Duloxetine-induced hypomania: case report and brief review of the literature on SNRIs-induced mood switching

Managing Bipolar Disease Complicated with Psychosis in Conjunction with Polypharmacy, Parkinson’s Disease, and Multiple Comorbidities

The lifelong prevalence of bipolar disorder in adults, including subsyndromal forms, has increased over the years in the United States. By contrast, neurodegenerative diseases such as Parkinson’s disease have demonstrated an age-related rise in prevalence. As the global population manages to live longer thanks to sociomedical developments, it is expected to observe a rise in the occurrence of comorbid neuropsychiatric disorders. Herein, we present the case and management regimen of a 51-year-old female patient with multiple comorbidities and in the presence of polypharmacy. She was diagnosed with Parkinson’s disease and bipolar disorder type I alongside multiple comorbidities; her polypharmacy and medical history presented a significant clinical challenge in managing her condition. This case report focuses on the pharmacologic management of neuropsychiatric disorders titrated to this patient’s particular needs, which were complicated by psychosis and comorbidities.

Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention

Feeling irritable is a common experience, both in health and disease. In the context of psychiatric illnesses, it is a transdiagnostic phenomenon that features across all ages, and often causes significant distress and impairment. In mood disorders, irritability is near ubiquitous and plays a central role in diagnosis and yet, despite its prevalence, it remains poorly understood. A neurobiological model of irritability posits that, in children and adolescents, it is consequent upon deficits in reward and threat processing, involving regions such as the amygdala and frontal cortices. In comparison, in adults with mood disorders, the few studies that have been conducted implicate the amygdala, orbitofrontal cortices, and hypothalamus; however, the patterns of activity in these areas are at variance with the findings in youth. These age-related differences seem to extend to the neurochemistry of irritability, with links between increased monoamine transmission and irritability evident in adults, but aberrant levels of, and responses to, dopamine in youth. Presently, there are no specific treatments that have significant efficacy in reducing irritability in mood disorders. However, treatments that hold some potential and warrant further exploration include agents that act on serotonergic and dopaminergic systems, especially as irritability may serve as a prognostic indicator for overall clinical responsiveness to specific medications. Therefore, for understanding and treatment of irritability to advance meaningfully, it is imperative that an accurate definition and means of measuring irritability are developed. To achieve this, it is necessary that the subjective experience of irritability, both in health and illness, is better understood. These insights will inform an accurate, comprehensive, and valid interrogation of the qualities of irritability in health and illness, and allow not only a clinical appreciation of the phenomenon, but also a deeper understanding of its important role within the development and manifestation of mood disorders.

Black cohosh associated mania in a patient with unipolar depression

Black cohosh (actaea racemosa, cimicifuga racemosa) a popular complementary medicine, is commonly prescribed as an alternative drug to hormone replacement therapy for the treatment of menopause symptoms and menstrual pain. Studies on the black cohosh's psychological effects are generally focused on the perimenopausal depression and anxiety; and, its effects have been considered to be affiliated with its serotonergic and dopaminergic activities. We report a patient presenting with acute onset mania associated with black cohosh use, probably due to its psychopharmacological activities on serotonergic and dopaminergic receptors. We suggest that black cohosh must be used cautiously in the patients with history of unipolar depression or bipolar disorder.

SNRIs achieve faster antidepressant effects than SSRIs by elevating the concentrations of dopamine in the forebrain

