Effects of olanzapine alone and olanzapine/fluoxetine combination on health-related quality of life in patients with bipolar depression: Secondary analyses of a double-blind, placebo-controlled, randomized clinical trial

Assessing the meaningful change threshold of Quality of Life in Depression Scale using data from two phase 3 studies of esketamine nasal spray

BACKGROUND

Major depressive disorder (MDD) directly impacts patients' lives including symptoms, functioning and health-related quality-of-life (HRQoL). Patient-reported outcomes can capture these impacts, however interpretation of clinical meaningfulness of these measurements are often not readily available. Meaningful change thresholds (MCTs) can be derived for clinical outcome assessments to quantify the change in symptoms that is meaningful to the patient following pharmacologic treatment or other interventions. The objective of this analysis was to determine the within-patient MCT of the self-reported Quality-of-Life in Depression Scale (QLDS) among patients with MDD and active suicidal ideation with intent (MDSI) using an anchor-based approach.

METHODS

Data from 2 randomized phase-3 trials of esketamine nasal spray (ASPIRE I and ASPIRE II) were analyzed. The Montgomery-Åsberg Depression Rating Scale (MADRS) was the primary anchor with three different severity criteria. Other anchor variables utilized were Clinical Global Impression of Severity of Suicidality-revised version, Clinical Global Impression of Imminent Suicide Risk, and EuroQol Visual Analog Scale [EQ-VAS]. Spearman correlation coefficients between the change in QLDS and anchor variables were calculated. The mean change in QLDS score at Day 25 from baseline was calculated based on the categorical change in the anchor. Coefficient yield from linear regression of the mean changes in EQ-VAS and QLDS, and distribution-based approach with ½ SD of change in QLDS were considered.

RESULTS

In ASPIRE I, mean (SD) improvement in QLDS score among patients with one category improvement in MADRS from baseline to Day 25 was - 8.22 (8.87), - 8.30 (9.01), and - 8.20 (8.92) using severity criteria #1, #2, and #3, respectively. Patients who achieved a 7-point improvement (MCT) in EQ-VAS yielded a mean - 9.69-point improvement in QLDS at Day 25. The ½ SD of change in QLDS was 5.63. Similar results were obtained for ASPIRE II. The MCTs identified using multiple anchors across both trials ranged from - 11.4 to - 6.7 and had an overall mean of - 7.90 (ASPIRE I) and - 7.92 (ASPIRE II). Thus, an 8-point change was recommended as the MCT for QLDS.

CONCLUSION

The recommended MCT will help quantify within-person changes in HRQoL using patient-reported QLDS and determine meaningful treatment benefit in an MDD patient population with acute suicidal ideation or behavior.

TRIAL REGISTRATION

Name of the registry: ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

ASPIRE I (NCT03039192), ASPIRE II (NCT03097133). Date of registration: February 01, 2017; March 31, 2017. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03039192 ; https://clinicaltrials.gov/ct2/show/NCT03097133 .

Adjunctive antidepressants for the acute treatment of bipolar depression: A systematic review and meta-analysis

BACKGROUND

The depressive phase of bipolar disorder causes significant functional impairment and disease burden. The efficacy and safety of antidepressants in the treatment of bipolar depression has long been a subject of debate.

AIMS

To synthesize evidence of the effectiveness, risk of mood switching, and tolerability of adjunctive antidepressants in acute bipolar depression compared to using mood stabilizers or antipsychotics alone.

METHOD

Multiple databases were searched for randomized controlled trials, including open label and double-blinded, for patients ages 18 or older with acute bipolar depression, comparing efficacy and adverse events in those who used adjunctive antidepressants versus without. Risk of bias and outcomes were assessed using the Cochrane Risk of Bias Tool. This study has PROSPERO registration CRD42016037701.

RESULTS

Nineteen studies met inclusion criteria. Adjunctive antidepressants showed no significant effect on improving response rate (RR=1.10, 95%CI: 0.98-1.23). Subgroup analysis showed that adjunctive antidepressants with antipsychotics had a small but significantly better response rate compared to antipsychotics alone, which was not seen with adjunctive antidepressants with mood stabilizers. However, that finding was limited by studies predominantly using olanzapine as the antipsychotic medication. Adjunctive antidepressants had no clinically significant impact (but a small statistically significant impact) on improving depressive symptoms (SMD=-0.13, 95%CI: -0.24 to -0.02). There was no association with increased mood switch (RR=0.97, 95%CI: 0.68-1.39) and there was an association with lower dropout due to inefficacy (RR=0.66, 95%CI: 0.45∼0.98).

CONCLUSIONS

There is no evidence of adjunctive antidepressants clinically improving response rate or depressive symptoms for acute bipolar depression. They are well tolerated, without increasing the risk of short-term mood switch.

A Prospective, Randomized, Open-Label Study Comparing the Efficacy and Safety of Clonazepam versus Nortriptyline on Quality of Life in 40+ Years old Women Presenting with Restless Leg Syndrome

Introduction

Restless legs syndrome (RLS) is a neurological disorder characterized by an urge to move the legs usually accompanied by unpleasant leg sensations. RLS also impacts health related quality of life (QOL) in patients suffering from it. Further, it affects women more than men. Although a voluminous literature of studies is available evaluating the role of benzodiazepines (clonazepam and antidepressant (nortriptyline) in the treatment of RLS, but to the best of our knowledge, no comparative study is available comparing both of these drugs for efficacy and safety for the treatment of RLS QoL among 40 + years old women.

Materials and Methods

A prospective, randomized, open label comparative study was conducted in Postgraduate Department of Pharmacology in collaboration with the Department of General Medicine, Government Medical College, Jammu, a tertiary care teaching hospital for 1 year.

