1
|
Hu Y, Zhang H, Wang H, Wang C, Kung S, Li C. Adjunctive antidepressants for the acute treatment of bipolar depression: A systematic review and meta-analysis. Psychiatry Res 2022; 311:114468. [PMID: 35248807 DOI: 10.1016/j.psychres.2022.114468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND The depressive phase of bipolar disorder causes significant functional impairment and disease burden. The efficacy and safety of antidepressants in the treatment of bipolar depression has long been a subject of debate. AIMS To synthesize evidence of the effectiveness, risk of mood switching, and tolerability of adjunctive antidepressants in acute bipolar depression compared to using mood stabilizers or antipsychotics alone. METHOD Multiple databases were searched for randomized controlled trials, including open label and double-blinded, for patients ages 18 or older with acute bipolar depression, comparing efficacy and adverse events in those who used adjunctive antidepressants versus without. Risk of bias and outcomes were assessed using the Cochrane Risk of Bias Tool. This study has PROSPERO registration CRD42016037701. RESULTS Nineteen studies met inclusion criteria. Adjunctive antidepressants showed no significant effect on improving response rate (RR=1.10, 95%CI: 0.98-1.23). Subgroup analysis showed that adjunctive antidepressants with antipsychotics had a small but significantly better response rate compared to antipsychotics alone, which was not seen with adjunctive antidepressants with mood stabilizers. However, that finding was limited by studies predominantly using olanzapine as the antipsychotic medication. Adjunctive antidepressants had no clinically significant impact (but a small statistically significant impact) on improving depressive symptoms (SMD=-0.13, 95%CI: -0.24 to -0.02). There was no association with increased mood switch (RR=0.97, 95%CI: 0.68-1.39) and there was an association with lower dropout due to inefficacy (RR=0.66, 95%CI: 0.45∼0.98). CONCLUSIONS There is no evidence of adjunctive antidepressants clinically improving response rate or depressive symptoms for acute bipolar depression. They are well tolerated, without increasing the risk of short-term mood switch.
Collapse
Affiliation(s)
- Yuliang Hu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Huijuan Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongyan Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chris Wang
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon Kung
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chunbo Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Brain Science and Technology Research Center, Shanghai Jiao Tong University, Shanghai, China; CAS Center for Excellence in Brain Science and Intelligence Technology (CEBSIT), Chinese Academy of Science, China; Institute of Psychology and Behavioral Science, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
2
|
Abstract
Many patients under treatment for mood disorders, in particular patients with bipolar mood disorders, experience episodes of mood switching from one state to another. Various hypotheses have been proposed to explain the mechanism of mood switching, spontaneously or induced by drug treatment. Animal models have also been used to test the role of psychotropic drugs in the switching of mood states. We examine the possible relationship between the pharmacology of psychotropic drugs and their reported incidents of induced mood switching, with reference to the various hypotheses of mechanisms of mood switching.
Collapse
|
3
|
Valvassori SS, Cararo JH, Marino CAP, Possamai-Della T, Ferreira CL, Aguiar-Geraldo JM, Dal-Pont GC, Quevedo J. Imipramine induces hyperactivity in rats pretreated with ouabain: Implications to the mania switch induced by antidepressants. J Affect Disord 2022; 299:425-434. [PMID: 34910958 PMCID: PMC10485776 DOI: 10.1016/j.jad.2021.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/02/2021] [Accepted: 12/10/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Bipolar disorder (BD) is a psychiatric disorder with complex therapy, besides the treatment with antidepressants induce a mania switch. OBJECTIVE Investigate the effect of the administration of imipramine (IMI) in rats submitted to intracerebroventricular (ICV) administrations of ouabain (OUA). METHODS Adult Wistar rats (n = 28) were submitted to only one ICV administration of OUA or artificial cerebrospinal fluid. On the 7th and 9th days following the ICV administration, animals were submitted to a behavioral analysis comprising open field task and forced swimming test. Between the 9th and 14th days, the rats received one daily intraperitoneal administration of IMI or saline (Sal). On the 15th day rats were submitted to the last session of behavioral analysis, followed by euthanasia. The frontal cortex and hippocampus were dissected for the subsequent biochemical assessments: oxidative parameters, and Na+/K+-ATPase activity. RESULTS OUA administration induced a manic-like effect on the 7th day and a depressive-like behavior on the 14th day. In contrast, IMI administration elicited significant mania switch-like effect on this same stage in animals who received OUA. OUA increased oxidative damage and activity of antioxidant enzymes in the brain of rats. IMI potentialized the oxidative damage of OUA. No significant differences between groups were observed in the Na+/K+-ATPase activity. CONCLUSION The present study suggests that residual effects from inhibition of the Na+K+ATPase could be involved in the manic-switch observed in bipolar patients. Besides, the OUA model of bipolar disorder could be used to study bipolar disorder in the context of mania switch.
