Memantine as an Adjuvant Treatment for Obsessive Compulsive Symptoms in Manic Phase of Bipolar Disorder: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

Lithium, the gold standard drug for bipolar disorder: analysis of current clinical studies

Lithium is the gold standard drug in the treatment of bipolar disorder. Despite increasing scientific interest, relatively few patients with bipolar disorder receive lithium therapy. Lithium is the only drug that is effective in the prophylaxis of manic, depressive, and suicidal symptoms. Lithium therapy is also associated with a variety of adverse drug reactions and the need for therapeutic drug monitoring. Numerous studies have focussed on the efficacy and safety of both lithium-monotherapy and lithium-add-on therapy. The aim of this study is to provide a systematic overview of clinical studies on lithium therapy for bipolar disorder from the last 7 years and to present a critical analysis of these studies. The results provide an up-to-date overview of the efficacy, tolerability, and safety of lithium therapy for bipolar disorder and thus improve the pharmacotherapy of bipolar disorder. A total of 59 studies were analysed using various analysis parameters. The studies were also categorised into different subgroups. These are lithium-monotherapy, lithium vs. placebo/drug, and lithium + adjunctive therapy. The majority of the studies (N = 20) had a duration of only 3-8 weeks. Only 13 studies lasted for > 40 weeks. Lithium was superior to aripiprazole, valproic acid, and quetiapine in terms of improving manic symptoms. Lithium therapy resulted in a lower relapse rate compared to valproic acid therapy. Lithium was more neuroprotectively effective than quetiapine. Fourteen of the 22 add-on therapies to lithium showed a predominantly positive effect on the treatment outcome compared to lithium-monotherapy. Only the add-on therapy with sertraline led to a higher rate of study discontinuations than lithium-monotherapy. Lithium is a safe and effective treatment option for children. However, risperidone and quetiapine were superior to lithium in some aspects, which is why these drugs should be considered as an alternative treatment option for children. Collectively, current clinical studies highlight the relevance of lithium in the treatment of bipolar disorder.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Treatment-resistant OCD: Pharmacotherapies in adults

Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Is quetiapine effective for obsessive and compulsive symptoms in patients with bipolar disorder? A randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

The aim of this study is to examine the effects of quetiapine as an adjuvant treatment for obsessive-compulsive (OC) symptoms in patients with bipolar disorder (BD) type I.

METHODS

In this 8-week double-blind placebo-controlled randomized clinical trial, 47 patients with BD in euthymic phase that had OC symptoms were randomly allocated to receive either quetiapine or placebo plus their routine medications (lithium + clonazepam). Yale-Brown Obsessive-Compulsive Scale (YBOCS) was used to assess the outcomes. Adverse effects were also recorded.

RESULTS

Of 47 BD patients with OC symptoms that were randomly allocated in two groups of quetiapine (n = 24) and placebo group (n = 23), 40 patients (20 in quetiapine group and 20 in placebo group) completed the trial. Throughout the trial, the mean score of YBOCS in the quetiapine group dropped from 24.37 ± 1.51 to 15.26 ± 1.16 (P < .001) and in the placebo group decreased from 24.21 ± 1.33 to 23.94 ± 1.66 (P = 1.97). At the end of the study, 12 (60%) patients in the quetiapine group and 1 (5%) patient in the placebo group had more than 34% decline in YBOCS score (P < .001). No serious adverse effects were reported in two groups.

CONCLUSIONS

Our double-blind placebo-controlled clinical trial showed that quetiapine may be an effective adjuvant agent for reducing OC symptoms in BD patients.

Moving beyond first-line treatment options for OCD

OCD is characterized by obsessions and compulsions that cause distress, are time-consuming, and interfere with a patient's social, occupational, or other areas of functioning. SSRIs are first-line pharmacologic treatment options and produce response rates of up to 60% in patients with OCD. Several potential strategies have been evaluated for enhancing patient response, including high-dose SSRI therapy, antipsychotic augmentation, and memantine augmentation. Three patient cases are used to explore treatment guidelines, evaluate existing literature, and provide pharmacotherapy recommendations for the management of patients with OCD when first-line therapy fails.

Pharmacotherapeutic Strategies and New Targets in OCD

Effective pharmacological and psychotherapeutic treatments are well established for obsessive-compulsive disorder (OCD). Serotonin reuptake inhibitors (SRIs) are first-line treatment and are of benefit to about half of patients. Augmentation of SRI treatment with low-dose neuroleptics is an evidence-based second-line strategy. Specialty psychotherapy is also used as both first-line and second-line treatment and can benefit many. However, a substantial number of patients do not respond to these treatments. New alternatives are urgently needed. This review summarizes evidence for these established pharmacotherapeutic strategies, and for others that have been investigated in refractory disease but are not supported by the same level of evidence. We focus on three neurotransmitter systems in the brain: serotonin, dopamine, and glutamate. We summarize evidence from genetic, neuroimaging, animal model, and other lines of investigation that probe these three systems in patients with OCD. We also review recent work on predictors of response to current treatments. While many studies suggest abnormalities that may provide insight into the pathophysiology of the disorder, most studies have been small, and non-replication of reported findings has been common. Nevertheless, the gradual accrual of evidence for neurotransmitter dysregulation may in time lead the way to new pharmacological strategies.

