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Azorin JM, Simon N. Dopamine Receptor Partial Agonists for the Treatment of Bipolar Disorder. Drugs 2020; 79:1657-1677. [PMID: 31468317 DOI: 10.1007/s40265-019-01189-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Bipolar disorder is a chronic, disabling, and costly illness with frequent relapses and recurrences, high rates of co-morbid conditions, and poor adherence to treatment. Mood stabilizers and antipsychotics are the cornerstones of treatment. Dopamine receptor partial agonists are a novel class of antipsychotic agents with original pharmacodynamic properties. Among them, two have been approved by the US Food and Drug Administration for the treatment of bipolar disorder. Aripiprazole (oral formulation) has been approved as monotherapy for the treatment of manic/mixed episodes in adult and pediatric populations and for maintenance treatment in adults, and as adjunctive treatment to mood stabilizers, for the acute treatment of manic/mixed episodes and for maintenance in adults. An intramuscular formulation of aripiprazole has been approved for the treatment of agitation in mania and a long-acting injectable formulation has been approved as maintenance treatment. In the USA, cariprazine has been approved as monotherapy for the acute treatment of manic/mixed as well as bipolar depressive episodes. Brexpiprazole is not yet approved to treat bipolar disorder. The evidence supporting these indications is reviewed via an analysis of clinical registration trials as well as additional studies, on the basis of a systematic literature search. Further studies dealing with other aspects of bipolar illness are also presented. Aripiprazole and cariprazine are efficacious and generally well tolerated agents that have shown cost effectiveness, and may therefore enrich our therapeutic armamentarium for bipolar illness. Brexpiprazole, which displays an overall promising tolerability profile, deserves further efficacy studies.
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Affiliation(s)
- Jean-Michel Azorin
- Department of Psychiatry, Sainte Marguerite Hospital, 13009, Marseille, France.
| | - Nicolas Simon
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Hôpital Sainte Marguerite, Service de Pharmacologie Clinique, CAP, Marseille, France
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Cosgrove L, Cristea IA, Shaughnessy AF, Mintzes B, Naudet F. Digital aripiprazole or digital evergreening? A systematic review of the evidence and its dissemination in the scientific literature and in the media. BMJ Evid Based Med 2019; 24:231-238. [PMID: 31320322 DOI: 10.1136/bmjebm-2019-111204] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND In November 2017, the Food and Drug Administration (FDA) approved a version of a second-generation antipsychotic, aripiprazole, embedded with a sensor (Abilify MyCite). OBJECTIVE To systematically review the evidence supporting the FDA's approval of digital aripiprazole and how that evidence was disseminated in the scientific literature and news reports. STUDY SELECTION Prospective, double-blind, randomised controlled trials (RCTs), non-randomised and non-comparative studies were included if they focused on the use of digital aripiprazole. All scientific publications citing the trials were included if written in English. For the news reports, all languages were included if an English translation was available, and all records that were published after FDA approval were included. FINDINGS In the primary evidence search, no RCT comparing digital aripiprazole with a non-digital formulation, other active comparators or placebo was found. Only three non-comparative uncontrolled cohorts were found. No study provided data on remission, quality of life or any efficacy outcome. Fourteen scientific papers were identified that cited the trials and 70 news stories met the inclusion criteria. Almost 80% (11/14) of the scientific papers and three-fourths (52/70) of the news stories conveyed an unsupported impression of benefit. CONCLUSIONS Regulatory approval for this first-ever digital drug was based on weak evidence, and there was no evidence of better adherence with the digital version of aripiprazole compared with the non-digital version. The possibilities afforded by this technology make room for a new type of evergreening (ie, patenting of older drugs with a sensor as a 'new invention'). Both the scientific literature and news reports conveyed an unsupported impression of benefit. TRIAL REGISTRATION NUMBER CRD42018089515.