Collapse
Affiliation(s)
- Samira S Valvassori
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil.
| | - José H Cararo
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Carlos Augusto P Marino
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Taise Possamai-Della
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Camila L Ferreira
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Jorge M Aguiar-Geraldo
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Gustavo C Dal-Pont
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - João Quevedo
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil; Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.; Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.; Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| |
Collapse
|
4
|
Bipolar Disorder and Cardiovascular Risk in Rural versus Urban Populations in Colombia: A Comparative Clinical and Epidemiological Evaluation. Ann Glob Health 2021; 87:112. [PMID: 34824993 PMCID: PMC8603855 DOI: 10.5334/aogh.3479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Various multifactorial elements may contribute toward the urban and rural disparities in cardiovascular disease (CVD) risk, particularly among patients with psychiatric diseases. Objective: To investigate whether rural patients diagnosed and treated for Bipolar Disorder (BD) have different risk profiles and outcomes of CVD compared to urban (BD) patients. Methods: We conducted a case-control study that included 125 BD patients (cases) from rural Filadelfia, Colombia and 250 BD patients (controls) treated in Bogotá, Colombia. Cases and controls were 2:1, matched by age and sex. We applied the Framingham Heart Study (FHS) risk calculator to assess risk. Differences by rural/urban status (i.e., case-control status) were assessed by chi-square, paired t-tests, and logistic regression. Findings: Rural BD patients were found to have lower education (p = 1.0 × 10–4), alcohol consumption (p = 3.0 × 10–4), smoking (p = 0.015), psychiatric (p = 1.0 × 10–4) and CV family history (p = 0.0042) compared to urban BD patients. Rural BD patients were 81% more likely to have a more favorable CVD risk profile (OR: 0.19, 95% CI [0.06–0.62]) than urban BD patients, despite rural BD patients having increased CVD morbidity (p = 1.0 × 10–2). Conclusion: Based on increase in morbidity but lower predictive risk in the rural population, our study suggests that the FHS-CVD calculator may not be optimal to assess CVD risk in this population.
Collapse
|
5
|
Berkol TD, Balcioglu YH, Kirlioglu SS, Ozarslan Z, Islam S, Ozyildirim I. Clinical characteristics of antidepressant use and related manic switch in bipolar disorder. ACTA ACUST UNITED AC 2019; 24:45-52. [PMID: 30842399 PMCID: PMC8015534 DOI: 10.17712/nsj.2019.1.20180008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the association between clinical and treatment characteristics and antidepressants (AD)-induced manic switch in bipolar disorder (BD). METHODS Total of 238 euthymic BD patients, who had been followed-up for at least 6 months at the outpatient clinic of Haseki Training and Research Hospital in istanbul, Turkey, were enrolled in this cross-sectional study in 2016. Semi-structured data form, the mood chart, and the mirror-designated assessment were applied to all subjects. The files of the patients were retrospectively reviewed and the patients using ADs were compared as AD-monotherapy (AD-m) and AD-combination (AD-c) groups, then divided into 2 subgroups according to the presence/absence of manic switch under AD treatment. RESULTS Fifty eight (47.15%) patients out of 123 who received ADs at least once had experienced a manic switch under AD treatment. The rate of manic switch in AD-m patients was significantly higher than the AD-c group. Independent from being monotherapy or combined treatment, AD use longer than 12 months was negatively associated with the occurrence of manic switch. CONCLUSION Our study suggests that the risk of manic switch is especially prominent in the first months of AD use. Antidepressants use in combining it with a mood stabilizers (MS) may not be adequate in preventing switches in shorter terms. However, in longer term uses addition of MS to ADs may decrease the risk of switches.
Collapse
Affiliation(s)
- Tonguc D Berkol
- Department of Psychiatry, Bakirkoy Prof. Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
6
|
Capote HA, Rainka M, Westphal ES, Beecher J, Gengo FM. Ropinirole in Bipolar Disorder: Rate of Manic Switching and Change in Disease Severity. Perspect Psychiatr Care 2018; 54:100-106. [PMID: 28105645 DOI: 10.1111/ppc.12205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/01/2016] [Accepted: 11/25/2016] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To determine the effects of ropinirole on manic switching and disease severity in bipolar disorder. DESIGN AND METHODS A cross-sectional survey was conducted in 23 bipolar depressed patients using ropinirole combination therapy (Young Mania Rating Scale [YMRS], Bipolar Inventory of Symptoms Scale [BISS]). Retrospective Clinical Global Impression of Change (CGI-C) and CGI-S (Severity) were captured via chart review. FINDINGS One patient (4.3%) experienced induction of mania (YMRS). All patients responded or partially responded to ropinirole (CGIs). YMRS and BISS mania scores were correlated. PRACTICE IMPLICATIONS Ropinirole has a low rate of manic switching and significantly reduces bipolar depression severity.
Collapse
Affiliation(s)
- Horacio A Capote
- Director, Neuropsychiatry Division, Dent Neurologic Institute, Buffalo, New York, USA
| | - Michelle Rainka
- Clinical Pharmacist, Research Division, Dent Neurologic Institute, Buffalo, New York, USA
| | - Erica S Westphal
- Research Associate, Dent Neurologic Institute, Buffalo, New York, USA
| | - Jonathan Beecher
- Research Intern, Dent Neurologic Institute, Buffalo, New York, USA
| | - Francis M Gengo
- Director of Research Division, Dent Neurologic Institute, Buffalo, New York, USA
| |
Collapse
|
7
|
Yamaguchi Y, Kimoto S, Nagahama T, Kishimoto T. Dosage-related nature of escitalopram treatment-emergent mania/hypomania: a case series. Neuropsychiatr Dis Treat 2018; 14:2099-2104. [PMID: 30147322 PMCID: PMC6103304 DOI: 10.2147/ndt.s168078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Several studies have documented that treatment with various antidepressant agents can result in mood switching during major depressive episodes. Escitalopram, one of the newer selective serotonin reuptake inhibitors (SSRIs), is considered preferable due to its relatively high efficacy and acceptability. Although a few cases of escitalopram treatment-emergent mania have been reported, it remains unknown whether this effect is dose-related. METHOD In the present report, we discuss three cases of treatment-emergent mania/hypomania in patients receiving escitalopram for major depressive episodes. No patients had a family or personal history of bipolar disorder. RESULTS In all three cases, manic or hypomanic symptoms emerged within 1 month right after the dosage of escitalopram was increased to 20 mg/day. Moreover, manic episodes subsided as the dosage of escitalopram was reduced. Mood switching was not observed after the cessation of escitalopram treatment. CONCLUSION Our case series indicates that escitalopram may induce treatment-emergent mania/hypomania in a dose-related manner. Treatment at lower doses and with careful upward titration might be favorable in certain patients with bipolar depression and major depressive disorder in order to minimize the risk of mood switching.
