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Honeycutt DC, Blom TJ, Ramsey LB, Strawn JR, Bruns KM, Welge JA, Patino LR, Singh MK, DelBello MP. Pharmacogenetic Factors Influence Escitalopram Pharmacokinetics and Adverse Events in Youth with a Family History of Bipolar Disorder: A Preliminary Study. J Child Adolesc Psychopharmacol 2024; 34:42-51. [PMID: 38377518 PMCID: PMC10880264 DOI: 10.1089/cap.2023.0073] [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] [Indexed: 02/22/2024]
Abstract
Introduction: Escitalopram is an effective and generally well-tolerated antidepressant, but children of parents with bipolar disorder (BD) may be at increased risk for adverse events associated with antidepressants, including increased irritability, restlessness, impulsivity, and manic symptoms. This risk may be influenced by polymorphisms in genes encoding cytochrome P450 enzymes (CYP2C19 or CYP2D6), the serotonin transporter (SLC6A4), and the serotonin receptor 2A subtype (HTR2A). We explored whether gene-drug interactions influence the emergence of adverse events in depressed and/or anxious youth with a family history of BD. Materials and Methods: Children and adolescents aged 12-17 years with a first-degree relative with bipolar I disorder were treated with escitalopram and monitored for adverse effects, underwent pharmacogenetic testing, and provided serum escitalopram levels. Emergence of adverse events was determined by study clinicians, and symptoms were tracked using the Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) and Pediatric Adverse Events Rating Scale. Clinical Pharmacogenetics Implementation Consortium guidelines were used to determine CYP2C19 and CYP2D6 phenotypes. Results: Slower CYP2C19 metabolizers had greater dose-normalized 24-hour area under the curve (AUC0-24; p = 0.025), trough concentrations (Ctrough; p = 0.013), and elimination half-lives (t1/2; p < 0.001). CYP2D6 phenotype was not significantly associated with any pharmacokinetic parameter. Slower CYP2D6 metabolizers had increased TEASAP akathisia (p = 0.015) scores. HTR2A A/A and A/G genotypes were associated with increased TEASAP "self-injury, suicidality, and harm to others" subscale scores (p = 0.017). Escitalopram maximum concentration, AUC0-24, CYP2C19 phenotype, and SLC6A4 genotype were not associated with adverse events. Conclusions: CYP2C19 phenotype influences escitalopram pharmacokinetics whereas CYP2D6 phenotype does not. Slower CYP2D6 metabolism was associated with increased akathisia, and HTR2A A/A or A/G genotypes were associated with increased risk of self-harm or harm to others. Larger cohorts are needed to identify associations between genetic test results and antidepressant-associated adverse events. Trial Registration: ClinicalTrials.gov identifier: NCT02553161.
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Affiliation(s)
- Duncan C. Honeycutt
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J. Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laura B. Ramsey
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Child and Adolescent Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kaitlyn M. Bruns
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jeffrey A. Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Luis R. Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Manpreet K. Singh
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa P. DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Arai K, Nonaka M, Shimada S, Nakamura M. Vortioxetine as a potential alternative for patients with escitalopram-induced jitteriness/anxiety syndrome: A report of three cases. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2023; 2:e158. [PMID: 38868737 PMCID: PMC11114283 DOI: 10.1002/pcn5.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 06/14/2024]
Abstract
Background Jitteriness/anxiety syndrome is a recognized adverse effect observed during the initiation or change of dose in antidepressant treatment. Managing patients who develop this syndrome remains a challenge. While escitalopram is a widely used antidepressant known to cause these symptoms, this report explores vortioxetine as a therapeutic alternative. Case Presentation Three distinct clinical scenarios were observed in patients who manifested jitteriness/anxiety syndrome while on escitalopram treatment for depression. Patient A was initiated on escitalopram and experienced an initial alleviation in depressive symptoms, but 3 months later displayed mood elevation, talkativeness, and increased activity, which disturbed his daily life. A transition to vortioxetine subsequently resolved the mood elevation. Patient B exhibited elevated mood, hyperactivity, irritability, and talkativeness just 6 days post-initiation of treatment with escitalopram. After the discontinuation of escitalopram and unsuccessful trials with aripiprazole, lurasidone, and lamotrigine, her depressive mood intensified, culminating in suicidal ideation. Starting vortioxetine led to a consistent improvement of her symptoms, and she resumed work and was emotionally stable. Patient C was initially diagnosed with bipolar disorder and faced a relapse into depression despite undergoing various treatments. After 2 weeks on escitalopram, she exhibited irritability and self-harm urges. Three months later, after being re-diagnosed with depressive disorders with anxious distress, vortioxetine was administered, which significantly reduced her depressive symptoms and allowed her to continue her education. Conclusion Vortioxetine presents as a promising therapeutic alternative that is worth considering for patients with escitalopram-induced jitteriness/anxiety syndrome.
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Affiliation(s)
- Kaoru Arai
- Department of PsychiatryKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Mari Nonaka
- Department of PsychiatryKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Shoko Shimada
- Department of PsychiatryKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Masayuki Nakamura
- Department of PsychiatryKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
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Buckley V, Young AH, Smith P. Child and adolescent anxiety as a risk factor for bipolar disorder: A systematic review of longitudinal studies. Bipolar Disord 2023; 25:278-288. [PMID: 36949612 DOI: 10.1111/bdi.13322] [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] [Indexed: 03/24/2023]
Abstract
OBJECTIVES Several studies have suggested that anxiety disorders in childhood and adolescence often precede the onset of bipolar disorder. We therefore systematically reviewed the relationship between child and adolescent anxiety and later bipolar disorder. METHODS Online databases (Medline [for Ovid], EMBASE and PsychINFO) were searched for original, peer-reviewed studies examining the relationship between child and adolescent anxiety and later bipolar disorder. Studies in both community samples and bipolar offspring samples were included. RESULTS A total of 16 studies were included in the review. The results were broadly consistent and revealed that child and adolescent anxiety disorders are associated with later bipolar disorder in community samples. In bipolar offspring, child and adolescent anxiety disorders are a marker of increased risk and predict the onset of bipolar disorder and other major mood disorders. CONCLUSIONS There is evidence that anxiety disorders in childhood and adolescence increase the risk of later bipolar disorder. Anxiety disorders may be a useful target for early intervention in those at high-risk of bipolar disorder.
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Affiliation(s)
- Vanessa Buckley
- Department of Psychology, Institute of Psychology, Psychiatry and Neuroscience, King's College London, DeCrespigny Park, London, SE5 8AF, UK
| | - Allan H Young
- Department of Psychological Medicine, Institute of Psychology, Psychiatry and Neuroscience, King's College London, DeCrespigny Park, London, SE5 8AF, UK
| | - Patrick Smith
- Department of Psychology, Institute of Psychology, Psychiatry and Neuroscience, King's College London, DeCrespigny Park, London, SE5 8AF, UK
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Yang J, Lei D, Suo X, Tallman MJ, Qin K, Li W, Bruns KM, Blom TJ, Duran LRP, Cotton S, Sweeney JA, Gong Q, DelBello MP. A preliminary study of the effects of mindfulness-based cognitive therapy on structural brain networks in mood-dysregulated youth with a familial risk for bipolar disorder. Early Interv Psychiatry 2022; 16:1011-1019. [PMID: 34808702 DOI: 10.1111/eip.13245] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/17/2021] [Accepted: 11/07/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Mindfulness-based cognitive therapy for children (MBCT-C), as a psychotherapeutic intervention, has been shown to be effective for treating mood dysregulation (MD). While previous neuroimaging studies of MD have reported both pre-treatment structural and functional alterations, the effects of MBCT-C on brain morphological network organisation has not been investigated. METHODS We investigated brain morphological network organisation in 10 mood-dysregulated youth with familial risk for bipolar disorder and 15 matched healthy comparison youth (HC). Effects of 12 weeks of MBCT-C were examined in the mood-dysregulated youth. Topological properties of brain networks used for analyses were constructed based on morphological similarities in regional grey matter using a graph-theory approach using MRI data. RESULTS At baseline, compared with the HC group, the mood-dysregulated group exhibited increased global efficiency (Eglob ), decreased path length (Lp ), and abnormal nodal properties, mainly in the limbic system. Right temporal pole alterations at baseline predicted change in Child and Adolescent Mindfulness Measure scores after treatment. The mood-dysregulated group showed significant decreases in both the Eglob and Lp metrics after MBCT-C, suggesting an improved capacity for optimal information processing. Changes in Lp were correlated with changes in Emotion Regulation Checklist scores. Our results show significant topological alterations in the mood-dysregulated group as compared to controls at baseline. After MBCT-C, disrupted topological properties in the mood-dysregulated group were significantly reduced. CONCLUSION MBCT-C may facilitate clinically meaningful changes in the brain structural network in mood-dysregulated individuals.
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Affiliation(s)
- Jing Yang
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China.,Department of Radiology, Chongqing University Cancer Hospital, School of Medicine, Chongqing University, Chongqing, China
| | - Du Lei
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Xueling Suo
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Maxwell J Tallman
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kun Qin
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Wenbin Li
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kaitlyn M Bruns
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Luis Rodrigo Patino Duran
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sian Cotton
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - John A Sweeney
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Qiyong Gong
- Huaxi MR Research Center (HMRRC), Departments of Radiology, West China Hospital of Sichuan University, Chengdu, China.,Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu, China.,Functional and Molecular Imaging Key Laboratory of Sichuan Province, Huaxi Xiamen Hospital of Sichuan University, Xiamen, China
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Spielberg JM, Sadeh N, Cha J, Matyi MA, Anand A. Affect Regulation-Related Emergent Brain Network Properties Differentiate Depressed Bipolar Disorder From Major Depression and Track Risk for Bipolar Disorder. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2022; 7:765-773. [PMID: 34637954 PMCID: PMC8993939 DOI: 10.1016/j.bpsc.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Individuals with or at risk for bipolar disorder (BD) often present initially for the treatment of depressive symptoms. Unfortunately, pharmacological treatments for major depressive disorder (MDD) can be iatrogenic, precipitating mania that may not have otherwise occurred. Current diagnostic procedures rely solely on self-reported/observable symptoms, and thus alternative data sources, such as brain network properties, are needed to supplement current self-report/observation-based indices of risk for mania. METHODS Brain connectivity during affect maintenance/regulation was examined in a large (N = 249), medication-free sample of currently depressed patients with BD (n = 50) and MDD (n = 116) and healthy control subjects (n = 83). BD risk was categorized in a subset of patients with MDD. We used graph theory to identify emergent network properties that differentiated between patients with BD and MDD and between patients with MDD at high and low risk for BD. RESULTS BD and MDD differed in the extent to which the rostral anterior cingulate cortex was embedded in the local network, amount of influence the hippocampus exerted over global network communication, and clarity of orbitofrontal cortex communication. Patients with MDD at high risk for BD showed a pattern of local network clustering around the right amygdala that was similar to the pattern observed in healthy control subjects, whereas patients with MDD at low risk for BD deviated from this pattern. CONCLUSIONS BD and MDD differed in emergent network mechanisms subserving affect regulation, and amygdala properties tracked BD risk in patients with MDD. If replicated, our findings may be combined with other markers to assess the presence of BD and/or BD risk in individuals presenting with depressive symptoms to prevent the use of iatrogenic treatments.
