Verapamil and valproic acid treatment of prolonged mania

Calcium Channel Antagonists for Mood Disorders

PURPOSE

Development of new thymoleptic medications has primarily centered on anticonvulsants and antipsychotic drugs. Based on our studies of intracellular calcium ion signaling in mood disorders, we were interested in the use of novel medications that act on this mechanism of neuronal activation as potential mood stabilizers.

METHOD

We reviewed the dynamics of the calcium second messenger system and the international body of data demonstrating increased baseline and stimulated intracellular calcium levels in peripheral cells of patients with bipolar mood disorders. We then examined studies of the effect of established mood stabilizers on intracellular calcium ion levels and on mechanisms of mobilization of this second messenger. After summarizing studies of calcium channel blocking agents, whose primary action is to attenuate hyperactive intracellular calcium signaling, we considered clinical experience with this class of medications and the potential for further research.

FINDINGS

Established mood stabilizers normalize increased intracellular calcium ion levels in bipolar disorder patients. Most case series and controlled studies suggest an antimanic and possibly mood stabilizing effect of the calcium channel blocking medications verapamil and nimodipine, with fewer data on isradipine. A relatively low risk of teratogenicity and lack of cognitive adverse effects or weight gain suggest possible applications in pregnancy and in patients for whom these are considerations.

IMPLICATIONS

Medications that antagonize hyperactive intracellular signaling warrant more interest than they have received in psychiatry. Further experience will clarify the applications of these medications alone and in combination with more established mood stabilizers.

Applications of calcium channel blockers in psychiatry: pharmacokinetic and pharmacodynamic aspects of treatment of bipolar disorder

Introduction: Calcium channel blockers (CCBs) comprise a heterogeneous group of medications that reduce calcium influx and attenuate cellular hyperactivity. Evidence of hyperactive intracellular calcium ion signaling in multiple peripheral cells of patients with bipolar disorder, calcium antagonist actions of established mood stabilizers, and a relative dearth of treatments have prompted research into potential uses of CCBs for this common and disabling condition. Areas covered: This review provides a comprehensive overview of intracellular calcium signaling in bipolar disorder, structure and function of calcium channels, pharmacology of CCBs, evidence of efficacy of CCBs in bipolar disorder, clinical applications, and directions for future research. Expert opinion: Despite mixed evidence of efficacy, CCBs are a promising novel approach to a demonstrated cellular abnormality in both poles of bipolar disorder. Potential advantages include low potential for sedation and weight gain, and possible usefulness for pregnant and neurologically impaired patients. Further research should focus on markers of a preferential response, studies in specific bipolar subtypes, development of CCBs acting preferentially in the central nervous system and on calcium channels that are primarily involved in neuronal signaling and plasticity.

Modulation of ion channels in clinical psychopharmacology: adults and younger people

This review focuses on the use of Na(+), Ca(2+) and Cl(-) channel modulators in psychiatric disease. Drugs that modulate ion channels have been used in psychiatry for more than a century, and in this review we critically evaluate clinical research that reports the therapeutic effects of drugs acting on GABA(A), voltage-gated Na(+) and voltage-gated Ca(2+) channels in pediatric and adult patients. As in other fields, the evidence underpinning the use of medicines in younger people is far less robust than for adults. In addition, we discuss some current developments and highlight clinical disorders in which current molecules could be further tested. Notable success stories, such as benzodiazepines (in sleep and anxiety disorders) and antiepileptics (in bipolar disorder), have been the result of serendipitous discoveries or refinements of serendipitous discoveries, as in all other major treatments in psychiatry. Genomic, high-throughput screening and molecular pharmacology discoveries may, however, guide further developments in the future. This could include increased research in promising targets that have been perceived as commercially risky, such as selective α-subunit GABA(A) receptors.

