Adjunctive Aripiprazole in Bipolar I Depression

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on bipolar depression

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.

Depression and schizophrenia

Depressive symptoms commonly occur in schizophrenia and have a significant impact on the distress and burden of the illness. Yet they are often overlooked, inadequately characterised by current classification systems and not consistently integrated into treatment. We discuss nosology, practical and clinical implications of symptom differentiation, and the role of causal and confounding factors, including iatrogenic, as targets for therapeutic intervention. The evidence base of psychosocial and psychotropic management is reviewed, with recommendations for the treatment of established syndromal depression in people with schizophrenia.

The ARIQUELI study: potentiation of quetiapine in bipolar I nonresponders with lithium versus aripiprazole

BACKGROUND

The treatment of bipolar disorder (BD) remains a challenge due to the complexity of the disease. Current guidelines represent an effort to assist clinicians in routine practice but have several limitations, particularly concerning long-term treatment. The ARIQUELI (efficacy and tolerability of the combination of lithium or aripiprazole in young bipolar non or partial responders to quetiapine monotherapy) study aims to evaluate two different augmentation strategies for quetiapine nonresponders or partial responders in acute and maintenance phases of BD treatment.

METHODS/DESIGN

The ARIQUELI study is a single-site, parallel-group, randomized, outcome assessor-blinded trial. BD I patients according to the DSM-IV-TR, in depressive, manic/hypomanic or mixed episode, aged 18 to 40 years, are eligible. After diagnostic assessments, patients initiated treatment in phase I with quetiapine. Nonresponders or partial responders after 8 weeks are allocated into one of two groups, potentiated with either lithium (0.5 to 0.8 mEq/l) or aripiprazole (10 or 15 mg). Patients will be followed up for 8 weeks in phase I (acute treatment), 6 months in phase II (continuation treatment) and 12 months in phase III (maintenance treatment). Outcome assessors are blinded to the treatment. The primary outcome is the evaluation of changes in mean scores on the CGI-BP-M between baseline and the endpoint at the end of each study phase.

DISCUSSION

The ARIQUELI study is currently in progress, with patients undergoing acute treatment (phase I), potentiation (phase II) and maintenance (phase III). The study will be extended until January 2015. Trials comparing lithium and aripiprazole with potentiate treatment in young BD I nonresponders to quetiapine in monotherapy can provide relevant information on the safety of these drugs in clinical practice. Long-term treatment is an issue of great importance and should be evaluated further through more in-depth studies given that BD is a chronic disease.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01710163.

Aripiprazole as augmentation therapy in bipolar patients with current minor or subsyndromal mood symptoms

Background

This study aims to evaluate the effectiveness of aripiprazole augmentation of maintenance treatment for bipolar disorder in patients with minor or subsyndromal mood episodes while on a stable dose of a mood stabiliser and/or antidepressant.

Methods

All subjects had a diagnosis of bipolar I or II disorder (Diagnostic and Statistical Manual of Mental Disorders-4th Edition, Text Revision). Open-label aripiprazole was given over 8 weeks initially. The starting dose was 5 to 15 mg/day with a mean final dose of 11.5 mg (±4.6). Patients were assessed at weeks 0, 2, 4 and 8 with the Montgomery-Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS) and Clinical Global Impression of Severity (CGI-S).

Results and discussion

Seventeen of 20 (85%) patients completed week 4, while 14 (70%) patients completed 8 weeks. For intention-to-treat data, there was a significant decrease in MADRS scores over the course of treatment, with a reduction of 6.40 points at endpoint (p < 0.0005). Improvement from baseline was significant at week 2 and remained through to week 8. Similarly, CGI-S scores significantly decreased over the course of study, but not YMRS scores. Aripiprazole was shown to be a modestly effective augmentation therapy for depressive symptoms in bipolar I and II in this small open-label study.

Retrospective evaluation of an inpatient psychiatric pharmacist consultation service

OBJECTIVE

To describe and evaluate clinical outcomes of pharmacist consult service recommendations in an inpatient psychiatric setting.

DESIGN

Retrospective study.

SETTING

Austin, TX, between September 1, 2005, and May 31, 2006.