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Affiliation(s)
- Jeffrey M Spielberg
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware.
| | - Naomi Sadeh
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware
| | - Jungwon Cha
- Center for Behavioral Health, Cleveland Clinic, Cleveland, Ohio; Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Melanie A Matyi
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware
| | - Amit Anand
- Center for Behavioral Health, Cleveland Clinic, Cleveland, Ohio; Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Koc D, Ince E, San T, Akan P, Paketci A, Bober E, Tecirli ND, Inal N, Akay AP. Association between thyroid autoimmunity and antidepressant treatment-emergent mania in pediatric mood disorders. Psychiatry Res 2022; 314:114676. [PMID: 35709636 DOI: 10.1016/j.psychres.2022.114676] [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: 10/23/2021] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 10/18/2022]
Abstract
Risk factors associated with antidepressant treatment-emergent mania(ATEM) are poorly characterized in child and adolescent populations. To identify better biomarkers, we aimed to explore whether thyroid autoimmunity is associated with ATEM in pediatric mood disorders. We enrolled two groups of pediatric mood disorders, those with ATEM+ (n = 29) and those with ATEM- controls (n = 31). All diagnoses were made according to structured interviews by the clinicians. Autoimmune thyroiditis (anti-thyroid peroxidase antibodies [TPO-abs] and thyroid function (thyroid-stimulating hormone [TSH] and free thyroxin [FT4]) were assessed. Logistic regression was used to explore the relationship between TPO-abs seroprevalence and ATEM+ while controlling for covariates. Group comparisons showed that the patient with ATEM+ had significantly higher seroprevalence and titer of TPO-abs compared to ATEM- controls. In logistic regression analysis adjusting for age, gender, Tanner stage, body mass index, antipsychotic treatments, smoking status and family history of thyroid disorder, the seroprevalence of TPO-abs (>60 U/mL) was significantly associated with ATEM+ (OR = 3.67, 95% confidence interval [CI] = 1.2-11.1, p = 0.022). Our findings demonstrated that seroprevalence and titer of TPO-abs in pediatric mood disorders are associated with ATEM+ status. TPO-abs could potentially serve as a biomarker when assessing the risk of ATEM in the child and adolescent population.
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Affiliation(s)
- Dogukan Koc
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Ecem Ince
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Tugba San
- Department of Neuroscience, Graduate School of Health Sciences, Dokuz Eylul University, Izmir, Turkey
| | - Pınar Akan
- Department of Biochemistry, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ahu Paketci
- Department of Pediatric Endocrinology, Dokuz Eylul University, Izmir, Turkey
| | - Ece Bober
- Department of Pediatric Endocrinology, Dokuz Eylul University, Izmir, Turkey
| | - Nese Direk Tecirli
- Department of Psychiatry, Istanbul University Faculty of Medicine, Izmir, Turkey
| | - Neslihan Inal
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Aynur Pekcanlar Akay
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, Dr Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Goldwaser EL, Aaronson ST. Optimizing Use of Vagus Nerve Stimulation for the Psychiatric Patient. Psychiatr Ann 2022. [DOI: 10.3928/00485713-20220621-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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A Double-Blind Randomized Trial to Investigate Mechanisms of Antidepressant-Related Dysfunctional Arousal in Depressed or Anxious Youth at Familial Risk for Bipolar Disorder. J Pers Med 2022; 12:jpm12061006. [PMID: 35743790 PMCID: PMC9225632 DOI: 10.3390/jpm12061006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/11/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
Antidepressants are standardly used to treat moderate to severe symptoms of depression and/or anxiety in youth but may also be associated with rare but serious psychiatric adverse events such as irritability, agitation, aggression, or suicidal ideation. Adverse events are especially common in youth with a family history of bipolar disorder (BD) who are at heightened risk for dysfunction in neurobiological systems that regulate emotion and arousal. To further understand this phenomenon, this study will examine (a) baseline risk factors associated with dysfunctional arousal in a sample of youth at high-risk for BD treated with or without an antidepressant, (b) whether antidepressant-related changes in arousal are mediated by changes in prefrontal-limbic circuitry, and (c) whether pharmacogenetic factors influence antidepressant-related changes in arousal. High-risk youth (aged 12-17 years with moderate to severe depressive and/or anxiety symptoms and at least one first-degree relative with bipolar I disorder) will be randomized to receive psychotherapy plus escitalopram or psychotherapy plus placebo. Neuroimaging and behavioral measures of arousal will be collected prior to randomization and at 4 weeks. Samples for pharmacogenetic analysis (serum escitalopram concentration, CYP2C19 metabolizer phenotype, and HTR2A and SLC6A4 genotypes) will be collected at 8 weeks. Youth will be followed for up to 16 weeks to assess change in arousal measures.
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Simonoff E, Mowlem F, Pearson O, Anagnostou E, Donnelly C, Hollander E, King BH, McCracken JT, Scahill L, Sikich L, Pickles A. Citalopram Did Not Significantly Improve Anxiety in Children with Autism Spectrum Disorder Undergoing Treatment for Core Symptoms: Secondary Analysis of a Trial to Reduce Repetitive Behaviors. J Child Adolesc Psychopharmacol 2022; 32:233-241. [PMID: 35501967 PMCID: PMC11075077 DOI: 10.1089/cap.2021.0137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: Anxiety disorders are among the most common co-occurring conditions in autism spectrum disorder (ASD). Despite their prevalence and impact, there are no randomized controlled trials (RCTs) aimed at evaluating the efficacy of selective serotonin reuptake inhibitors (SSRIs) for anxiolysis in this population, who may have a different biological basis for anxiety. Methods: Secondary analyses of the STAART double-blind, placebo-controlled RCT of citalopram in children with ASD examined whether citalopram reduced anxiety measured on the parent-reported Child and Adolescent Symptom Inventory-4 (CASI-4) as the primary outcome. An intention-to-treat analysis involving all 149 participants used multiple imputations for missing data and included baseline stratification factors of age group and site, among others. We prespecified as clinically significant a 33% reduction in anxiety in citalopram versus placebo, coinciding with 80% power. We tested whether communicative ability on the Vineland Communication score moderated treatment effect and explored whether initial anxiety was associated with greater adverse events, which could impact on dose titration and achieving optimal dose. Results: Both groups showed substantial reduction in anxiety. Citalopram was associated with a nonsignificant 16.5% greater reduction (observed coefficient = -0.181, bootstrap standard error = 0.126, p = 0.151, confidence interval = -0.428 to 0.066). Anxiety reports were significantly lower in children with reduced communicative ability, but communicative ability did not moderate the treatment effect (interaction p = 0.294). Initial anxiety levels were not associated with increased adverse effects (interaction ps 0.162-0.954). Conclusion: Citalopram did not statistically significantly improve anxiety in children with ASD. Clinicians should be cautious in their use of SSRIs for this indication. There remains a need for well-powered clinical trials testing the efficacy of SSRIs among autistic children with anxiety disorders.
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Affiliation(s)
- Emily Simonoff
- Department of Child & Adolescent Psychiatry and Institute of Psychiatry, Psychology & Neuroscience and Maudsley Biomedical Research Centre for Mental Health, King's College London, London, United Kingdom
| | - Florence Mowlem
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience and Maudsley Biomedical Research Centre for Mental Health, King's College London, London, United Kingdom
| | - Oliver Pearson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience and Maudsley Biomedical Research Centre for Mental Health, King's College London, London, United Kingdom
| | - Evdokia Anagnostou
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Craig Donnelly
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Eric Hollander
- Autism and Obsessive Compulsive Spectrum Program, Psychiatric Research Institute of Montefiore Einstein, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Bryan H. King
- Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - James T. McCracken
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lawrence Scahill
- Department of Pediatrics, Marcus Autism Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Linmarie Sikich
- Department of Psychiatry, Duke Center for Autism and Brain Development, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew Pickles
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience and Maudsley Biomedical Research Centre for Mental Health, King's College London, London, United Kingdom
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Inal N, Ermis C, Koc D, Aksoy S, Karacetin G, Tuncturk M, Eray S, Karabina B, Faruk Akca O, Ozgul D, Gunay Kilic B, Cikili Uytun M, Besenek M, Kavurma C, Bilac O, Gokcen C, Topal Z, Percinel Yazıcı I, Sapmaz SY, Ozyurt G, Diler RS. Index depressive episode and antidepressant exposure were associated with illness characteristics of pediatric bipolar disorder. Acta Psychiatr Scand 2022; 145:200-208. [PMID: 34076890 DOI: 10.1111/acps.13333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 05/31/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Pediatric bipolar disorder (PBD) is a serious, recurrent disorder leading to severe functional impairment. As a first mood episode, index episode could affect the long-term course of the illness. This study aimed to investigate the clinical characteristics of youth with PBD from our multicenter, nationwide, naturalistic follow-up samples and to identify (i) the effects of index mood episode and (ii) the effect of previous antidepressant treatments on the age at mania onset of PBD. METHOD The study sample consisted of 271 youth with BD-I followed by the child and adolescent psychiatry clinics of seven different university hospitals and three research state hospitals, representing six geographic regions across Turkey. All diagnoses were made according to structured interviews, and all data were retrospectively obtained from clinical records by the clinicians. RESULTS When patients with index depressive/mixed episodes (IDE, n=129) and patients with index (hypo)manic episodes (IME, n=142) were compared, the total number of mood episodes and rapid cycling feature were significantly higher in the IDE group than in the IME group. The Cox regression analysis adjusted for sociodemographic and illness characteristics revealed female adolescents in the IDE group treated with antidepressants were more likely to have an earlier onset of mania (hazard ratio=2.03, 95% confidence interval=1.31-3.12, p=0.001). CONCLUSION This is the first large-scale nationwide follow-up study in Turkey that indicated prior antidepressant treatments were associated with an earlier onset of mania in youth, particularly in adolescent females. Larger prospective studies are needed to identify neurodevelopmental processes underlying PBD and initiate prevention approaches.
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Affiliation(s)
- Neslihan Inal
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Cagatay Ermis
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Dogukan Koc
- Department of Child and Adolescent Psychiatry, Medical Faculty, Dokuz Eylul University, Izmir, Turkey
| | - Sena Aksoy
- Department of Child and Adolescent Psychiatry, Kastamonu Training and Research Hospital, Kastamonu, Turkey
| | - Gul Karacetin
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Mustafa Tuncturk
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Safak Eray
- Department of Child and Adolescent Psychiatry, Medical Faculty, Bursa Uludag University, Bursa, Turkey
| | - Berna Karabina
- Department of Child and Adolescent Psychiatry, Medical Faculty, Bursa Uludag University, Bursa, Turkey
| | - Omer Faruk Akca
- Department of Child and Adolescent Psychiatry, Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Dilek Ozgul
- Department of Child and Adolescent Psychiatry, Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Birim Gunay Kilic
- Department of Child and Adolescent Psychiatry, Medical Faculty, Ankara University, Ankara, Turkey
| | - Merve Cikili Uytun
- Department of Child and Adolescent Psychiatry, Medical Faculty, Ankara University, Ankara, Turkey
| | - Mert Besenek
- Department of Child and Adolescent Psychiatry, Recep Tayyip Erdogan University, Rize Training and Research Hospital, Rize, Turkey
| | - Canem Kavurma
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey
| | - Oznur Bilac
- Department of Child and Adolescent Psychiatry, Manisa Mental Health Hospital, Manisa, Turkey
| | - Cem Gokcen
- Department of Child and Adolescent Psychiatry, Medical Faculty, Gaziantep University, Gaziantep, Turkey
| | - Zehra Topal
- Department of Child and Adolescent Psychiatry, Medical Faculty, Gaziantep University, Gaziantep, Turkey
| | - Ipek Percinel Yazıcı
- Department of Child and Adolescent Psychiatry, Medical Faculty, Firat University, Elazig, Turkey
| | - Sermin Yalin Sapmaz
- Department of Child and Adolescent Psychiatry, Medical Faculty, Manisa Celal Bayar University Faculty of Medicine, Manisa, Turkey
| | - Gonca Ozyurt
- Department of Child and Adolescent Psychiatry, Medical Faculty, Izmir Katip Celebi University, İzmir, Turkey
| | - Rasim Somer Diler
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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11
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Nery FG, Tallman MJ, Cecil KM, Blom TJ, Patino LR, Adler CM, DelBello MP. N-acetylcysteine for depression and glutamate changes in the left prefrontal cortex in adolescents and young adults at risk for bipolar disorder: A pilot study. Early Interv Psychiatry 2022; 16:195-199. [PMID: 33797205 DOI: 10.1111/eip.13149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 01/19/2023]
Abstract
AIMS To investigate the mechanism of action of N-acetylcysteine (NAC) in depressive symptoms in young individuals at familial risk for bipolar disorder. METHODS We conducted an 8-week open label clinical trial of NAC 2400 mg/days in 15-24 years old depressed offspring of a bipolar I disorder parent, with baseline and endpoint proton magnetic resonance spectroscopy acquired within the left ventrolateral prefrontal cortex (VLPFC). RESULTS Nine participants were enrolled and finished the study. NAC significantly improved depressive and anxiety symptom scores, and clinical global impression (all p < .001). There was a non-significant reduction in glutamate levels in the left VLPFC. Reduction in depressive symptom scores was positively associated with reduction in glutamate levels in the left VLPFC (p = .007). CONCLUSIONS This pilot study suggests that NAC might be efficacious for depressive symptoms in at-risk youth, and that its mechanism of action involves the modulation of glutamate in the left VLPFC.
