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Kriner P, Brieger P, Pogarell O, Schüle C, Mußmann L, Korbmacher J, Seemüller F. Treatment of bipolar depression: clinical practice vs. adherence to guidelines-data from a Bavarian drug surveillance project. Front Psychiatry 2024; 15:1425549. [PMID: 39015883 PMCID: PMC11250482 DOI: 10.3389/fpsyt.2024.1425549] [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: 04/30/2024] [Accepted: 06/07/2024] [Indexed: 07/18/2024] Open
Abstract
Objectives Pharmacotherapy of bipolar depression (BPD) is confronted with major clinical challenges, like limited evidence-based treatment options, regular cases of treatment resistance, and risk of treatment-emergent affective switches. Medical guidelines can support practitioners to make decisions based on current scientific evidence. The objective of this study is to evaluate to what extent recommendations of the 2019 German S3 guidelines "Diagnosis and Treatment of Bipolar Disorders" are reflected in clinical practice in inpatient treatment. Methods We conducted a descriptive analysis of prescription numbers in 2,627 patients with BPD in a naturalistic inpatient setting analyzing data from the ongoing Bavarian multicenter drug safety project Pharmaco-Epidemiology and Vigilance (Pharmako-EpiVig) from the years 2014-2022. Results Of the patients, 38% were not administered any drug explicitly recommended for treatment of BPD, that is, quetiapine, lamotrigine, carbamazepine, or olanzapine. Only 6% of the patients received monotherapy with one of those drugs. Of the patients, 34% were administered ≥4 psychotropic drugs simultaneously. Patients received 912 different therapy regimens of mono or combination therapy with mood stabilizers (MS), atypical antipsychotics (AAP), and antidepressants. Of the patients, 72% received an antidepressant and 6% without concomitant prescription of an AAP or MS. Prescription rates of venlafaxine (21% to 14%) and tricyclic antidepressants (9% to 6%) decreased significantly from the first (2014-2016) to the last (2020-2022) observed time period. Of the patients, 60% received an MS. Prescription rate of valproate (22% to 14%) decreased significantly, while lithium prescription increased significantly (29% to 35%). Of the patients, 71% were administered an AAP. Quetiapine was the most prescribed drug overall (43%). Only two patients were administered a combination of olanzapine and fluoxetine. Conclusion Our results demonstrate a substantial gap between guideline recommendations and current clinical practice. The remarkable heterogeneity in treatment regimens, with no discernible dominant treatment approach, is in part a reflection of the complexity of bipolar disorder but also substantiates the need of comprehensive recommendations regarding combination therapies. Increase in lithium prescription is an encouraging development due to its unique efficacy in maintenance treatment. To improve the quality of clinical practice guideline implementation, more randomized controlled trials should be conducted in the future to prospectively investigate different implementation strategies.
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Affiliation(s)
- Paul Kriner
- Department of Psychiatry and Psychotherapy, kbo-Lech-Mangfall-Klinik Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Peter Brieger
- Department of Psychiatry and Psychotherapy, kbo-Isar-Amper-Klinikum, Haar, Germany
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Cornelius Schüle
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Lisa Mußmann
- Bavarian Institute for Data, Analysis and Quality Assurance, Munich, Germany
| | - Julie Korbmacher
- Bavarian Institute for Data, Analysis and Quality Assurance, Munich, Germany
| | - Florian Seemüller
- Department of Psychiatry and Psychotherapy, kbo-Lech-Mangfall-Klinik Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
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Villa NAE, Pausescu DG, Espiridion ED. Agranulocytosis Associated With Psychiatric Polypharmacy: Lessons Learned From a Clinical Case. Cureus 2024; 16:e56701. [PMID: 38646228 PMCID: PMC11032694 DOI: 10.7759/cureus.56701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Psychiatric polypharmacy involves the use of two or more psychotropic medications to manage a mental and emotional condition. The prevalence of psychotropic polypharmacy has been increasing since the 1990s and has been attributed to the rise in multiple psychiatric conditions presenting in one patient. However, as the prevalence of polypharmacy increases to maximize therapeutic advantages, so does the adverse effect profile of those drugs used in combination, leading to very life-threatening effects such as agranulocytosis. Thus, we report a case of agranulocytosis secondary to polypharmacy in a patient with a history of multiple complex psychiatric conditions. The patient is a 20-year-old female with a past medical history of major depressive disorder, borderline personality disorder, post-traumatic stress disorder, anxiety disorder, hypothyroidism, and ulcerative colitis. Her psychiatric conditions were managed with multiple medications including chlorpromazine, and clozapine was recently added a month prior to admission. Upon admission, the patient was hemodynamically stable and febrile, with complaints of generalized body aches and myalgia. Laboratory results showed profound leukopenia with a white blood cell count of 1.0x103/uL and a neutrophil number of 0.02x103/uL. The patient was admitted to the hospital for neutropenic sepsis and was aggressively treated with intravenous antibiotics. Her clozapine and chlorpromazine were discontinued. In this report, we discuss the association between chlorpromazine and clozapine use and agranulocytosis, emphasizing the importance of regular monitoring and heightened awareness for patients on these medications. This case also underscores the necessity for cautious polypharmacy medication management in individuals with complex psychiatric conditions, highlighting the potential life-threatening consequences of polypharmacy in this population.
