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Cai L, Chen G, Yang H, Bai Y. Efficacy and safety profiles of mood stabilizers and antipsychotics for bipolar depression: a systematic review. Int Clin Psychopharmacol 2023:00004850-990000000-00058. [PMID: 36947416 DOI: 10.1097/yic.0000000000000449] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The whole picture of psychotropics for bipolar depression (BPD) remains unclear. This review compares the differences in efficacy and safety profiles among common psychotropics for BPD. MEDLINE, EMBASE, and PsycINFO were searched for proper studies. The changes in the depressive rating scale, remission/response rates, nervous system adverse events (NSAEs), gastrointestinal adverse events (GIAEs), metabolic parameters, and prolactin were compared between medication and placebo or among medications with the Cohen's d or number needed to treat/harm. The search provided 10 psychotropics for comparison. Atypical antipsychotics (AAPs) were superior to lithium and lamotrigine at alleviating acute depressive symptoms. Lithium was more likely to induce dry mouth and nausea. Cariprazine and aripiprazole seemed to be associated with an increased risk of akathisia and upper GIAEs. Lurasidone was associated with an increased risk of developing akathisia and hyperprolactinemia. Olanzapine, olanzapine-fluoxetine combination (OFC), and quetiapine were associated with an increased risk of NSAEs, metabolic risk, dry mouth, and constipation. Cariprazine, lurasidone, OFC, or quetiapine was optimal monotherapy for BPD. Further studies are needed to assess the efficacy and safety of lamotrigine for treating BPD. Adverse events varied widely across different drug types due to variations in psychopharmacological mechanisms, dosages, titration, and ethnicities.
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Affiliation(s)
| | - Guanjie Chen
- Teaching Management Office, Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen, Guangdong, China
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Zhang L, Zhang H, Lv LX, Tan Q, Xu X, Hu J, Zi L, Cooper J, Phansalkar A, Wang G. A randomised, double-blind, placebo-controlled study to evaluate the safety and efficacy of lamotrigine in the maintenance treatment of Chinese adult patients with bipolar I disorder. Int J Bipolar Disord 2022; 10:20. [PMID: 35909213 PMCID: PMC9339436 DOI: 10.1186/s40345-022-00266-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lamotrigine is approved as a maintenance therapy for bipolar I disorder in many countries, including China in 2021. This study evaluated the efficacy and safety of lamotrigine in controlling relapse and/or recurrence of mood episodes in Chinese patients with bipolar I disorder. Methods Patients aged ≥ 18 years with bipolar I disorder who met response criteria (Clinical Global Impression–Severity [CGI-S] score of ≤ 3 for ≥ 4 consecutive weeks) during treatment with lamotrigine in a 6–16 week open-label (OL) phase, and who were maintained for ≥ 1 week on lamotrigine 200 mg/day monotherapy, were randomised (1:1) to continue receiving lamotrigine 200 mg/day or switch to placebo in a 36-week randomised double-blind (RD) phase. The primary efficacy outcome measure was time from entry into the RD phase to intervention for relapse and/or recurrence of a mood episode (TIME). Post hoc analyses assessed the impact of OL baseline mood severity on TIME. Safety assessments were conducted throughout the study. Results Of 420 patients treated in the OL phase, 264 were randomised to receive lamotrigine (n = 131) or placebo (n = 133). Overall, 112 patients had an intervention for relapse and/or recurrence of a mood episode (lamotrigine, n = 50/130 [38.5%]; placebo, n = 62/133 [46.6%]), with no significant difference in TIME between groups (adjusted hazard ratio [95% confidence interval (CI)] 0.93 [0.64, 1.35]; p = 0.701). Post hoc analyses indicated a significant difference in TIME, favouring lamotrigine over placebo, for patients with baseline CGI-S score ≥ 4 (hazard ratio [95% CI] 0.52 [0.30, 0.89]; p = 0.018) and with baseline Hamilton Depression Rating Scale ≥ 18 or Young Mania Rating Scale ≥ 10 (0.44 [hazard ratio [95% CI] 0.25, 0.78]; p = 0.005). Lamotrigine was well tolerated with no new safety signals. Conclusions Lamotrigine was not significantly superior to placebo in preventing relapse and/or recurrence of mood episodes in this study of Chinese patients with bipolar I disorder but post hoc analyses suggested a therapeutic benefit in patients with moderate/severe mood symptoms at baseline. The discrepancy between these findings and the positive findings of the pivotal studies may be attributable to the symptom severity of the bipolar patients recruited, a high dropout rate, and the comparatively short duration of the RD phase rather than race/ethnicity differences. Clinical trial registration ClinicalTrial.gov Identifier NCT01602510; 21st May 2012; https://clinicaltrials.gov/ct2/show/NCT01602510. Supplementary Information The online version contains supplementary material available at 10.1186/s40345-022-00266-4.
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Affiliation(s)
- Ling Zhang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital , Capital Medical University, 100088, Beijing, China
| | - Honggeng Zhang
- Department of Psychiatry, Brains Hospital of Hunan Province, Changsha, China
| | - Lu-Xian Lv
- Department of Psychiatry, Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, People's Republic of China
| | - Qingrong Tan
- Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiufeng Xu
- Department of Psychiatry, First Affiliated Hospital of Kunming Medical University, Kunming, People's Republic of China
| | - Jian Hu
- The First Affiliated Hospital of Harbin Medical University, Nangang, Harbin, People's Republic of China
| | - Lu Zi
- GlaxoSmithKline R&D Co., Ltd, Shanghai, China
| | - James Cooper
- GlaxoSmithKline R&D Ltd, Brentford, Middlesex, UK
| | - Abhay Phansalkar
- GlaxoSmithKline India Global Services Private Ltd, Mumbai, India
| | - Gang Wang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital , Capital Medical University, 100088, Beijing, China. .,Advanced Innovation Center for Human Brain Protection , Capital Medical University , 100069, Beijing, China.
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Hu Y, Zhang H, Wang H, Wang C, Kung S, Li C. Adjunctive antidepressants for the acute treatment of bipolar depression: A systematic review and meta-analysis. Psychiatry Res 2022; 311:114468. [PMID: 35248807 DOI: 10.1016/j.psychres.2022.114468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND The depressive phase of bipolar disorder causes significant functional impairment and disease burden. The efficacy and safety of antidepressants in the treatment of bipolar depression has long been a subject of debate. AIMS To synthesize evidence of the effectiveness, risk of mood switching, and tolerability of adjunctive antidepressants in acute bipolar depression compared to using mood stabilizers or antipsychotics alone. METHOD Multiple databases were searched for randomized controlled trials, including open label and double-blinded, for patients ages 18 or older with acute bipolar depression, comparing efficacy and adverse events in those who used adjunctive antidepressants versus without. Risk of bias and outcomes were assessed using the Cochrane Risk of Bias Tool. This study has PROSPERO registration CRD42016037701. RESULTS Nineteen studies met inclusion criteria. Adjunctive antidepressants showed no significant effect on improving response rate (RR=1.10, 95%CI: 0.98-1.23). Subgroup analysis showed that adjunctive antidepressants with antipsychotics had a small but significantly better response rate compared to antipsychotics alone, which was not seen with adjunctive antidepressants with mood stabilizers. However, that finding was limited by studies predominantly using olanzapine as the antipsychotic medication. Adjunctive antidepressants had no clinically significant impact (but a small statistically significant impact) on improving depressive symptoms (SMD=-0.13, 95%CI: -0.24 to -0.02). There was no association with increased mood switch (RR=0.97, 95%CI: 0.68-1.39) and there was an association with lower dropout due to inefficacy (RR=0.66, 95%CI: 0.45∼0.98). CONCLUSIONS There is no evidence of adjunctive antidepressants clinically improving response rate or depressive symptoms for acute bipolar depression. They are well tolerated, without increasing the risk of short-term mood switch.
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Affiliation(s)
- Yuliang Hu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Huijuan Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongyan Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chris Wang
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon Kung
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chunbo Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Brain Science and Technology Research Center, Shanghai Jiao Tong University, Shanghai, China; CAS Center for Excellence in Brain Science and Intelligence Technology (CEBSIT), Chinese Academy of Science, China; Institute of Psychology and Behavioral Science, Shanghai Jiao Tong University, Shanghai, China.
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Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S. Lamotrigine in the maintenance treatment of bipolar disorder. Cochrane Database Syst Rev 2021; 9:CD013575. [PMID: 34523118 PMCID: PMC8440301 DOI: 10.1002/14651858.cd013575.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bipolar disorder is a chronic mental disorder with repetitive mania/hypomania as well as depressive episodes, which eventually results in marked impairment in overall functioning and health-related quality of life. A worldwide prevalence rate of 2.4% has been reported. The risk of suicide is higher in people with bipolar disorder than those with other mental disorders. Therefore, effective management of bipolar disorder in the maintenance period is warranted to minimize the risk of relapse or recurrence. Although lithium has been the standard treatment of bipolar disorder for many years, it is associated with adverse effects and teratogenicity. Lamotrigine is approved to be expected for prevention of recurrence for the maintenance treatment of bipolar disorder. In addition, lamotrigine is as effective as lithium. Therefore, we performed a systematic review to confirm the efficacy and safety of lamotrigine in the maintenance treatment of bipolar disorder. OBJECTIVES To assess the efficacy and tolerability of lamotrigine in the maintenance treatment of bipolar disorder. SEARCH METHODS We searched Ovid MEDLINE, Embase, PsycINFO, the Cochrane Common Mental Disorders Group's Specialized Register (CCMDCTR) and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 21 May 2021. We also searched international trial registries and contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials enrolling adults with bipolar disorder who were treated with lamotrigine, placebo or lithium. DATA COLLECTION AND ANALYSIS Two reviews authors independently checked the eligibility of studies and extracted data using a standardized form. Data extracted included study characteristics, participant characteristics, intervention details, settings, and outcome measures in the term of efficacy and tolerability. Study information were then entered into RevMan web. MAIN RESULTS We included 11 studies with a total of 2314 participants in this review; 1146 were randomized to lamotrigine, 869 were randomized to placebo and, 299 to lithium. We rated all studies as having an unclear risk of bias in at least one domain of Cochrane's tool for assessing risk of bias, with the most commonly observed weakness being selection bias (random sequence generation and allocation concealment). We judged five studies to be at a high risk of detection bias (blinding of outcome assessment). These potential biases pose as major threat to the validity of the included studies in this review. Outcomes of efficacy showed a possible advantage of lamotrigine over placebo. The estimated risk ratio (RR) for recurrence of manic symptom at one year as measured by the Young Mania Rating Scale (YMRS) was 0.67, (95% confidence interval (CI) 0.51 to 0.87; 3 studies, 663 participants; low-certainty evidence) in favor of lamotrigine. The RR of clinical worsening with the need for additional psychotropic treatment (RR 0.82, 95% CI 0.70 to 0.98; 4 studies, 756 participants) based on moderate-certainty evidence. The possible benefits of lamotrigine were also seen for the outcome of treatment withdrawal due to any reason at 6-12 months after treatment (RR 0.88, 95% CI 0.78 to 0.99; 4 studies, 700 participants; moderate-certainty evidence). Regarding tolerability, our analyses showed that the incidence rates of adverse effects were similar between the lamotrigine group and the placebo group (short-term effect: RR 1.07, 95% CI 0.81 to 1.42; 5 studies, 1138 participants; very low-certainty evidence; long-term effect: RR 0.97, 95% CI 0.77 to 1.23; 4 studies, 756 participants; moderate-certainty evidence). In the comparison between lamotrigine and lithium, efficacy was similar between groups except for recurrence of mania episode at one year. Recurrence of manic symptoms was higher in the lamotrigine group than that of the lithium group (RR 2.13, 95% CI 1.32 to 3.44; 3 studies, 602 participants; moderate-certainty evidence). Analysis of adverse effects at 6-12 months showed that a lower proportion of participants experienced at least one adverse effect when treated with lamotrigine compared to lithium (RR 0.70, 95% CI 0.51 to 0.96; 4 studies, 691 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Low- to moderate-certainty evidence collectively suggests that lamotrigine may be superior to placebo as a treatment modality for bipolar disorder. In comparison to lithium, people with bipolar disorder seem to tolerate lamotrigine better in the long run; however, the demonstrated efficacy in the maintenance of bipolar disorder was similar between the two groups.
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Affiliation(s)
| | - Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Kita-Ku, Japan
| | - Norio Watanabe
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
| | - Takashi Fujiwara
- Department of Otolaryngology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shinji Sakamoto
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Peters EM, Lodhi RJ, Zhang Y, Li H, Balbuena L. Lamotrigine for acute bipolar depression: An exploratory item-level analysis. Brain Behav 2021; 11:e2222. [PMID: 34124858 PMCID: PMC8413740 DOI: 10.1002/brb3.2222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/30/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Lamotrigine is used to treat bipolar depression despite inconsistent evidence. Here we present the results of an exploratory item-level analysis of pooled data from five randomized placebo-controlled trials of lamotrigine for acute bipolar depression. The goal was to determine if certain depression scale items were more responsive to lamotrigine treatment. METHODS The pooled sample contained 1072 adult outpatients treated for up to 7-10 weeks. Depressive symptoms were measured with the Hamilton Depression Rating Scale and the Montgomery-Åsberg Depression Rating Scale. Change scores on individual scale items were compared between treatment groups. RESULTS There were statistically significant effects on items assessing depressed mood/sadness, lack of interest/anhedonia, pessimism/guilt, and anergia/fatigue, on both scales. However, there was marked variation in the baseline symptom prevalence, and items with higher scores at baseline tended to have larger and statistically significant treatment effects. CONCLUSIONS The results suggested a significant treatment effect on core symptoms of depression. A floor effect appeared to limit the sensitivity of other scale items. Given the exploratory nature of the analysis, firm conclusions cannot be drawn, although the results were consistent with past research. Relying on total depression scale sum scores over targeted assessments of core depressive symptoms may have impeded signal detection in the original trials.
