Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Reduced risk of hospitalisation with risperidone long-acting injectable. Results of the french cohort for the general study of schizophrenia (CGS)

Introduction

Medication non-adherence is a significant risk factor for rehospitalisation in schizophrenia patients. Delayed release formulations like R-LAI may reduce rehospitalisation.

Objectives

To examine the association between R-LAI use and hospitalisation in schizophrenia patients.

Aims

To assess the effect of R-LAI, compared to non-use and use of other antipsychotic drugs, on the risk of hospitalization in real-life settings.

Method

The CGS study recruited schizophrenia patients from 177 public and private wards of psychiatric hospitals across France. Inclusion criteria were schizophrenia (DSM-IV), age 15–65 years, ambulatory/hospitalised for < 93 days at entry. Patients were followed up to 12 months for antipsychotic use and hospitalisation. The recruitment was stratified for long-acting second generation antipsychotic use. Multivariate Poisson regression adjusted for confounding with propensity scores and allowing for autocorrelation was used to estimate relative rates of hospitalisation.

Results

Of 2092 eligible patients, 1859 were included. Their mean age was 38.1 ± 11.1 years, 68.6% were male and 37.8% were hospitalised for < 93 days at entry. A total of 1659 patients (89.2%) were followed up for 12 months, accumulating 933 hospital stays (53.0 per 100 person-years). Compared to other schizophrenia patients, patients on R-LAI were younger, had more often a history of previous hospitalisation for equivalent severity, living conditions and other characteristics. The adjusted relative rate of hospitalisation for R-LAI use against non-use was 0.66 [95% CI 0.46–0.96], and 0.53 [95% CI 0.32–0.88] against long-acting first generation antipsychotics.

Conclusions

Use of R-LAI was associated with lower rates of hospitalization compared to non-use of R-LAI.

Influence of the serotonin transporter gene polymorphism, cannabis and childhood sexual abuse on phenotype of bipolar disorder: a preliminary study

OBJECTIVE

The gene coding for the 5-HT transporter (5-HTT) is considered as a candidate gene for bipolar disorder, either as a "vulnerability" or as a "modifying the phenotype" gene. Psychotic symptoms occur at least once in one bipolar patient out of two, the relevant risk factors being insufficiently understood. The gene × environment interaction approach offers the opportunity to disentangle the latter, including childhood sexual abuse and cannabis abuse.

METHODS

We investigated the 5-HTTLPR of the 5-HTT gene (G) and the presence of childhood sexual abuse and cannabis comorbidity (E) in 137 bipolar patients with (versus without) lifetime psychotic symptoms.

RESULTS

The short allele and cannabis abuse were significantly more frequent among patients with psychotic symptoms than in those without (p=0.01 and p=0.004, respectively), while childhood sexual abuse was not. Complex interactions were found between presence of the short allele, cannabis abuse or dependence and childhood sexual abuse.

CONCLUSIONS

The short allele of the 5-HTTLPR polymorphism of the 5-HTT gene was a risk factor for psychotic symptoms in bipolar disorder in the present sample, directly but also indirectly, through the presence of cannabis abuse or dependence, as an exacerbating factor heightening psychotic symptoms.

Use of the EQ-5D among patients suffering from dementia

BACKGROUND AND OBJECTIVE

This study was designed to determine the acceptability, feasibility, reliability, and validity of the French version of EQ-5D measuring HRQol in subjects with dementia.

METHODS

EQ-5D was administered to 142 subjects. The feasibility and acceptability were determined by the refusal rate, the type of administration, and the percentage and distribution of missing data. Test-retest reliability was studied by kappa coefficients and validity by agreement between subjects' and proxies' assessments.

RESULTS

The response rate was satisfactory. The instrument discriminated well among the subjects. Test-retest reliability was average. The validity was poor if we consider the agreement between patients' and caregivers' reports, but other criteria of validity produced better results. Subjects' responses on each dimension were related with their global judgment of health in the expected direction. Significant relations were found between the Katz index of ADL and self-rated difficulties only for expected dimensions. Relations with age and with gender were in line with expectations.

CONCLUSION

Results led to consider that patients' responses are not entirely devoid of judgment. It seems that dementia patients are capable of expressing their health-related quality of life through a brief instrument as the EQ-5D.

