Newsletter No. 3, 2008 www.psychopharmbulletin.com Volume 41 • Number 3 • 2008
Psychopharmacology BULLETIN Newsletter
the advance newsletter of Psychopharmacology BULLETIN
Summary—Index of This Issue On-Press
Cocaine is a Major Risk Factor for Antipsychotic Induced Akathisia, Parkinsonism and Dyskinesia
abstract ~ Objective: To assess the relative contribution of different drugs of abuse to extrapyramidal side effects (EPS) of antipsychotic drugs. Method: 106 consecutively contacted or admitted male patients in the Psychiatric Center of Surinam (PCS) with schizophrenia or a related disorder were included. Prevalence and severity of EPS were measured with the Unified Parkinson’s Disease Rating Scale (UPDRS), the Abnormal Involuntary Movement rating Scale (AIMS), the Barnes Akathisia Rating Scale (BARS) and the Dystonia rating scale. Recent use of cigarettes, cannabis, alcohol, and cocaine were assessed. Standard multiple regression analyses were used to evaluate the relative contribution of above-mentioned drugs of abuse controlled for milligrams haloperidol equivalent a day and use of anticholinergic medication. Results: Recent cocaine use was significantly associated with severity of dyskinesia (p 5 0.001), parkinsonism (p 5 0.007), and akathisia (p , 0.001) (n 5 106). Conclusions: Recent cocaine use is a major risk factor for antipsychotic induced EPS.
Arija Maat, Annemarie Fouwels, Lieuwe de Haan, Psychopharmacology Bulletin. 2008;41(3):5–10.
The Efficacy and Tolerability of Once-Daily Extended Release Quetiapine Fumarate in Hospitalized Patients with Acute Schizophrenia: A 6-Week Randomized, Double-Blind, Placebo-Controlled Study
abstract ~ Objectives: This study aimed to demonstrate efficacy of once-daily extended release quetiapine fumarate (quetiapine XR) versus placebo in patients with acute schizophrenia. Methods: In this 6-week, randomized, double-blind study (5077IL/0041) patients were randomized to receive quetiapine XR (300, 600, or 800 mg/day), quetia- pine fumarate immediate release (quetiapine IR) [300 or 600 mg/day], or placebo. Primary endpoint was change from baseline in the Positive and Negative Syndrome Scale (PANSS) total score at Day 42. Secondary variables included PANSS response rate at Day 42 ($30% decrease in PANSS total score from baseline) and Clinical Global Impressions Severity (CGI-S) and Improvement (CGI-I) ratings. Safety assessments included adverse event (AE) reporting and laboratory measures. Results: Of 532 patients randomized, 222 (41.7%) completed the study. Improvements in PANSS total scores from baseline to Day 42 across treatment groups were: quetiapine XR 300 mg/day 25.01, 600 mg/day 213.01 and 800 mg/day 211.17, quetiapine IR 300 mg/day 29.42 and 600 mg/day 26.97, and placebo 25.19; the difference in change was statistically significant only for quetiapine XR 600 mg/day (p 5 0.033). There were no statistically significant differences between active treatment groups and placebo for PANSS response rates. Several post hoc analyses were conducted to explain the study efficacy outcome but these were inconclusive. Quetiapine XR was generally well tolerated with the majority of AEs being mild or moderate in intensity and no unexpected AEs. Conclusions: Superior efficacy of quetiapine XR versus placebo in patients with schizophrenia was demonstrated for quetiapine XR 600 mg/day. The safety and tolerability profile of quetiapine XR was similar to that of quetiapine IR.
Jean-Pierre Lindenmayer, David Brown, Sherry Liu, Martin Brecher, and Didier Meulien, on behalf of the Study 41 inv,estigators, Psychopharmacology Bulletin. 2008;41(3):11-35.
A Major Change of Prescribing Pattern in Absence of Adequate Evidence: Benzodiazepines Versus Newer Antidepressants in Anxiety Disorders
abstract ~ We performed a systematic review of controlled trials on anxiety disorders treatment (generalized anxiety disorder, panic disorder, social phobia and post-traumatic stress disorder) published from 1980 to 2006, and identified trials comparing the efficacy of benzodiazepines (BZD) with that of antidepressants, in particular comparisons between BZD and newer antidepressants. Among 969 publications, 274 double-blind randomized controlled studies remained after using our exclusion criteria. These studies comprised altogether 439 comparisons. There were in total 23 comparisons of antidepressants versus BZD. Among these, 22 compared the efficacy of older antidepressants versus BZD, whereas only 1 concerned the comparison of a newer antidepressant versus BZD. It showed comparable efficacy between venlafaxine and diazepam in the treatment of generalized anxiety disorder. Our study shows that the major change of prescribing pattern from BZD to newer antidepressants in anxiety disorders has occurred in absence of comparative data of high level of proof.
Patricia Berney, Demian Halperin, Rodrigo Tango, Isabelle Daeniker-Dayer, Pierre Schulz, Psychopharmacology Bulletin. 2008;41(3):39–47.