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Affiliation(s)
- Evyn M Peters
- Department of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rohit J Lodhi
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Yanbo Zhang
- Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada
| | - Hua Li
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lloyd Balbuena
- Department of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Vandevelde A, Benbrika S, Madigand J, Dollfus S. Common mechanisms involved in manic switch and pain relief induced by lamotrigine: A case report and a literature review. L'ENCEPHALE 2021; 47:235-237. [PMID: 33648755 DOI: 10.1016/j.encep.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 11/15/2022]
Affiliation(s)
- A Vandevelde
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France; UNICAEN, ISTS EA 7466, GIP Cyceron, Normandie Université, boulevard Henri-Becquerel, BP5229, 14074 Caen cedex, France; UNICAEN, UFR de médecine (Medical School), Normandie Université, 14000 Caen, France
| | - S Benbrika
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France
| | - J Madigand
- CHU de Caen, Service de psychiatrie de l'enfant et de l'adolescent, 14000 Caen, France; Inserm, U1077, neuropsychologie et imagerie de la mémoire humaine, UNICAEN, Normandie Université, 14000 Caen, France
| | - S Dollfus
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France; UNICAEN, ISTS EA 7466, GIP Cyceron, Normandie Université, boulevard Henri-Becquerel, BP5229, 14074 Caen cedex, France; UNICAEN, UFR de médecine (Medical School), Normandie Université, 14000 Caen, France.
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Bahji A, Ermacora D, Stephenson C, Hawken ER, Vazquez G. Comparative Efficacy and Tolerability of Adjunctive Pharmacotherapies for Acute Bipolar Depression: A Systematic Review and Network Meta-analysis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:274-288. [PMID: 33174452 PMCID: PMC7958200 DOI: 10.1177/0706743720970857] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We investigated the comparative efficacy and tolerability of augmentation strategies for bipolar depression. DATA SOURCES We conducted a systematic review and network meta-analysis of 8 electronic databases for double-blind, randomized controlled trials of adjunctive pharmacotherapies for acute bipolar depression. DATA EXTRACTION AND SYNTHESIS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and applied the Cochrane risk of bias tool for study quality appraisal. Two reviewers independently abstracted data. We resolved all discrepancies by consensus. MAIN OUTCOMES AND MEASURES Primary outcomes were response and completion of treatment. We estimated summary rate ratios (RRs) and standardized mean differences (SMDs) relative to placebo controls using frequentist random-effects network meta-analysis. RESULTS We identified 69 trials meeting eligibility criteria (8,007 participants, 42.8 years, 58.0% female). Adjunctive racemic intravenous ketamine, coenzyme Q10, pramipexole, fluoxetine, and lamotrigine were more effective than placebo. Summary RRs for response ranged between 1.51 (95% confidence interval [CI], 1.11 to 2.06) for fluoxetine and 12.49 (95% CI, 3.06 to 50.93) for racemic intravenous ketamine. For completion of treatment, risperidone appeared less tolerable than placebo (RR = 0.59; 95% CI, 0.38 to 0.94), while fluoxetine seemed more tolerable than placebo (RR = 1.13; 95% CI, 1.02 to 1.24). None of the investigated agents were associated with increased treatment-emergent mood switches. CONCLUSIONS AND RELEVANCE The evidence for augmentation strategies in bipolar depression is limited to a handful of agents. Fluoxetine appeared to have the most consistent evidence base for both efficacy and tolerability. There remains a need for additional research exploring novel treatment strategies for bipolar depression, particularly head-to-head studies.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Alberta, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Anees Bahji, MD, Addiction Psychiatry Fellow, Department of Psychiatry, University of Calgary, 2500 University Drive NW., Calgary, Alberta, Canada T2N 1N4. Emails: ;
| | - Dylan Ermacora
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Callum Stephenson
- School of Kinesiology and Health Studies, Queen’s University, Kingston, Ontario, Canada
| | - Emily R. Hawken
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Providence Care Hospital, Kingston, Ontario, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada
- Providence Care Hospital, Kingston, Ontario, Canada
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Haggarty SJ, Karmacharya R, Perlis RH. Advances toward precision medicine for bipolar disorder: mechanisms & molecules. Mol Psychiatry 2021; 26:168-185. [PMID: 32636474 DOI: 10.1038/s41380-020-0831-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/23/2020] [Accepted: 06/19/2020] [Indexed: 01/10/2023]
Abstract
Given its chronicity, contribution to disability and morbidity, and prevalence of more than 2%, the effective treatment, and prevention of bipolar disorder represents an area of significant unmet medical need. While more than half a century has passed since the introduction of lithium into widespread use at the birth of modern psychopharmacology, that medication remains a mainstay for the acute treatment and prevention of recurrent mania/hypomania and depression that characterize bipolar disorder. However, the continued limited understanding of how lithium modulates affective behavior and lack of validated cellular and animal models have resulted in obstacles to discovering more effective mood stabilizers with fewer adverse side effects. In particular, while there has been progress in developing new pharmacotherapy for mania, developing effective treatments for acute bipolar depression remain inadequate. Recent large-scale human genetic studies have confirmed the complex, polygenic nature of the risk architecture of bipolar disorder, and its overlap with other major neuropsychiatric disorders. Such discoveries have begun to shed light on the pathophysiology of bipolar disorder. Coupled with broader advances in human neurobiology, neuropharmacology, noninvasive neuromodulation, and clinical trial design, we can envision novel therapeutic strategies informed by defined molecular mechanisms and neural circuits and targeted to the root cause of the pathophysiology. Here, we review recent advances toward the goal of better treatments for bipolar disorder, and we outline major challenges for the field of translational neuroscience that necessitate continued focus on fundamental research and discovery.
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Affiliation(s)
- Stephen J Haggarty
- Chemical Neurobiology Laboratory, Center for Genomic Medicine, Massachusetts General Hospital, Departments of Psychiatry & Neurology, Harvard Medical School, 185 Cambridge Street, Boston, MA, USA.
| | - Rakesh Karmacharya
- Center for Genomic Medicine, Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School Boston, Boston, MA, USA.,Schizophrenia and Bipolar Disorder Program, McLean Hospital, Belmont, MA, USA
| | - Roy H Perlis
- Center for Quantitative Health, Center for Genomic Medicine and Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Melancholic Features in Bipolar Depression and Response to Lamotrigine: A Pooled Analysis of Five Randomized Placebo-Controlled Trials. J Clin Psychopharmacol 2021; 41:315-319. [PMID: 33779579 PMCID: PMC8083162 DOI: 10.1097/jcp.0000000000001393] [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] [Indexed: 12/30/2022]
Abstract
BACKGROUND A pilot study suggested lamotrigine may be more effective for bipolar depression with melancholic features. We tested this hypothesis in a pooled analysis of 5 randomized double-blind placebo-controlled trials of lamotrigine for acute bipolar depression. METHODS The pooled sample consisted of 1072 adult outpatients. Depressive symptoms were assessed for 7 to 10 weeks with the Hamilton Depression Rating Scale and the Montgomery-Åsberg Depression Rating Scale. The outcome measure was end-trial response (score reduction ≥ 50%). Melancholic features were assessed with both the Structured Clinical Interview for DSM-IV and baseline depression scale items, according to DSM criteria. RESULTS The item-based melancholic specifier was associated with numerically larger treatment effects, although subgroup-treatment interactions in logistic regression models did not reach statistical significance. The small subgroup of patients with severe psychomotor retardation also appeared to benefit from lamotrigine. However, the Structured Clinical Interview for DSM-IV melancholic specifier was not associated with larger treatment effects. Baseline depression severity was inconsistently associated with response, depending on which scale was used to define severity. The 2 melancholia variables had poor agreement despite having similar prevalences. CONCLUSIONS Our results do not clearly support the original hypothesis but do reinforce the importance of replicating secondary analyses of clinical trials with additional data.
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Besag FMC, Vasey MJ, Sharma AN, Lam ICH. Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan: a systematic review. Ther Adv Psychopharmacol 2021; 11:20451253211045870. [PMID: 34646439 PMCID: PMC8504232 DOI: 10.1177/20451253211045870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/25/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Bipolar disorder (BD) is a cyclic mood disorder characterised by alternating episodes of mania/hypomania and depression interspersed with euthymic periods. Lamotrigine (LTG) demonstrated some mood improvement in patients treated for epilepsy, leading to clinical studies in patients with BD and its eventual introduction as maintenance therapy for the prevention of depressive relapse in euthymic patients. Most current clinical guidelines include LTG as a recommended treatment option for the maintenance phase in adult BD, consistent with its global licencing status. AIMS To review the evidence for the efficacy and safety of LTG in the treatment of all phases of BD. METHODS PubMed was searched for double-blind, randomised, placebo-controlled trials using the keywords: LTG, Lamictal, 'bipolar disorder', 'bipolar affective disorder', 'bipolar I', 'bipolar II', cyclothymia, mania, manic, depression, depressive, 'randomised controlled trial', 'randomised trial', RCT and 'placebo-controlled' and corresponding MeSH terms. Eligible articles published in English were reviewed. RESULTS Thirteen studies were identified. The strongest evidence supports utility in the prevention of recurrence and relapse, particularly depressive relapse, in stabilised patients. Some evidence suggests efficacy in acute bipolar depression, but findings are inconsistent. There is little or no strong evidence in support of efficacy in acute mania, unipolar depression, or rapid-cycling BD. Few controlled trials have evaluated LTG in bipolar II or in paediatric patients. Indications for safety, tolerability and patient acceptability are relatively favourable, provided there is slow dose escalation to reduce the probability of skin rash. CONCLUSION On the balance of efficacy and tolerability, LTG might be considered a first-line drug for BD, except for acute manic episodes or where rapid symptom control is required. In terms of efficacy alone, however, the evidence favours other medications.
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Affiliation(s)
- Frank M C Besag
- East London NHS Foundation Trust, 9 Rush Court, Bedford MK40 3JT, UK
| | | | - Aditya N Sharma
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ivan C H Lam
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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11
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Acceptability of Acute and Maintenance Pharmacotherapy of Bipolar Disorder: A Systematic Review of Randomized, Double-Blind, Placebo-Controlled Clinical Trials. J Clin Psychopharmacol 2020; 40:167-179. [PMID: 32134852 DOI: 10.1097/jcp.0000000000001169] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE/BACKGROUND The aim of the study was to estimate and rank the risk for the discontinuation due to adverse events (DAEs), 7% or more weight gain (WG), and somnolence during the acute and maintenance treatment of bipolar disorder with a mood stabilizer or an antipsychotic monotherapy. METHODS/PROCEDURES The search of MEDLINE, EMBASE, PsycINFO, and clinicaltrials.gov from the inception to December 31, 2018, provided 32 studies in mania, 16 in bipolar depression, and 13 in maintenance. Data of DAEs, WG, and somnolence from each study were extracted. The risk for these variables of an active treatment relative to placebo was estimated with a number needed to harm (NNH) as a single study and pooled sample. FINDINGS/RESULTS For DAEs, pooled NNH ranged from 19 with carbamazepine to -21 with quetiapine-XR in mania, 11 with quetiapine-IR 600 mg/d to -37 with olanzapine/fluoxetine combination in bipolar depression, and 5 with lithium to -8 with asenapine in maintenance. For WG, pooled NNH ranged from 9 with olanzapine to -78 with aripiprazole in mania, 5 with olanzapine to -112 with lithium in bipolar depression, and 4 with olanzapine to 126 with asenapine in maintenance. For somnolence, pooled NNH was from 5 with carbamazepine to 23 with cariprazine in mania, 3 with quetiapine-XR 300 mg/d to 79 with lurasidone in bipolar depression, and 11 with olanzapine to -49 with aripiprazole in maintenance. IMPLICATIONS/CONCLUSIONS All medications studied in bipolar disorder were relatively well tolerated during different phases of treatment; however, the risk for short- and long-term WG and somnolence varied widely among included psychotropics.
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Wang D, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on bipolar depression. Bipolar Disord 2020; 22:472-489. [PMID: 31650675 DOI: 10.1111/bdi.12860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Psychopharmacology Algorithm Project at the Harvard South Shore Program (PAPHSS) published algorithms for bipolar depression in 1999 and 2010. Developments over the past 9 years suggest that another update is needed. METHODS The 2010 algorithm and associated references were reevaluated. A literature search was conducted on PubMed for recent studies and review articles to see what changes in the recommendations were justified. Exceptions to the main algorithm for special patient populations, including those with attention-deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), substance use disorders, anxiety disorders, and women of childbearing potential, and those with common medical comorbidities were considered. RESULTS Electroconvulsive therapy (ECT) is still the first-line option for patients in need of urgent treatment. Five medications are recommended for early usage in acute bipolar depression, singly or in combinations when monotherapy fails, the order to be determined by considerations such as side effect vulnerability and patient preference. The five are lamotrigine, lurasidone, lithium, quetiapine, and cariprazine. After trials of these, possible options include antidepressants (bupropion and selective serotonin reuptake inhibitors are preferred) or valproate (very small evidence-base). In bipolar II depression, the support for antidepressants is a little stronger but depression with mixed features and rapid cycling would usually lead to further postponement of antidepressants. Olanzapine+fluoxetine, though Food and Drug Administration (FDA) approved for bipolar depression, is not considered until beyond this point, due to metabolic side effects. The algorithm concludes with a table of other possible treatments that have some evidence. CONCLUSIONS This revision incorporates the latest FDA-approved treatments (lurasidone and cariprazine) and important new studies and organizes the evidence systematically.
