observational design, the lack of a control group, the inclusion of outpatients only, the unblinded outcomes assessment, and the flexibility of the add-on schedule. The findings of the present study showed that off-label use of pramipexole as augmentation of traditional AD is an effective and safe 24 weeks treatment of resistant unipolar and bipolar depression. These results need confirmation from randomized clinical trials on larger samples.
Collapse
|
6
|
Tundo A, Musetti L, Del Grande C, de Filippis R, Proietti L, Cambiali E, Franceschini C, Dell'Osso L. Is short-term antidepressant treatment effective and safe in bipolar depression? Results from an observational multicenter study. Hum Psychopharmacol 2021; 36:e2773. [PMID: 33351233 DOI: 10.1002/hup.2773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/27/2020] [Accepted: 12/01/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To investigate the short-term effectiveness and the short-term and long-term safety of acute antidepressant (AD) treatment of bipolar depression in a naturalistic setting. METHODS Patients with bipolar (n = 86) or unipolar (n = 111) depression were consecutively recruited and treated with AD (combined with mood stabilizer [MS] and/or second-generation antipsychotics in bipolar depression). Exclusion criteria were mixed depression, high mood instability, previous predominantly mixed depression (both bipolar and unipolar depression), rapid cycling course and previous switch AD-emerging (bipolar depression). RESULTS After 12 weeks of treatment, no difference was found in remission, response and improvement rates between bipolar and unipolar depression. Concerning short-term safety, switching and suicidality did not differ significantly between the two groups, and no suicide attempt was observed. Concerning long-term safety, patients with bipolar depression had a significant reduction of depressive and total recurrences during the year of follow-up, compared to the year before entering the study, without significant changes in (hypo)mania and mixed depression recurrences, and suicide rates. CONCLUSIONS Acute AD treatment of bipolar depression is effective in the short-term and safe in the short- and long-term, when administered in combination with MSs and/or second-generation antipsychotics, with a low risk of switch, mixed depression and cycle acceleration.
Collapse
Affiliation(s)
| | - Laura Musetti
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Claudia Del Grande
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | | | | | - Erika Cambiali
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Caterina Franceschini
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| |
Collapse
|
7
|
Rhee TG, Olfson M, Nierenberg AA, Wilkinson ST. 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. Am J Psychiatry 2020; 177:706-715. [PMID: 32312111 PMCID: PMC7577523 DOI: 10.1176/appi.ajp.2020.19091000] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Pharmacological options for treating bipolar disorder have increased over the past 20 years, with several second-generation antipsychotics receiving regulatory approval in the 1990s. The authors describe trends in use of pharmacological agents in the outpatient management of bipolar disorder. METHODS Using nationally representative data from the 1997-2016 National Ambulatory Medical Care Surveys, the authors examined trends in the use of mood stabilizers, first- and second-generation antipsychotics, and antidepressants among psychiatrist visits for which bipolar disorder was listed among the primary diagnoses. A logistic regression model was used to identify statistically significant trends, with covariates including age, gender, race/ethnicity, and primary insurance. RESULTS Antipsychotics were increasingly more commonly prescribed, increasing from 12.4% of outpatient visits for bipolar disorder in the 1997-2000 period to 51.4% in the 2013-2016 period (adjusted odds ratio=5.05, 95% CI=3.65-7.01). Use of mood stabilizers decreased from 62.3% of visits for bipolar disorder in the 1997-2000 period to 26.4% in the 2013-2016 period (adjusted odds ratio=0.18, 95% CI=0.13-0.27). Prescription of antidepressants occurred in 47.0% of visits for bipolar disorder in the 1997-2000 period and 57.5% in the 2013-2016 period. Prescription of an antidepressant without a mood stabilizer increased substantially, from 17.9% in the 1997-2000 period to 40.9% in the 2013-2016 period (adjusted odds ratio=2.88, 95% CI=2.06-4.03). CONCLUSIONS Substantial changes have occurred in the treatment of bipolar disorder over the past 20 years, with second-generation antipsychotics in large measure supplanting traditional mood stabilizers. Antidepressant prescriptions persisted despite a lack of evidence for their efficacy in bipolar disorder and concerns about increasing the risk of mania. Research is needed to compare the real-world effectiveness and tolerability of newer antipsychotics with those of traditional mood stabilizers.