Conclusion

Clonazepam proved to be significantly better in improving RLSQoL score. Difference between respective baselines of both groups was statistically insignificant.

Quality of life in bipolar disorder: towards a dynamic understanding

BACKGROUND

Although quality of life (QoL) is receiving increasing attention in bipolar disorder (BD) research and practice, little is known about its naturalistic trajectory. The dual aims of this study were to prospectively investigate: (a) the trajectory of QoL under guideline-driven treatment and (b) the dynamic relationship between mood symptoms and QoL.

METHODS

In total, 362 patients with BD receiving guideline-driven treatment were prospectively followed at 3-month intervals for up to 5 years. Mental (Mental Component Score - MCS) and physical (Physical Component Score - PCS) QoL were measured using the self-report SF-36. Clinician-rated symptom data were recorded for mania and depression. Multilevel modelling was used to analyse MCS and PCS over time, QoL trajectories predicted by time-lagged symptoms, and symptom trajectories predicted by time-lagged QoL.

RESULTS

MCS exhibited a positive trajectory, while PCS worsened over time. Investigation of temporal relationships between QoL and symptoms suggested bidirectional effects: earlier depressive symptoms were negatively associated with mental QoL, and earlier manic symptoms were negatively associated with physical QoL. Importantly, earlier MCS and PCS were both negatively associated with downstream symptoms of mania and depression.

CONCLUSIONS

The present investigation illustrates real-world outcomes for QoL under guideline-driven BD treatment: improvements in mental QoL and decrements in physical QoL were observed. The data permitted investigation of dynamic interactions between QoL and symptoms, generating novel evidence for bidirectional effects and encouraging further research into this important interplay. Investigation of relevant time-varying covariates (e.g. medications) was beyond scope. Future research should investigate possible determinants of QoL and the interplay between symptoms and wellbeing/satisfaction-centric measures of QoL.

Effects of venlafaxine versus lithium monotherapy on quality of life in bipolar II major depressive disorder: Findings from a double-blind randomized controlled trial

Bipolar disorder is associated with decreased quality of life, especially during depressive episodes. There are few studies that have examined whether quality of life improves following pharmacological treatments of bipolar depression. In this exploratory study, we examined the effects of antidepressant versus mood stabilizer monotherapy on quality of life ratings in bipolar II subjects during acute (12 week) treatment. Data were derived from a randomized double-blind comparison of venlafaxine (n = 65) versus lithium (n = 64) monotherapy. The Quality of Life Index (QLI) was administered at baseline (n = 126; 98%) and again at the end of treatment. We explored treatment differences in continuous changes on the QLI using last-observation carried forward. Additionally, we explored the likelihood of experiencing clinically-significant improvements as well as baseline correlates of QLI and changes in QLIe. Venlafaxine was superior to lithium in reducing symptoms of depression during acute treatment. However, there were no significant differences between treatments in QLI ratings. Changes in symptoms of depression were correlated to, but not redundant, with improvements in QLI ratings. These findings suggest that quality of life may be an important secondary outcome to target and measure as a part of comparative clinical trials of pharmacotherapy for bipolar II depression.

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

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.

Effects on health-related quality of life in patients treated with lurasidone for bipolar depression: results from two placebo controlled bipolar depression trials

BACKGROUND

Depressive symptoms associated with bipolar disorder negatively impact health-related quality of life (HRQoL). The efficacy of lurasidone in reducing depressive symptoms has been previously demonstrated. The objective of this study was to examine the direct and indirect effect (mediated through improvement in depression symptoms) of lurasidone in improving patient HRQoL.

METHODS

A secondary analysis of data was conducted of two 6-week, double-blind, placebo-controlled trials assessing the effect of lurasidone (lurasidone monotherapy [20-60 mg/day or 80-120 mg/day]; lurasidone adjunctive to lithium or valproate [20-120 mg/day]) in patients with bipolar depression. Patient HRQoL was measured using the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q SF). Depression symptoms were measured using the Montgomery-Asberg Depression Rating Scale (MADRS). Analysis of covariance (ANCOVA) was used to estimate the effect of lurasidone on improvement in the Q-LES-Q SF percentage maximum score from baseline to 6 weeks. Path analysis was used to evaluate the total effect (β1), as well as the indirect (β2*β3) and direct (β4) effect of lurasidone on Q-LES-Q SF change through improvements in MADRS.

RESULTS

A total of 340 and 485 patients from the monotherapy and adjunctive therapy, respectively, were included in the analysis. At 6-weeks, ANCOVA analyses demonstrated that lurasidone provided significant improvement in adjusted mean Q-LES-Q SF scores in comparison to placebo for monotherapy (22.9 and 22.7 vs. 15.2, both p < 0.01) and adjunctive therapy (23.1 vs. 17.9, p = 0.01). Path analyses indicated that lurasidone treatment predicted MADRS improvement (monotherapy: β2 = -0.44, p < 0.001; adjunctive therapy: β2 = -0.34, p = 0.003), which subsequently predicted improvement in Q-LES-Q SF (monotherapy: β3 = -0.73, p < 0.001; adjunctive therapy: β3 = -0.75, p < 0.001); however, the effect of lurasidone on improvement in Q-LES-Q SF was largely mediated by change in MADRS (monotherapy: β4 = 0.11, p = 0.13; adjunctive therapy: β4 = 0.02, p = 0.77).

CONCLUSIONS

Lurasidone as a monotherapy and adjunctive to lithium or valproate is an effective treatment for improving HRQoL in patients with bipolar depression. However, improvement in HRQoL was not independent of improvement in depression, indicating that the effect of lurasidone on improving patient HRQoL may act through a reduction in depressive symptoms associated with bipolar disorder.