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Affiliation(s)
- Dana Wang
- Rivia Medical PLLC, New York, NY, USA
| | - David N Osser
- Department of Psychiatry, Harvard Medical School, VA Boston Healthcare System, Brockton Division, Brockton, MA, USA
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Earley WR, Burgess MV, Khan B, Rekeda L, Suppes T, Tohen M, Calabrese JR. Efficacy and safety of cariprazine in bipolar I depression: A double-blind, placebo-controlled phase 3 study. Bipolar Disord 2020; 22:372-384. [PMID: 31628698 PMCID: PMC7318333 DOI: 10.1111/bdi.12852] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the efficacy, safety, and tolerability of cariprazine in the treatment of the depressed phase of bipolar I disorder in adults (NCT02670538). METHODS In this phase 3 double-blind placebo-controlled study, adult patients with bipolar I disorder according to the Diagnostic and Statistical Manual - 5th Edition criteria and a current depressive episode were randomized to placebo (n = 167), cariprazine 1.5 mg/day (n = 168) or cariprazine 3.0 mg/day (n = 158). Efficacy parameters were changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) total scores (primary) and Clinical Global Impressions - Severity (CGI-S) scores (secondary) from baseline to Week 6 compared to placebo. A mixed-model for repeated measures was used to estimate the least-squares mean differences (LSMD); P-values were adjusted for multiplicity. Adverse events (AEs), laboratory results, vital signs, and suicide risk were monitored. RESULTS Cariprazine 1.5 mg/day significantly reduced depressive symptoms on the primary (MADRS LSMD = -2.5; adjusted P = .0417) and secondary (CGI-S LSMD = -0.3; adjusted P = .0417) efficacy parameters vs placebo; differences were not statistically significant for cariprazine 3.0 mg/day. Common treatment-emergent AEs (≥5% in either cariprazine group and at least twice the incidence of placebo) were akathisia, restlessness, nausea, and fatigue. Mean metabolic parameter changes were low and generally comparable among groups; mean weight increases were ≤0.5 kg for all groups. CONCLUSIONS Cariprazine 1.5 mg/day significantly reduced depressive symptoms in adults with bipolar I depression compared to placebo, but differences were not significant for cariprazine 3.0 mg/day. The safety and tolerability profiles were similar to previous studies of cariprazine.
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Affiliation(s)
| | | | - Barbara Khan
- Department of Clinical DevelopmentAllergan plcMadisonNJUSA
| | | | - Trisha Suppes
- Department of Psychiatry and Behavioral SciencesStanford University School of Medicine and V.A. Palo Alto Health Care SystemPalo AltoCAUSA
| | - Mauricio Tohen
- Department of Psychiatry and Behavioral SciencesUniversity of New MexicoAlbuquerqueNMUSA
| | - Joseph R. Calabrese
- Department of PsychiatryCase Western Reserve School of MedicineClevelandOHUSA
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Bahji A, Ermacora D, Stephenson C, Hawken ER, Vazquez G. Comparative efficacy and tolerability of pharmacological treatments for the treatment of acute bipolar depression: A systematic review and network meta-analysis. J Affect Disord 2020; 269:154-184. [PMID: 32339131 DOI: 10.1016/j.jad.2020.03.030] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We investigated the comparative efficacy and tolerability of pharmacological treatment strategies for the treatment of acute bipolar depression. DATA SOURCES A systematic review and network meta-analysis was conducted by searching eight registries for published and unpublished, double-blind, randomized controlled trials of pharmacotherapies for the acute treatment of bipolar depression. DATA EXTRACTION AND SYNTHESIS PRISMA guidelines were used for abstracting data, while the Cochrane Risk of Bias Tool was used to assess data quality. Data extraction was done independently by two reviewers, with discrepancies resolved by consensus. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES Primary outcomes were efficacy (response and remission rate) and acceptability (completion of treatment and dropouts due to adverse events). Summary odds ratios (ORs) were estimated using pairwise and network meta-analysis with random effects. RESULTS Identified citations (4,404) included 50 trials comprising 11,448 participants. Escitalopram, phenelzine, moclobemide, carbamazepine, sertraline, lithium, paroxetine, aripiprazole, gabapentin and ziprasidone appear to be ineffective as compared to placebo in treatment of bipolar depression. Divalproex, olanzapine/fluoxetine, olanzapine, quetiapine, cariprazine, and lamotrigine, appear to be effective as compared to placebo in treatment of bipolar depression according to the network meta-analysis. Aripiprazole showed higher discontinuation rates versus placebo due to the appearance of any adverse event. Quetiapine was better than placebo at reducing treatment-emergent affective switches. For Bipolar I Disorder, cariprazine, fluoxetine, imipramine, lamotrigine, lurasidone, olanzapine-fluoxetine, and olanzapine were significantly better than placebo at response, while fluoxetine, imipramine, cariprazine, lurasidone, olanzapine-fluoxetine, and olanzapine were significantly better than placebo at remission. CONCLUSIONS AND RELEVANCE These results could serve evidence-based practice and inform patients, physicians, guideline developers, and policymakers on the relative benefits of the different antidepressants, antipsychotics, and mood-stabilizing agents for the treatment of bipolar depression. REGISTRATION PROSPERO (CRD42019122172).
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Dylan Ermacora
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Callum Stephenson
- School of Kinesiology and Health Studies, Queen's University, Kingston, Ontario, Canada
| | - Emily R Hawken
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada; Providence Care Hospital, Kingston, Ontario, Canada
| | - Gustavo Vazquez
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
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Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S. Lamotrigine in the maintenance treatment of bipolar disorder. Hippokratia 2020. [DOI: 10.1002/14651858.cd013575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Kazumasa Kotake
- Okayama Saiseikai General Hospital; Department of Pharmacy; Kita-Ku Okayama Japan
| | - Norio Watanabe
- Kyoto University Graduate School of Medicine/School of Public Health; Department of Health Promotion and Human Behavior; Yoshida Konoe-cho, Sakyo-ku Kyoto Kyoto Japan 606-8501
| | - Takashi Fujiwara
- Kurashiki Central Hospital; Department of Otolaryngology; 1-1-1 Miwa Kurashiki Okayama Japan 710-8602
| | - Shinji Sakamoto
- Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Department of Neuropsychiatry; Okayama Okayama Japan
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Abstract
Abstract
Purpose of Review
This paper aims to review current available treatment options and to consider future directions in the treatment of bipolar depression.
Recent Findings
There are a limited number of established treatments that have demonstrated varied efficacy in acute bipolar depression including modern antipsychotics (quetiapine, lurasidone, olanzapine ± fluoxetine and recently cariprazine) and mood stabilisers (lamotrigine and valproate). Lithium has a role in protecting against depressive relapses and suicide. Alternative and experimental treatments including pramipexole, modafinil/armodafinil, omega-3 fatty acids and thyroxine may be used to augment the treatment of bipolar depression. Ketamine represents a major breakthrough, producing rapid reductions in depressive symptoms even in cases of treatment-resistance, but challenges remain in how best to maintain response and reduce unwanted side effects.
Summary
There remains uncertainty with regard to the relative efficacy and safety of established and experimental treatments for bipolar depression. Further work using consistent, optimal trial designs as well as further investigation into novel compounds and treatment interventions is warranted.
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Yalin N, Young AH. Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatr Dis Treat 2020; 16:1459-1472. [PMID: 32606699 PMCID: PMC7294105 DOI: 10.2147/ndt.s245166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
Depression accounts for the predominant burden associated with bipolar disorder. The identification and management of bipolar depression are challenging, since bipolar depression differs from unipolar depression, responding poorly to traditional antidepressants, which may also induce a switch to hypomania/mania, mixed states and/or cause rapid cycling. Current treatment options for bipolar depression are limited and guidelines vary greatly in their recommendations, reflecting gaps and inconsistencies in the current evidence base. Moreover, some treatment options, such as quetiapine and olanzapine-fluoxetine, although clearly efficacious, may be associated with adverse cardiometabolic side effects, which can be detrimental to the long-term physical health and well-being of patients, increasing the likelihood of treatment non-adherence and relapse. Evidence for some more recent therapeutic options, including lurasidone and cariprazine, suggests that patients' symptoms can be effectively managed without compromising their physical health. In addition, novel agents targeting alternative neurotransmitter pathways and inflammatory processes (such as ketamine and N-acetyl cysteine) are emerging as promising potential options for the treatment of bipolar depression in the future.
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Affiliation(s)
- Nefize Yalin
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Allan H Young
- Centre for Affective Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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18
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Cheniaux E, Nardi AE. Evaluating the efficacy and safety of antidepressants in patients with bipolar disorder. Expert Opin Drug Saf 2019; 18:893-913. [DOI: 10.1080/14740338.2019.1651291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Elie Cheniaux
- Departamento de Psiquiatria e Medicina Legal, Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
- Departamento de Especialidades Médicas, Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM/UERJ), Rio de Janeiro, Brazil
| | - Antonio E. Nardi
- Departamento de Psiquiatria e Medicina Legal, Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
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Jha MK, Murrough JW. Psychopharmacology and Experimental Therapeutics for Bipolar Depression. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:232-237. [PMID: 32047368 PMCID: PMC6999209 DOI: 10.1176/appi.focus.20190009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bipolar disorder is a chronic illness that affects 2%-4% of U.S. adults during their lifetime. The course of bipolar disorder is commonly characterized by prolonged periods of depression interspersed with manic-hypomanic episodes. Management of depression among patients with bipolar disorder is challenging because of the limited number of medications currently approved by the Food and Drug Administration, the high proportion of patients who do not respond to these medications, and the metabolic and other side effects associated with long-term use of these medications. In addition to reviewing the clinical options available to patients with bipolar depression and their treatment providers, this article presents an evidence-based management approach and discusses the off-label uses of currently available treatments and experimental therapeutics under development.
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Affiliation(s)
- Manish K Jha
- Depression and Anxiety Center for Discovery and Treatment and Departments of Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York City
| | - James W Murrough
- Depression and Anxiety Center for Discovery and Treatment and Departments of Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, New York City
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20
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Goldberg JF. Personalized Pharmacotherapy for Bipolar Disorder: How to Tailor Findings From Randomized Trials to Individual Patient-Level Outcomes. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:206-217. [PMID: 32047366 PMCID: PMC6999206 DOI: 10.1176/appi.focus.20190005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The quest for "personalized medicine" in psychiatry has focused mainly on pursuing potential biomarkers such as pharmacogenetic predictors of drug response. However, the collective randomized trial database across phases of bipolar disorder allows one to identify clinical characteristics that inform the likelihood of desired treatment outcomes. In turn, those characteristics, termed moderators and mediators of drug response, enable those who administer treatment to construct clinical profiles that can help them tailor pharmacotherapies to the features of a given patient rather than simply to an overall diagnosis. Bipolar disorder typically involves more heterogeneous than uniform clinical presentations, partly because of its highly prevalent psychiatric and medical comorbid conditions. Further clinical diversity arises from characteristics such as bipolar I versus II disorder subtype, rapid cycling, mixed versus pure affective episodes, psychosis, anxiety, chronicity, cognitive dysfunction, and suicidality, among other distinguishing features. By coupling such profiles with an awareness of the psychotropic breadth of spectrum held by particular medications, clinicians can devise strategic combination therapy regimens, capitalizing on synergies and using drugs that exert multiple relevant effects, addressing comorbid conditions, incorporating medications that could offset adverse effects of other agents, and avoiding or deprescribing medication options that lack known evidence to target symptoms within the clinical profile of a given patient.
