Antipsychotics as antidepressants

Exploring Adverse Drug Reactions in Psychotropic Medications: A Retrospective Analysis of Portuguese Pharmacovigilance Data

Psychotropic drugs (PDs) include anxiolytics, sedatives and hypnotics, antidepressants, and antipsychotics, and they are available as medicines with different safety profiles. Given Portugal's high anxiolytic consumption and the rising prevalence of mental disorders, safety monitoring is crucial. This study aimed to analyze the individual case safety reports (ICSR) of suspected adverse drug reactions (ADRs) related to PDs, obtained through spontaneous reporting, and recorded in the Portuguese National Pharmacovigilance System between January 2017 and December 2021. This observational and retrospective study analyzed the ICSRs of suspected ADRs to PDs. Most reports pertained to female individuals (67.78%) between 18 and 64 years of age (63.71%). The pharmaceutical industry was the primary source of these reports (62.16%). Antidepressants were responsible for most ICSRs (61.90%). At least one serious ADR was recorded in 58.44% of the reports, and 43.84% of ADRs evolved into "cure". The most-observed ADRs were nausea (10.92%), dizziness (10.70%), and off-label use (10.30%). In the causality assessment, 45.49% of ADRs were classified as "possible", and only 4.96% were classified as "definitive". The current analysis helps to strengthen the safety evidence for PDs. In the future, some measures could be implemented to improve the use of and/or access to PDs, as well as to reinforce the rate of suspected ADR reports within the community, contributing to the safety data available.

Evaluating lumateperone for its use in treating depressive episodes associated with bipolar I or II disorder in adults

INTRODUCTION

Lumateperone is a novel antipsychotic medication that has recently received approval by the United States Food and Drug Administration for treatment of major depressive episodes of type I and II bipolar disorder. It is approved for use as monotherapy or as an adjunctive treatment to lithium or valproic acid.

AREAS COVERED

Clinical trials performed with lumateperone for bipolar disorder were reviewed. Additionally, pharmacodynamic actions of lumateperone are reviewed. Lumateperone is superior to placebo whether used alone or in combination with a mood stabilizer in patients with type I or type II bipolar disorder. It achieves this effect with minimal dopamine blockade-related side effects due to less than 50% dopamine D2 receptor occupancy. While the pharmacodynamic profile of lumateperone is unique, the mechanism of action in bipolar depression remains obscure.

EXPERT OPINION

Lumateperone is an antipsychotic with full antagonist effects at the post-synaptic D2, and partial agonist effects at the presynaptic D2. This unique profile allows for both antipsychotic and antidepressant effects at the same dose, which does not produce dopamine-related side effects. Consequently, lumateperone is exceptionally well tolerated compared to other antidepressant-acting antipsychotic agents. It is now the only agent approved as an adjunct to the mood stabilizer for bipolar II depression.

Weight-centric treatment of depression and chronic pain

Background

Depression and chronic pain are two major chronic non-communicable diseases (CNCD). Considering the bidirectional relationship between obesity and CNCD, it is of the utmost importance to understand the effect of medications utilized to treat these diseases on body weight.

Methods

This is a clinical review on the effect of medications for depression and chronic pain on body weight. We searched PubMed, Scopus, MEDLINE, and Google Scholar databases for studies on the topic from January 1, 1950 to April 1, 2022 in English language. Additionally, we present expert opinions in the fields of obesity, depression and chronic pain, providing a weight-centric approach to treat depression and chronic pain.

Results

Several antidepressant and chronic pain medications are associated with weight gain. Selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidases, mirtazapine and trazodone are common antidepressants that can increase body weight while bupropion is significantly associated with weight loss. Gabapentin and pregabalin are common chronic pain medications that are linked to weight gain. On the other hand, topiramate is associated with significant weight loss. Obesity, depression and chronic pain experts recommend avoiding medications that can increase body weight if another effective alternative is available.

Conclusion

By shifting prescribing practices toward a weight-conscious approach (i.e., switching from weight gain medications to weight loss/neutral), it is possible to mitigate the incidence of drug-induced weight gain.

