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Broers B, Bianchi F. Cannabinoids for Behavioral Symptoms in Dementia: An Overview. PHARMACOPSYCHIATRY 2024; 57:160-168. [PMID: 38447959 DOI: 10.1055/a-2262-7837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Dementia, with loss of memory, cognitive abilities, and independent daily functioning, is increasing worldwide, related to an aging population. Currently, there is no curative treatment for dementia. Treatment of the frequently occurring behavioral and psychological symptoms of dementia (BPSD) is partially effective and associated with significant side effects. Cannabinoids are lipophilic molecules acting on the CB1 end CB2 receptors, essential for main biological processes such as sleep, appetite, memory, and pain. Cannabinoids might have a positive impact on amyloid formation in Alzheimer's disease, the main form of dementia, and on BPSD symptoms. Most knowledge currently concerns delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). In the context of dementia and BPSD, THC might be beneficial for associated spasticity and possible pain or lack of appetite and CBD probably works better on sleep, agitation, and anxiety. This overview of prospective clinical studies and randomized clinical trials, published between 2005 and April 2023, using cannabinoids for BPSD suggests that older studies using low-dose oral synthetic THC showed no positive results. Still, more recent studies using THC/CBD-based oral medication at higher doses show promising results and are feasible and safe in this elderly polymedicated population. Several RCTs are ongoing and planned worldwide, and we hope other trials will follow to establish clinical efficiency and optimal dosing, as well as other outcomes such as deprescribing other medications and facilitation of care. We suggest that researchers also address the more sociological aspects of prescribing cannabinoids for dementia and BPSD in their specific context.
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Affiliation(s)
- Barbara Broers
- Geneva University Hospitals, Primary Care Division, Geneva, Switzerland
| | - Federica Bianchi
- Geneva University Hospitals, Palliative Care Division, Geneva, Switzerland
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2
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Murphy K, Khan A, Bachu A, Tampi R. Treatment of behavioral and psychological symptoms of dementia using transcranial magnetic stimulation: a systematic review. Int Psychogeriatr 2023; 35:611-622. [PMID: 36803624 DOI: 10.1017/s1041610223000091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Behavioral and psychological symptoms of dementia (BPSD) are a group of noncognitive symptoms that occur commonly among individuals with dementia. These symptoms worsen the morbidity and mortality among individuals with dementia and significantly increase the cost of caring for these individuals. Transcranial magnetic stimulation (TMS) has been shown to have some benefits in the treatment of BPSD. This review provides an updated summary of the effect of TMS on BPSD. METHODS We conducted a systematic review of PubMed, Cochrane, and Ovid databases on the use of TMS to treat BPSD. RESULTS We found 11 randomized controlled studies that evaluated the use of TMS among individuals with BPSD. Three of these studies examined the effect of TMS on apathy, two of which showed significant benefit. Seven studies showed that TMS significantly improves BPSD: six using repetitive transcranial magnetic stimulation (rTMS) and one using transcranial direct current stimulation (tDCS). Four studies, two evaluating tDCS, one evaluating rTMS, and one evaluating intermittent theta-burst stimulation (iTBS) showed a nonsignificant impact of TMS on BPSD. Adverse events were predominantly mild and transitory in all studies. CONCLUSION Available data from this review indicate that rTMS is beneficial for individuals with BPSD, especially among individuals with apathy, and is well tolerated. However, more data are needed to prove the efficacy of tDCS and iTBS. Additionally, more randomized controlled trials with longer treatment follow-up and standardized use of BPSD assessments are needed to determine the best dose, duration, and modality for effective treatment of BPSD.
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Affiliation(s)
- Kayla Murphy
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amber Khan
- Montefiore Medical Center, Bronx, NY, USA
| | - Anil Bachu
- Department of Psychiatry, Baptist Health-UAMS, North Little Rock, AR, USA
| | - Rajesh Tampi
- Department of Psychiatry, Creighton University School of Medicine, Omaha, NE, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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3
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Solmi M, De Toffol M, Kim JY, Choi MJ, Stubbs B, Thompson T, Firth J, Miola A, Croatto G, Baggio F, Michelon S, Ballan L, Gerdle B, Monaco F, Simonato P, Scocco P, Ricca V, Castellini G, Fornaro M, Murru A, Vieta E, Fusar-Poli P, Barbui C, Ioannidis JPA, Carvalho AF, Radua J, Correll CU, Cortese S, Murray RM, Castle D, Shin JI, Dragioti E. Balancing risks and benefits of cannabis use: umbrella review of meta-analyses of randomised controlled trials and observational studies. BMJ 2023; 382:e072348. [PMID: 37648266 PMCID: PMC10466434 DOI: 10.1136/bmj-2022-072348] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To systematically assess credibility and certainty of associations between cannabis, cannabinoids, and cannabis based medicines and human health, from observational studies and randomised controlled trials (RCTs). DESIGN Umbrella review. DATA SOURCES PubMed, PsychInfo, Embase, up to 9 February 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Systematic reviews with meta-analyses of observational studies and RCTs that have reported on the efficacy and safety of cannabis, cannabinoids, or cannabis based medicines were included. Credibility was graded according to convincing, highly suggestive, suggestive, weak, or not significant (observational evidence), and by GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (RCTs). Quality was assessed with AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2). Sensitivity analyses were conducted. RESULTS 101 meta-analyses were included (observational=50, RCTs=51) (AMSTAR 2 high 33, moderate 31, low 32, or critically low 5). From RCTs supported by high to moderate certainty, cannabis based medicines increased adverse events related to the central nervous system (equivalent odds ratio 2.84 (95% confidence interval 2.16 to 3.73)), psychological effects (3.07 (1.79 to 5.26)), and vision (3.00 (1.79 to 5.03)) in people with mixed conditions (GRADE=high), improved nausea/vomit, pain, spasticity, but increased psychiatric, gastrointestinal adverse events, and somnolence among others (GRADE=moderate). Cannabidiol improved 50% reduction of seizures (0.59 (0.38 to 0.92)) and seizure events (0.59 (0.36 to 0.96)) (GRADE=high), but increased pneumonia, gastrointestinal adverse events, and somnolence (GRADE=moderate). For chronic pain, cannabis based medicines or