Lamotrigine in the treatment of bipolar disorder

Aggression as psychiatric side effect of newer AEDs in patients with epilepsy: Cross-sectional study based on Buss-Perry Aggression Questionnaire

PURPOSE

Aggression-irritability is the most commonly encountered antiepileptic-drug-induced psychiatric adverse effects. In this cross-sectional study, we tried to assess antiepileptic-drug-induced aggression in patients with epilepsy (PWE) with a standardized rating scale.

METHODS

Two hundred sixty-six consecutive outpatients receiving treatment for epilepsy with antiepileptic drugs (AEDs) were initially examined, and the effects of the investigated drugs in regard to aggression were investigated using the Buss-Perry Aggression Questionnaire (BAQ). We compared BAQ scores as a function of a specific class of AEDs, levetiracetam (LEV), lacosamaide (LCM), perampanel (PER), and carbamazepine (CBZ), and determined whether AED type had a relationship with aggression. Additionally, the association of BAQ score with other clinico-demographic variables was also assessed.

RESULTS

One-way ANOVA revealed that the LEV group had a significantly higher mean BAQ score as compared to the CBZ (P = 0.001) and LCM (P = 0.029) groups for total score. In subscale analysis, the LEV group had higher scores than the CBZ group for the physical aggression (p = 0.01), verbal aggression (p = 0.02) and hostility (p = 0.01) subscales, while the LEV group had a significantly higher mean score than the LCM group for hostility (p = 0.025). In multiple regression analysis, LEV had a statistically significant impact on increased total BAQ score (B = 0.119, p = 0.049). In contrast, CBZ (B = -0.191, p = 0.002), older age at epilepsy onset (B = -0.269, p = 0.000) and female gender (B = -0.210, p = 0.000) had a significant association with lower total BAQ score.

CONCLUSIONS

Our results indicate that LEV is associated with increased aggression, while CBZ and LCM showed effects to reduce aggression.

The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF)

There is considerable diversity in how treatment-resistant depression (TRD) is defined. However, every definition incorporates the concept that patients with TRD have not benefited sufficiently from one or more adequate trials of antidepressant treatment. This review examines the issues fundamental to the systematic evaluation of antidepressant treatment adequacy and resistance. These issues include the domains of interventions deemed effective in treatment of major depressive episodes (e.g., pharmacotherapy, brain stimulation, and psychotherapy), the subgroups of patients for whom distinct adequacy criteria are needed (e.g., bipolar vs. unipolar depression, psychotic vs. nonpsychotic depression), whether trials should be rated dichotomously as adequate or inadequate or on a potency continuum, whether combination and augmentation strategies require specific consideration, and the criteria used to evaluate the adequacy of treatment delivery (e.g., dose, duration), trial adherence, and clinical outcome. This review also presents the Antidepressant Treatment History Form: Short-Form (ATHF-SF), a completely revised version of an earlier instrument, and details how these fundamental issues were addressed in the ATHF-SF.

Developments in depression in epilepsy: screening, diagnosis, and treatment

INTRODUCTION

Depression is one of the most frequent comorbidities in epilepsy affecting between 17% and 22% of patients, but it is still underdiagnosed and undertreated. Areas covered: This paper discusses recent advances about screening, diagnosis, and treatment of depression in epilepsy taking into account the heterogeneity of clinical scenarios where depression can occur. Expert opinion: A number of screening instruments are now validated for adults with epilepsy, and their psychometric properties are discussed but the NDDI-E is the most practical and cost-effective. Challenges in diagnosing depression in epilepsy are discussed including reasons for the atypical features of mood disorders in epilepsy. Psychological treatments and/or SSRIs are indicated, but the level of evidence is still low. Even if there is no reason to hypothesise that internationally accepted guidelines of treatment of depression outside epilepsy may not be valid, rigorous studies are needed in order to have proper outcome measures. Epilepsy centers should have well-defined care pathways for depression in order to provide access to mental health support when needed.

Mood Disorders in Epilepsy

Mood disorders associated with epilepsy are very common and overrepresented compared with other chronic medical conditions. Depression is a particularly common and worrisome comorbidity, especially because suicidality seems to be increased significantly in the context of epilepsy. Although psychosocial stressors commonly are associated, intrinsic characteristics of seizure disorders may contribute to the expression of depressive symptoms. Depression and epilepsy may exacerbate each other. Epilepsy with seizure foci in the temporal lobe may represent a higher risk of developing depression, especially if the seizures do not generalize. Treatment of depression is multifaceted and includes psychotherapy and sophisticated regimens of anticonvulsants. Most antidepressants may be used safely and effectively in the context of depression, although high-quality evidence is lacking. Ultimately, treatment of comorbid mood disorder has important implications for outcome and quality of life, perhaps even more than treatment of epilepsy itself.