TRIAL REGISTRATION

Clinicaltrials.gov identifiers: NCT00868699 and NCT00868452 (both registered March 23, 2009).

Differences in quality of life outcomes among depressed spinal cord injury trial participants

OBJECTIVE

To assess the role that treatment response plays in a randomized controlled trial of an antidepressant among people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD) in explaining quality of life (QOL), assessed both globally as life satisfaction and in terms of physical and mental health-related QOL.

DESIGN

Multivariable analyses were conducted, controlling for demographic, neurologic, and participatory factors and perceived functional limitations.

SETTING

Rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the Project to Improve Symptoms and Mood after Spinal Cord Injury randomized controlled trial, 124 participated in this study. All participants were between the ages of 18 and 64 years, at least 1 month post-SCI, met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for MDD, and completed the core measures used in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the Medical Outcomes Study 12-Item Short-Form Health Survey.

RESULTS

Reduction in depressive symptoms over the course of a 12-week trial was predictive of increased QOL, which was measured as life satisfaction and mental well-being, within the context of other explanatory factors. However, reduction in symptoms did not explain differences in physical well-being among those with MDD. Perceived functional disability explained all 3 indices of QOL.

CONCLUSIONS

Greater recognition has been given to QOL outcomes as endpoints of clinical trials because these often reflect participants' reported outcomes. Our findings support the association of QOL to the reduction of depression symptoms among trial participants. This association differs depending on how QOL is defined and measured, with stronger relations observed with life satisfaction and mental well-being among those diagnosed with MDD. The lack of association between depression and physical well-being may be explained by participants' subjective interpretation of physical well-being after SCI and their expectations and perceptions of improved physical health-related QOL based on the use of assistive technology. Consistent with our findings, pain is likely to play a role in decreasing physical QOL among those with incomplete injuries. Practicing caution is suggested in using physical well-being as an endpoint in trials among people with SCI.

Olanzapine plus fluoxetine for bipolar disorder: a systematic review and meta-analysis

BACKGROUND

Olanzapine plus fluoxetine combination (OFC) is one of the current approaches for treating the depressive phase of bipolar disorder. Our objective was to synthesize the evidence on the efficacy of OFC therapy in bipolar depressed patients.

METHODS

We searched for randomized controlled trials (RCTs) on MEDLINE, Embase and other databases. Independent researchers selected the studies and extracted the data. The GRADE approach was used to assess the quality of the evidence. The Mantel-Haenszel random effect model was used to perform the meta-analyses.

RESULTS

From 627 unique records retrieved, four RCTs were included (1330 patients). OFC improved the response compared to olanzapine (relative risk [RR]=1.58; 95% confidence interval [95% CI]: 1.27, 1.97) and to placebo (RR=1.99; 95% CI: 1.49, 2.65) but not to lamotrigine (low-quality evidence). Similar results were found for remission and relapse rates. No differences were identified for levels of depression and mania symptoms (low-quality evidence) and incidence of mania (moderate-quality evidence). Adverse effects were more common in patients treated with OFC than in those treated with lamotrigine (RR=1.13; 95% CI: 1.04, 1.23), but no difference was found relative to the patients treated with olanzapine (low-quality evidence).

LIMITATIONS

Despite the totality of the evidence included, there are few RCTs available regarding the efficacy of OFC therapy for bipolar depression. The risk of attrition and reporting bias is also a concern.

CONCLUSIONS

OFC therapy improved the response, remission, and relapse rates among other outcomes. However, a worse profile of adverse reactions was observed in some comparisons. These data clarify the therapeutic use of OFC as an option to olanzapine in bipolar depression. The quality of the evidence could be improved by additional comparisons and higher rates of treatment adherence.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

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.

Second generation antipsychotics in the treatment of bipolar depression: a systematic review and meta-analysis

Depressive symptoms and episodes dominate the course of bipolar disorder. However, the therapeutic armamentarium for bipolar depression is limited. Recent evidence points to the efficacy of second generation antipsychotics (SGAs) for the treatment of bipolar depression. We conducted a systematic review and meta-analysis of the efficacy and safety of SGAs (randomized, double-blind, placebo-controlled trials; used in monotherapy) in the treatment of adult patients with bipolar depression. Publication bias was corrected for by performing similar searches using the clinical trials register of the respective pharmaceutical companies, the Cochrane Database and ClinicalTrials.gov. Seven published papers were identified on the use of aripiprazole, olanzapine and quetiapine. Internal validity of the trials was fairly good, external validity only moderate. Different outcome measures of efficacy and safety were assessed. When the individual trials were looked at, quetiapine and to a lesser extent olanzapine demonstrated significant improvement in MADRS (Montgomery-Åsberg Depression Rating Scale) total scores. This was not demonstrated for aripiprazole. Efficacy was hampered by adverse events, such as weight gain, akathisia and somnolence/sedation. Both clinical heterogeneity of the included trials and statistical heterogeneity of the meta-analytic data were considerable. The number of quetiapine trials was disproportionate to the number of trials of aripiprazole and olanzapine. Further research is needed to assess differential efficacy of the different SGAs and their use in clinical practice.