PATIENTS

105 patients receiving a pharmacy consult while admitted to the Austin State Hospital.

INTERVENTION

Completion of consultation pursuant to provider referral.

MAIN OUTCOME MEASURES

Clinical Global Impression (CGI)-Severity (CGI-S) and CGI-Improvement (CGI-I) scores were retrospectively determined by blinded psychiatric pharmacy specialists upon review of physician progress notes.

RESULTS

A total of 105 pharmacy consultations and associated physician progress notes were reviewed. Overall, 73% of the primary consultation recommendations were implemented. The most common reasons for referral to the psychopharmacology service were nonresponse to treatment and aggression. Patients with high implementation of consultation recommendations displayed more favorable endpoint CGI-S scores and displayed a greater CGI-I response rate compared with patients with low implementation of consult recommendations.

CONCLUSION

Implementing clinical pharmacists' consult recommendations was associated with significantly greater improvement in overall severity of illness and global improvement. This study supports the positive role that pharmacists have in optimizing patient care and clinical outcomes.

A clinical review of aripiprazole in bipolar depression and maintenance therapy of bipolar disorder

BACKGROUND

Bipolar disorder is a chronic, recurrent disorder with a significant negative impact on quality of life. Effective treatments are available for acute mania. In contrast, there is a lack of consensus on the treatment of acute bipolar depression and long treatment options for bipolar disorder require more study. Aripiprazole is FDA approved for the treatment of acute mania. This paper reviews current data on the efficacy of aripiprazole in the treatment of acute bipolar depression and in maintenance therapy of bipolar disorder.

METHODS

PubMed and abstracts of recent conferences were searched for randomized, double-blind studies that investigated the efficacy of aripiprazole in acute bipolar depression or maintenance therapy of bipolar disorder.

RESULTS

Two studies assessed the efficacy of aripiprazole monotherapy in the treatment of acute bipolar depression. These showed that although aripiprazole significantly reduced depressive symptoms early in treatment, the results were not significantly different from placebo at the primary end point of week 8. As to long-term treatment, aripiprazole was superior to placebo in delaying time to relapse for manic episodes, but not for depressive episodes after 26 and 100 weeks of maintenance therapy. Aripiprazole was as effective as lithium, and adjunctive aripiprazole with lithium or valproate was more effective than placebo plus lithium or valproate, in preventing a manic relapse. Reductions in manic and mixed relapse rates compared to placebo were achieved in a study combining aripiprazole with lamotrigine; however, the results were not statistically significant. Similar to other maintenance studies, depressive relapse rates were not significantly reduced compared to placebo.

LIMITATIONS

Negative findings for aripiprazole in the treatment of acute bipolar depression have been attributed to high study doses, rapid titration, and high placebo rates. A recent post-hoc analysis demonstrated that aripiprazole was more effective in patients with severe depressive symptoms, particularly for patients on a lower dose. Further research is needed to confirm this finding. The inability of aripiprazole to reduce the time to depressive relapse during maintenance therapy may be due to the recruitment of patients with an index manic episode and a consequent lower incidence of depressive relapses. Therefore, studies using a depression index episode are needed to appropriately evaluate relapse prevention.

CONCLUSIONS

Although aripiprazole has proven efficacy for acute mania and the prevention of mania, the evidence available thus far does not support the efficacy of aripiprazole for the treatment of acute bipolar depression and prevention of depressive relapse. Further studies with appropriate doses and a depressive index episode are needed to clarify the role of aripiprazole in bipolar disorder.

Aripiprazole: a clinical review of its use for the treatment of anxiety disorders and anxiety as a comorbidity in mental illness

BACKGROUND

Although anxiety disorders are common, optimal treatment is elusive. More than half of anxiety patients treated with an adequate course of antidepressants fail to fully improve: treatment resistance, residual symptoms, and recurrence/relapse remain a challenge. Recently, atypical antipsychotics have been considered for treatment-resistant anxiety disorders. This review will explore the available data for the role of aripiprazole in the treatment of anxiety.

METHODS

PubMed and conference abstracts were searched for randomized, double-blind studies that investigated the efficacy of aripiprazole in anxiety; its efficacy in bipolar disorder and depression was also explored for comparison.