Pharmacological interventions for bipolar youth: Developmental considerations

Despite the high prevalence rate, there have been relatively few controlled studies to systematically examine pharmacological treatments for children and adolescents with bipolar disorder. We review the differences in clinical characteristics between youth and adults with bipolar disorder and the extant literature of pharmacological treatments for children and adolescents with bipolar disorder, as well as discuss the effectiveness of pharmacological interventions for treating children and adolescents who are at familial risk for developing bipolar disorder. Although the number of controlled studies of youth with manic and mixed episodes is rapidly growing, there are few studies examining treatments for depression and the prevention of recurrent affective episodes in this population. Although children and adolescents with bipolar disorder commonly present with co-occurring psychiatric disorders, such as attention-deficit/hyperactivity disorder, there are limited data to guide the treatment of these patients. Recently, studies have begun to characterize prodromal manifestations of bipolar disorder and identify early intervention strategies for treating children and adolescents with an elevated risk for developing bipolar disorder.

Management options for bipolar disorder in children and adolescents

During recent years there has been a dramatic increase in the use of psychotropic medication for the treatment of bipolar disorder (BPD) in children. There is an emerging set of data to support this use.Mood stabilizers, including lithium and valproic acid (valproate sodium), have generally formed the mainstay of treatment in children and adolescents with BPD. However, the atypical antipsychotics, such as risperidone, aripiprazole, and quetiapine may be more effective as first-line treatment options and in some ways easier to use than the traditional mood stabilizers. As in adults, mood stabilization is often difficult to achieve in pediatric patients with BPD, and combined treatment with mood stabilizers and atypical antipscyhotics is commonly used. Data from controlled trials of psychotropic medications in children and adolescents with BPD are very limited, and hence, in the majority of cases physicians base their treatment decisions on data from case reports, case series, or open trials. More controlled studies of both monotherapy and polypharmacotherapy for BPD in children and adolescents are needed.

Somatic treatment of bipolar disorder in children and adolescents

The currently available data from randomized, controlled trials and a considerable amount of open clinical data suggest that adolescent-onset bipolar disorder probably responds to the same agents as adult-onset bipolar disorder. Research examining psychopharmacologic treatment approaches in the early-onset bipolar disorder is limited, however. Methodologic problems include small sample sizes, lack of comparison groups, retrospective designs,and lack of standardized measures. In addition, sometimes no clear differentiation is made between mania and bipolar disorder, the latter term being used broadly in the literature. Often the studies show that symptoms improve because of treatment, but the functioning of the patients does not improve significantly. More research is clearly needed in all aspects of this disorder but especially in examining the efficacy of various types of treatment, its longitudinal course, and diagnostic issues. The indications for, and the overall duration of, long-term maintenance therapy need further study.Many adolescents and children with bipolar disorder do not respond to any of the first-line pharmacologic treatments; therefore, studies with novel agents should be extended to patients in this age range. Furthermore, physicians will probably continue to use combination therapies when confronted by either lack of efficacy or delayed onset of efficacy with a single agent. Thus, such resultant drug-drug interactions also should also be systematically studied [97].

The use of mood stabilizers and atypical antipsychotics in children and adolescents with bipolar disorders

The clinical use of mood stabilizers and antipsychotics in children and adolescents with bipolar disorders has increased significantly over the past few years. These agents have multiple effects and interactions. This articles reviews the studies that support the use of mood stabilizers and atypical antipsychotics in children and adolescents with bipolar disorders and presents information on these agent's pharmacokinetics, dosing, and drug interactions.

Psychopharmacology and mental retardation: a 10 year review (1990-1999)

We conducted a 10 year review of the literature pertaining to psychopharmacology and mental retardation. Studies were included or excluded from the review based on meeting one or more of the methodological criteria normally considered fundamental for sound scientific research. The vast majority of studies conducted in the last 10 years in this area had major methodological flaws. While a large number of medications were prescribed for various psychological disorders and behavior problems, most drug administrations were not based in science, were not evaluated appropriately, and generally did not follow best practices for treatment of persons with mental retardation. Very few medications prescribed were behavior or psychiatric symptom specific; that is, most medications were given to suppress a myriad of aberrant behaviors thus chemically restraining the individual in question. Practices such as these present serious problems for service providers due to the deleterious side effects of many psychotropic medications and the federal government's intervention into the care-provision practices of developmental centers, community homes, and other living arrangements for persons with mental retardation. Implications of our review are discussed.