Receptor targets for antidepressant therapy in bipolar disorder: an overview

The treatment of bipolar depression is one of the most challenging issues in contemporary psychiatry. Currently only quetiapine and the olanzapine-fluoxetine combination are officially approved by the FDA against this condition. The neurobiology of bipolar depression and the possible targets of bipolar antidepressant therapy remain relatively elusive. We performed a complete and systematic review to identify agents with definite positive or negative results concerning efficacy followed by a second systematic review to identify the pharmacodynamic properties of these agents. The comparison of properties suggests that the stronger predictors for antidepressant efficacy in bipolar depression were norepinephrine alpha-1, dopamine D1 and histamine antagonism, followed by 5-HT2A, muscarinic and dopamine D2 and D3 antagonism and eventually by norepinephrine reuptake inhibition and 5HT-1A agonism. Serotonin reuptake which constitutes the cornerstone in unipolar depression treatment does not seem to play a significant role for bipolar depression. Our exhaustive review is compatible with a complex model with multiple levels of interaction between the major neurotransmitter systems without a single target being either necessary or sufficient to elicit the antidepressant effect in bipolar depression.

Antidepressant treatment for acute bipolar depression: an update

While studies in the past have focused more on treatment of the manic phase of bipolar disorder (BD), recent findings demonstrate the depressive phase to be at least as debilitating. However, in contrast to unipolar depression, depression in bipolar patients exhibits a varying response to antidepressants, raising questions regarding their efficacy and tolerability. Methods. We conducted a MEDLINE and Cochrane Collaboration Library search for papers published between 2005 and 2011 on the subject of antidepressant treatment of bipolar depression. Sixty-eight articles were included in the present review. Results. While a few studies did advocate the use of antidepressants, most well-controlled studies failed to show a robust effect of antidepressants in bipolar depression, regardless of antidepressant class or bipolar subtype. There was no significant increase in the rate of manic/hypomanic switch, especially with concurrent use of mood stabilizers. Prescribing guidelines published in recent years rely more on atypical antipsychotics, especially quetiapine, as a first-line therapy. Conclusions. Antidepressants probably have no substantial role in acute bipolar depression. However, in light of conflicting results between studies, more well-designed trials are warranted.

Bipolar depression: an evidence-based approach

Bipolar disorder is a complex, multidimensional illness that is often difficult to treat. Unfortunately, bipolar patients are much more likely to experience depression, which is all too often severe and a potentially lethal phase of the illness. In addition, pharmacotherapies with strong evidence for bipolar depression are limited. Most treatments are based on unsupported extrapolation from the treatment of unipolar depression or are derived largely from the clinical practice experience. In this article, we focus on the treatment of bipolar depression, with particular focus on evidence from the existing literature, to help guide readers in clinical practice.

General and comparative efficacy and effectiveness of antidepressants in the acute treatment of depressive disorders: a report by the WPA section of pharmacopsychiatry

Current gold standard approaches to the treatment of depression include pharmacotherapeutic and psychotherapeutic interventions with social support. Due to current controversies concerning the efficacy of antidepressants in randomized controlled trials, the generalizability of study findings to wider clinical practice and the increasing importance of socioeconomic considerations, it seems timely to address the uncertainty of concerned patients and relatives, and their treating psychiatrists and general practitioners. We therefore discuss both the efficacy and clinical effectiveness of antidepressants in the treatment of depressive disorders. We explain and clarify useful measures for assessing clinically meaningful antidepressant treatment effects and the types of studies that are useful for addressing uncertainties. This includes considerations of methodological issues in randomized controlled studies, meta-analyses, and effectiveness studies. Furthermore, we summarize the differential efficacy and effectiveness of antidepressants with distinct pharmacodynamic properties, and differences between studies using antidepressants and/or psychotherapy. We also address the differential effectiveness of antidepressant drugs with differing modes of action and in varying subtypes of depressive disorder. After highlighting the clinical usefulness of treatment algorithms and the divergent biological, psychological, and clinical efforts to predict the effectiveness of antidepressant treatments, we conclude that the spectrum of different antidepressant treatments has broadened over the last few decades. The efficacy and clinical effectiveness of antidepressants is statistically significant, clinically relevant, and proven repeatedly. Further optimization of treatment can be helped by clearly structured treatment algorithms and the implementation of psychotherapeutic interventions. Modern individualized antidepressant treatment is in most cases a well-tolerated and efficacious approach to minimize the negative impact of otherwise potentially devastating and life-threatening outcomes in depressive disorders.

Class effect of pharmacotherapy in bipolar disorder: fact or misbelief?

BACKGROUND

Anecdotal reports suggests that most clinicians treat medications as belonging to a class with regard to all therapeutic indications; this means that the whole 'class' of drugs is considered to possesses a specific therapeutic action. The present article explores the possible existence of a true 'class effect' for agents available for the treatment of bipolar disorder.

METHODS

We reviewed the available treatment data from randomized controlled trials (RCTs) and explored 16 'agent class'/'treatment issue' cases for bipolar disorder. Four classes of agents were examined: first-generation antipsychotics (FGAs), second-generation antipsychotics (SGAs), antiepileptics and antidepressants, with respect to their efficacy on four treatment issues of bipolar disorder (BD) (acute mania, acute bipolar depression, maintenance against mania, maintenance against depression).

RESULTS

From the 16 'agent class'/' treatment issue' cases, only 3 possible class effects were detected, and they all concerned acute mania and antipsychotics. Four effect cases have not been adequately studied (FGAs against acute bipolar depression and in maintenance protection from depression, and antidepressants against acute mania and protection from mania) and they all concern treatment cases with a high risk of switching to the opposite pole, thus research in these areas is poor. There is no 'class effect' at all concerning antiepileptics.

CONCLUSIONS

The available data suggest that a 'class effect' is the exception rather than the rule in the treatment of BD. However, the possible presence of a 'class effect' concept discourages clinicians from continued scientific training and reading. Focused educational intervention might be necessary to change this attitude.