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Affiliation(s)
- Fabiano G Nery
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Maxwell J Tallman
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kim M Cecil
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Luis R Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Caleb M Adler
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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12
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O'Donnell C, Demler TL, Trigoboff E. Selective Serotonin Reuptake Inhibitors (SSRIs) and Their Effect on Patient Aggression in Adult Patients in a State Psychiatric Facility: A Retrospective Analysis. INNOVATIONS IN CLINICAL NEUROSCIENCE 2022; 19:33-38. [PMID: 35382065 PMCID: PMC8970236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The utility of selective serotonin reuptake inhibitors (SSRIs) has been overshadowed by the box warning they received when the United States (US) Food and Drug Administration (FDA) identified an increased risk of suicidality in patients 24 years of age or younger. Newer studies have identified suicidality as self-aggression and hypothesized whether this might also apply to aggression toward others. The controversy surrounding SSRIs has led to a decrease in prescriptions from healthcare clinicians and number of patients seeking the necessary treatment. The objective of this study was to determine if there is a relationship between SSRI use and aggressive behavior in an inpatient state psychiatric facility. DESIGN Using a retrospective analysis, patients (N=64) admitted to an inpatient state psychiatric facility between January 1, 2013, and December 31, 2020, who were taking SSRIs were assessed to determine if they had an increased risk of aggression, whether toward themselves or others. Patients served as their own comparators and were required to have a period without an SSRI and an equivalent period taking an SSRI. Patients were assessed through markers of aggression, including psychiatric emergencies; restraints; seclusions; as needed (PRN) medication use or STAT medication use for agitation, aggression, violence, poor impulse control, or psychosis; and PRN nicotine use. RESULTS There was no statistical significance in any of the analyses demonstrating that SSRI use led to an increased risk of aggression in this sample of inpatients. CONCLUSION The FDA warning of increased risk of suicidality and case reports of aggression potentially associated with the use of certain antidepressants should not prevent prescribers from treating adult patients with SSRI medications.
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Affiliation(s)
- Carolyn O'Donnell
- Drs. O'Donnell, Demler, and Trigoboff are with the State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice in Buffalo, New York
- Drs. O'Donnell and Demler are with the New York State Office of Mental Health at Buffalo Psychiatric Center in Buffalo, New York
- Drs. Demler and Trigoboff are with the State University of New York at Buffalo School of Medicine, Department of Psychiatry in Buffalo, New York
| | - Tammie Lee Demler
- Drs. O'Donnell, Demler, and Trigoboff are with the State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice in Buffalo, New York
- Drs. O'Donnell and Demler are with the New York State Office of Mental Health at Buffalo Psychiatric Center in Buffalo, New York
- Drs. Demler and Trigoboff are with the State University of New York at Buffalo School of Medicine, Department of Psychiatry in Buffalo, New York
| | - Eileen Trigoboff
- Drs. O'Donnell, Demler, and Trigoboff are with the State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice in Buffalo, New York
- Drs. O'Donnell and Demler are with the New York State Office of Mental Health at Buffalo Psychiatric Center in Buffalo, New York
- Drs. Demler and Trigoboff are with the State University of New York at Buffalo School of Medicine, Department of Psychiatry in Buffalo, New York
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13
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Murphy SE, Capitão LP, Giles SLC, Cowen PJ, Stringaris A, Harmer CJ. The knowns and unknowns of SSRI treatment in young people with depression and anxiety: efficacy, predictors, and mechanisms of action. Lancet Psychiatry 2021; 8:824-835. [PMID: 34419187 DOI: 10.1016/s2215-0366(21)00154-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 01/12/2023]
Abstract
The use of SSRIs for the treatment of depression and anxiety in young people is increasing. However, the effects of SSRIs in adolescence, a time when there are substantial changes in neural, cognitive, and social functioning, are not well understood. Here, we review evidence from clinical trials about the benefits and risks of SSRIs in young people and consider their mechanisms of action, as shown through human experimental work and animal models. We emphasise key outstanding questions about the effects of SSRIs in youth, identified through gaps in the literature and in consultation with young people with lived experience. It is crucial to characterise the mechanisms underpinning risks and benefits of SSRIs in this age group to progress the field, and to narrow the chasm between the widespread use of SSRIs in youth and the science on which this use is based.
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Affiliation(s)
- Susannah E Murphy
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Liliana P Capitão
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Sophie L C Giles
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Philip J Cowen
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Argyris Stringaris
- Section of Clinical and Computational Psychiatry, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Catherine J Harmer
- University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK.
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14
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Abstract
Irritability, anger, and aggression, although not specific for pediatric bipolar disorder (BD), can be a common finding and an important source of distress and impairment in these patients. Over the past 2 decades the diagnostic significance of irritability in pediatric BD has been highly debated. Beyond the debate of its diagnostic significance, the clinical importance of irritability, anger, and aggression in youth with BD has been well established. In this review, the authors discuss evaluation and management strategies of irritability, anger, and aggression in youth with BD.
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15
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Del Favero E, Montemagni C, Bozzatello P, Brasso C, Riccardi C, Rocca P. The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives. ACTA ACUST UNITED AC 2021; 57:medicina57060545. [PMID: 34071356 PMCID: PMC8229021 DOI: 10.3390/medicina57060545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 12/14/2022]
Abstract
The onset of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder could be considered as an important alarm bell for the development of the disease and should be carefully detected. The management of prodromes in bipolar high-risk patients appears to be an important means of prevention; nevertheless, at the moment, there aren’t clear and widely shared treatment indications. The aim of this review is to summarize the available treatment options (pharmacological, psychosocial and nutraceutical) for the management of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder.
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Affiliation(s)
- Elisa Del Favero
- Dipartimento di Neuroscienze “Rita Levi Montalcini”, Università degli Studi di Torino, Via Cherasco 11, 10126 Turin, Italy; (E.D.F.); (P.B.); (C.B.); (C.R.)
| | - Cristiana Montemagni
- Dipartimento di Neuroscienze e Salute Mentale, A.O.U. Città Della Salute e Della Scienza, via Cherasco 11, 10126 Turin, Italy;
| | - Paola Bozzatello
- Dipartimento di Neuroscienze “Rita Levi Montalcini”, Università degli Studi di Torino, Via Cherasco 11, 10126 Turin, Italy; (E.D.F.); (P.B.); (C.B.); (C.R.)
| | - Claudio Brasso
- Dipartimento di Neuroscienze “Rita Levi Montalcini”, Università degli Studi di Torino, Via Cherasco 11, 10126 Turin, Italy; (E.D.F.); (P.B.); (C.B.); (C.R.)
| | - Cecilia Riccardi
- Dipartimento di Neuroscienze “Rita Levi Montalcini”, Università degli Studi di Torino, Via Cherasco 11, 10126 Turin, Italy; (E.D.F.); (P.B.); (C.B.); (C.R.)
| | - Paola Rocca
- Dipartimento di Neuroscienze “Rita Levi Montalcini”, Università degli Studi di Torino, Via Cherasco 11, 10126 Turin, Italy; (E.D.F.); (P.B.); (C.B.); (C.R.)
- Dipartimento di Neuroscienze e Salute Mentale, A.O.U. Città Della Salute e Della Scienza, via Cherasco 11, 10126 Turin, Italy;
- Correspondence:
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16
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Qin K, Lei D, Yang J, Li W, Tallman MJ, Duran LRP, Blom TJ, Bruns KM, Cotton S, Sweeney JA, Gong Q, DelBello MP. Network-level functional topological changes after mindfulness-based cognitive therapy in mood dysregulated adolescents at familial risk for bipolar disorder: a pilot study. BMC Psychiatry 2021; 21:213. [PMID: 33910549 PMCID: PMC8080341 DOI: 10.1186/s12888-021-03211-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/09/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Given that psychopharmacological approaches routinely used to treat mood-related problems may result in adverse outcomes in mood dysregulated adolescents at familial risk for bipolar disorder (BD), Mindfulness-Based Cognitive Therapy for Children (MBCT-C) provides an alternative effective and safe option. However, little is known about the brain mechanisms of beneficial outcomes from this intervention. Herein, we aimed to investigate the network-level neurofunctional effects of MBCT-C in mood dysregulated adolescents. METHODS Ten mood dysregulated adolescents at familial risk for BD underwent a 12-week MBCT-C intervention. Resting-state functional magnetic resonance imaging (fMRI) was performed prior to and following MBCT-C. Topological metrics of three intrinsic functional networks (default mode network (DMN), fronto-parietal network (FPN) and cingulo-opercular network (CON)) were investigated respectively using graph theory analysis. RESULTS Following MBCT-C, mood dysregulated adolescents showed increased global efficiency and decreased characteristic path length within both CON and FPN. Enhanced functional connectivity strength of frontal and limbic areas were identified within the DMN and CON. Moreover, change in characteristic path length within the CON was suggested to be significantly related to change in the Emotion Regulation Checklist score. CONCLUSIONS 12-week MBCT-C treatment in mood dysregulated adolescents at familial risk for BD yield network-level neurofunctional effects within the FPN and CON, suggesting enhanced functional integration of the dual-network. Decreased characteristic path length of the CON may be associated with the improvement of emotion regulation following mindfulness training. However, current findings derived from small sample size should be interpreted with caution. Future randomized controlled trials including larger samples are critical to validate our findings.
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Affiliation(s)
- Kun Qin
- grid.412901.f0000 0004 1770 1022Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Du Lei
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Jing Yang
- grid.412901.f0000 0004 1770 1022Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Wenbin Li
- grid.412901.f0000 0004 1770 1022Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China ,grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Maxwell J. Tallman
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Luis Rodrigo Patino Duran
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Thomas J. Blom
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Kaitlyn M. Bruns
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Sian Cotton
- grid.24827.3b0000 0001 2179 9593Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - John A. Sweeney
- grid.412901.f0000 0004 1770 1022Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China ,grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Qiyong Gong
- Huaxi MR Research Center (HMRRC), Department of Radiology, West China Hospital of Sichuan University, Chengdu, China. .,Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu, China. .,Functional and Molecular Imaging Key Laboratory of Sichuan Province, Chengdu, China.
| | - Melissa P. DelBello
- grid.24827.3b0000 0001 2179 9593Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH USA
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17
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Karakaya SEK, Yektaş Ç, Tufan AE. Activation Syndrome in a Patient With Attention-Deficit/Hyperactivity Disorder Treated With Atomoxetine: A Case Report. Clin Neuropharmacol 2021; 44:101-103. [PMID: 33661138 DOI: 10.1097/wnf.0000000000000447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT "Activation syndrome" represents a cluster of symptoms of excessive emotional arousal or behavioral activation, which emerges after the first few weeks of antidepressant treatment or a dose increase and resolves with dose reduction or cessation of treatment. It was reported after treatment with selective serotonin reuptake inhibitor and serotonin-norepinephrine reuptake inhibitor group of agents, but no case of activation syndrome has been reported with the norepinephrine reuptake inhibitor group. Atomoxetine is a norepinephrine reuptake inhibitor and nonstimulant and is used to manage symptoms of attention-deficit/hyperactivity disorder (ADHD). Atomoxetine-related symptoms of mania and hypomania were reported in literature previously. Here, we report a case of activation syndrome arising after atomoxetine (ATX) dose titration in a prepubertal male child with ADHD. Differentiation of activation symptoms from mania/hypomania symptoms after treatment with ATX may be important for the clinicians to manage the adverse effects and understand the risk factors behind activation syndrome with use of ATX in children and adolescents diagnosed with ADHD.