Present and future antipsychotic drugs: a systematic review of the putative mechanisms of action for efficacy and a critical appraisal under a translational perspective

Antipsychotics represent the mainstay of schizophrenia pharmacological therapy, and their role has been expanded in the last years to mood disorders treatment. Although introduced in 1952, many years of research were required before an accurate picture of how antipsychotics work began to emerge. Despite the well-recognized characterization of antipsychotics in typical and atypical based on their liability to induce motor adverse events, their main action at dopamine D2R to elicit the "anti-psychotic" effect, as well as the multimodal action at other classes of receptors, their effects on intracellular mechanisms starting with receptor occupancy is still not completely understood. Significant lines of evidence converge on the impact of these compounds on multiple molecular signaling pathways implicated in the regulation of early genes and growth factors, dendritic spine shape, brain inflammation, and immune response, tuning overall the function and architecture of the synapse. Here we present, based on PRISMA approach, a comprehensive and systematic review of the above mechanisms under a translational perspective to disentangle those intracellular actions and signaling that may underline clinically relevant effects and represent potential targets for further innovative strategies in antipsychotic therapy.

A retrospective naturalistic study on the psychopharmacological treatment of schizoaffective disorder

Evidence on the effectiveness of psychopharmacological treatment of schizoaffective disorder is scarce and mostly comes from indirect, nonspecific sources. We carried out a large retrospective study (n = 770) of every other consecutively numbered clinical record with a recorded ICD-10 diagnosis of schizoaffective disorder in the Andalusian Health Service record system. We gathered sociodemographic, drug treatment and clinical outcomes such as improvement, relapses and change over time on DSM-5 psychotic dimensions. We analyzed data to explore associations between drug use and clinical improvement. Antipsychotics were the most commonly used drugs (77%). 22.4% of patients experienced at least a mild improvement. Clozapine (odds ratio [OR] = 2.4) and aripiprazole (OR = 2.3) for global improvement, and quetiapine (OR = 3.5) for depression were the most effective drugs. Antidepressants, mood stabilizers and benzodiazepines were also associated with a better outcome in some DSM-5 dimensions such as delusions, hallucinations and language, respectively. Antipsychotic monotherapy was not associated with a better outcome. Our findings corroborate the role of antipsychotics as the essential psychopharmacological treatment for different symptoms of schizoaffective disorder. However, the role of mood stabilizers, antidepressants or BZD is controversial and should be individually considered.

Advances in the psychopharmacotherapy of bipolar disorder type I

INTRODUCTION

Research into the pharmacologic management of bipolar type I illness continues to progress.

AREAS COVERED

Randomized clinical trials performed with type I bipolar disorder in the years 2015 to August 2020 are reviewed. There are new indications for the use of cariprazine, for bipolar mania and depression, and a long-acting injectable formulation of aripiprazole has also been approved for relapse prevention in bipolar illness. Most of the randomized clinical trials are effectiveness studies.

EXPERT OPINION

Over the 20 years from 1997 through 2016, the use of lithium and other mood stabilizers has declined by 50%, while the use of both second-generation antipsychotics (SGAs) and antidepressants has increased considerably. Over the same time period (1990-2017), disability-adjusted life years (DALYs) increased by 54.4%, from 6.02 million in 1990 to 9.29 million in 2017 which is greater than the 47.74% increase in incidence of the disease, suggesting that the changes in prescribing patterns have not been helpful for our patients. Furthermore, recent effectiveness studies continue to confirm the superiority of lithium and other mood stabilizers in the management of bipolar illness for both psychiatric and medical outcomes, reaffirming their role as foundational treatments in the management of type I bipolar disorder. Clinicians need to reassess their prescribing habits.

Different molecular targets, one purpose – treatment of depression

Although vast scientific progress has been made, the current pharmacotherapy of depression is still not fully effective. In adults, depressive disorders are among the most common diseases in industrialized countries, impact upon all aspects of family and working life and significantly disturb social functioning. Moreover, increasingly, they affect children and teenagers.

