Efficacy of atypical antipsychotics in mood disorders

Self-injurious behaviour in autistic children: a neuro-developmental theory of social and environmental isolation

RATIONALE

Self-injurious behaviour is not one of the three core symptoms that define autism. However, children on the autism spectrum appear to be particularly vulnerable. Afflicted children typically slap their faces, punch or bang their heads, and bite or pinch themselves. These behaviours can be extremely destructive, and they interfere with normal social and educational activities. However, the neurobiological mechanisms that confer vulnerability in children with autism have not been adequately described.

OBJECTIVES

This review explores behavioural and neurobiological characteristics of children with autism that may be relevant for an increased understanding of their vulnerability for self-injurious behaviour.

METHODS

Behavioural characteristics that are co-morbid for self-injurious behaviour in children with autism are examined. In addition, the contributions of social and environmental deprivation in self-injurious institutionalized orphans, isolated rhesus macaques, and additional animal models are reviewed.

RESULTS

There is extensive evidence that social and environmental deprivation promotes self-injurious behaviour in both humans (including children with autism) and animal models. Moreover, there are multiple lines of convergent neuroanatomical, neurophysiological, and neurochemical data that draw parallels between self-injurious children with autism and environmentally deprived humans and animals.

CONCLUSIONS

A hypothesis is presented that describes how the core symptoms of autism make these children particularly vulnerable for self-injurious behaviour. Relevant neurodevelopmental pathology is described in cortical, limbic, and basal ganglia brain regions, and additional research is suggested.

The association of bipolar spectrum disorders and borderline personality disorder

Bipolar disorder (BD) and borderline personality disorder (BPD) are two different entities sharing a variety of common features in a number of fields and, thus, presenting difficulties in their differential diagnosis. The aim of the review is to identify similarities and differences between BD and BPD concerning the symptomatology, causes, course and treatment of the two disorders. A systematic electronic search of Pubmed (Medline) was conducted in order to identify all relevant scientific articles published between 1990 and 2010. The main common clinical features of BD and BPD are affective instability and impulsivity, which, however, present with quality differences in each disorder. In the field of neuroanatomy, BD and BPD demonstrate similarities such as alterations in the limbic system, as well as specific differences, such as the increase in size of the amygdala in BD and the decrease in BPD. Both disorders appear to have a significant percentage of heritability, but environmental factors seem to hold an important role in BPD, in particular. Both BD and BPD are affected by alterations in the dopaminergic and serotonergic system. Fuctionability and prognosis are slightly worse for BPD. Concerning medication treatment, antidepressants are considered effective in BPD, whereas mood stabilizers are the main treatment of choice in BD. The effectiveness of a variety of psychotherapeutic methods is still under research for both disorders. Despite the similarities and differences already being traced in clinical and biological fields, the relationship of the two disorders has not yet been thoroughly defined.

Efficacy of antimanic treatments in mixed states

OBJECTIVE

To review the efficacy of pharmacological agents in bipolar mixed states.

METHODS

We conducted a PubMed search of all English-language articles involving Food and Drug Administration (FDA)-approved agents for manic/mixed states in adults with bipolar I disorder. We also included names of agents established as efficacious in acute mania/mixed states that have not received FDA approval for bipolar disorder. Bibliographies from relevant articles were also searched. The efficacy of each agent in the mixed state subpopulation was reviewed, as evidenced by change from baseline on total scores of mania [e.g., Young Mania Rating Scale (YMRS)] and depression [e.g., Montgomery-Åsberg Depression Rating Scale (MADRS)] measures.

RESULTS

No available study is dedicated exclusively to the evaluation of mixed state populations. Although key inclusion and exclusion criteria are similar across treatment studies, mixed states have been variably defined and measured. The use of conventional manic and depressive metrics in bipolar mixed states perpetuates the unproven notion that mixed states are the consequence of coexisting depression and mania. Notwithstanding the methodological limitations, there are numerically more studies that exist for atypical antipsychotic agents than for any other class. On the basis of symptomatic improvement, recommendations for and/or strong admonishments against any established antimanic agents (e.g., lithium) cannot be made. An emergent signal supports combination treatment strategies (e.g., atypical antipsychotic plus divalproex) over mood stabilizer monotherapy (e.g., divalproex). Available evidence does not empirically support the hypothesis that conventional antipsychotics engender and/or amplify depressive symptoms in bipolar mixed states.