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Affiliation(s)
- Joseph F Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City
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21
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Earley W, Burgess MV, Rekeda L, Dickinson R, Szatmári B, Németh G, McIntyre RS, Sachs GS, Yatham LN. Cariprazine Treatment of Bipolar Depression: A Randomized Double-Blind Placebo-Controlled Phase 3 Study. Am J Psychiatry 2019; 176:439-448. [PMID: 30845817 DOI: 10.1176/appi.ajp.2018.18070824] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Cariprazine, a dopamine D3/D2 and 5-HT1A receptor partial agonist, was found to be effective in treating bipolar I depression in a previous phase 2 study. This phase 3 study further assessed the efficacy, safety, and tolerability of cariprazine in bipolar I depression. METHODS In a double-blind placebo-controlled study, adult participants (18-65 years old) who met DSM-5 criteria for bipolar I disorder and a current depressive episode were randomly assigned to receive placebo (N=158) or cariprazine at 1.5 mg/day (N=157) or 3.0 mg/day (N=165). The primary and secondary efficacy parameters were changes from baseline to week 6 in Montgomery-Åsberg Depression Rating Scale (MADRS) score and Clinical Global Impressions severity (CGI-S) score, respectively. Least squares mean differences were estimated using a mixed model for repeated measures, and p values were adjusted for multiplicity. RESULTS Both dosages of cariprazine were significantly more effective than placebo in improving depressive symptoms (reducing MADRS total score); the least squares mean differences were -2.5 (95% CI=-4.6, -0.4) for cariprazine at 1.5 mg/day and -3.0 (95% CI=-5.1, -0.9) for cariprazine at 3.0 mg/day. Both cariprazine dosages were associated with lower CGI-S scores compared with placebo, but the differences did not reach statistical significance after adjustment for multiplicity (least squares mean difference, -0.2 [95% CI=-0.5, 0.0] for the 1.5 mg/day group and -0.3 [95% CI=-0.5, 0.0] for the 3.0 mg/day group). Common treatment-emergent adverse events (in at least 5% of participants in either cariprazine treatment group and twice the rate of the placebo group) were nausea, akathisia, dizziness, and sedation. Mean changes in weight and metabolic parameters were relatively small and comparable across groups. CONCLUSIONS Cariprazine, at both 1.5 mg/day and 3.0 mg/day, was effective, generally well tolerated, and relatively safe in reducing depressive symptoms in adults with bipolar I depression.
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Affiliation(s)
- Willie Earley
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Maria Victoria Burgess
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Ludmyla Rekeda
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Regan Dickinson
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Balázs Szatmári
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - György Németh
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Roger S McIntyre
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Gary S Sachs
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
| | - Lakshmi N Yatham
- Allergan, Madison, N.J. (Earley, Burgess, Rekeda, Dickinson); Gedeon Richter, Budapest, Hungary (Szatmári, Németh); the Mood Disorders Psychopharmacology Unit, University Health Network, Toronto (McIntyre); the Department of Psychiatry, Harvard Medical School, and the Bipolar Clinic and Research Program, Massachusetts General Hospital, Boston (Sachs); and the Department of Psychiatry, University of British Columbia, Vancouver (Yatham)
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Hidalgo-Mazzei D, Berk M, Cipriani A, Cleare AJ, Florio AD, Dietch D, Geddes JR, Goodwin GM, Grunze H, Hayes JF, Jones I, Kasper S, Macritchie K, McAllister-Williams RH, Morriss R, Nayrouz S, Pappa S, Soares JC, Smith DJ, Suppes T, Talbot P, Vieta E, Watson S, Yatham LN, Young AH, Stokes PRA. Treatment-resistant and multi-therapy-resistant criteria for bipolar depression: consensus definition. Br J Psychiatry 2019; 214:27-35. [PMID: 30520709 PMCID: PMC7613090 DOI: 10.1192/bjp.2018.257] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Most people with bipolar disorder spend a significant percentage of their lifetime experiencing either subsyndromal depressive symptoms or major depressive episodes, which contribute greatly to the high levels of disability and mortality associated with the disorder. Despite the importance of bipolar depression, there are only a small number of recognised treatment options available. Consecutive treatment failures can quickly exhaust these options leading to treatment-resistant bipolar depression (TRBD). Remarkably few studies have evaluated TRBD and those available lack a comprehensive definition of multi-therapy-resistant bipolar depression (MTRBD).AimsTo reach consensus regarding threshold definitions criteria for TRBD and MTRBD. METHOD Based on the evidence of standard treatments available in the latest bipolar disorder treatment guidelines, TRBD and MTRBD criteria were agreed by a representative panel of bipolar disorder experts using a modified Delphi method. RESULTS TRBD criteria in bipolar depression was defined as failure to reach sustained symptomatic remission for 8 consecutive weeks after two different treatment trials, at adequate therapeutic doses, with at least two recommended monotherapy treatments or at least one monotherapy treatment and another combination treatment. MTRBD included the same initial definition as TRBD, with the addition of failure of at least one trial with an antidepressant, a psychological treatment and a course of electroconvulsive therapy. CONCLUSIONS The proposed TRBD and MTRBD criteria may provide an important signpost to help clinicians, researchers and stakeholders in judging how and when to consider new non-standard treatments. However, some challenging diagnostic and therapeutic issues were identified in the consensus process that need further evaluation and research.Declaration of interestIn the past 3 years, M.B. has received grant/research support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis, Mayne Pharma, Servier, Woolworths, Avant and the Harry Windsor Foundation, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier, Solvay and Wyeth and served as a consultant to Allergan, Astra Zeneca, Bioadvantex, Bionomics, Collaborative Medicinal Development, Eli Lilly, Grunbiotics, Glaxo SmithKline, Janssen Cilag, LivaNova, Lundbeck, Merck, Mylan, Otsuka, Pfizer and Servier. A.C. has received fees for lecturing from pharmaceutical companies namely Lundbeck and Sunovion. A.J.C. has in the past 3 years received honoraria for speaking from Astra Zeneca and Lundbeck, honoraria for consulting from Allergan, Janssen, Lundbeck and LivaNova and research grant support from Lundbeck. G.M.G. holds shares in P1Vital and has served as consultant, advisor or CME speaker for Allergan, Angelini, Compass pathways, MSD, Lundbeck, Otsuka, Takeda, Medscape, Minervra, P1Vital, Pfizer, Servier, Shire and Sun Pharma. J.G. has received research funding from National Institute for Health Research, Medical Research Council, Stanley Medical Research Institute and Wellcome. H.G. received grants/research support, consulting fees or honoraria from Gedeon Richter, Genericon, Janssen Cilag, Lundbeck, Otsuka, Pfizer and Servier. R.H.M.-W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, Liva Nova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. R.M. has received research support from Big White Wall, Electromedical Products, Johnson and Johnson, Magstim and P1Vital. S.N. received honoraria from Lundbeck, Jensen and Otsuka. J.C.S. has received funds for research from Alkermes, Pfizer, Allergan, J&J, BMS and been a speaker or consultant for Astellas, Abbott, Sunovion, Sanofi. S.W has, within the past 3 years, attended advisory boards for Sunovion and LivaNova and has undertaken paid lectures for Lundbeck. D.J.S. has received honoraria from Lundbeck. T.S. has reported grants from Pathway Genomics, Stanley Medical Research Institute and Palo Alto Health Sciences; consulting fees from Sunovion Pharamaceuticals Inc.; honoraria from Medscape Education, Global Medical Education and CMEology; and royalties from Jones and Bartlett, UpToDate and Hogrefe Publishing. S.P. has served as a consultant or speaker for Janssen, and Sunovion. P.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. E.V. received grants/ research support, consulting fees or honoraria from Abbott, AB-Biotics, Allergan, Angelini, Dainippon Sumitomo, Ferrer, Gedeon Richter, Janssen, Lundbeck, Otsuka and Sunovion. L.N.Y. has received grants/research support, consulting fees or honoraria from Allergan, Alkermes, Dainippon Sumitomo, Janssen, Lundbeck, Otsuka, Sanofi, Servier, Sunovion, Teva and Valeant. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has also previously received funding for investigator-initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth. P.R.A.S. has received research funding support from Corcept Therapeutics Inc. Corcept Therapeutics Inc fully funded attendance at their internal conference in California USA and all related expenses. He has received grant funding from the Medical Research Council UK for a collaborative study with Janssen Research and Development LLC. Janssen Research and Development LLC are providing non-financial contributions to support this study. P.R.A.S. has received a presentation fee from Indivior and an advisory board fee from LivaNova.
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Affiliation(s)
- Diego Hidalgo-Mazzei
- Postdoctoral Researcher,Centre for Affective Disorders,Institute of Psychiatry,Psychology and Neuroscience, King's College London,UK;and Consultant Psychiatrist,Bipolar Disorders Programme,Department of Psychiatry and Psychology,Institute of Neurosciences,Hospital Clinic de Barcelona,CIBERSAM, IDIBAPS,Spain
| | - Michael Berk
- NHMRC Senior Principal Research Fellow,Alfred Deakin Professor of Psychiatry,School of Medicine,Deakin University and Barwon Health; Director, IMPACT Strategic Research Centre (Innovation in Mental and Physical Health and Clinical Treatment); Professorial Research Fellow, The Florey Institute of Neuroscience and Mental Health; Professorial Research Fellow, The National Centre of Excellence in Youth Mental Health; and Professorial Research Fellow,Department of Psychiatry,University of Melbourne,Australia
| | - Andrea Cipriani
- NIHR Research Professor,Department of Psychiatry,University of Oxford, Warneford Hospital; and Honorary Consultant Psychiatrist,Oxford Health NHS Foundation Trust,UK
| | - Anthony J Cleare
- Professor of Psychopharmacology and Affective Disorders,Institute of Psychiatry,Psychology and Neuroscience,King's College London; andConsultant Psychiatrist,Maudsley Hospital,South London and Maudsley NHS Foundation Trust (SLaM),UK
| | - Arianna Di Florio
- Clinical Research Fellow,Division of Psychological Medicine and Clinical Neurosciences,MRC Centre for Neuropsychiatric Genetics and Genomics,Cardiff University,UK
| | - Daniel Dietch
- GP Partner,Lonsdale Medical Centre; andVisiting Lecturer,Department of Psychological Medicine,Institute of Psychiatry,Psychology and Neuroscience,King's College London,UK
| | - John R Geddes
- NIHR Senior Investigator,Professor of Epidemiological Psychiatry,University of Oxford and Oxford Health NHS Foundation Trust,UK
| | - Guy M Goodwin
- Professor and Senior Research Fellow,Department of Psychiatry,University of Oxford, Warneford Hospital,UK
| | - Heinz Grunze
- Head of Department of Adult Psychiatry,Klinikum am Weissenhof,Weinsberg & Paracelsus Medical University,Germany
| | - Joseph F Hayes
- Senior Research Fellow,UCLH NIHR Biomedical Research Centre,Division of Psychiatry,University College London; and Honorary Consultant Psychiatrist,Camden and Islington NHS Foundation Trust,UK
| | - Ian Jones
- Director and Clinical Professor,National Centre for Mental Health,MRC Centre for Neuropsychiatric Genetics and Genomics,Cardiff University,UK
| | - Siegfried Kasper
- Professor of Psychiatry and Chairman of the Department of Psychiatry and Psychotherapy,Medical University Vienna,MUV, AKH, Währinger Gürtel,Austria
| | - Karine Macritchie
- Lead Consultant Psychiatrist, OPTIMA Mood Disorders Service,South London and Maudsley NHS Foundation Trust (SLaM),UK
| | - R Hamish McAllister-Williams
- Professor of Affective Disorders,Institute of Neuroscience, Newcastle University; and Honorary Consultant Psychiatrist,Regional Affective Disorders Service,Northumberland Tyne and Wear NHS Foundation Trust,UK
| | - Richard Morriss
- Professor of Psychiatry and Honorary Consultant Psychiatrist,Centre for Mood Disorders,Institute of Mental Health, University of Nottingham and Nottinghamshire Healthcare NHS Foundation Trust,UK
| | - Sam Nayrouz
- Consultant Psychiatrist and Director of Clinical Studies,West London Mental NHS Health Trust;and Honorary Senior Lecturer,Imperial College School of Medicine,UK
| | - Sofia Pappa
- Consultant Psychiatrist and Research Lead,West London Mental Health Trust;NW London Specialty Lead in Mental Health,National Institute for Health Research; and Honorary Senior Clinical Lecturer,Imperial College London,UK
| | - Jair C Soares
- Director,Center of Excellence on Mood Disorders, Department of Psychiatry and Behavioral Sciences,McGovern Medical School; and Executive Director,The University of Texas Harris County Psychiatric Center,USA
| | - Daniel J Smith
- Professor of Psychiatry and Lister Institute Prize Fellow, Institute of Health and Wellbeing,Mental Health, University of Glasgow,Gartnavel Royal Hospital,UK
| | - Trisha Suppes
- Professor,Department of Psychiatry & Behavioral Sciences,Stanford University School of Medicine; Director, VA Palo Alto Bipolar and Depression Research Program; and Director,VA Palo Alto CSP NODES,Palo Alto,USA
| | - Peter Talbot
- Clinical Senior Lecturer in Psychiatry,University of Manchester; and Honorary Consultant Psychiatrist and Director,Specialist Service for Affective Disorders,Greater Manchester Mental Health NHS Foundation Trust,UK
| | - Eduard Vieta
- Head of Department and Professor of Psychiatry,Bipolar disorders programme,Department of Psychiatry and Psychology,Institute of Neurosciences, Hospital Clinic, University of Barcelona,CIBERSAM, IDIBAPS,Spain
| | - Stuart Watson
- Clinical Senior Lecturer and Consultant Psychiatrist,Northern Centre for Mood Disorders,Institute for Neuroscience, Newcastle University and Northumberland Tyne and Wear NHS Foundation Trust,UK
| | - Lakshmi N Yatham
- Professor of Psychiatry,University of British Columbia; Regional Head,Department of Psychiatry,Vancouver Coastal Health/Providence Healthcare; and Regional Program Medical Director,Vancouver Coastal Health/Providence Healthcare,Canada
| | - Allan H Young
- Chair of Mood Disorders and Director of the Centre for Affective Disorders,Department of Psychological Medicine,King's College London,South London and Maudsley NHS Foundation Trust (SLaM);Academic Director,Psychological Medicine and Integrated Care Clinical Academic Group; and NIHR Senior Investigator,Institute of Psychiatry,Psychology and Neuroscience,King's College London,South London and Maudsley NHS Foundation Trust (SLaM),UK
| | - Paul R A Stokes
- Clinical Senior Lecturer in Mood Disorders and Consultant Psychiatrist,National Affective Disorders Service; Academic Psychiatry Training Programme Lead,Institute of Psychiatry,Psychology and Neuroscience,King's College London,South London and Maudsley NHS Foundation Trust (SLaM); andCRN South London Lead for Mental Health,Centre for Affective Disorders, Institute of Psychiatry,Psychology and Neuroscience,King's College London,South London and Maudsley NHS Foundation Trust (SLaM),UK
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23
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Woo YS, Bahk WM, Lee JG, Jeong JH, Kim MD, Sohn I, Shim SH, Jon DI, Seo JS, Min KJ, Kim W, Song HR, Yoon BH. Korean Medication Algorithm Project for Bipolar Disorder 2018 (KMAP-BP 2018): Fourth Revision. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2018; 16:434-448. [PMID: 30466216 PMCID: PMC6245301 DOI: 10.9758/cpn.2018.16.4.434] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 12/12/2022]
Abstract
Objective The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) was first published in 2002 through an expert consensus of opinion, and updated in 2006, 2010, and 2014. This study constitutes the fourth revision of the KMAP-BP. Methods A 50-item questionnaire was used to obtain the consensus of experts regarding pharmacological treatment strategies for various phases of adult bipolar disorder and six items for pediatric bipolar disorder. The review committee included 84 Korean psychiatrists and 43 child and adolescent psychiatry experts. Results The preferred first-step strategies for acute mania were the combination of a mood stabilizer (MS) and an atypical antipsychotic (AAP), MS monotherapy, and AAP monotherapy. A combination of a MS and an AAP, and AAP monotherapy were preferred for psychotic mania. The first-step strategies for mild to moderate bipolar depression were monotherapy with MS, AAP, or lamotrigine (LMT), and the combination of a MS and an AAP or LMT, or a combination of an AAP and LMT. The combination of two among a MS, AAP, and LMT were preferred for non-psychotic severe depression. A combination of a MS and an AAP or the combination of an AAP with an antidepressant or LMT were the first-line options for psychotic severe depression. Conclusion The recommendations of the KMAP-BP 2018 have changed from the previous version by reflecting recent developments in pharmacotherapy for bipolar disorder. KMAP-BP 2018 provides clinicians with a wealth of information regarding appropriate strategies for treating patients with bipolar disorder.