Depressive disorders have a complex etiology. This includes a number of mechanisms that are not yet fully understood. Therefore, the current review concentrates on bringing to the foreground the many molecular areas involved in occurrence of this disease. The work highlights the notion that depression has a complex pharmacology and inevitably requires the adoption of individual pharmacotherapy. This manuscript concentrates on currently used drugs drawn from diverse therapeutic groups and presents new promising targets for the treatment of depression. This is a particularly important issue due to the continuous lack of effective therapy and the constant search for new drugs and molecular targets for its treatment.

Predictors of quetiapine extended-release formulation add-on in older patients exposed to antidepressant drugs: A Danish register-based cohort study

OBJECTIVE

This study investigated which comorbidities or comedications increased the probability of receiving quetiapine extended-release formulation (quetiapine XR) as an add-on treatment.

METHODS

Danish administrative registers were used as data sources. The study period was from 01 January 2011 to 01 July 2017. New users of selective serotonin reuptake inhibitors (SSRI), serotonin and norepinephrine reuptake inhibitors (SNRI), atypical antidepressants (AAD), and tricyclic antidepressants (TCA) aged ≥65 years were included in the study population. A multivariable Cox regression model was used to find predictors for receiving quetiapine XR add-on within the first year of antidepressant therapy.

RESULTS

A total of 123 655 new users of SSRI, SNRI, TCA, and AAD were eligible. The study population was composed of 57.7% females and the mean age was 77.2 years (SD 7.9 years). SSRI users comprised 49.6% of the study population. Among users of antidepressants, 171 (0.14%) patients received quetiapine XR as add-on treatment. In the adjusted analyses, female patients (HR 0.70; 95%CI 0.52-0.95) and glucocorticoid users (HR 0.41; 95%CI 0.21-0.80) had a significantly lower hazard of receiving quetiapine XR. Patients with dementia (HR 2.43; 95%CI 1.52-3.87) had a significantly higher hazard of receiving quetiapine XR than patients without this condition. When compared with SSRI users, AAD (HR 1.80; 95%CI 1.31-2.46) and TCA users (HR 0.18; 95%CI 0.06-0.49) had an increased/reduced hazard of receiving quetiapine XR, respectively.

CONCLUSIONS

This study suggests that the choice of prescribing quetiapine add-on is driven by patient's differences in comorbidities, comedications and the type of antidepressant drug.

Fractures in the framework: limitations of classification systems in psychiatry

This article examines the limitations of existing classification systems from the historical, cultural, political, and legal perspectives. It covers the evolution of classification systems with particular emphasis on the DSM and ICD systems. While pointing out the inherent Western bias in these systems, it highlights the potential of misuse of these systems to subserve other agendas. It raises concerns about the reliability, validity, comorbidity, and heterogeneity within diagnostic categories of contemporary classification systems. Finally, it postulates future directions in alternative methods of diagnosis and classification factoring in advances in artificial intelligence, machine learning, genetic testing, and brain imaging. In conclusion, it emphasizes the need to go beyond the limitations inherent in classifications systems to provide more relevant diagnoses and effective treatments.


Studies on Haloperidol and Adjunctive α-Mangostin or Raw Garcinia mangostana Linn Pericarp on Bio-Behavioral Markers in an Immune-Inflammatory Model of Schizophrenia in Male Rats

