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Terao I, Kodama W. Comparative Efficacy of Dopamine Partial Agonists by Doses for Treatment-Resistant Depression: A Systematic Review and Dose-Response Model-Based Network Meta-analysis. J Clin Psychopharmacol 2024; 44:413-417. [PMID: 38639435 DOI: 10.1097/jcp.0000000000001862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND The augmentative antidepressant effects of dopamine partial agonists (aripiprazole, brexpiprazole, and cariprazine) for treatment-resistant depression have been compared in a previous network meta-analysis. However, the comparative efficacy of the dose-responses of these drugs remains unclear. Therefore, we aimed to estimate the dose-response relationships and compare the effects of each dopamine partial agonist doses. METHODS We conducted a systematic review of the Cochrane Library, PubMed, CINHAL, and ClinicalTrials.gov databases until January 1, 2023. Double-blind, randomized, placebo-controlled trials evaluating aripiprazole, brexpiprazole, and cariprazine for treatment-resistant depression were included. A random-effect dose-response model-based network meta-analysis was conducted. This study was registered in PROSPERO (CRD42023393035). RESULTS The maximum effective doses were 5.5 mg for aripiprazole, 1.6 mg for brexpiprazole, and 1.5 mg for cariprazine, respectively. Although all doses of the 3 drugs were significantly more effective than placebo, aripiprazole ranging from 5.5 to 12.5 mg was significantly more effective than brexpiprazole 0.5 mg and cariprazine ranging from 0.5 to 1 mg. Moreover, aripiprazole ranging from 7.5 to 12.5 mg was significantly more effective than all doses of cariprazine. In addition, brexpiprazole ranging from 1 to 3 mg was significantly more effective than cariprazine 0.5 mg and brexpiprazole ranging from 1.6 to 2.5 mg was significantly superior to cariprazine 1 mg. There were no doses at which brexpiprazole overcame aripiprazole, and cariprazine overcame aripiprazole or brexpiprazole. CONCLUSIONS Aripiprazole, brexpiprazole, and cariprazine may be effective in treatment-resistant depression in that order, with the maximum effective doses at 5.5 mg, 1.6 mg, and 1.5 mg, respectively.
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Affiliation(s)
- Itsuki Terao
- From the Department of Psychiatry, Ikokoro Clinic Nihonbashi
| | - Wakako Kodama
- Department of Psychiatry, Negishi Hospital, Tokyo, Japan
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Martins-Correia J, Fernandes LA, Kenny R, Salas B, Karmani S, Inskip A, Pearson F, Watson S. Cariprazine in the acute treatment of unipolar and bipolar depression: A systematic review and meta-analysis. J Affect Disord 2024; 362:297-307. [PMID: 38942207 DOI: 10.1016/j.jad.2024.06.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/15/2024] [Accepted: 06/25/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Cariprazine has emerged as a promising augmenting treatment agent for unipolar depression and as a monotherapy option for bipolar depression. We evaluated cariprazine's efficacy in treating acute major depressive episodes in individuals with major depressive disorder (MDD) or bipolar disorder. METHODS A systematic review was conducted on MEDLINE, Embase, PsycINFO, Scopus and Web of Science, ClinicalTrials.gov and ScanMedicine. Study quality was assessed using the RoB 2 tool. Pairwise and dose-response meta-analyses were conducted with RStudio. Evidence quality was assessed with GRADE. RESULTS Nine RCTs meeting inclusion criteria encompassed 4889 participants. Cariprazine, compared to placebo, significantly reduced the MADRS score (MD = -1.49, 95 % CI: -2.22 to -0.76) and demonstrated significantly higher response (RR = 1.21, 95 % CI: 1.12 to 1.30) and remission (RR = 1.19, 95 % CI: 1.06 to 1.34) rates. Subgroup analysis unveiled statistically significant reductions in MADRS score in MDD (MD = -1.15, 95 % CI: -2.04 to -0.26) and bipolar I disorder (BDI) (MD = -2.53, 95 % CI: -3.61 to -1.45), higher response rates for both MDD (RR = 1.19, 95 % CI: 1.08 to 1.31) and BDI (RR = 1.27, 95 % CI: 1.10 to 1.46), and higher remission rates only for BDI (RR = 1.41, 95 % CI: 1.24 to 1.60). A higher rate of treatment discontinuation due to adverse events was observed. LIMITATIONS Reliance solely on RCTs limits generalisability; strict criteria might not reflect real-world diversity. CONCLUSIONS Cariprazine demonstrates efficacy in treating major depressive episodes, although variations exist between MDD and BDI and tolerability may be an issue.
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Affiliation(s)
- João Martins-Correia
- Department of Public Health and Forensic Sciences, Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Luís Afonso Fernandes
- Department of Psychiatry, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - Ryan Kenny
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; National Institute for Health Research Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Salas
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sneha Karmani
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Alex Inskip
- National Institute for Health Research Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; National Institute for Health Research Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stuart Watson
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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Ali E, Latif F, Mashkoor Y, Sheikh A, Iqbal A, Owais R, Ahmed J, Naveed S, Moeed A, Ullah I, Mughal S. Role of adjunctive cariprazine for treatment-resistant depression in patients with major depressive disorder: A systematic review and meta-analysis of randomized controlled trials. Asian J Psychiatr 2024; 95:104005. [PMID: 38513509 DOI: 10.1016/j.ajp.2024.104005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Cariprazine is an orally active dopamine D3-preferring D3/D2 receptor and serotonin 5-HT1A receptor partial agonist, being considered as a treatment for refractory MDD. Therefore, we aim to perform the first meta-analysis of current literature, to collate changes in depression from baseline and assess tolerability of adjunctive cariprazine in MDD populace. METHODS PubMed, Embase, Google Scholar, ClinicalTrials.Gov, and Cochrane Library were searched from inception till 1st September 2023. RCTs of adult patients with refractory MDD under adjunctive cariprazine vs. placebo were included. Primary outcomes included improvement in MADRS, CGI-S, and HAM-D 17 scores. Secondary outcomes included treatment-emergent adverse events. The statistical analysis was performed using generic inverse variance with random-effects model. The overall risk ratios (RR) were calculated for dichotomous outcomes. RESULTS A total of five RCTs were analysed, enrolling 2013 participants (cariprazine: 959 participants, Placebo: 1054). Supplementation of ADT with cariprazine demonstrated a significant improvement in MADRAS, CGI-S and HAMD-17 scores from baseline (LSMD: -1.88, 95% CI [-2.94, -0.83], p=0.0005), (LSMD: -0.18, 95% CI [-0.29, -0.07], p=0.002), and (LSMD: -0.96, 95% CI [-1.70, -0.21], p=0.01) respectively. Treatment with adjunctive cariprazine therapy demonstrated significantly increased incidence of akathisia, nausea, dizziness, fatigue, restlessness, somnolence, and tremors when compared with placebo. CONCLUSION Our meta-analysis provides evidence supporting the efficacy of adjunctive cariprazine in patients with refractory MDD. However, it is essential to consider the safety profile of cariprazine, particularly the increased risk of adverse events. The vigilant monitoring and management of these side effects should be integrated into clinical practice to minimize discontinuation rates and optimize patient outcomes.
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Affiliation(s)
- Eman Ali
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Fakhar Latif
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Yusra Mashkoor
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ayesha Sheikh
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Amna Iqbal
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Rabia Owais
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Jawad Ahmed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Sadiq Naveed
- Psychiatry Program Director at Eastern Connecticut Health Network, CT, USA; Associate Professor of Psychiatry, University of Connecticut, CT, USA; Associate Professor of Psychiatry, Frank H. Netter School of Medicine at Quinnipiac University, CT, USA; Fellow, Infant, Parent Mental Health, University of Massachusetts, Boston, USA
| | - Abdul Moeed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Sanila Mughal
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan.
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Sattaf F, Scherf-Clavel M, Unterecker S, Reif A, Hahn M. Recommendation for a Therapeutic Reference Range of Cariprazine-A Short Communication. Ther Drug Monit 2024; 46:270-273. [PMID: 38018849 DOI: 10.1097/ftd.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/19/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic reference ranges are essential for therapeutic drug monitoring to evaluate results and adjust pharmacotherapy. The measured serum concentrations of cariprazine-treated patients have frequently been found to lie beyond the currently used therapeutic reference range; furthermore, reliable data for establishing evidence-based therapeutic ranges are scarce. The current therapeutic reference ranges have only been estimated; however, real-world data on cariprazine are missing. Individual serum concentrations were analyzed, and the validity of the currently used reference ranges was assessed. METHODS Serum concentrations of 19 psychiatric patients treated with cariprazine without pharmacokinetic abnormalities were retrospectively analyzed. Only the last measurement per patient was included in the analysis, and patients who underwent a dose adjustment in the subsequent 2 weeks after sampling were excluded (assuming that the target dose and response had been achieved at that time). Serum concentrations were compared with the therapeutic reference range (10-20 ng/mL) of the Arbeitsgemeinschaft für Neuropsychiatrie und Pharmakotherapie consensus guidelines of 2017 and with a recent recommendation for a lower therapeutic reference range (5-15 ng/mL). RESULTS The mean serum concentration was 9.1 ± 4.1 SD ng/mL. A total of 47.4% of the values were within the therapeutic reference range of 10-20 ng/mL, and 78.9% fell within the range of 5-15 ng/mL. CONCLUSIONS These results support previous recommendations for lowering the therapeutic reference range to 5-15 ng/mL. The calculated therapeutic reference range was 5.0-13.2 ng/mL. It may even be potentially lower because clinicians may have tried to titrate the dose to a serum concentration within the current therapeutic reference range of 10-20 ng/mL.
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Affiliation(s)
- Fabian Sattaf
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Frankfurt am Main
| | - Maike Scherf-Clavel
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg; and
| | - Stefan Unterecker
- Department of Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg; and
| | - Andreas Reif
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Frankfurt am Main
| | - Martina Hahn
- Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Frankfurt am Main
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt am Main, Germany
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Xie M, Qiu Y, Wang M, Wei X, Tao Y, Duan A, Shang J, Gao W, Wang Z. Adjunctive cariprazine as a novel effective strategy for treating major depressive disorder: A systematic review and meta-analysis. J Psychiatr Res 2024; 172:71-80. [PMID: 38367320 DOI: 10.1016/j.jpsychires.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 12/14/2023] [Accepted: 02/07/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Cariprazine has been approved by the Food and Drug Administration for treating bipolar depression and as an adjunctive treatment for Major Depressive Disorder (MDD). However, it remains unclear about its pharmacological efficacy in treating MDD. Therefore, a meta-analysis was conducted to investigate the adjunctive use of cariprazine in MDD. METHODS Electronic databases were searched for eligible studies evaluating the efficacy and safety of cariprazine in patients with MDD up to November 15, 2023. The changes in Montgomery-Asberg Depression Rating Scale (MADRS) score and incidence of adverse events (AEs), which represents of efficacy and tolerability, are considered as the main outcomes. RESULTS A total of 3066 patients with MDD included in all across 5 RCTs. With regard to MADRS score, cariprazine group showed better results than control group (SMD = -0.12, 95% CI -0.19 to -0.04, P = 0.002, 5 RCTs, n = 3066). Cariprazine, meanwhile, improved the MADRS response (RR = 1.19, 95% CI 1.08 to 1.31, P = 0.0004, 5 RCTs, n = 3066). For safety outcomes, statistical difference was observed in AEs (RR = 1.26, 95% CI 1.18 to 1.35, P < 0.00001, 5 RCTs, n = 3077). The suicide ideation and SAEs showed no statistical difference between two groups. CONCLUSION Cariprazine demonstrated antidepressant effect as an augmentation therapy in treating MDD. Meanwhile, the tolerability of it was acceptable as an adjunctive treatment. However, studies with larger sample sizes are still needed to explore the optimal dosage.