Developing and Testing Adaptive Treatment Strategies Using Substance-Induced Psychosis
as an Example
Abstract ~ Decisions concerning treatment changes pervade the management of chronic psychiatric disorders that resist definitive cure, yet empirical evidence for the comparative clinical effectiveness of treatment strategies remains underdeveloped. In this paper we exploit the example of psychosis following substance use to illustrate some new developments in clinical trials design that can provide the most solid evidence base for defining successful strategies. The intent is to explore the strengths and limitations of the methodological approach through a meaningful clinical example, with an emphasis on concepts and issues. Both methodology and clinical science are overviewed.
Ree Dawson, Alan I. Green, Robert E. Drake, Thomas H. McGlashan, Bella Schanzer, Philip W. Lavori Psychopharmacology Bulletin. 2008;41(3):51–67.
Psychometric Evaluation of a Patient-Rated Troubling Symptom Scale for Generalized Anxiety Disorder Clinical Trials
ABSTRACT ~ Background: The majority of clinical outcome assessments developed for generalized anxiety disorder (GAD) may not efficiently and sensitively reflect heterogeneous symptom clusters from a patient perspective. The Patient-Rated Troubling Symptoms Scale for Anxiety (PaRTS-A) instrument was developed to provide an individualized assessment of patient relevant GAD symptoms. Objective: The objective of this analysis was to evaluate the psychometric characteristics of the PaRTS-A. Methods: Data were taken from a 6-week clinical trial evaluating the efficacy of adjunctive risperidone therapy in GAD patients undergoing standard treatment. Patients completed the PaRTS-A, the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and the Sheehan Disability Scale (SDS) as well as impressions of improvement. Physicians completed the Hamilton Anxiety Rating Scale (HAM-A). A instrument characteristics were assessed through statistical tests of reliability, reproducibility, construct and discriminant validity, and responsiveness. Results: In the item response theory (IRT) analysis, the PaRTS-A items fit into a single construct of anxiety. Internal consistency reliability exceeded 0.70. The PaRTS-A total score was moderately correlated with the Q-LES-Q and the SDS. The PaRTS-A distinguished between patients with high and low HAM-A scores (p,0.001). The PaRTS-A was responsive to changes in clinical status and the minimal important difference was identified. Conclusion: The PaRTS-A provides a unique patient-rated assessment of anxiety symptoms. The instrument may provide clinicians with useful information regarding patient’s self-rated anxiety disorder symptoms and the hierarchy of symptoms that they considered most troubling. Our analysis suggests that the PaRTS-A is an internally consistent, valid, and responsive instrument that may be a beneficial adjunct to other instruments in clinical trials.
Gahan J. Pandina, Dennis A. Revicki, Leah Kleinman, Ibrahim Turkoz, Jasmanda Wu, Ramy Mahmoud, Georges M. Gharabawi, Psychopharmacology Bulletin. 2008;41(3):68–90.
Placebo Response in Depression: A Perspective for Clinical Practice
abstract ~ Practicing clinicians appreciate that depression is not an easy disorder to treat and manage. Despite the plethora of new treatments—both pharmacological and non pharmacological—that has flooded the market in the past years, we are still nowhere close to obtaining full symptom relief for all patients and eradicating the morbidity and mortality associated with depression.
In this context, recent methodological research, concentrating on the effectiveness of antidepressants has raised doubts about their therapeutic index. Because of obtuseness of the methodology and biased interpretations, we are submitting this perspective to clinicians so that they can appreciate some of the deficits of the recent research publications. For the practicing clinician, the best available data suggest that clinically depressed patients warrant treatment and the most robust available body of data (published and unpublished) would favor the use of antidepressants.
Arif Khan, Shirin Khan, Psychopharmacology Bulletin. 2008;41(3):91–98.
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Psychopharmacology BULLETIN Newsletter
the advance newsletter of Psychopharmacology BULLETIN
Summary—Index of This Issue On-Press
• ORIGINAL RESEARCH
• EVIDENCE-BASED MEDICINE
Are SNRIs More Effective than SSRIs? A Review of the Current State of the Controversy—p.2
The selective serotonin reuptake inhibitors (SSRI) are widely considered to be the first choice for antidepressant therapy. There is evidence from inpatient studies dating to 1986, however, suggesting that the tricyclic antidepressant clomipramine, which inhibits reuptake of both serotonin and norepinephrine, may have greater efficacy than some SSRIs for severe depression. There is controversy whether the newer, better tolerated, and safer serotonin norepinephrine reuptake inhibitors (SNRIs; venlafaxine, duloxetine, and—in some countries—milnacipran and desvenlafaxine) are more efficacious than SSRIs.
Michael E. Thase, MD
Criteria for Defining Symptomatic and Sustained Remission in Bipolar I Disorder: a Post-Hoc Analysis of a 26-Week Aripiprazole Study—pp.2/3
In aripiprazole-treated patients, symptomatic remission rates were consistent at weeks 8, 16, and 26; sustained remission rates at week 8 were retained at weeks 16 and 26. The authors concluded that when discerning an operational definition of remission in patients with a recent manic or mixed episode, the YMRS 7 criterion and sustaining this criterion for 8 weeks can be a useful clinical or research tool for assessing clinical recovery.