cannabinoids reduced pain by 30% (0.59 (0.37 to 0.93), GRADE=high), across different conditions (n=7), but increased psychological distress. For epilepsy, cannabidiol increased risk of diarrhoea (2.25 (1.33 to 3.81)), had no effect on sleep disruption (GRADE=high), reduced seizures across different populations and measures (n=7), improved global impression (n=2), quality of life, and increased risk of somnolence (GRADE=moderate). In the general population, cannabis worsened positive psychotic symptoms (5.21 (3.36 to 8.01)) and total psychiatric symptoms (7.49 (5.31 to 10.42)) (GRADE=high), negative psychotic symptoms, and cognition (n=11) (GRADE=moderate). In healthy people, cannabinoids improved pain threshold (0.74 (0.59 to 0.91)), unpleasantness (0.60 (0.41 to 0.88)) (GRADE=high). For inflammatory bowel disease, cannabinoids improved quality of life (0.34 (0.22 to 0.53) (GRADE=high). For multiple sclerosis, cannabinoids improved spasticity, pain, but increased risk of dizziness, dry mouth, nausea, somnolence (GRADE=moderate). For cancer, cannabinoids improved sleep disruption, but had gastrointestinal adverse events (n=2) (GRADE=moderate). Cannabis based medicines, cannabis, and cannabinoids resulted in poor tolerability across various conditions (GRADE=moderate). Evidence was convincing from observational studies (main and sensitivity analyses) in pregnant women, small for gestational age (1.61 (1.41 to 1.83)), low birth weight (1.43 (1.27 to 1.62)); in drivers, car crash (1.27 (1.21 to 1.34)); and in the general population, psychosis (1.71 (1.47 to 2.00)). Harmful effects were noted for additional neonatal outcomes, outcomes related to car crash, outcomes in the general population including psychotic symptoms, suicide attempt, depression, and mania, and impaired cognition in healthy cannabis users (all suggestive to highly suggestive). CONCLUSIONS Convincing or converging evidence supports avoidance of cannabis during adolescence and early adulthood, in people prone to or with mental health disorders, in pregnancy and before and while driving. Cannabidiol is effective in people with epilepsy. Cannabis based medicines are effective in people with multiple sclerosis, chronic pain, inflammatory bowel disease, and in palliative medicine but not without adverse events. STUDY REGISTRATION PROSPERO CRD42018093045. FUNDING None.
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Affiliation(s)
- Marco Solmi
- Department of Psychiatry, University of Ottawa, Ontario, ON, Canada
- On Track: The Champlain First Episode Psychosis Program, Department of Mental Health, The Ottawa Hospital, Ontario, ON, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Early Psychosis: Interventions and Clinical detection Lab, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychosis Studies, King's College London, London, UK
- Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton, and NHS Trust, Southampton, UK
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Marco De Toffol
- Psychiatry Unit, Veris Delli Ponti Scorrano Hospital, Department of Mental Health, ASL Lecce, Lecce, Italy
| | - Jong Yeob Kim
- Yonsei University College of Medicine, Seoul, South Korea
| | - Min Je Choi
- Yonsei University College of Medicine, Seoul, South Korea
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Trevor Thompson
- Centre of Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Joseph Firth
- Division of Psychology and Mental Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alessandro Miola
- Neurosciences Department, Padua Neuroscience Center, University of Padua, Italy
| | - Giovanni Croatto
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | - Francesca Baggio
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | - Silvia Michelon
- Department of Mental Health, AULSS 7 Pedemontana Veneto, Italy
| | - Luca Ballan
- Department of Mental Health, AULSS 7 Pedemontana Veneto, Italy
| | - Björn Gerdle
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Francesco Monaco
- Department of Mental Health, Asl Salerno, Salerno, Italy
- European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Pierluigi Simonato
- Department of Clinical, Pharmaceutical and Biological Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Paolo Scocco
- Mental Health Department, ULSS 6 Euganea, Padova, Italy
| | - Valdo Ricca
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giovanni Castellini
- Psychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, University School of Medicine Federico II, Naples, Italy
| | - Andrea Murru
- Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical detection Lab, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychosis Studies, King's College London, London, UK
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
- Meta-Research Innovation Center Berlin, Berlin Institute of Health, Charité Universitätsmedizin, Berlin, Germany
- Departments of Medicine, of Epidemiology and Population Health, of Biomedical Data Science, and of Statistics, Stanford University, Stanford, CA, USA
| | - Andrè F Carvalho
- IMPACT - The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, VIC, Australia
| | - Joaquim Radua
- Institut d'Investigacions Biomediques August Pi i Sunyer, CIBERSAM, Instituto de Salud Carlos III, University of Barcelona, Barcelona, Spain
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Samuele Cortese
- Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton, and NHS Trust, Southampton, UK
- Clinical and Experimental Sciences (Central Nervous System and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
- Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York City, New York, NY, USA
| | - Robin M Murray
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College of London, London, UK
| | - David Castle
- Department of Psychiatry, University of Tasmania, Sandy Bay, TAS, Australia
- Co-Director, Centre for Mental Health Service Innovation, Department of Health, Tasmania, Australia
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Severance Underwood Meta-research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - Elena Dragioti
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Research Laboratory Psychology of Patients, Families and Health Professionals, Department of Nursing, School of Health Sciences, University of Ioannina, Ioannina, Greece
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4
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Wolfe D, Corace K, Butler C, Rice D, Skidmore B, Patel Y, Thayaparan P, Michaud A, Hamel C, Smith A, Garber G, Porath A, Conn D, Willows M, Abramovici H, Thavorn K, Kanji S, Hutton B. Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature. PLoS One 2023; 18:e0281826. [PMID: 36800328 PMCID: PMC9937508 DOI: 10.1371/journal.pone.0281826] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/31/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals. OBJECTIVE To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults. METHODS Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings. FINDINGS From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding. DISCUSSION The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.