Collapse
Affiliation(s)
- Yasunari Yamaguchi
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| | - Sohei Kimoto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| | - Takeshi Nagahama
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| | - Toshifumi Kishimoto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| |
Collapse
|
8
|
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
|
9
|
Scott J, Brichant-Petitjean C, Etain B, Henry C, Kahn JP, Azorin JM, Leboyer M, Bellivier F. A re-examination of antidepressant treatment-emergent mania in bipolar disorders: evidence of gender differences. Acta Psychiatr Scand 2017; 135:479-488. [PMID: 28369709 DOI: 10.1111/acps.12728] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To explore the prevalence and clinical profile of males and females who develop antidepressant treatment-emergent mania (ATEM). METHOD From an original sample of 754 patients with BD, we identified ATEM+ cases (n = 75) and ATEM- controls (n = 135) that met stringent criteria. We specifically examined the combinations of clinical factors that best classified males and females as ATEM+ cases. RESULTS Seventy-five individuals were classified as ATEM+; 87% of ATEM events occurred during antidepressant monotherapy. Regression analyses demonstrated that the presence of an alcohol and/or substance use disorder [Odds Ratio (OR) 6.37], a history of one or more suicide attempts (OR 4.19) and higher number of depressive episodes per year of illness (OR 1.71) correctly classified 73% of males. In contrast, 84% of females were correctly classified on the basis of a positive history of thyroid disorder (OR 3.23), a positive family history of BD I (OR 2.68) and depressive onset polarity (OR 2.01). CONCLUSION Using stringent definitions of ATEM status to reduce the probability of inclusion of false-positive cases and false-negative controls, we identified for the first time that the risk profiles for the development of an ATEM differ significantly according to gender.
Collapse
Affiliation(s)
- J Scott
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Affective Disorders, IoPPN, Kings College, London, UK
| | - C Brichant-Petitjean
- Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, AP-HP, Paris, France.,INSERM, Unité UMR-S 1144, Variabilité de Réponse aux Psychotropes, Université Paris Descartes-Paris Diderot, Paris, France.,Université Paris Diderot, Paris, France
| | - B Etain
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France
| | - C Henry
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France.,Unité Perception et Mémoire, Institut Pasteur, Paris, France
| | - J-P Kahn
- Fondation FondaMental, Créteil, France.,Service de Psychiatrie et Psychologie Clinique, Centre Psychothérapique de Nancy et CHU de Nancy, Vandoeuvre les Nancy, France.,Université de Lorraine, Nancy, France
| | - J-M Azorin
- Fondation FondaMental, Créteil, France.,AP-HM, Pôle de psychiatrie, Hôpital Sainte Marguerite, Marseille, France
| | - M Leboyer
- Groupe Henri Mondor-Albert Chenevier, Pôle de Psychiatrie, AP-HP, Créteil, France.,Unité 955, Equipe de Psychiatrie Translationnelle, IMRB, INSERM, Créteil, France.,Faculté de Médecine, IFR10, Université Paris Est Créteil, Créteil, France.,Fondation FondaMental, Créteil, France
| | - F Bellivier
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Affective Disorders, IoPPN, Kings College, London, UK.,Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, AP-HP, Paris, France.,Fondation FondaMental, Créteil, France
| |
Collapse
|
10
|
Nusslock R, Young CB, Damme KSF. Elevated reward-related neural activation as a unique biological marker of bipolar disorder: assessment and treatment implications. Behav Res Ther 2014. [PMID: 25241675 DOI: 10.1016/j.brat.2014.08.011.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Growing evidence indicates that risk for bipolar disorder is characterized by elevated activation in a fronto-striatal reward neural circuit involving the ventral striatum and orbitofrontal cortex, among other regions. It is proposed that individuals with abnormally elevated reward-related neural activation are at risk for experiencing an excessive increase in approach-related motivation during life events involving rewards or goal striving and attainment. In the extreme, this increase in motivation is reflected in hypomanic/manic symptoms. By contrast, unipolar depression (without a history of hypomania/mania) is characterized by decreased reward responsivity and decreased reward-related neural activation. Collectively, this suggests that risk for bipolar disorder and unipolar depression are characterized by distinct and opposite profiles of reward processing and reward-related neural activation. The objective of the present paper is threefold. First, we review the literature on reward processing and reward-related neural activation in bipolar disorder, and in particular risk for hypomania/mania. Second, we propose that reward-related neural activation reflects a biological marker of differential risk for bipolar disorder versus unipolar depression that may help facilitate psychiatric assessment and differential diagnosis. We also discuss, however, the challenges to using neuroscience techniques and biological markers in a clinical setting for assessment and diagnostic purposes. Lastly, we address the pharmacological and psychosocial treatment implications of research on reward-related neural activation in bipolar disorder.