Major depressive disorder (MDD) is a severe mental disorder with a high disability rate worldwide. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are the most common agents for antidepressant use. SSRIs and SNRIs are believed to achieve antidepressant effects through the activation of serotonergic or noradrenergic systems. However, whether the dopaminergic system is involved remains unclear. In our study, a genetically encoded dopamine sensor and in vivo fiber photometry recordings were used to measure the dopamine concentrations in the medial prefrontal cortex (mPFC) and nucleus accumbens (NAc) after acute intraperitoneal injection of SSRIs or SNRIs. Combined with the behavioral tests, we found that SNRIs increased dopamine concentrations in both the mPFC and the NAc and showed faster antidepressant effects than SSRIs. To verify the enhanced dopamine levels induce the faster antidepressant effects of SNRIs, we employed dopamine receptor antagonists to specifically block the dopaminergic function. The results showed that the faster antidepressant effects of SNRIs were weakened by the dopamine receptor antagonists. Altogether, our study reveals that SNRIs achieve faster antidepressant effects than SSRIs by elevating the dopamine concentrations in the mPFC and the NAc. Our work proposes further mechanisms for the first-line antidepressants, which provides more basis for clinical treatments. This article is part of the special issue on Stress, Addiction and Plasticity.

Dosage-related nature of escitalopram treatment-emergent mania/hypomania: a case series

OBJECTIVE

Several studies have documented that treatment with various antidepressant agents can result in mood switching during major depressive episodes. Escitalopram, one of the newer selective serotonin reuptake inhibitors (SSRIs), is considered preferable due to its relatively high efficacy and acceptability. Although a few cases of escitalopram treatment-emergent mania have been reported, it remains unknown whether this effect is dose-related.

METHOD

In the present report, we discuss three cases of treatment-emergent mania/hypomania in patients receiving escitalopram for major depressive episodes. No patients had a family or personal history of bipolar disorder.

RESULTS

In all three cases, manic or hypomanic symptoms emerged within 1 month right after the dosage of escitalopram was increased to 20 mg/day. Moreover, manic episodes subsided as the dosage of escitalopram was reduced. Mood switching was not observed after the cessation of escitalopram treatment.

CONCLUSION

Our case series indicates that escitalopram may induce treatment-emergent mania/hypomania in a dose-related manner. Treatment at lower doses and with careful upward titration might be favorable in certain patients with bipolar depression and major depressive disorder in order to minimize the risk of mood switching.

Mental Healthcare Delivery in Rural Greece: A 10-year Account of a Mobile Mental Health Unit

Introduction:

Patients living in rural and remote areas may have limited access to mental healthcare due to lack of facilities and socioeconomic reasons, and this is the case of rural areas in Eastern Europe countries. In Greece, community mental health service delivery in rural areas has been implemented through the development of the Mobile Mental Health Units (MMHUs).

Methods:

We present a 10-year account of the operation of the MMHU of the prefectures of Ioannina and Thesprotia (MMHU I-T) and report on the impact of the service on mental health delivery in the catchment area. The MMHU I-T is a multidisciplinary community mental health team which delivers services in rural and mountainous areas of Northwest Greece.

Results:

The MMHU I-T has become an integral part of the local primary care system and is well known to the population of the catchment area. By the end of 2016, the majority of patients (60%) were self-referred or family-referred, compared to 24% in the first 2 years. Currently, the number of active patients is 293 (mean age 63 years, 49.5% are older adults), and the mean caseload for each member of the team is 36.6. A significant proportion of patients (28%) receive care with regular domiciliary visits, and the provision of home-based care was correlated with the age of the patients. Within the first 2 years of operation of the MMHU I-T hospitalizations of treatment, engaged patients were reduced significantly by 30.4%, whereas the treatment engagement rates of patients with psychotic disorders were 67.2% in 5 years.

Conclusions:

The MMHU I-T and other similar units in Greece are a successful paradigm of a low-cost service which promotes mental health in rural, remote, and deprived areas. This model of care may be informative for clinical practice and health policy given the ongoing recession and health budget cuts. It suggests that rural mental healthcare may be effectively delivered by integrating generic community mental health mobile teams into the primary care system.

Prevalence of fibromyalgia and co-morbid bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Fibromyalgia (FM) is a chronic disorder with high morbidity and significant health service utilization costs. Few studies have reported on the phenotypic overlap of FM and bipolar disorder (BD). The aim of this review is to qualitatively and quantitatively summarize the results and clinical implications of the extant literature on the co-occurrence of FM and BD.