Pharmacological Treatment for Comorbid Bipolar Disorder and Obsessive-Compulsive Disorder in Adults

Comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) is fairly common, and the treatment of these conditions when comorbid is challenging. Serotonin reuptake inhibitors, the first option for treatment of OCD, can worsen BD symptoms, and mood stabilizers are generally not efficacious for OCD. Our goal in this article is to assess the clinical effectiveness of pharmacotherapies for comorbid BD-OCD in adults. We searched the Medline, Embase, and Cochrane Central Register of Controlled Trials databases on April 30, 2017, and we also searched the reference lists of identified articles. Studies published beginning January 1, 2007 were included, without language restrictions. Narrative and systematic reviews, letters to the editor, and book chapters were excluded. Two authors independently assessed the quality of the studies and extracted data. Seven studies met our inclusion criteria. Findings from double-blind, randomized, placebo-controlled trials were pooled for analysis. Findings from this pooled analysis indicated that augmentation of mood-stabilizer treatment with glutamate modulator agents (topiramate or memantine) may favor full response of obsessive-compulsive symptoms (risk ratio: 2.62, 95% confidence interval: 1.45-4.74) in patients with BD type I and OCD in the manic phase, and that it does not significantly induce adverse effects (risk ratio: 1.26, 95% confidence interval: 0.53-3.01). Results of a narrative synthesis of observational studies indicated greater efficacy of mood-stabilizer treatment, with serotonin reuptake inhibitors less used. Findings from studies employing different designs were not compared, and our results should be interpreted cautiously.

Pregabalin augmentation for resistant obsessive-compulsive disorder: a double-blind placebo-controlled clinical trial

BACKGROUND AND OBJECTIVE

Glutamate dysfunction has been shown to be associated with pathophysiology of obsessive-compulsive disorder (OCD). Our objective is to survey the effects of pregabalin (a glutamate-modulating agent) as an augmenting treatment for resistant OCD.

PATIENTS AND METHODS

In this 12-week double-blind placebo-controlled clinical trial, 56 patients with resistant OCD were randomly allocated to receive either pregabalin or placebo plus their current medication (sertraline). Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to evaluate the outcomes. Adverse effects were also registered.

RESULTS

Of the 56 patients with resistant OCD who were randomly allocated in 2 groups of pregabalin (n = 28) and placebo group (n = 28), 42 patients (22 in pregabalin group and 20 in placebo group) completed the trial. Throughout the trial, the mean score decreased from 26.13± 7.03 to 8.81 ± 3.47 in the pregabalin group (p < 0) and from 26.85 ± 4.34 to 17.63 ± 4.22 in the placebo group (p < 0). At the end of trial, 16 (57.14%) patients in the pregabalin group and 2 (7.14%) patients in the placebo group showed more than 35% decline in YBOCS (p < .01). The pregabalin group showed good tolerability and safety.

CONCLUSIONS

Our study revealed that pregabalin, as an augmenting medication, is more effective than placebo in the treatment of patients with resistant OCD.

A systematic review and meta-analysis: Memantine augmentation in moderate to severe obsessive-compulsive disorder

A considerable proportion of obsessive-compulsive disorder (OCD) patients receiving first-line pharmacological therapy, fail to fully respond to treatment and continue to exhibit significant symptoms. In this systematic review, we evaluate the efficacy of memantine, as a glutamate-modulating agent, in moderate to severe OCD. Single and double blinded as well as open-label trials of memantine augmentation in adults with OCD were considered. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores were the primary outcome measure. The electronic databases of PubMed, Scopus, Embase and Google Scholar were searched for relevant trials using keywords 'obsessive-compulsive disorder OR OCD' AND 'memantine'. The meta-analysis of eight studies involving 125 OCD subjects receiving memantine augmentation exhibited a significant overall mean reduction of 11.73 points in Y-BOCS scores. The categorical analysis of treatment response (a minimum of 35% reduction in Y-BOCS) in four double-blind placebo-controlled studies indicated that OCD patients receiving memantine augmentation were 3.61 times more likely to respond to treatment than those receiving placebo. We found that 20 mg/day memantine augmentation to first-line pharmacological treatment for a period of at least 8 weeks is a safe and effective intervention for moderate to severe OCD.