Association between the tryptophan hydroxylase gene and manic-depressive illness

BACKGROUND

Genes encoding proteins involved in serotonergic metabolism are major candidates in association studies of mood disorders and suicidal behavior. This association study explores whether the tryptophan hydroxylase (TPH) gene, which codes for the rate-limiting enzyme of serotonin biosynthesis, is a susceptibility factor for manic-depressive illness, with or without a history of suicide attempts.

METHODS

The TPH intron 7 A218C polymorphism was determined using a polymerase chain reaction-based method in DNA samples from 152 patients with bipolar disorder and 94 healthy control subjects.

RESULTS

There was a significant association between TPH genotypes and manic-depressive illness. Among patients with bipolar disorder, no association was found between TPH alleles and suicidal behavior.

CONCLUSIONS

This result suggests the involvement of the TPH gene in susceptibility to manic-depressive illness. This preliminary result requires confirmation in further groups of patients and controls.

Frontal 5-HT2A receptors studied in depressive patients during chronic treatment by selective serotonin reuptake inhibitors

To investigate adaptative changes of 5-HT2A receptors induced by SSRIs, six patients chronically treated for a depressive episode (four with fluoxetine, two with fluvoxamine) were studied with PET and [18F]setoperone. They were compared to eight untreated depressive patients. The mean frontal to cerebellum radioactivity concentration ratio, an index of the [18F]setoperone specific binding to 5-HT2A receptors, was higher in treated than in untreated patients, when age was taken into account. This suggests that chronic treatment by SSRIs could induce an up-regulation of the 5-HT2A receptors, and that 5-HT2A receptor down-regulation is not a common mechanism for the therapeutic effects of all serotoninergic antidepressive drugs.

[Behavior regarding therapeutic drugs and self concept of elderly persons with chronic diseases]

This research on a sample of 133 persons older than 60 years and suffering from chronic diseases, concerns their practices towards medicines. Various practices displayed can be grouped in three different ways according to the regularity and the order of medicine taking, forgetting, self-medication, etc.; they seem to be linked neither to sex or age of subjects nor to variables directly or indirectly affected by the disease (number and type of medicines, gravity of the disease, subjective health). The understanding of these differential practices is improved if we consider the self-concept of subjects, that is to say their different positions in an organized whole of personality traits; this position reflects traits that they recognize as being more or less constitutive of their identity, that which motivates and gives sense to the totality of their life conduct.

[Associated psychotropic drugs in deficit schizophrenia]

Therapy with classical neuroleptics is not effective enough and its adverse effects are quite disabling, especially in chronic or negative schizophrenia; that is probably why adjunctive therapy is so common. Still conclusive evidence concerning the potential benefit of one or another therapeutic association is scarce. Intrinsic heterogeneity of schizophrenias and tremendous methodological problems constitute plausible explanations. Besides studies are usually realised among unselected patients. Available data about adjunctive therapy with anticholinergics, propranolol, antidepressants, benzodiazepines, lithium and carbamazepine are briefly reviewed here.

The estimated density of D2 striatal receptors in schizophrenia. A study with positron emission tomography and 76Br-bromolisuride

The striatal D2 receptors of 19 untreated schizophrenics and 14 normal control subjects were investigated with PET and 76Br-bromolisuride. The ratio of radioactivity in the striatum to that in the cerebellum was taken as an index of the striatal D2 receptor density. There was no significant difference between the control and the schizophrenic groups, nor any difference between subgroups of patients defined by clinical type or course of illness, and no relationship between the striatum:cerebellum activity ratio and SANS or SAPS ratings of symptoms. Unlike in the controls, this ratio was not correlated with age in schizophrenics. This study suggests that there is no quantitative abnormality of striatal D2 dopamine receptors in schizophrenia.

[The mesencephalic dopaminergic system. Implications for neuroleptic treatment]

Thirty years ago, dopamine was identified as an essential neurotransmittor. Since then, it has been the most written about CNS molecule. Considerable evidence implicates disturbances of brain dopamine function in the pathophysiology of several psychiatric and neurologic disorders, especially schizophrenia and Parkinson's disease. In the last decade, there have been important advances in the understanding of the diversity of CNS dopamine neurons and the chemical basis of this diversity, which relies upon molecular physiology of D1 and D2 receptors. Heterogeneity is remarkable at different levels, anatomical, biochemical, morphological or functional; besides, region specific interactions with other neurotransmittors and sometimes colocalisation of dopamine with cholecystokinin and/or neurotensin suggest the integration of dopamine neurons in functional subunits.