CONCLUSIONS

All proven antimanic agents (including lithium), can be recommended in the treatment of mixed/dysphoric states. The totality of evidence with attention paid to the therapeutic index of each agent would suggest that atypical antipsychotics and divalproex be considered as first-line treatment, with lithium and carbamazepine as second-line. Most individuals will require combination therapy for the treatment of mixed states; variable combinations of atypical antipsychotics and conventional mood stabilizers have the most replicated evidence.

Atypical antipsychotics as "mood stabilizers": a retrospective chart review

BACKGROUND

Introduction and common usage of atypical antipsychotics in maintenance therapy for bipolar disorders is an innovative perspective. The aim of the present study was to compare the efficacy of atypical antipsychotics (AA) used either as monotherapy or in combination with a mood stabilizer (MS) in the maintenance treatment.

METHOD

55 patients treated with AA either alone or in combination with a MS for bipolar I disorder which were followed up for 6 months were retrospectively evaluated. Clinical status was evaluated with Bech Rafaelsen Mania Rating Scale (BRMRS), 24-item Hamilton Depression Scale (HAMD) and Clinical Global Impressions Scale (CGI).

RESULTS

Having similar demographic and clinical backgrounds, patients on with both treatment groups had significant clinical improvement. During the maintenance phase, numbers of total attacks were not significantly different between the two treatment groups.

CONCLUSION

Our naturalistic, controlled retrospective observations suggest the potential use of atypical antipsychotics in the long-term management of bipolar I disorder. Larger and prospective studies are needed to determine the role of atypical antipsychotics more clearly in the maintenance treatment of bipolar disorder. To the best of our knowledge this is the first study comparing MS+AA with only AA treatment regimen.

The interface between borderline personality disorder and bipolar spectrum disorders

OBJECTIVE

This review examines whether borderline personality disorder (BPD) should be considered part of the bipolar spectrum.

METHODS

A literature review examined studies of co-occurrence, phenomenology, family prevalence, medication response, longitudinal course, and etiology.

RESULTS

Borderline personality disorder and bipolar disorder co-occur, but their relationship is not consistent or specific. There are overlaps but important differences in phenomenology and in medication response. Family studies suggest clear distinctions, and it is unusual for BPD to evolve into bipolar disorder. Research is insufficient to establish whether these disorders have a common etiology.

CONCLUSIONS

Existing data fail to support the conclusion that BPD and bipolar disorders exist on a spectrum but allows for the possibility of partially overlapping etiologies.

Schizoaffective disorders are psychotic mood disorders; there are no schizoaffective disorders

Schizoaffective disorder (SA D/O), introduced in 1933 by Dr. Jacob Kasanin, represented a first, modest change in our concept about the diagnoses of psychotic patients away from the beliefs of E. Bleuler, i.e., that hallucinations and delusions define schizophrenia, and toward the recognition of a significant role for mood disorders. SA D/O established a connection between schizophrenia and mood disorders, traditionally considered mutually exclusive, a connection that has strengthened progressively toward the diagnostic unity of all three disorders. A basic tenet of medicine holds that if discrepant symptoms can be explained by one disease instead of two or more, it is likely there is only one disease. The scientific justification for SA D/O and schizophrenia as disorders distinct from a psychotic mood disorder has been questioned. The "schizo" prefix in SA D/O rests upon the presumption that the diagnostic symptoms for schizophrenia are disease specific. They are not, since patients with severe mood disorders can evince any or all of the "schizophrenic" symptoms. "Schizophrenic" symptoms mean "psychotic" and not any specific disease. These data and a very low interrater reliability for SA D/O suggest that the concepts of SA D/O and schizophrenia as valid diagnoses are flawed. Clinically SA D/O remains popular because it encompasses both schizophrenia and psychotic mood disorder when there is a diagnostic question. We present a review of the literature in table form based on an assignment of each article assigned to one of five categories that describe the possible relationships between SA D/O, schizophrenia and psychotic mood disorders. We conclude that the data overall are compatible with the hypothesis that a single disease, a mood disorder, with a broad spectrum of severity, rather than three different disorders, accounts for the functional psychoses.

The use of atypical antipsychotics beyond psychoses: efficacy of quetiapine in bipolar disorder

BACKGROUND AND RATIONALE

Atypical antpsychotics have been sucessfully used in the treatment of bipolar disorder (BD), either as adjunctive or as monotherapy. Quetiapine is an atypical antipsychotic extensively used in the treatment of psychotic disorders. It has serotonergic and dopaminergic activity and it appears to be selective for the mesolimbic and mesocortical dopamine system. The aim of this paper was to review the recent literature on the use of quetiapine in the treatment of BD.