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Affiliation(s)
| | - Çiğdem Yektaş
- Department of Child and Adolescent Psychiatry, Uskudar University Faculty of Medicine, Istanbul
| | - Ali Evren Tufan
- Department of Child and Adolescent Psychiatry, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey
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18
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Nery FG, Masifi SL, Strawn JR, Duran LR, Weber WA, Welge JA, Adler CM, Strakowski SM, DelBello MP. Association between poor tolerability of antidepressant treatment and brain functional activation in youth at risk for bipolar disorder. ACTA ACUST UNITED AC 2021; 43:70-74. [PMID: 32876131 PMCID: PMC7861172 DOI: 10.1590/1516-4446-2019-0803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/05/2020] [Indexed: 11/22/2022]
Abstract
Objective: To investigate whether poor antidepressant tolerability is associated with functional brain changes in children and adolescents of parents with bipolar I disorder (at-risk youth). Methods: Seventy-three at-risk youth (ages 9-20 years old) who participated in a prospective study and had an available baseline functional magnetic resonance imaging (fMRI) scan were included. Research records were reviewed for the incidence of adverse reactions related to antidepressant exposure during follow-up. The sample was divided among at-risk youth without antidepressant exposure (n=21), at-risk youth with antidepressant exposure and no adverse reaction (n=12), at-risk youth with antidepressant-related adverse reaction (n=21), and healthy controls (n=20). The fMRI task was a continuous performance test with emotional distracters. Region-of-interest mean activation in brain areas of the fronto-limbic emotional circuit was compared among groups. Results: Right amygdala activation in response to emotional distracters significantly differed among groups (F3,66 = 3.1, p = 0.03). At-risk youth with an antidepressant-related adverse reaction had the lowest amygdala activation, while at-risk youth without antidepressant exposure had the highest activation (p = 0.004). Conclusions: Decreased right amygdala activation in response to emotional distracters is associated with experiencing an antidepressant-related adverse reaction in at-risk youth. Further studies to determine whether amygdala activation is a useful biomarker for antidepressant-related adverse events are needed.
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Affiliation(s)
- Fabiano G Nery
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sheela L Masifi
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Luis R Duran
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Wade A Weber
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Jeffrey A Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Caleb M Adler
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stephen M Strakowski
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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19
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Nery FG, Wilson AR, Schneider MR, Strawn JR, Patino LR, McNamara RK, Adler CM, Strakowski SM, DelBello MP. Medication exposure and predictors of first mood episode in offspring of parents with bipolar disorder: a prospective study. ACTA ACUST UNITED AC 2020; 42:481-488. [PMID: 32401870 PMCID: PMC7524417 DOI: 10.1590/1516-4446-2019-0802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/01/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To prospectively investigate whether baseline clinical characteristics and medication exposure predict development of major depressive disorder or bipolar disorder in offspring of parents with bipolar disorder. METHODS Youth aged 9-20 years with at least one biological parent with bipolar disorder and no prior history of mood or psychotic episodes (n=93) were prospectively evaluated and treated naturalistically during the study. Participants were divided into two groups: converters, defined as those who met DSM-IV criteria for a mood episode during follow-up (n=19); or non-converters (n=74). Logistic regression models were used to investigate associations between baseline clinical variables and medication exposure during follow-up and risk of developing a first mood episode (conversion). RESULTS Multivariate regression analyses showed that baseline anxiety disorders and subsyndromal mood disorders were associated with increased risk of conversion during follow-up. Adding medication exposure to the multivariate model showed that exposure to antidepressants during follow-up was associated with increased risk of conversion. CONCLUSIONS Caution should be used when treating bipolar offspring with anxiety and/or emerging depressive symptoms using antidepressant agents, given the increased risk of developing a major mood disorder.
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Affiliation(s)
- Fabiano G Nery
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anna R Wilson
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Luis R Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert K McNamara
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Caleb M Adler
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stephen M Strakowski
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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20
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Post RM, Goldstein BI, Birmaher B, Findling RL, Frey BN, DelBello MP, Miklowitz DJ. Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data. J Affect Disord 2020; 272:508-520. [PMID: 32553395 PMCID: PMC8986089 DOI: 10.1016/j.jad.2020.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/03/2020] [Accepted: 03/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated. METHODS We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms. RESULTS A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database. LIMITATIONS Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study. CONCLUSIONS Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.
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Affiliation(s)
- Robert M Post
- Bipolar Collaborative Network, Professor of Psychiatry George Washington Medical School, Bethesda, MD, Washington, DC, United States.
| | - Benjamin I Goldstein
- Departments of Psychiatry and Pharmacology, University of Toronto; Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre, Canada
| | - Boris Birmaher
- University of Pittsburgh School of Medicine, Psychiatry Research Pathway, United States
| | - Robert L Findling
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, United States
| | - Benicio N Frey
- Mood Disorders Program, Department of Psychiatry and Behavioural Neurosciences, Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Melissa P DelBello
- University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David J Miklowitz
- Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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21
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Kryza-Lacombe M, Kiefer C, Schwartz KT, Strickland K, Wiggins JL. Attention shifting in the context of emotional faces: Disentangling neural mechanisms of irritability from anxiety. Depress Anxiety 2020; 37:645-656. [PMID: 32253797 PMCID: PMC8312255 DOI: 10.1002/da.23010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 01/31/2020] [Accepted: 02/24/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Irritability predicts concurrent and prospective psychiatric disorders across the lifespan. Anxiety commonly co-occurs with irritability, and such comorbidity complicates care. Understanding the mechanisms of comorbid traits is necessary to inform treatment decisions. This study aimed to disentangle neural mechanisms of irritability from anxiety in the context of attentional shifting toward and away from emotional faces in youths from treatment-seeking families. METHODS Youths (N = 45), mean age = 14.01 years (standard deviation = 1.89) completed a dot-probe task during functional magnetic resonance imaging acquisition. Whole-brain activation analyses evaluated the effect of irritability on neural reactivity in the context of varying attentional shifting toward and away from emotional faces, both depending on and above and beyond anxiety (i.e., with anxiety as [a] a moderator and [b] a covariate, respectively). RESULTS Higher irritability levels related to distinct task-related patterns of cuneus activation, depending on comorbid anxiety levels. Increased irritability also related to distinct task-related patterns of parietal, temporal, occipital, and cerebellar activation, controlling for anxiety. Overall, youths with higher levels of irritability evinced more pronounced fluctuations in neural reactivity across task conditions. CONCLUSION The present study contributes to a literature delineating the unique and shared neural mechanisms of overlapping symptom dimensions, which will be necessary to ultimately build a brain- and behavior-based nosology that forms the basis for more targeted and effective treatments.
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Affiliation(s)
- Maria Kryza-Lacombe
- San Diego State University/University of California, San Diego, Joint Doctoral Program in Clinical Psychology, San Diego, California
| | - Cynthia Kiefer
- Department of Psychology, San Diego State University, San Diego, California
| | - Karen T.G. Schwartz
- San Diego State University/University of California, San Diego, Joint Doctoral Program in Clinical Psychology, San Diego, California
| | - Katie Strickland
- Department of Psychology, San Diego State University, San Diego, California
| | - Jillian Lee Wiggins
- San Diego State University/University of California, San Diego, Joint Doctoral Program in Clinical Psychology, San Diego, California,Department of Psychology, San Diego State University, San Diego, California
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22
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McNamara RK, Strawn JR, Tallman MJ, Welge JA, Patino LR, Blom TJ, DelBello MP. Effects of Fish Oil Monotherapy on Depression and Prefrontal Neurochemistry in Adolescents at High Risk for Bipolar I Disorder: A 12-Week Placebo-Controlled Proton Magnetic Resonance Spectroscopy Trial. J Child Adolesc Psychopharmacol 2020; 30:293-305. [PMID: 32167792 PMCID: PMC7310320 DOI: 10.1089/cap.2019.0124] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives: To evaluate the clinical and neurochemical effects of 12-week fish oil, a source of omega-3 polyunsaturated fatty acids (n-3 PUFAs), in depressed adolescents with a family history of bipolar I disorder. Methods: Adolescents with a current Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision diagnosis of Major Depressive Disorder or Depressive Disorder not otherwise specified, a Childhood Depression Rating Scale-Revised (CDRS-R) Version raw score of ≥40, and at least one biological parent with bipolar I disorder were randomized to double-blind treatment with fish oil (2100 mg/day) or placebo for 12 weeks. The primary outcome measure was change in CDRS-R total score, and secondary outcomes measures were change in manic symptoms (Young Mania Rating Scale), global symptom and functioning measures (Clinical Global Impression-Severity [CGI-S] /CGI Improvement [CGI-I], Children's Global Assessment Scale, and Child Behavior Checklist), safety and laboratory measures, and anterior cingulate cortex (ACC) and bilateral ventrolateral prefrontal cortex neurometabolite concentrations using proton magnetic resonance spectroscopy at 4 T. Results: Fifty-six patients were randomized, and 42 completed the 12-week trial (placebo: n = 21; fish oil, n = 21). Subjects randomized to fish oil, but not placebo, exhibited a significant baseline to endpoint increase in erythrocyte n-3 PUFAs. Reductions in CDRS-R scores did not differ between treatment groups (p = 0.15), and similar remission (p = 0.58) and response (p = 0.77) rates were observed. Fish oil produced a significantly greater decrease in CGI-S (p = 0.0042) and CGI-I (p = 0.036) scores compared with placebo. Baseline to endpoint change in ACC creatine (p = 0.004) and ACC choline (Cho) (p = 0.024) differed significantly between groups. Baseline ACC Cho levels were inversely correlated with baseline and baseline to endpoint change in CDRS-R scores, and baseline to endpoint change in ACC Cho correlated with baseline-endpoint change in CDRS-R scores and n-3 PUFA. There were no group differences in safety and tolerability ratings or laboratory measures. Conclusions: Fish oil monotherapy was not superior to placebo for reducing depressive symptoms in high-risk youth as assessed by the CDRS-R, but was safe and well tolerated and superior to placebo on clinician ratings of global symptom improvement. Associations among ACC Cho levels, depression symptom severity, and n-3 PUFA warrant additional investigation.
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Affiliation(s)
- Robert K. McNamara
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Address correspondence to: Robert K. McNamara, PhD, Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 260 Stetson Street, Cincinnati, OH 45219-0516, USA
| | - Jeffrey R. Strawn
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Max J. Tallman
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jeffrey A. Welge
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - L. Rodrigo Patino
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas J. Blom
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Melissa P. DelBello
- Division of Bipolar Disorders Research, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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23
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Cotton S, Kraemer KM, Sears RW, Strawn JR, Wasson RS, McCune N, Welge J, Blom TJ, Durling M, Delbello MP. Mindfulness-based cognitive therapy for children and adolescents with anxiety disorders at-risk for bipolar disorder: A psychoeducation waitlist controlled pilot trial. Early Interv Psychiatry 2020; 14:211-219. [PMID: 31264800 PMCID: PMC7307795 DOI: 10.1111/eip.12848] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 04/22/2019] [Accepted: 06/09/2019] [Indexed: 11/29/2022]
Abstract
AIM Previous studies suggest that Mindfulness-Based Cognitive Therapy for Children (MBCT-C) is feasible and may improve anxiety and emotion regulation in youth with anxiety disorders at-risk for bipolar disorder. However, controlled studies are warranted to replicate and extend these findings. METHODS In the current study, 24 youth with anxiety disorders who have at least one parent with bipolar disorder participated in a MBCT-C treatment period (n = 24; Mage = 13.6, 75% girls, 79% White) with a subset also participating in a prior psychoeducation waitlist control period (n = 19 Mage = 13.8, 68% girls, 84% White). Participants in both the waitlist and MBCT-C periods completed independently-rated symptom scales at each time point. Participants in the waitlist period received educational materials 12 weeks prior to the beginning of MBCT-C. RESULTS There were significantly greater improvements in overall clinical severity in the MBCT-C period compared to the waitlist period, but not in clinician- and child-rated anxiety, emotion regulation or mindfulness. However, increases in mindfulness were associated with improvements in anxiety and emotion regulation in the MBCT-C period, but not the waitlist period. CONCLUSIONS Findings suggest that MBCT-C may be effective for improving overall clinical severity in youth with anxiety disorders who are at-risk for bipolar disorder. However, waitlist controlled designs may inflate effect sizes so interpret with caution. Larger studies utilizing prospective randomized controlled designs are warranted.