Novel glutamatergic agents for major depressive disorder and bipolar disorder

Mood disorders such as major depressive disorder (MDD) and bipolar disorder (BPD) are common, chronic, recurrent mental illnesses that affect the lives and functioning of millions of individuals worldwide. Growing evidence suggests that the glutamatergic system is central to the neurobiology and treatment of these disorders. Here, we review data supporting the involvement of the glutamatergic system in the pathophysiology of mood disorders as well as the efficacy of glutamatergic agents as novel therapeutics.

Long-term treatment of bipolar disorder with a radioelectric asymmetric conveyor

BACKGROUND

The bipolar spectrum disorders are considered an important and frequent psychiatric problem. The clinical complexity of these illnesses due to the coexistence of depressive and excitative phases is correlated with the global difficulty of adequate treatment; consequently, the prognosis is not optimal. For this reason, in recent years, novel nonpharmacologic physical approaches have been tested for bipolar disorders, with encouraging results. The aim of this study was to evaluate the long-term effectiveness of a radioelectric asymmetric brain stimulation device associated with lithium (REAC-lithium) versus previous treatments in subjects with bipolar disorder I or II, evaluated as the number of recurrences compared with the period of illness preceding treatment with REAC-lithium.

METHODS

The charts of 56 bipolar patients attending our institute were retrospectively evaluated. Treatment with REAC-lithium was administered following the standard Rinaldi-Fontani Institute protocol. Add-on treatments were allowed in the event of manic or depressive recurrence. Eight patients (Group 1) were followed for 30.2 ± 3.0 months, 14 patients (Group 2) were followed for 25.3 ± 3.3 months, 25 patients (Group 3) were followed for 20.3 ± 1.6 months, and nine patients (Group 4) were followed for 16.2 ± 0.5 months.

RESULTS

After REAC-lithium treatment, the number of manic and depressive episodes in Group 1 decreased from 2.1 ± 0.6 and 3.0 ± 0.7 to 0.12 ± 0.0 and 0.8 ± 0.4, respectively. In Group 2, the number of manic and depressive episodes decreased from 2.4 ± 0.6 and 3.9 ± 0.7 to 0.14 ± 0.2 and 0.0 ± 0.0, respectively. In Group 3, the number of manic and depressive episodes decreased from 2.6 ± 0.8 and 3.6 ± 0.9 to 0.04 ± 0.0 and 0.0 ± 0.0, respectively. In Group 4, the number of manic and depressive episodes decreased from 2.6 ± 1.1 and 3.7 ± 1.0 to 0.1 ± 0.0 and 0.0 ± 0.0, respectively. All results were statistically significant.

CONCLUSION

REAC showed good efficacy in treating both the manic and depressive phases of bipolar disorder, and in the prevention of recurrences/relapses.

Magnetic resonance spectroscopy studies of glutamate-related abnormalities in mood disorders

In mood disorders, there is growing evidence for glutamatergic abnormalities derived from peripheral measures of glutamatergic metabolites in patients, postmortem studies on glutamate-related markers, and animal studies on the mechanism of action of available treatments. Magnetic resonance spectroscopy (MRS) has the potential to corroborate and extend these findings with the advantage of in vivo assessment of glutamate-related metabolites in different disease states, in response to treatment, and in relation with functional imaging data. In this article, we first review the biological significance of glutamate, glutamine, and Glx (composed mainly of glutamate and glutamine). Next, we review the MRS literature in mood disorders, examining these glutamate-related metabolites. Here, we find a highly consistent pattern of Glx-level reductions in major depressive disorder and elevations in bipolar disorder. In addition, studies of depression, regardless of diagnosis, provide suggestive evidence for reduced glutamine/glutamate ratio and in mania for elevated glutamine/glutamate ratio. These patterns suggest that the glutamate-related metabolite pool (not all of it necessarily relevant to neurotransmission) is constricted in major depressive disorder and expanded in bipolar disorder. Depressive and manic episodes may be characterized by modulation of the glutamine/glutamate ratio in opposite directions, possibly suggesting reduced versus elevated glutamate conversion to glutamine by glial cells, respectively. We discuss the implications of these results for the pathophysiology of mood disorders and suggest future directions for MRS studies.