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Affiliation(s)
- Minjia Xie
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Youjia Qiu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Menghan Wang
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province, 215002, China
| | - Xingzhou Wei
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province, 215002, China
| | - Yuchen Tao
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province, 215002, China
| | - Aojie Duan
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Jing Shang
- Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Wei Gao
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China.
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
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6
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Gill H, Chen-Li DCJ, Haikazian S, Seyedin S, McIntyre RS, Mansur RB, DiVincenzo JD, Phan L, Rosenblat JD. Adjunctive cariprazine for major depressive disorder: a systematic review and meta-analysis. CNS Spectr 2024:1-10. [PMID: 38555956 DOI: 10.1017/s1092852924000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Converging evidence has suggested that treatment augmentation with a second-generation atypical antipsychotic (SGA) may improve treatment outcomes in major depressive disorder (MDD) patients after an incomplete response to a first-line antidepressant. Cariprazine is a recently approved SGA for MDD augmentation. Herein, we evaluate both continuous (ie, change in depressive symptom severity scores over time) and categorical (ie, remission and response rates) outcomes. Following a full-text review, four randomized controlled trials (RCTs) were included in our meta-analysis, while five studies were included for a qualitative review. Risk ratios (RRs) were calculated for all included randomized controlled studies to determine the relative response and remission rates of cariprazine compared to placebo augmentation. The RR for all-cause dropout was also determined as a proxy for overall acceptability. Two studies found a statistically significant treatment response using cariprazine augmentation. One study observed depressive symptom remission for cariprazine compared to placebo. Our random-effects model revealed moderate antidepressant effects of cariprazine, with a standardized mean difference (SMD) in Montgomery-Åsberg Depression Rating Scale (MADRS) scores of -1.79 (95% CI): -2.89, -0.69). Our pooled response RR and remission RR were calculated as 1.21 (95% CI: 1.05, 1.39, P=0.008) and 0.99 (95% CI: 0.84, 1.17, P=0.91), respectively. The RR for response was statistically significant (P<0.05). However, the RR for remission was not statistically significant. The findings from our meta-analysis include a variable magnitude of effects. Evidence suggests cariprazine may be an effective treatment for MDD; however, further results are needed to clarify this relation.
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Affiliation(s)
- Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - David C J Chen-Li
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Sipan Haikazian
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Sam Seyedin
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Joshua D DiVincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Lee Phan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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7
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Thase ME, Yeung PP, Rekeda L, Liu M, Varughese S. Safety and tolerability of cariprazine for the adjunctive treatment of major depressive disorder: a pooled analysis of phase 2b/phase 3 clinical trials. Int Clin Psychopharmacol 2024:00004850-990000000-00124. [PMID: 38277187 DOI: 10.1097/yic.0000000000000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
To characterize the safety and tolerability of adjunctive cariprazine in patients with major depressive disorder (MDD) and inadequate response to monotherapy antidepressant treatment (ADT). Post hoc analyses evaluated pooled data from 2 fixed-dose phase 3 cariprazine studies (1.5 and 3 mg/d [approved doses for MDD]). In a separate safety analysis, cariprazine 0.1-4.5 mg/d was evaluated using data from the 2 fixed-dose trials plus 3 flexible-dose studies grouped by modal-daily dose. In the pooled phase 3 studies (placebo = 503, 1.5 mg/d = 502, 3 mg/d = 503), overall cariprazine-treated patients had high rates of study completion (90%). Patients had mostly mild/moderate treatment-emergent adverse events that caused premature discontinuation of 4.3%. Only akathisia, nausea, and insomnia occurred in ≥5% of cariprazine patients (any group) and at twice the rate of placebo; potential dose-dependent responses were observed for akathisia and insomnia. Cariprazine had a neutral metabolic profile, with mean weight increase of <1 kg. Modal-dose results were similar, and both analyses were consistent with the known safety profile of cariprazine across its approved indications. Adjunctive cariprazine therapy was safe and generally well tolerated in patients with MDD who had not obtained an adequate response to ADT monotherapy; no new safety signals were identified.
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Affiliation(s)
- Michael E Thase
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Meng Liu
- AbbVie, Florham Park, New Jersey, USA
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McIntyre RS, Alsuwaidan M, Baune BT, Berk M, Demyttenaere K, Goldberg JF, Gorwood P, Ho R, Kasper S, Kennedy SH, Ly-Uson J, Mansur RB, McAllister-Williams RH, Murrough JW, Nemeroff CB, Nierenberg AA, Rosenblat JD, Sanacora G, Schatzberg AF, Shelton R, Stahl SM, Trivedi MH, Vieta E, Vinberg M, Williams N, Young AH, Maj M. Treatment-resistant depression: definition, prevalence, detection, management, and investigational interventions. World Psychiatry 2023; 22:394-412. [PMID: 37713549 PMCID: PMC10503923 DOI: 10.1002/wps.21120] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Treatment-resistant depression (TRD) is common and associated with multiple serious public health implications. A consensus definition of TRD with demonstrated predictive utility in terms of clinical decision-making and health outcomes does not currently exist. Instead, a plethora of definitions have been proposed, which vary significantly in their conceptual framework. The absence of a consensus definition hampers precise estimates of the prevalence of TRD, and also belies efforts to identify risk factors, prevention opportunities, and effective interventions. In addition, it results in heterogeneity in clinical practice decision-making, adversely affecting quality of care. The US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have adopted the most used definition of TRD (i.e., inadequate response to a minimum of two antidepressants despite adequacy of the treatment trial and adherence to treatment). It is currently estimated that at least 30% of persons with depression meet this definition. A significant percentage of persons with TRD are actually pseudo-resistant (e.g., due to inadequacy of treatment trials or non-adherence to treatment). Although multiple sociodemographic, clinical, treatment and contextual factors are known to negatively moderate response in persons with depression, very few factors are regarded as predictive of non-response across multiple modalities of treatment. Intravenous ketamine and intranasal esketamine (co-administered with an antidepressant) are established as efficacious in the management of TRD. Some second-generation antipsychotics (e.g., aripiprazole, brexpiprazole, cariprazine, quetiapine XR) are proven effective as adjunctive treatments to antidepressants in partial responders, but only the olanzapine-fluoxetine combination has been studied in FDA-defined TRD. Repetitive transcranial magnetic stimulation (TMS) is established as effective and FDA-approved for individuals with TRD, with accelerated theta-burst TMS also recently showing efficacy. Electroconvulsive therapy is regarded as an effective acute and maintenance intervention in TRD, with preliminary evidence suggesting non-inferiority to acute intravenous ketamine. Evidence for extending antidepressant trial, medication switching and combining antidepressants is mixed. Manual-based psychotherapies are not established as efficacious on their own in TRD, but offer significant symptomatic relief when added to conventional antidepressants. Digital therapeutics are under study and represent a potential future clinical vista in this population.
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Affiliation(s)
- Roger S McIntyre
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Mohammad Alsuwaidan
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Bernhard T Baune
- Department of Psychiatry, University of Münster, Münster, Germany
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Michael Berk
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
- Deakin University IMPACT Institute, Geelong, VIC, Australia
| | - Koen Demyttenaere
- Department of Psychiatry, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip Gorwood
- Department of Psychiatry, Sainte-Anne Hospital, Paris, France
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Institute for Health Innovation and Technology, National University of Singapore, Singapore
| | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy and Center of Brain Research, Molecular Neuroscience Branch, Medical University of Vienna, Vienna, Austria
| | - Sidney H Kennedy
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Josefina Ly-Uson
- Department of Psychiatry and Behavioral Medicine, University of The Philippines College of Medicine, Manila, The Philippines
| | - Rodrigo B Mansur
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - R Hamish McAllister-Williams
- Northern Center for Mood Disorders, Translational and Clinical Research Institute, Newcastle University, and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - James W Murrough
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua D Rosenblat
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Gerard Sanacora
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Alan F Schatzberg
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard Shelton
- Department of Psychiatry, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Madhukar H Trivedi
- Department of Psychiatry, University of Illinois Chicago, Chicago, IL, USA
| | - Eduard Vieta
- Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
| | - Maj Vinberg
- Mental Health Centre, Northern Zealand, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Nolan Williams
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Allan H Young
- Department of Psychological Medicine, King's College London, London, UK
| | - Mario Maj
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
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9
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Gill JS. Cariprazine in an Adolescent with Tourette Syndrome with Comorbid Attention Deficit Hyperactive Disorder and Depression: A Case Report. Healthcare (Basel) 2023; 11:2531. [PMID: 37761728 PMCID: PMC10530423 DOI: 10.3390/healthcare11182531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Tourette syndrome is a complex neuropsychiatric condition that manifests in childhood and is often associated with other psychiatric comorbidities. This case report describes a young male with Tourette syndrome with major depressive disorder and attention deficit hyperactivity disorder (ADHD) who experienced troublesome side effects due to his existing medications (escitalopram, risperidone, and methylphenidate). In order to control his tics, ameliorate depressive symptoms, and eliminate side effects of stiffness and sedation, risperidone was switched to cariprazine, a third-generation antipsychotic medication with D3-D2 partial agonism. In addition, the antidepressant dose was also increased. With the new combination, the patient reported good control of his tics, together with significant improvement in depressive symptoms and no side effects. Based on this case and the reviewed literature, cariprazine might be a viable option for patients with Tourette syndrome with other comorbid illnesses who are prone to side effects of medication.
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Affiliation(s)
- Jesjeet Singh Gill
- Department of Psychological Medicine, University Malaya, Kuala Lumpur 50603, Malaysia
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Vas C, Jain A, Trivedi M, Jha MK, Mathew SJ. Pharmacotherapy for Treatment-Resistant Depression: Antidepressants and Atypical Antipsychotics. Psychiatr Clin North Am 2023; 46:261-275. [PMID: 37149344 DOI: 10.1016/j.psc.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Treatment-resistant depression (TRD) affects one in three patients with major depressive disorder and is associated with increased risk of all-cause mortality. Studies of real-world practices suggest that antidepressant monotherapy continues to be the most widely used treatment after inadequate response to a first-line treatment. However, rates of remission with antidepressants in TRD are suboptimal. Atypical antipsychotics are the most widely studied augmentation agent and aripiprazole, brexpiprazole, cariprazine, quetiapine extended-release, and olanzapine-fluoxetine combination are approved for depression. Benefits of using atypical antipsychotics for TRD has to be weighted against their potential adverse events, such as weight gain, akathisia, and tardive dyskinesia.