RESULTS

A number of studies have shown atypical antipsychotics to be effective in anxiety, and currently available data suggest that aripiprazole augmentation in patients with anxiety disorders is likely as effective as other atypical antipsychotic drugs. Although there have been no randomized, controlled trials, aripiprazole has been found to be effective in treating anxiety disorders in two open-label trials. This combined with the larger data base demonstrating its utility in bipolar disorder and depression, its safety profile and its unique mechanism of action, make aripiprazole for anxiety an intriguing avenue of exploration.

LIMITATIONS

Data from large randomized, controlled trials on the use of atypical antipsychotics for anxiety in general, and aripiprazole in particular, are currently lacking.

CONCLUSION

The results of open-label trials of aripiprazole in anxiety provide enough support to warrant its further study. This, combined with a larger data base demonstrating its utility in bipolar disorder and depression, its safety profile and its unique mechanism of action, make aripiprazole for anxiety an intriguing avenue of exploration.

The psychopharmacology algorithm project at the Harvard South Shore Program: an update on bipolar depression

This updated version of the bipolar depression algorithm of the Psychopharmacology Algorithm Project at the Harvard South Shore Program aims to provide an organized, sequential, and evidence-supported approach for the treatment of that disorder. After initial evaluation and diagnosis, the psychiatrist should first assess whether there is an urgent indication for ECT. If ECT is not indicated, and the patient has psychotic symptoms, then an antipsychotic should be part of the medication regimen. Next, if the patient is not currently treated with mood stabilizers, there is a slight preference for lithium. If lithium is not effective or tolerated, treatment with quetiapine or lamotrigine should be initiated. If the patient is currently taking other mood stabilizers, their dosage should be optimized, and the clinician should consider adding or switching to lithium, quetiapine, or lamotrigine. Next, if the patient is not at especially high risk of mood destabilization, an antidepressant can be added in the bipolar depressed patient who has failed trials of lithium, quetiapine, and lamotrigine. Rapid-cycling depressed patients may require combinations of two or three mood stabilizers. ECT, along with other psychopharmacological options, could be reconsidered for the treatment of refractory bipolar depressed patients.

Efficacy and safety of aripiprazole in the treatment of bipolar disorder: a systematic review

BACKGROUND

The current article is a systematic review concerning the efficacy and safety of aripiprazole in the treatment of bipolar disorder.

METHODS

A systematic Medline and repositories search concerning the usefulness of aripiprazole in bipolar disorder was performed, with the combination of the words 'aripiprazole' and 'bipolar'.

RESULTS

The search returned 184 articles and was last updated on 15 April 2009. An additional search included repositories of clinical trials and previous systematic reviews specifically in order to trace unpublished trials. There were seven placebo-controlled randomised controlled trials (RCTs), six with comparator studies and one with add-on studies. They assessed the usefulness of aripiprazole in acute mania, acute bipolar depression and during the maintenance phase in comparison to placebo, lithium or haloperidol.

CONCLUSION

Aripiprazole appears effective for the treatment and prophylaxis against mania. The data on bipolar depression are so far negative, however there is a need for further study at lower dosages. The most frequent adverse effects are extrapyramidal signs and symptoms, especially akathisia, without any significant weight gain, hyperprolactinaemia or laboratory test changes.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009

The Canadian Network for Mood and Anxiety Treatments (CANMAT) published guidelines for the management of bipolar disorder in 2005, with a 2007 update. This second update, in conjunction with the International Society for Bipolar Disorders (ISBD), reviews new evidence and is designed to be used in conjunction with the previous publications. The recommendations for the management of acute mania remain mostly unchanged. Lithium, valproate, and several atypical antipsychotics continue to be first-line treatments for acute mania. Tamoxifen is now suggested as a third-line augmentation option. The combination of olanzapine and carbamazepine is not recommended. For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. New data support the use of adjunctive modafinil as a second-line option, but also indicate that aripiprazole should not be used as monotherapy for bipolar depression. Lithium, lamotrigine, valproate, and olanzapine continue to be first-line options for maintenance treatment of bipolar disorder. New data support the use of quetiapine monotherapy and adjunctive therapy for the prevention of manic and depressive events, aripiprazole monotherapy for the prevention of manic events, and risperidone long-acting injection monotherapy and adjunctive therapy, and adjunctive ziprasidone for the prevention of mood events. Bipolar II disorder is frequently overlooked in treatment guidelines, but has an important clinical impact on patients' lives. This update provides an expanded look at bipolar II disorder.