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Affiliation(s)
- Lisa Cosgrove
- Counseling and School Psychology, University of Massachusetts Boston, Boston, Massachusetts, USA
| | - Ioana Alina Cristea
- Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania
- METRICS (Meta-research Innovation Center at Stanford), Stanford University, California, USA
| | - Allen F Shaughnessy
- Department of Family Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Barbara Mintzes
- School of Pharmacy, Faculty of Medicine and Health, and Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
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Tournier M, Neumann A, Pambrun E, Weill A, Chaffiol JP, Alla F, Bégaud B, Maura G, Verdoux H. Conventional mood stabilizers and/or second-generation antipsychotic drugs in bipolar disorders: A population-based comparison of risk of treatment failure. J Affect Disord 2019; 257:412-420. [PMID: 31306992 DOI: 10.1016/j.jad.2019.07.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/03/2019] [Accepted: 07/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The study compared treatment failure when using three therapeutic strategies in bipolar disorders: (i) mood stabilizers (MSs: lithium, valpromide, divalproate, carbamazepine, lamotrigine) without second-generation antipsychotic (SGAP); (ii) SGAPs (aripiprazole, olanzapine, risperidone, quetiapine) without MS; (iii) combination of MSs and SGAPs. METHODS A historical cohort study was conducted using the French national healthcare databases in 20,086 outpatients aged 21+, newly treated with one of the three treatment strategies in 2011-2012, and diagnosed with a bipolar disorder. A composite outcome was based on indicators of treatment failure identified over 12 months: treatment discontinuation, switch or addition, psychiatric hospitalisation, suicide attempt, and death. For each strategy, the cumulative incidence of treatment failure was calculated while adjusting for covariates by propensity score weighting. RESULTS A total of 8,225 patients (40.9%) were newly dispensed MSs, 9,342 (46.5%) SGAPs, and 2,519 (12.5%) both MSs and SGAPs. The one-year adjusted cumulative incidence of treatment failure was 75.7% (95%CI 74.9;76.3) in patients using MSs, 75.3% (74.6;76.0) in patients using SGAPs, and 60.5% (58.3;62.6) in patients with the combination. The adjusted difference in incidence for SGAPs compared with MSs was -0.40% (-1.4;0.6 p = 0.4) in the whole population, -2.2% (-3.3; -1.2 p < 0.002) in patients under 65 years and +6.7% (4.1;9.1 p < 0.002) in patients 65 years and over. LIMITATIONS Combinations of MSs and SGAPs could not be directly compared with MS or SGAP monotherapies. CONCLUSIONS One-year treatment failure was high. Overall, no difference in treatment failure was observed between MS or SGAP strategy but differences might exist depending on age.
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Affiliation(s)
- Marie Tournier
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology research team, UMR 1219, F-33000 Bordeaux, France; Hospital Charles Perrens, F-33000 Bordeaux, France.
| | - Anke Neumann
- Department of Studies in Public Health, French National Health Insurance (Assurance Maladie/CNAM-TS), 75 986 Paris Cedex20, France
| | - Elodie Pambrun
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology research team, UMR 1219, F-33000 Bordeaux, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (Assurance Maladie/CNAM-TS), 75 986 Paris Cedex20, France
| | | | - François Alla
- Department of Studies in Public Health, French National Health Insurance (Assurance Maladie/CNAM-TS), 75 986 Paris Cedex20, France
| | - Bernard Bégaud
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology research team, UMR 1219, F-33000 Bordeaux, France; University Hospital, F-33000 Bordeaux, France
| | - Géric Maura
- Department of Studies in Public Health, French National Health Insurance (Assurance Maladie/CNAM-TS), 75 986 Paris Cedex20, France
| | - Hélène Verdoux
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Pharmacoepidemiology research team, UMR 1219, F-33000 Bordeaux, France; Hospital Charles Perrens, F-33000 Bordeaux, France
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Montastruc F, Bénard-Laribière A, Noize P, Pambrun E, Diaz-Bazin F, Tournier M, Bégaud B, Pariente A. Antipsychotics use: 2006-2013 trends in prevalence and incidence and characterization of users. Eur J Clin Pharmacol 2018; 74:619-626. [PMID: 29307053 DOI: 10.1007/s00228-017-2406-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/19/2017] [Indexed: 01/27/2023]
Abstract
PURPOSE The present study was conducted to describe antipsychotic (AP) prevalent and incident use, characteristics of AP users, and their trends in the French population. METHODS A cross-sectional study was repeated yearly from January 1, 2007 to December 31, 2013 (for prevalence analysis) or to December 31, 2012 (for incidence analysis) using the French Health Insurance reimbursement database (Echantillon Généraliste de Bénéficiaires, EGB). For each year studied, prevalent and incident AP users were described in terms of age and gender overall, and according to the type of AP (FGAPs or SGAPs) used at index date. In addition, concurrent medications and comorbidities that a priori contraindicate the use of drugs having atropinic properties were researched. RESULTS Prevalence and incidence remained relatively stable along the 2007-2013 period. Trends slightly decreased, from 2.07% (n = 10,252) to 2.05% (n = 11,015) for prevalence, and from 0.73% (n = 3461) to 0.66% (n = 3363) for incidence, especially in elderly, in contrast of children and adolescents (+ 39% for prevalence, from 184 to 271). The number of coprescribed drugs was found high (median = 5) and remained constant over time. In 2013, about 7% of prevalent AP users presented with a comorbidity increasing the risk of atropinic ADRs, and 36% used at least one concurrent atropinic drug. In incident AP users, these numbers were of 8 and 29%, respectively. CONCLUSIONS The present study highlighted a marked shift from FGAPs toward SGAPs, as well as an increase in AP use in children and adolescents in France.