Collapse
Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL, USA.
| | - Christina B Young
- Department of Psychology, Northwestern University, Evanston, IL, USA
| | | |
Collapse
|
11
|
Nusslock R, Young CB, Damme KSF. Elevated reward-related neural activation as a unique biological marker of bipolar disorder: assessment and treatment implications. Behav Res Ther 2014; 62:74-87. [PMID: 25241675 DOI: 10.1016/j.brat.2014.08.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/17/2014] [Accepted: 08/18/2014] [Indexed: 12/29/2022]
Abstract
Growing evidence indicates that risk for bipolar disorder is characterized by elevated activation in a fronto-striatal reward neural circuit involving the ventral striatum and orbitofrontal cortex, among other regions. It is proposed that individuals with abnormally elevated reward-related neural activation are at risk for experiencing an excessive increase in approach-related motivation during life events involving rewards or goal striving and attainment. In the extreme, this increase in motivation is reflected in hypomanic/manic symptoms. By contrast, unipolar depression (without a history of hypomania/mania) is characterized by decreased reward responsivity and decreased reward-related neural activation. Collectively, this suggests that risk for bipolar disorder and unipolar depression are characterized by distinct and opposite profiles of reward processing and reward-related neural activation. The objective of the present paper is threefold. First, we review the literature on reward processing and reward-related neural activation in bipolar disorder, and in particular risk for hypomania/mania. Second, we propose that reward-related neural activation reflects a biological marker of differential risk for bipolar disorder versus unipolar depression that may help facilitate psychiatric assessment and differential diagnosis. We also discuss, however, the challenges to using neuroscience techniques and biological markers in a clinical setting for assessment and diagnostic purposes. Lastly, we address the pharmacological and psychosocial treatment implications of research on reward-related neural activation in bipolar disorder.
Collapse
Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL, USA.
| | - Christina B Young
- Department of Psychology, Northwestern University, Evanston, IL, USA
| | | |
Collapse
|
12
|
Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: a review. J Affect Disord 2013; 148:129-35. [PMID: 23219059 DOI: 10.1016/j.jad.2012.10.033] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 10/23/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Compare reported rates of mood-shifts from major depression to mania/hypomania/mixed-states during antidepressant (AD)-treatment and rates of diagnostic change from major depressive disorder (MDD) to bipolar disorder (BPD). METHODS Searching computerized literature databases, followed by summary analyses. RESULTS In 51 reports of patients diagnosed with MDD and treated with an AD, the overall risk of mood-switching was 8.18% (7837/95,786) within 2.39 ± 2.99 years of treatment, or 3.42 (95% CI: 3.34-3.50) %/year. Risk was 2.6 (CI: 2.5-2.8) times greater with/without AD-treatment by meta-analysis of 10 controlled trials. Risk increased with time up to 24 months of treatment, with no secular change (1968-2012). Incidence rates were 4.5 (CI: 4.1-4.8)-times greater among juveniles than adults (5.62/1.26 %/year; p<0.0001). In 12 studies the overall rate of new BPD-diagnoses was 3.29% (1928/56,754) within 5.38 years (0.61 [0.58-0.64] %/year), or 5.6-times lower (3.42/0.61) than annualized rates of mood-switching. CONCLUSIONS AD-treatment was associated with new mania-like responses in 8.18% of patients diagnosed with unipolar MDD. Contributions to mood-switching due to unrecognized BPD versus mood-elevating pharmacological effects, as well as quantitative associations between switching and later diagnosis of BPD not associated with AD-treatment remain uncertain. LIMITATIONS Rates and definitions of mood-switching with ADs varied greatly, exposure-times rarely were precisely defined, and there was little information on predictive associations between mood-switches and BPD-diagnosis.
Collapse
|
13
|
Fornaro M, Martino M, De Pasquale C, Moussaoui D. The argument of antidepressant drugs in the treatment of bipolar depression: mixed evidence or mixed states? Expert Opin Pharmacother 2012; 13:2037-51. [PMID: 22946746 DOI: 10.1517/14656566.2012.719877] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The role of antidepressant drugs in acute and maintenance treatment of bipolar depression is a matter of debate that cannot be decided from the evidence available in the current literature. AREAS COVERED This review includes two sections: in the first, important contributions from the current literature, emphasizing randomized controlled trials (RCTs) and meta-analysis, highlight current controversies and methodological issues; in the second, the impact of mixed depressive features in bipolar depression is evaluated from a psychopathological perspective. EXPERT OPINION Methodological issues may complicate evaluation of the evidence from RCTs regarding antidepressants and mixed states. Moreover, nosological constructs may also contribute to the inconclusive findings, by introducing heterogeneity in patient selection and diagnosis. Acknowledging the impact of mixed features in the course of bipolar depression, essentially by the careful reading of classical Kraepelinian contributions, could enhance clinical management. This would in turn allow a more judicious use of antidepressants, ideally helping to shed some light on the much controversial 'antidepressant-related suicidality', and help to further clarify the reasons for the current literature discordance on this topic.