Schizophrenia is a severe brain disorder that is associated with neurodevelopmental insults, such as prenatal inflammation, that introduce redox-immune-inflammatory alterations and risk for psychotic symptoms later in life. Nutraceuticals may offer useful adjunctive benefits. The aim of this study was to examine the therapeutic effects of Garcinia mangostana Linn (GML) and one of its active constituents, α-mangostin (AM), alone and as adjunctive treatment with haloperidol (HAL) on schizophrenia related bio-behavioral alterations in a maternal immune-activation (MIA) model. Sprague-Dawley dams were exposed to lipopolysaccharide (LPS) (n = 18) or vehicle (n = 3) on gestational days 15 and 16. Male offspring (n = 72) were treated from PND 52-66 with either vehicle, HAL (2 mg/kg), GML (50 mg/kg), HAL + GML, AM (20 mg/kg), or HAL + AM. Control dams and control offspring were treated with vehicle. In order to cover the mood-psychosis continuum, prepulse inhibition (PPI) of startle, open field test (locomotor activity), and the forced swim test (depressive-like behavior) were assessed on PND's 64-65, followed by assay of frontal-cortical lipid peroxidation and plasma pro-inflammatory cytokines, viz. interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α). MIA-induced deficits in sensorimotor gating were reversed by HAL and HAL + GML, but not GML and AM alone. MIA-induced depressive-like behavior was reversed by AM and GML alone and both in combination with HAL, with the combinations more effective than HAL. MIA-induced cortical lipid peroxidation was reversed by HAL and AM, with elevated IL-6 levels restored by GML, AM, HAL, and HAL + GML. Elevated TNF-α was only reversed by GML and HAL + GML. Concluding, prenatal LPS-induced psychotic- and depressive-like bio-behavioral alterations in offspring are variably responsive to HAL, GML, and AM, with depressive (but not psychosis-like) manifestations responding to GML, AM, and combinations with HAL. AM may be a more effective antioxidant than GML in vivo, although this does not imply an improved therapeutic response, for which trials are required.

Sex differences in gene expression related to antipsychotic induced weight gain

Antipsychotics are crucial for the treatment of schizophrenia and contribute to weight gain in psychosis, particularly during early phases. Antipsychotic Induced Weight Gain (AIWG) might contribute to reduce the quality of life, drug compliance and to increase mortality. To characterize sex differences of gene expression related to AIWG, we sequenced total mRNA from blood samples of schizophrenia patients, before and after 3 months of antipsychotic-treatment. We analyzed schizophrenia patients according to their sex (38 males and 39 females) and their BMI increase after medication, characterizing the differential gene expression before and after medication. Individuals in each group were categorized in patients who gain weight and those whose do not gain weight. The “weight gain” groups included patients with an increase of body mass index (BMI) > 1.0 points (27 males and 23 females with a median BMI increase of 2.68 and 2.32 respectively). The “no weight gain” groups included patients with a change of BMI between < 1.0 and > -1.0 points (11 males and 16 females with a median BMI increase of 0.21 and 0.16 respectively). The males had 331 genes with significant differential expression in the weight gain group and 24 genes in the no weight gain group. The females had 119 genes with significant differential expression in the weight gain group and 75 genes in the no weight gain group. Both weight gain groups were significantly enriched with “obesity” genes (Fisher; p = 1.1E-09 and p = 0.0001 respectively), according to the Gene Reference into Function (GeneRIF) database.In conclusion, we characterized genes with differential expression associated to AIWG that are specific to males, to females and common to both sexes. These genes are good candidates to depict the biological processes involved in AIWG and provide additional evidence of the genetic links between weight gain and the immune system.

Altered gene expression in antipsychotic-induced weight gain

Antipsychotic drugs are one of the largest types of prescribed drugs. However, antipsychotic-induced weight gain (AIWG) is a major problem for the patients. AIWG increases cardiovascular and cerebrovascular morbidity and mortality, and reduces quality of life and drug compliance. To characterize changes in gene expression related to AIWG, we sequenced total messenger RNA from the blood samples of two groups of schizophrenia patients before and after 3 months of treatment with antipsychotics. The "weight gain" group was defined by an increase of body mass index (BMI) >1.5 points (18 patients; median BMI increase = 2.69) and the "no weight gain" group was defined by a change of BMI between <1.0 and >-1.0 points (18 patients; median BMI increase = 0.26). We found 115 genes with significant differential expression in the weight gain group before and after medication and 156 in the no weight gain group before and after medication. The weight gain group was significantly enriched with genes related to "obesity" and "BMI" (Fisher; p = 0.0002 and 0.01, respectively) according to the Gene Reference into Function (GeneRIF) database. In the no weight gain group, the enrichment was much smaller (Fisher; p = 0.02 and 0.79). This study is a first step toward detecting genetic factors that cause AIWG and to generating prediction tests in future studies with larger data sets.