Prakash S.Masand, MD, James Eudicone, MS, Andrei Pikalov, MD, PhD, Robert D.McQuade, PhD, Ronald N.Marcus, MD, Estelle Vester-Blokland, MD, and Berit X. Carlson, PhD
Bipolar I Depression Outpatient Treatment Quality and Costs in Usual Care Practice —p.3
Fifty-six percent of the patients diagnosed with bipolar I depression received both an antimanic agent and psychotherapy during their acute phase depression treatment, whereas 15 percent received an antimanic agent without psychotherapy. Eighteen to 28 percent of spending was accounted for by treatment that did not meet the standards of practice guidelines—and two-thirds to three-quarters of it was treatment that included an antidepressant without anantimanic agent (care that is advised by guidelines).
Alisa B.Busch, MD, MS, Richard G.Frank, PhD, and Gary Sachs, MD
Addressing Methodological Issues in Studying Antidepressant Onset Efficacy Using Prespecified Sensitivity Analyses—p.4
Assessing antidepressant onset efficacy presents substantial methodological challenges. Most assessments of onset efficacy are based on post hoc analyses. This article presents a case study of a prospectively designed trial to compare antidepressant onset efficacy. The authors concluded that prospectively designed studies (as opposed to retrospective comparisons) can be implemented and sensitivity analyses can be used to address concerns regarding assumptions and arbitrary decisions.
Ilya Lipkovich, PhD, Craig H.Mallinckrodt, PhD, Apurva Prakash, BA, and Andrew A.Nierenberg, MD
Are SNRIs More Effective than SSRIs? A Review of the Current State of the Controversy
Within 5 years of the introduction of fluoxetine in late 1987, the selective serotonin reuptake inhibitor (SSRI) class of antidepressants had supplanted the tricyclic antidepressants (TCA) as the first-line pharmacotherapy for major depressive disorder throughout much of the industrialized world. There is no doubt that pharmaceutical marketing played a large role in the rapid ascendance of the SSRI class (i.e., the TCAs were no longer patented drugs and, as such, were not marketed, whereas the SSRIs were vigorously promoted). Nevertheless, the SSRIs had a number of real advantages over the TCAs, including being easier to prescribe, better tolerated, and much safer in overdose.
The controversy about the relative efficacy of different types of antidepressants continues in part because there are numerous problems that limit the sensitivity of randomized controlled trials (RCTs) to detect efficacy differences between active antidepressants. Although there is only a partial solution to the problem of inadequately powered studies, meta-analysis permits quantitative synthesis of results from a group of relevant RCTs comparing various types of antidepressants. Meta-analyses of RCTs comparing the SSRIs with two of the SNRIs—venlafaxine and duloxetine—may have greater efficacy, though there is essentially no evidence that either of these drugs is superior to escitalopram. For venlafaxine, which is so far the most extensively studied SNRI, the magnitude of this advantage versus SSRIs other than escitalopram is modest in unselected patient groups (NNT values range between 10 and 15) and appears to be greater versus fluoxetine than other members of the class. For duloxetine, the advantage versus paroxetine and fluoxetine appears to be limited to more severely depressed patients, and confidence in this finding is limited by the fact that the studies used minimum therapeutic doses of SSRIs. With respect to the other two SNRIs, there are no data yet available to evaluate the relative efficacy of desvenlafaxine. Available data suggest that there is no efficacy advantage for milnacipran. The latter finding, coupled with the failure of both venlafaxine and duloxetine to significantly separate from escitalopram, highlights the limited clinical utility of comparisons across particular classes of medication.
Michael E. Thase, MD. Psychopharmacology Bulletin. 2008;41(2):In Press.
Criteria for Defining Symptomatic and Sustained Remission in Bipolar I Disorder:
a Post-Hoc Analysis of a 26-Week Aripiprazole Study (Study CN138-010)
Bipolar I disorder is a lifelong episodic illness that is characterized by manic or depressive episodes followed by symptom-free periods. Remission is a key goal after treating an acute episode of bipolar I disorder; however, there are no established definitions to measure clinical recovery, and recurrence occurs frequently in this patient population. Further understanding is needed for the correlation between attaining remission at a specific time point and maintaining sustained remission during treatment. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) examined time to recurrence of mania, hypomania, mixed state, or a depressive episode in subjects who were symptomatic at study entry but subsequently achieved recovery and determined that recurrence was frequent and associated with the presence of residual mood symptoms at initial recovery.
In conclusion, the use of more rigorous criteria to define symptomatic or sustained remission for fewer patients with bipolar I disorder and may be more useful in assessing remission in clinical trials compared with the standard criterion. These data confirm that sustaining remission is challenging and there is fluctuation in symptomatic stability in the bipolar population. Sustained remission for 8 weeks appears to be a good predictor for continued remission, as shown by the high retention rate of sustained remission at weeks 16 and 26 in aripiprazole-treated patients with bipolar I disorder using either standard or more rigorous criteria. The more rigorous YMRS criterion of 7 also appears to be a more discriminative indicator for the potential to relapse than the standard criterion (YMRS 12). When discerning an operational definition of remission in patients with a recent manic or mixed episode, the YMRS 7 criterion and sustaining this criterion for 8 weeks can bea useful clinical or research tool for assessing clinical recovery.