Collapse
Affiliation(s)
- Michele Fornaro
- University of Catania, Department of Formative Sciences, via Teatro Greco n.78, Catania, ZIP 95124, Italy.
| | | | | | | |
Collapse
|
14
|
Gitlin MJ. Antidepressants in bipolar depression: much confusion, many questions, few answers. Aust N Z J Psychiatry 2012; 46:295-7. [PMID: 22508587 DOI: 10.1177/0004867412440893] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael J Gitlin
- Department of Psychiatry, Geffen School of Medicine, UCLA, Los Angeles, CA 90095, USA.
| |
Collapse
|
15
|
Biernacka JM, McElroy SL, Crow S, Sharp A, Benitez J, Veldic M, Kung S, Cunningham JM, Post RM, Mrazek D, Frye MA. Pharmacogenomics of antidepressant induced mania: a review and meta-analysis of the serotonin transporter gene (5HTTLPR) association. J Affect Disord 2012; 136:e21-e29. [PMID: 21680025 DOI: 10.1016/j.jad.2011.05.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 05/18/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Antidepressants can trigger a rapid mood switch from depression to mania. Identifying genetic risk factors associated with antidepressant induced mania (AIM) may enable individualized treatment strategies for bipolar depression. This review and meta-analysis evaluates the evidence for association between the serotonin transporter gene promoter polymorphism (5HTTLPR) and AIM. METHODS Medline up to November 2009 was searched for key words bipolar, antidepressant, serotonin transporter, SLC6A4, switch, and mania. RESULTS Five studies have evaluated the SLC6A4 promoter polymorphism and AIM in adults (total N=340 AIM+ cases, N=543 AIM- controls). Although a random effects meta-analysis showed weak evidence of association of the S allele with AIM+ status, a test of heterogeneity indicated significant differences in estimated genetic effects between studies. A similar weak association was observed in a meta-analysis based on a subset of three studies that excluded patients on mood stabilizers; however the result was again not statistically significant. LIMITATIONS Few pharmacogenomic studies of antidepressant treatment of bipolar disorder have been published. The completed studies were underpowered and often lacked important phenotypic information regarding potential confounders such as concurrent use of mood stabilizers or rapid cycling. CONCLUSIONS There is insufficient published data to confirm an association between 5HTTLPR and antidepressant induced mania. Pharmacogenomic studies of antidepressant induced mania have high potential clinical impact provided future studies are of adequate sample size and include rigorously assessed patient characteristics (e.g. ancestry, rapid cycling, concurrent mood stabilization, and length of antidepressant exposure).
Collapse
Affiliation(s)
- Joanna M Biernacka
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States.
| | - Susan L McElroy
- Lindner Center of HOPE, Mason, OH, United States; University of Cincinnati College of Medicine, Cincinnati, OH, United States; The Bipolar Collaborative Network, Bethesda, MD, United States
| | - Scott Crow
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Alexis Sharp
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Joachim Benitez
- Department of Psychiatry, Austin Medical Center, Mayo Health System, Austin, MN, United States
| | - Marin Veldic
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Julie M Cunningham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Robert M Post
- The Bipolar Collaborative Network, Bethesda, MD, United States
| | - David Mrazek
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; The Bipolar Collaborative Network, Bethesda, MD, United States
| |
Collapse
|
16
|
Abstract
BACKGROUND Research suggests that current diagnostic criteria for bipolar disorders may fail to include milder, but clinically significant, bipolar syndromes and that a substantial percentage of these conditions are diagnosed, by default, as unipolar major depression. Accordingly, a number of researchers have argued for the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to better account for subsyndromal hypomanic presentations. METHODS The present paper is a critical review of research on subthreshold bipolarity, and an assessment of some of the challenges that researchers and clinicians might face if the DSM-5 were designed to systematically document subsyndromal hypomanic presentations. RESULTS Individuals with major depressive disorder (MDD) who display subsyndromal hypomanic features, not concurrent with a major depressive episode, have a more severe course compared to individuals with MDD and no hypomanic features, and more closely resemble individuals with bipolar disorder on a number of clinical validators. CONCLUSION There are clinical and scientific reasons for systematically documenting subsyndromal hypomanic presentations in the assessment and diagnosis of mood disorders. However, these benefits are balanced with important challenges, including (i) the difficulty in reliably identifying subsyndromal hypomanic presentations, (ii) operationalizing subthreshold bipolarity, (iii) differentiating subthreshold bipolarity from borderline personality disorder, (iv) the risk of over-diagnosing bipolar spectrum disorders, and (v) uncertainties about optimal interventions for subthreshold bipolarity.
Collapse
Affiliation(s)
- Robin Nusslock
- Department of Psychology, Northwestern University, Evanston, IL 60208, USA.
| | | |
Collapse
|
17
|
Abstract
Patients with bipolar disorder spend more time in a depressed than manic state, even with individualized treatment. To date, bipolar depression is often misdiagnosed and ineffectively managed both for acute episodes and residual symptoms. This review attempts to summarize the current status of available treatment strategies in the treatment of bipolar depression. For acute and prophylactic treatment, a substantial body of evidence supports the antidepressive efficacy of lithium for bipolar disorders and its antisuicidal effects. Among numerous anticonvulsants with mood-stabilizing properties, valproate and lamotrigine could be first-line options for bipolar depression. Due to receptor profile, mood-stabilizing properties of second-generation antipsychotics have been explored, and up to date, quetiapine and olanzapine appear to be a reasonable option for bipolar depression. The usefulness of antidepressants in bipolar depression is still controversial. Current guidelines generally recommend the cautious antidepressant use in combination with mood stabilizers to reduce the risk of mood elevation or cycle acceleration. Results from clinical trials on psychosocial intervention are promising, especially when integrated with pharmacotherapy. Most patients with bipolar depression need individualized and combined treatment, although the published evidence on this type of treatment strategy is limited. Future studies on the utility of currently available agents and modalities including psychosocial intervention are required.