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Affiliation(s)
- Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Goo Lee
- Department of Psychiatry, Inje University Haeundae Paik Hospital, Inje University College of Medicine and Paik Institute for Clinical Research, Busan, Korea.,Department of Health Science and Technology, Graduate School of Inje University, Busan, Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Moon-Doo Kim
- Department of Psychiatry, Jeju National University Hospital, Jeju, Korea
| | - InKi Sohn
- Department of Psychiatry, Keyo Hospital, Keyo Medical Foundation, Uiwang, Korea
| | - Se-Hoon Shim
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Duk-In Jon
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jeong Seok Seo
- Department of Psychiatry, School of Medicine, Konkuk University, Chungju, Korea
| | - Kyung Joon Min
- Department of Psychiatry, Chung-Ang University College of Medicine, Seoul, Korea
| | - Won Kim
- Department of Psychiatry, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hoo-Rim Song
- Department of Psychiatry, Myongji Hospital, Goyang, Korea
| | - Bo-Hyun Yoon
- Department of Psychiatry, Naju National Hospital, Naju, Korea
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24
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Baggiani G, Ambrosiani L, Trincas P, Burrai C, Bocchetta A. Psychotropic Medication of Acute Episodes of Mood Disorders: Current Prescription Attitude in Two Psychiatric Wards in Cagliari, Italy. Clin Pract Epidemiol Ment Health 2018; 14:236-249. [PMID: 30972122 PMCID: PMC6407645 DOI: 10.2174/1745017901814010236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/25/2018] [Accepted: 10/02/2018] [Indexed: 11/22/2022]
Abstract
Background: Medication of acute episodes of mood disorders has changed over the last decades following the results of randomized clinical trials. Objective: The aim of this study was to analyze medication prescribed at discharge from two psychiatric wards. We focused on hospitalization as one of the best opportunities to start prophylaxis. Methods: We examined retrospectively the clinical records of 357 patients hospitalized for mood episodes in two psychiatric wards in the Cagliari area (SPDC-1 and SPDC-2) between 1 January and 31 December 2016. We focused on the psychotropic medication prescribed at discharge from the hospital. Results: Most patients were discharged with antipsychotics (86%) and/or benzodiazepines (89%). Combined medication was frequent, including various co-administration of first-generation and/or second-generation antipsychotics (26% of patients), or antipsychotics combined with mood-stabilizers (51% of patients). There was a preferential prescription of first-generation antipsychotics in SPDC-1, and of second-generation antipsychotics in SPDC-2. Prescription of lithium was significantly more frequent in SPDC-1. Conclusion: Although the treatment was in line with randomized clinical trials, the choice of individual psychotropic agents differed significantly between the two wards. Different prescription attitudes can have consequences on the long-term outcome of patients discharged from the hospital after an acute mood episode.
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Affiliation(s)
- Gioia Baggiani
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Luca Ambrosiani
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Pierfranco Trincas
- Psychiatric Ward Unit 2, "Santissima Trinità Hospital", ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Caterina Burrai
- Psychiatric Ward Unit 1, "Santissima Trinità Hospital", ATS Sardegna, ASSL Cagliari, Cagliari, Italy
| | - Alberto Bocchetta
- Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
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25
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Abstract
Depression is the predominant pole of disability in bipolar disorder and compared with mania/hypomania, has less systematic research guiding the development of treatment especially in its acute phase (acute bipolar depression). The deficiency in the management of the acute bipolar depression largely reflects the natural divergence of opinion resulting from significant knowledge gaps. At present, there are only 3 approved drug treatments for acute bipolar depression: olanzapine/fluoxetine combination, quetiapine (immediate or extended release), and lurasidone (monotherapy or adjunctive to lithium or valproate). Nonapproved agents and nonpharmacologic treatment such as lamotrigine, antidepressants, modafinil, pramipexole, ketamine, and electroconvulsive therapy are often prescribed to treat acute bipolar depression. This article discusses the challenges of diagnosing bipolar depression, and reviews above treatment options for acute bipolar depression.
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Affiliation(s)
- Yu-Chih Shen
- Department of Psychiatry, Buddhist Tzu Chi General Hospital, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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26
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Nagai G, Mihara K, Kagawa S, Nakamura A, Suzuki T, Nemoto K, Kondo T. A Partial Response at Week 4 Can Predict Subsequent Outcome during Lamotrigine Augmentation Therapy in Treatment-Resistant Depressive Disorder: A Preliminary Study. Neuropsychobiology 2018; 76:187-192. [PMID: 29961057 DOI: 10.1159/000489967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The present study prospectively examined whether or not a partial response at week 4 predicts subsequent response at week 8 during lamotrigine augmentation therapy in 51 (16 males and 35 females) inpatients with treatment-resistant depressive disorder using an open-study design. METHODS The subjects were 51 depressed patients who had already shown insufficient response to at least 3 psychotropics including antidepressants, mood stabilizers, and atypical antipsychotics. The diagnoses were major depressive disorder (n = 19), bipolar I disorder (n = 9), and bipolar II disorder (n = 23). The final doses of lamotrigine were 100 mg/day for 29 subjects who were not taking valproate and 75 mg/day for 22 subjects taking valproate. Depressive symptoms were evaluated by the Montgomery-Åsberg Depression Rating Scale (MADRS) before the start of lamotrigine and then at week 4, and finally after the 8th week of treatment. RESULTS A significant linear relationship was found between percent improvements in MADRS scores at weeks 4 and 8 (r = 0.492, y = 0.438x + 30.223, R2 = 0.226, p < 0.001). The receiver operating characteristics analysis indicated that a percent improvement of 16% or greater at week 4 was significantly (p < 0.01) predictive of response (50% or more reduction in the MADRS score). The patients were significantly divided by the cut-off point into the responders and the nonresponders (18/26 vs. 1/25, p < 0.001). CONCLUSION The present study suggests that a partial response at week 4 can predict subsequent outcome at week 8 during lamotrigine augmentation therapy in patients with treatment-resistant depressive disorder, and that the absence of a partial improvement at week 4 is highly predictive of nonresponse.
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Affiliation(s)
- Goyo Nagai
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kazuo Mihara
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Shoko Kagawa
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Akifumi Nakamura
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Takeshi Suzuki
- Department of Hospital Pharmacy, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kenji Nemoto
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tsuyoshi Kondo
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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27
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Bartoli F, Clerici M, Di Brita C, Riboldi I, Crocamo C, Carrà G. Effect of clinical response to active drugs and placebo on antipsychotics and mood stabilizers relative efficacy for bipolar depression and mania: A meta-regression analysis. J Psychopharmacol 2018; 32:416-422. [PMID: 29338576 DOI: 10.1177/0269881117749851] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Randomised placebo-controlled trials investigating treatments for bipolar disorder have been hampered by wide variations of active drugs and placebo clinical response rates. It is important to estimate whether the active drug or placebo response has a greater influence in determining the relative efficacy of drugs for psychosis (antipsychotics) and relapse prevention (mood stabilisers) for bipolar depression and mania. METHODS We identified 53 randomised, placebo-controlled trials assessing antipsychotic or mood stabiliser monotherapy ('active drugs') for bipolar depression or mania. We carried out random-effects meta-regressions, estimating the influence of active drugs and placebo response rates on treatment relative efficacy. RESULTS Meta-regressions showed that treatment relative efficacy for bipolar mania was influenced by the magnitude of clinical response to active drugs ( p=0.002), but not to placebo ( p=0.60). On the other hand, treatment relative efficacy for bipolar depression was influenced by response to placebo ( p=0.047), but not to active drugs ( p=0.98). CONCLUSIONS Despite several limitations, our unexpected findings showed that antipsychotics / mood stabilisers relative efficacy for bipolar depression seems unrelated to active drugs response rates, depending only on clinical response to placebo. Future research should explore strategies to reduce placebo-related issues in randomised, placebo-controlled trials for bipolar depression.
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Affiliation(s)
- Francesco Bartoli
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Massimo Clerici
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Carmen Di Brita
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Ilaria Riboldi
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Cristina Crocamo
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Giuseppe Carrà
- 1 Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy.,2 Division of Psychiatry, University College London, UK
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28
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Li Y, Zhang F, Xu Y, Hu J, Li H. Pharmacokinetics, Safety, and Tolerability of Lamotrigine Chewable/Dispersible Tablet Following Repeat-Dose Administration in Healthy Chinese Volunteers. Clin Pharmacol Drug Dev 2018; 7:627-633. [PMID: 29578646 DOI: 10.1002/cpdd.449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 01/22/2018] [Indexed: 11/08/2022]
Abstract
In this open-label, single-center study, the pharmacokinetics, safety, and tolerability of lamotrigine chewable/dispersible tablets were assessed in healthy Chinese volunteers. Each volunteer (N = 16) received repeat doses of oral lamotrigine titrated from 25 mg to 50 mg to 100 mg over 42 days and was followed up for 10-17 days. Safety and tolerability were assessed throughout the study. Lamotrigine pharmacokinetic parameters were estimated using noncompartmental analysis. Overall, 15 (94%) volunteers completed the study. Lamotrigine serum concentrations peaked 2.5 hours postdose, with a mean terminal half-life of 36.8 hours. The apparent lamotrigine oral clearance was 1577.88 mL/h. The accumulation ratios (day 14 vs day 1) were 2.53 and 2.58 for area under the curve and peak concentration, respectively. Lamotrigine 25 to 100 mg once daily exhibited dose-proportional pharmacokinetics (based on area under the curve and peak concentration), following repeat dosing. Nine volunteers reported adverse events, 2 experienced oropharyngeal pain, each receiving 25 mg and 50 mg. One volunteer withdrew due to an increase in liver enzymes. No deaths, serious adverse effects, or skin rashes were reported during the study. No new safety concerns were observed. Overall, the pharmacokinetic profiles after repeat doses of lamotrigine chewable/dispersible tablets once daily in a Chinese population were similar to those observed in Western populations.
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Affiliation(s)
- Yan Li
- Shanghai Mental Health Center, Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Zhang
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Yanmei Xu
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Joice Hu
- GlaxoSmithKline (China) R&D Company Limited, Shanghai, China
| | - Huafang Li
- Shanghai Mental Health Center, Shanghai Key Laboratory of Psychotic Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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29
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Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, Sharma V, Goldstein BI, Rej S, Beaulieu S, Alda M, MacQueen G, Milev RV, Ravindran A, O'Donovan C, McIntosh D, Lam RW, Vazquez G, Kapczinski F, McIntyre RS, Kozicky J, Kanba S, Lafer B, Suppes T, Calabrese JR, Vieta E, Malhi G, Post RM, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord 2018; 20:97-170. [PMID: 29536616 PMCID: PMC5947163 DOI: 10.1111/bdi.12609] [Citation(s) in RCA: 909] [Impact Index Per Article: 151.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 12/14/2022]
Abstract
The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.