Prakash S. Masand, MD, James Eudicone, MS, Andrei Pikalov, MD, PhD, Robert D.McQuade, PhD, Ronald N. Marcus, MD, Estelle Vester-Blokland, MD, and Berit X. Carlson, PhD.
Psychopharmacology Bulletin. 2008;41(2):In Press.
Bipolar I Depression Outpatient Treatment Quality and Costs in Usual Care Practice
Bipolar disorder treatment is complicated and evolving. Maximizing lithium therapy has historically been recommended as the first-line treatment. More recently, other agents such as lamotrigine, quetiapine, and a combination of olanzapine and fluoxetine have begun to demonstrate efficacy. The role of antidepressants in the treatment of bipolar depression has been uncertain, including concerns that they may induce mania or mood cycling, thus worsening the course of illness. And while practice guidelines have long recommended psychotherapy in the treatment of bipolar depression, only recently have specific psychotherapies been shown to demonstrate efficacy in randomized controlled trials.
This study provides new information regarding the longitudinal quality and costs of care for bipolar depression. A sizable proportion of the treatment dollars spent on persons with new episodes of bipolar I depression went toward care that did not meet the standards of practice guidelines—and much of that represented treatment advised against by guidelines because it could worsen the course of the illness. This observation provides an important clinical and policy opportunity to redirect resources to be consistent with practice guideline standards. This study also provides evidence that when conducting studies using administrative data, hospital admissions alone do not adequately describe affective instability for patients with bipolar disorder, since much switch in polarity occurred in the outpatient setting. This knowledge is useful to researchers and policy makers when using administrative data in conducting quality assessment for systems of care.
Alisa B. Busch, MD, MS, Richard G. Frank, PhD, and Gary Sachs, MD.
Psychopharmacology Bulletin. 2008;41(2):In Press.
Addressing Methodological Issues in Studying Antidepressant Onset Efficacy Using Prespecified Sensitivity Analyses
Antidepressant medications typically exhibit a delay of at least 2 weeks following the start of therapy before patients experience clinically relevant improvement. During this latency period, patients remain symptomatic and functionally impaired, with an associated risk for suicide and morbidity, a prolonged reduction in quality of life, and a continued loss of work productivity. In contrast, antidepressants with a more rapid onset of action may offer potential benefits. Therefore, the development of new pharmacotherapies, with rapid onset of action, is an active area of research.
Studying onset of antidepressant action poses formidable methodological challenges. This article illustrates, however, that prospectively designed studies (as opposed to retrospective comparisons) can be implemented and that sensitivity analyses can be used to address concerns regarding assumptions and arbitrary decisions. Based on these results, we offer the following recommendations when developing future studies to assess antidepressant onset efficacy: A unidimensional subscale assessing core depressive symptoms (such as the HAMD Maier subscale) may be able to better distinguish differing drug effects when compared with the multidimensional HAMD Total score. A traditional assessment schedule (weekly visits) is adequate for assessing treatment group differences when used in conjunction with a categorical repeated measures analytic approach and does not increase the burden of implementing the study, the study cost, or the risk of increased placebo response (as would be more likely for a study using more frequent study visits). Onset of action can be based on 20–30% initial improvement, and the additional requirement that the improvement be sustained or exceeded throughout acute treatment may better differentiate drug effects from placebo.
Ilya Lipkovich, PhD, Craig H.Mallinckrodt, PhD, Apurva Prakash, BA, and Andrew A. Nierenberg, MD
Psychopharmacology Bulletin. 2008;41(2):In Press.
A Placebo-Controlled Trial of Guanfacine for the Treatment of Posttraumatic Stress Disorder in Veterans
Preclinical and clinical studies demonstrate a hyperactivity of the norepinephrine system in patients with posttraumatic stress disorder (PTSD). Alpha-2 adrenergic agonists have been shown to ameliorate symptoms of posttraumatic stress disorder, likely due to their ability to dampen noradrenergic tone. This study tests the ability of the alpha-2 adrenergic agonist, guanfacine to reduce the symptoms of PTSD.
Patients with chronic PTSD were randomized to an 8-week double-blind, placebo-controlled treatment of guanfacine followed by a 2 month open-label extension phase. Patients were maintained on their stable doses of allowed antidepressants during the trial. There were no significant differences in the drug versus placebo responses for the clinician-administered or patient self-report outcome measures in this small sample of predominantly male combat veterans with PTSD. However, the medication was well tolerated. Similar to previous findings, this small pilot study failed to show differences in the response to guanfacine versus placebo in a small sample of predominantly male combat veterans with PTSD. Lori Davis, MD, L. Charles Ward, PhD, Ann Rasmusson, MD, Jason M. Newell, LCSW, PIP, Elizabeth Frazier MS, and Steven M. Southwick, MD. Psychopharmacology Bulletin. 2008;41(1):In Press.