Off-label use of antipsychotics and associated factors in community living older adults. Aging Ment Health 2019;23:158-165. [PMID: 29156947 DOI: 10.1080/13607863.2017.1401583]

BACKGROUND

Given the common off-label use of antipsychotics (AP), we aimed to assess the factors associated with this use in community living older adults.

METHODS

The study sample consisted of a large representative sample of older adults (n = 4108), covered under a public drug insurance plan in Canada. Off-label use of antipsychotics was defined by the absence of an approved indication for this use, according to Health Canada's drug product database. Multinomial logistic regression was used to assess the factors associated with off-label use.

RESULTS

The prevalence of antipsychotics use was 2.5%, of which 78% was off-label. Compared to non-use, off-label antipsychotics use was negatively associated with advanced age (≥75 vs. 65-74 years old) (OR: 0.46; 95%CI: 0.27-0.78); and positively associated with higher education level (OR: 2.68; 95% CI: 1.64-4.40), higher number of outpatient visits (≥6) (OR: 2.39; 95%CI: 1.34-4.25), antidepressant or benzodiazepine use (OR: 5.81; 95%CI: 3.31-10.21), and the presence of an organic brain syndrome & Alzheimer's (OR: 5.73; 95%CI: 1.74-18.89). Compared to labeled use, off-label use was less likely in those with major depression (OR: 0.02; 95%CI: <0.01-0.11) and with insomnia (OR: 0.13; 95%CI: 0.02-0.91).

CONCLUSIONS

The majority of antipsychotics prescribed to community living older adults were off-label. This off-label use was more likely in complex clinical cases with multiple outpatient visits and other psychotropic drugs use. Further research should focus on the long-term effects associated with off-label use of antipsychotics.

A 12-Month Open-Label Extension Study of the Safety and Tolerability of Lisdexamfetamine Dimesylate for Major Depressive Disorder in Adults

PURPOSE/BACKGROUND

Psychostimulant augmentation is considered a potential treatment strategy for individuals with major depressive disorder who do not adequately respond to antidepressant monotherapy. The primary objective of this 12-month open-label extension study was to evaluate the safety and tolerability of lisdexamfetamine dimesylate (LDX) as augmentation therapy to an antidepressant in adults with major depressive disorder.

METHODS/PROCEDURES

Eligible adults who completed 1 of 3 short-term antecedent LDX augmentation of antidepressant monotherapy studies were treated with dose-optimized LDX (20-70 mg) for up to 52 weeks while continuing on the index antidepressant (escitalopram, sertraline, venlafaxine extended-release, or duloxetine) assigned during the antecedent short-term studies. Safety and tolerability assessments included the occurrence of treatment-emergent adverse events and vital sign changes.

FINDINGS/RESULTS

All 3 antecedent studies failed to meet the prespecified primary efficacy endpoint, so this open-label study was terminated early. Headache (15.5% [241/1559]), dry mouth (13.6% [212/1559]), insomnia (13.1% [204/1559]), and decreased appetite (12.1% [189/1559]) were the most frequently reported treatment-emergent adverse events. The greatest mean ± SD increases observed for systolic and diastolic blood pressure and for pulse were 2.6 ± 10.85 and 1.7 ± 7.94 mm Hg and 6.9 ± 10.27 bpm, respectively. Monitoring determined that less than 1% of participants experienced potentially clinically important changes in systolic blood pressure (10 [0.6%]), diastolic blood pressure (8 [0.5%]), or pulse (6 [0.4%]).

IMPLICATIONS/CONCLUSIONS

The overall safety and tolerability of long-term LDX augmentation of antidepressant monotherapy was consistent with the profiles of the short-term antecedent studies, with no evidence of new safety signals.

Effect of N-Desalkylquetiapine/Quetiapine Plasma Level Ratio on Anxiety and Depression in Bipolar Disorder: A Prospective Observational Study

BACKGROUND

The aim of this study was to analyze the relationships between quetiapine and N-desalkylquetiapine plasma levels and clinical improvement, particularly, in regard to depressive and anxious symptoms and to hostility.