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Affiliation(s)
- François Montastruc
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France.
- Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, Faculté de Médecine de Toulouse, Centre Hospitalier Universitaire, Toulouse, France.
| | - Anne Bénard-Laribière
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
- CHU Bordeaux, Pole de Santé Publique, Centre Régional de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
| | - Pernelle Noize
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
- CHU Bordeaux, Pole de Santé Publique, Centre Régional de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
| | - Elodie Pambrun
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
| | - Fabienne Diaz-Bazin
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
| | - Marie Tournier
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
| | - Bernard Bégaud
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
- CHU Bordeaux, Pole de Santé Publique, Centre Régional de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
| | - Antoine Pariente
- Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, University Bordeaux, F-33000, Bordeaux, France
- CHU Bordeaux, Pole de Santé Publique, Centre Régional de Pharmacovigilance de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
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Johnson A, Thornby KA, Ferrill M. Critical Appraisal of Biomedical Literature With a Succinct Journal Club Template: The ROOTs Format. Hosp Pharm 2017; 52:488-495. [PMID: 29276278 DOI: 10.1177/0018578717721104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Journal clubs are a valuable tool to assist pharmacists in the evaluation of biomedical literature and to promote adoption of evidence-based practices. The concise ROOTs (relevance, observe validity, obtain clinically significant results, and translate results to clinical practice) method was developed to help simplify and provide structure to any journal club process. Although there are a variety of recommended practices on how to conduct journal clubs using a variety of questions and checklists, many are cumbersome and difficult to complete and present in less than 30 minutes. The concise ROOTs journal club format may be beneficial for clinicians to help them develop an efficient and consistent means to appraise evidence in clinical practice. A sample completed ROOTs template, utilizing the 2015 IMPROVE-IT trial, is provided to further assist in utilizing the template.
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Affiliation(s)
- Ashley Johnson
- Jonathan M. Wainwright Memorial VA Medical Center, Wainwright Drive Walla Walla, WA, USA
| | | | - Mary Ferrill
- California Health Sciences University, Clovis, CA, USA
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Tsai AC. Lay worker-administered behavioral treatments for psychological distress in resource-limited settings: Time to move from evidence to practice? PLoS Med 2017; 14:e1002372. [PMID: 28809928 PMCID: PMC5557352 DOI: 10.1371/journal.pmed.1002372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In this Perspective on the study by Bryant and colleagues, Alex Tsai discusses the evidence supporting lay worker-administered, behavioral interventions for women survivors of interpersonal violence.
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Affiliation(s)
- Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
- MGH Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, Kasper S, Moeller HJ. The International College of Neuro-Psychopharmacology (CINP) Treatment Guidelines for Bipolar Disorder in Adults (CINP-BD-2017), Part 2: Review, Grading of the Evidence, and a Precise Algorithm. Int J Neuropsychopharmacol 2017; 20:121-179. [PMID: 27816941 PMCID: PMC5409012 DOI: 10.1093/ijnp/pyw100] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 02/05/2023] Open
Abstract
Background The current paper includes a systematic search of the literature, a detailed presentation of the results, and a grading of treatment options in terms of efficacy and tolerability/safety. Material and Methods The PRISMA method was used in the literature search with the combination of the words 'bipolar,' 'manic,' 'mania,' 'manic depression,' and 'manic depressive' with 'randomized,' and 'algorithms' with 'mania,' 'manic,' 'bipolar,' 'manic-depressive,' or 'manic depression.' Relevant web pages and review articles were also reviewed. Results The current report is based on the analysis of 57 guideline papers and 531 published papers related to RCTs, reviews, posthoc, or meta-analysis papers to March 25, 2016. The specific treatment options for acute mania, mixed episodes, acute bipolar depression, maintenance phase, psychotic and mixed features, anxiety, and rapid cycling were evaluated with regards to efficacy. Existing treatment guidelines were also reviewed. Finally, Tables reflecting efficacy and recommendation levels were created that led to the development of a precise algorithm that still has to prove its feasibility in everyday clinical practice. Conclusions A systematic literature search was conducted on the pharmacological treatment of bipolar disorder to identify all relevant random controlled trials pertaining to all aspects of bipolar disorder and graded the data according to a predetermined method to develop a precise treatment algorithm for management of various phases of bipolar disorder. It is important to note that the some of the recommendations in the treatment algorithm were based on the secondary outcome data from posthoc analyses.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Lakshmi Yatham