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Affiliation(s)
| | | | - Eduardo D Espiridion
- Psychiatry, West Virginia School of Osteopathic Medicine, Lewisburg, USA
- Psychiatry, Drexel University College of Medicine, Philadelphia, USA
- Psychiatry, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
- Psychiatry, Reading Hospital-Tower Health, West Reading, USA
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Singh B, Yocum AK, Strawbridge R, Burdick KE, Millett CE, Peters AT, Sperry SH, Fico G, Vieta E, Verdolini N, Godin O, Leboyer M, Etain B, Tso IF, Coombes BJ, McInnis MG, Nierenberg AA, Young AH, Ashton MM, Berk M, Williams LJ, Keramatian K, Yatham LN, Overs BJ, Fullerton JM, Roberts G, Mitchell PB, Andreassen OA, Andreazza AC, Zandi PP, Pham D, Biernacka JM, Frye MA. Patterns of pharmacotherapy for bipolar disorder: A GBC survey. Bipolar Disord 2024; 26:22-32. [PMID: 37463846 PMCID: PMC10794603 DOI: 10.1111/bdi.13366] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVES To understand treatment practices for bipolar disorders (BD), this study leveraged the Global Bipolar Cohort collaborative network to investigate pharmacotherapeutic treatment patterns in multiple cohorts of well-characterized individuals with BD in North America, Europe, and Australia. METHODS Data on pharmacotherapy, demographics, diagnostic subtypes, and comorbidities were provided from each participating cohort. Individual site and regional pooled proportional meta-analyses with generalized linear mixed methods were conducted to identify prescription patterns. RESULTS This study included 10,351 individuals from North America (n = 3985), Europe (n = 3822), and Australia (n = 2544). Overall, participants were predominantly female (60%) with BD-I (60%; vs. BD-II = 33%). Cross-sectionally, mood-stabilizing anticonvulsants (44%), second-generation antipsychotics (42%), and antidepressants (38%) were the most prescribed medications. Lithium was prescribed in 29% of patients, primarily in the Australian (31%) and European (36%) cohorts. First-generation antipsychotics were prescribed in 24% of the European versus 1% in the North American cohort. Antidepressant prescription rates were higher in BD-II (47%) compared to BD-I (35%). Major limitations were significant differences among cohorts based on inclusion/exclusion criteria, data source, and time/year of enrollment into cohort. CONCLUSIONS Mood-stabilizing anticonvulsants, second-generation antipsychotics, and antidepressants were the most prescribed medications suggesting prescription patterns that are not necessarily guideline concordant. Significant differences exist in the prescription practices across different geographic regions, especially the underutilization of lithium in the North American cohorts and the higher utilization of first-generation antipsychotics in the European cohorts. There is a need to conduct future longitudinal studies to further explore these differences and their impact on outcomes, and to inform and implement evidence-based guidelines to help improve treatment practices in BD.