METHODS

This was a prospective observational study that involved 37 outpatients diagnosed as having bipolar disorder I or II. All the patients were observed during a clinical acute and postacute phase. Patients were prescribed 50-800 mg of quetiapine. Patients were evaluated at baseline, after 15 days and after 3 months using the Brief Psychiatry Rating Scale with particular reference to the dimensions of depression, anxiety, and hostility. The plasma concentrations of quetiapine and N-desalkylquetiapine were determined after 3 months using blood samples taken at steady state.

RESULTS

There was a significant relationship between the N-desalkylquetiapine/quetiapine ratio and the improvement in the depression dimension, and there was not a significant relationship between the N-desalkylquetiapine/quetiapine ratio and anxiety and hostility improvement. Quetiapine treatment was well tolerated, and there were no extrapyramidal, anticholinergic, or other side effects to note. There was no relationship between plasma quetiapine or N-desalkylquetiapine concentrations and side effects.

CONCLUSIONS

Our findings confirm the efficacy of quetiapine on depressive symptoms, and the available data support that quetiapine's antidepressant activity is mediated by the active metabolite norquetiapine, and it exemplifies the case of an active metabolite that can make a drug like quetiapine originally introduced as an antipsychotic a useful antidepressant agent.

Blood Gene Expression Profile Predicts Response to Antipsychotics

Antipsychotic drugs are one of the largest types of prescribed drugs and have large inter-individual differences in efficacy, but there is no methodology to predict their clinical effect. Here we show a four-gene blood expression profile to predict the response to antipsychotics in schizophrenia patients before treatment. We sequenced total mRNA from blood samples of antipsychotic naïve patients who, after 3 months of treatment, were in the top 40% with the best response (15 patients) and in the bottom 40% with the worst response (15 patients) according to the Brief Psychiatric Rating Scale (BPRS). We characterized the transcriptome before treatment of these 30 patients and found 130 genes with significant differential expression (P_adj value < 0.01) associated with clinical response. Then, we used Random Forests, an ensemble learning method for classification and regression, to obtain a list of predictor genes. The expression of four genes can predict the response to antipsychotic medication with a cross-validation accuracy estimation of 0.83 and an area under the curve of 0.97 using a logistic regression. We anticipate that this approach is a gateway to select the specific antipsychotic that will produce the best response to treatment for each specific patient.

The Place of Antipsychotics in the Therapy of Anxiety Disorders and Obsessive-Compulsive Disorders

PURPOSE OF REVIEW

The purpose of this review was to assess and present the findings up to this date on the efficacy of antipsychotics in the treatment of generalized anxiety disorders (GAD), social anxiety disorders (SAD), panic disorders (PD), and obsessive-compulsive disorders (OCD), mostly based on published randomized controlled trials (RCTs) or on open-label studies when RCT were lacking.

RECENT FINDINGS

Quetiapine could be recommended in patients with GAD. The efficacy of aripiprazole in two open-label studies on patients with antidepressant-refractory GAD should be assessed in RCTs. Despite preliminary positive results in open studies, there are currently no strong evidence for the effectiveness of antipsychotics in refractory SAD and in refractory PD. Conversely, risperidone and aripiprazole can be used for the treatment of refractory OCD as augmentation agents to antidepressants. Contrary to SAD and PD, this review found evidence for the use of second-generation antipsychotics in GAD and OCD. Otherwise, first-generation antipsychotics cannot be recommended in anxiety disorders and OCD.

Lurasidone in the Treatment of Bipolar Depression: Systematic Review of Systematic Reviews

INTRODUCTION

A burgeoning number of systematic reviews considering lurasidone in the treatment of bipolar depression have occurred since its Food and Drug Administration extended approval in 2013. While a paucity of available quantitative evidence still precludes preliminary meta-analysis on the matter, the present quality assessment of systematic review of systematic reviews, nonetheless, aims at highlighting current essential information on the topic.