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Affiliation(s)
- Dianna Wolfe
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kim Corace
- Institute of Mental Health Research at The Royal, University of Ottawa, Ottawa, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | | | | | | | | | - Alan Michaud
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Andra Smith
- School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Canada
| | - Gary Garber
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Amy Porath
- Canadian Center for Substance Use and Addiction, Ottawa, Canada
| | - David Conn
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Baycrest Health Sciences, Toronto, Canada
| | - Melanie Willows
- Institute of Mental Health Research at The Royal, University of Ottawa, Ottawa, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Hanan Abramovici
- Health Canada, Office of Cannabis Science and Surveillance, Ottawa, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Salmaan Kanji
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- * E-mail:
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5
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Exploring the Potential of Cannabinoid Nanodelivery Systems for CNS Disorders. Pharmaceutics 2023; 15:pharmaceutics15010204. [PMID: 36678832 PMCID: PMC9863859 DOI: 10.3390/pharmaceutics15010204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
Cannabinoids have a major therapeutic value in a variety of disorders. The concepts of cannabinoids are difficult to develop, but they can be used and are advantageous for a number of diseases that are not sufficiently managed by existing treatments. Nanoconjugation and encapsulation techniques have been shown to be effective in improving the delivery and the therapeutic effectiveness of drugs that are poorly soluble in water. Because the bioavailability of cannabinoids is low, the challenge is to explore different administration methods to improve their effectiveness. Because cannabinoids cross the blood-brain-barrier (BBB), they modify the negative effects of inflammatory processes on the BBB and may be a key factor in the improvement of BBB function after ischemic disease or other conditions. This review discusses various types of cannabinoid administration, as well as nanotechnologies used to improve the bioavailability of these compounds in CNS diseases.
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Kamaruzzaman MA, Romli MH, Abas R, Vidyadaran S, Hidayat Baharuldin MT, Nasaruddin ML, Thirupathirao V, Sura S, Warsito K, Mohd Nor NH, Azwaruddin MA, Alshawsh MA, Mohd Moklas MA. Regulatory role of the endocannabinoid system on glial cells toward cognitive function in Alzheimer's disease: A systematic review and meta-analysis of animal studies. Front Pharmacol 2023; 14:1053680. [PMID: 36959856 PMCID: PMC10028478 DOI: 10.3389/fphar.2023.1053680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/08/2023] [Indexed: 03/06/2023] Open
Abstract
Objective: Over the last decade, researchers have sought to develop novel medications against dementia. One potential agent under investigation is cannabinoids. This review systematically appraised and meta-analyzed published pre-clinical research on the mechanism of endocannabinoid system modulation in glial cells and their effects on cognitive function in animal models of Alzheimer's disease (AD). Methods: A systematic review complying with PRISMA guidelines was conducted. Six databases were searched: EBSCOHost, Scopus, PubMed, CINAHL, Cochrane, and Web of Science, using the keywords AD, cannabinoid, glial cells, and cognition. The methodological quality of each selected pre-clinical study was evaluated using the SYRCLE risk of bias tool. A random-effects model was applied to analyze the data and calculate the effect size, while I2 and p-values were used to assess heterogeneity. Results: The analysis included 26 original articles describing (1050 rodents) with AD-like symptoms. Rodents treated with cannabinoid agonists showed significant reductions in escape latency (standard mean difference [SMD] = -1.26; 95% confidence interval [CI]: -1.77 to -0.76, p < 0.00001) and ability to discriminate novel objects (SMD = 1.40; 95% CI: 1.04 to 1.76, p < 0.00001) compared to the control group. Furthermore, a significant decrease in Aβ plaques (SMD = -0.91; 95% CI: -1.55 to -0.27, p = 0.006) was observed in the endocannabinoid-treated group compared to the control group. Trends were observed toward neuroprotection, as represented by decreased levels of glial cell markers including glial fibrillary acid protein (SMD = -1.47; 95% CI: -2.56 to -0.38, p = 0.008) and Iba1 (SMD = -1.67; 95% CI: -2.56 to -0.79, p = 0.0002). Studies on the wild-type mice demonstrated significantly decreased levels of pro-inflammatory markers TNF-α, IL-1, and IL-6 (SMD = -2.28; 95% CI: -3.15 to -1.41, p = 0.00001). Despite the non-significant decrease in pro-inflammatory marker levels in transgenic mice (SMD = -0.47; 95% CI: -1.03 to 0.08, p = 0.09), the result favored the endocannabinoid-treated group over the control group. Conclusion: The revised data suggested that endocannabinoid stimulation promotes cognitive function via modulation of glial cells by decreasing pro-inflammatory markers in AD-like rodent models. Thus, cannabinoid agents may be required to modulate the downstream chain of effect to enhance cognitive stability against concurrent neuroinflammation in AD. Population-based studies and well-designed clinical trials are required to characterize the acceptability and real-world effectiveness of cannabinoid agents. Systematic Review Registration: [https://inplasy.com/inplasy-2022-8-0094/], identifier [Inplasy Protocol 3770].
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Affiliation(s)
- Mohd Amir Kamaruzzaman
- Department of Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | - Muhammad Hibatullah Romli
- Department of Nursing and Rehabilitation, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | - Razif Abas
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | - Sharmili Vidyadaran
- Department of Pathology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | | | | | | | - Sreenivasulu Sura
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
- Department of Preclinical Sciences, Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, Kampar, Malaysia
| | - Kabul Warsito
- Department of Agrotechnology, Faculty of Science and Technology, University of Pembangunan Panca Budi, Medan, Indonesia
| | - Nurul Huda Mohd Nor
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | - Muhammad Amsyar Azwaruddin
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
| | - Mohammed Abdullah Alshawsh
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Science, Monash University, Clayton, VIC, Australia
- *Correspondence: Mohamad Aris Mohd Moklas, ; Mohammed Abdullah Alshawsh,
| | - Mohamad Aris Mohd Moklas
- Department of Human Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Kuala Lumpur, Malaysia
- *Correspondence: Mohamad Aris Mohd Moklas, ; Mohammed Abdullah Alshawsh,
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7
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Maziero MP, Rocha NP, Teixeira AL. Antipsychotics in Alzheimer's Disease: Current Status and Therapeutic Alternatives. Curr Alzheimer Res 2023; 20:682-691. [PMID: 38409713 DOI: 10.2174/0115672050287534240215052417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/28/2024]
Abstract
Psychosis and hyperactive behaviors, such as agitation and wandering, affect a significant proportion of patients with Alzheimer's disease (AD). These symptoms are often treated with antipsychotics, usually in an off-label approach. This mini-review provides an updated perspective on the pharmacological approach for the neuropsychiatric symptoms (NPS) in AD. The results of new studies have provided a better understanding of AD-related NPS management, but high-quality evidence still needs to be obtained. Herein, we argue for a more cautious approach to the use of antipsychotics in AD and highlight the importance of exploring alternative treatments for NPS. By doing so, we can ensure that patients with AD receive optimal care that is both effective and safe.