Collapse
Affiliation(s)
- Jae Seung Chang
- Department of Psychiatry and Behavioral Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyooseob Ha
- Department of Psychiatry and Behavioral Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|
18
|
Tondo L, Vázquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand 2010; 121:404-14. [PMID: 19958306 DOI: 10.1111/j.1600-0447.2009.01514.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review available data pertaining to risk of mania-hypomania among bipolar (BPD) and major depressive disorder (MDD) patients with vs. without exposure to antidepressant drugs (ADs) and consider effects of mood stabilizers. METHOD Computerized searching yielded 73 reports (109 trials, 114 521 adult patients); 35 were suitable for random effects meta-analysis, and multivariate-regression modeling included all available trials to test for effects of trial design, AD type, and mood-stabilizer use. RESULTS The overall risk of mania with/without ADs averaged 12.5%/7.5%. The AD-associated mania was more frequent in BPD than MDD patients, but increased more in MDD cases. Tricyclic antidepressants were riskier than serotonin-reuptake inhibitors (SRIs); data for other types of ADs were inconclusive. Mood stabilizers had minor effects probably confounded by their preferential use in mania-prone patients. CONCLUSION Use of ADs in adults with BPD or MDD was highly prevalent and moderately increased the risk of mania overall, with little protection by mood stabilizers.
Collapse
Affiliation(s)
- L Tondo
- Department of Psychiatry and Neuroscience Program, Harvard Medical School and McLean Division of Massachusetts General Hospital, Boston, MA, USA.
| | | | | |
Collapse
|
19
|
Grunze H, Vieta E, Goodwin GM, Bowden C, Licht RW, Möller HJ, Kasper S. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the treatment of acute bipolar depression. World J Biol Psychiatry 2010; 11:81-109. [PMID: 20148751 DOI: 10.3109/15622970903555881] [Citation(s) in RCA: 228] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES These guidelines are based on a first edition that was published in 2002, and have been edited and updated with the available scientific evidence until September 2009. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute bipolar depression in adults. METHODS The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A-F). As these guidelines are intended for clinical use, the scientific evidence was finally assigned different grades of recommendation to ensure practicability. RESULTS We identified 10 pharmacological monotherapies or combination treatments with at least limited positive evidence for efficacy in bipolar depression, several of them still experimental and backed up only by a single study. Only one medication was considered to be sufficiently studied to merit full positive evidence. CONCLUSIONS Although major advances have been made since the first edition of this guideline in 2002, there are many areas which still need more intense research to optimize treatment. The majority of treatment recommendations is still based on limited data and leaves considerable areas of uncertainty.
Collapse
Affiliation(s)
- Heinz Grunze
- Newcastle University, RVI, Division of Psychiatry, Institute of Neuroscience, Newcastle upon Tyne, UK.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Abstract
BACKGROUND Although depression accounts for a large part of the burden associated with bipolar disorder, its drug treatment has been under-studied. OBJECTIVE To provide the best available evidence supporting the pharmacotherapy of bipolar depression. METHODS A systematic review was conducted, focusing on randomized, controlled trials (RCTs) and meta-analyses. RESULTS/CONCLUSIONS Despite FDA approval of both the olanzapine-fluoxetine combination and quetiapine for the treatment of acute bipolar depression, independent RCTs (i.e., not trials conducted 'under the umbrella' of a drug company) have not found any drug to have antidepressant effects similar to those seen in unipolar depression. A practice-based suggestion, valuable for both short- and long-term treatment, might be to have a background of mood stabilizers and to add drugs, following one of several treatment options, trusting to find a drug with a degree of effectiveness by trial and error. The list of drugs that could be used would include all the current antidepressants, the olanzapine-fluoxetine combination and probably quetiapine too. Special features and situations might also influence treatment options.
Collapse
Affiliation(s)
- Jean-Michel Azorin
- Pôle Universitaire de Psychiatrie-Solaris, Hôpital Ste Marguerite, 13274 Marseille Cedex 9, France.
| | | |
Collapse
|
21
|
Licht RW, Gijsman H, Nolen WA, Angst J. Are antidepressants safe in the treatment of bipolar depression? A critical evaluation of their potential risk to induce switch into mania or cycle acceleration. Acta Psychiatr Scand 2008; 118:337-46. [PMID: 18754834 DOI: 10.1111/j.1600-0447.2008.01237.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To address whether switch of depression into hypomania or mania or cycle acceleration in patients with bipolar disorder is caused by antidepressants or whether this phenomenon is attributable to the natural history of bipolar disorder itself. METHOD A critical review of the literature, pointing at sources of bias that have been previously overlooked. For examining the causation in question, the Bradford-Hill criteria were applied, i.e. specificity of the potential causative agent, strength of effect, consistency in findings, dose-response relation, temporal relation with exposure to agent preceding effect and biological plausibility. RESULTS There is a scarcity of randomized studies addressing the question, and the available studies all suffer from various forms of bias. However, there is some evidence suggesting that antidepressants given in addition to a mood stabilizer are not associated with an increased rate of switch when compared with the rate associated with the mood stabilizer alone. CONCLUSION When combined with a mood stabilizer, antidepressants given for acute bipolar depression seemingly do not induce a switch into hypomania or mania. Whether antidepressants may accelerate episode frequency and/or may cause other forms of destabilization in patients with bipolar disorder remain to be properly studied.