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Affiliation(s)
- Balwinder Singh
- Mayo Clinic, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anastasia K Yocum
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Rebecca Strawbridge
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Katherine E Burdick
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Caitlin E Millett
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy T Peters
- Dauten Family Center for Bipolar Treatment Innovation, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah H Sperry
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Giovanna Fico
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Norma Verdolini
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
- Local Health Unit Umbria 1, Department of Mental Health, Mental Health Center of Perugia, Perugia, Italy
| | - Ophelia Godin
- INSERM U955, IMRB, Translational Neuro-Psychiatry, Fondation FondaMental, Univ Paris Est Créteil, Créteil, France
- Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), APHP, Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Créteil, France
| | - Marion Leboyer
- INSERM U955, IMRB, Translational Neuro-Psychiatry, Fondation FondaMental, Univ Paris Est Créteil, Créteil, France
- Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), APHP, Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Créteil, France
| | - Bruno Etain
- Groupe Hospitalo-universitaire AP-HP Nord, DMU Neurosciences, Hôpital Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, AP-HP, Paris, France
| | - Ivy F Tso
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry & Behavioral Health, The Ohio State University, Columbus, Ohio, USA
| | - Brandon J Coombes
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Melvin G McInnis
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew A Nierenberg
- Dauten Family Center for Bipolar Treatment Innovation, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Melanie M Ashton
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Michael Berk
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, Florey Institute for Neuroscience and Mental Health and the Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lana J Williams
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Kamyar Keramatian
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Lakshmi N Yatham
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Bronwyn J Overs
- Neuroscience Research Australia, Randwick, Sydney, New South Wales, Australia
| | - Janice M Fullerton
- Neuroscience Research Australia, Randwick, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Gloria Roberts
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Philip B Mitchell
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ole A Andreassen
- NORMENT Centre, Division of Mental Health and Addiction, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Ana C Andreazza
- Department of Pharmacology & Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Peter P Zandi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Daniel Pham
- The Milken Institute, Washington, District of Columbia, USA
| | - Joanna M Biernacka
- Mayo Clinic, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
- Groupe Hospitalo-universitaire AP-HP Nord, DMU Neurosciences, Hôpital Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, INSERM UMRS 1144, Université de Paris, AP-HP, Paris, France
| | - Mark A Frye
- Mayo Clinic, Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
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Anger Å, Wallerblad A, Kaaman L, Broman R, Holmberg J, Lundgren T, Salomonsson S, Sundberg CJ, Martinsson L. Introducing Braining-physical exercise as adjunctive therapy in psychiatric care: a retrospective cohort study of a new method. BMC Psychiatry 2023; 23:566. [PMID: 37550641 PMCID: PMC10405422 DOI: 10.1186/s12888-023-05053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Patients with severe mental disorders suffer from higher rates of poor somatic health and have shorter life expectancy than the average population. Physical activity can treat and prevent several diseases, e.g. cardiovascular and metabolic disorders as well as psychiatric symptoms. It is therefore of utmost importance to develop effective methods to integrate physical activity into psychiatric care. To meet this need, the physical activity intervention Braining was developed. This study aims to describe Braining, to assess the number of patients reached during the first years of pilot testing, to analyze clinical data in the group of patients participating in Braining 2017-2020 and to assess the intervention. METHODS In this descriptive retrospective study we analyzed data from all patients participating in Braining training sessions ≥ 3 times (n = 239), the Braining Participants. Regular patients at the clinic served as a comparison. Furthermore, medical records were studied for a smaller cohort (n = 51), the Braining Pilot Cohort. Data was analyzed using Chi-square and Fisher's tests. RESULTS During the introduction period of Braining, 580 patients attended an information meeting about Braining, or at least one training session. 239 patients participated in ≥ 3 training sessions, considered to be participants of Braining. These Braining Participants (n = 239), ages 19 to 82, males 23.4%, attended between 3 and 308 training sessions (median 9). The main diagnoses were affective and anxiety disorders. Number of diagnoses ranged from 0 to 10 (median = 2). For the subsample, the Braining Pilot Cohort (n = 51), participants attended between 3 and 208 training sessions (median = 20). Twelve percent were working full-time, and symptom severity of depression and general anxiety was moderate. Two thirds had ≥ 3 different classes of medication. Regarding metabolic morbidity, 28 had been diagnosed with hypertension, though blood lipids, blood glucose as well as blood pressure were within the normal range. Thirty-seven percent were prescribed Physical Activity on Prescription during 2017-2020. One severe adverse event was reported. CONCLUSIONS The Braining intervention reached all age-groups and patients with a wide and representative diagnostic panorama, suggesting that Braining could be a promising and safe method for implementing physical activity in a psychiatric patient population.
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Affiliation(s)
- Åsa Anger
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden.