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Affiliation(s)
- Lakshmi N Yatham
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | | | - Sagar V Parikh
- Department of PsychiatryUniversity of MichiganAnn ArborMIUSA
| | - Ayal Schaffer
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | - David J Bond
- Department of PsychiatryUniversity of MinnesotaMinneapolisMNUSA
| | - Benicio N Frey
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada
| | - Verinder Sharma
- Departments of Psychiatry and Obstetrics & GynaecologyWestern UniversityLondonONCanada
| | | | - Soham Rej
- Department of PsychiatryMcGill UniversityMontrealQCCanada
| | - Serge Beaulieu
- Department of PsychiatryMcGill UniversityMontrealQCCanada
| | - Martin Alda
- Department of PsychiatryDalhousie UniversityHalifaxNSCanada
| | - Glenda MacQueen
- Department of PsychiatryUniversity of CalgaryCalgaryABCanada
| | - Roumen V Milev
- Departments of Psychiatry and PsychologyQueen's UniversityKingstonONCanada
| | - Arun Ravindran
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | | | - Diane McIntosh
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | - Raymond W Lam
- Department of PsychiatryUniversity of British ColumbiaVancouverBCCanada
| | - Gustavo Vazquez
- Departments of Psychiatry and PsychologyQueen's UniversityKingstonONCanada
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonONCanada
| | | | - Jan Kozicky
- School of Population and Public HealthUniversity of British ColumbiaVancouverBCCanada
| | | | - Beny Lafer
- Department of PsychiatryUniversity of Sao PauloSao PauloBrazil
| | - Trisha Suppes
- Bipolar and Depression Research ProgramVA Palo AltoDepartment of Psychiatry & Behavioral Sciences Stanford UniversityStanfordCAUSA
| | - Joseph R Calabrese
- Department of PsychiatryUniversity Hospitals Case Medical CenterCase Western Reserve UniversityClevelandOHUSA
| | - Eduard Vieta
- Bipolar UnitInstitute of NeuroscienceHospital ClinicUniversity of BarcelonaIDIBAPS, CIBERSAMBarcelonaCataloniaSpain
| | - Gin Malhi
- Department of PsychiatryUniversity of SydneySydneyNSWAustralia
| | - Robert M Post
- Department of PsychiatryGeorge Washington UniversityWashingtonDCUSA
| | - Michael Berk
- Deakin UniveristyIMPACT Strategic Research CentreSchool of Medicine, Barwon HealthGeelongVic.Australia
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Rocamora R, Ley M, Molins A, Toledo M, Sansa G, Bertol V, Becerra JL, Carreño M, Mauri JÁ. Effect of lacosamide on depression and anxiety symptoms in patients with focal refractory epilepsy: A prospective multicenter study. Epilepsy Behav 2018; 79:87-92. [PMID: 29253680 DOI: 10.1016/j.yebeh.2017.10.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/17/2017] [Accepted: 10/27/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Depression is the main psychiatric comorbidity in epilepsy with an estimated prevalence between 20% and 55% and one of the main determinants of quality of life. The aim of this study was to investigate the effect of lacosamide (LCM) on mood and anxiety symptoms in patients with focal onset seizures (FOS). The secondary objective was to evaluate if the potential modifications in variables were related to seizure control or to the intrinsic effect of LCM. MATERIAL AND METHODS We performed a prospective multicenter study in 8 tertiary epilepsy centers in adults with FOS in which LCM was initiated as add-on therapy. Patients' mood and quality of life were evaluated through questionnaires and scales such as the Beck Depression Inventory-II (BDI-II), the State-Trait Anxiety Inventory (STAI-S/T), the Hospital Anxiety and Depression Scale (HADS), and the Quality of Life in Epilepsy-10 (QOLIE-10). Initiation of psychotropic medication was not allowed during the observation period. Patients with diagnosis of major depression or bipolar disorder were excluded. Evaluations were scheduled before LCM treatment, at 3 and 6months. RESULTS Forty-nine patients were included (51% female) with an average age of 39.5years (range 18-65). At the start of treatment with LCM, 65.3% of the patients were on treatment with one antiepileptic drug (AED). Based on BDI-II, 38.8% of patients had depressive symptoms and 46.9% according to HADS Depression (HADS-D), 63.3% of patients presented pathological levels of anxiety (STAI-S/T), and 44.9% according to HADS Anxiety (HADS-A). Quality of Life in Epilepsy-10 showed that 57.1% of patients had a relevant reduction in their quality of life. After LCM, the score on the BDI-II depression scale decreased significantly (p<0.001). Based on the STAI and HADS-anxiety scales, patients who had a pathological anxiety at baseline, significantly improved. The QOLIE-10 improved significantly over the observation period (p<0.001). At 6months, 28.3% of patients were seizure-free (67.4% were responders). The improvements on depression and anxiety scores were not statistically related to seizure control. CONCLUSION Lacosamide seems to have a positive effect on depressive and anxiety symptoms. Although the efficacy of LCM in seizure control was demonstrated, the antidepressant and anxiolytic effect on mood and anxiety seems to be an independent factor.
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Affiliation(s)
- Rodrigo Rocamora
- Epilepsy Unit, Department of Neurology, Hospital del Mar, Barcelona, Spain.
| | - Miguel Ley
- Epilepsy Unit, Department of Neurology, Hospital del Mar, Barcelona, Spain.
| | - Albert Molins
- Department of Neurology, Hospital Trueta, Girona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain.
| | - Gemma Sansa
- Department of Neurology, Hospital de Parc Taulí, Sabadell, Spain
| | - Vicente Bertol
- Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Juan-Luis Becerra
- Epilepsy Unit, Department of Neurology, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Mar Carreño
- Epilepsy Unit, Department of Neurology, Hospital Clinic, Barcelona, Spain.
| | - José-Ángel Mauri
- Department of Neurology, Hospital Lozano Blesa, Zaragoza, Spain.
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Morsel AM, Morrens M, Sabbe B. An overview of pharmacotherapy for bipolar I disorder. Expert Opin Pharmacother 2018; 19:203-222. [PMID: 29361880 DOI: 10.1080/14656566.2018.1426746] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Bipolar I disorder (BD I) is complex with a chronic course that significantly impacts a sufferer's quality of life. As of right now, there are many available treatments that aim to rapidly treat manic or depressive episodes and stabilize mood. The purpose of this report is to provide an up-to-date comprehensive review of the available evidence-based trials of pharmacotherapy for the treatment of BD I. AREAS COVERED This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of current pharmacotherapy in adults with BD I from phase III to clinical practice. Monotherapy and combination therapy for acute and long-term treatment were reviewed for this purpose. EXPERT OPINION There are many treatments available for BD mania; however, the depressive and stabilization phases of the illness remain a clinical challenge. Unfortunately, randomized controlled trials do not represent 'real world' patients, as their strict inclusion and exclusion criteria do not allow for different features sometimes present in patients to be considered. Research efforts must also focus on treating cognitive deficits, which adds to lower functional outcome. The authors believe that there is dire need for new, more targeted treatments in BD I, with a critical view of the side effects.
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Affiliation(s)
- Anne Michal Morsel
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium
| | - Manuel Morrens
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium.,b Psychiatric University Hospital Duffel - University Hospital Antwerp , Duffel , Belgium
| | - Bernard Sabbe
- a Collaborative Antwerp Psychiatric Research Institute (CAPRI) , University of Antwerp , Antwerp , Belgium.,b Psychiatric University Hospital Duffel - University Hospital Antwerp , Duffel , Belgium
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Antidepressants and Mood Stabilizers: Novel Research Avenues and Clinical Insights for Bipolar Depression. Int J Mol Sci 2017; 18:ijms18112406. [PMID: 29137178 PMCID: PMC5713374 DOI: 10.3390/ijms18112406] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 12/31/2022] Open
Abstract
The concept of the bipolar-spectrum and of mixed features being a bridge between major depressive disorders and bipolar disorders (BDs) has become increasingly important in mood-disorder diagnoses. Under these circumstances, antidepressants (ADs) and mood stabilizers (MSs) should be used with caution in the treatment of major depressive episodes (MDEs) and to obtain long-term stability in BDs. Before treating MDEs, screening tools, specific symptom evaluation and medical history should be used to distinguish between bipolarity and mixed features in patients for whom AD monotherapy may present a risk. In these patients, a combination of ADs plus MSs or atypical antipsychotics is recommended, rather than AD monotherapy. Studies evaluating MSs for bipolar depression suggest that lamotrigine is the most reliable treatment and lithium has modest effects; there is a lack of clear evidence regarding the efficacy of valproate and carbamazepine. Recently, significant progress has been made with respect to the pathophysiology of mood disorders and the application of potential biomarkers. There is an opportunity to study novel drug mechanisms through the rediscovery of fast-acting drugs such as ketamine. It is anticipated that future research developments will involve the discovery of potential targets for new drugs and their application to personalized treatments.
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Zimmerman M, Holst CG, Clark HL, Multach M, Walsh E, Rosenstein LK, Gazarian D. The Psychiatric Inclusion and Exclusion Criteria in Placebo-Controlled Monotherapy Trials of Bipolar Depression: An Analysis of Studies of the Past 20 Years. CNS Drugs 2016; 30:1209-1218. [PMID: 27541608 DOI: 10.1007/s40263-016-0381-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Concerns about the generalizability of pharmacotherapy efficacy trials to "real-world" patients have been raised for more than 40 years. Almost all of this literature has focused on treatment studies of major depressive disorder (MDD). OBJECTIVE The aim of the study was to review the psychiatric inclusion and exclusion criteria used in placebo-controlled trials that assessed the efficacy of medications for bipolar depression (bipolar disorder efficacy trials [BDETs]) and compare the criteria used in BDETs with those used in efficacy trials of antidepressants to treat MDD (antidepressant efficacy trials [AETs]). METHODS We searched the MEDLINE, Embase, and PsycINFO databases for articles published from January 1995 through December 2014. We identified 170 placebo-controlled AETs and 22 BDETs published during these 20 years. Two of the authors independently reviewed each article and completed a pre-specified information extraction form listing the psychiatric inclusion and exclusion criteria used in the study. RESULTS Six inclusion/exclusion criteria were used in at least half of the BDETs: minimum severity on a depression symptom severity scale, significant suicidal ideation, diagnosis of alcohol or drug use disorder, presence of a comorbid nondepressive, nonsubstance use Axis I disorder, current episode of depression being too long, and absence of current manic symptoms. BDETs were significantly less likely than AETs to exclude patients with a history of psychotic features/disorders, borderline personality disorder, and post-traumatic stress disorder and more likely to exclude individuals who scored too low on the first item of the Hamilton Depression Rating Scale. Nearly two-thirds of the BDETs placed an upper limit on the duration of the current depressive episode, three times higher than the rate in the AETs. There was no difference on other variables between the AETs and BDETs. CONCLUSIONS Similar to treatment studies of nonbipolar MDD, the treatment studies of bipolar depression frequently excluded patients with comorbid psychiatric and substance use disorders and insufficient severity of depressive symptoms as rated on standardized scales. These findings indicate that concerns about the generalizability of data from trials of recently approved medications for the treatment of bipolar depression are as relevant as the concerns that have been raised about studies of antidepressants for nonbipolar depression.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA. .,Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, 146 West River Street, Providence, RI, 02904, USA.
| | | | - Heather L Clark
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Matthew Multach
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Emily Walsh
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Lia K Rosenstein
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Douglas Gazarian
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
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Lamotrigine compared to placebo and other agents with antidepressant activity in patients with unipolar and bipolar depression: a comprehensive meta-analysis of efficacy and safety outcomes in short-term trials. CNS Spectr 2016; 21:403-418. [PMID: 27686028 DOI: 10.1017/s1092852916000523] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To meta-analytically summarize lamotrigine's effectiveness and safety in unipolar and bipolar depression. METHODS We conducted systematic PubMed and SCOPUS reviews (last search =10/01/2015) of randomized controlled trials comparing lamotrigine to placebo or other agents with antidepressant activity in unipolar or bipolar depression. We performed a random-effects meta-analysis of depression ratings, response, remission, and adverse effects calculating standardized mean difference (SMD) and risk ratio (RR) ±95% confidence intervals (CIs). RESULTS Eighteen studies (n=2152, duration=9.83 weeks) in patients with unipolar depression (studies=4, n=187; monotherapy vs lithium=1, augmentation of antidepressants vs placebo=3) or bipolar depression (studies=14, n=1965; monotherapy vs placebo=5, monotherapy vs lithium or olanzapine+fluoxetine=2, augmentation of antidepressants vs placebo=1, augmentation of mood stabilizers vs placebo=3, augmentation of mood stabilizers vs trancylpromine, citalopram, or inositol=3) were meta-analyzed. Lamotrigine's efficacy for depressive symptoms did not differ significantly in monotherapy vs augmentation studies (vs. placebo: p=0.98, I2=0%; vs active agents: p=0.48, I2=0%) or in unipolar vs bipolar patients (vs placebo: p=0.60, I2=0%), allowing pooling of each placebo-controlled and active-controlled trials. Lamotrigine outperformed placebo regarding depressive symptoms (studies=11, n=713 vs n=696; SMD=-0.15, 95% CI=-0.27, -0.02, p=0.02, heterogeneity: p=0.24) and response (after removing one extreme outlier; RR=1.42, 95% CI=1.13-1.78; p=0.003, heterogeneity: p=0.08). Conversely, lamotrigine did not differ regarding efficacy on depressive symptoms, response, or remission from lithium, olanzapine+fluoxetine, citalopram, or inositol (studies=6, n=306 vs n=318, p-values=0.85-0.92). Adverse effects and all-cause/specific-cause discontinuation were similar across all comparisons. CONCLUSIONS Lamotrigine was superior to placebo in improving unipolar and bipolar depressive symptoms, without causing more frequent adverse effects/discontinuations. Lamotrigine did not differ from lithium, olanzapine+fluoxetine, citalopram, or inositol.