Treatment of Children With ADHD: Results of a Randomized, Multicenter, Double-Blind, Crossover Study of Extended-Release Dexmethylphenidate and d,l-Methyl-phenidate and Placebo in a Laboratory Classroom Setting
The results from this study replicate in many ways those reported in 2 previous studies demonstrating a rapid onset and 12-hour duration of effect with d-MPH-ER in the treatment of children with ADHD. Specifically, in those double-blind, placebo-controlled, crossover studies in children 6 to 12 years old, d-MPH-ER was statistically superior to placebo for all efficacy outcome measures at all time points tested, from 0.5 hours up to 12 hours postdose. All active treatments were well tolerated. The majority of AEs were mild to moderate in severity with abdominal pain, decreased appetite, and headache the most common AEs. No patients withdrew due to AEs. The tolerability profile was similar to that reported for d,l-MPH and d-MPH. Both d-MPH-ER and d,l-MPH-ER at both doses, administered once daily, were effective in treating ADHD symptoms in children 6 to 12 years old as assessed over a 12-hour laboratory classroom day. d-MPH -ER was observed to have an onset of effect 0.5 hours postdose and a duration of action of at least 12 hours. d,l-MPH-ER 36 mg/day and 54 mg/day had a slower onset of effect than d-MPH-ER but had a stronger effect during the later part of the day. Treatment with d-MPH-ER 20 mg/day and 30 mg/day, and d,l-MPH-ER 36 mg/day and 54 mg/day was well tolerated. Raul Silva, MD, Rafael Muniz, MD, Kevin McCague, MA, Ann Childress, MD, Matthew Brams, MD, and Alice Mao, MD.
Psychopharmacology Bulletin. 2008;41(1):In Press.
Efficacy of Duloxetine for the Treatment of Depression: Relationship to Most Recent Antidepressant Trials
Data collected from a multicenter trial that evaluated the safety and efficacy of duloxetine for the treatment of major depressive disorder were analyzed to determine the relationship between response to
previous antidepressant treatment and degree of response to duloxetine. Eighty-two patients, with documented antidepressant usage history, were included in the analysis. Participants were required, at baseline of the duloxetine treatment protocol, to be 18 years of age and meet criteria for major depressive disorder. Patients, whose data were included in these analyses, were classified as belonging to one of three groups based on the most recent antidepressant treatment received: nonresponders, partial responders, and responders without remission. Time to first response, first remission, sustained response and sustained remission during the first 12 weeks of duloxetine treatment were compared across patient groups.
Response and remission with duloxetine treatment ranged between 57% and 68% and 29% and 57%, respectively, and did not differ significantly across previous response levels. An additional analysis, collapsing the partial responder and responder without remission groups, indicated significantly lower rates of remission in those patients who demonstrated nonresponse to the most recent antidepressant treatment. Findings suggest that patient response to duloxetine, when used as a switch treatment, may not be significantly influenced by degree of response to the most recent antidepressant treatment. Timothy Petersen, PhD., Roy H. Perlis, MD, Chris Ticknor, MD, Jim Lohr, MD, H. Brent Solvason, MD, PhD., John P. O’Reardon, MD, Madelaine M. Wohlreich, MD, Charissa Andreotti, ScB, Michael Wilson MS, and Maurizio Fava, MD.
Psychopharmacology Bulletin. 2008;41(1):In Press.
A Pilot Controlled Trial of Bupropion XL vs. Escitalopram in Generalized Anxiety Disorder
Twenty-four participants with GAD between the ages 18 and 64 years enrolled in a 12-week, double-blind, randomized, trial to compare the efficacy and safety of bupropion XL (150-300mg/day) with the
selective serotonin reuptake inhibitor escitalopram (10-20mg/day) in outpatients diagnosed with generalized anxiety disorder.
Findings from this pilot project suggest bupropion XL may be useful in treating GAD. These preliminary results warrant further research to explore the use of bupropion XL in the treatment of GAD. These results agree with recent controlled and open trials, case reports, and animal studies which have identified decreases in anxiety levels during treatment with bupropion hydrochloride. To our knowledge, the use of bupropion
XL in the treatment of GAD has not been previously studied. This is surprising, considering most treatments used to reduce symptoms of major depression also reduce symptoms of GAD. Clinicians may be hesitant to use bupropion due to past reports of the lack of efficacy and exacerbation of anxiety during treatment initiation in panic disorder patients. However, most antidepressants, including tricyclics and SRIs, also have activating effects during treatment initiation that eventually dissipate. In addition, the slowly releasing formulation of bupropion XL may be better tolerated in these regards than the faster releasing formulations used in previous studies. Alexander Bystritsky, MD, Lauren Kerwin, BA, Jamie D. Feusner, MD, and Tanya Vapnik, PhD. Psychopharmacology Bulletin. 2008;41(1):In Press.
Psychopharmacotherapy in Eating Disorders: A Systematic Analysis
The most common and serious eating disorders, which are particularly prevalent in young women, are anorexia nervosa, bulimia nervosa, and binge-eating disorders. Further, the prevalence of unspecific hyperphagous eating disorders frequently causing obesity is substantially increasing. All of these eating disorders tend to be chronic and comorbid to psychiatric diagnoses.