Collapse
Affiliation(s)
- Taeho Greg Rhee
- Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT,Department of Psychiatry, School of Medicine, Yale University, New Haven, CT
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Andrew A. Nierenberg
- Center of Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA,Department of Psychiatry, Harvard Medical School, Harvard University, Boston, MA
| | - Samuel T. Wilkinson
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT
| |
Collapse
|
8
|
Cheniaux E, Nardi AE. Evaluating the efficacy and safety of antidepressants in patients with bipolar disorder. Expert Opin Drug Saf 2019; 18:893-913. [DOI: 10.1080/14740338.2019.1651291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Elie Cheniaux
- Departamento de Psiquiatria e Medicina Legal, Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
- Departamento de Especialidades Médicas, Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM/UERJ), Rio de Janeiro, Brazil
| | - Antonio E. Nardi
- Departamento de Psiquiatria e Medicina Legal, Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
| |
Collapse
|
9
|
Tundo A, de Filippis R, De Crescenzo F. Pramipexole in the treatment of unipolar and bipolar depression. A systematic review and meta-analysis. Acta Psychiatr Scand 2019; 140:116-125. [PMID: 31111467 DOI: 10.1111/acps.13055] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Several depressed patients do not respond to traditional antidepressants. Our aim was to systematically review the effectiveness and safety of pramipexole in unipolar and bipolar depression. METHODS We conducted a systematic review of randomized clinical trials (RCTs) and observational studies on pramipexole for patients with major depressive episodes, following PRISMA guidelines. Our primary outcome measure was treatment response at endpoint. The study protocol was registered on PROSPERO: CRD42018108699. RESULTS We found five RCTs, three open-label trials and five observational studies, with 504 participants (57% women; mean age, 45.3 years; mean sample size, 39; median duration of treatment, 8 weeks; mean follow-up duration, 45 weeks; mean maximum dose, 1.62 mg). We found an overall short-term response rate of 52.2% and remission rate of 36.1%, and an overall long-term response rate of 62.1% and remission rate of 39.6%. In RCTs, patients treated with pramipexole had a superior response rate compared with placebo (RR: 1.77; 95% CI: 1.11-2.82) and similar to SSRIs (RR: 0.93; 95% CI: 0.44-1.95). Acceptability and tolerability were good, with nausea being the most frequent side-effect. CONCLUSION Our study found some evidence for an effect of pramipexole for the treatment of major depressive episodes.
Collapse
Affiliation(s)
- A Tundo
- Istituto di Psicopatologia, Rome, Italy
| | | | - F De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, UK.,Department (DPUO), Pediatric University Hospital, Bambino Gesù Children's Hospital, Rome, Italy.,Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| |
Collapse
|
10
|
Tundo A, Musetti L, de Filippis R, Grande CD, Falaschi V, Proietti L, Dell'Osso L. Is there a relationship between depression with anxious distress DSM-5 specifier and bipolarity? A multicenter cohort study on patients with unipolar, bipolar I and II disorders. J Affect Disord 2019; 245:819-826. [PMID: 30699865 DOI: 10.1016/j.jad.2018.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/02/2018] [Accepted: 11/03/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND To estimate the prevalence of DSM-5 anxious distress specifier (ADS) in depressed patients with major depressive disorder (MDD) or bipolar I or II disorder (BD), and to compare socio-demographic and clinical characteristics, and response to naturalistic short-term treatment between ADS and non-ADS group. METHODS 241 outpatients with a major depressive episode (MDE) were consecutively recruited. Outcome were remission (HDRS21 total score < 7), response (≥50% reduction of baseline HDRS21) and improvement (CGI-i score ≤ 2) after 12 weeks of treatment sustained for 4 weeks. RESULTS ADS was more frequent in BD than in MDD (respectively, 66.9% and 51.2%, χ2 = 6.1, p = 0.013). Compared with those non-ADS, patients with ADS had more severe depressive (respectively, HDRS21 total score 20.0 ± 4.4 and 18.6 ± 3.9, t-test = 2.67, p = 0.008) and mania symptoms (respectively, Y-MRS total score 2.2 ± 2.9 and 1.3 ± 2.3, M-W-test = 2.86; p = 0.004) at intake, a higher rate of BD family history (respectively, 35.2% and 22.2%, Χ2-test 10.4, p = 0.004) and more previous hypomanic episodes (respectively, (median (range) 0 (0-20) and 0 (0-15), MW-test = 2.39 p = 0.017). In the MDD group, patients with ADS had higher scores on hyperthymic temperament and mania symptoms (Y-MRS total score (median (range) 2.2 (0-26) and 0 (0-11), respectively, M-W test 2.071, p = 0.038). ADS and no-ADS patients did not significantly differ on outcome measures. LIMITATIONS The observational nature of the study and the absence of blinding in outcome assessment. CONCLUSIONS ADS is the most common DSM-5 specifier for MDE, is more frequent in BD and need a personalized treatment with moderate use of antidepressants, mostly tricyclic.