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Affiliation(s)
- Sian Cotton
- Department of Family and Community Medicine, Division of Integrative Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kristen M Kraemer
- Department of Psychology, University of Cincinnati, Cincinnati, Ohio
| | - Richard W Sears
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey R Strawn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel S Wasson
- Department of Family and Community Medicine, Division of Integrative Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nina McCune
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jeffrey Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Thomas J Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michelle Durling
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Melissa P Delbello
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
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24
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Angal S, DelBello M, Zalpuri I, Singh MK. Clinical Conundrum: How do you treat youth with depression and a family history of bipolar disorder? Bipolar Disord 2019; 21:383-386. [PMID: 31025454 PMCID: PMC6597299 DOI: 10.1111/bdi.12788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Sarthak Angal
- Stanford University School of Medicine, Stanford, California
| | | | - Isheeta Zalpuri
- Stanford University School of Medicine, Stanford, California
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25
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Nery FG, Weber WA, Blom TJ, Welge J, Patino LR, Strawn JR, Chu WJ, Adler CM, Komoroski RA, Strakowski SM, DelBello MP. Longitudinal proton spectroscopy study of the prefrontal cortex in youth at risk for bipolar disorder before and after their first mood episode. Bipolar Disord 2019; 21:330-341. [PMID: 30864200 DOI: 10.1111/bdi.12770] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To investigate neurochemical abnormalities in the left and right ventrolateral prefrontal cortex (VLPFC) and anterior cingulate cortex (ACC) of youth at risk for bipolar disorder using proton magnetic resonance spectroscopy before and after their first mood episode. METHODS Children and adolescents offspring of parents with bipolar I disorder (at-risk group, n = 117) and matched healthy controls (HC group, n = 61) were recruited at the University of Cincinnati. At-risk subjects had no lifetime major mood and psychotic disorders at baseline, and were followed up every 4 months to monitor for development of a major depressive, manic, hypomanic, or mixed mood episode. Levels of N-acetyl-aspartate (NAA), phosphocreatine plus creatine (PCr + Cr), choline-containing compounds, myo-inositol, and glutamate were determined using LCModel and corrected for partial volume effects. RESULTS There were no baseline differences in metabolite levels for any of the brain regions between at-risk and HC youth. Nineteen at-risk subjects developed a first mood episode during follow-up. Survival analyses showed that baseline PCr + Cr levels in the left VLPFC significantly predicted a mood episode during follow-up in the at-risk group (HR: 0.47, 95% CI: 0.27-0.82, P = 0.008). There were no longitudinal changes in metabolites levels in the VLPFC and ACC before and after a mood episode in at-risk subjects. CONCLUSIONS We found no evidence for abnormal proton spectroscopy metabolite levels in the VLPFC and ACC of at-risk youth, prior and after the development of their first mood episode. Preliminary findings of association between baseline PCr + Cr levels in the left VLPFC and risk to develop a mood episode warrant further investigation.
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Affiliation(s)
- Fabiano G Nery
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Wade A Weber
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Thomas J Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jeffrey Welge
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Luis R Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Wen-Jang Chu
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Caleb M Adler
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard A Komoroski
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Stephen M Strakowski
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Melissa P DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH
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26
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Sub-threshold bipolar disorder in medication-free young subjects with major depression: Clinical characteristics and antidepressant treatment response. J Psychiatr Res 2019; 110:1-8. [PMID: 30579045 DOI: 10.1016/j.jpsychires.2018.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study, for the first time, compared illness and antidepressant response characteristics of young subjects with major depression (MDD) at low (LRMDD) or high-risk (HRMDD) for developing bipolar disorder with characteristics of young bipolar (BPD) subjects and healthy controls (HC). METHODS One hundred and six young (15-30 yr), medication-free subjects MDD subjects (HRMDD, N = 51; LRMDD, N = 55) were compared with 32 BPD (Type I: 14; Type II: 18) as well as 49 HC subjects. Baseline illness characteristics and frequency of comorbid conditions were examined using Analysis of Variance and Cochran-Armitage trend test. Additionally, in MDD subjects, the effect of open-label antidepressant treatment for up to 24 months with periodic assessments was compared between HRMDD and LRMDD groups for treatment response, remission and (hypo)mania switch while controlling for attrition. RESULTS Significant gradation from LRMDD to HRMDD to BPD groups was found for increasing occurrence of alcohol dependence (p = 0.006), comorbid PTSD (p = 0.006), borderline personality traits (p = 0.001), and occurrence of melancholic features (p < 0.005). Antidepressant treatment response was similar between the two groups except that for the 12-month period HRMDD showed a trend for a lower response. Switch to (hypo)mania was infrequent in both groups though the HRMDD showed a higher occurrence of spikes in (hypo)mania symptoms (>25% increase in YMRS scores)(p = 0.04). CONCLUSION Findings of the study indicate that a substantial proportion of young MDD subjects share BPD illness characteristics. These HRMDD subjects, if treated with antidepressants, need to be monitored for development of BPD. TRIAL REGISTRATION NCT01811147.
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27
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The Impact of Antidepressant Dose and Class on Treatment Response in Pediatric Anxiety Disorders: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry 2018; 57:235-244.e2. [PMID: 29588049 PMCID: PMC5877120 DOI: 10.1016/j.jaac.2018.01.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 01/25/2018] [Accepted: 01/25/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the trajectory and magnitude of antidepressant response as well as the effect of antidepressant class and dose on symptomatic improvement in pediatric anxiety disorders. METHOD Weekly symptom severity data were extracted from randomized, parallel group, placebo-controlled trials of selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs) in pediatric anxiety disorders. Treatment response was modeled for the standardized change in continuous measures of anxiety using Bayesian updating. Posterior distributions for each study served as informative conjugate prior to distributions update subsequent study posteriors. Change in symptom severity was evaluated as a function of time, class and, for SSRIs, standardized dose. RESULTS Data from 9 trials (SSRIs: n = 5; SNRIs, n = 4) evaluating 7 medications in 1,673 youth were included. In the logarithmic model of treatment response, statistically, but not clinically, significant treatment effects emerged within 2 weeks of beginning treatment (standardized medication-placebo difference = -0.054, credible interval [CI] = -0.076 to -0.032, p = .005, approximate Cohen's d ≤ 0.2) and by week 6, clinically significant differences emerged (standardized medication-placebo difference = -0.120, CI = -0.142 to -0.097, p = .001, approximate Cohen's d = 0.44). Compared to SNRIs, SSRIs resulted in significantly greater improvement by the second week of treatment (p = .0268), and this advantage remained statistically significant through week 12 (all p values <.03). Improvement occurred earlier with high-dose SSRI treatment (week 2, p = .002) compared to low-dose treatment (week 10, p = .025), but SSRI dose did not have an impact on overall response trajectory (p > .18 for weeks 1-12). CONCLUSIONS In pediatric patients with generalized, separation, and/or social anxiety disorders, antidepressant-related improvement occurred early in the course of treatment, and SSRIs were associated with more rapid and greater improvement compared to SNRIs.
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28
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Nuñez NA, Comai S, Dumitrescu E, Ghabrash MF, Tabaka J, Saint-Laurent M, Vida S, Kolivakis T, Fielding A, Low N, Cervantes P, Booij L, Gobbi G. Psychopathological and sociodemographic features in treatment-resistant unipolar depression versus bipolar depression: a comparative study. BMC Psychiatry 2018; 18:68. [PMID: 29548306 PMCID: PMC5857132 DOI: 10.1186/s12888-018-1641-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Some authors have hypothesized that Treatment-Resistant Unipolar Depression (TRD-UP) should be considered within the bipolar spectrum disorders and that hidden bipolarity may be a risk factor for TRD-UP. However, there are neither studies comparing clinical and sociodemographic data of patients with TRD-UP versus Bipolar (BP) disorders nor are there any examining differences versus Bipolar type I (BP-I) and Bipolar type II (BP-II). METHODS Charts analysis was conducted on 194 patients followed at the Mood Disorders Clinic of the McGill University Health Center. Sociodemographic, clinical features and depression scales were collected from patients meeting DSM-IV criteria for TRD-UP (n = 100) and BP (n = 94). Binary logistic regression analysis was conducted to examine clinical predictors independently associated with the two disorders. RESULTS Compared to BP, TRD-UP patients exhibited greater severity of depression, prevalence of anxiety and panic disorders, melancholic features, Cluster-C personality disorders, later onset of depression and fewer hospitalizations. Binary logistic regression indicated that higher comorbidity with anxiety disorders, higher depression scale scores and lower global assessment of functioning (GAF) scores, and lower number of hospitalizations and psychotherapies differentiated TRD-UP from BP patients. We also found that the rate of unemployment and the number of hospitalizations for depression was higher in BP-I than in BP-II, while the rate of suicide attempts was lower in BP-I than in BP-II depressed patients. CONCLUSIONS These results suggest that TRD-UP constitutes a distinct psychopathological condition and not necessarily a prodromal state of BP depression.
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Affiliation(s)
- Nicolas A. Nuñez
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Stefano Comai
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000000417581884grid.18887.3eDivision of Neuroscience, San Raffaele Scientific Institute and Vita-Salute University, Milan, Italy
| | - Eduard Dumitrescu
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Maykel F. Ghabrash
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - John Tabaka
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Marie Saint-Laurent
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Stephen Vida
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Theodore Kolivakis
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Allan Fielding
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Nancy Low
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Pablo Cervantes
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC Canada
| | - Linda Booij
- 0000 0004 1936 8649grid.14709.3bDepartment of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC Canada ,0000 0001 2292 3357grid.14848.31Department of Psychology, Concordia University and Sainte-Justine Hospital Research Center, University of Montréal, Montréal, QC Canada
| | - Gabriella Gobbi
- Department of Psychiatry, Neurobiological Psychiatry Unit, McGill University Health Center (MUHC), McGill University, Room 220, 1033 Pine Avenue West,, Montreal, QC, Canada. .,Department of Psychiatry, Mood Disorder Clinic, McGill University Health Center, McGill University, Montreal, QC, Canada.
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Luft MJ, Lamy M, DelBello MP, McNamara RK, Strawn JR. Antidepressant-Induced Activation in Children and Adolescents: Risk, Recognition and Management. Curr Probl Pediatr Adolesc Health Care 2018; 48:50-62. [PMID: 29358037 PMCID: PMC5828909 DOI: 10.1016/j.cppeds.2017.12.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The tolerability of antidepressants is poorly characterized in children and adolescents with depressive and anxiety disorders. Among adverse events that affect the tolerability of antidepressants in youth is activation, a cluster of symptoms that represent a hyperarousal event characterized by impulsivity, restlessness, and/or insomnia. This cluster of symptoms was first identified as a side effect of selective serotonin and selective serotonin norepinephrine inhibitors (SSRIs and SSNRIs) in the early 1990s; however, activation remains poorly characterized in terms of prevalence, risk factors, and pathophysiology. This article describes the pathophysiology of antidepressant-related activation, predictors of activation and its clinical management in youth with depressive and anxiety disorders who are treated with antidepressant medications.
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Affiliation(s)
- Marissa J Luft
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Martine Lamy
- Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Melissa P DelBello
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229
| | - Robert K McNamara
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559
| | - Jeffrey R Strawn
- Department of Psychiatry, University of Cincinnati, College of Medicine, Cincinnati, OH 45267-0559; Department of Pediatrics, Division of Child & Adolescent Psychaitry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229.