Due to the multifactorial aetiology these disorders require a multimodal treatment. Among different treatment options, symptomatic psychopharmacotherapy has been an important component and especially in recent decades, it has been subject to many trials. This article gives an overview of the current literature, summarizing diagnostic criteria, epidemiology, and critically discussing psychopharmacotherapy of those eating disorders. Based on the literature and our clinical experience the psychopharmacological recommendations for patients with anorexia nervosa, bulimia nervosa, binge-eating disorder are suggested. Andrea Riedl, MD, Janine Becker, MD, M. Rauchfuss, MD, and Burghard F. Klapp, MD.
Psychopharmacology Bulletin. 2008;41(1):In Press.
Clinical and Pharmacoeconomic Evaluation of Switch to Olanzapine in Veterans with Schizophrenia or Schizoaffective Disorder
This study examines the cost effectiveness outcome of olanzapine treatment in veterans with schizophrenia or schizoaffective disorder. Health care utilization and costs associated with prospective olanzapine treatment were compared with those of retrospective first generation neuroleptic treatment in a mirror image design.
For VA outpatient and inpatient care, study patients incurred an average cost difference of -$1,289 (NS) and -$6,682 (NS), respectively. Combining inpatient and outpatient VA care, patients incurred an annual difference of -$7,971 per patient. These numerically lower costs were due, in part, to a slower growth rate in outpatient encounters, lower overall cost per outpatient encounter, and a lower overall inpatient encounter rate.
Olanzapine treatment resulted in improvements in positive and general psychiatric symptoms, as well as quality of life. Negative symptoms did not significantly change. Though not statistically significant, the post-baseline health care costs and utilization declined. Lori L. Davis, MD, Marshall E. Cates, PharmD, BCPP, FASHP, Joette S. Lowe, PharmD, L. Charles Ward, PhD, Jeffrey D. Johnson, RN, BSN, Raela B. Williford, PharmD, Sandra M. Ambrose, MSN, Brandi L. Thomas, LCSW, and Terrell Michael Kashner, PHd, JD, MPH. Psychopharmacology Bulletin. 2008;41(1):In Press.
Patterns of Pharmacotherapy and Treatment Response in Elderly Adults with Bipolar Disorder
Several guidelines have been proposed for treatment, but there is limited data on best treatment practices in elderly bipolar patients. This study assessed patterns of psychopharmacological treatment and treatment response in acutely ill bipolar patients over the age of 60.
Naturalistic pharmacologic data was obtained on 138 acutely ill elderly bipolar patients from the Duke University Medical Center electronic psychiatric record. Standard mood stabilizers (lithium, valproate, carbamazepine, and lamotrigine) were the most prescribed medications (68%), followed by antipsychotics (54%), and antidepressants (34%). Combination therapy was more common than monotherapy (57% vs 38%). Remission was achieved in 35% of subjects while 32% showed no significant improvement. There was no difference in antipsychotic prescription between old-old and young-old patients.
In this naturalistic, “real-setting” study of pharmacologic treatment, acutely ill elderly bipolar patients were treated primarily with mood stabilizing agents, followed by antipsychotics and antidepressants. Combination therapy is much more common than monotherapy. Results can be useful in understanding the current clinical standard of care in elderly bipolar patients, and are consistent with current clinical guidelines for mixed-age bipolar patients. John L. Beyer, MD, Bruce Burchitt, PhD, Kenneth Gersing, MD, and K. Ranga R. Krishnan, MD. Psychopharmacology Bulletin. 2008;41(1):In Press.
editor-in-chief
Michael E. Thase, MD
University of Pittsburgh
School of Medicine
Pittsburgh, PA
editor emeritus
Charles B. Nemeroff,
MD, PhD
Emory University
School of Medicine
Atlanta, GA
publisher and
editorial director
MedWorks Media Global, LLC
James M. La Rossa Jr.
(T) 310.829.4290
(F) 310.829.4289
ceo@medworksmedia.com
associate editor,
negative trial outcomes
David V. Sheehan, MD, MBA
University of South Florida
College of Medicine
Tampa, FLA
associate editor, brain imaging
J. Douglas Bremner, MD
Emory University
School of Medicine
Atlanta, GA
associate editor,
evidence-based medicine
K. Ranga Rama Krishnan, MD
Duke University Medical Center
Durham, NC
associate editor,
translational neuroscience
Husseini K. Manji,
MD, FRCPC
National Institute of
Mental Health
Bethesda, MD
associate editor, drug disposition
and pharmacokinetics
C. Lindsay DeVane, PharmD
Medical University of
South Carolina
Charleston, SC
associate editor,
complicated case histories
Boadie Dunlop, MD
Emory University
School of Medicine
Atlanta, GA
Dennis S. Charney, MD
National Institute of
Mental Health
Bethesda, MD
Jack M. Gorman, MD
Columbia University
College of Physicians & Surgeons
New York, NY
Steven Hyman, MD
Harvard University
Cambridge, MA
Herbert D. Kleber, MD
Columbia University
College of Physicians & Surgeons
New York, NY
Alan I. Leshner, PhD
National Institutes of Health
Bethesda, MD
Jeffrey A. Lieberman, MD
University of North Carolina
School of Medicine
Chapel Hill, NC
Peter P. Roy-Byrne, MD
University of Washington
School of Medicine
Seattle, WA
Alan F. Schatzberg, MD
Stanford University School of Medicine
Stanford, CA
Carol Tamminga, MD
University of Texas
Southwestern Medical Center
Dallas, TX
Karen Dineen Wagner,
MD, PhD
University of Texas
Medical School
Galveston, TX
Daniel R. Weinberger, MD
National Institute of
Mental Health
Bethesda, MD
This newsletter is a synopsis of topical issues to be published in Psychopharmacology Bulletin. It is provided as a free service to news organizations on record with an interest in psychiatric matters, and to the medical community.