Calcium channel antagonists for the treatment of bipolar disorder

Calcium channel antagonists (CCAs) have many clinical applications, including their possible use in the treatment of bipolar disorder. Two justifications for this last application are some overlap in physiological activities of CCAs with those of lithium, and a possible association between bipolar disorder and calcium dysregulation. While the data from earlier studies support the use of verapamil in treating bipolar mania. more recent better-controlled trials have not. This paper reviews the available body of data regarding CCAs in the treatment of bipolar disorder, concluding there is presently limited support for their efficacy.

Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder

OBJECTIVE

To develop effect sizes for 3 mood stabilizers--lithium, divalproex sodium, and carbamazepine--for the acute-phase treatment of bipolar I or II disorder, mixed or manic episode, in children and adolescents aged 8 to 18 years.

METHOD

Forty-two outpatients with a mean age of 11.4 years (20 with bipolar I disorder and 22 with bipolar II disorder) were randomly assigned to 6 weeks of open treatment with either lithium, divalproex sodium, or carbamazepine. The primary efficacy measures were the weekly Clinical Global Impression Improvement scores and the Young Mania Rating Scale (Y-MRS).

RESULTS

Using a > or = 50% change from baseline to exit in the Y-MRS scores to define response, the effect size was 1.63 for divalproex sodium, 1.06 for lithium, and 1.00 for carbamazepine. Using this same response measure with the intent-to-treat sample, the response rates were as follows: sodium divalproex, 53%; lithium, 38%; and carbamazepine, 38% (chi 2(2) = 0.85, p = .60). All 3 mood stabilizers were well tolerated, and no serious adverse effects were seen.

CONCLUSIONS

Divalproex sodium, lithium, and carbamazepine all showed a large effect size in the open treatment of children and adolescents with bipolar I or II disorder in a mixed or manic episode.

Bipolar disorder in youth

The debate regarding the possible existence of prepubertal bipolar illness has surfaced at various points in history. In its most recent incarnation, proponents of a childhood bipolar diagnosis argue that there is an early-onset form of bipolar illness that is highly comorbid and characterized by simultaneous irritability and depression. Others have suggested that childhood manic symptoms are more likely a nonspecific indicator of risk, or may be the result of symptom overlap with various other forms of childhood pathology. This article briefly reviews pertinent findings from epidemiologic, developmental, family, and treatment studies that shed light on the etiology, phenomenology, and developmental significance of manic symptoms in young people.

Comprehensive review of the psychiatric uses of valproate

The therapeutic effects of valproate in psychiatric conditions are most substantially recognized in bipolar disorder. However, this well-tolerated medication may be beneficial in the treatment of other mental illnesses. In this article, the authors comprehensively review studies of valproate as treatment for psychiatric conditions, including bipolar, depressive, anxiety, and psychotic disorders; alcohol withdrawal and dependence; tardive dyskinesia; agitation associated with dementia; and borderline personality disorder. Valproate shows the most promising efficacy in treating mood and anxiety disorders, with possible efficacy in the treatment of agitation and impulsive aggression, and less convincing therapeutic response in treating psychosis and alcohol withdrawal or dependence. The authors conclude with a brief summary of its mechanism of action and therapeutic spectrum.