METHODS

A systematic search of PubMed/Medline, Cochrane, PsycINFO, CINAHL and Embase was conducted to search for relevant articles. Articles were included if incidence and/or prevalence of BD was determined in the FM sample. Results of prevalence were pooled from all studies. Pooled odds ratio (OR) was calculated based on case-control studies using standard meta-analytic methods.

RESULTS

A total of nine studies were included. The pooled rate of BD comorbidity in samples of FM patients was 21% (n=678); however, results varied greatly as a function of study methodology. Case-controlled studies revealed a pooled OR of 7.55 of BD co-morbidity in samples of FM patients [95% Confidence Interval (CI)=3.9-14.62, FM n=268, controls n=413] with low heterogeneity (I(2)=0%).

LIMITATIONS

The current study was limited by the low number of available studies and heterogeneity of study methods and results.

CONCLUSIONS

These data strongly suggest an association between BD and FM. Future studies employing a validated diagnostic screen are needed in order to more accurately determine the prevalence of BD in FM. An adequate psychiatric assessment is recommended in FM patients with suspected symptoms consistent with BD prior to administration of antidepressants in the treatment of FM.

Carbamazepine in bipolar disorder with pain: reviewing treatment guidelines

OBJECTIVE

To determine if any monotherapy drug treatment has robust efficacy to treat comorbid bipolar disorder and chronic pain.

DATA SOURCES

The American Psychiatric Association (APA) treatment guidelines for bipolar mood disorder and the 2012 Cochrane database for pain disorders.

STUDY SELECTION

We relied on the treatment guides to determine if the drugs that are APA guideline-supported to treat bipolar disorder have supporting data from the Cochrane database for chronic pain.

DATA SYNTHESIS

No single drug was mentioned by either guideline to treat this comorbidity. However, carbamazepine was the only drug that has guideline-supported robust efficacy in the management of each condition separately.

CONCLUSIONS

Carbamazepine was found to have strong preclinical data for the treatment of comorbid bipolar mood disorder and chronic pain disorders. While requiring more studies in this population, we propose that this treatment modality may benefit patients.

Duloxetine in affective disorders: a naturalistic study on psychiatric and medical comorbidity, use in association and tolerability across different age groups

Objective:

Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), is currently approved in many countries for the treatment of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). The present naturalistic study was aimed to investigate tolerability of Duloxetine in a sample of patients with affective disorders and psychiatric/medical comorbidity, comparing tolerability in monotherapy versus polytherapy and across different age groups.

Methods:

The sample included 165 patients, affected by anxiety and/or mood disorders with or without comorbidity, who had been taken Duloxetine for at least 1 month. Sample variables were collected through a retrospective chart review.

Results:

Most common primary diagnoses were MDD (49.1 %), Bipolar Disorder (BD) (15.7 %) and GAD (5.5%). The 40 % of the sample had psychiatric comorbidity: in particular, anxiety disorders (15.8 %) (GAD 7.9%, Panic Disorder –PD- 7.3%) and personality disorders (9.1%) as the most frequent ones. With respect to medical comorbidities (68% of the sample), hypertension (12.1%) and diabetes (7.3%) were the most common ones. Mean duration of treatment and dosage of Duloxetine were, respectively, 11 months (± 9.1) and 70 mg/day (± 28.6). The 68 % of the sample received Duloxetine in association with other drugs. Minor side-effects, in particular drowsiness and gastrointestinal problems, were reported by 15 % of the sample. No difference in terms of tolerability across distinct groups, divided on the basis of mono- vs polytherapy as well as of different age, was found.

Conclusion:

Duloxetine, mostly administered in patients with affective disorders with psychiatric/ medical comorbidity and in association with other drugs, appeared to be well tolerated, showing limited rates of side effects of mild intensity. Further naturalistic studies are warranted to confirm present results.