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Affiliation(s)
- Collin Vas
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Ayush Jain
- The Shri Ram School, Aravali, Gurgaon, Haryana, India
| | - Mili Trivedi
- Colleyville Heritage High School, Colleyville, TX, USA
| | - Manish Kumar Jha
- Center for Depression Research and Clinical Care, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9119, USA.
| | - Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, The Menninger Clinic, Houston, TX, USA
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Tarzian M, Ndrio M, Kaja S, Beason E, Fakoya AO. Cariprazine for Treating Schizophrenia, Mania, Bipolar Depression, and Unipolar Depression: A Review of Its Efficacy. Cureus 2023; 15:e39309. [PMID: 37378203 PMCID: PMC10292137 DOI: 10.7759/cureus.39309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
This drug review presents a comprehensive review of Cariprazine, a medication that received FDA approval in 2015 for treating schizophrenia and bipolar disorder. The paper begins by exploring Cariprazine's mechanism of action, which involves modulating dopamine and serotonin receptors. Additionally, the review assesses Cariprazine's metabolic profile and notes its low potential for weight gain and metabolic side effects. The study examines Cariprazine's efficacy and safety in treating various psychiatric disorders, such as schizophrenia, bipolar maintenance, mania, and bipolar depression. A meticulous analysis of clinical trials is included, demonstrating Cariprazine's potential advantages over existing medications used for these disorders. Additionally, the review covers Cariprazine's recent approval as an adjuvant treatment for unipolar depression. Furthermore, the paper examines the limitations of Cariprazine, such as the absence of head-to-head trials comparing it to other commonly used medications for these disorders. The paper concludes by emphasizing the need for more research to establish Cariprazine's position in treating schizophrenia and bipolar disorder and determine its comparative effectiveness with other available treatments.
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Affiliation(s)
- Martin Tarzian
- Psychiatry, University of Medicine and Health Sciences, Basseterre, KNA
| | - Mariana Ndrio
- Psychiatry and Behavioral Sciences, University of Medicine and Health Sciences, Basseterre, KNA
| | - Srujan Kaja
- Psychiatry, Larkin Community Hospital, Miami, USA
| | - Elisabeth Beason
- Cardiology, University of Medicine and Health Sciences, Basseterre, KNA
| | - Adegbenro O Fakoya
- Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
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Sachs GS, Yeung PP, Rekeda L, Khan A, Adams JL, Fava M. Adjunctive Cariprazine for the Treatment of Patients With Major Depressive Disorder: A Randomized, Double-Blind, Placebo-Controlled Phase 3 Study. Am J Psychiatry 2023; 180:241-251. [PMID: 36789515 DOI: 10.1176/appi.ajp.20220504] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy of cariprazine, a dopamine D3-preferring D3/D2 and serotonin 5-HT1A receptor partial agonist, as adjunctive therapy for patients with major depressive disorder and nonresponse to at least one antidepressant monotherapy. METHODS In this double-blind placebo-controlled study, adults with major depressive disorder and inadequate response to antidepressants alone were randomized in a 1:1:1 ratio to placebo, cariprazine at 1.5 mg/day, or cariprazine at 3.0 mg/day. The primary outcome was change from baseline to week 6 in total score on the Montgomery-Åsberg Depression Rating Scale (MADRS). Least-squares mean differences were estimated in the modified intent-to-treat (mITT) population using a mixed-effects model for repeated measures with adjustment for multiple comparisons. RESULTS The mITT population comprised 751 patients (placebo: N=249; cariprazine 1.5 mg/day: N=250; cariprazine 3.0 mg/day: N=252). At week 6, the mean reduction from baseline in MADRS total score was significantly greater with cariprazine 1.5 mg/day than with placebo (-14.1 vs. -11.5) but not with cariprazine 3.0 mg/day (-13.1). Significant differences between the cariprazine 1.5 mg/day and placebo groups were also observed at weeks 2 and 4. Meeting the MADRS response criteria was significantly more likely among patients receiving cariprazine 1.5 mg/day than placebo (44.0% vs. 34.9%); remission rates were not significantly different among groups. Common treatment-emergent adverse events (≥5% in either cariprazine group and twice the placebo rate) were akathisia and nausea. CONCLUSIONS Adjunctive cariprazine at 1.5 mg/day demonstrated efficacy in reducing depressive symptoms in adults with major depressive disorder and inadequate response to antidepressants alone. Cariprazine was generally well tolerated, with a safety profile that was consistent with previous findings.
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Affiliation(s)
- Gary S Sachs
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
| | - Paul P Yeung
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
| | - Ludmyla Rekeda
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
| | - Arifulla Khan
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
| | - Julie L Adams
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
| | - Maurizio Fava
- Department of Psychiatry, Harvard Medical School, and Massachusetts General Hospital, Boston (Sachs, Fava); Signant Health, Blue Bell, Penn. (Sachs); AbbVie, Madison, N.J. (Yeung, Rekeda, Adams); Northwest Clinical Research Center, Bellevue, Wash. (Khan)
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Jha MK, Mathew SJ. Pharmacotherapies for Treatment-Resistant Depression: How Antipsychotics Fit in the Rapidly Evolving Therapeutic Landscape. Am J Psychiatry 2023; 180:190-199. [PMID: 36855876 DOI: 10.1176/appi.ajp.20230025] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
One in three adults with major depressive disorder (MDD) do not experience clinically significant improvement after multiple sequential courses of antidepressants and have treatment-resistant depression (TRD). The presence of TRD contributes to the morbidity and excess mortality associated with MDD and has been linked to significantly increased health care expenses. In the absence of a consensus definition of TRD, this report takes a broad approach by considering inadequate response to one or more courses of antidepressants and focuses on atypical antipsychotics that are approved by the U.S. Food and Drug Administration for treatment of depression (aripiprazole, brexpiprazole, cariprazine, extended-release quetiapine, and olanzapine-fluoxetine combination). While multiple acute-phase studies have demonstrated the efficacy of these medications in improving depressive symptoms, clinically meaningful improvement (i.e., remission) remains limited, with significant concerns about side effects (including weight gain, metabolic dysfunction, extrapyramidal symptoms, and tardive dyskinesia), especially with long-term use. With the rapidly evolving landscape of antidepressant treatments over the past few years, which has witnessed approval of rapid-acting antidepressants (e.g., esketamine nasal spray and dextromethorphan-bupropion combination) and several more in the late-stage pipeline (e.g., zuranolone and psilocybin), it remains to be seen whether the use of atypical antipsychotics will go the way of the older and rarely prescribed antidepressants (such as tricyclics and monoamine oxidase inhibitors). Pragmatic clinical trials are needed to compare the effectiveness of atypical antipsychotics with TRD-specific pharmacotherapies and neuromodulation treatments and to identify the optimal sequencing of these varied approaches for patients with MDD. When using atypical antipsychotics, clinicians and patients are encouraged to use a shared decision-making approach by personalizing treatment selection based on anticipated side effects, tolerability, cost, and feasibility.
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Affiliation(s)
- Manish K Jha
- Center for Depression Research and Clinical Care, Department of Psychiatry, UT Southwestern Medical Center, and O'Donnell Brain Institute, UT Southwestern Medical Center, Dallas (Jha); Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Mathew); Michael E. DeBakey VA Medical Center, Houston (Mathew); Menninger Clinic, Houston (Mathew)
| | - Sanjay J Mathew
- Center for Depression Research and Clinical Care, Department of Psychiatry, UT Southwestern Medical Center, and O'Donnell Brain Institute, UT Southwestern Medical Center, Dallas (Jha); Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Mathew); Michael E. DeBakey VA Medical Center, Houston (Mathew); Menninger Clinic, Houston (Mathew)
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Galmes LN, Rancans E. Successful high dose antipsychotic treatment with cariprazine in patients on the schizophrenia spectrum: Real-world evidence from a Spanish hospital setting. Front Psychiatry 2023; 14:1112697. [PMID: 36911111 PMCID: PMC9998536 DOI: 10.3389/fpsyt.2023.1112697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/01/2023] [Indexed: 03/14/2023] Open
Abstract
Real-world evidence fills in an important gap by providing data on the effectiveness and tolerability of new medications in everyday patients. In this data collection form a Spanish hospital, the effectiveness and tolerability of cariprazine were evaluated in 14 patients who were admitted to the hospital due to an acute episode of schizophrenia or schizoaffective disorder. The collected data included demographic characteristics, history of disorder and previous treatment, and details of cariprazine therapy such as dosing, side effects and measurements of effectiveness via scales. Difference between admission and discharge on the Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity (CGI-S) scale scores were evaluated using the Wilcoxon Signed-Rank test. Significant improvement was detected in nearly all patients (one patient dropped out) as measured by the BPRS Total, Negative symptom, Positive symptom, and Hostility scores. At admission, patients were markedly-moderately ill and at discharge the severity was reduced to borderline ill and normal according to the CGI-S. The CGI-Improvement scale also indicated very much and much improvement at discharge. Importantly, patients left the hospital with high doses of cariprazine, i.e., 7.5 mg/day or even 9.0 mg/day, but this did not cause safety problems; cariprazine well-tolerated as only a few patients experienced side effects such as akathisia. The results provide novel evidence regarding the tolerability and effectiveness of cariprazine in high doses patients on the schizophrenia spectrum.
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Affiliation(s)
| | - Elmars Rancans
- Department of Psychiatry and Addiction Disorders, Riga Stradins University, Riga, Latvia
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Vasiliu O. Investigational Drugs for the Treatment of Depression (Part 1): Monoaminergic, Orexinergic, GABA-Ergic, and Anti-Inflammatory Agents. Front Pharmacol 2022; 13:884143. [PMID: 35774601 PMCID: PMC9237478 DOI: 10.3389/fphar.2022.884143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/14/2022] [Indexed: 12/27/2022] Open
Abstract
Therapeutic management of depression has currently important limitations, and its low efficacy is reflected in high rates of non-response even after multiple trials of antidepressants. Almost two-thirds of the patients diagnosed with major depression who received a 4–6 weeks trial of antidepressant could not reach remission, and more than 30% of these patients are considered treatment-resistant. In bipolar depression, the situation is also discouraging if we analyze the high suicide rate, the risk for the treatment-emergent affective switch when antidepressants are added, the high rate of treatment resistance (up to 25%), and the severe functional impairments associated with these episodes. Therefore, new therapeutic agents are needed, as well as new pathogenetic models for depression. The vast majority of the currently approved antidepressants are based on the monoamine hypothesis, although new drugs exploiting different neurotransmitter pathways have been recently approved by FDA. Brexanolone, an allopregnanolone analog, is an example of such new antidepressants, and its approval for post-partum depression inspired the search for a new generation of neurosteroids and GABA-ergic modulators, with an easier way of administration and superior tolerability profile. Orexin receptors antagonists are also extensively studied for different psychiatric disorders, depression included, in phase II trials. Antiinflammatory drugs, both cyclo-oxygenase 2 inhibitors and biological therapy, are investigated in patients with depressive disorders based on the proven correlation between inflammation and mood disorders in preclinical and clinical studies. Also, a new generation of monoamine-based investigational drugs is explored, ranging from triple reuptake inhibitors to atypical antipsychotics, in patients with major depression. In conclusion, there is hope for new treatments in uni- and bipolar depression, as it became clear, after almost seven decades, that new pathogenetic pathways should be targeted to increase these patients’ response rate.