Collapse
Affiliation(s)
- R W Licht
- Mood Disorders Research Unit, Aarhus University Hospital, Risskov, Denmark.
| | | | | | | |
Collapse
|
22
|
Eppel AB. Antidepressants in the treatment of bipolar disorder: decoding contradictory evidence and opinion. Harv Rev Psychiatry 2008; 16:205-9. [PMID: 18569041 DOI: 10.1080/10673220802160381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Alan Brian Eppel
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 50 Charlton Ave. East, Hamilton, Ontario L8N 4A6, Canada.
| |
Collapse
|
23
|
Goodwin GM, Anderson I, Arango C, Bowden CL, Henry C, Mitchell PB, Nolen WA, Vieta E, Wittchen HU. ECNP consensus meeting. Bipolar depression. Nice, March 2007. Eur Neuropsychopharmacol 2008; 18:535-49. [PMID: 18501566 DOI: 10.1016/j.euroneuro.2008.03.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 02/22/2008] [Accepted: 03/12/2008] [Indexed: 12/16/2022]
Abstract
DSM-IV, specifically its text revision DSM-IV-TR, remains the preferred diagnostic system. When employed in general population samples, prevalence estimates of bipolar disorder are relatively consistent across studies in Europe and USA. In community studies, first onset of bipolar mood disorder is usually in the mid-teenage years and twenties, and the occurrence of a major depressive episode or hypomania is usually its first manifestation. Since reliable criteria for delineating unipolar (UP) and bipolar (BI) depression cross-sectionally are currently lacking, there is a longitudinal risk - probably over 10% - that initial UP patients ultimately turn out as BP in the longer run. Its early onset implies a severe potential burden of disease in terms of impaired social and neuropsychological development, most of which is attributable to depression. BIPOLAR DEPRESSION IN CHILDREN: Bipolar I disorder is rare in prepubertal children, when defined according to unmodified DSM-IV-TR criteria. A broad diagnosis of bipolar disorder risks confounding with other childhood psychopathology and has less predictive value for bipolar disorder in adulthood than the conservative definition. Nevertheless, empirical studies of drug and other treatments and longitudinal studies to assess validity of the broadly defined phenotype in children and adolescents are desirable, rather than extrapolation from adult bipolar practice. The need for an increased capacity to conduct reliable trials in children and adolescents is a challenge to Europe, whose healthcare system should allow greater participation and collaboration than other regions, via clinical networks. ECNP will aspire to facilitate such developments. BIPOLAR DEPRESSION IN ADULTS - UNIPOLAR/BIPOLAR CONTRAST: Despite some differences in symptom profiles and severity measures, a cross-sectional categorical distinction between bipolar (BP) and unipolar (UP) depression is currently impossible. For regulatory purposes, a major depressive episode, meeting DSM-IV-TR criteria, remains the same diagnosis, irrespective of the overall course of the disorder. However, in refining diagnosis in future studies and DSM-V, a probabilistical approach to the UP/BP distinction is more likely to be informative as recommended by the International Society for Bipolar Disorders (ISBD). Anxiety is a commonly present, often at syndromal levels, in bipolar populations. Thus, RCT inclusion criteria for trials not targeting anxiety, should accept co-morbid anxiety disorders as part of the history and even current anxiety symptoms, where these are not dominating the mental state at recruitment to a study. Rapid cycling patients defined as those suffering from 4 or more episodes per year, may also be recruited into trials of bipolar depression without impairing assay sensitivity. Illness severity critically affects assay sensitivity. The minimum scores for entry into a bipolar depression trials should be >20 on HAM-D (17 item scale). However, efficacy is best detected in patients with HAM-D >24 at baseline. THE USE OF RATING SCALES IN BIPOLAR DEPRESSION: There is some dissatisfaction with the HAM-D or MADRS as the preferred primary outcome for trials, although they probably capture global severity adequately. Secondary measures to capture so-called atypical symptoms (such as hypersomnia or hyperphagia), or specific psychopathology more common in bipolar participants (such as lability of mood), could be informative as secondary measures. TREATMENT STUDIES IN BIPOLAR DEPRESSION: Monotherapy trials against placebo remain the gold-standard design for determining efficacy in bipolar depression. The confounding effects of co-medication are emerging from the literature on antidepressant studies in bipolar depression, often conducted in combination with antimanic agents to avoid possible switch to mood elevation. Three arm trials, including the compound to be tested, placebo, and a standard comparator, are generally preferred in order to ensure assay sensitivity and a better picture of benefit-risk ratio. However, in the absence of any gold-standard, two-arm trials may be enough. If efficacy happens to be proven as monotherapy, new compounds may be tested in adjunctive-medication placebo-controlled designs. Younger adults, without an established need for long-term medication, may be particularly suitable for clinical trials requiring placebo controls. The conversion rate of initial UP depression, converting to become BP in the long run is estimated to be 10%. Switch to mania or hypomania may be the consequence of active treatment for bipolar depression. Some medicines such as the tricyclic antidepressants and venlafaxine may be more likely to provoke switch than others, but this increased rate of switch may not be seen until about 10 weeks of treatment. Twelve week trials against placebo are necessary to determine the risk of switch and to establish continuing effects. Careful assessment at 6-8 weeks is required to ensure that patients who are failing to respond do not continue in a study for unacceptable periods of time. To capture a switch event, studies