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30
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Zalpuri I, Singh MK. Treatment of psychiatric symptoms among offspring of parents with bipolar disorder. ACTA ACUST UNITED AC 2017; 4:341-356. [PMID: 29503793 DOI: 10.1007/s40501-017-0126-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose of Review Bipolar disorder is highly familial and has a protracted and diagnostically confusing prodrome. This review critically evaluates recently published literature relevant to the treatment of psychiatric symptoms in high-risk offspring of parents with Bipolar Disorder. Recent Findings Non-pharmacological treatment options including psychotherapy, resilience promotion through good sleep, diet, and exercise hygiene, and omega-3 fatty acid supplementation are important first line interventions for high-risk offspring. There has been some success in treating this population with open-label trials with mood stabilizers and atypical antipsychotics; however, these results have not been replicated in randomized controlled trails. Summary Despite some progress in early identification of symptoms in offspring of parents with Bipolar Disorder, there is scarce evidence supporting the treatment of these high-risk youth to prevent psychiatric symptoms from progressing to threshold bipolar or other psychiatric disorders. There is a need for prospective and randomized trials and research that identifies reliable biomarkers to individualize treatments for these youth.
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Affiliation(s)
- Isheeta Zalpuri
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
| | - Manpreet K Singh
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA
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31
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Bjørklund LB, Horsdal HT, Mors O, Gasse C, Østergaard SD. Psychopharmacological treatment of psychotic mania and psychotic bipolar depression compared to non-psychotic mania and non-psychotic bipolar depression. Bipolar Disord 2017; 19:505-512. [PMID: 28593691 DOI: 10.1111/bdi.12504] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/16/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVES An evidence base for the treatment of mania and bipolar depression with psychotic symptoms is lacking. Nevertheless, clinicians may have a preference for treating episodes of bipolar disorder with or without psychotic symptoms in different ways, which is likely to reflect notions of differential efficacy of treatments between these subtypes. This study aimed to investigate whether the psychopharmacological treatment of psychotic and non-psychotic episodes of mania and bipolar depression, respectively, differs in clinical practice. METHODS We conducted a register-based study assessing the psychopharmacological treatment of all individuals receiving their first diagnosis of mania or bipolar depression between 2010 and 2012. The psychopharmacological treatment within 3 months following the time of diagnosis was considered. Potential differences in psychopharmacological treatment between the psychotic and non-psychotic subtypes of mania and bipolar depression, respectively, were investigated by means of Pearson's χ2 test and logistic regression adjusted for sex and age at diagnosis of bipolar disorder. RESULTS A total of 827 patients were included in the analyses. The adjusted odds ratio (aOR) for treatment with an antipsychotic was 1.71 (95% confidence interval [CI]: 1.18-2.48, P<.01) for psychotic mania and 3.89 (95% CI: 1.95-7.76, P<.001) for psychotic bipolar depression. The aOR for treatment with the combination of an antipsychotic and an anticonvulsant was 1.60 (95% CI: 1.06-2.43, P<.05) for psychotic mania. The aOR for treatment with the combination of an antipsychotic and an antidepressant was 2.50 (95% CI: 1.43-4.37, P<.01) for bipolar psychotic depression. CONCLUSIONS It would be of interest to conduct studies evaluating whether antipsychotics represent the superior pharmacological treatment for psychotic mania and psychotic bipolar depression.
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Affiliation(s)
| | - Henriette T Horsdal
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Ole Mors
- Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark.,iPSYCH, Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
| | - Christiane Gasse
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark.,iPSYCH, Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark.,CIRRAU, Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Søren D Østergaard
- Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark.,iPSYCH, Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Ratheesh A, Cotton SM, Davey CG, Adams S, Bechdolf A, Macneil C, Berk M, McGorry PD. Ethical considerations in preventive interventions for bipolar disorder. Early Interv Psychiatry 2017; 11:104-112. [PMID: 27027848 DOI: 10.1111/eip.12340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/17/2016] [Accepted: 02/18/2016] [Indexed: 11/28/2022]
Abstract
AIM Early intervention and prevention of serious mental disorders such as bipolar disorder has the promise of decreasing the burden associated with these disorders. With increasing early and preventive intervention efforts among cohorts such as those with a familial risk for bipolar disorder, there is a need to examine the associated ethical concerns. The aim of this review was to examine the ethical issues underpinning the clinical research on pre-onset identification and preventive interventions for bipolar disorder. METHODS We undertook a PubMed search updated to November 2014 incorporating search terms such as bipolar, mania, hypomania, ethic*(truncated), early intervention, prevention, genetic and family. RESULTS Fifty-six articles that were identified by this method as well as other relevant articles were examined within a framework of ethical principles including beneficence, non-maleficence, respect for autonomy and justice. The primary risks associated with research and clinical interventions include stigma and labelling, especially among familial high-risk youth. Side effects from interventions are another concern. The benefits of preventive or early interventions were in the amelioration of symptoms as well as the possibility of minimizing disability, cognitive impairment and progression of the illness. Supporting the autonomy of individuals and improving access to stigma-free care may help moderate the potential challenges associated with the risks of interventions. CONCLUSIONS Concerns about the risks of early identification and pre-onset interventions should be balanced against the potential benefits, the individuals' right to choice and by improving availability of services that balance such dilemmas.
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Affiliation(s)
- Aswin Ratheesh
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Susan M Cotton
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Christopher G Davey
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Adams
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Andreas Bechdolf
- Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia.,Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, Vivantes Hospital am Urban and Vivantes Hospital im Friedrichshain, Charite Universitätsmedizin, Berlin, Germany
| | - Craig Macneil
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael Berk
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Department of Psychiatry, Deakin University, Geelong, Victoria, Australia.,IMPACT Strategic Research Centre, Geelong, Victoria, Australia
| | - Patrick D McGorry
- Orygen, The National Centre for Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia
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Cotton S, Luberto CM, Sears RW, Strawn JR, Stahl L, Wasson RS, Blom TJ, Delbello MP. Mindfulness-based cognitive therapy for youth with anxiety disorders at risk for bipolar disorder: a pilot trial. Early Interv Psychiatry 2016; 10:426-34. [PMID: 25582800 DOI: 10.1111/eip.12216] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 12/02/2014] [Indexed: 12/01/2022]
Abstract
AIM Children and adolescents with bipolar parents have an elevated risk for anxiety disorders. However, antidepressant medications commonly used to treat symptoms of anxiety may accelerate the onset of mania in these already at-risk youth. Therefore, studies evaluating innovative non-pharmacologic treatments for anxiety in this population are urgently needed. METHODS Subjects participated in 12 weekly sessions of mindfulness-based cognitive therapy for children (MBCT-C), a manualized group psychotherapeutic intervention utilizing cognitive behavioural principles and mindfulness exercises to increase regulation of attention and non-judgmental acceptance of present moment thoughts, emotions and experiences. Independent raters administered symptoms rating scales prior to each treatment session. Spearman correlations and paired-samples signed rank tests were used to examine outcomes. After-intervention surveys and session transcripts were reviewed to assess feasibility and acceptability of the intervention. RESULTS Participants included 10 youth (meanage = 13.2; 80% girls; 40% biracial) with generalized, social and/or separation anxiety disorders, and a parent with bipolar disorder. Clinician-rated anxiety was significantly reduced after intervention (meanbefore = 11.1; meanafter = 4.3; P < 0.01), as well as youth-rated trait anxiety (P = 0.03). Parent-rated emotion regulation significantly increased from before to after intervention (P = 0.05). Increases in mindfulness were associated with decreases in anxiety (P = 0.03). Finally, children and parents/guardians reported high levels of feasibility, acceptability and usefulness of the intervention. CONCLUSION Findings support the feasibility, acceptability and preliminary efficacy of MBCT-C for treating anxiety in youth at risk for bipolar disorder. Future controlled and larger studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Sian Cotton
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
| | - Christina M Luberto
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Psychology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Richard W Sears
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA.,Clinical Psychology Program, Union Institute & University, Cincinnati, Ohio, USA
| | - Jeffrey R Strawn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Lauren Stahl
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rachel S Wasson
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Thomas J Blom
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
| | - Melissa P Delbello
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA
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34
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Amitai M, Kronenberg S, Carmel M, Michaelovsky E, Frisch A, Brent D, Apter A, Chen A, Weizman A, Fennig S. Pharmacogenetics of citalopram-related side effects in children with depression and/or anxiety disorders. J Neural Transm (Vienna) 2016; 123:1347-1354. [PMID: 27324805 DOI: 10.1007/s00702-016-1585-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/12/2016] [Indexed: 01/26/2023]
Abstract
Pharmacogenetic approach to antidepressant (AD) response is a promising avenue toward individualizing AD treatment. This is particularly relevant in pediatric populations because of concerns about the suicide risk of serotonin selective reuptake inhibitors (SSRIs), resulting in a black-box warning. However, to date, no specific gene or polymorphism has been consistently implicated as a marker of AD side effect (SE) in the pediatric population. The aim of this study was to examine the association between polymorphisms in genes related to the serotonergic system and citalopram SE's in children and adolescents with major depressive disorder (MDD)/dysthymia and/or anxiety disorders. Outpatients (N = 87, 44 % males), aged 7-18 years with a DSM-IV-TR diagnosis of MDD/dysthymia and/or an anxiety disorder were treated in an 8-week open trial with 20-40 mg/day of citalopram. SE's were rated using a questionnaire devised specifically for this study. Association analysis between known/candidate genetic variants in three genes (5-HTR2A, 5-HTR1Dβ, 5-HTR2C) and SE's was conducted. Agitation was more common in boys than girls (male:female 42.1 vs. 18.7 %, χ 2 = 5.61, df = 1, p = 0.018). Subjects with 5-HTR1Dβ CC genotype showed more agitation vs. both CG and GG genotypes (CC:CG:GG 71.4 vs. 33.3 vs. 18.1 %, χ 2 = 8.99, df = 2, p = 0.011). The 5-HTR1Dβ CC genotype was associated with more reports of agitation. It has been suggested that agitation may be an intermediate phenotype to suicidal behavior. Thus, it seems that 5-HTR1Dβ polymorphism may be involved in citalopram-related agitation in children and adolescents treated for depression and/or anxiety.
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Affiliation(s)
- Maya Amitai
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,The Ruhman Family Laboratory for Research on the Neurobiology of Stress, Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel.
| | - Sefi Kronenberg
- Department of Psychiatry, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Miri Carmel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Elena Michaelovsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Amos Frisch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Felsenstein Medical Research Center, Petach Tikva, Israel
| | - David Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alan Apter
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Chen
- The Ruhman Family Laboratory for Research on the Neurobiology of Stress, Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel.,Department of Stress Neurobiology and Neurogenetics, Max-Planck Institute of Psychiatry, Munich, Germany
| | - Abraham Weizman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Felsenstein Medical Research Center, Petach Tikva, Israel.,Research Unit, Geha Mental Health Center, Petach Tikva, Israel
| | - Silvana Fennig
- Department of Psychological Medicine, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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McNamara RK. Role of Omega-3 Fatty Acids in the Etiology, Treatment, and Prevention of Depression: Current Status and Future Directions. JOURNAL OF NUTRITION & INTERMEDIARY METABOLISM 2016; 5:96-106. [PMID: 27766299 DOI: 10.1016/j.jnim.2016.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Over the past three decades a body of translational evidence has implicated dietary deficiency in long-chain omega-3 (LCn-3) fatty acids, including eicosapenaenoic acid (EPA) and docosahexaenoic acid (DHA), in the pathophysiology and etiology of major depressive disorder (MDD). Cross-national and cross-sectional data suggest that greater habitual intake of preformed EPA+DHA is associated with reduced risk for developing depressive symptoms and syndromal MDD. Erythrocyte EPA and DHA composition is highly correlated with habitual fish or fish oil intake, and case-control studies have consistently observed lower erythrocyte EPA and/or DHA levels in patients with MDD. Low erythrocyte EPA+DHA composition may also be associated with increased risk for suicide and cardiovascular disease, two primary causes of excess premature mortality in MDD. While controversial, dietary EPA+DHA supplementation may have antidepressant properties and may augment the therapeutic efficacy of antidepressant medications. Neuroimaging and rodent neurodevelopmental studies further suggest that low LCn-3 fatty acid intake or biostatus can recapitulate central pathophysiological features associated with MDD. Prospective findings suggest that low LCn-3 fatty acid biostatus increases risk for depressive symptoms in part by augmenting pro-inflammatory responsivity. When taken collectively, these translational findings provide a strong empirical foundation in support of dietary LCn-3 fatty acid deficiency as a modifiable risk factor for MDD. This review provides an overview of this translational evidence and then discusses future directions including strategies to translate this evidence into routine clinical screening and treatment algorithms.