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Dyrmishi E, De Pieri M, Ferrari M, Traber R, Preve M, De Peri L, Bolla E. Case Report: Long-Acting Oral Cariprazine. Front Psychiatry 2022; 13:876003. [PMID: 35573352 PMCID: PMC9093047 DOI: 10.3389/fpsyt.2022.876003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Cariprazine is a third-generation antipsychotic, approved for the treatment of schizophrenia and bipolar disorder and used off-label for schizoaffective disorder and treatment-resistant depression. Cariprazine is a partial agonist at dopamine receptors D2 and D3 and serotonin receptor 5HT1A and an antagonist at serotonin receptors 5HT2B and 5HT2A. It is metabolized by CYP3A4 in desmetyl-cariprazine and didesmethyl-cariprazine, both active metabolites with a half-life of 1-2 days and 2-3 weeks, respectively. Case Report Here we show the cases of 3 outpatients diagnosed with bipolar I disorder (two patients) and schizoaffective disorder (one patients) and characterized by low adherence to treatment, satisfactory cognitive and personal functioning and average disease severity to whom we administered cariprazine as a monotherapy, on a two-times a week schedule (i.e., every 72-96 h). We evaluated response to treatment and disease remission according to conventional definitions, using rating scales BPRS, PANSS and BDI-II. Two-times a week treatment was set either after a disease relapse (one patient), after a sustained remission obtained with daily administration of cariprazine (one patient) or since our first evaluation (one patient). After 4 weeks of treatment all three patients satisfied criteria for response to treatment and remission, a result that was sustained for 8 (in one patients) and 12 months (in other two patients) and still ongoing. Discussion Reported results support our hypothesis that long half-lives of cariprazine and its metabolites provide an adequate therapeutic response with a two-times a week administration. In selected patients, cariprazine administered as a "oral long-acting" seems effective in treating acute episodes of illness and in sustaining remission, combining advantages of oral and long-acting injectable antipsychotics concerning therapeutic alliance.
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Affiliation(s)
| | - Marco De Pieri
- PhD Program in Clinical and Experimental Medicine and Medical Humanities, University of Insubria, Varese, Italy
- Center for Research in Medical Pharmacology, Varese, Italy
| | - Marco Ferrari
- Center for Research in Medical Pharmacology, Varese, Italy
| | - Rafael Traber
- Organizzazione Sociopsichiatrica Cantonale, Mendrisio, Switzerland
| | - Matteo Preve
- Organizzazione Sociopsichiatrica Cantonale, Mendrisio, Switzerland
| | - Luca De Peri
- Organizzazione Sociopsichiatrica Cantonale, Mendrisio, Switzerland
| | - Emilio Bolla
- Organizzazione Sociopsichiatrica Cantonale, Mendrisio, Switzerland
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Nuñez NA, Joseph B, Pahwa M, Kumar R, Resendez MG, Prokop LJ, Veldic M, Seshadri A, Biernacka JM, Frye MA, Wang Z, Singh B. Augmentation strategies for treatment resistant major depression: A systematic review and network meta-analysis. J Affect Disord 2022; 302:385-400. [PMID: 34986373 PMCID: PMC9328668 DOI: 10.1016/j.jad.2021.12.134] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To compare the efficacy and discontinuation of augmentation agents in adult patients with treatment-resistant depression (TRD). We conducted a systematic review and network meta-analyses (NMA) to combine direct and indirect comparisons of augmentation agents. METHODS We included randomized controlled trials comparing one active drug with another or with placebo following a treatment course up to 24 weeks. Nineteen agents were included: stimulants, atypical antipsychotics, thyroid hormones, antidepressants, and mood stabilizers. Data for response/remission and all-cause discontinuation rates were analyzed. We estimated effect-size by relative risk using pairwise and NMA with random-effects model. RESULTS A total of 65 studies (N = 12,415) with 19 augmentation agents were included in the NMA. Our findings from the NMA for response rates, compared to placebo, were significant for: liothyronine, nortriptyline, aripiprazole, brexpiprazole, quetiapine, lithium, modafinil, olanzapine (fluoxetine), cariprazine, and lisdexamfetamine. For remission rates, compared to placebo, were significant for: thyroid hormone(T4), aripiprazole, brexpiprazole, risperidone, quetiapine, and olanzapine (fluoxetine). Compared to placebo, ziprasidone, mirtazapine, and cariprazine had statistically significant higher discontinuation rates. Overall, 24% studies were rated as having low risk of bias (RoB), 63% had moderate RoB and 13% had high RoB. LIMITATIONS Heterogeneity in TRD definitions, variable trial duration and methodological clinical design of older studies and small number of trials per comparisons. CONCLUSIONS This NMA suggests a superiority of the regulatory approved adjunctive atypical antipsychotics, thyroid hormones, dopamine compounds (modafinil and lisdexamfetamine) and lithium. Acceptability was lower with ziprasidone, mirtazapine, and cariprazine. Further research and head-to-head studies should be considered to strengthen the best available options for TRD.
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Affiliation(s)
- Nicolas A Nuñez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Boney Joseph
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Mehak Pahwa
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Rakesh Kumar
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Manuel Gardea Resendez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Larry J Prokop
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Marin Veldic
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Ashok Seshadri
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States; Department of Psychiatry and Psychology, Mayo Clinic Health System, Austin, MN, United States
| | - Joanna M Biernacka
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Zhen Wang
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States; Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Balwinder Singh
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States.
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Csehi R, Dombi ZB, Sebe B, Molnár MJ. Real-Life Clinical Experience With Cariprazine: A Systematic Review of Case Studies. Front Psychiatry 2022; 13:827744. [PMID: 35370825 PMCID: PMC8970284 DOI: 10.3389/fpsyt.2022.827744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background The hierarchy of evidence coming from evidence-based medicine favors meta-analyses and randomized controlled trials over observational studies and clinical cases. Nonetheless, in the field of psychiatry, where conditions are much more complex, additional evidence coming from real-world clinical practice is necessary to complement data from these gold standards. Thus, in this systematic review, the aim is to summarize the evidence coming from clinical case reports regarding cariprazine, a third-generation antipsychotic drug that has been approved for the treatment of schizophrenia and bipolar I disorder with manic, depressive or mixed features in adults. Methods A systematic review was performed using Embase and Pubmed databases searching for English-language cases published in peer-reviewed journals between 2000 January and 2021 September with the following search terms: (cariprazin* OR "rgh-188" OR rgh188 OR vraylar OR reagila) AND ("case report*" OR "case report"/de OR "case stud*" OR "case study"/de OR "case seri*"). Results After the removal of duplicates, 49 articles were retrieved via the search, from which 22 were suitable for this review. These 22 articles encompassed 38 cases from which 71% described patients with schizophrenia, 16% patients with psychotic disorders, 5% patients with mood disorder and 8% described patients with other disorders such as Wernicke-Korsakoff syndrome, borderline personality disorder and obsessive-compulsive disorder with paranoid schizophrenia. The median age of patients was 31, and half of them were female. The majority of patients (76%) started cariprazine with 1.5 mg/day, and the most common maintenance dose was 4.5 mg/day (34%) and 3.0 mg/day (29%). Conclusion Cariprazine was found to be safe and effective in a wide range of psychiatric conditions with different symptom profiles from acute psychotic symptoms through addiction to negative and cognitive symptoms. The results are in-line with the established evidence from clinical trials, however, they also show how cariprazine can be successfully utilized for treating certain symptoms irrespective of the indication.
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Affiliation(s)
- Réka Csehi
- Global Medical Division, Gedeon Richter Plc, Budapest, Hungary
| | - Zsófia Borbála Dombi
- Global Medical Division, Gedeon Richter Plc, Budapest, Hungary
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Barbara Sebe
- Global Medical Division, Gedeon Richter Plc, Budapest, Hungary
| | - Mária Judit Molnár
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Budapest, Hungary
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Pavlichenko A, Gubina A. Symptomatic Profile of Cariprazine in the Context of ICD-11 Domains for Schizophrenia: Review of Clinically Oriented Studies: Симптоматический профиль карипразина в контексте доменов шизофрении в МКБ -11: обзор клинически ориентированных исследований. CONSORTIUM PSYCHIATRICUM 2022; 3:45-61. [PMID: 39045357 PMCID: PMC11262089 DOI: 10.17816/cp105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/10/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION One of the innovations in the ICD-11grouping "Schizophrenia and Other Primary Psychotic Disorders" is the implementation of six symptom domains intended to improve diagnostics and treatment of these mental conditions in clinical practice. In this respect, evaluation of the effects of various psychotropic drugs, primarily antipsychotic agents, on the specified psychotic symptom domains is a critical task. The antipsychotic agent cariprazine, registered in many countries worldwide (including Russia) for schizophrenia treatment, was selected as the psychotropic drug model for the purposes of the present review. METHODS For the purposes of this review the MEDLINE, Cochrane Central Register of Controlled Trials, and PubMed databases were searched for randomized controlled trials comparing cariprazine with a placebo, or a placebo and one or several antipsychotic agents, and that was performed within the period from January 2014 to March 2021. RESULTS Cariprazine has proved its efficiency in relation to all symptom groups of the ICD-11 domain "Positive Symptoms", and may be considered a front-line therapy for treatment of the first and multiple episodes of schizophrenia, disorganized thinking, and behavioral disorders in the form of aggressiveness and hostility. Cariprazine has the best evidential base for treatment of various symptoms within the ICD-11 domain "Negative Symptoms" among all antipsychotic agents. The data with regard to the effects of cariprazine on the domain "Depressive Mood Symptoms" are controversial. No data concerning the effects of cariprazine on the domain "Manic Mood Symptoms" are available, but the effectiveness of cariprazine monotherapy for manic episodes without any psychomotor agitation signs in the instance of bipolar disorder has been demonstrated. The effectiveness of cariprazine therapy for the ICD-11 domain "Psychomotor Symptoms" has not been investigated, either within the framework of monotherapy or in the course of adjuvant therapy. The effectiveness of cariprazine has been demonstrated in treatment of the domain "Cognitive Symptoms", and the pro-cognitive effect of the drug has developed regardless of its impact on any other schizophrenia symptoms. The drug's capability to improve the functioning of patients with schizophrenia was demonstrated regardless of the impact on psychotic symptoms. CONCLUSION Cariprazine is the first-line drug for treatment of the domain "Negative Symptoms" as well as representing front-line therapy for the treatment of ICD-11 domains "Positive Symptoms" and "Cognitive Symptoms". Additional studies will be required in order to evaluate the effects of cariprazine on the ICD-11 domains "Manic Mood Symptoms" and "Depressive Mood Symptoms".
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Duque-Yemail JD, Avila JC. Switching Clozapine to Cariprazine in Three Patients with Persistent Symptoms of Schizophrenia: A Case Series. Neuropsychiatr Dis Treat 2022; 18:1433-1440. [PMID: 35859803 PMCID: PMC9289754 DOI: 10.2147/ndt.s367922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Despite many available treatments for schizophrenia, several unmet needs persist in treating individuals with this disorder, and the response rate to first-line antipsychotics remains relatively low. Clozapine has shown efficacy in treating schizophrenia patients who failed to respond to previous antipsychotics. However, side effects and the need for routine blood tests have limited its use as a first-line treatment. Cariprazine is a D2/D3 partial agonist antipsychotic with a mechanism of action that differs from other antipsychotics due to its higher affinity for D3 receptors. Several trials have demonstrated the efficacy of cariprazine on positive and negative symptoms of schizophrenia and have shown that it is a well-tolerated treatment. In this series, we present 3 cases of patients diagnosed with schizophrenia who were initially under treatment with clozapine. Despite some initial improvement, the patients showed persisting positive and negative symptoms or developed limiting side effects while in treatment with clozapine. Cariprazine treatment was titrated concurrently with clozapine tapering until its discontinuation. Significant improvement in both positive and negative symptoms was observed up to 14 months after starting cariprazine, and resolution of side effects was reported in all cases. Our case series supports cariprazine as an effective treatment for positive and negative symptoms in patients who failed to adequately respond or poorly tolerated treatment with clozapine, as well as a potential treatment in dual disorders, specifically psychotic disorders and cocaine use disorder.