Effect of divalproex sodium on aggression and self-injurious behaviour in adults with intellectual disability: a retrospective review

The aim of the present study was to evaluate the efficacy of divalproex sodium treatment in adults with intellectual disability, and aggressive or self-injurious behaviour. Twenty-eight adults aged between 20 and 63 years of age with severe, long-lasting behavioural problems were treated with divalproex sodium (dosage 500-4000 mg day(-1)). Clinical changes were assessed at 2-73 months into the pharmacological treatment utilizing the Clinical Global Impression Severity (CGI-S) scale, and monthly behavioural counts of aggressive and self-injurious acts. Seventy-one percent of subjects demonstrated a moderate or marked improvement on the CGI-S; another 21% demonstrated mild benefits. Among the patients for whom objective prospective behavioural counts were available, 88% showed a significant reduction in aggression and self-injurious behaviour, 46% had other psychotropic medications discontinued, and another 39% had psychotropic medications decreased. One patient had serious thrombocytopenia which required the discontinuation of divalproex sodium, and one other had vomiting and worsened aggression. The present preliminary, uncontrolled study suggests that adults with intellectual disability, and aggressive or self-injurious behaviour may respond to divalproex sodium, and that this drug is well-tolerated in the majority of subjects.

Chronic verapamil modifies striatal and frontal cortex dopamine levels

In an attempt to elucidate if a change in dopamine (DA) levels was involved in the antimanic action of verapamil reported in various clinical studies, monoamine concentrations in three brain regions (striatum, frontal cortex and hippocampus) obtained from verapamil-treated rats (10 mg/kg i.p. per day for 21 days) were quantified by HPLC coupled to electrochemical detection, and compared with monoamine concentrations in haloperidol-treated animals (5 mg/kg i.p. per day for 21 days). We have found that verapamil and haloperidol, when injected for 3 weeks to rats sacrificed 2 h after the last injection, decreased the striatal DA concentration to a similar extent. This decrease was not observed in short-term (one injection 2 h before sacrifice) verapamil- or haloperidol-treated rats. Moreover, after such a single injection of verapamil the striatal DA concentration was even increased. The striatal concentration of 3,4-dihydroxyphenylacetic acid (DOPAC) was increased about two-fold by haloperidol, but not by verapamil. This haloperidol-induced increase in striatal DOPAC was similar after one injection and after 21 days of haloperidol administration. Neither verapamil nor haloperidol modified the concentrations of homovanillic acid (HVA) or 3-methoxytyramine (3-MT) in the striatum. In the frontal cortex, chronic verapamil increased the concentrations of DA two-fold, and chronic haloperidol increased the concentration of DOPAC two-fold. The other DA metabolites, namely HVA and 3-MT were not significantly changed. The concentration of serotonin (5-HT) and its main metabolite, 5-hydroxyindoleacetic acid (5-HIAA), in control, verapamil- and haloperidol-treated rats were similar in the three brain regions studied. We conclude that DA autoreceptors are implicated in verapamil's effects on frontal cortex and striatum DA levels; and that the presumed antimanic action exerted by verapamil is due to its long-term effect on these receptors.

The emerging role of valproate in bipolar disorder and other psychiatric disorders

Although valproate, a simple branched-chain fatty acid, is generally considered to be an antiepileptic agent, a large literature dating back to 1966 describes its use in primary psychiatric disorders. The significant role that gamma-aminobutyric acid plays in mood provided the rationale to examine valproate in this regard. Numerous uncontrolled as well as placebo- and lithium-controlled studies verified the drug's efficacy in the short-term management of bipolar and schizoaffective disorders. The response appears to be independent of response to traditional therapies such as lithium, neuroleptics, and carbamazepine, and may be maintained for extended periods of time. Valproate should be considered not only in patients with mood disorders who are intolerant of or nonresponsive to traditional therapies, but also in those with rapid cycling, electroencephalographic abnormalities, head trauma antedating the onset of psychiatric illness, or any other factor suggesting an organic component. Preliminary uncontrolled studies suggest that the drug may also eventually play a role in the management of panic disorder and behavioral dyscontrol (agitation, aggression, temper outbursts). Its adverse event profile is well known from years of experience in the management of epilepsy and does not appear to be altered in the presence of psychiatric disorders. Similarly, the drug-drug interaction potential of valproate is reasonably well known, although further research into interactions with psychotropic agents is warranted.