Collapse
Affiliation(s)
| | - Laura Musetti
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, Pisa 56100, Italy.
| | | | - Claudia Del Grande
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, Pisa 56100, Italy
| | - Valentina Falaschi
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, Pisa 56100, Italy
| | | | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, Pisa 56100, Italy
| |
Collapse
|
11
|
Fornaro M, Anastasia A, Monaco F, Novello S, Fusco A, Iasevoli F, De Berardis D, Veronese N, Solmi M, de Bartolomeis A. Clinical and psychopathological features associated with treatment-emergent mania in bipolar-II depressed outpatients exposed to antidepressants. J Affect Disord 2018. [PMID: 29525354 DOI: 10.1016/j.jad.2018.02.085] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Treatment-emergent affective switch (TEAS), including treatment-emergent mania (TEM), carry significant burden in the clinical management of bipolar depression, whereas the use of antidepressants raises both efficacy, safety and tolerability concerns. The present study assesses the prevalence and clinical correlates of TEM in selected sample of Bipolar Disorder (BD) Type-II (BD-II) acute depression outpatients. METHODS Post-hoc analysis of the clinical and psychopathological features associated with TEM among 91 BD-II depressed outpatients exposed to antidepressants. RESULTS Second-generation antipsychotics (SGA) (p = .005), lithium (≤ .001), cyclothymic/irritable/hyperthymic temperaments (p = ≤ .001; p = .001; p = .003, respectively), rapid-cycling (p = .005) and depressive mixed features (p = .003) differed between TEM+ cases vs. TEM- controls. Upon multinomial logistic regression, the accounted psychopathological features correctly classified as much as 88.6% of TEM+ cases (35/91 overall sample, or 38.46% of the sample), yet not statistically significantly [Exp(B) = .032; p = ns]. Specifically, lithium [B = - 2.385; p = .001], SGAs [B = - 2.354; p = .002] predicted lower rates of TEM+ in contrast to the number of lifetime previous psychiatric hospitalizations [B = 2.380; p = .002], whereas mixed features did not [B = 1.267; p = ns]. LIMITATIONS Post-hoc analysis. Lack of systematic pharmacological history record; chance of recall bias and Berkson's biases. Permissive operational criterion for TEM. Relatively small sample size. CONCLUSIONS Cyclothymic temperament and mixed depression discriminated TEM+ between TEM- cases, although only lithium and the SGAs reliably predicted TEM+/- grouping. Larger-sampled/powered longitudinal replication studies are warranted to allow firm conclusions on the matter, ideally contributing to the identification of clear-cut sub-phenotypes of BD towards patient-tailored-pharmacotherapy.
Collapse
Affiliation(s)
- Michele Fornaro
- New York State Psychiatric Institute, Columbia University, NYC, NY, USA; Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Annalisa Anastasia
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Francesco Monaco
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neuroscience, University of Salerno, Salerno, Italy.
| | - Stefano Novello
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Andrea Fusco
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Felice Iasevoli
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| | - Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital "G. Mazzini", ASL 4, 64100 Teramo, Italy.
| | | | - Marco Solmi
- Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy.
| | - Andrea de Bartolomeis
- Federico II University, Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Naples, Italy.
| |
Collapse
|
12
|
Is Ketamine the Future Clozapine for Depression? A Case Series and Literature Review on Maintenance Ketamine in Treatment-resistant Depression With Suicidal Behavior. J Psychiatr Pract 2018; 24:279-291. [PMID: 30427812 DOI: 10.1097/pra.0000000000000316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.