Lamotrigine as an augmentation agent in treatment-resistant obsessive-compulsive disorder: a case report

Obsessive-compulsive disorder (OCD) is a relatively common, often chronic and disabling disorder with high rates of partial and/or absent response to standard, recommended treatments. We report a case of treatment-resistant OCD that was successfully treated with a pharmacological augmentation of lamotrigine plus clomipramine. The patient, a 59-year-old woman, was on a stable dose of clomipramine (225 mg/day) when she was started on lamotrigine (up to 150 mg/day). After 10 weeks of this treatment, her clinical condition remarkably improved, as indicated by a significant decrease of the Yale-Brown Obsessive-Compulsive Scale. This case suggests some preliminary evidence that the addition of glutamatergic agent lamotrigine may be useful in treatment-resistant OCD. However, further controlled studies are needed to support this finding.

Genetic association studies of glutamate, GABA and related genes in schizophrenia and bipolar disorder: a decade of advance

Schizophrenia (SZ) and bipolar disorder (BD) are debilitating neurobehavioural disorders likely influenced by genetic and non-genetic factors and which can be seen as complex disorders of synaptic neurotransmission. The glutamatergic and GABAergic neurotransmission systems have been implicated in both diseases and we have reviewed extensive literature over a decade for evidence to support the association of glutamate and GABA genes in SZ and BD. Candidate-gene based population and family association studies have implicated some ionotrophic glutamate receptor genes (GRIN1, GRIN2A, GRIN2B and GRIK3), metabotropic glutamate receptor genes (such as GRM3), the G72/G30 locus and GABAergic genes (e.g. GAD1 and GABRB2) in both illnesses to varying degrees, but further replication studies are needed to validate these results. There is at present no consensus on specific single nucleotide polymorphisms or haplotypes associated with the particular candidate gene loci in these illnesses. The genetic architecture of glutamate systems in bipolar disorder need to be better studied in view of recent data suggesting an overlap in the genetic aetiology of SZ and BD. There is a pressing need to integrate research platforms in genomics, epistatic models, proteomics, metabolomics, neuroimaging technology and translational studies in order to allow a more integrated understanding of glutamate and GABAergic signalling processes and aberrations in SZ and BD as well as their relationships with clinical presentations and treatment progress over time.

The role of the tripartite glutamatergic synapse in the pathophysiology and therapeutics of mood disorders

Bipolar disorder and major depressive disorder are common, chronic, and recurrent mood disorders that affect the lives of millions of individuals worldwide. Growing evidence suggests that glutamatergic system dysfunction is directly involved in mood disorders. This article describes the role of the "tripartite glutamatergic synapse," comprising presynaptic and postsynaptic neurons and glial cells, in the pathophysiology and therapeutics of mood disorders. Glutamatergic neurons and glia directly control synaptic and extrasynaptic glutamate levels/ release through integrative effects that target glutamate excitatory amino acid transporters, postsynaptic density proteins, ionotropic receptors (alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid [AMPA], N-methyl-D-aspartate [NMDA], and kainate), and metabotropic receptors. This article also explores the glutamatergic modulators riluzole and ketamine, which are considered valuable proof-of-concept agents for developing the next generation of antidepressants and mood stabilizers. In therapeutically relevant paradigms, ketamine preferentially targets postsynaptic AMPA/NMDA receptors, and riluzole preferentially targets presynaptic voltage-operated channels and glia.

Effect of Adjunctive Lamotrigine Treatment on the Plasma Concentrations of Clozapine, Risperidone and Olanzapine in Patients With Schizophrenia or Bipolar Disorder

The effect of lamotrigine on the steady-state plasma concentrations of the atypical antipsychotics clozapine, olanzapine, and risperidone was investigated in patients with schizophrenia or bipolar disorder stabilized on chronic treatment with clozapine (200-500 mg/day; n = 11), risperidone (3-6 mg/day; n = 10) or olanzapine (10-20 mg/day; n = 14)). Lamotrigine was titrated up to a final dosage of 200 mg/day over 8 weeks, and pharmacokinetic assessments were made at baseline and during treatment weeks 6 and 10, at lamotrigine dosages of 100 and 200 mg/day respectively. The plasma concentrations of clozapine, norclozapine, risperidone, and 9-hydroxy-risperidone did not change significantly during treatment with lamotrigine. The mean plasma concentrations of olanzapine were 31 +/- 7 ng/mL at baseline, 32 +/- 7 ng/mL at week 6, and 36 +/- 9 ng/mL at week 10, the difference between week 10 and baseline being statistically significant (P < 0.05). Adjunctive lamotrigine therapy was well tolerated in all groups. These findings indicate that lamotrigine, at the dosages recommended for use as a mood stabilizer, does not affect the plasma levels of clozapine, risperidone, and their active metabolites. The modest elevation in plasma olanzapine concentration, possibly due to inhibition of UGT1A4-mediated olanzapine glucuronidation, is unlikely to be of clinical significance.