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Affiliation(s)
- Maria Paula Maziero
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
| | - Natalia P Rocha
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
| | - Antonio L Teixeira
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Texas 77030, USA
- The Glenn Biggs Institute for Alzheimer's & Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, TX, USA
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8
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Ramm RM, Lerner ZI, Levy-Meeks GS, Burke RV, Raven MC, Song A, Glass MH. A Case Report of Treatment-Resistant Agitation in Dementia with Lewy Bodies: Medical Marijuana as an Alternative to Antipsychotics. J Palliat Med 2022; 26:737-740. [PMID: 36576970 DOI: 10.1089/jpm.2022.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Palliative care teams are often consulted to assist in treating persistent dementia-related behavioral issues. Delta-9-tetrahydrocannabinol (THC) offers an alternative to traditional antipsychotic drugs in the long-term management of dementia with behavioral change. We present the case of an 85-year-old man with dementia with Lewy bodies with worsening aggression refractory to antipsychotic management. Multiple regimens of antipsychotics failed both in the outpatient and inpatient settings. After exhausting other options and in the setting of worsening agitation, a tincture of THC was prescribed. After starting THC tincture, the patient's behavior rapidly improved, and he was discharged home to the care of his spouse. The challenges of prescribing and obtaining THC are discussed.
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Affiliation(s)
- Rebecca M Ramm
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Zachary I Lerner
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Garrett S Levy-Meeks
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Texas Houston School of Medicine, Houston, Texas, USA
| | - Rebecca V Burke
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mary C Raven
- Medical Director, Palliative Medicine Program, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana, USA
| | - Amanda Song
- Department of Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Marcia H Glass
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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9
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Tampi RR, Tampi DJ, Farheen SA, Ochije SI, Joshi P. Propranolol for the management of behavioural and psychological symptoms of dementia. Drugs Context 2022; 11:dic-2022-8-3. [PMID: 36544625 PMCID: PMC9753600 DOI: 10.7573/dic.2022-8-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
Propranolol is a β-adrenergic antagonist used in the management of hypertension, cardiac arrhythmia, and angina pectoris. There is some evidence that propranolol may benefit individuals with behavioural and psychological symptoms of dementia (BPSD). A total of three case series, one randomized controlled trial and one case report were identified (from a literature search of three major databases: PubMed, Ovid, and Cochrane collaboration) that assessed the use of propranolol for the management of BPSD. From these studies, it appears that propranolol improves BPSD, including agitation and aggression. Propranolol is also well tolerated with no significant bradycardia or hypotension noted in these studies. Current data on the use of propranolol for the management of BPSD are limited in comparison to other pharmacological agents (atypical antipsychotics, antidepressants, acetylcholinesterase inhibitors, memantine, and cannabinoids) and treatment modalities (repetitive transcranial magnetic stimulation and electroconvulsive therapy). The efficacy and safety of these treatments among individuals with BPSD has been evaluated in multiple controlled studies. In clinical practice, the routine use of propranolol among people with BPSD cannot be recommended at this time given the limited data. However, propranolol can be trialled among individuals with BPSD when symptoms have not responded adequately to other medications. Propranolol may also be used prior to embarking on trials of repetitive transcranial magnetic stimulation and electroconvulsive therapy among people with BPSD given the greater acceptance of this medication in the general population.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, Creighton University School of Medicine, Omaha, NE, USA,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA,Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA
| | - Deena J Tampi
- Co-Founder and Managing Principal, Behavioral Health Advisory Group, Princeton, NJ, USA
| | - Syeda Arshiya Farheen
- Department of Psychiatry & Behavioral Sciences, Cleveland Clinic Akron General, Akron, OH, USA
| | - Sochima I Ochije
- Department of Psychiatry, Emory University Hospital, Atlanta GA, USA
| | - Pallavi Joshi
- Department of Psychiatry, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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10
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Tampi RR, Jeste DV. Dementia Is More Than Memory Loss: Neuropsychiatric Symptoms of Dementia and Their Nonpharmacological and Pharmacological Management. Am J Psychiatry 2022; 179:528-543. [PMID: 35921394 DOI: 10.1176/appi.ajp.20220508] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neuropsychiatric symptoms of dementia (NPS) are a group of noncognitive symptoms that occur in over 90% of individuals with dementia. NPS seem to result from a complex interaction among various biological, psychosocial, and environmental factors, and they are associated with greater morbidity and mortality, higher caregiver burden and burnout, high risk of nursing home placement, and increased cost of care for patients with dementia. Use of standardized assessment tools like the Neuropsychiatric Inventory can assist with qualifying and quantifying NPS. In this review, the authors evaluate the evidence for efficacy and safety of nonpharmacological and pharmacological interventions for treating NPS, mostly based on published meta-analyses. Commonly prescribed medications include atypical antipsychotics, acetylcholinesterase inhibitors, memantine, antidepressants, and mood stabilizers. There are also limited data on cannabinoids, repetitive transcranial magnetic stimulation, and ECT in individuals with NPS. Available evidence indicates that several nonpharmacological interventions are beneficial in the management of NPS and are recommended as first-line treatments. Pharmacotherapy should be reserved for the treatment of more severe or refractory NPS or where nonpharmacological management is not feasible. Atypical antipsychotics have shown mostly modest benefit in reducing NPS, and their use is limited by their adverse effect profiles. Recent investigations suggest potential strategies for preventing or at least reducing the risk of dementia and NPS. The authors conclude with brief guidelines for clinical practice as well as future research.