The psychopharmacology algorithm project at the Harvard South Shore Program: An algorithm for adults with obsessive-compulsive disorder

A previous algorithm for the pharmacological treatment of obsessive-compulsive disorder was published in 2012. Developments over the past 7 years suggest an update is needed. The authors conducted searches in PubMed, focusing on new studies and reviews since 2012 that would support or change previous recommendations. We identified exceptions to the main algorithm, including pregnant women and women of child-bearing potential, the elderly, and patients with common medical and psychiatric co-morbidities. Selective serotonin reuptake inhibitors (SSRIs) are still first-line. An adequate trial requires a period at typical antidepressant doses and dose adjustments guided by a plasma level to evaluate for poor adherence or ultra-rapid metabolism. If the response is inadequate, consider a trial of another SSRI this time possibly taken to a very high dose. Clomipramine could be an alternative. If the response to the second trial remains inadequate, the next recommendation is to augment with aripiprazole or risperidone. Alternatively, augmentation with novel agents could be selected, including glutamatergic (memantine, riluzole, topiramate, n-acetylcysteine, lamotrigine), serotonergic (ondansetron), and anti-inflammatory (minocycline, celecoxib) agents. A third option could be transcranial magnetic stimulation. Lastly, after several of these trials, deep brain stimulation and cingulotomy have evidence for a role in the most treatment-refractory patients.

Updates in treating comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review

BACKGROUND

In the last five years, the debate around the comorbidity between bipolar disorder (BD) and obsessive-compulsive disorder (OCD) has flourished within the international psychiatric community and several studies have been published on therapeutic strategies.

METHODS

An update of our previous systematic review was conducted on clinical management of comorbid BD-OCD patients. Relevant papers published from July 1st 2013 to September 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Fifteen studies were included. In all selected studies BD-OCD patients received mood stabilizers, alone or with second-generation antipsychotics (SGAs). Aripiprazole augmentation demonstrated to be effective as maintenance therapy and for treating obsessive-compulsive symptoms during manic episodes (40% of the studies, 6/15). Addition of antidepressants to mood stabilizers led to clinical remission of both conditions in only one case report.

LIMITATIONS

Almost 50% of the selected studies are case reports. Enrolment of subjects mainly from outpatient specialty units might have introduced selection bias and limited community-wide generalizability.

CONCLUSIONS

Mood stabilization should be the primary goal in treating BD-OCD patients. Aripiprazole augmentation to lithium carbonate seemed to be the best option in treatment-resistance comorbid patients. Addition of SRIs may be needed only in a minority of BD patients with refractory OCD.

Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes

The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.

Comparing escitaloipram with sertraline for obsessive and compulsive symptoms in patients with obsessive compulsive disorder: A comparative double blind clinical trial

BACKGROUND

Escitalopram has some unique features among selective serotonin reuptake inhibitors. The aim of this survey is to compare the efficacy of escitalopram with sertraline on obsessive and compulsive symptoms in patients with Obsessive Compulsive Disorder (OCD).

METHODS

In this 12-week double blind controlled randomized clinical trial, 57 patients with OCD were randomly allocated to receive escitalopram or sertraline. Yale Brown obsessive compulsive behavior scale (YBOCS) was used to assess the outcomes. Adverse effects were also recorded.

RESULTS

41 patients (20 in the escitalopram group and 21 in the sertraline group) completed the trial. In the escitalopram group 15 (70%) patients and in the sertraline group 16 (76.19%) patients showed more than 34% decrease in mean YBOCS score at the end of the trial (P=0.531). The two groups revealed significant decrease in YBOCS scores without significant difference (P=0.861) at week 12. No serious adverse effects were reported.

CONCLUSIONS

Our results demonstrated that escitalopram is as effective as sertraline in treatment of obsessions and compulsions in patients with OCD. However, it needs to be noted that our study is preliminary and larger double blind controlled studies are needed to confirm the results.

Aripiprazole as an adjuvant treatment for obsessive and compulsive symptoms in manic phase of bipolar disorder: A randomized, double-blind, placebo-controlled clinical trial

BACKGROUND AND OBJECTIVE

Our Objective is to study the effects of aripiprazole as an adjuvant treatment for obsessive and compulsive (OC) symptoms in patients with bipolar disorder (BD) type I, manic phase.

PATIENTS AND METHODS

In this 8-week, double-blind, placebo-controlled randomized clinical trial, 56 patients with BD who had OC symptoms were randomly allocated to receive aripiprazole or placebo plus their routine medication regimen (lithium + clonazepam). Yale Brown obsessive compulsive behavior scale (YBOCS) was administered to evaluate the outcomes. Adverse effects were also registered.

RESULTS

Of 56 BD patients with OC symptoms which were randomly allocated in two groups of aripiprazole (n = 29) and placebo group (n = 27), 46 patients (23 in aripiprazole group and 23 in placebo group) completed the trial. Throughout the trial, the mean score of YBOCS in the aripiprazole group decreased from 21 ± 4.81 to 9.6 ± 2.2 (P < 0.001) and in the placebo group dropped from 20.46 ± 4.8 to 17.32 ± 3.7 (P < 0.001). At the end of the study, 21 (91.30%) patients in the aripiprazole group and 1 (4.34%) patient in the placebo group had >34% decline in YBOCS score (P < 0.01). No serious adverse effects were reported in any groups.

CONCLUSIONS

The results of our study revealed that aripiprazole can be used as an effective adjuvant agent for treatment of obsessive and compulsive symptoms in manic patients.