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Heinz Grunze
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Eduard Vieta
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Allan Young
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Pierre Blier
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Siegfried Kasper
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
| | - Hans Jurgen Moeller
- 3rd Department of Psychiatry, School of Medicine, Aristotle University, Thessaloniki, Greece; Department of Psychiatry, University of British Columbia, Mood Disorders Centre of Excellence, Djavad Mowafaghian Centre for Brain Health, Canada; Paracelsus Medical University, Salzburg, Austria; Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain; Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; The Royal Institute of Mental Health Research, Department of Psychiatry, University of Ottawa, Ottawa, Canada; Department of Psychiatry and Psychotherapy, Medical University Vienna, MUV, AKH, Vienna, Austria; Psychiatric Department Ludwig Maximilians University, Munich, Germany
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Systematic review of enriched enrolment, randomised withdrawal trial designs in chronic pain: a new framework for design and reporting. Pain 2016; 156:1382-1395. [PMID: 25985142 DOI: 10.1097/j.pain.0000000000000088] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Enriched enrolment, randomised withdrawal (EERW) pain trials select, before randomisation, patients who respond by demonstrating a predetermined degree of pain relief and acceptance of adverse events. There is uncertainty over the value of this design. We report a systematic review of EERW trials in chronic noncancer pain together with a critical appraisal of methods and potential biases in the methods used and recommendations for the design and reporting of future EERW trials. Electronic and other searches found 25 EERW trials published between 1995 and June 2014, involving 5669 patients in a randomised withdrawal phase comparing drug with placebo; 13 (median, 107 patients) had a randomised withdrawal phase of 6 weeks or less, and 12 (median, 334) lasted 12 to 26 weeks. Risks of bias included short duration, inadequate outcome definition, incomplete outcome data reporting, small size, and inadequate dose tapering on randomisation to placebo. Active treatment was usually better than placebo (22/25 trials). This review reduces the uncertainty around the value of EERW trials in pain. If properly designed, conducted, and reported, they are feasible and useful for making decisions about pain therapies. Shorter, small studies can be explanatory; longer, larger studies can inform practice. Current evidence is inadequate for valid comparisons in outcome between EERW and classical trials, although no gross differences were found. This systematic review provides a framework for assessing potential biases and the value of the EERW trials, and for the design of future studies by making recommendations for the conduct and reporting of EERW trials.
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Abstract
INTRODUCTION Knowledge of the factors affecting the adoption of new medications can enhance mental health care and guide quality improvement and policy development. Food and Drug Administration indications for treating bipolar disorder with several second-generation antipsychotics (SGAs) in the 2000s represent an opportunity to identify factors that impact the spread of a then-innovative treatment through a new population. METHODS Analysis of Department of Veterans Affairs administrative data identified the population of 170,811 veterans diagnosed with bipolar disorder from 2003 to 2010. We analyzed time trends and predictors of antimanic choice (SGA vs other) among the 40,512 outpatients with bipolar disorder who initiated their first VA outpatient antimanic prescription, using multinomial logistic regression in month-by-month analyses. We conducted classwise analyses and investigated prespecified predictors among specific agents. RESULTS In classwise analyses, SGAs supplanted lithium, valproate, and carbamazepine/oxcarbazepine as the most commonly initiated antimanics by 2007. Psychosis, but not other indices of severity, predicted SGA initiation. Demographic analyses did not identify substantial disparities in initiation of SGAs. Drug-specific analyses revealed some consideration of medical comorbidities in choosing among specific antimanic agents, although effect sizes were small. Most patients initiating an antimanic had received an antidepressant in the previous year. DISCUSSION Second-generation antipsychotics quickly became the frontline antimanic treatment for bipolar disorder, although antidepressants most commonly predated antimanic prescriptions. Second-generation antipsychotics were used for a broad range of patients rather than being restricted to a severely ill subpopulation. The modest association of antimanic choice with relevant medical comorbidities suggests that continued attention to quality prescribing practices is warranted.