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Affiliation(s)
- Rajesh R Tampi
- Department of Psychiatry, Creighton University School of Medicine, Omaha (Tampi); Department of Psychiatry, Yale School of Medicine, New Haven, Conn. (Tampi); Department of Psychiatry, Department of Neurosciences, and Sam and Rose Stein Institute for Research on Aging, University of California San Diego, San Diego (Jeste)
| | - Dilip V Jeste
- Department of Psychiatry, Creighton University School of Medicine, Omaha (Tampi); Department of Psychiatry, Yale School of Medicine, New Haven, Conn. (Tampi); Department of Psychiatry, Department of Neurosciences, and Sam and Rose Stein Institute for Research on Aging, University of California San Diego, San Diego (Jeste)
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11
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Hallinan CM, Eden E, Graham M, Greenwood LM, Mills J, Popat A, Truong L, Bonomo Y. Over the counter low-dose cannabidiol: A viewpoint from the ACRE Capacity Building Group. J Psychopharmacol 2022; 36:661-665. [PMID: 34344208 DOI: 10.1177/02698811211035394] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Amidst growing global acceptance of medicinal cannabinoids as a potential therapeutic interest in cannabidiol (CBD) is increasing. In Australia in 2020, a government inquiry examined the barriers that the public are experiencing in accessing medicinal cannabis. A number of recommendations to improve access were made. In response to these recommendations, the Australian therapeutics regulatory authority down-scheduled CBD from Prescription Only (Schedule 4) to Pharmacist Only (Schedule 3). As a group of early to mid-career researchers of the Australian Centre for Cannabinoid Clinical and Research Excellence (ACRE), we propose some considerations in relation to over-the-counter availability of CBD and opportunities to improve knowledge about its potential therapeutic benefits alongside its increased uptake.
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Affiliation(s)
- Christine Mary Hallinan
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.,Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Edward Eden
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | - Myfanwy Graham
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia
| | | | - Jessica Mills
- School of Psychology, Illawarra Health and Medical Research Institute (IHMRI), Faculty of the Arts Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, Australia
| | - Amirali Popat
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Woolloongabba, QLD, Australia
| | - Linda Truong
- School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, Sydney Children's Hospital Randwick, Sydney, NSW, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yvonne Bonomo
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.,Department of Addiction Medicine, St Vincent's Hospital Melbourne, VIC, Australia
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12
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Bahji A, Breward N, Duff W, Absher N, Patten SB, Alcorn J, Mousseau DD. Cannabinoids in the management of behavioral, psychological, and motor symptoms of neurocognitive disorders: a mixed studies systematic review. J Cannabis Res 2022; 4:11. [PMID: 35287749 PMCID: PMC8922797 DOI: 10.1186/s42238-022-00119-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Abstract
Aim
We undertook this systematic review to determine the efficacy and safety of cannabis-based medicine as a treatment for behavioral, psychological, and motor symptoms associated with neurocognitive disorders.
Methods
We conducted a PRISMA-guided systematic review to identify studies using cannabis-based medicine to treat behavioral, psychological, and motor symptoms among individuals with Alzheimer's disease (AD) dementia, Parkinson’s disease (PD), and Huntington’s disease (HD). We considered English-language articles providing original data on three or more participants, regardless of design.
Findings
We identified 25 studies spanning 1991 to 2021 comprised of 14 controlled trials, 5 pilot studies, 5 observational studies, and 1 case series. In most cases, the cannabinoids tested were dronabinol, whole cannabis, and cannabidiol, and the diagnoses included AD (n = 11), PD (n = 11), and HD (n = 3). Primary outcomes were motor symptoms (e.g., dyskinesia), sleep disturbance, cognition, balance, body weight, and the occurrence of treatment-emergent adverse events.
Conclusions
A narrative summary of the findings from the limited number of studies in the area highlights an apparent association between cannabidiol-based products and relief from motor symptoms in HD and PD and an apparent association between synthetic cannabinoids and relief from behavioral and psychological symptoms of dementia across AD, PD, and HD. These preliminary conclusions could guide using plant-based versus synthetic cannabinoids as safe, alternative treatments for managing neuropsychiatric symptoms in neurocognitive vulnerable patient populations.
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Viana MDB, de Aquino PEA, Estadella D, Ribeiro DA, Viana GSDB. Cannabis sativa and Cannabidiol: A Therapeutic Strategy for the Treatment of Neurodegenerative Diseases? Med Cannabis Cannabinoids 2022; 5:207-219. [PMID: 36467781 PMCID: PMC9710321 DOI: 10.1159/000527335] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/04/2022] [Indexed: 08/27/2023] Open
Abstract
This work is a literature review, presenting the current state of the use of cannabinoids on neurodegenerative diseases. The emphasis is on Parkinson's (PD) and Alzheimer's (AD) diseases, the two most prevalent neurological diseases. The review goes from Cannabis sativa and its hundreds of bioactive compounds to Δ9-tetrahydrocannabinol (THC) and mainly cannabidiol (CBD) and their interactions with the endocannabinoid receptors (CB1 and CB2). CBD molecular targets were also focused on to explain its neuroprotective action mechanism on neurodegenerative diseases. Although THC is the main psychoactive component of C. sativa, and it may induce transient psychosis-like symptoms, growing evidence suggests that CBD may have protective effects against the psychotomimetic effects of THC and therapeutic properties. Furthermore, a great number of recent works on the neuroprotective and anti-inflammatory CBD effects and its molecular targets are also reviewed. We analyzed CBD actions in preclinical and in clinical trials, conducted with PD and AD patients. Although the data on preclinical assays are more convincing, the same is not true with the clinical data. Despite the consensus among researchers on the potential of CBD as a neuroprotective agent, larger and well-designed randomized clinical trials will be necessary to gather conclusive results concerning the use of CBD as a therapeutic strategy for the treatment of diseases such as PD and AD.