should include scales to define the phenomenology of the event (e.g. hypomania or mania) and its severity. These may be best applied shortly after the clinical decision that switch is occurring. Long-term treatment is commonly required in bipolar disorder. Trials to detect maintenance of effect or continued response in bipolar depression should follow a 'relapse prevention' design: i.e. patients are treated in an index episode with the medicine of interest and then randomized to either continue the active treatment or placebo. However, acute withdrawal of active medication after treatment response might artificially enhance effect size due to active drug withdrawal effects. A short taper is usually desirable. Longer periods of stabilisation are also desirable for up to 3 months: protocol compliance may then be difficult to achieve in practice and so will certainly make studies more difficult and expensive to conduct. The addition of a medicine to other agents during or after the resolution of a depressive or manic episode, and its subsequent investigation as monotherapy against placebo to prevent further relapse (as in the lamotrigine maintenance trials) is clinically informative. Assay sensitivity and patient acceptability are enhanced if the outcome in long-term studies is 'time to intervention for a new episode' for discontinuation designs.
Collapse
Affiliation(s)
- Guy M Goodwin
- University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Moncrieff J. The creation of the concept of an antidepressant: An historical analysis. Soc Sci Med 2008; 66:2346-55. [DOI: 10.1016/j.socscimed.2008.01.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Indexed: 10/22/2022]
|
25
|
Affiliation(s)
- E Haffen
- Service de Psychiatrie de l'Adulte, CHU Saint-Jacques, Université de Besançon, 25030 cedex
| | | |
Collapse
|
26
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
27
|
Loftis JM, Matthews AM, Hauser P. Psychiatric and substance use disorders in individuals with hepatitis C: epidemiology and management. Drugs 2006; 66:155-74. [PMID: 16451091 DOI: 10.2165/00003495-200666020-00003] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatitis C virus (HCV) infection is a major health concern in the US as well as in other countries worldwide. Treatment issues and disease management strategies are complicated by the extremely high rate of psychiatric and substance use disorders in those who have HCV. The majority of new and existing cases of HCV are related to injection drug use and, in this population, the prevalence of psychiatric comorbidity is high. Optimally, all patients with HCV should be screened for psychiatric and substance use disorders before initiation of antiviral therapy. If a patient screens positive, he or she should be referred to a mental healthcare provider or addiction specialist, assessed for the presence of a psychiatric or substance use disorder, and appropriately treated prior to initiation of antiviral (i.e. interferon) therapy. Although interferon-based therapies can lead to severe neuropsychiatric adverse effects, including in rare instances suicide, evidence suggests that many patients with comorbid psychiatric and substance use diagnoses can be treated safely and effectively using comanagement strategies. However, most patients with HCV are not treated with antiviral therapy. Therefore, we must expand our definition of HCV 'treatment' to include treatment of the comorbid psychiatric and substance use disorders that accompany HCV infection and precede antiviral therapy. This paper reviews the epidemiology and management of psychiatric and substance use disorders in patients with HCV, the issue of psychiatric and substance use disorders as contraindications for antiviral therapy, and current treatment strategies for HCV patients with these comorbid conditions.
Collapse
Affiliation(s)
- Jennifer M Loftis
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | | | | |
Collapse
|
28
|
Abstract
Major depression is believed to be a multifactorial disorder involving predisposing temperament and personality traits, exposure to traumatic and stressful life events, and biological susceptibility. Depression, both unipolar and bipolar, is a "phasic" disease. Stressful life events are known to trigger depressive episodes, while their influence seems to decrease over the course of the illness. This suggests that depression is associated with progressive stress response abnormalities, possibly linked to impairments of structural plasticity and cellular resilience. It therefore appears crucial to adequately treat depression in the early stages of the illness, in order to prevent morphological and functional abnormalities. While evidence suggests that a severely depressed patient needs antidepressant drug therapy and that a non-severely depressed patient may benefit from other approaches (ie, "nonbiological"), little research has been done on the effectiveness of different treatments for depression. The assertion that the clinical efficacy of antidepressants is comparable between the classes and within the classes of those medications may be true from a statistical viewpoint, but is of limited value in practice. The antidepressant drugs may produce differences in therapeutic response and tolerability. Among the possible predictors of outcome in depression treatment, those derived from clinical assessment, neuroendocrine investigations, polysomnographic sleep parameters, genetic variables, and brain imaging techniques have been extensively studied. This article also reviews therapeutic strategies used when initial treatment fails, and describes briefly new concepts in antidepressant therapies such as the regulation of disturbances in circadian rhythms. The treatment of depressive illness does not stop with treatment of acute episodes, and has to be envisaged as a continuous therapeutic intervention, of which we are still not able to determine the optimal duration of treatment and the moment that it should be ceased.
Collapse
|