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Affiliation(s)
- Juan D Duque-Yemail
- Psychiatry Resident, Department of Mental Health, Vall d'Hebron University Hospital, Barcelona, Spain
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21
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Barman R, Majumder P, Doifode T, Kablinger A. Newer antipsychotics: Brexpiprazole, cariprazine, and lumateperone: A pledge or another unkept promise? World J Psychiatry 2021; 11:1228-1238. [PMID: 35070772 PMCID: PMC8717034 DOI: 10.5498/wjp.v11.i12.1228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 07/28/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
Antipsychotic agents are used for various indications in the treatment of psychiatric disorders. Despite their proven roles in multiple conditions, the treatment-emergent side effects of antipsychotic medications, such as metabolic side effects, are often the limiting factor for their long-term and short-term uses. Moreover, antipsychotic medications are often criticized for being less effective in treating different disabling symptoms such as negative symptoms of schizophrenia. As a result, the search for safer and more efficacious antipsychotic agents is ongoing. Newer antipsychotic agents are gaining attention related to emerging efficacy and tolerability data in treating neuropsychiatric conditions. In this review, we attempt to appraise the scientific data on psychopharmacology, safety profile, and efficacy of the newer additions to the list of second-generation antipsychotics, namely brexpiprazole, cariprazine, and lumateperone. We conducted a selective review utilizing PubMed, clinicaltrials.gov, and Cochrane databases to gather appropriate publications, keeping broad inclusion criteria. There were no restrictions on the age of the study population or the year of publication. We also cross-referenced articles and references to capture all existing studies. Our review of the current literature indicates that all three antipsychotic agents appear to be promising based on their short-term studies, while long-term studies remain limited. There is also a need for a head to head comparison between the newer antipsychotics with the other antipsychotic agents to ascertain if the newer agents are any better than the others.
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Affiliation(s)
- Rajdip Barman
- Department of Psychiatry, Genesis Health System, Davenport, IA 52804, United States
| | | | - Tejaswini Doifode
- Department of Psychiatry and Behavioral Science, Carilion Clinic-Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, United States
| | - Anita Kablinger
- Department of Psychiatry and Behavioral Science, Carilion Clinic-Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, United States
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22
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Batinic B, Ristic I, Zugic M, Baldwin DS. Treatment of Symptom Clusters in Schizophrenia, Bipolar Disorder and Major Depressive Disorder With the Dopamine D3/D2 Preferring Partial Agonist Cariprazine. Front Psychiatry 2021; 12:784370. [PMID: 34887792 PMCID: PMC8649660 DOI: 10.3389/fpsyt.2021.784370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/02/2021] [Indexed: 01/07/2023] Open
Abstract
Cariprazine is currently approved for the treatment of patients with schizophrenia (USA and EU), and for manic, depressive, and episodes with mixed features in bipolar I disorder (USA): several randomized controlled studies have also explored its efficacy in patients with major depressive disorder. This review summarizes its current therapeutic uses and potential advantages for treating the main symptoms of schizophrenia, bipolar I and major depressive disorder, considering its pharmacodynamic properties, efficacy, and tolerability. Its predominantly D3 receptor preferring affinity, with functional selectivity according to the prevailing neuronal environment, contributes to its efficacy across a wide array of psychopathological symptoms (including reality distortion, disorganized thought, negative symptoms, mood disturbance, anhedonia, and cognitive impairment), and to a favorable side effect profile. Cariprazine may be a "drug of choice" in patients with predominant negative and cognitive symptoms of schizophrenia, as well as those with metabolic syndrome. Further investigation of its relative efficacy when compared to aripiprazole or other active comparators is warranted. Its effectiveness in the treatment of bipolar mania, bipolar I depression and bipolar I episodes with mixed features, with minimal accompanying metabolic changes is well-established. The longer half-life and delayed time to relapse in patients diagnosed with schizophrenia when compared to other second-generation antipsychotics represent other advantages, given the high rates of non-adherence and frequent relapses seen in clinical practice. Its efficacy in overlapping symptom domains in other major psychiatric disorders appears promising.
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Affiliation(s)
- Borjanka Batinic
- Clinic of Psychiatry, University Clinical Centre of Serbia, Belgrade, Serbia
- Department of Psychology, Faculty of Philosophy, University of Belgrade, Belgrade, Serbia
| | - Ivan Ristic
- Department of Epidemiology, Medical School, University of Belgrade, Belgrade, Serbia
- Department of Psychiatry, Institute of Mental Health, Belgrade, Serbia
| | - Milica Zugic
- Department of Psychiatry, Institute of Mental Health, Belgrade, Serbia
| | - David S. Baldwin
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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23
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Sforzini L. Lost in translation. The quest for definitions of treatment-resistant depression with a focus on inflammation-related gene expression. Brain Behav Immun Health 2021; 16:100331. [PMID: 34514443 PMCID: PMC7611643 DOI: 10.1016/j.bbih.2021.100331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Approximately one third of individuals with major depressive disorder (MDD) do not respond to antidepressant treatments; but what does treatment-resistant depression (TRD) mean? With this article, I aim to provide an overview of the clinical and operational criteria currently used to define TRD, highlighting core gaps in knowledge and open questions to be addressed in order to drive future research in the field. Importantly, a better definition of TRD must include a better characterization of the biological and molecular correlates of non-response. Among these potential biomarkers, compelling evidence reveals a potential role of inflammation-related gene expression signatures. A more accurate clinical and etiopathological characterization of TRD subjects may help to identify biologically based MDD clinical phenotypes to be targeted in future research and finally achieve better outcomes.
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Affiliation(s)
- Luca Sforzini
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
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24
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Jones BDM, Razza LB, Weissman CR, Karbi J, Vine T, Mulsant LS, Brunoni AR, Husain MI, Mulsant BH, Blumberger DM, Daskalakis ZJ. Magnitude of the Placebo Response Across Treatment Modalities Used for Treatment-Resistant Depression in Adults: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2125531. [PMID: 34559231 PMCID: PMC8463940 DOI: 10.1001/jamanetworkopen.2021.25531] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
IMPORTANCE The placebo effect in depression clinical trials is a substantial factor associated with failure to establish efficacy of novel and repurposed treatments. However, the magnitude of the placebo effect and whether it differs across treatment modalities in treatment-resistant depression (TRD) is unclear. OBJECTIVE To examine the magnitude of the placebo effect in patients with TRD across different treatment modalities and its possible moderators. DATA SOURCES Searches were conducted on MEDLINE, Web of Science, and PsychInfo from inception to June 21, 2021. STUDY SELECTION Randomized clinical trials (RCTs) were included if they recruited patients with TRD and randomized them to a placebo or sham arm and a pharmacotherapy, brain stimulation, or psychotherapy arm. DATA EXTRACTION AND SYNTHESIS Independent reviewers used standard forms for data extraction and quality assessment. Random-effects analyses and standard pairwise meta-analyses were performed. MAIN OUTCOMES AND MEASURES The primary outcome was the Hedges g value for the reported depression scales. Secondary outcomes included moderators assessed via meta-regression and response and remission rates. Heterogeneity was assessed with the I2 test, and publication bias was evaluated using the Egger test and a funnel plot. Cochrane Risk of Bias Tool was used to estimate risks. RESULTS Fifty RCTs were included involving various types of placebo or sham interventions with a total of 3228 participants (mean [SD] age, 45.8 [6.0] years; 1769 [54.8%] female). The pooled placebo effect size for all modalities was large (g = 1.05; 95% CI, 0.91-1.1); the placebo effect size in RCTs of specific treatment modalities did not significantly differ. Similarly, response and remission rates associated with placebo were comparable across modalities. Heterogeneity was large. Three variables were associated with a larger placebo effect size: open-label prospective treatment before double-blind placebo randomization (β = 0.35; 95% CI, 0.11 to 0.59; P = .004), later year of publication (β = 0.03; 95% CI, 0.003 to 0.05; P = .03), and industry-sponsored trials (β = 0.34; 95% CI, 0.09 to 0.58; P = .007). The number of failed interventions was associated with the probability a smaller placebo effect size (β = -0.12; 95% CI, -0.23 to -0.01, P = .03). The Egger test result was not significant for small studies' effects. CONCLUSIONS AND RELEVANCE This analysis may provide a benchmark for past and future clinical RCTs that recruit patients with TRD standardizing an expected placebo effect size.
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Affiliation(s)
- Brett D. M. Jones
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lais B. Razza
- Department of Internal Medicine, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
- Laboratory of Neurosciences, Instituto Nacional de Biomarcadores em Neuropsiquiatria, Department and Institute of Psychiatry, Faculdade de Medicina, University of Sao Paulo, Sao Paulo, Brazil
| | - Cory R. Weissman
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jewel Karbi
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Tya Vine
- Michael G. Degroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Andre R. Brunoni
- Department of Internal Medicine, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
- Laboratory of Neurosciences, Instituto Nacional de Biomarcadores em Neuropsiquiatria, Department and Institute of Psychiatry, Faculdade de Medicina, University of Sao Paulo, Sao Paulo, Brazil
| | - M. Ishrat Husain
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Benoit H. Mulsant
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Daniel M. Blumberger
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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25
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Vázquez GH, Bahji A, Undurraga J, Tondo L, Baldessarini RJ. Efficacy and Tolerability of Combination Treatments for Major Depression: Antidepressants plus Second-Generation Antipsychotics vs. Esketamine vs. Lithium. J Psychopharmacol 2021; 35:890-900. [PMID: 34238049 PMCID: PMC8358538 DOI: 10.1177/02698811211013579] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Successful treatment of major depressive disorder (MDD) can be challenging, and failures ("treatment-resistant depression" [TRD]) are frequent. Steps to address TRD include increasing antidepressant dose, combining antidepressants, adding adjunctive agents, or using nonpharmacological treatments. Their relative efficacy and tolerability remain inadequately tested. In particular, the value and safety of increasingly employed second-generation antipsychotics (SGAs) and new esketamine, compared to lithium as antidepressant adjuncts remain unclear. METHODS We reviewed randomized, placebo-controlled trials and used random-effects meta-analysis to compare odds ratio (OR) versus placebo, as well as numbers-needed-to-treat (NNT) and to-harm (NNH), for adding SGAs, esketamine, or lithium to antidepressants for major depressive episodes. RESULTS Analyses involved 49 drug-placebo pairs. By NNT, SGAs were more effective than placebo (NNT = 11 [CI: 9-15]); esketamine (7 [5-10]) and lithium (5 [4-10]) were even more effective. Individually, aripiprazole, olanzapine+fluoxetine, risperidone, and ziprasidone all were more effective (all NNT < 10) than quetiapine (NNT = 13), brexpiprazole (16), or cariprazine (16), with overlapping NNT CIs. Risk of adverse effects, as NNH for most-frequently reported effects, among SGAs versus placebo was 5 [4-6] overall, and highest with quetiapine (NNH = 3), lowest with brexpiprazole (19), 5 (4-6) for esketamine, and 9 (5-106) with lithium. The risk/benefit ratio (NNH/NNT) was 1.80 (1.25-10.60) for lithium and much less favorable for esketamine (0.71 [0.60-0.80]) or SGAs (0.45 [0.17-0.77]). CONCLUSIONS Several modern antipsychotics and esketamine appeared to be useful adjuncts to antidepressants for acute major depressive episodes, but lithium was somewhat more effective and better tolerated. LIMITATIONS Most trials of adding lithium involved older, mainly tricyclic, antidepressants, and the dosing of adjunctive treatments were not optimized.