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Newsletter No. 4, 2007 www.psychopharmbulletin.com Volume 40 • Number 3 • 2007
This newsletter is a synopsis of topical issues to be published in Psychopharmacology Bu l l e t i n. It is provided as a
free service to news organizations on record with an interest in psychiatric matters, and to the medical community.
ORIGINAL RESEARCH • EVIDENCE-BASED MEDICINE
BOYS AND AFRICAN AMERICANS GET THE MOST ATYPICAL ANTIPSYCHOTICS
Psychotropic medications are increasingly being used by children and adolescents. This is particularly true with respect to
atypical antipsychotics such as risperidone, olanzapine, quetiapine, aripiprazole, clozapine, and ziprasidone. Researchers evaluated whether males were receiving more antipsychotics than females, the diagnosis related to its usage, and the effects of race in the use of antipsychotics.—p.2
BRAVE NEWWORLD: STANDARDS FOR TRIALS IN BIPOLAR DISORDER
In 1988, a task force was convened to define operational criteria for change points in the clinical course of unipolar depressive illness. Some years later, a similar effort was made for schizophrenia. These investigators, who comprise a work group of experts on bipolar disorder, was organized to develop consensus operational definitions for bipolar disorder.—p.2
USE OF EVIDENCE-BASED GUIDELINES FOR CHRONIC MENTAL DISORDERS
These findings suggest that the Systematic Treatment Enhancement Program for Bipolar Disorder is most accurately
viewed as an effectiveness trial of evidence-based treatments for bipolar disorder, rather than “treatment as usual.” Tactics thatprovide physicians with a range of reasonable choices, flexibility, and provided multi-modal training in best practices appear to be effective in optimizing the use of evidence-based treatments in this large national trial.—p.3
HOW LONG DO PSYCHIATRISTSWAIT FOR RESPONSE BEFORE SWITCHING AGENTS?
For how long should an antipsychotic be tried before it is considered ineffective and switched is an important, but as yet,
unanswered question in the treatment of schizophrenia. Switching too early leads to classifying actually effective drugs as ineffective. Waiting too long leads to longer suffering and hospitalization. There is now mounting evidence suggesting that hypothesis of the delay of onset of action of antipsychotic drugs was not correct, but rather that antipsychotic effects can already be seen during the first days of treatment.—p. 3
FEAR, ANXIETY, AND THE NEUROIMAGING OF PTSD
The clinical manifestations of PTSD involve both a fear response and an anxiety response. Fear occurs at the time of exposure to trauma while anxiety develops over time. Both emotions can be present in PTSD. Neuroimaging provides a modality or technique to help define the neural circuitry involved in PTSD. The purpose of this paper is to review the neurobiology of fear and anxiety and to review imaging studies to date and suggest further directions for re s e a rc h . — p. 4
THE USE OF ALTERNATIVE MEDICINE IN BIPOLAR PATIENTS
A substantial number of patients diagnosed with bipolar disorder are using complementary and alternative medicine
(CAM). CAM use may be popular among patients because conventional pharmacotherapy for managing bipolar symptoms
can also disrupt quality of life. Mental health providers should be aware of CAM use among patients with bipolar disorder,
and assess the potential impact of CAM use on treatment course.—p.4
PREDICTING ANTIPSYCHOTIC USE IN CHILDREN
Psyc h o t ropic medications are increasingly being used by children and adolescents. In an earlier re p o rt
the authors noted that boys we re receiving atypical antipsychotics more frequently than we re girls (70%
of the claims). Since diagnosis was not available in the data, they we re unable to ascertain the reasons for
this. In the present analysis, the investigators examined a large clinical mental health database in order to
a s c e rtain the reason for antipsychotic use. They evaluated the extent to which race, gender, age and type
of diagnosis accounted for atypical antipsychotic use in children. The authors used an anonymous clinical
database created at Duke Un i versity Medical Center. The database is based on the clinical document of
care in the De p a rtment of Psychiatry. The data is de-identified per HIPAA guidelines and has an IRB
exemption for use in clinical re s e a rch. Patients analyzed we re seen from 1999 to 2005 and we re below
the age of 18 at the time of clinical care. 3268 patients, with a total of 7701 visits comprise the analysis
sample. Age, gender, race and diagnosis we re extracted as predictors of use of atypical antipsychotics.
Results: African Americans we re slightly more likely to use an atypical than whites. Males and older child
ren we re also more likely to use an atypical. Patients whose diagnoses were classified as either psychotic
or internalizing were also more likely to use an antipsychotic.