[Bipolar depression: a review of current therapeutic strategies]

It is now acknowledged that depressive symptoms dominate the natural history of bipolar affective disorder. Treating bipolar depression therefore represents a major therapeutic issue that has paradoxically been understudied compared to the treatment of acute manic or hypomanic episodes. Thanks to a computerized and manual bibliographic search, we reviewed the literature pertaining to the somatic treatments of bipolar depression. It is initially advisable to implement or optimize the thymoregulator treatment by carrying out a blood titration and by adjusting the therapeutic rates as well as possible towards the upper recommended levels. In the second place, the adjunction of another mood stabilizer may be necessary to obtain euthymia while preventing a mood switch to mania. Atypical antipsychotics may have some efficacy in treating bipolar depression, but further evidence is needed. Antidepressants are generally prohibited due to the risk of induction of mania or rapid cycling. Their use is generally limited to severe cases in which the association of at least two mood stabilizers has failed.

Management of bipolar depression

Patients with bipolar disorder spend more time in a depressed than manic state, even with individualized treatment. To date, bipolar depression is often misdiagnosed and ineffectively managed both for acute episodes and residual symptoms. This review attempts to summarize the current status of available treatment strategies in the treatment of bipolar depression. For acute and prophylactic treatment, a substantial body of evidence supports the antidepressive efficacy of lithium for bipolar disorders and its antisuicidal effects. Among numerous anticonvulsants with mood-stabilizing properties, valproate and lamotrigine could be first-line options for bipolar depression. Due to receptor profile, mood-stabilizing properties of second-generation antipsychotics have been explored, and up to date, quetiapine and olanzapine appear to be a reasonable option for bipolar depression. The usefulness of antidepressants in bipolar depression is still controversial. Current guidelines generally recommend the cautious antidepressant use in combination with mood stabilizers to reduce the risk of mood elevation or cycle acceleration. Results from clinical trials on psychosocial intervention are promising, especially when integrated with pharmacotherapy. Most patients with bipolar depression need individualized and combined treatment, although the published evidence on this type of treatment strategy is limited. Future studies on the utility of currently available agents and modalities including psychosocial intervention are required.

Neurocognitive dysfunction and psychosocial outcome in patients with bipolar I disorder at 15-year follow-up

OBJECTIVE

Despite increasing interest in cognitive dysfunction in bipolar disorder, little is known about its impact on functional outcome relative to affective symptoms.

METHOD

A total of 33 bipolar I subjects were evaluated at index hospitalization and prospectively followed up 15 years later. Affective symptoms, cognition, global functioning, work, and social adjustment were assessed at follow-up and analyzed by linear regression.

RESULTS

Global functional impairment was significantly associated with poor performance on a cognitive measure of processing speed (WAIS Digit Symbol). Digit symbol performance also was the sole significant predictor of social functioning. Neither symptom severity nor course of illness features significantly contributed to global and social functioning. In contrast, verbal learning deficits, recent depression, and lifetime hospitalizations all were independently associated with work disability.

CONCLUSION

Processing speed is robustly associated with social and global functioning in bipolar disorder. Poor work functioning is significantly related to subsyndromal depression, course of illness, and verbal learning deficits. Cognitive and mood symptoms warrant consideration as independent determinants of functioning in patients with bipolar disorder many years after an index manic episode.

Pharmaceutical treatment of acute bipolar depression

The treatment of bipolar depression is one of the most challenging fields in contemporary psychiatry. The best data concern the antipsychotics quetiapine and the olanzapine-fluoxetine combination. However, the usefulness of antidepressants in bipolar depression remains controversial; positive data are available for fluoxetine but negative results have been published for paroxetine. Accumulated knowledge so far suggests that bipolar patients need continuous administration of an antimanic agent even during the acute depressive phase. Although our knowledge is indeed limited, the development of guidelines for polypharmacy is necessary and should be done as soon as possible.

Safety and efficacy of quetiapine in bipolar depression

OBJECTIVE

To review the clinical data investigating the efficacy and safety of quetiapine in bipolar depression.

DATA SOURCES

Searches of MEDLINE and PubMed (1977-July 2009) were conducted using the key words quetiapine and bipolar depression. The references of literature found were cross-referenced. The pharmaceutical company that produces quetiapine was contacted to obtain the posters for the EMBOLDEN I and EMBOLDEN II trials.

STUDY SELECTION AND DATA EXTRACTION

Only double-blind, placebo-controlled trials were included for review, as well as any subanalyses of the literature that matched this criterion.

DATA SYNTHESIS

There was a total of 5 double-blind, placebo-controlled trials and 5 subanalyses reviewed. The results of these data demonstrated quetiapine's efficacy in the treatment of depressive phases of bipolar disorder, including statistically significant improvement in the Montgomery-Asberg Depression Rating Scale (MADRS). In the trials reviewed in this article, the change in MADRS scores ranged from -15.4 to -16.94 within the quetiapine groups, and from -10.26 to -11.93 in the placebo groups. There were also statistically significant improvements in the Hamilton Anxiety Rating Scale, the Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire, the Pittsburgh Sleep Quality Index, and the Sheehan Disability Scale. All of these trials had a duration of 8 weeks and therefore cannot be applied to the long-term use of quetiapine in bipolar depression. The most common adverse events were sedation, somnolence, and dry mouth. The overall dropout rates for the trials reviewed ranged from 24% to 47%.

CONCLUSIONS

Based on the literature reviewed here, quetiapine appears to be a safe and efficacious short-term treatment option for bipolar depression. Patients with bipolar type I showed greater improvement on the MADRS than those with bipolar type II. Patients with a rapid-cycling disease course showed an improvement in depressive symptoms, regardless of bipolar type.