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Affiliation(s)
- Gustavo H. Vázquez
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, Queen’s University, Kingston, Canada,Gustavo H. Vázquez, Department of Psychiatry, Queen’s University, 752 King Street, Kingston, ON K7P0H9, Canada.
| | - Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Juan Undurraga
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Neurology & Psychiatry, Clinica Alemana Universidad del Desarrollo, Santiago, Chile,Early Intervention Program, Instituto Psiquiátrico Dr J. Horwitz Barak, Santiago, Chile
| | - Leonardo Tondo
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, McLean Hospital & Harvard Medical School, Boston, MA, USA,Lucio Bini Mood Disorder Centers, Cagliari & Rome, Italy
| | - Ross J. Baldessarini
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA, USA,Department of Psychiatry, McLean Hospital & Harvard Medical School, Boston, MA, USA
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26
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Grigolon RB, Trevizol AP, Gerchman F, Bambokian AD, Magee T, McIntyre RS, Gomes FA, Brietzke E, Mansur RB. Is Obesity A Determinant Of Success With Pharmacological Treatment For Depression? A Systematic Review, Meta-Analysis And Meta-Regression. J Affect Disord 2021; 287:54-68. [PMID: 33773359 DOI: 10.1016/j.jad.2021.03.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The bidirectional association between Major Depressive Disorder (MDD) and obesity suggests that body mass index (BMI) at the baseline could influence remission rates (RR) with pharmacological treatment. We evaluated the influence of baseline BMI on the chances of remission among patients with MDD administered antidepressants. METHODS Based on the guidelines of the PRISMA statement, we conducted a systematic review on PubMed, Cochrane and Embase databases with subsequent meta-analysis and meta-regression. We included only randomized controlled trials evaluating the efficacy of antidepressants of different classes (monotherapy and combined therapies) that evidenced baseline BMI assessment. We created a model to describe the linear relationship between baseline BMI and RR. RESULTS Our systematic review yielded 70 studies with a total of 9,779 patients in the active group and 7,136 patients in the placebo group. In placebo controlled studies, BMI influenced the RR of patients randomized to active treatment. The RR for antidepressants in monotherapy was higher in normal weight to overweight patients rather than obese patients (33% vs 12%, respectively). Also in monotherapy, the RR is higher when the study is conducted on patients with a lower baseline BMI (p=0.029). For combined therapies, the pooled RR was higher in obese patients rather than in normal weight to overweight patients (75% vs 17%, respectively). LIMITATIONS BMI provides no information about body composition and obesity can be related to several potential confounders that potentially influence RR. CONCLUSION The RR with antidepressant therapy seems to be associated with baseline BMI in patients with MDD, although this simple variable was insufficiently explored so far.
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Affiliation(s)
- Ruth Bartelli Grigolon
- Post-Graduation Program in Psychiatry and Medical Psychology, Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Alisson P Trevizol
- Temerty Centre for Therapeutic Brain Stimulation and the Mood and Anxiety Ambulatory Services at the Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Fernando Gerchman
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Service of Endocrinology and Metabology, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Taylor Magee
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit (MDPU), Toronto Western Hospital, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation (BCDF), Toronto, ON, Canada
| | - Fabiano A Gomes
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada; Inpatient Psychiatric Unit, Kingston General Hospital, Kingston Health Science Centre, Kingston, ON, Canada; Centre for Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada
| | - Elisa Brietzke
- Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada; Inpatient Psychiatric Unit, Kingston General Hospital, Kingston Health Science Centre, Kingston, ON, Canada; Centre for Neuroscience Studies (CNS), Queen's University, Kingston, ON, Canada.
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit (MDPU), Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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27
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Mucci F, Della Vecchia A, Baroni S, Marazziti D. Cariprazine as a therapeutic option for schizophrenia: a drug evaluation. Expert Opin Pharmacother 2021; 22:415-426. [PMID: 33126812 DOI: 10.1080/14656566.2020.1845315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Schizophrenia is a very disabling condition that may result in a significant impairment of individual, professional, and social adjustments. Antipsychotics (APs), the first-line treatment for schizophrenia, in many cases modify the course of the disease, by reducing the institutionalization risk, at the price of severe and invalidating side effects. Cariprazine is one of the latest second-generation APs (SGAs) acting as a partial agonist of type 2 and 3 dopamine receptors, which was recently approved for the treatment of adult schizophrenia.Areas covered: The authors provide a critical review and commentary on the currently available data on the effectiveness and tolerability of cariprazine in schizophrenic patients, with a particular focus on its specific target symptoms.Expert opinion: Cariprazine appears significantly effective on both acute and maintenance treatment of schizophrenia, and in improving positive, negative, and cognitive symptoms, slightly more than other SGAs. It shows a good safety and tolerability profile, with akathisia being its most common side effect. Although further independent studies are needed to clarify its precise advantages over other SGAs, cariprazine seems a promising compound not only in schizophrenia, but also in a broad range of psychiatric conditions, including perhaps bipolar and addictive disorders.
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Affiliation(s)
- Federico Mucci
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena Italy
| | - Alessandra Della Vecchia
- Department Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Stefano Baroni
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena Italy
| | - Donatella Marazziti
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena Italy.,Saint Camillus International University of Health and Medical Sciences, Unicamillus University of Rome, Italy
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28
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Molnar MJ, Molnar V, Fedor M, Csehi R, Acsai K, Borsos B, Grosz Z. Improving Mood and Cognitive Symptoms in Huntington's Disease With Cariprazine Treatment. Front Psychiatry 2021; 12:825532. [PMID: 35222108 PMCID: PMC8866559 DOI: 10.3389/fpsyt.2021.825532] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022] Open
Abstract
In Huntington's disease (HD), the main clinical symptoms include depression, apathy, cognitive deficits, motor deficiencies and involuntary movements. Cognitive, mood and behavioral changes may precede motor symptoms by up to 15 years. The treatment of these diverse symptoms is challenging. Tetrabenazine and deutetrabenazine are the only medications specifically approved for Huntington's chorea, but they do not affect the non-motor symptoms. For these, antidepressants, antipsychotics, and benzodiazepines have demonstrated benefit in some cases and can be used off-label. These drugs, due to sedative side effects, may negatively influence cognition. Sixteen patients having HD received a 12-week off-label cariprazine (CAR) treatment (1.5-3 mg/day). Cognitive performance and behavioral changes were measured by the Addenbrooke Cognitive Examination (ACE) test, the Cognitive and Behavioral part of the Unified Huntington's Disease Rating Scale (UHDRS), and the Beck Depression Inventory (BDI). Mixed model for repeated measures was fitted to the data, with terms of visit, baseline (BL) and their interaction. Cariprazine treatment resulted in the following changes from BL to week 12, respectively: the mean score of BDI decreased from 17.7 ± 10.7 to 10.0 ± 10.7 (p <0.0097), while the Behavioral Assessment score of the UHDRS decreased from 54.9 ± 11.3 to 32.5 ± 15.4 (p < 0.0001); ACE score increased from 75.1 ± 11.0 to 89.0 ± 9.3 (p < 0.0001); Cognitive Verbal Fluency score from 6.2 ± 2.5 to 7.7 ± 2.7 (p < 0.0103); Symbol Digit Test from 9.2 ± 6.9 to 12.3 ± 8.9 (p < 0.0009). Mild akathisia was the most frequent side effect, presenting in 2 out of 16 patients (12.5%). We conclude that CAR had a positive effect on depressive mood, apathy and cognitive functions in patients with early stage of HD. Based on the neurobiological basis of these symptoms, CAR can improve the dopamine imbalance of the prefrontal cortex. This draws attention to the transdiagnostic approach which supports the further understanding of the similar symptomatology of different neuropsychiatric disorders and helps to identify new indications of pharmaceutical compounds.
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Affiliation(s)
- Maria Judit Molnar
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Budapest, Budapest, Hungary
| | - Viktor Molnar
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Budapest, Budapest, Hungary
| | - Mariann Fedor
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Budapest, Budapest, Hungary
| | - Reka Csehi
- Global Medical Division, Richter Gedeon Plc., Budapest, Hungary
| | - Karoly Acsai
- Global Medical Division, Richter Gedeon Plc., Budapest, Hungary
| | - Beata Borsos
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Budapest, Budapest, Hungary
| | - Zoltan Grosz
- Institute of Genomic Medicine and Rare Disorders, Semmelweis University Budapest, Budapest, Hungary
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29
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Mohr P, Masopust J, Kopeček M. Dopamine Receptor Partial Agonists: Do They Differ in Their Clinical Efficacy? Front Psychiatry 2021; 12:781946. [PMID: 35145438 PMCID: PMC8821167 DOI: 10.3389/fpsyt.2021.781946] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/09/2021] [Indexed: 01/05/2023] Open
Abstract
Dopamine receptor partial agonists (DRPAs; aripiprazole, brexpiprazole, and cariprazine) constitute a novel class of antipsychotics. Although they share a similar mechanism of action, DRPAs differ in their pharmacodynamics, pharmacokinetics, drug interactions, or safety and tolerability. The antipsychotic efficacy of all three drugs was established in several placebo-controlled randomized trials (RCTs) in schizophrenia, both acute phase and relapse prevention. In addition, each of the DRPA agents has been tested in other psychiatric disorders, including bipolar disorder or major depression. However, a few studies have examined their comparative clinical efficacy. There are no head-to-head comparisons between aripiprazole, brexpiprazole, or cariprazine. In two acute schizophrenia RCTs of cariprazine and brexpiprazole, aripiprazole was used as an indirect comparator to control for study sensitivity. To assess potential differences in the efficacy of DRPAs, we reviewed data from controlled trials, systematic reviews, and meta-analyses. Our results showed that the acute antipsychotic effects of DRPAs, as measured by the number needed to treat, are comparable. The three agents were superior to placebo in acute treatment, and cariprazine was found to be effective in the reduction of primary negative symptoms of schizophrenia. In the therapy of bipolar disorder, aripiprazole and cariprazine showed antimanic efficacy, cariprazine was also effective in the management of bipolar depression, and aripiprazole was effective for relapse prevention. The addon administration of aripiprazole or brexpiprazole reduced symptoms of major depression. Aripiprazole can control acute agitation associated with psychosis or bipolar disorder; brexpiprazole showed the potential to manage agitation in dementia patients. Aripiprazole has also established evidence of efficacy in children and adolescents and other conditions: OCD, tic disorders, and autism spectrum disorder. Our review of published data suggests that in terms of clinical efficacy, DRPAs are a heterogeneous group, with each drug possessing its own therapeutic benefits.