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Stein AC, Müller LG, Ferreira AG, Braga A, Betti AH, Centurião FB, Scherer EB, Kolling J, von Poser GL, Wyse AT, Rates SM. Uliginosin B, a natural phloroglucinol derivative with antidepressant-like activity, increases Na+,K+-ATPase activity in mice cerebral cortex. REVISTA BRASILEIRA DE FARMACOGNOSIA-BRAZILIAN JOURNAL OF PHARMACOGNOSY 2016. [DOI: 10.1016/j.bjp.2016.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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McCraw S, Parker G. The comparative short-term outcome of bipolar II disorder patients variably meeting or not meeting DSM-5 duration criteria following lamotrigine treatment. J Psychopharmacol 2016; 30:554-8. [PMID: 26905918 DOI: 10.1177/0269881116632378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is accruing clinical and empirical evidence supporting the efficacy of lamotrigine as a treatment for bipolar II disorder. However, the treatment response experienced by those with 'short duration' hypomania (or 'other specified' bipolar disorder) has been under-researched. We reviewed a clinical sample of 123 patients diagnosed with a bipolar II disorder three months following their initial assessment. A research interview evaluated treatment strategies implemented, depressive and hypomanic episode pattern and functional outcomes. Of patients who had achieved a minimum level of 75 mg of lamotrigine, n = 51 were assigned to the BP II disorder group (i.e., hypomanic episodes lasted four days or longer) and n = 28 to the short duration group (i.e., hypomanic episodes always lasted less than four days). There were no significant differences between the two groups at the three-month follow-up on self-report measures of changes in depressive and hypomanic episode pattern or functioning across six domains (i.e., intimate relationships, family relationships, friendships, work relationships, work performance, overall quality of life), and with the majority of patients reporting some level of improvement. Study limitations include being an observational, uncontrolled design with a relatively small sample size for detecting statistical differences. Nonetheless, lamotrigine appeared to be a suitable medication to be trialled in patients who alternate between depressive episodes and short periods of hypomania, (as for those with DSM-defined hypomanic episodes), and should prompt further investigation.
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Affiliation(s)
- Stacey McCraw
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia Black Dog Institute, Sydney, NSW, Australia
| | - Gordon Parker
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia Black Dog Institute, Sydney, NSW, Australia
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Muneer A. Pharmacotherapy of Acute Bipolar Depression in Adults: An Evidence Based Approach. Korean J Fam Med 2016; 37:137-48. [PMID: 27274384 PMCID: PMC4891315 DOI: 10.4082/kjfm.2016.37.3.137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/17/2016] [Accepted: 02/25/2016] [Indexed: 11/03/2022] Open
Abstract
In the majority of cases of bipolar disorder, manic episodes are usually brief and typically responsive to currently available psychopharmacological agents. In contrast, depressive manifestations are more prevalent and persistent, and can present as major depressive/mixed episodes or residual interepisode symptoms. The depressive phase is often associated with other neuropsychiatric conditions, such as anxiety spectrum disorders, substance use disorders, stressor-related disorders, and eating disorders. It is viewed as a systemic disease with associated ailments such as metabolic syndrome, diabetes mellitus, and cardiovascular disease. There is an increased rate of mortality not only from suicide, but also from concomitant physical illness. This scenario is made worse by the fact that depressive symptoms, which represent the main disease burden, are often refractory to existing psychotropic drugs. As such, there is a pressing need for novel agents that are efficacious in acute depressive exacerbations, and also have applicable value in preventing recurrent episodes. The rationale of the present review is to delineate the pharmacotherapy of the depressive phase of bipolar disorder with medications for which there is evidence in the form of observational, open-label, or double-blind randomized controlled studies. In the treatment of acute bipolar depression in adults, a comprehensive appraisal of the extant literature reveals that among mood stabilizers, the most robust proof of efficacy exists for divalproex sodium; while atypical antipsychotics, which include olanzapine, quetiapine, lurasidone, and cariprazine, are also effective, as demonstrated in controlled trials.
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Affiliation(s)
- Ather Muneer
- Department of Psychiatry, Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
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Karanti A, Kardell M, Lundberg U, Landén M. Changes in mood stabilizer prescription patterns in bipolar disorder. J Affect Disord 2016; 195:50-6. [PMID: 26859073 DOI: 10.1016/j.jad.2016.01.043] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/06/2016] [Accepted: 01/28/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lithium is a first line treatment option in bipolar disorder, but several alternative treatments have been introduced in recent years, such as antiepileptic and atypical antipsychotic drugs. Little is known about how this has changed the prescription patterns. We investigated possible changes in the use of mood stabilizers and antidepressants in Sweden during 2007-2013. METHODS Data was collected from Swedish registers: the National Quality Assurance Register for bipolar disorder (BipoläR), the Prescribed Drug Register, and the Patient Register. Logistic regression models with drug use as outcomes were used to adjust for confounding factors such as sex, age, year of registration, and subtypes of bipolar disorder. RESULTS In both bipolar subtypes, lithium use decreased steadily during the study period, while the use of lamotrigine and quetiapine increased. The use of valproate decreased in bipolar II disorder and the use of olanzapine decreased among women. The use of antidepressant remained principally unchanged but increased somewhat in bipolar I disorder. LIMITATIONS We only report data from 2007 as the coverage of BipoläR prior to 2007 was too low to allow for reliable analyses. CONCLUSION Significant changes in the prescription of drugs in the treatment of bipolar disorder have occurred in recent years in Sweden. Further studies are needed to clarify whether these changes alter the outcome in bipolar disorder.
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Affiliation(s)
- Alina Karanti
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Mathias Kardell
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; National Quality Register for Bipolar Disorder (BipoläR), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulrika Lundberg
- National Quality Register for Bipolar Disorder (BipoläR), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Landén
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; National Quality Register for Bipolar Disorder (BipoläR), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Iovieno N, Nierenberg AA, Parkin SR, Hyung Kim DJ, Walker RSW, Fava M, Papakostas GI. Relationship between placebo response rate and clinical trial outcome in bipolar depression. J Psychiatr Res 2016; 74:38-44. [PMID: 26736040 DOI: 10.1016/j.jpsychires.2015.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/14/2015] [Accepted: 12/17/2015] [Indexed: 11/19/2022]
Abstract
The aim of this work is to investigate the impact of placebo response rates on the relative risk of response to drug versus placebo in randomized, double-blind, placebo-controlled clinical trials of pharmacological therapy in Bipolar Depression (BPD). Medline/PubMed publication databases were searched for randomized, double-blind, placebo-controlled trials of oral drugs used as monotherapy for the treatment of BPD. The search was limited to articles published between January 1980 and September 2015. Data extracted from 12 manuscripts and one poster with yet unpublished results, representing a total of 17 clinical trials were pooled (n = 6578). Pooled response rates for drug and placebo were 55.1% and 39.2%, corresponding to a risk ratio (RR) for responding to active treatment versus placebo of 1.29 (p < 0.001). Clinical response was defined as a 50% or greater reduction in depression scores, baseline to endpoint. A higher placebo response rate correlated with a significantly lower RR of responding to pharmacotherapy versus placebo (p = 0.002). The pooled drug and placebo response rates for studies with a placebo response rate ≤ 30% were 50.5% versus 26.6%, while corresponding values from studies with a placebo response rate >30 were 55.0% versus 41.6%. These results suggest that the relative efficacy of the active drug compared to placebo in clinical trials for BPD is highly heterogeneous across studies with different placebo response rates, with a worse performance in showing a superiority of the drug versus placebo for studies with placebo response rates >30%. It is important to maintain placebo response rates below this critical threshold, since this is one of the most challenging obstacles for new treatment development in BPD.
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Affiliation(s)
- Nadia Iovieno
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA.
| | - Andrew A Nierenberg
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Bipolar Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susannah R Parkin
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Ju Hyung Kim
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rosemary S W Walker
- Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maurizio Fava
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA; Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George I Papakostas
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA; Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, Hopwood M, Lyndon B, Mulder R, Murray G, Porter R, Singh AB. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2015; 49:1087-206. [PMID: 26643054 DOI: 10.1177/0004867415617657] [Citation(s) in RCA: 511] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility. METHODS Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders. RESULTS The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care. CONCLUSIONS The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. MOOD DISORDERS COMMITTEE Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh. INTERNATIONAL EXPERT ADVISORS Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham. AUSTRALIAN AND NEW ZEALAND EXPERT ADVISORS Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.
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Affiliation(s)
- Gin S Malhi
- Discipline of Psychiatry, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, NSW, Australia CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Darryl Bassett
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia School of Medicine, University of Notre Dame, Perth, WA, Australia
| | - Philip Boyce
- Discipline of Psychiatry, Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre (MAPrc), Monash University Central Clinical School and The Alfred, Melbourne, VIC, Australia
| | - Kristina Fritz
- CADE Clinic, Discipline of Psychiatry, Sydney Medical School - Northern, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
| | - Bill Lyndon
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia Mood Disorders Unit, Northside Clinic, Greenwich, NSW, Australia ECT Services Northside Group Hospitals, Greenwich, NSW, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Greg Murray
- Department of Psychological Sciences, School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Richard Porter
- Department of Psychological Medicine, University of Otago-Christchurch, Christchurch, New Zealand
| | - Ajeet B Singh
- School of Medicine, Deakin University, Geelong, VIC, Australia
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Parker G, McCraw S. The 'disconnect' between initial judgments of lamotrigine vs. its real-world effectiveness in managing bipolar disorder. A tale with wider ramifications. Acta Psychiatr Scand 2015; 132:345-54. [PMID: 25912532 DOI: 10.1111/acps.12427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To detail the disconnect between the quantified efficacy of the mood stabilizer lamotrigine in its registration controlled trials and its later judged clinical effectiveness and consider some determinants of disconnects between some efficacy trial findings and 'real-world' clinical effectiveness judgments. METHOD Published articles considering lamotrigine as a treatment for the bipolar I or II disorders were selected for review. While randomized controlled trials were weighted, we also consider open trials and effectiveness observations from clinician researchers and demonstrate that lamotrigine has been quite variably judged over time. RESULTS We suggest that the early trials evaluating lamotrigine for acute bipolar disorder depression focused on a suboptimal clinical target, and in so doing, ensured less lamotrigine efficacy compared with trials of bipolar disorder preventative treatment. Moreover, a number of additional methodological limitations compromised analyses. We also detail variable reporting of actual study results. The initial sharp disconnect (between efficacy and effectiveness judgments) has narrowed as lamotrigine has been evaluated and progressively taken up as a maintenance mood stabilizer. CONCLUSION The lamotrigine disconnect story provides a number of salutary lessons that are salient to evaluating the effectiveness and ecological niche of any psychotropic medication. The lamotrigine story presented here argues strongly for the wisdom of encouraging an iterative process between efficacy studies and clinical observation.
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Affiliation(s)
- G Parker
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Sydney, NSW, Australia
| | - S McCraw
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia.,Black Dog Institute, Sydney, NSW, Australia
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Abstract
This double-blind, sham-controlled study sought to investigate the effectiveness of cranial electrotherapy stimulation (CES) for the treatment of bipolar II depression (BD II). After randomization, the active group participants (n = 7) received 2 mA CES treatment for 20 minutes five days a week for 2 weeks, whereas the sham group (n = 9) had the CES device turned on and off. Symptom non-remitters from both groups received an additional 2 weeks of open-label active treatment. Active CES treatment but not sham treatment was associated with a significant decrease in the Beck Depression Inventory (BDI) scores from baseline to the second week (p = 0.003) maintaining significance until week 4 (p = 0.002). There was no difference between the groups in side effects frequency. The results of this small study indicate that CES may be a safe and effective treatment for BD II suggesting that further studies on safety and efficacy of CES may be warranted.
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Mood instability in bipolar disorder type I versus type II-continuous daily electronic self-monitoring of illness activity using smartphones. J Affect Disord 2015; 186:342-9. [PMID: 26277270 DOI: 10.1016/j.jad.2015.06.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND A substantial proportion of patients with bipolar disorder remain symptomatic during inter-episode periods, and mood instability is associated with high risk of relapse and hospitalization. Few studies have investigated long-term daily illness activity and none has compared bipolar type I and II using daily data. The objectives were to investigate differences in daily illness activity between bipolar disorder type I and II. METHODS A smartphone-based system for self-monitoring was developed. A total of 33 patients treated in a mood clinic used the system for daily self-monitoring during a median period of 310 days [IQR 189; 437]. Data presented summarize over 8500 observations. RESULTS Patients with bipolar disorder type II (n=20), compared to patients with bipolar disorder type I (n=13), experienced a significant lower mean level of mood on a scale from -3; +3 (-0.54 (95% CI: -0.74; -0.35) versus -0.19 (95% CI: -0.35; -0.02), p=0.02), less time euthymic (51.0% (95% CI: 36.4; 65.7) versus 74.5% (95% CI: 62.4; 86.7), p=0.03) and a higher proportion of time with depressive symptoms (45.1% (95% CI: 30.6; 59.5) versus 18.8% (95% CI: 6.9; 30.7), p=0.01). The proportion of time spent with (hypo)manic symptoms did not differ (2.7% (95% CI: 0.1; 5.5) versus 5.5% (95% CI: 3.1; 7.8), p=0.17). LIMITATIONS Patients received different types, doses and combinations of psychopharmacological treatment. CONCLUSION Euthymia was obtained for a substantial proportion of time in patients with bipolar disorder type I, but despite on-going treatment only for half of the time for patients with bipolar disorder type II. This emphasizes the need for improving treatment strategies for bipolar disorder type II.