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Comparison of Drug Utilization Patterns in Observational Data: Antiepileptic Drugs in Pediatric Patients. Paediatr Drugs 2015; 17:401-10. [PMID: 26070280 PMCID: PMC4573831 DOI: 10.1007/s40272-015-0139-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Physicians require information on the comparative benefits and harms of medications for optimal treatment decisions. However, this type of data is limited, especially for pediatric patients. OBJECTIVE Our aim was to use observational data to measure and compare medication utilization patterns in a pediatric patient population. METHODS Using pharmacy claims data from a large, national-scale insurance program in the USA, we identified all patients with a diagnosis of epilepsy treated with a first-generation antiepileptic drug (carbamazepine, ethosuximide, phenobarbital, phenytoin, or valproate) or a second-generation antiepileptic drug [carbamazepine extended release (XR), gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, valproate XR, or zonisamide]. Treatment periods were defined on the basis of prescription fill dates and medication days supplied. Medication use was measured for individual antiepileptic drugs and for first-generation and second-generation drugs as groups. RESULTS There were 2527 patients (54 %) who initiated therapy with first-generation antiepileptics and 2139 patients (46 %) who initiated therapy with second-generation antiepileptics. First- and second-generation drugs had the same 1-year retention rates [26 % (95 % confidence interval (CI) 24-28) and 26 % (95 % CI 25-28), respectively], and 26 % of patients (95 % CI 25-28) and 29 % of patients (95 % CI 27-31) who started on a first- or second-generation antiepileptic medication, respectively, resumed treatment with the initial drug after discontinuation. Overall, 73 % of patients (95 % CI 71-74) were treated with only one antiepileptic drug, with similar rates for patients started on first- and second-generation drugs [71 % (95 % CI 69-73) versus 74 % (95 % CI 72-76)]. CONCLUSION Comparing drug utilization patterns in a pediatric population using observational data, we found similar rates of retention and therapeutic changes. These findings are consistent with the available comparative data and demonstrate an approach that could be extended to other drug classes and conditions in pediatric populations to examine drug effectiveness.
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The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania. Harv Rev Psychiatry 2014; 22:274-94. [PMID: 25188733 DOI: 10.1097/hrp.0000000000000018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This new algorithm for the pharmacotherapy of acute mania was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The authors conducted a literature search in PubMed and reviewed key studies, other algorithms and guidelines, and their references. Treatments were prioritized considering three main considerations: (1) effectiveness in treating the current episode, (2) preventing potential relapses to depression, and (3) minimizing side effects over the short and long term. The algorithm presupposes that clinicians have made an accurate diagnosis, decided how to manage contributing medical causes (including substance misuse), discontinued antidepressants, and considered the patient's childbearing potential. We propose different algorithms for mixed and nonmixed mania. Patients with mixed mania may be treated first with a second-generation antipsychotic, of which the first choice is quetiapine because of its greater efficacy for depressive symptoms and episodes in bipolar disorder. Valproate and then either lithium or carbamazepine may be added. For nonmixed mania, lithium is the first-line recommendation. A second-generation antipsychotic can be added. Again, quetiapine is favored, but if quetiapine is unacceptable, risperidone is the next choice. Olanzapine is not considered a first-line treatment due to its long-term side effects, but it could be second-line. If the patient, whether mixed or nonmixed, is still refractory to the above medications, then depending on what has already been tried, consider carbamazepine, haloperidol, olanzapine, risperidone, and valproate first tier; aripiprazole, asenapine, and ziprasidone second tier; and clozapine third tier (because of its weaker evidence base and greater side effects). Electroconvulsive therapy may be considered at any point in the algorithm if the patient has a history of positive response or is intolerant of medications.
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Abstract
Data on the efficacy and safety of psychiatric medicines should form the foundation of evidence-based treatment practices. The US Food and Drug Administration (FDA) reviews such data in determining whether to approve new treatments, and the published literature serves as a repository for evidence on treatment benefits and harms. We describe the FDA review of clinical trials, examining the underlying logic and legal guidelines. Several FDA reviews provide evidence that the agency requires only minimal efficacy for psychiatric drugs. Further, in some instances, the FDA has relied on secondary rather than primary outcomes and has discounted the findings of negative studies in its review of antidepressant and antipsychotic medications. The published literature provides another lens into the safety and efficacy of treatments. We describe how treatment efficacy is systematically overstated and treatment-related harms are understated in the scientific literature. Suggestions are provided to improve public access to underlying safety and efficacy data and for the FDA to potentially improve its review process.