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Affiliation(s)
- Pavel Mohr
- National Institute of Mental Health, Klecany, Czechia.,Faculty of Medicine, Charles University, Prague, Czechia
| | - Jirí Masopust
- Psychiatric Clinic of the University Hospital Hradec Kràlové, Charles University, Hradec Kràlové, Czechia
| | - Miloslav Kopeček
- National Institute of Mental Health, Klecany, Czechia.,Faculty of Medicine, Charles University, Prague, Czechia
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30
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Resolution of Citalopram Sexual Adverse Effects With Low Dose of Cariprazine: A Case Report. Clin Neuropharmacol 2020; 43:164-165. [PMID: 32947429 DOI: 10.1097/wnf.0000000000000409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Sexual dysfunction is a common adverse effect in selective serotonin reuptake inhibitors users. We report a case of substantial improvement in sexual function with cariprazine at very low dosage.
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Edinoff A, Ruoff MT, Ghaffar YT, Rezayev A, Jani D, Kaye AM, Cornett EM, Kaye AD, Viswanath O, Urits I. Cariprazine to Treat Schizophrenia and Bipolar Disorder in Adults. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:83-117. [PMID: 33012874 PMCID: PMC7511151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF REVIEW Antipsychotics are the standard of care when it comes to the treatment of Schizophrenia, and they are often used in Bipolar as well. Their use can come with adverse effects such as extrapyramidal movements, metabolic complications as well as cardiovascular complications such as a prolonged QT interval. Treatment for these side effects ranges from the treatment of the complications up to the cessation of the medication, which could come at the expense of the user's stability. Both schizophrenia and bipolar disorder have an increased risk of suicide and increased morbidity. The purpose of this review presents the background, evidence, and indications for the use of the new second-generation antipsychotic Cariprazine, which has a primary function as a D3 and D2 partial agonist, with higher selectivity for the D3 receptor type. RECENT FINDINGS Schizophrenia is currently teated by dopamine antagonists and/or 5HT modulators, each with their own set of side effects. Bipolar disorder is mostly treated with mood stabilizers. Studies looking at the efficacy and safety of cariprazine have shown in two phase II trials and phase III trials the decrease in PANSS scores in schizophrenia. The most common adverse effects were akathisia, insomnia, constipation, and other extrapyramidal side effects. A unique side effect of Cariprazine caused bilateral cataract and cystic degeneration of the retina in the dog following daily oral administration for 13 weeks and/or 1 year and retinal degeneration in rats following daily oral administration for 2 years. Another study showed that cariprazine had significant efficacy in preventing relapse in patients with schizophrenia. The time to the loss of sustained remission was significantly longer (P = .0020) for cariprazine compared to placebo (hazard ratio = 0.51) during the double-blind treatment. 60.5% of patients treated with cariprazine and 34.9% of patients treated with placebo sustained remission through the final visit (odds ratio [OR] = 2.85; P = .0012; number needed to treat [NNT] = 4. Another Phase IIIb study looked at negative symptoms and used the Positive and Negative Syndrome Scale Factor Score for Negative Symptoms (PANSS-FSNS), and it found that the use of cariprazine, from baseline to week 26, led to a greater least-squares mean change in PANSS-FSNS than did risperidone. Another study looked at the quality of life years with the treatment of cariprazine and showed those treated with cariprazine had superior quality of life compared to those treated with risperidone. In terms of bipolar disorder, it showed a decrease in depressive symptoms as measured by decreased MADRs scores with a dose of 3.0mg/day. A phase II study looked at the use of cariprazine in mania or mix states and showed cariprazine significantly decreased YMRS scores compared to placebo, least-square mean difference of -6.1 (p < 0.001). The metabolic parameters demonstrated comparable changes except for fasting glucose in which cariprazine was associated with elevations in glucose levels compared to placebo (p < 0.05). Another phase III study showed significant differences in YMRS total score mean change between cariprazine versus placebo-treated group. Changes in metabolic profiles in all mentioned studies were minimal. SUMMARY Cariprazine, in recent studies, has shown some promise in being able to treat both bipolar disorder in manic, depressed, and mixed states as well as schizophrenia. Side effects noted as adverse events in these studies are similar in profile to the medications that were developed in the past. With better relapse prevention, cariprazine could be a reasonable alternative clozapine.
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Affiliation(s)
- Amber Edinoff
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Miriam T Ruoff
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Yahya T Ghaffar
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Arthur Rezayev
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Devanshi Jani
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Adam M Kaye
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Elyse M Cornett
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Alan D Kaye
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Omar Viswanath
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Ivan Urits
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
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Carter B, Strawbridge R, Husain MI, Jones BDM, Short R, Cleare AJ, Tsapekos D, Patrick F, Marwood L, Taylor RW, Mantingh T, de Angel V, Nikolova VL, Carvalho AF, Young AH. Relative effectiveness of augmentation treatments for treatment-resistant depression: a systematic review and network meta-analysis. Int Rev Psychiatry 2020; 32:477-490. [PMID: 32498577 DOI: 10.1080/09540261.2020.1765748] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Most interventions for treatment-resistant depression (TRD) are added as augmenters. We aimed to determine the relative effectiveness of augmentation treatments for TRD. This systematic review and network meta-analysis (NMA) sought all randomized trials of pharmacological and psychological augmentation interventions for adults meeting the most common clinical criteria for TRD. The NMA compared the intervention effectiveness of depressive symptoms for TRD augmentation. Of 36 included trials, 27 were suitable for inclusion in NMA, and no psychological trials could be included in the absence of a common comparator. Antipsychotics (13 trials), mood stabilizers (three trials), NMDA-targeting medications (five trials), and other mechanisms (3 trials) were compared against placebo. NMDA treatments were markedly superior to placebo (ES = 0.91, 95% CI 0.67 to 1.16) and head-to-head NMA suggested that NMDA therapies had the highest chance of being an effective treatment option compared to other pharmacological classes. This study provides the most comprehensive evidence of augmenters' effectiveness for TRD, and our GRADE recommendations can be used to guide guidelines to optimize treatment choices. Although conclusions are limited by paucity of, and heterogeneity between, trials as well as inconsistent reports of treatment safety. This work supports the use of NMDA-targeting medications such as ketamine.
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Affiliation(s)
- Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London
| | - Rebecca Strawbridge
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Muhammad Ishrat Husain
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Brett D M Jones
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roxanna Short
- Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony J Cleare
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dimosthenis Tsapekos
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Fiona Patrick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Lindsey Marwood
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rachael W Taylor
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tim Mantingh
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Valeria de Angel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Viktoriya L Nikolova
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Earley WR, Burgess MV, Khan B, Rekeda L, Suppes T, Tohen M, Calabrese JR. Efficacy and safety of cariprazine in bipolar I depression: A double-blind, placebo-controlled phase 3 study. Bipolar Disord 2020; 22:372-384. [PMID: 31628698 PMCID: PMC7318333 DOI: 10.1111/bdi.12852] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the efficacy, safety, and tolerability of cariprazine in the treatment of the depressed phase of bipolar I disorder in adults (NCT02670538). METHODS In this phase 3 double-blind placebo-controlled study, adult patients with bipolar I disorder according to the Diagnostic and Statistical Manual - 5th Edition criteria and a current depressive episode were randomized to placebo (n = 167), cariprazine 1.5 mg/day (n = 168) or cariprazine 3.0 mg/day (n = 158). Efficacy parameters were changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) total scores (primary) and Clinical Global Impressions - Severity (CGI-S) scores (secondary) from baseline to Week 6 compared to placebo. A mixed-model for repeated measures was used to estimate the least-squares mean differences (LSMD); P-values were adjusted for multiplicity. Adverse events (AEs), laboratory results, vital signs, and suicide risk were monitored. RESULTS Cariprazine 1.5 mg/day significantly reduced depressive symptoms on the primary (MADRS LSMD = -2.5; adjusted P = .0417) and secondary (CGI-S LSMD = -0.3; adjusted P = .0417) efficacy parameters vs placebo; differences were not statistically significant for cariprazine 3.0 mg/day. Common treatment-emergent AEs (≥5% in either cariprazine group and at least twice the incidence of placebo) were akathisia, restlessness, nausea, and fatigue. Mean metabolic parameter changes were low and generally comparable among groups; mean weight increases were ≤0.5 kg for all groups. CONCLUSIONS Cariprazine 1.5 mg/day significantly reduced depressive symptoms in adults with bipolar I depression compared to placebo, but differences were not significant for cariprazine 3.0 mg/day. The safety and tolerability profiles were similar to previous studies of cariprazine.
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Affiliation(s)
| | | | - Barbara Khan
- Department of Clinical DevelopmentAllergan plcMadisonNJUSA
| | | | - Trisha Suppes
- Department of Psychiatry and Behavioral SciencesStanford University School of Medicine and V.A. Palo Alto Health Care SystemPalo AltoCAUSA
| | - Mauricio Tohen
- Department of Psychiatry and Behavioral SciencesUniversity of New MexicoAlbuquerqueNMUSA
| | - Joseph R. Calabrese
- Department of PsychiatryCase Western Reserve School of MedicineClevelandOHUSA
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Yan T, Greene M, Chang E, Houle CR, Tarbox MH, Broder MS. Impact of Atypical Antipsychotics as Adjunctive Therapy on Psychiatric Cost and Utilization in Patients with Major Depressive Disorder. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:81-89. [PMID: 32104020 PMCID: PMC7012250 DOI: 10.2147/ceor.s231824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/17/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction Patients with major depressive disorder (MDD) incur high costs, despite established treatment options. Adding an atypical antipsychotic (AAP) to antidepressant therapy has shown to reduce depressive symptoms in MDD, but it remains unclear with which adjunctive AAP to initiate. As economic burden is one factor that can influence treatment selection, this study's objective was to evaluate the impact of adjunctive AAP choice on psychiatric costs and healthcare utilization in MDD. Materials and Methods This retrospective cohort study analyzed de-identified data from: (1) IBM® MarketScan® Commercial (C), Medicare Supplemental (MS), and MarketScan Multi-State Medicaid (M) Databases, and (2) Optum® Clinformatics® Datamart. Adult MDD patients were included if they had: initiated adjunctive AAPs during study identification period (7/1/15-9/30/16 MarketScan C/MS, and Optum; 7/1/15-6/30/16 MarketScan M), and ≥12 months of continuous enrollment before (baseline) and after (follow-up) first treatment date. Models included generalized linear models (GLMs) for psychiatric costs (total inpatient and outpatient services, excluding outpatient pharmacy costs), and a two-part model (logistic regression for psychiatric hospitalizations, GLM for psychiatric hospitalization costs among hospitalized patients); models were adjusted for baseline characteristics. Results The final study sample consisted of 10,325 patients (7657 aripiprazole, 1219 brexpiprazole, 827 lurasidone, 622 quetiapine). Using brexpiprazole as reference, lurasidone and quetiapine users had $1662 and $3894 higher psychiatric costs, respectively. Psychiatric costs were not statistically significantly different between aripiprazole and brexpiprazole (p>0.05). Quetiapine users had $15,159 (p<0.001) higher psychiatric hospitalization costs among those hospitalized, and higher odds of psychiatric hospitalization [2.11 (1.46-3.04); p<0.001] compared to brexpiprazole users. No statistically significant differences observed in psychiatric hospitalization risk comparing aripiprazole and lurasidone with brexpiprazole (p>0.05). Conclusion In MDD, brexpiprazole users had significantly lower psychiatric costs than lurasidone and quetiapine users, and significantly lower psychiatric hospitalization risk than quetiapine users. Adjunctive AAP choice may impact subsequent healthcare costs and utilization in MDD.