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Abstract
OBJECTIVE To consolidate the evidence from the literature to evaluate the role of ketamine in the treatment of bipolar depression. METHODS Major databases, including MEDLINE, EMBASE, Cochrane, and Scopus, were searched through October 2014, for studies reporting the role of ketamine in the treatment of bipolar depression. Only randomized controlled trials were included in the meta-analysis. We calculated standardized mean differences (SMDs) with SE for each study included in the meta-analysis. A random effect model was used to calculate the pooled SMDs. Heterogeneity was assessed using the Cochran Q test and I statistic. RESULTS Of the 721 articles that were screened, 5 studies that enrolled a total of 125 subjects with bipolar depression (mean age, 44.6±4.3 y and 65.6% females) were included in the systematic review; 3 randomized controlled trials (69 subjects) were included in the meta-analysis. The meta-analysis showed significant improvement in depression among patients receiving a single dose of intravenous ketamine compared with those who received placebo (SMD=-1.01; 95% confidence interval, -1.37, -0.66; P<0.0001). The maximum improvement was observed 40 minutes after the ketamine infusion. No heterogeneity was observed between the studies (Cochran Q test P=0.38, I=0%). The 2 studies that were excluded from the meta-analysis also showed significant improvement in depression after ketamine therapy. Individual studies also reported improvement in anhedonia and suicidal ideation after ketamine therapy. None of the subjects had serious side effects, and the side effects were similar between the ketamine and placebo groups. CONCLUSIONS This study suggests that ketamine is effective in treatment-resistant bipolar depression and may reduce suicidal ideation and anhedonia.
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Prabhavalkar KS, Poovanpallil NB, Bhatt LK. Management of bipolar depression with lamotrigine: an antiepileptic mood stabilizer. Front Pharmacol 2015; 6:242. [PMID: 26557090 PMCID: PMC4615936 DOI: 10.3389/fphar.2015.00242] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/08/2015] [Indexed: 11/13/2022] Open
Abstract
The efficacy of lamotrigine in the treatment of focal epilepsies have already been reported in several case reports and open studies, which is thought to act by inhibiting glutamate release through voltage-sensitive sodium channels blockade and neuronal membrane stabilization. However, recent findings have also illustrated the importance of lamotrigine in alleviating the depressive symptoms of bipolar disorder, without causing mood destabilization or precipitating mania. Currently, no mood stabilizers are available having equal efficacy in the treatment of both mania and depression, two of which forms the extreme sides of the bipolar disorder. Lamotrigine, a well established anticonvulsant has received regulatory approval for the treatment and prevention of bipolar depression in more than 30 countries worldwide. Lamotrigine, acts through several molecular targets and overcomes the major limitation of other conventional antidepressants by stabilizing mood from “below baseline” thereby preventing switches to mania or episode acceleration, thus being effective for bipolar I disorder. Recent studies have also suggested that these observations could also be extended to patients with bipolar II disorder. Thus, lamotrigine may supposedly fulfill the unmet requirement for an effective depression mood stabilizer.
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Affiliation(s)
- Kedar S Prabhavalkar
- Department of Pharmacology, Dr. Bhanuben Nanavati College of Pharmacy , Mumbai, India
| | - Nimmy B Poovanpallil
- Department of Pharmacology, Dr. Bhanuben Nanavati College of Pharmacy , Mumbai, India
| | - Lokesh K Bhatt
- Department of Pharmacology, Dr. Bhanuben Nanavati College of Pharmacy , Mumbai, India
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Bowden CL, Singh V. The use of antidepressants in bipolar disorder patients with depression. Expert Opin Pharmacother 2015; 17:17-25. [PMID: 26479314 DOI: 10.1517/14656566.2016.1104299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The proportion of time that bipolar patients experience depressive symptoms and clinical states, with associated psychosocial impairment and elevated risk of suicide, is significantly greater than the time spent in manic/hypomanic forms of bipolar disorders. Yet, manic states and symptoms have been the focus and interest of most clinical research over the past quarter century. Not a single antidepressant approved for treatment of major depressive disorder, as monotherapy, has received regulatory approval for treatment of bipolar depression as monotherapy, despite their common use in bipolar depression. AREAS COVERED We reviewed randomized studies, particularly ones initially intended for registration purposes, and systematic treatment guidelines, in development of this guide to treatment decision and implementation of interventions for depression in bipolar disorders. EXPERT OPINION The Expert Opinion section emphasizes strategies, not individual agents. The efficacious performance of mood stabilizers and second-generation antipsychotics as a component of the strategy is strongly supported by published studies. However, this section relies largely on secondary publications and our combined clinical experience, as few randomized, blinded studies have had, as their focus, the comparison of combined regimens for depression. This article summarizes the design features and results of studies dealing with depressive features and intervention strategies for bipolar disorders. The emphasis of the recommendations is on pragmatic treatment decisions that clinicians can make to enhance the probability of both short and long term benefits for patients.
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Affiliation(s)
- Charles L Bowden
- a Clinical Professor of Psychiatry and Pharmacology , University of Texas Health Science Center at San Antonio , San Antonio , TX , USA
| | - Vivek Singh
- b Professor and Chairman for Department of Psychiatry, Paul L. Foster School of Medicine , Texas Tech University Health Sciences Center , El Paso , TX , USA
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Ketter TA, Yang R, Frye MA. Adjunctive armodafinil for major depressive episodes associated with bipolar I disorder. J Affect Disord 2015; 181:87-91. [PMID: 25933099 DOI: 10.1016/j.jad.2015.04.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In a previous study, adjunctive armodafinil 150 mg/day significantly improved depressive symptoms associated with bipolar I disorder. METHODS Multicenter, double-blind study of patients with a major depressive episode despite bipolar I disorder maintenance therapy randomized to adjunctive placebo or adjunctive armodafinil 150 or 200mg/day for 8 weeks; for logistical reasons, assignment to armodafinil 200mg/day was discontinued early. Primary efficacy was measured by change from baseline to week 8 in 30-Item Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C30) total score. RESULTS Patients were randomized to adjunctive placebo (n=230), adjunctive armodafinil 150 mg/day (n=232), or adjunctive armodafinil 200mg/day (n=30; analyzed for safety only). Least-square mean change in IDS-C30 total score was numerically superior for adjunctive armodafinil 150 mg/day vs adjunctive placebo, but was not statistically significant (p=0.13). Armodafinil was well-tolerated. Adverse events (AEs) observed in >5% with adjunctive armodafinil 150 mg/day and more frequently than with adjunctive placebo were headache (16% [38/231] vs 13% [30/229]) and nausea (7% [17/231] vs 2% [5/229]). The most common AEs with adjunctive armodafinil 200mg/day were diarrhea and dry mouth (17% [5/30] each vs 6% [13/229] and 1% [3/229], respectively, with adjunctive placebo). LIMITATIONS Early study discontinuation for logistical reasons by the sponsor limited adjunctive armodafinil 200-mg/day assessment. CONCLUSIONS FDA-approved bipolar I depression treatments are limited. Adjunctive armodafinil 150 mg/day reduced depressive symptoms associated with bipolar I disorder to a greater extent than adjunctive placebo, although the difference failed to reach statistical significance. Safety data indicate treatment with adjunctive armodafinil was well-tolerated.
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Affiliation(s)
| | - Ronghua Yang
- Teva Pharmaceutical Industries Ltd., Frazer, PA, USA
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Chen DG. Meta-analysis for psychiatric research using free software R. SHANGHAI ARCHIVES OF PSYCHIATRY 2015; 27:195-9. [PMID: 26300603 PMCID: PMC4526834 DOI: 10.11919/j.issn.1002-0829.215063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/18/2015] [Indexed: 11/21/2022]
Abstract
Summary This paper provides a brief overview of meta-analysis (MA) with emphasis on classical fixedeffects and random-effects MA models. It illustrates the application of MA models with the open-source software R using publicly available data from five studies on lamotrigine to treat bipolar depression and finds that meta-analysis identifies a statistically significant advantage of lamotrigine over placebo that was not evident in the individual studies.
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Affiliation(s)
- Ding-Geng Chen
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, United States
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Hasler G, Wolf A. Toward stratified treatments for bipolar disorders. Eur Neuropsychopharmacol 2015; 25:283-94. [PMID: 25595029 DOI: 10.1016/j.euroneuro.2014.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/07/2014] [Accepted: 12/23/2014] [Indexed: 01/02/2023]
Abstract
In bipolar disorders, there are unclear diagnostic boundaries with unipolar depression and schizophrenia, inconsistency of treatment guidelines, relatively long trial-and-error phases of treatment optimization, and increasing use of complex combination therapies lacking empirical evidence. These suggest that the current definition of bipolar disorders based on clinical symptoms reflects a clinically and etiologically heterogeneous entity. Stratification of treatments for bipolar disorders based on biomarkers and improved clinical markers are greatly needed to increase the efficacy of currently available treatments and improve the chances of developing novel therapeutic approaches. This review provides a theoretical framework to identify biomarkers and summarizes the most promising markers for stratification regarding beneficial and adverse treatment effects. State and stage specifiers, neuropsychological tests, neuroimaging, and genetic and epigenetic biomarkers will be discussed with respect to their ability to predict the response to specific pharmacological and psychosocial psychotherapies for bipolar disorders. To date, the most reliable markers are derived from psychopathology and history-taking, while no biomarker has been found that reliably predicts individual treatment responses. This review underlines both the importance of clinical diagnostic skills and the need for biological research to identify markers that will allow the targeting of treatment specifically to sub-populations of bipolar patients who are more likely to benefit from a specific treatment and less likely to develop adverse reactions.
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Affiliation(s)
- Gregor Hasler
- Department of Molecular Psychiatry, University Hospital of Psychiatry, University of Bern, Bolligenstrasse 111, 3000 Bern, Switzerland.
| | - Andreas Wolf
- Department of Molecular Psychiatry, University Hospital of Psychiatry, University of Bern, Bolligenstrasse 111, 3000 Bern, Switzerland
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Pichler EM, Hattwich G, Grunze H, Muehlbacher M. Safety and tolerability of anticonvulsant medication in bipolar disorder. Expert Opin Drug Saf 2015; 14:1703-24. [PMID: 26359219 DOI: 10.1517/14740338.2015.1088001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Anticonvulsants (AC) are widely used and recommended as a treatment option in different phases of bipolar disorder (BD). In contrast to ample evidence for efficacy in acute mania, there is generally less unambiguous evidence for maintenance treatment or bipolar depression, and data on long-term tolerability in BD are sparse, although this varies greatly between different compounds. This review summarizes the clinically relevant tolerability and safety profile of ACs commonly used for the treatment of BD based on findings from randomized controlled trials (RCT). AREAS COVERED Systematic search of the English literature between January 1991 and May 2015 revealed a total of nine RCTs investigating valproate, five RCTs with carbamazepine and 8 with lamotrigine For these ACs we found information on side effect profiles for both acute and maintenance RCTs, albeit of varying quality, whereas for topiramate (five RCTs), gabapentin and esclicarbazepine acetate (one RCT each) only acute treatment RCTs have been published. Descriptive side effect profiles from open-label studies exist for several other ACs rarely used in BD, and are included in this review as a brief narrative chapter. EXPERT OPINION Whereas both valproate and carbamazepine are associated with, in part, severe adverse events, lamotrigine emerges as a relatively safe and well tolerated treatment option, especially in maintenance treatment and prevention of depressive relapse in BD. Lack of proven efficacy and side effect profile of other, less rigorously studied ACs restricts their use only to very selected BD cases.
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Affiliation(s)
- Eva Maria Pichler
- a Paracelsus Private Medical University, Department of Psychiatry and Psychotherapy , Ignaz Harrer Strasse 79, 5020 Salzburg, Austria +43 6 62 44 83 43 00 ; +43 6 62 44 83 43 04 ;
| | - Georg Hattwich
- a Paracelsus Private Medical University, Department of Psychiatry and Psychotherapy , Ignaz Harrer Strasse 79, 5020 Salzburg, Austria +43 6 62 44 83 43 00 ; +43 6 62 44 83 43 04 ;
| | - Heinz Grunze
- a Paracelsus Private Medical University, Department of Psychiatry and Psychotherapy , Ignaz Harrer Strasse 79, 5020 Salzburg, Austria +43 6 62 44 83 43 00 ; +43 6 62 44 83 43 04 ;
| | - Moritz Muehlbacher
- a Paracelsus Private Medical University, Department of Psychiatry and Psychotherapy , Ignaz Harrer Strasse 79, 5020 Salzburg, Austria +43 6 62 44 83 43 00 ; +43 6 62 44 83 43 04 ;
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