Quetiapine monotherapy in the treatment of depressive episodes of bipolar I and II disorder: Improvements in quality of life and quality of sleep

INTRODUCTION

The depressive symptoms of bipolar disorder impact health-related quality of life, quality of sleep and functioning. The BOLDER I and II trials demonstrated that quetiapine significantly improves depressive symptoms in patients with acute bipolar depression. Post-hoc analysis of the BOLDER I and II data permits a detailed investigation of the effects of quetiapine on these other measures in this patient population.

METHODS

Secondary analysis was performed on data from BOLDER I and II, which were two 8-week, double-blind, randomized, placebo-controlled studies of quetiapine at fixed doses (300 or 600 mg/day) in a total of 1051 patients with acute depressive episodes of bipolar I or II disorder. Measures included the Short-Form Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q SF) in BOLDER I and II, the Pittsburgh Sleep Quality Index (PSQI) in BOLDER I, and the Sheehan Disability Scale (SDS) in BOLDER II. Analyses of Q-LES-Q SF score changes were based on data from the combined BOLDER I and II populations, and analyses of PSQI and SDS score changes were based on BOLDER I and BOLDER II populations, respectively.

RESULTS

Assessments at day 57 by mixed-model repeated measures analysis demonstrated that quetiapine relative to placebo provided significant or numerical improvements in rating scale score on the Q-LES-Q SF (10.89 with 300 mg/day and 12.14 with 600 mg/day vs. 7.79 with placebo; p<0.001 for each quetiapine dose), PSQI (-5.34 and -6.00 vs. -3.35; p<0.001, each dose), and SDS (-7.78 and -8.25 vs. -6.49; p=0.156 and 0.054, respectively). Effect sizes at day 57 with quetiapine 300 and 600 mg/day, respectively, were 0.34 and 0.46 for Q-LES-Q SF, 0.59 and 0.79 for PSQI, and 0.17 and 0.23 for SDS. Improvements were evident at first post-baseline assessment on day 29 and were consistent over the majority of rating scale domains. Quetiapine was generally well tolerated and most adverse events were of mild to moderate intensity.

CONCLUSIONS

Quetiapine monotherapy is effective in improving impairment in important aspects of life that accompany improvements in depressive symptoms in patients with acute bipolar depression.

Burden of bipolar depression: impact of disorder and medications on quality of life

Bipolar disorder is a complex, chronic psychiatric condition characterized by recurring episodes of depressive illness and mania or hypomania. Although the manic or hypomanic episodes define the disorder, recent research has shown that depressive symptoms predominate over manic symptoms in the majority of patients, and that bipolar depression accounts for much of the significant morbidity and mortality associated with bipolar disorder. Given these findings, there has been a recent upsurge of interest in furthering our understanding of the burden of depression in bipolar disorder. At the same time, increasing scientific attention is now being paid to expanding the measurement of outcome in bipolar disorder to encompass broader indicators of response, one of which is the assessment of quality of life (QOL). In this review, we provide a summary of the current knowledge about QOL in the depressive phase of bipolar disorder, and the effects of pharmacological treatment interventions for bipolar disorder upon QOL. It appears that QOL is poorer in bipolar disorder than in other mood disorders and anxiety disorders, but that schizophrenia might compromise QOL more severely than bipolar disorder. Existing data also suggest that, for patients with bipolar disorder, QOL is negatively associated with depression, both as a cross-sectional mood state and perhaps also as a feature of the patient's course. Despite its clinical and public health importance, bipolar depression has only recently started to receive the attention it warrants in clinical trials, and many important questions about its optimal pharmacological management remain to be answered. There is also a paucity of information about the impact of pharmacological interventions on QOL in bipolar depression. To our knowledge, only two clinical trials to date have specifically examined the impact of medications on QOL in patients with bipolar depression. A small number of other studies have examined the effects of depressive symptoms on QOL in patients who are experiencing manic or mixed episodes. Nonetheless, QOL appears to be a meaningful and important indicator of outcome and recovery in this patient population, and one that warrants further scientific interest and energy.

Treatment of bipolar depression: an update

This article attempts to summarize the current status of our knowledge and practice in the acute treatment and prophylaxis of bipolar depression. For prophylactic treatment, our knowledge about lithium firmly supports its usefulness against bipolar depression and its specific effectiveness for suicidal prevention. Valproic acid and carbamazepine could be effective, too, while lamotrigine which seems to be preferably effective against depression but not mania. The FDA has approved the olanzapine-fluoxetine combination and quetiapine monotherapy for the treatment of acute bipolar depression. The usefulness of antidepressants in bipolar depression is controversial both for acute and prophylactic treatment; guidelines suggest their cautious use and always in combination with an antimanic and mood stabilizer agent, because in some patients they may induce switching to mania or hypomania, mixed episodes and rapid cycling. Data on psychosocial intervention are restricted to the maintenance phase. Electroconvulsive therapy and transcranial magnetic stimulation are additional options for refractory patients. Bipolar depression seems to be a more difficult condition to treat than mania. Most patients need complex combination treatment although the published evidence on this type of treatment is limited.

Mismatch between self-reported quality of life and functional assessment in acute mania: a matter of unawareness of illness?

BACKGROUND

Studies addressing self-reported quality of life (QoL) in acute mania are scarce and inconsistent. While it has been suggested that there is some disagreement between objective measures and subjective QoL as reported by acutely manic patients, this issue has not been systematically studied. This study aims to investigate the self-reported QoL in manic, depressed, and euthymic BD subjects, as compared to matched healthy controls.

METHODS

One-hundred and twenty type-I bipolar patients (40 manic, 40 depressed, and 40 euthymic) and 40 matched controls were studied. Self-reported QoL was assessed using the World Health Organization's Quality of Life Instrument-Short Version (WHOQOL-BREF). Objective functioning was assessed using the Global Assessment of Functioning (GAF), and depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale-17 items (HDRS) and the Young Mania Rating Scale (YMRS), respectively.