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Affiliation(s)
- Glen I Spielmans
- Department of Psychology, Metropolitan State University, Saint Paul, Minnesota 55108
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Abstract
Publication bias undermines the integrity of the evidence base by inflating apparent drug efficacy and minimizing drug harms, thus skewing the risk-benefit ratio. This paper reviews the topic of publication bias with a focus on drugs prescribed for psychiatric conditions, especially depression, schizophrenia, bipolar disorder, and autism. Publication bias is pervasive; although psychiatry/psychology may be the most seriously afflicted field, it occurs throughout medicine and science. Responsibility lies with various parties (authors as well as journals, academia as well as industry), so the motives appear to extend beyond the financial interests of drug companies. The desire for success, in combination with cognitive biases, can also influence academic authors and journals. Amid the flood of new medical information coming out each day, the attention of the news media and academic community is more likely to be captured by studies whose results are positive or newsworthy. In the peer review system, a fundamental flaw arises from the fact that authors usually write manuscripts after they know the results. This allows hindsight and other biases to come into play, so data can be "tortured until they confess" (a detailed example is given). If a "publishable" result cannot be achieved, non-publication remains an option. To address publication bias, various measures have been undertaken, including registries of clinical trials. Drug regulatory agencies can provide valuable unpublished data. It is suggested that journals borrow from the FDA review model. Because the significance of study results biases reviewers, results should be excluded from review until after a preliminary judgment of study scientific quality has been rendered, based on the original study protocol. Protocol publication can further enhance the credibility of the published literature.
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Affiliation(s)
- Erick H Turner
- Behavioral Health and Neurosciences Division, Portland Veterans Affairs Medical Center, P3MHDC, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA.
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Müller-Oerlinghausen B. [Are atypical antipsychotic drugs the first line treatment for bipolar disorders? Against]. DER NERVENARZT 2013; 83:1191-2. [PMID: 22911321 DOI: 10.1007/s00115-012-3619-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Spielmans GI, Berman MI, Linardatos E, Rosenlicht NZ, Perry A, Tsai AC. Adjunctive atypical antipsychotic treatment for major depressive disorder: a meta-analysis of depression, quality of life, and safety outcomes. PLoS Med 2013; 10:e1001403. [PMID: 23554581 PMCID: PMC3595214 DOI: 10.1371/journal.pmed.1001403] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 01/31/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Atypical antipsychotic medications are widely prescribed for the adjunctive treatment of depression, yet their total risk-benefit profile is not well understood. We thus conducted a systematic review of the efficacy and safety profiles of atypical antipsychotic medications used for the adjunctive treatment of depression. METHODS AND FINDINGS We included randomized trials comparing adjunctive antipsychotic medication to placebo for treatment-resistant depression in adults. Our literature search (conducted in December 2011 and updated on December 14, 2012) identified 14 short-term trials of aripiprazole, olanzapine/fluoxetine combination (OFC), quetiapine, and risperidone. When possible, we supplemented published literature with data from manufacturers' clinical trial registries and US Food and Drug Administration New Drug Applications. Study duration ranged from 4 to 12 wk. All four drugs had statistically significant effects on remission, as follows: aripiprazole (odds ratio [OR], 2.01; 95% CI, 1.48-2.73), OFC (OR, 1.42; 95% CI, 1.01-2.0), quetiapine (OR, 1.79; 95% CI, 1.33-2.42), and risperidone (OR, 2.37; 95% CI, 1.31-4.30). The number needed to treat (NNT) was 19 for OFC and nine for each other drug. All drugs with the exception of OFC also had statistically significant effects on response rates, as follows: aripiprazole (OR, 2.07; 95% CI, 1.58-2.72; NNT, 7), OFC (OR, 1.30, 95% CI, 0.87-1.93), quetiapine (OR, 1.53, 95% CI, 1.17-2.0; NNT, 10), and risperidone (OR, 1.83, 95% CI, 1.16-2.88; NNT, 8). All four drugs showed statistically significant effects on clinician-rated depression severity measures (Hedges' g ranged from 0.26 to 0.48; mean difference of 2.69 points on the Montgomery-Asberg Depression Rating Scale across drugs). On measures of functioning and quality of life, these medications produced either no benefit or a very small benefit, except for risperidone, which had a small-to-moderate effect on quality of life (g = 0.49). Treatment was linked to several adverse events, including akathisia (aripiprazole), sedation (quetiapine, OFC, and aripiprazole), abnormal metabolic laboratory results (quetiapine and OFC), and weight gain (all four drugs, especially OFC). Shortcomings in study design and data reporting, as well as use of post hoc analyses, may have inflated the apparent benefits of treatment and reduced the apparent incidence of adverse events. CONCLUSIONS Atypical antipsychotic medications for the adjunctive treatment of depression are efficacious in reducing observer-rated depressive symptoms, but clinicians should interpret these findings cautiously in light of (1) the small-to-moderate-sized benefits, (2) the lack of benefit with regards to quality of life or functional impairment, and (3) the abundant evidence of potential treatment-related harm. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Glen I Spielmans
- Department of Psychology, Metropolitan State University, St Paul, Minnesota, United States of America.