Effect of aripiprazole on self-reported anhedonia in bipolar depressed patients

Some studies have suggested that aripiprazole might be a useful treatment for bipolar depression. There are no studies evaluating the effect of aripiprazole on anhedonia. In the present study, effects of aripiprazole were investigated under routine clinical conditions. Anhedonia was measured in patients with bipolar disorder type I (n=50) using the self-rated Snaith-Hamilton Pleasure Scale (SHAPS) and depression was assessed using the Montgomery-Asberg Depression Rating Scale. Anhedonia was present in 52% of all patients and was significantly reduced during treatment with aripiprazole. All patients completed the 16-week trial. Only 16% of patients experienced side effects (akathisia, headache). Future studies should investigate the specificity of anti-anhedonic and anti-depressant properties of aripiprazole in bipolar patients.

A prospective, open-label study of Aripiprazole mono- and adjunctive treatment in acute bipolar depression

OBJECTIVE

To examine the efficacy and tolerability of aripiprazole treatment for acute bipolar depression.

METHODS

A six-week prospective, nonrandomized, open label study was conducted in depressed bipolar outpatients (types I, II, and NOS), as diagnosed by DSM-IV criteria. Previous treatments were continued unchanged, and new treatments not permitted, except lorazepam up to 2 mg daily. Aripiprazole was dosed flexibly up to a maximum of 30 mg daily, based on tolerability and efficacy. Montgomery-Asberg Depression Rating Scale (MADRS) and Mania Rating Scale (MRS) scores were used to assess changes in mood symptoms. Side effect outcomes were measured. Data was analyzed using last observation carried forward methodology and Analysis of Variance.

RESULTS

Twenty patients (15 men, 5 women) with bipolar disorder (10 type I, 7 type II, 3 type NOS) enrolled in the study. Mean endpoint dose was 13.6 mg/d+/-10.0 mg/d. Thirteen (65%) patients completed 6 weeks of treatment. MADRS and MRS scores significantly improved during treatment. 44% of patients who completed at least one week of treatment were considered responders, based on > or =50% decrease in MADRS scores from baseline. Side effect measures were mostly unchanged during treatment.

CONCLUSION

Depressive symptoms improved in bipolar patients treated with open-label aripiprazole.

Adjunctive aripiprazole for bupropion-resistant major depression

OBJECTIVE

To examine the effects of adjunctive aripiprazole in patients with major depression refractory to adequate therapy with bupropion.

CASE SUMMARY

Four consecutive patients diagnosed with major depression that was not responsive to a minimum of 2 months of therapy with bupropion 150-450 mg/day were given adjunctive aripiprazole 2.5-10 mg/day and followed for at least 4 months. Chart notes were used to record patient responses. All patients reported rapid improvement in depressive symptoms following the addition of low-dose aripiprazole. Antidepressant effects were sustained for at least 4 months in all patients; however, the mood disturbance subsequently returned in 2 patients. Adjunctive aripiprazole was well tolerated, with one patient developing akathisia that responded to lowering the aripiprazole dose and another exhibiting worsening of preexisting insomnia. Weight and metabolic parameters were not monitored during the observation period.

DISCUSSION

Transitory improvements in depressive symptoms that occurred in some of the 4 patients may have been due to compensatory mechanisms in dopaminergic systems. Adjunctive use of the atypical antipsychotic aripiprazole has been demonstrated to benefit depressed patients who are resistant to selective serotonin-reuptake inhibitors. The response to aripiprazole in patients refractory to bupropion has not been previously reported.

CONCLUSIONS

Adjunctive aripiprazole given in low doses resulted in rapid improvements in depressed patients who were refractory to adequate therapy with bupropion. Additional studies are required to determine whether these results can be generalized to other depressed individuals who are refractory to bupropion treatment.

Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.