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Affiliation(s)
- Tingjian Yan
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Mallik Greene
- Otsuka Pharmaceutical Development & Commercialization, Inc, Princeton, NJ, 08540, USA
| | - Eunice Chang
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | | | - Marian H Tarbox
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
| | - Michael S Broder
- Partnership for Health Analytic Research, LLC, Beverly Hills, CA 90212, USA
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Stahl SM, Laredo S, Morrissette DA. Cariprazine as a treatment across the bipolar I spectrum from depression to mania: mechanism of action and review of clinical data. Ther Adv Psychopharmacol 2020; 10:2045125320905752. [PMID: 32110377 PMCID: PMC7016327 DOI: 10.1177/2045125320905752] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
Cariprazine is one of the newest dopamine-serotonin partial agonists, also known as 'atypical' second generation antipsychotics. Originally approved for acute and maintenance treatment of schizophrenia as well as for acute mania and mixed mania/depression, cariprazine has now been approved for bipolar I depression. Additionally, post hoc analyses of bipolar I depressed subjects show that both those with and those without concurrent manic features were improved following treatment with cariprazine. Maintenance studies are in progress in bipolar disorder, as are studies to augment antidepressants in unipolar major depressive episodes insufficiently responsive to treatment. Here, we review specifically the efficacy and safety data of cariprazine in bipolar I disorder and discuss the hypothesized mechanism of action of cariprazine and how it could theoretically be linked to caprazine's broad therapeutic actions across the mood disorder spectrum.
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Affiliation(s)
| | | | - Debbi Ann Morrissette
- Neuroscience Education Institute, 5900 La Place Court, Suite 120, Carlsbad, CA 92008, USA
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Davies P, Ijaz S, Williams CJ, Kessler D, Lewis G, Wiles N. Pharmacological interventions for treatment-resistant depression in adults. Cochrane Database Syst Rev 2019; 12:CD010557. [PMID: 31846068 PMCID: PMC6916711 DOI: 10.1002/14651858.cd010557.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although antidepressants are often a first-line treatment for adults with moderate to severe depression, many people do not respond adequately to medication, and are said to have treatment-resistant depression (TRD). Little evidence exists to inform the most appropriate 'next step' treatment for these people. OBJECTIVES To assess the effectiveness of standard pharmacological treatments for adults with TRD. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (March 2016), CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science (31 December 2018), the World Health Organization trials portal and ClinicalTrials.gov for unpublished and ongoing studies, and screened bibliographies of included studies and relevant systematic reviews without date or language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with participants aged 18 to 74 years with unipolar depression (based on criteria from DSM-IV-TR or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria or Research Diagnostic Criteria) who had not responded to a minimum of four weeks of antidepressant treatment at a recommended dose. Interventions were: (1) increasing the dose of antidepressant monotherapy; (2) switching to a different antidepressant monotherapy; (3) augmenting treatment with another antidepressant; (4) augmenting treatment with a non-antidepressant. All were compared with continuing antidepressant monotherapy. We excluded studies of non-standard pharmacological treatments (e.g. sex hormones, vitamins, herbal medicines and food supplements). DATA COLLECTION AND ANALYSIS Two reviewers used standard Cochrane methods to extract data, assess risk of bias, and resolve disagreements. We analysed continuous outcomes with mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (CI). For dichotomous outcomes, we calculated a relative risk (RR) and 95% CI. Where sufficient data existed, we conducted meta-analyses using random-effects models. MAIN RESULTS We included 10 RCTs (2731 participants). Nine were conducted in outpatient settings and one in both in- and outpatients. Mean age of participants ranged from 42 - 50.2 years, and most were female. One study investigated switching to, or augmenting current antidepressant treatment with, another antidepressant (mianserin). Another augmented current antidepressant treatment with the antidepressant mirtazapine. Eight studies augmented current antidepressant treatment with a non-antidepressant (either an anxiolytic (buspirone) or an antipsychotic (cariprazine; olanzapine; quetiapine (3 studies); or ziprasidone (2 studies)). We judged most studies to be at a low or unclear risk of bias. Only one of the included studies was not industry-sponsored. There was no evidence of a difference in depression severity when current treatment was switched to mianserin (MD on Hamilton Rating Scale for Depression (HAM-D) = -1.8, 95% CI -5.22 to 1.62, low-quality evidence)) compared with continuing on antidepressant monotherapy. Nor was there evidence of a difference in numbers dropping out of treatment (RR 2.08, 95% CI 0.94 to 4.59, low-quality evidence; dropouts 38% in the mianserin switch group; 18% in the control). Augmenting current antidepressant treatment with mianserin was associated with an improvement in depression symptoms severity scores from baseline (MD on HAM-D -4.8, 95% CI -8.18 to -1.42; moderate-quality evidence). There was no evidence of a difference in numbers dropping out (RR 1.02, 95% CI 0.38 to 2.72; low-quality evidence; 19% dropouts in the mianserin-augmented group; 38% in the control). When current antidepressant treatment was augmented with mirtazapine, there was little difference in depressive symptoms (MD on Beck Depression Inventory (BDI-II) -1.7, 95% CI -4.03 to 0.63; high-quality evidence) and no evidence of a difference in dropout numbers (RR 0.50, 95% CI 0.15 to 1.62; dropouts 2% in mirtazapine-augmented group; 3% in the control). Augmentation with buspirone provided no evidence of a benefit in terms of a reduction in depressive symptoms (MD on Montgomery and Asberg Depression Rating Scale (MADRS) -0.30, 95% CI -9.48 to 8.88; low-quality evidence) or numbers of drop-outs (RR 0.60, 95% CI 0.23 to 1.53; low-quality evidence; dropouts 11% in buspirone-augmented group; 19% in the control). Severity of depressive symptoms reduced when current treatment was augmented with cariprazine (MD on MADRS -1.50, 95% CI -2.74 to -0.25; high-quality evidence), olanzapine (MD on HAM-D -7.9, 95% CI -16.76 to 0.96; low-quality evidence; MD on MADRS -12.4, 95% CI -22.44 to -2.36; low-quality evidence), quetiapine (SMD -0.32, 95% CI -0.46 to -0.18; I2 = 6%, high-quality evidence), or ziprasidone (MD on HAM-D -2.73, 95% CI -4.53 to -0.93; I2 = 0, moderate-quality evidence) compared with continuing on antidepressant monotherapy. However, a greater number of participants dropped out when antidepressant monotherapy was augmented with an antipsychotic (cariprazine RR 1.68, 95% CI 1.16 to 2.41; quetiapine RR 1.57, 95% CI: 1.14 to 2.17; ziprasidone RR 1.60, 95% CI 1.01 to 2.55) compared with antidepressant monotherapy, although estimates for olanzapine augmentation were imprecise (RR 0.33, 95% CI 0.04 to 2.69). Dropout rates ranged from 10% to 39% in the groups augmented with an antipsychotic, and from 12% to 23% in the comparison groups. The most common reasons for dropping out were side effects or adverse events. We also summarised data about response and remission rates (based on changes in depressive symptoms) for included studies, along with data on social adjustment and social functioning, quality of life, economic outcomes and adverse events. AUTHORS' CONCLUSIONS A small body of evidence shows that augmenting current antidepressant therapy with mianserin or with an antipsychotic (cariprazine, olanzapine, quetiapine or ziprasidone) improves depressive symptoms over the short-term (8 to 12 weeks). However, this evidence is mostly of low or moderate quality due to imprecision of the estimates of effects. Improvements with antipsychotics need to be balanced against the increased likelihood of dropping out of treatment or experiencing an adverse event. Augmentation of current antidepressant therapy with a second antidepressant, mirtazapine, does not produce a clinically important benefit in reduction of depressive symptoms (high-quality evidence). The evidence regarding the effects of augmenting current antidepressant therapy with buspirone or switching current antidepressant treatment to mianserin is currently insufficient. Further trials are needed to increase the certainty of these findings and to examine long-term effects of treatment, as well as the effectiveness of other pharmacological treatment strategies.
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Affiliation(s)
- Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Sharea Ijaz
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
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Davis JM. Commentary on: Corponi F., Fabbri C, Bitter, I. Montgomery, S., Vieta, E., Kaspar, S., Pallanti S., Serretti A. Novel antipsychotics specificity profile: A clinically oriented review of lurasidone, brexpiprazole, cariprazine and lumateperone. Eur Neuropsychopharmacol 2019; 29:1061-1062. [PMID: 31371104 DOI: 10.1016/j.euroneuro.2019.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 11/18/2022]
Affiliation(s)
- John M Davis
- University of Il at Chicago, Psychiatry, 1601 W Taylor St., Chicago, IL 60612, United States.
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Mallet J, Gorwood P, Le Strat Y, Dubertret C. Major Depressive Disorder (MDD) and Schizophrenia- Addressing Unmet Needs With Partial Agonists at the D2 Receptor: A Review. Int J Neuropsychopharmacol 2019; 22:651-664. [PMID: 31406978 PMCID: PMC6822140 DOI: 10.1093/ijnp/pyz043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/20/2019] [Accepted: 08/07/2019] [Indexed: 12/28/2022] Open
Abstract
Second-generation antipsychotics are common candidates for the adjunctive treatment of major depressive disorder and for the treatment of schizophrenia. However, unmet needs remain in the treatment of both disorders. Considering schizophrenia, antipsychotics are the most common treatment and have demonstrated good efficacy. Still, side effects of these treatments are commonly reported and may impact adherence to the medication and functioning in patients with schizophrenia. Regarding major depressive disorder, despite the availability of several classes of antidepressants, many patients do not achieve remission. Adjunctive treatment with antipsychotics may improve clinical and functional outcomes. Compared with dopamine D2 receptor antagonism that is exhibited by most antipsychotics, partial agonism may result in improved outcomes in major depressive disorder and in schizophrenia. Aripiprazole, cariprazine, and brexpiprazole have partial agonism at the dopamine D2 receptor and could potentially overcome limitations associated with D2 antagonism. The objectives of this review were (1) to discuss the goal of treatment with second-generation antipsychotics in major depressive disorder and schizophrenia, and the clinical factors that should be considered, and (2) to examine the short- and long-term existing data on the efficacy and safety of D2 receptor partial agonists (aripiprazole, cariprazine, and brexpiprazole) in the adjunctive treatment of major depressive disorder and in the treatment of schizophrenia.
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Affiliation(s)
- Jasmina Mallet
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
| | - Philip Gorwood
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,GHU Paris, CMME, Sainte-Anne hospital; University of Paris, France,Correspondence: Professor Philip Gorwood, MD, PhD, CMME, GHU Paris Psychiatrie, 100 rue de la Sante, 75014 Paris, France ()
| | - Yann Le Strat
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
| | - Caroline Dubertret
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), France,Psychiatry Department, University Hospital Louis Mourier; Paris Diderot University, France
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