RESULTS

Manic patients presented the lowest GAF measures but reported same overall QoL as euthymic patients and controls, and better QoL than depressed patients. Within the manic subgroup, there was a significant inverse correlation between psychological QoL and GAF scores (r=-0.54; p=0.001).

LIMITATIONS

The cross-sectional design and the lack of control for potential comorbid conditions are the major limitations of the present study.

CONCLUSIONS

Our findings suggest that this mismatch between objective and subjective measures during acute mania may be associated with a lack of insight or awareness of their own illness.

Treatment of bipolar disorder: a complex treatment for a multi-faceted disorder

BACKGROUND

Manic-depression or bipolar disorder (BD) is a multi-faceted illness with an inevitably complex treatment.

METHODS

This article summarizes the current status of our knowledge and practice of its treatment.

RESULTS

It is widely accepted that lithium is moderately useful during all phases of bipolar illness and it might possess a specific effectiveness on suicidal prevention. Both first and second generation antipsychotics are widely used and the FDA has approved olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole for the treatment of acute mania. These could also be useful in the treatment of bipolar depression, but only limited data exists so far to support the use of quetiapine monotherapy or the olanzapine-fluoxetine combination. Some, but not all, anticonvulsants possess a broad spectrum of effectiveness, including mixed dysphoric and rapid-cycling forms. Lamotrigine may be effective in the treatment of depression but not mania. Antidepressant use is controversial. Guidelines suggest their cautious use in combination with an antimanic agent, because they are supposed to induce switching to mania or hypomania, mixed episodes and rapid cycling.

CONCLUSION

The first-line psychosocial intervention in BD is psychoeducation, followed by cognitive-behavioral therapy. Other treatment options include Electroconvulsive therapy and transcranial magnetic stimulation. There is a gap between the evidence base, which comes mostly from monotherapy trials, and clinical practice, where complex treatment regimens are the rule.

Health-related quality of life and functioning in bipolar disorder: the impact of pharmacotherapy

Bipolar disorder has a major deleterious impact on many aspects of a patient's functioning and health-related quality of life. Although the formal measurement of these deficits has been neglected until recently, many well-designed trials now include an assessment of functioning and health-related quality of life using one or more rating scales. This review describes recent developments in the measurement of functioning and health-related quality of life in bipolar disorder, and discusses the evidence that medications that improve symptoms in bipolar disorder also offer clinically relevant benefits in functioning and health-related quality of life. Direct comparisons of the benefits of medications including atypical antipsychotics are problematic due to differences in trial populations, study durations and rating scales. Data from quetiapine trials indicate that this medication offers prompt and sustained improvement of functioning in patients with mania and enhancement of health-related quality of life in patients with bipolar depression, to accompany the significant improvements in mood episodes.

Augmentation by citalopram of risperidone-induced monoamine release in rat prefrontal cortex

RATIONALE

A typical antipsychotics (APDs), e.g. olanzapine and risperidone, have been reported to be effective adjunctive treatment for depression if selective serotonin (5-HT) reuptake inhibitors (SSRIs) alone are ineffective.

OBJECTIVES AND METHODS

We utilized microdialysis in awake, freely moving rats to study the effect of risperidone in combination with citalopram, an SSRI, on extracellular 5-HT, dopamine (DA), and norepinephrine (NE) efflux in rat medial prefrontal cortex (mPFC).

RESULTS

Risperidone (1.0 mg/kg, s.c.), given alone, significantly increased 5-HT, DA, and NE concentrations in the mPFC. Citalopram (10 mg/kg, s.c.), by itself, produced a significant increase in 5-HT levels only. The combination of risperidone and citalopram produced significantly greater increases in efflux of both DA and NE than risperidone alone. However, the effect of this combination on extracellular 5-HT concentrations was not significantly different than that of citalopram alone. The augmentation of DA and NE efflux induced by risperidone plus citalopram could be partially blocked by the selective 5-HT1A antagonist, WAY 100635 (0.2 mg/kg, s.c.).

CONCLUSIONS

The results suggest that the ability of atypical APDs to augment the therapeutic efficacy of SSRIs in major depression and treatment-resistant depression may be due, at least in part, to potentiation of SSRI-induced increases in cortical DA and NE. The contributions of 5-HT1A receptor stimulation and 5-HT2A and alpha2 adrenergic receptor antagonism to this augmentation are discussed.

Quality of life in bipolar disorder: a review of the literature

A sizable body of research has now examined the complex relationship between quality of life (QoL) and depressive disorder. Uptake of QoL research in relation to bipolar disorder (BD) has been comparatively slow, although increasing numbers of QoL studies are now being conducted in bipolar populations. We aimed to perform a review of studies addressing the assessment of generic and health-related QoL in patients with bipolar disorder.

A literature search was conducted in a comprehensive selection of databases including MEDLINE up to November 2004. Key words included: bipolar disorder or manic-depression, mania, bipolar depression, bipolar spectrum and variants AND quality of life, health-related QoL, functional status, well-being and variants. Articles were included if they were published in English and reported on an assessment of generic or health-related QoL in patients with BD. Articles were not included if they had assessed fewer than 10 patients with BD, were only published in abstract form or only assessed single dimensions of functioning.

The literature search initially yielded 790 articles or abstracts. Of these, 762 did not meet our inclusion criteria, leaving a final total of 28 articles. These were sub-divided into four categories (assessment of QoL in patients with BD at different stages of the disorder, comparisons of QoL in Patients with BD with that of other patient populations, QoL instrument evaluation in patients with BD and treatment studies using QoL instruments to assess outcome in Patients with BD) and described in detail.