Collapse
|
13
|
Fornaro M, Anastasia A, Novello S, Fusco A, Solmi M, Monaco F, Veronese N, De Berardis D, de Bartolomeis A. Incidence, prevalence and clinical correlates of antidepressant-emergent mania in bipolar depression: a systematic review and meta-analysis. Bipolar Disord 2018; 20:195-227. [PMID: 29441650 DOI: 10.1111/bdi.12612] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 12/15/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment-emergent mania (TEM) represents a common phenomenon inconsistently reported across primary studies, warranting further assessment. METHODS A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were conducted. Major electronic databases were searched from inception to May 2017 to assess the incidence and prevalence rates and clinical features associated with manic switch among bipolar depressed patients receiving antidepressants, using meta-regression and subgroup analysis. RESULTS Overall, 10 098 depressed patients with bipolar disorder (BD) across 51 studies/arms were included in the quantitative analysis. The cumulative incidence of cases (TEM+ ) among 4767 patients with BD over 15 retrospective studies was 30.9% (95% confidence interval [CI] 19.6-45.0%, I2 = 97.9%). The cumulative incidence of TEM+ among 1929 patients with BD over 12 prospective open studies was 14.4% (95% CI 7.4-26.1%, I2 = 93.7%). The cumulative incidence of TEM+ among 1316 patients with BD over 20 randomized controlled trials (RCTs) was 11.8% (95% CI 8.4-16.34%, I2 = 73.46%). The pooled prevalence of TEM+ among 2086 patients with BD over four cross-sectional studies was 30.9% (95% CI 18.1-47.4%, I2 = 95.6%). Overall, concurrent lithium therapy predicted the lowest TEM rates. Inconsistent operational definitions of TEM were recorded, and the lack of information about age, sex, co-occurring anxiety, and other clinically relevant moderators precluded further stratification of the results. CONCLUSIONS Rates of TEM vary primarily depending on study setting, which is concordant with the high degree of heterogeneity of the included records. Forthcoming RCT studies should adopt consistent operational definitions of TEM and broaden the number of moderators, in order to contribute most effectively to the identification of clear-cut sub-phenotypes of BD and patient-tailored pharmacotherapy.
Collapse
Affiliation(s)
- Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Annalisa Anastasia
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Stefano Novello
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Andrea Fusco
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| | - Marco Solmi
- Neuroscience Department, University of Padua, Padua, Italy.,Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy
| | - Francesco Monaco
- Department of Medicine, Surgery and Dentistry 'Scuola Medica Salernitana', Section of Neuroscience, University of Salerno, Salerno, Italy
| | - Nicola Veronese
- Azienda Ospedaliera di Padova, Padua Hospital, Psychiatry Unit, Padua, Italy.,National Research Council, Aging Branch, Padua, Italy
| | - Domenico De Berardis
- National Health Service, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Teramo, Italy
| | - Andrea de Bartolomeis
- Section of Psychiatry, Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University, Naples, Italy
| |
Collapse
|
14
|
Abstract
Depression remains a significant debilitating and frequent phase of illness for patients with bipolar disorder. There are few FDA-approved medications for its treatment, only one of which includes a traditional antidepressant (olanzapine-fluoxetine combination), despite studies that demonstrate traditional antidepressants are one of the most commonly prescribed class of medications for bipolar patients in a depressive episode. While traditional antidepressants remain the primary option for treatment of unipolar depression, their use in bipolar depression has been controversial due to a limited efficacy evidence and the concern for potential harm. This chapter reviews the current data concerning the use of traditional antidepressants in bipolar disorder, and the current expert treatment guideline recommendations for their use.
Collapse
|
15
|
Lima AF, Miguel SR, Cohen M, Zimmermann JJ, Shansis FM, Cruz LN, Ziegelmann PK, Polanczyk CA, Fleck MP. Effectiveness evaluation of mood disorder treatment algorithms in Brazilian public healthcare patients. ACTA ACUST UNITED AC 2017; 40:26-34. [PMID: 28832750 PMCID: PMC6899428 DOI: 10.1590/1516-4446-2016-2147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
Abstract
Objective: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. Methods: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). Results: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ∼6 years and the use of mood stabilizers began ∼12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. Conclusions: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. Clinical trial registration: NCT02901249, NCT02870283, NCT02918097
Collapse
Affiliation(s)
- Ana F Lima
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Sandro R Miguel
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Mírian Cohen
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Jacques J Zimmermann
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | | | - Luciane N Cruz
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Patrícia K Ziegelmann
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil.,Departamento de Estatística, Instituto de Matemática, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Ciências da Saúde: Cardiologia e Ciências Cardiovasculares, UFRGS, Porto Alegre, RS, Brazil
| | - Carisi A Polanczyk
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Hospital de Clínicas de Porto de Alegre (HCPA), Porto Alegre, RS, Brazil.,Programa de Pós-Graduação em Ciências da Saúde: Cardiologia e Ciências Cardiovasculares, UFRGS, Porto Alegre, RS, Brazil
| | - Marcelo P Fleck
- Departamento de Psiquiatria e Medicina Legal, Faculdade de Medicina, UFRGS, Porto Alegre, RS, Brazil
| |
Collapse
|
16
|
Abstract
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.
Collapse
|