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Affiliation(s)
- Milena de Barros Viana
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Campus Santos, Santos, Brazil
| | | | - Débora Estadella
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Campus Santos, Santos, Brazil
| | - Daniel Araki Ribeiro
- Department of Biosciences, Federal University of São Paulo (UNIFESP), Campus Santos, Santos, Brazil
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14
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Pautex S, Bianchi F, Daali Y, Augsburger M, de Saussure C, Wampfler J, Curtin F, Desmeules J, Broers B. Cannabinoids for behavioral symptoms in severe dementia: Safety and feasibility in a long-term pilot observational study in nineteen patients. Front Aging Neurosci 2022; 14:957665. [PMID: 36247984 PMCID: PMC9557769 DOI: 10.3389/fnagi.2022.957665] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/07/2022] [Indexed: 11/20/2022] Open
Abstract
Context The management of behavioral symptoms and rigidity in patients with dementia constitutes a significant challenge. Short-term studies suggest an interest in the use of medical cannabis, but long-term data are lacking. Objectives The objective of this study was to investigate the feasibility and long-term safety of administering tetrahydrocannabinol/cannabidiol (THC/CBD) treatment as an additional drug to a poly medicated population with severe dementia, evaluate clinical improvements, and collect information on the pharmacokinetics of cannabinoids and possible drug-drug interactions. Methods A prospective observational study of patients with severe dementia living in a long-term care home to whom the physicians had prescribed a medical cannabis treatment. Data were collected over 2 years. We assessed the changes in medical cannabis dosages, safety parameters, variations in neuropsychiatric problems, agitation, rigidity, the most invalidating daily activity, and disabling behavior trouble scores. We evaluated the pharmacokinetics of cannabinoids by measuring plasma levels and analyzing the enzymatic activity. Results We assessed 19 patients (81.4 years-17 women and two men) receiving an average of 12.4 mg THC/24.8 mg CBD per day for up to 13 months, with no reported problems related to the treatment and limited adverse drug reactions. Clinical scores showed a marked improvement that was stable over time, deprescription of other medications, and care facilitated. The pharmacokinetic evaluation showed an expected slight reduction in the enzymatic activity of CYP1A2 and CYP2C19. Conclusion A long-term THC/CBD (1:2) medication can be administered safely and with overall positive clinical improvement to poly medicated older adults with severe dementia and associated problems. The results must be confirmed in a randomized trial.
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Affiliation(s)
- Sophie Pautex
- Palliative Medicine Division, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Federica Bianchi
- Palliative Medicine Division, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
- Long-Term Care Home “les Tilleuls”, Fondation pour l’Accueil et l’Hébergement de Personnes Âgées, Geneva, Switzerland
- *Correspondence: Federica Bianchi, ,
| | - Youssef Daali
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Clinical Pharmacology and Toxicology Division, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland
| | - Marc Augsburger
- Unit of Forensic Toxicology and Chemistry, University Centre of Legal Medicine Lausanne-Geneva, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Christian de Saussure
- Long-Term Care Home “les Tilleuls”, Fondation pour l’Accueil et l’Hébergement de Personnes Âgées, Geneva, Switzerland
| | - James Wampfler
- Long-Term Care Home “les Tilleuls”, Fondation pour l’Accueil et l’Hébergement de Personnes Âgées, Geneva, Switzerland
| | - François Curtin
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Clinical Pharmacology and Toxicology Division, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jules Desmeules
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Clinical Pharmacology and Toxicology Division, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland (ISPSO), University of Geneva, Geneva, Switzerland
| | - Barbara Broers
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Primary Care Division, Geneva University Hospitals, Geneva, Switzerland
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15
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Heilman KM, Nadeau SE. Emotional and Neuropsychiatric Disorders Associated with Alzheimer's Disease. Neurotherapeutics 2022; 19:99-116. [PMID: 35013934 PMCID: PMC9130428 DOI: 10.1007/s13311-021-01172-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 01/03/2023] Open
Abstract
Alzheimer's disease is associated with impairments in emotional communication including comprehension and production of facial emotional expressions, comprehension of affective prosody, and alexithymia. It is also associated with disorders of emotional experience including mood disorders (depression and anxiety), agitation/aggression, and psychosis. Agitation/aggression and psychosis are particularly disruptive, are associated with earlier institutionalization, and pose a major challenge to institutional management. Treatment of disorders of emotional experience has been primarily pharmacologic (reviewed here in detail) and has relied heavily on antipsychotic medications despite the small effect sizes demonstrated in a large number of randomized controlled trials and the prevalence of serious side effects associated with these drugs. Recent studies suggest that treatment with pimavanserin, an antipsychotic without activity at dopamine receptors, may represent an important advance for treatment of psychotic manifestations, even as the drug appears to pose significant risk. Dextromethorphan/quinidine may represent an important advance in the treatment of agitation/aggression. There is also compelling evidence that sleep disorders, which are common among patients with Alzheimer's disease and are readily treatable, may potentiate psychotic manifestations and agitation/aggression, but further studies are needed.
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Affiliation(s)
- Kenneth M Heilman
- Geriatric Research, Education, and Clinical Center, Malcom Randall VA Medical Center, 1601 SW Archer Road, Gainesville, FL, 32608-1197, USA
- The Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, 1601 SW Archer Road, Gainesville, FL, 32608-1197, USA
- Malcom Randall VA Medical Center and the Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Stephen E Nadeau
- Research Service, Malcom Randall VA Medical Center, 1601 SW Archer Road, Gainesville, FL, 32608-1197, USA.
- The Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, 1601 SW Archer Road, Gainesville, FL, 32608-1197, USA.
- Malcom Randall VA Medical Center and the Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.
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16
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Outen JD, Burhanullah H, Vandrey R, Amjad H, Harper DG, Patrick RE, May RL, Agronin ME, Forester BP, Rosenberg PB. Cannabinoids for Agitation in Alzheimer's Disease. Am J Geriatr Psychiatry 2021; 29:1253-1263. [PMID: 33573996 PMCID: PMC8313629 DOI: 10.1016/j.jagp.2021.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Agitation is a common neuropsychiatric symptom of Alzheimer's disease (AD) that greatly impacts quality of life and amplifies caregiver burden. Agitation in AD may be associated with volume loss in the anterior cingulate cortex, posterior cingulate cortex, insula, amygdala, and frontal cortex, as well as with degeneration of monoaminergic neurotransmission, disrupted circadian rhythms, and frailty. Current pharmacologic options have troubling safety concerns and only modest efficacy. There is increasing interest in cannabinoids as promising agents due to preclinical and early clinical research that suggest cannabinoids can elicit anxiolytic, antidepressant, and/or anti-inflammatory effects. Cannabinoids may relieve agitation by regulating neurotransmitters, improving comorbidities and circadian rhythms, and increasing cerebral circulation. Here we discuss the possible contributory mechanisms for agitation in AD and the therapeutic relevance of cannabinoids, including CBD and THC.