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Affiliation(s)
- Robert K McNamara
- Department of Psychiatry and Behavioral Neuroscience, Division of Bipolar Disorders Research, University of Cincinnati College of Medicine, Cincinnati, OH 45219-0516
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36
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Strawn JR, Cotton S, Luberto CM, Patino LR, Stahl LA, Weber WA, Eliassen JC, Sears R, DelBello MP. Neural Function Before and After Mindfulness-Based Cognitive Therapy in Anxious Adolescents at Risk for Developing Bipolar Disorder. J Child Adolesc Psychopharmacol 2016; 26:372-9. [PMID: 26783833 PMCID: PMC4876535 DOI: 10.1089/cap.2015.0054] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We sought to evaluate the neurophysiology of mindfulness-based cognitive therapy for children (MBCT-C) in youth with generalized, social, and/or separation anxiety disorder who were at risk for developing bipolar disorder. METHODS Nine youth (mean age: 13 ± 2 years) with a generalized, social, and/or separation anxiety disorder and a parent with bipolar disorder completed functional magnetic resonance imaging (fMRI) while performing a continuous processing task with emotional and neutral distractors (CPT-END) prior to and following 12 weeks of MBCT-C. RESULTS MBCT-C was associated with increases in activation of the bilateral insula, lentiform nucleus, and thalamus, as well as the left anterior cingulate while viewing emotional stimuli during the CPT-END, and decreases in anxiety were correlated with change in activation in the bilateral insula and anterior cingulate during the viewing of emotional stimuli (p < 0.05, uncorrected; p < 0.005 corrected; cluster size, 37 voxels). CONCLUSIONS MBCT-C treatment in anxious youth with a familial history of bipolar disorder is associated with increased activation of brain structures that subserve interoception and the processing of internal stimuli-functions that are ostensibly improved by this treatment.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Cincinnati Children's Hospital Medical Center, Department of Psychiatry, Cincinnati, Ohio
| | - Sian Cotton
- Department of Family and Community Medicine, University of Cincinnati, Center for Imaging Research, University of Cincinnati, Cincinnati, Ohio
| | - Christina M. Luberto
- Department of Family and Community Medicine, University of Cincinnati, Center for Imaging Research, University of Cincinnati, Cincinnati, Ohio
| | - L. Rodrigo Patino
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Lauren A. Stahl
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Wade A. Weber
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - James C. Eliassen
- Department of Family and Community Medicine, University of Cincinnati, Center for Imaging Research, University of Cincinnati, Cincinnati, Ohio
| | - Richard Sears
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Melissa P. DelBello
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Cincinnati Children's Hospital Medical Center, Department of Psychiatry, Cincinnati, Ohio
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37
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Roy-Byrne P. Treatment-refractory anxiety; definition, risk factors, and treatment challenges. DIALOGUES IN CLINICAL NEUROSCIENCE 2016. [PMID: 26246793 PMCID: PMC4518702 DOI: 10.31887/dcns.2015.17.2/proybyrne] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to “pseudo-resistance” (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true “treatment resistance.” Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.
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Affiliation(s)
- Peter Roy-Byrne
- Professor of Psychiatry, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington, USA; Founding Partner, Psychiatric Medicine Associates, Seattle, Wash-ington, USA
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38
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Lotrich FE, Sears B, McNamara RK. Polyunsaturated fatty acids moderate the effect of poor sleep on depression risk. Prostaglandins Leukot Essent Fatty Acids 2016; 106:19-25. [PMID: 26598106 PMCID: PMC4775327 DOI: 10.1016/j.plefa.2015.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/09/2015] [Accepted: 10/10/2015] [Indexed: 12/25/2022]
Abstract
Although potentially modifiable risk factors for interferon-alpha (IFN-α)-associated depression (IFN-MDD) have been identified, it is not currently known how they interact to confer risk. In the present study we prospectively investigated interactions among poor sleep quality, high-stress, pre-existing depressive symptoms, and polyunsaturated fatty acid status. Non-depressed hepatitis C patients (n=104) were followed prospectively during IFN-α therapy. IFN-MDD occurs in 20-40% of patients and was diagnosed using the Structured Clinical Interview of DSM-IV (SCID-IV), with incidence examined using Cox regression. Baseline Pittsburgh Sleep Quality Inventory (PSQI), Perceived Stress Scale (PSS), Beck Depression Inventory (BDI), and a range of plasma long-chain fatty acid levels were measured (gas chromatography) - focusing on the ratio of arachidonic acid (AA) to docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) (AA/EPA+DHA). The AA/EPA+DHA ratio (Β=0.40 ± 0.16; p=0.006), PSQI (Β=0.12 ± 0.04; p=0.001), PSS (Β=0.07 ± 0.02; p<0.001), and baseline BDI (Β=0.05 ± 0.02; p<0.001) each individually predicted IFN-MDD incidence. In step-wise Cox regression eliminating non-significant variables, two interactions remained significantly predictive: PSQI*AA/EPA+DHA (p=0.008) and PSS*AA/EPA+DHA (p=0.01). Receiver Operator Curves (ROC) were used to examine the specificity and sensitivity of IFN-MDD prediction. When sleep was normal (PSQI<5), AA/EPA+DHA was strongly predictive of IFN-MDD (AUC=91 ± 6; p=0.002). For example, among those with AA/EPA+DHA less than the median (4.15), none with PSQI<5 developed depression. Conversely, neither PSS nor PSQI was statistically associated with depression risk in those with an elevated AA/EPA+DHA ratio. These data demonstrate that the AA/EPA+DHA ratio moderates the effect of poor sleep on risk for developing IFN-MDD and may have broader implications for predicting and preventing MDD associated with inflammation.
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Affiliation(s)
- Francis E Lotrich
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Barry Sears
- Inflammation Research Foundation, Marblehead, MA, United States
| | - Robert K McNamara
- Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Cornacchio D, Crum KI, Coxe S, Pincus DB, Comer JS. Irritability and Severity of Anxious Symptomatology Among Youth With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry 2016; 55:54-61. [PMID: 26703910 PMCID: PMC5340317 DOI: 10.1016/j.jaac.2015.10.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/23/2015] [Accepted: 10/26/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Most research on irritability and child psychopathology has focused on depressive disorders, bipolar disorder, and/or oppositional defiant disorder (ODD). Less is known about relationships between child anxiety and irritability and moderators of such associations. METHOD Structural equation modeling (SEM) was used to examine associations between anxiety severity and irritability in a large sample of treatment-seeking youth with anxiety disorders (N = 663, aged 7-19 years, mean = 12.25 years), after accounting for comorbid depressive disorders and ODD. Additional analyses examined whether associations were moderated by child gender, age, and generalized anxiety disorder (GAD) status. RESULTS There was a direct link between child anxiety and irritability even after accounting for comorbid depressive disorders and ODD. Links between child anxiety and irritability were robust across child gender and age. Furthermore, relationships between child anxiety and irritability were comparable across youth with and without GAD, suggesting that the anxiety-irritability link is relevant across child anxiety disorders and not confined to youth with GAD. CONCLUSION Findings add to an increasing body of evidence linking child irritability to a range of internalizing and externalizing psychopathologies, and suggest that child anxiety assessment should systematically incorporate irritability evaluations. Moreover, youth in clinical settings displaying irritability should be assessed for the presence of anxiety. Treatments for childhood anxiety may do well to incorporate new treatment modules as needed that specifically target problems of irritability.
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Affiliation(s)
- Danielle Cornacchio
- Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami
| | - Kathleen I. Crum
- Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami
| | - Stefany Coxe
- Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami
| | - Donna B. Pincus
- Center for Anxiety and Related Disorders (CARD), Boston University, Boston
| | - Jonathan S. Comer
- Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami
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40
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Belvederi Murri M, Prestia D, Mondelli V, Pariante C, Patti S, Olivieri B, Arzani C, Masotti M, Respino M, Antonioli M, Vassallo L, Serafini G, Perna G, Pompili M, Amore M. The HPA axis in bipolar disorder: Systematic review and meta-analysis. Psychoneuroendocrinology 2016; 63:327-42. [PMID: 26547798 DOI: 10.1016/j.psyneuen.2015.10.014] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/09/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To provide a quantitative and qualitative synthesis of the available evidence on the role of Hypothalamic-Pituitary-Adrenal (HPA) axis in the pathophysiology of Bipolar Disorder (BD). METHODS Meta-analysis and meta-regression of case-control studies examining the levels of cortisol, ACTH, CRH levels. Systematic review of stress reactivity, genetic, molecular and neuroimaging studies related to HPA axis activity in BD. RESULTS Forty-one studies were included in the meta-analyses. BD was associated with significantly increased levels of cortisol (basal and post-dexamethasone) and ACTH, but not of CRH. In the meta-regression, case-control differences in cortisol levels were positively associated with the manic phase (p=0.005) and participants' age (p=0.08), and negatively with antipsychotics use (p=0.001). Reviewed studies suggest that BD is associated with abnormalities of stress-related molecular pathways in several brain areas. Variants of HPA axis-related genes seem not associated with a direct risk of developing BD, but with different clinical presentations. Also, studies on unaffected relatives suggest that HPA axis dysregulation is not an endophenotype of BD, but seems related to environmental risk factors, such as childhood trauma. Progressive HPA axis dysfunction is a putative mechanism that might underlie the clinical and cognitive deterioration of patients with BD. CONCLUSIONS BD is associated with dysfunction of HPA axis activity, with important pathophysiological implications. Targeting HPA axis dysfunctions might be a novel strategy to improve the outcomes of BD.
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Affiliation(s)
- Martino Belvederi Murri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy; Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK.
| | - Davide Prestia
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Valeria Mondelli
- Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK
| | - Carmine Pariante
- Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, King's College London, London, UK
| | - Sara Patti
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Benedetta Olivieri
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Costanza Arzani
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Mattia Masotti
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Matteo Respino
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Marco Antonioli
- Section of Psychiatry, Department of Neuroscience and Infant-Maternal Science, University of Sassari, Italy
| | - Linda Vassallo
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
| | - Giampaolo Perna
- San Benedetto Hospital, Hermanas Hospitalarias, Department of Clinical Neuroscience, Albese con Cassano, Como, Italy
| | - Maurizio Pompili
- Suicide Prevention Center, Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Italy
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Salpekar JA, Joshi PT, Axelson DA, Reinblatt SP, Yenokyan G, Sanyal A, Walkup J, Vitiello B, Luby J, Wagner KD, Nusrat N, Riddle MA. Depression and Suicidality Outcomes in the Treatment of Early Age Mania Study. J Am Acad Child Adolesc Psychiatry 2015; 54:999-1007.e4. [PMID: 26598475 PMCID: PMC4660262 DOI: 10.1016/j.jaac.2015.09.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 09/03/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the efficacy of mood-stabilizing medications for depression and suicidality in pediatric bipolar disorder. METHOD The Treatment of Early Age Mania (TEAM) study is a multicenter, prospective, randomized, masked comparison of divalproex sodium (VAL), lithium carbonate (LI), and risperidone (RISP) in an 8-week parallel clinical trial. A total of 279 children and adolescents with DSM-IV diagnoses of bipolar I disorder, mixed or manic, aged 6 to 15 years were enrolled. The primary outcome measure was improvement on the Clinical Global Impression scale for depression (CGI-BP-I-D). Secondary outcome measures included the Children's Depression Rating Scale (CDRS-R) and suicidality status. Statistics included longitudinal analysis of outcomes using generalized linear mixed models with random intercept both for the complete data set and by using last observation carried forward. RESULTS CGI-BP-I-D ratings were better in the RISP group (60.7%) as compared to the LI (42.2%; p = .03) or VAL (35.0%; p = .003) groups from baseline to the end of the study. CDRS scores in all treatment groups improved equally by study end. In week 1, scores were lower with RISP compared to VAL (mean = 4.72, 95% CI = 2.67, 6.78), and compared to LI (mean = 3.63, 95% CI = 1.51, 5.74), although group differences were not present by the end of the study. Suicidality was infrequent, and there was no overall effect of treatment on suicidality ratings. CONCLUSION Depressive symptoms, present in the acutely manic or mixed phase of pediatric bipolar disorder, improved with all 3 medications, though RISP appeared to yield more rapid improvement than LI or VAL and was superior using a global categorical outcome. Clinical trial registration information-Study of Outcome and Safety of Lithium, Divalproex and Risperidone for Mania in Children and Adolescents (TEAM); http://clinicaltrials.gov; NCT00057681.