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Poon SH, Sim K, Sum MY, Kuswanto CN, Baldessarini RJ. Evidence-based options for treatment-resistant adult bipolar disorder patients. Bipolar Disord 2012; 14:573-84. [PMID: 22938165 DOI: 10.1111/j.1399-5618.2012.01042.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Many patients diagnosed with bipolar disorder (BD) respond incompletely or unsatisfactorily to available treatments. Given the potentially devastating nature of this prevalent disorder, there is a pressing need to improve clinical care of such patients. METHODS We performed a literature review of the research findings related to treatment-resistant BD reported through February 2012. RESULTS Therapeutic trials for treatment-resistant bipolar mania are uncommon, and provide few promising leads other than the use of clozapine. Far more pressing challenges are the depressive-dysthymic-dysphoric-mixed phases of BD and long-term prophylaxis. Therapeutic trials for treatment-resistant bipolar depression have assessed anticonvulsants, modern antipsychotics, glutamate [N-methyl-D-aspartate (NMDA)] antagonists, dopamine agonists, calcium-channel blockers, and thyroid hormones, as well as behavioral therapy, sleep deprivation, light therapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation, and deep brain stimulation-all of which are promising but limited in effectiveness. Several innovative pharmacological treatments (an anticholinesterase, a glutamine antagonist, a calcium-channel blocker, triiodothyronine, olanzapine and topiramate), ECT, and cognitive-behavior therapy have some support for long-term treatment of resistant BD patients, but most of trials of these treatments have been methodologically limited. CONCLUSIONS Most studies identified were small, involved supplementation of typically complex ongoing treatments, varied in controls, randomization, and blinding, usually involved brief follow-up, and lacked replication. Clearer criteria for defining and predicting treatment resistance in BD are needed, as well as improved trial design with better controls, assessment of specific clinical subgroups, and longer follow-up.
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Affiliation(s)
- Shi Hui Poon
- Department of General Psychiatry, Institute of Mental Health, 10 Buangkok ViewSingapore 539747
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Tsai AC, Karasic DH, Hammer GP, Charlebois ED, Ragland K, Moss AR, Sorensen JL, Dilley JW, Bangsberg DR. Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial. Am J Public Health 2012; 103:308-15. [PMID: 22720766 DOI: 10.2105/ajph.2011.300422] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008. METHODS We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL). RESULTS The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes. CONCLUSIONS Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.
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Affiliation(s)
- Alexander C Tsai
- Langley Porter Psychiatric Institute, University of California, San Francisco, CA, USA.
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Fountoulakis KN, Kasper S, Andreassen O, Blier P, Okasha A, Severus E, Versiani M, Tandon R, Möller HJ, Vieta E. Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry. Eur Arch Psychiatry Clin Neurosci 2012; 262 Suppl 1:1-48. [PMID: 22622948 DOI: 10.1007/s00406-012-0323-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, School of Medicine, Aristotle University of Thessaloniki, 6 Odysseos str./1st Parodos Ampelonon str., Pylaia, Thessaloniki, Greece.