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Affiliation(s)
- John D. Outen
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Haroon Burhanullah
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Ryan Vandrey
- Behavioral Pharmacology Research, Johns Hopkins University School of Medicine
| | - Halima Amjad
- Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine
| | - David G. Harper
- Division of Geriatric Psychiatry, McLean Hospital,Department of Psychiatry, Harvard Medical School
| | - Regan E. Patrick
- Division of Geriatric Psychiatry, McLean Hospital,Department of Psychiatry, Harvard Medical School
| | - Rose L. May
- Division of Geriatric Psychiatry, McLean Hospital
| | - Marc E. Agronin
- Department of Mental Health and Clinical Research, Miami Jewish Health
| | - Brent P. Forester
- Division of Geriatric Psychiatry, McLean Hospital,Department of Psychiatry, Harvard Medical School
| | - Paul B. Rosenberg
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine
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17
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Riera R, Pacheco RL, Bagattini ÂM, Martimbianco ALC. Efficacy and safety of therapeutic use of cannabis derivatives and their synthetic analogs: Overview of systematic reviews. Phytother Res 2021; 36:5-21. [PMID: 34841610 DOI: 10.1002/ptr.7263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 08/05/2021] [Accepted: 08/14/2021] [Indexed: 01/08/2023]
Abstract
The debate on the use of cannabinoids for therapeutic purposes is constantly on the rise. This overview aimed to map the evidence on the therapeutic effects of cannabis derivatives and their synthetic analogs. Systematic reviews (SRs) of randomized trials were identified through a comprehensive search in several databases, and their methodological quality were evaluated with AMSTAR-2. The results for main outcomes are presented, prioritizing those from updated and better quality SRs. Finally, 68 SRs, addressing 37 different health conditions, were included. The methodological quality was high for eight SRs. The evidence certainty (GRADE) for the effects of cannabinoids is not high for any of the outcomes identified. Evidence certainty was moderate for the following: (a) cannabidiol appears to be beneficial for quality of life but increases the risk of adverse events in ulcerative colitis; (b) cannabinoids in general appear to have no clinically important benefit for chronic non-oncologic pain, spasticity-related pain in multiple sclerosis, or for acute post-operative pain; (c) cannabinoids in general appear to have a benefit in reducing chemotherapy-related nausea and vomiting. For all other outcomes from remaining comparisons, the evidence certainty was low, very low, or not evaluated, which prevents recommendations for or against their routine use.
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Affiliation(s)
- Rachel Riera
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo - SP, Brazil
| | - Rafael Leite Pacheco
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (Unifesp), São Paulo - SP, Brazil.,Centro de Pesquisa Médica, Centro Universitário São Camilo (CUSC), São Paulo - SP, Brazil
| | - Ângela Maria Bagattini
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Instituto de Medicina Tropical e Saúde Publica, Universidade Federal de Goiás (UFG), Goiânia - GO, Brazil
| | - Ana Luiza Cabrera Martimbianco
- Health Technology Assessment Centre, Hospital Sírio-Libanês, São Paulo - SP, Brazil.,Mestrado Profissional em Saúde e Meio Ambiente, Universidade Metropolitana de Santos (Unimes), Santos - SP, Brazil
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19
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Bosnjak Kuharic D, Markovic D, Brkovic T, Jeric Kegalj M, Rubic Z, Vuica Vukasovic A, Jeroncic A, Puljak L. Cannabinoids for the treatment of dementia. Cochrane Database Syst Rev 2021; 9:CD012820. [PMID: 34532852 PMCID: PMC8446835 DOI: 10.1002/14651858.cd012820.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dementia is a common chronic condition, mainly affecting older adults, characterised by a progressive decline in cognitive and functional abilities. Medical treatments for dementia are limited. Cannabinoids are being investigated for the treatment of dementia. OBJECTIVES To determine the efficacy and safety of cannabinoids for the treatment of dementia. SEARCH METHODS We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialised Register - on 8 July 2021, using the terms cannabis or cannabinoid or endocannabinoid or cannabidiol or THC or CBD or dronabinol or delta-9-tetrahydrocannabinol or marijuana or marihuana or hashish. The register contains records from all major healthcare databases (the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS), as well as from many clinical trials registries and grey literature sources. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of cannabinoids for the treatment of dementia. We included participants of any age and of either sex with diagnosed dementia of any subtype, or with unspecified dementia of any severity, from any setting. We considered studies of cannabinoids administered by any route, at any dose, for any duration, compared with placebo, no treatment, or any active control intervention. DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected studies for inclusion, extracted data, and assessed the risk of bias in included studies. When necessary, other review authors were involved in reaching consensus decisions. We conducted meta-analyses using a generic inverse variance fixed-effect model to derive estimates of effect size. We used GRADE methods to assess our confidence in the effect estimates. MAIN RESULTS We included four studies (126 participants) in this review. Most participants had Alzheimer's disease; a few had vascular dementia or mixed dementia. Three studies had low risk of bias across all domains; one study had unclear risk of bias for the majority of domains. The included studies tested natural delta-9-tetrahydrocannabinol (THC) (Namisol) and two types of synthetic THC analogue (dronabinol and nabilone). Three trials had a cross-over design. Interventions were applied over 3 to 14 weeks; one study reported adverse events over 70 weeks of follow-up. One trial was undertaken in the USA, one in Canada, and two in The Netherlands. Two studies reported non-commercial funding, and two studies were conducted with the support of both commercial and non-commercial funding. Primary outcomes in this review were changes in global and specific cognitive function, overall behavioural and psychological symptoms of dementia (BPSD), and adverse events. We found very low-certainty evidence suggesting there may be little or no clinically important effect of a synthetic THC analogue on cognition assessed with the standardised Mini-Mental State Examination (sMMSE) (mean difference (MD) 1.1 points, 95% confidence interval (CI) 0.1 to 2.1; 1 cross-over trial, 28 participants). We found low-certainty evidence suggesting there may be little or no clinically important effect of cannabinoids on overall behavioural and psychological symptoms of dementia assessed with the Neuropsychiatric Inventory (or its modified nursing home version) (MD -1.97, 95% CI -3.87 to -0.07; 1 parallel group and 2 cross-over studies, 110 participants). All included studies reported data on adverse events. However, the total number of adverse events, the total numbers of mild and moderate adverse events, and the total number of serious adverse events (SAEs) were not reported in a way that permitted meta-analysis. There were no clear differences between groups in numbers of adverse events, with the exception of sedation (including lethargy), which was more frequent among participants taking nabilone (N = 17) than placebo (N = 6) (odds ratio (OR) 2.83, 95% CI 1.07 to 7.48; 1 cross-over study, 38 participants). We judged the certainty of evidence for adverse event outcomes to be low or very low due to serious concerns regarding imprecision and indirectness. AUTHORS' CONCLUSIONS Based on data from four small, short, and heterogeneous placebo-controlled trials, we cannot be certain whether cannabinoids have any beneficial or harmful effects on dementia. If there are benefits of cannabinoids for people with dementia, the effects may be too small to be clinically meaningful. Adequately powered, methodologically robust trials with longer follow-up are needed to properly assess the effects of cannabinoids in dementia.