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
| | - Anna Wallerblad
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Leida Kaaman
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Rebecka Broman
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden
| | - Johan Holmberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden
| | - Tobias Lundgren
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden
| | - Sigrid Salomonsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden
| | - Carl Johan Sundberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lina Martinsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, Plan 7, 113 64, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Poranen J, Koistinaho A, Tanskanen A, Tiihonen J, Taipale H, Lähteenvuo M. Twenty-year medication use trends in first-episode bipolar disorder. Acta Psychiatr Scand 2022; 146:583-593. [PMID: 36177718 PMCID: PMC9828455 DOI: 10.1111/acps.13504] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/16/2022] [Accepted: 09/23/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To study the medication use patterns in patients newly diagnosed with bipolar disorder (BD) in Finland during the past 20 years. METHODS All persons diagnosed with BD between 1996 and 2018, aged 16-65 years, with no previous BD diagnosis were identified from nationwide Finnish registers (N = 26,395). The point prevalences of medication use were observed up until 5 years after the first diagnosis. Five sub-cohorts according to calendar year of first diagnosis were also formed and the prevalence of medication use was compared between sub-cohorts 3 months after diagnosis. Medication data were modeled with the PRE2DUP-method using dispensing data. RESULTS The prevalence of overall medication use declined during the 5-year follow-up period in the total cohort. The highest prevalence of use was seen 3 months after diagnosis for the three main medication classes-antidepressants (40.8%), antipsychotics (30.8%) and mood stabilizers (29.2%). The prevalence of lithium use varied between 5.9% and 6.5% during the 5 years in the total cohort, and the lowest prevalence of use at 3 months was seen in sub-cohort diagnosed in 2016-2018 (4.1%) versus 12.1% in 1996-2000 sub-cohort. The prevalence of benzodiazepine use was between 12.4% and 13.5% and the prevalence of Z-drugs was between 7.3% and 7.9% during the 5 years. The prevalence of long-acting injectable antipsychotic (LAI) use was the highest in patients diagnosed in 2016-2018, although still only 0.8%. CONCLUSIONS (i) The use of antidepressants is too prevalent, (ii) the use of lithium is declining and needs to be increased, and (iii) LAIs are markedly underutilized as compared to their oral counterparts.
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Affiliation(s)
- Juulia Poranen
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland
| | - Aura Koistinaho
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland
| | - Antti Tanskanen
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Jari Tiihonen
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Center for Psychiatry ResearchStockholm City CouncilStockholmSweden
| | - Heidi Taipale
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,School of PharmacyUniversity of Eastern FinlandKuopioFinland
| | - Markku Lähteenvuo
- Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland
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Serafini G, Nasrallah HA, Amore M. The use of modern dopamine partial agonists in bipolar depression: is the evidence sound? Curr Med Res Opin 2022; 38:773-775. [PMID: 35361016 DOI: 10.1080/03007995.2022.2059973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health DINOGMI, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health DINOGMI, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Is Poor Lithium Response in Individuals with Bipolar Disorder Associated with Increased Degradation of Tryptophan along the Kynurenine Pathway? Results of an Exploratory Study. J Clin Med 2022; 11:jcm11092517. [PMID: 35566641 PMCID: PMC9103936 DOI: 10.3390/jcm11092517] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/15/2022] [Accepted: 04/27/2022] [Indexed: 11/17/2022] Open
Abstract
Bipolar disorder is associated with an inflammation-triggered elevated catabolism of tryptophan to the kynurenine pathway, which impacts psychiatric symptoms and outcomes. The data indicate that lithium exerts anti-inflammatory effects by inhibiting indoleamine-2,3-dioxygenase (IDO)-1 activity. This exploratory study aimed to investigate the tryptophan catabolism in individuals with bipolar disorder (n = 48) compared to healthy controls (n = 48), and the associations with the response to mood stabilizers such as lithium, valproate, or lamotrigine rated with the Retrospective Assessment of the Lithium Response Phenotype Scale (or the Alda scale). The results demonstrate an association of a poorer response to lithium with higher levels of kynurenine, kynurenine/tryptophan ratio as a proxy for IDO-1 activity, as well as quinolinic acid, which, overall, indicates a pro-inflammatory state with a higher degradation of tryptophan towards the neurotoxic branch. The treatment response to valproate and lamotrigine was not associated with the levels of the tryptophan metabolites. These findings support the anti-inflammatory properties of lithium. Furthermore, since quinolinic acid has neurotoxic features via the glutamatergic pathway, they also strengthen the assumption that the clinical drug response might be associated with biochemical processes. The relationship between the lithium response and the measurements of the tryptophan to the kynurenine pathway is of clinical relevance and may potentially bring advantages towards a personalized medicine approach to bipolar disorder that allows for the selection of the most effective mood-stabilizing drug.