Ken Gersing, MD, Bruce Bu rchett, PhD., JD, John March, MD, Truls Os t bye, MD, PhD, and
K. Ranga Rama Krishnan, MD
Psychopharmacology Bulletin. 2007;40(3)
DEFINING THE CLINICAL COURSE OF BIPOLAR DISORDER: RESPONSE, REMISSION,
RELAPSE, RECURRENCE, AND ROUGHENING
This manuscript presents working definitions for key clinical course indicators for bipolar disorder,
including response, remission, relapse, recurrence, and roughening. A work group of experts in bipolar disorder
reviewed prior efforts to define clinical course indicators for unipolar depression and for schizophrenia.
Using these efforts as templates, the work group developed consensus operational definitions.
The rationale for each of the definitions was a point in time when a treatment decision needed to be made.
The group defined response as a 50% reduction in a score from a standard rating scale of symptomatology
from an appropriate baseline, regardless of index episode type (manic, depressed, or mixed). In addition,
the other pole cannot be significantly worsened during response. Remission was defined as absence
or minimal symptoms of both mania and depression for at least 1 week. Sustained remission requires at
least 8 consecutive weeks of remission, and perhaps as many as 12 weeks. A relapse/recurrence was defined
as a return to the full syndrome criteria of an episode of mania, mixed episode, or depression following a
remission of any duration. Roughening was defined as a return of symptoms at a sub-syndromal level, perhaps
representing a prodrome of an impending episode. The work group recommends that all reports of
clinical trials in bipolar disorder include results using these definitions. This will introduce standards for
such re p o rts. Hopefully the definitions will be revised and improved over time.
Robert M.A. Hirschfeld, MD, Joseph Calabrese, MD, Mark A. Frye, MD, Philip W. Lavori, PhD, Gary
Sachs, MD, Michael E. Thase, MD, and Karen Wagner, MD, PhD
Psychopharmacology Bulletin. 2007;40(3)
CONCORDANCE WITH TREATMENT GUIDELINES FOR BIPOLAR DISORDER: DATAFROM THE SYSTEMATIC TREATMENT ENHANCEMENT PROGRAM FOR BIPOLARDISORDER
Concordance with evidence-based guidelines in the treatment of chronic mental disorders is typicallylow. This study assesses the degree of concordance to recommendations of published treatment guidelinesfor bipolar disorder in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).Potential demographic and clinical predictors of adherence were examined. STEP-BD treating psychiatristsparticipated in extensive training in evidence-based pharmacological management focusing on publishedclinical practice guidelines. Recommended medications and dosing for each specific mood episodewere extracted from published treatment guidelines and collapsed into a composite guideline. Prescribedmedication information for patients at the first visit in a prospectively observed new-onset mood episode(depressive, mixed, or hypomanic/manic) was then compared to guideline recommendations. The currentstudy included 964 STEP-BD patients, observed over 2 years, who experienced a prospectively observedepisode (n=716 depressive; n=182 hypomanic/manic; n=66 mixed). Guideline concordant treatmentswere prescribed in 81.8% of mixed episodes, 81.9% of hypomanic/manic episodes, and 83.4% of depressiveepisodes, exceeding rates previously reported in randomized controlled trials of guideline implementation.Younger age of onset and receipt of adequate pharmacotherapy at STEP-BD entry predicted thosemore likely to receive guideline-concordant care. The use of guideline concordant pharmacological treatmentswas substantially higher than reported under naturalistic conditions. The authors speculated thatbasic provider education plus a collaborative approach to medication choice may have contributed to thehigh treatment concordance rates in this large national trial. As in other studies, few patient-specific factorswere associated with the likelihood of receiving guideline-concordant care.
Ellen B. Dennehy, PhD, Mark S. Bauer, MD, Roy H. Perlis, MD, Jane N. Kogan, PD, andGary S. Sachs, MD
Psychopharmacology Bulletin. 2007;40(3)
HOW LONG DO PSYCHIATRISTSWAIT FOR RESPONSE BEFORE THEY SWITCH TOANOTHER ANTIPSYCHOTIC?
For how long should an antipsychotic be tried before it is considered ineffective and switched is animportant, but as yet, unanswered question in the treatment of schizophrenia. Switching too early leads toclassifying actually effective drugs as ineffective. Waiting too long leads to longer suffering and hospitalization.There is now mounting evidence suggesting that hypothesis of the delay of onset of action of antipsychoticdrugs was not correct, but rather that antipsychotic effects can already be seen during the first daysof treatment. Studies which randomize non-responders at different time points to either switching or continuingmedication would be needed to determine the optimum duration of a trial, but such are not available.Therefore the recommendations found in guidelines to wait at least 2, 3, 4 or 6 weeks before makinga major change in treatment are not based on scientific evidence. In this context we examined how longpracticing hospital psychiatrists actually wait before they switch drugs for patients with schizophrenia andwhich factors predict longer medication trials.
Johannes Hamann, MD, Werner Kissling, MD and Stefan Leucht, MD
Psychopharmacology Bulletin. 2007;40(3).
FEAR, ANXIETY, AND THE NEUROIMAGING OF PTSD
The clinical manifestations of PTSD involve both a fear response and an anxiety response. Fear occurs at thetime of exposure to trauma while anxiety develops over time. Both emotions can be present in PTSD. A