The review indicated that there is growing interest in QoL research in bipolar populations. Although the scientific quality of the research identified was variable, increasing numbers of studies of good design are being conducted. The majority of the studies we identified indicated that QoL is markedly impaired in patients with BD, even when they are considered to be clinically euthymic. We identified several important avenues for future research, including a need for more assessment of QoL in hypo/manic patients, more longitudinal research and the development of a disease-specific measure of QoL for patients with BD.

Bipolar depression: issues in diagnosis and treatment

Although bipolar affective disorder is defined by the history of manic or hypomanic episodes, depression is arguably a more important facet of the illness. Depressive episodes, on average, are more numerous and last longer than manic or hypomanic episodes, and most suicides occur during these periods. Misdiagnosis of major depressive disorder delays initiation of appropriate therapy, further worsening prognosis. Distinguishing features of bipolar depression include earlier age of onset, a family history of bipolar disorder, presence of psychotic or reverse neurovegetative features, and antidepressant-induced switching. Bipolar I depressions should initially be treated with a mood stabilizer (carbamazapine, divalproex, lamotrigine, lithium, or an atypical antipsychotic); antidepressant monotherapy is contraindicated. More severe or "breakthrough" episodes often require a concomitant antidepressant, such as bupropion or a selective serotonin reuptake inhibitor (SSRI). The first treatment specifically approved for bipolar depression is a combination of the SSRI fluoxetine and the atypical antipsychotic olanzapine. For refractory depressive episodes, venlafaxine, the monoamine oxidase inhibitor tranylcypromine, and ECT are most widely recommended. The optimal duration of maintenance antidepressant therapy has not been established empirically and, until better evidence-based guidelines are established, should be determined on a case-by-case basis.

Chronic coadministration of olanzapine and fluoxetine activates locus coeruleus neurons in rats: implications for bipolar disorder

RATIONALE

The depressive phase of bipolar disorder (bipolar depression) is a difficult-to-treat form of depression. The olanzapine/fluoxetine combination (Symbyax) is the only medication approved to treat this disorder. The precise neural mechanisms responsible for its efficacy are not clearly understood.

OBJECTIVES

In order to further elucidate the neurobiological mechanisms responsible for the beneficial clinical effects of the olanzapine/fluoxetine combination, the current experiment was designed to investigate the effects of chronic coadministration of olanzapine and fluoxetine on electrophysiological activity in the locus coeruleus (LC).

METHODS

Rats received olanzapine for 3 weeks via subcutaneous osmotic pumps while simultaneously receiving daily intraperitoneal injections of fluoxetine. These chronically treated rats were anesthetized, and single-unit recordings of LC neurons were made.

RESULTS

Chronic administration of olanzapine alone significantly increased firing of LC neurons, while, as reported previously, chronic administration of fluoxetine alone significantly reduced firing of LC neurons. However, in the combination condition, olanzapine was able to block the fluoxetine-induced suppression of the LC, and a significant increase in LC activity was observed.

CONCLUSIONS

The observed increase in firing of LC neurons could lead to enhanced levels of norepinephrine release in projection areas and amelioration of the clinical symptoms of bipolar depression.

Retrospective Study of Olanzapine in Depressive and Anxious States in Primary Care

CONTEXT: Bipolar spectrum and treatment-resistant unipolar mood disorders are increasingly identified in primary care settings. Olanzapine demonstrates efficacy in the treatment of acute mania and bipolar depression and in bipolar maintenance therapy. Olanzapine-fluoxetine combination therapy shows efficacy in treatment-resistant depression. OBJECTIVE: To examine the efficacy and tolerability profile of olanzapine in various difficult-to-treat depressive and/or anxious states in primary care outpatients. METHOD: A retrospective chart review was conducted for all identifiable patients prescribed olanzapine for mood disorders (DSM-IV) during a 3-year period (July 1998-July 2001), utilizing clinician and nurse recall, sampling of general continuity clinic records, and a hand search of mood disorder clinic records. MAIN AND SECONDARY OUTCOME MEASURES: Initial and final scores on the Global Assessment of Functioning (GAF) scale, duration of therapy, and adverse effects. RESULTS: Thirty-seven patients were identified as having received treatment with olanzapine; 3 were referred to the mental health specialty sector at the time of treatment initiation, and 2 were lost to follow-up. Of the 32 patients receiving ongoing treatment by primary care clinicians, most were female (N = 23; 72%) and all were white (100%). Most were diagnosed with a mental illness in the bipolar spectrum (N = 25; 78%) and demonstrated treatment resistance with antidepressants and/or mood stabilizers (mean number of previous psychotropic medications = 3.7). In the group completing therapy (24 patients [75%]; mean duration of treatment = 242 days), GAF scores demonstrated a clinically and statistically significant improvement (mean initial GAF score = 59 +/- 9; mean final GAF score = 76 +/- 11; p < .0001). Twenty (83%) of these 24 patients demonstrated sustained improvement in their GAF scores. In the group that discontinued therapy (8 patients [25%]; mean duration of treatment = 123 days), GAF scores also demonstrated a clinically and statistically significant improvement (mean initial GAF score = 51 +/- 15; mean final GAF score = 70 +/- 11; p < .0001). Six (75%) of these 8 patients demonstrated sustained improvement in their GAF scores. For all patients, observed adverse effects included weight gain (25 patients [86%]; mean = 3.63 kg), sedation (6 patients [19%]), and dry mouth (1 patient [3%]). CONCLUSION: Olanzapine shows promise as an effective pharmacotherapeutic agent for primary care patients with mood disorders that lie along the bipolar spectrum or that are resistant to treatment with antidepressant monotherapies, but is associated with mild-to-moderate weight gain.