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Berwaerts J, Melkote R, Nuamah I, Lim P. A randomized, placebo- and active-controlled study of paliperidone extended-release as maintenance treatment in patients with bipolar I disorder after an acute manic or mixed episode. J Affect Disord 2012; 138:247-58. [PMID: 22377512 DOI: 10.1016/j.jad.2012.01.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 01/25/2012] [Accepted: 01/30/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Paliperidone ER monotherapy was efficacious in treating acute mania in two 3-week studies in patients with bipolar I disorder. We assessed its efficacy in a study investigating maintenance treatment of clinically stable patients with this disorder. METHODS Patients (n=766), aged 18 to 65 years inclusive, with current manic or mixed episodes were initially randomized (4:1) to flexibly-dosed paliperidone ER (3-12 mg/day) or olanzapine (5-20 mg/day; 3-week acute treatment phase); responders continued the same treatment (12-week continuation phase). Patients on paliperidone ER who achieved remission during this phase were randomized (1:1) to fixed-dose paliperidone ER (n=152) or placebo (n=148); those on olanzapine continued to receive that at fixed dose (n=83) (maintenance phase). RESULTS Median time to recurrence of any mood symptoms (primary endpoint) was: 558 days (paliperidone ER), 283 days (placebo) and not observed with olanzapine (<50% of patients experienced recurrence). Time to recurrence of any mood symptoms was significantly longer with paliperidone ER than placebo (p=0.017; based on weighted Z-test at 0.0198 significance level; hazard ratio [placebo: paliperidone ER; unweighted 95% confidence interval]: 1.43 [1.03; 1.98]); the difference was significant for preventing recurrence of manic, but not depressive, symptoms. Treatment-emergent adverse events (maintenance phase) occurred more often in olanzapine group (64%) than placebo (59%) or paliperidone ER groups (55%). LIMITATIONS Responder-enriched design prevents extrapolation of data to patients not previously stabilized on paliperidone ER. CONCLUSIONS Paliperidone ER significantly delayed the time to recurrence of any mood symptoms, versus placebo, in patients with bipolar I disorder. No new safety concerns emerged.
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Affiliation(s)
- Joris Berwaerts
- Psychiatry Clinical Development, Neuroscience Therapeutic Area, Janssen Research & Development, LLC, Raritan, NJ, USA.
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Dhillon S. Aripiprazole: a review of its use in the management of mania in adults with bipolar I disorder. Drugs 2012; 72:133-62. [PMID: 22191800 DOI: 10.2165/11208320-000000000-00000] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Aripiprazole (Abilify®) is an atypical antipsychotic indicated for the treatment of mania associated with bipolar I disorder. It is unique in its class, as it is a partial agonist of dopamine D(2) and D(3), and serotonin 5-HT(1A) receptors and a modest antagonist of 5-HT(2A) receptors. This article reviews the pharmacological properties, clinical efficacy and tolerability of oral aripiprazole in the management of mania associated with bipolar I disorder in adults. In well designed clinical trials in patients with recent manic or mixed episodes associated with bipolar I disorder, oral aripiprazole monotherapy or adjunctive therapy to lithium or valproate improved symptoms of mania following short-term (≤12 weeks) or maintenance (≤100 weeks) treatment. In addition, maintenance treatment with aripiprazole (as monotherapy or adjunctive therapy) prevented the recurrence of any mood episodes or manic episodes (but not depressive episodes) in patients who had previously been stabilized and maintained on aripiprazole. Aripiprazole was generally well tolerated in these studies and was associated with a low risk of prolactin elevation, corrected QT interval prolongation and metabolic disturbances. Extrapyramidal symptoms occurred in up to 28% of aripiprazole recipients, but after longer-term treatment (≤100 weeks), symptom severity did not differ significantly from that in placebo recipients. Aripiprazole treatment generally did not increase bodyweight to a clinically relevant extent; however, more patients receiving aripiprazole monotherapy than placebo had clinically significant bodyweight gain during 100 weeks' treatment. Additionally, in a comparative trial, aripiprazole monotherapy was at least as effective as haloperidol monotherapy in terms of improving symptoms of mania, but had the advantage of a lower incidence of some adverse events, such as extrapyramidal symptom-related adverse events. Further trials comparing aripiprazole with other agents, including atypical antipsychotics, would help to definitively position aripiprazole relative to these agents. Current guidelines recommend aripiprazole as a first-line option (as monotherapy or adjunctive therapy) for the short-term treatment of mania associated with bipolar I disorder, and as a first-line (as monotherapy) or second-line (as adjunctive therapy) option for preventing the recurrence of mood episodes during longer-term therapy.
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Cosgrove L, Krimsky S. A comparison of DSM-IV and DSM-5 panel members' financial associations with industry: a pernicious problem persists. PLoS Med 2012; 9:e1001190. [PMID: 22427747 PMCID: PMC3302834 DOI: 10.1371/journal.pmed.1001190] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Lisa Cosgrove and Sheldon Krimsky examine the new competing interest disclosure policy of the American Psychiatric Association (APA) and report that DSM panel members still have considerable financial conflicts of interest.
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Affiliation(s)
- Lisa Cosgrove
- Edmond J. Safra Center for Ethics, Harvard University, Cambridge, Massachusetts, USA.
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