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Hsu CW, Tsai SY, Wang LJ, Liang CS, Carvalho AF, Solmi M, Vieta E, Lin PY, Hu CA, Kao HY. Predicting Serum Levels of Lithium-Treated Patients: A Supervised Machine Learning Approach. Biomedicines 2021; 9:biomedicines9111558. [PMID: 34829787 PMCID: PMC8615637 DOI: 10.3390/biomedicines9111558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Routine monitoring of lithium levels is common clinical practice. This is because the lithium prediction strategies available developed by previous studies are still limited due to insufficient prediction performance. Thus, we used machine learning approaches to predict lithium concentration in a large real-world dataset. Real-world data from multicenter electronic medical records were used in different machine learning algorithms to predict: (1) whether the serum level was 0.6–1.2 mmol/L or 0.0–0.6 mmol/L (binary prediction), and (2) its concentration value (continuous prediction). We developed models from 1505 samples through 5-fold cross-validation and used 204 independent samples to test their performance by evaluating their accuracy. Moreover, we ranked the most important clinical features in different models and reconstructed three reduced models with fewer clinical features. For binary and continuous predictions, the average accuracy of these models was 0.70–0.73 and 0.68–0.75, respectively. Seven features were listed as important features related to serum lithium levels of 0.6–1.2 mmol/L or higher lithium concentration, namely older age, lower systolic blood pressure, higher daily and last doses of lithium prescription, concomitant psychotropic drugs with valproic acid and -pine drugs, and comorbid substance-related disorders. After reducing the features in the three new predictive models, the binary or continuous models still had an average accuracy of 0.67–0.74. Machine learning processes complex clinical data and provides a potential tool for predicting lithium concentration. This may help in clinical decision-making and reduce the frequency of serum level monitoring.
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Affiliation(s)
- Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-Y.L.); (C.-A.H.)
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (C.-W.H.); (H.-Y.K.)
| | - Shang-Ying Tsai
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan;
- Department of Psychiatry and Psychiatric Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei 110301, Taiwan
| | - Liang-Jen Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Chih-Sung Liang
- National Defense Medical Center, Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei 112003, Taiwan;
- National Defense Medical Center, Department of Psychiatry, Taipei 114201, Taiwan
| | - Andre F. Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, VIC 3216, Australia;
| | - Marco Solmi
- Psychiatry Department, University of Ottawa, Ottawa, ON K1N 6N5, Canada;
- The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, 08036 Barcelona, Catalonia, Spain;
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-Y.L.); (C.-A.H.)
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Chien-An Hu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-Y.L.); (C.-A.H.)
| | - Hung-Yu Kao
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (C.-W.H.); (H.-Y.K.)
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A Systematic Review of the Clinical Use of Gabapentin and Pregabalin in Bipolar Disorder. Pharmaceuticals (Basel) 2021; 14:ph14090834. [PMID: 34577534 PMCID: PMC8469561 DOI: 10.3390/ph14090834] [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] [Received: 08/02/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 01/04/2023] Open
Abstract
Despite its prevalence and disease burden, several chasms still exist with regard to the pharmacotherapy of bipolar disorder (BD). Polypharmacy is commonly encountered as a significant proportion of patients remain symptomatic, and the management of the depressive phase of the illness is a particular challenge. Gabapentin and pregabalin have often been prescribed off-label in spite of a paucity of evidence and clinical practice guidelines to support its use. This systematic review aimed to synthesize the available human clinical trials and inform evidence-based pharmacological approaches to BD management. A total of six randomized, controlled trials (RCTs) and 13 open-label trials involving the use of gabapentin and pregabalin in BD patients were reviewed. Overall, the studies show that gabapentin and its related drug pregabalin do not have significant clinical efficacy as either monotherapy or adjunctive therapy for BD. Gabapentin and pregabalin are probably ineffective for acute mania based on the findings of RCT, with only small open-label trials to support its potential adjunctive role. However, its effects on the long-term outcomes of BD remain to be elucidated. The evidence base was significantly limited by the generally small sample sizes and the trials also had heterogeneous designs and generally high risk of bias.
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