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Affiliation(s)
| | - Domagoj Markovic
- Clinic for Heart and Cardiovascular Diseases, University of Split Hospital Center, Split, Croatia
| | - Tonci Brkovic
- Division of Nephrology, Department of Internal Medicine, University of Split Hospital Center, Split, Croatia
| | | | - Zana Rubic
- Department of Clinical Microbiology, University of Split Hospital Center, Split, Croatia
| | - Ana Vuica Vukasovic
- Department of Nuclear Medicine, University of Split Hospital Center, Split, Croatia
| | - Ana Jeroncic
- Department of Research in Biomedicine and Health, University of Split School of Medicine, Split, Croatia
| | - Livia Puljak
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
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The Prevalence of Cannabis Use Disorder Comorbidity in Individuals With Bipolar Disorder: A Systematic Review and Meta-Analysis. CANADIAN JOURNAL OF ADDICTION 2021. [DOI: 10.1097/cxa.0000000000000123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bahji A. Response to Canadian Psychiatric Association Cannabinoid Products Position Statement: Potential for Ameliorating Cannabis Withdrawal. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:586-587. [PMID: 33998318 PMCID: PMC8138739 DOI: 10.1177/0706743720976452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Anees Bahji
- Department of Psychiatry, 2129University of Calgary, Alberta, Canada
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Bahji A, Meyyappan AC, Hawken ER, Tibbo PG. Pharmacotherapies for cannabis use disorder: A systematic review and network meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103295. [PMID: 34062288 DOI: 10.1016/j.drugpo.2021.103295] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to determine the efficacy and acceptability of pharmacotherapies for cannabis use disorder (CUD). METHODS We conducted a systematic review and frequentist network meta-analysis, searching five electronic databases for randomized placebo-controlled trials of individuals diagnosed with CUD receiving pharmacotherapy with or without concomitant psychotherapy. Primary outcomes were the reduction in cannabis use and retention in treatment. Secondary outcomes were adverse events, discontinuation due to adverse events, total abstinence, withdrawal symptoms, cravings, and CUD severity. We applied a frequentist, random-effects Network Meta-Analysis model to pool effect sizes across trials using standardized mean differences (SMD, g) and rate ratios (RR) with their 95% confidence intervals. RESULTS We identified a total of 24 trials (n=1912, 74.9% male, mean age 30.2 years). Nabilone (d=-4.47 [-8.15; -0.79]), topiramate (d=-3.80 [-7.06; -0.54]), and fatty-acid amyl hydroxylase inhibitors (d=-2.30 [-4.75; 0.15]) reduced cannabis use relative to placebo. Dronabinol improved retention in treatment (RR=1.27 [1.02; 1.57]), while topiramate worsened treatment retention (RR=0.62 [0.42; 0.91]). Gabapentin reduced cannabis cravings (d=-2.42 [-3.53; -1.32], while vilazodone worsened craving severity (d=1.69 [0.71; 2.66]. Buspirone (RR=1.14 [1.00; 1.29]), venlafaxine (RR=1.78 [1.40; 2.26]), and topiramate (RR=9.10 [1.27; 65.11]) caused more adverse events, while topiramate caused more dropouts due to adverse events. CONCLUSIONS Based on this review, some medications appeared to show promise for treating individual aspects of CUD. However, there is a lack of robust evidence to support any particular pharmacological treatment. There is a need for additional studies to expand the evidence base for CUD pharmacotherapy. While medication strategies may become an integral component for CUD treatment one day, psychosocial interventions should remain the first line given the limitations in the available evidence.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada.
| | - Arthi Chinna Meyyappan
- Department of Psychiatry, Queen's University, Kingston, ON, Canada; Centre for Neurosciences, Queen's University, Kingston, ON, Canada; Providence Care Hospital, Kingston, ON, Canada
| | - Emily R Hawken
- Department of Psychiatry, Queen's University, Kingston, ON, Canada; Centre for Neurosciences, Queen's University, Kingston, ON, Canada; Providence Care Hospital, Kingston, ON, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada; Nova Scotia Early Psychosis Program, Halifax, NS, Canada
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Aftab A, Lam JA, Liu F, Ghosh A, Sajatovic M. Recent developments in geriatric psychopharmacology. Expert Rev Clin Pharmacol 2021; 14:341-355. [PMID: 33499693 DOI: 10.1080/17512433.2021.1882848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There is a tremendous growing need to address the burden of geriatric psychiatric disorders. Recent developments relevant to geriatric psychiatry have focused on Alzheimer's disease (AD), severe/refractory depression, and cancer/end of life care. AREAS COVERED This is a non-systematic, narrative review (databases and websites for search: PubMed, Google Scholar, Medscape, ClinicalTrials.gov; focusing on the last 6 years), and covers developments in disease-modifying therapies for AD, diagnostic radiotracers for AD, medications for neuropsychiatric symptoms of dementia, ketamine/esketamine, psychedelics, and cannabinoids. EXPERT OPINION The focus of on-going trials of anti-amyloid agents has been on individuals with very early stage AD; several agents are under phase 3 investigation, and aducanumab is under FDA review. Amyloid and tau PET scans have been approved by the FDA to assist in the diagnoses of AD. Promising pharmaceuticals for neuropsychiatric symptoms of dementia include pimavanserin, brexpiprazole, escitalopram, dextromethorphan/quinidine, and lithium. Esketamine, although approved for treatment-resistant depression in general adults, failed to demonstrate efficacy in elderly patients in a phase 3 trial. There is preliminary evidence for benefit of psychedelic-assisted psychotherapy in end-of-life and cancer-related depression/anxiety. Evidence for the use of cannabinoids is currently lacking.
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Affiliation(s)
- Awais Aftab
- Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey A Lam
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Fred Liu
- Departments of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Anjan Ghosh
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Martha Sajatovic
- Departments of Psychiatry and Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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