METHODS

The literature databases currently available online were searched for papers on quetiapine and BD. Papers and reports published between January 1995 and June 2005 were selected and reviewed critically.

RESULTS

Augmentative low dose quetiapine was found to be effective in BD partially responsive to conventional mood-stabilizers. Manic and mixed episodes have been the best studied, and quetiapine was found to be effective either as monotherapy or as adjunctive therapy in both randomized clinical trials and open-label studies. Data on the use of quetiapine in bipolar depression showed a significant efficacy and high remission rates. Maintenance data suggested a role of quetiapine as a good alternative to classical mood stabilizers in reducing recurrence rates of BD. A few studies on the efficacy in rapid cycling BD have also been published.

CONCLUSIONS

Quetiapine is an effective agent for the short- and long-term treatment of BD. The mechanism of action of quetiapine as a mood stabilizer is still unknown. Some preliminary data suggest the involvement of glutamate pathways but further studies are needed to clarify this issue.

Considering the major mental disorders as clinical expressions of periodic pathological oscillations of the overall operating mode of brain function

The consideration of the collective significance of the shared characteristics and overlaps in the clinical expression and pharmacological responses of the major mental disorders (namely, schizophrenia, bipolar disorders, obsessive compulsive disorder, anxieties/phobias, borderline syndrome and possibly others) supports the following: (1) These disorders have a common, initial neurodevelopmental origin. (2) They occur probabilistically on some of "at-risk" individuals whose pre-existing, extreme, temperamental/structural variance confers vulnerability for such occurrence. (3) Lastly, each of these syndromes can be considered as a clinical expression of oscillations (i.e., a switch to a pathologically ordered phase) of the overall, common operating mode of brain function. This mode based on a particular-for-our-brain, emergent quality of complexity, normally ensures the synchrony, coordination, subtlety and robust flexibility in the expression of the components of each of the various higher faculties of the brain, namely, the faculty of: (1) mood modulation; (2) coordination of feelings, thoughts and the responses to the external world; and (3) keeping constrain and limited but appropriate input of primitive drives. The conclusions in this paper have important ramifications in rethinking the current nosological procrustean flawed classification and the neurodevelopmental origin of the major mental disorders as well as the biases shown in selecting subjects for research. It also opens opportunities in the future development of novel, effective, economical and harmless therapies that will restore and maintain the normal phase of the operating mode of brain function. For example, the patient can wear an appropriate electronic device that sends a particular type of signal to the brain which will affect remission and prevent relapses without harm. We can thus avoid the use of pharmacological agents which have limited effectiveness, severe, long-term side-effects and financial burden to the patient.

Open-label, 8-week trial of olanzapine and risperidone for the treatment of bipolar disorder in preschool-age children

BACKGROUND

To evaluate short-term safety and efficacy of atypical antipsychotics in a single-site, prospective, open-label, 8-week study of risperidone and olanzapine monotherapy in preschoolers with bipolar disorder (BPD).

METHODS

Risperidone was initiated at an open-label dose of .25 mg/day, increased weekly according to response and tolerability to a maximum does of 2.0 mg/day. Olanzapine was initiated at 1.25 mg/day and increased to no more than 10 mg/day.

RESULTS

Thirty-one children aged 4-6 years were treated with olanzapine (n = 15, 6.3 +/- 2.3 mg/day) or risperidone (n = 16, 1.4 +/- .5 mg/day). At study end point (week 8 or last observation carried forward), there was a 18.3 +/- 11.9 point (t = -5.6, p < .001) reduction in risperidone-treated subjects and a 12.1 +/- 10.4 point (t = -4.4, p < .001) reduction in Young Mania Rating Scale (YMRS) scores in olanzapine-treated subjects that did not differ between groups (t = 1.4, p = .2). Response criteria (Clinical Global Impression improvement of "Much" or "Very Much" improved or a YMRS change of >or= 30% or more) indicated no difference in rate of response with risperidone and olanzapine (69% vs. 53%, chi(2)((1)) = .8, p = .4).

CONCLUSIONS

This prospective open study suggests that treatment with risperidone or olanzapine may result in a rapid reduction of symptoms of mania in preschool children with BPD. Because of substantial residual symptomatology and adverse effects, however, a pressing need exists to identify additional safe and effective treatments for the management of BPD in this high-risk population.