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Affiliation(s)
- Jay A. Salpekar
- Kennedy Krieger Institute and Johns Hopkins University School of Medicine, Baltimore
| | - Paramjit T. Joshi
- Children's National Medical Center and George Washington University, Washington, DC.,American Academy of Child and Adolescent Psychiatry (AACAP) and with the American Board of Psychiatry and Neurology (ABPN)
| | - David A. Axelson
- Nationwide Children's Hospital and The Ohio State University, Columbus
| | | | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center at Johns Hopkins Bloomberg School of Public Health
| | - Abanti Sanyal
- Johns Hopkins Biostatistics Center at Johns Hopkins Bloomberg School of Public Health
| | - John Walkup
- New York Presbyterian Hospital—Weill Cornell Medical College, New York
| | | | | | | | - Nasima Nusrat
- Children's National Medical Center and George Washington University, Washington, DC
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Park MH, Sanders E, Howe M, Singh M, Hallmayer J, Kim E, Chang K. Association of Anxiety Symptoms in Offspring of Bipolar Parents with Serotonin Transporter-Linked Polymorphic Region (5-HTTLPR) Genotype. J Child Adolesc Psychopharmacol 2015. [PMID: 26218602 PMCID: PMC4545526 DOI: 10.1089/cap.2014.0115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Offspring of parents with bipolar disorder (BD) have been shown to be at high risk for BD. Anxiety symptoms, even at subclinical levels, have been associated with increased risk for BD in these youth. The s-allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) has been implicated in the pathophysiology of both BD and anxiety disorders and has been associated with pharmacological treatment response and increased risk for antidepressant side effects. Therefore, we aimed to explore 1) whether anxiety symptoms in offspring of BD parents were associated with presence of the 5-HTTLPR s-allele and 2) whether anxiety symptoms in the offspring of BD parents according to the 5-HTTLPR genotypes are related to antianxiety medication status. METHODS A total of 64 offspring of BD parents (mean age: 13.7 years) and 51 healthy controls (HC) (mean age: 13.7 years) were compared genetically and on the Multidimensional Anxiety Scale for Children (MASC). RESULTS Offspring of BD parents showed higher levels of overall anxiety than did the HC group. Only antianxiety medication naïve offspring of BD parents were found to have an association between 5-HTTLPR genotypes and anxiety symptoms. The antianxiety medication naïve offspring of BD parents with the s-allele showed higher level of overall anxiety than offspring of BD parents with the l/l genotype. No significant differences in anxiety symptoms or their association with the 5-HTTLPR genotype were found in the HC group. CONCLUSIONS This study indicated that there may be an association between 5-HTTLPR genotypes and anxiety symptoms in offspring of BD parents, and that antianxiety medication status may affect anxiety symptoms in the offspring of BD patients according to genotype.
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Affiliation(s)
- Min-Hyeon Park
- Department of Psychiatry, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Seoul, St. Mary's Hospital, Korea
| | - Erica Sanders
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Meghan Howe
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Manpreet Singh
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Joachim Hallmayer
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Eunjoo Kim
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kiki Chang
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
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Roy-Byrne P. Treatment-refractory anxiety; definition, risk factors, and treatment challenges. DIALOGUES IN CLINICAL NEUROSCIENCE 2015. [PMID: 26246793 DOI: 10.31887/dcns.2015.17.2/probyrne] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to "pseudo-resistance" (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true "treatment resistance." Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.
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Affiliation(s)
- Peter Roy-Byrne
- Professor of Psychiatry, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington, USA; Founding Partner, Psychiatric Medicine Associates, Seattle, Wash-ington, USA
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Abstract
Bipolar disorder (BPD) essentially has its onset during adolescence and early adulthood. It has the capacity to be highly disruptive, dislocating individuals from their normal developmental trajectory and potentially causing significant long-term co-morbidity and chronicity. At a societal level the burden created is greater than schizophrenia. This is not helped by the very substantial delays in its diagnosis and appropriate treatment. Thus, there is a clear rationale for intervening earlier and at a younger age. However, the field of early intervention in BPD is in its infancy. One approach that conceptually provides a basis for early intervention is the Clinical Staging Model (used widely in general medicine). This article outlines how this model helps in an understanding of the emerging stages of BPD. It also summarises the interventions that might be appropriately introduced if a person progresses from an early to a late stage of the illness. Early intervention has a well-established record in psychotic disorders. If it can be realised for BPDs, then it may hold out hope of better outcomes for the next generation of young people at risk.
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Stratford HJ, Cooper MJ, Di Simplicio M, Blackwell SE, Holmes EA. Psychological therapy for anxiety in bipolar spectrum disorders: A systematic review. Clin Psychol Rev 2015; 35:19-34. [DOI: 10.1016/j.cpr.2014.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 10/29/2014] [Accepted: 11/01/2014] [Indexed: 01/12/2023]
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Amitai M, Chen A, Weizman A, Apter A. SSRI-Induced Activation Syndrome in Children and Adolescents—What Is Next? ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s40501-015-0034-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bhowmik D, Aparasu RR, Rajan SS, Sherer JT, Ochoa-Perez M, Chen H. Risk of manic switch associated with antidepressant therapy in pediatric bipolar depression. J Child Adolesc Psychopharmacol 2014; 24:551-61. [PMID: 25470655 DOI: 10.1089/cap.2014.0028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the risk of manic switch associated with antidepressants in Medicaid-enrolled pediatric patients with bipolar depression. METHODS This retrospective cohort study involved 2003-2007 Medicaid Analytic eXtract (MAX) data from four geographically diverse states. The study sample included children and adolescents (ages 6-18 years) who had received a diagnosis of bipolar disorder on two or more separate occasions or during a hospital discharge, followed by a diagnosis of depression. According to the pharmacotherapy received by these patients in the 30 days around the index bipolar depression diagnosis, patients were categorized into five mutually exclusive groups. Manic switch was defined as having received a diagnosis of mania within 6 weeks after the initiation of bipolar depression treatment. Relative risks of manic switch between antidepressant monotherapy/polytherapy and their alternatives were assessed using Cox proportional hazards model. The robustness of the conventional Cox proportional hazards model toward possible bias caused by unobserved confounders was tested using instrumental variable analysis, and the uncertainty regarding manic switch definition was tested by altering the duration of follow-up. RESULTS After applying all the selection criteria, 179 antidepressant monotherapy, 1047 second-generation antipsychotic (SGA) monotherapy, 570 mood stabilizer monotherapy, 445 antidepressant polytherapy, and 1906 SGA-mood stabilizer polytherapy users were identified. In Cox proportional hazard analyses, both antidepressant monotherapy and polytherapy exhibited higher risk of manic switch than their alternatives (antidepressant monotherapy vs. SGA monotherapy, hazard ratio [HR]=2.87 [95% CI: 1.10-7.49]; antidepressant monotherapy vs. mood stabilizer monotherapy, HR=1.41 [95% CI: 0.52-3.80); antidepressant polytherapy vs. SGA-mood stabilizer polytherapy, HR=1.61 [95% CI: 0.90-2.89]). However, only the comparison between antidepressant monotherapy and SGA monotherapy was statistically significant. The instrumental variable analysis did not detect endogeneity of the treatment variables. Extending the follow-up period from 6 weeks to 8 and 12 weeks generated findings consistent with the main analysis. CONCLUSIONS Study findings indicated a higher risk of manic switch associated with antidepressant monotherapy than with SGA monotherapy in pediatric patients with bipolar depression. The finding supported the clinical practice of cautious prescribing of antidepressants for brief periods.
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Affiliation(s)
- Debajyoti Bhowmik
- 1 Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston , Houston, Texas
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McIntyre RS, Correll C. Predicting and preventing bipolar disorder: the need to fundamentally advance the strategic approach. Bipolar Disord 2014; 16:451-4. [PMID: 25090934 DOI: 10.1111/bdi.12216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Able JA, Liu Y, Jandacek R, Rider T, Tso P, McNamara RK. Omega-3 fatty acid deficient male rats exhibit abnormal behavioral activation in the forced swim test following chronic fluoxetine treatment: association with altered 5-HT1A and alpha2A adrenergic receptor expression. J Psychiatr Res 2014; 50:42-50. [PMID: 24360505 PMCID: PMC3904789 DOI: 10.1016/j.jpsychires.2013.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 11/01/2013] [Accepted: 11/20/2013] [Indexed: 12/25/2022]
Abstract
Omega-3 fatty acid deficiency during development leads to enduing alterations in central monoamine neurotransmission in rat brain. Here we investigated the effects of omega-3 fatty acid deficiency on behavioral and neurochemical responses to chronic fluoxetine (FLX) treatment. Male rats were fed diets with (CON, n = 34) or without (DEF, n = 30) the omega-3 fatty acid precursor alpha-linolenic acid (ALA) during peri-adolescent development (P21-P90). A subset of CON (n = 14) and DEF (n = 12) rats were administered FLX (10 mg/kg/d) through their drinking water for 30 d beginning on P60. The forced swimming test (FST) was initiated on P90, and regional brain mRNA markers of serotonin and noradrenaline neurotransmission were determined. Dietary ALA depletion led to significant reductions in frontal cortex docosahexaenoic acid (DHA, 22:6n-3) composition in DEF (-26%, p = 0.0001) and DEF + FLX (-32%, p = 0.0001) rats. Plasma FLX and norfluoxetine concentrations did not different between FLX-treated DEF and CON rats. During the 15-min FST pretest, DEF + FLX rats exhibited significantly greater climbing behavior compared with CON + FLX rats. During the 5-min test trial, FLX treatment reduced immobility and increased swimming in CON and DEF rats, and only DEF + FLX rats exhibited significant elevations in climbing behavior. DEF + FLX rats exhibited greater midbrain, and lower frontal cortex, 5-HT1A mRNA expression compared with all groups including CON + FLX rats. DEF + FLX rats also exhibited greater midbrain alpha2A adrenergic receptor mRNA expression which was positively correlated with climbing behavior in the FST. These preclinical data demonstrate that low omega-3 fatty acid status leads to abnormal behavioral and neurochemical responses to chronic FLX treatment in male rats.
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Affiliation(s)
- Jessica A. Able
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Yanhong Liu
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH 45267
| | - Ronald Jandacek
- Department of Pathology, University of Cincinnati, Cincinnati OH 45237
| | - Therese Rider
- Department of Pathology, University of Cincinnati, Cincinnati OH 45237
| | - Patrick Tso
- Department of Pathology, University of Cincinnati, Cincinnati OH 45237
| | - Robert K. McNamara
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, OH 45267,Corresponding author: Robert K. McNamara, Ph.D. Department of Psychiatry and Behavioral Neuroscience University of Cincinnati College of Medicine 260 Stetson Street Cincinnati, OH 45219-0516 PH: 513-558-5601 FAX: 513-558-4805
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