METHODS

Both published and unpublished systematic reviews about lurasidone mono- or adjunctive therapy in the treatment of bipolar depression were searched by two independent authors inquiring PubMed/Cochrane/Embase/Scopus from inception until October 2016.

RESULTS

Twelve included systematic reviews were of moderate-to-high quality and consistent in covering the handful of RCTs available to date, suggesting the promising efficacy, safety, and tolerability profile of lurasidone. Concordance on the drug profile seems to be corroborated by a steadily increasing number of convergent qualitative reports on the matter.

LIMITATIONS

Publication, sponsorship, language, citation, and measurement biases.

CONCLUSIONS

Despite being preliminary in nature, this overview stipulates the effectiveness of lurasidone in the acute treatment of Type I bipolar depression overall. As outlined by most of the reviewed evidence, recommendations for future research should include further controlled trials of extended duration.

Role of glial cell line-derived neurotrophic factor in the pathogenesis and treatment of mood disorders

Glial cell line-derived neurotrophic factor (GDNF) is widely recognized as a survival factor for dopaminergic neurons, but GDNF has also been shown to promote development, differentiation, and protection of other central nervous system neurons and was thought to play an important role in various neuropsychiatric disorders. Severe mood disorders, such as primarily major depressive disorder and bipolar affective disorder, attract particular attention. These psychopathologies are characterized by structural alterations accompanied by the dysregulation of neuroprotective and neurotrophic signaling mechanisms required for the maturation, growth, and survival of neurons and glia. The main objective of this review is to summarize the recent findings and evaluate the potential role of GDNF in the pathogenesis and treatment of mood disorders. Specifically, it describes (1) the implication of GDNF in the mechanism of depression and in the effect of antidepressant drugs and mood stabilizers and (2) the interrelation between GDNF and brain neurotransmitters, playing a key role in the pathogenesis of depression. This review provides converging lines of evidence that (1) brain GDNF contributes to the mechanism underlying depressive disorders and the effect of antidepressants and mood stabilizers and (2) there is a cross-talk between GDNF and neurotransmitters representing a feedback system: GDNF-neurotransmitters and neurotransmitters-GDNF.

Atypical Antipsychotics in the Treatment of Acute Bipolar Depression with Mixed Features: A Systematic Review and Exploratory Meta-Analysis of Placebo-Controlled Clinical Trials

Evidence supporting the use of second generation antipsychotics (SGAs) in the treatment of acute depression with mixed features (MFs) associated with bipolar disorder (BD) is scarce and equivocal. Therefore, we conducted a systematic review and preliminary meta-analysis investigating SGAs in the treatment of acute BD depression with MFs. Two authors independently searched major electronic databases from 1990 until September 2015 for randomized (placebo-) controlled trials (RCTs) or open-label clinical trials investigating the efficacy of SGAs in the treatment of acute bipolar depression with MFs. A random-effect meta-analysis calculating the standardized mean difference (SMD) between SGA and placebo for the mean baseline to endpoint change in depression as well as manic symptoms score was computed based on 95% confidence intervals (CI). Six RCTs and one open-label placebo-controlled studies (including post-hoc reports) representing 1023 patients were included. Participants received either ziprasidone, olanzapine, lurasidone, quetiapine or asenapine for an average of 6.5 weeks across the included studies. Meta-analysis with Duval and Tweedie adjustment for publication bias demonstrated that SGA resulted in significant improvements of (hypo-)manic symptoms of bipolar mixed depression as assessed by the means of the total scores of the Young Mania Rating Scale (YMRS) (SMD −0.74, 95% CI −1.20 to −0.28, n SGA = 907, control = 652). Meta-analysis demonstrated that participants in receipt of SGA (n = 979) experienced a large improvement in the Montgomery–Åsberg Depression Rating Scale (MADRS) scores (SMD −1.08, 95% CI −1.35 to −0.81, p < 0.001) vs. placebo (n = 678). Publication and measurement biases and relative paucity of studies. Overall, SGAs appear to offer favorable improvements in MADRS and YMRS scores vs. placebo. Nevertheless, given the preliminary nature of the present report, additional original studies are required to allow more reliable and clinically definitive conclusions.