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Davies P, Ijaz S, Williams CJ, Kessler D, Lewis G, Wiles N. Pharmacological interventions for treatment-resistant depression in adults. Cochrane Database Syst Rev 2019; 12:CD010557. [PMID: 31846068 PMCID: PMC6916711 DOI: 10.1002/14651858.cd010557.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although antidepressants are often a first-line treatment for adults with moderate to severe depression, many people do not respond adequately to medication, and are said to have treatment-resistant depression (TRD). Little evidence exists to inform the most appropriate 'next step' treatment for these people. OBJECTIVES To assess the effectiveness of standard pharmacological treatments for adults with TRD. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (March 2016), CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science (31 December 2018), the World Health Organization trials portal and ClinicalTrials.gov for unpublished and ongoing studies, and screened bibliographies of included studies and relevant systematic reviews without date or language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with participants aged 18 to 74 years with unipolar depression (based on criteria from DSM-IV-TR or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria or Research Diagnostic Criteria) who had not responded to a minimum of four weeks of antidepressant treatment at a recommended dose. Interventions were: (1) increasing the dose of antidepressant monotherapy; (2) switching to a different antidepressant monotherapy; (3) augmenting treatment with another antidepressant; (4) augmenting treatment with a non-antidepressant. All were compared with continuing antidepressant monotherapy. We excluded studies of non-standard pharmacological treatments (e.g. sex hormones, vitamins, herbal medicines and food supplements). DATA COLLECTION AND ANALYSIS Two reviewers used standard Cochrane methods to extract data, assess risk of bias, and resolve disagreements. We analysed continuous outcomes with mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (CI). For dichotomous outcomes, we calculated a relative risk (RR) and 95% CI. Where sufficient data existed, we conducted meta-analyses using random-effects models. MAIN RESULTS We included 10 RCTs (2731 participants). Nine were conducted in outpatient settings and one in both in- and outpatients. Mean age of participants ranged from 42 - 50.2 years, and most were female. One study investigated switching to, or augmenting current antidepressant treatment with, another antidepressant (mianserin). Another augmented current antidepressant treatment with the antidepressant mirtazapine. Eight studies augmented current antidepressant treatment with a non-antidepressant (either an anxiolytic (buspirone) or an antipsychotic (cariprazine; olanzapine; quetiapine (3 studies); or ziprasidone (2 studies)). We judged most studies to be at a low or unclear risk of bias. Only one of the included studies was not industry-sponsored. There was no evidence of a difference in depression severity when current treatment was switched to mianserin (MD on Hamilton Rating Scale for Depression (HAM-D) = -1.8, 95% CI -5.22 to 1.62, low-quality evidence)) compared with continuing on antidepressant monotherapy. Nor was there evidence of a difference in numbers dropping out of treatment (RR 2.08, 95% CI 0.94 to 4.59, low-quality evidence; dropouts 38% in the mianserin switch group; 18% in the control). Augmenting current antidepressant treatment with mianserin was associated with an improvement in depression symptoms severity scores from baseline (MD on HAM-D -4.8, 95% CI -8.18 to -1.42; moderate-quality evidence). There was no evidence of a difference in numbers dropping out (RR 1.02, 95% CI 0.38 to 2.72; low-quality evidence; 19% dropouts in the mianserin-augmented group; 38% in the control). When current antidepressant treatment was augmented with mirtazapine, there was little difference in depressive symptoms (MD on Beck Depression Inventory (BDI-II) -1.7, 95% CI -4.03 to 0.63; high-quality evidence) and no evidence of a difference in dropout numbers (RR 0.50, 95% CI 0.15 to 1.62; dropouts 2% in mirtazapine-augmented group; 3% in the control). Augmentation with buspirone provided no evidence of a benefit in terms of a reduction in depressive symptoms (MD on Montgomery and Asberg Depression Rating Scale (MADRS) -0.30, 95% CI -9.48 to 8.88; low-quality evidence) or numbers of drop-outs (RR 0.60, 95% CI 0.23 to 1.53; low-quality evidence; dropouts 11% in buspirone-augmented group; 19% in the control). Severity of depressive symptoms reduced when current treatment was augmented with cariprazine (MD on MADRS -1.50, 95% CI -2.74 to -0.25; high-quality evidence), olanzapine (MD on HAM-D -7.9, 95% CI -16.76 to 0.96; low-quality evidence; MD on MADRS -12.4, 95% CI -22.44 to -2.36; low-quality evidence), quetiapine (SMD -0.32, 95% CI -0.46 to -0.18; I2 = 6%, high-quality evidence), or ziprasidone (MD on HAM-D -2.73, 95% CI -4.53 to -0.93; I2 = 0, moderate-quality evidence) compared with continuing on antidepressant monotherapy. However, a greater number of participants dropped out when antidepressant monotherapy was augmented with an antipsychotic (cariprazine RR 1.68, 95% CI 1.16 to 2.41; quetiapine RR 1.57, 95% CI: 1.14 to 2.17; ziprasidone RR 1.60, 95% CI 1.01 to 2.55) compared with antidepressant monotherapy, although estimates for olanzapine augmentation were imprecise (RR 0.33, 95% CI 0.04 to 2.69). Dropout rates ranged from 10% to 39% in the groups augmented with an antipsychotic, and from 12% to 23% in the comparison groups. The most common reasons for dropping out were side effects or adverse events. We also summarised data about response and remission rates (based on changes in depressive symptoms) for included studies, along with data on social adjustment and social functioning, quality of life, economic outcomes and adverse events. AUTHORS' CONCLUSIONS A small body of evidence shows that augmenting current antidepressant therapy with mianserin or with an antipsychotic (cariprazine, olanzapine, quetiapine or ziprasidone) improves depressive symptoms over the short-term (8 to 12 weeks). However, this evidence is mostly of low or moderate quality due to imprecision of the estimates of effects. Improvements with antipsychotics need to be balanced against the increased likelihood of dropping out of treatment or experiencing an adverse event. Augmentation of current antidepressant therapy with a second antidepressant, mirtazapine, does not produce a clinically important benefit in reduction of depressive symptoms (high-quality evidence). The evidence regarding the effects of augmenting current antidepressant therapy with buspirone or switching current antidepressant treatment to mianserin is currently insufficient. Further trials are needed to increase the certainty of these findings and to examine long-term effects of treatment, as well as the effectiveness of other pharmacological treatment strategies.
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Affiliation(s)
- Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Sharea Ijaz
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
- University Hospitals Bristol NHS Foundation TrustNIHR ARC WestBristolUK
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
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Mandal S, Mamidipalli SS, Mukherjee B, Hara SKH. Perspectives, attitude, and practice of lithium prescription among psychiatrists in India. Indian J Psychiatry 2019; 61:451-456. [PMID: 31579157 PMCID: PMC6767820 DOI: 10.4103/psychiatry.indianjpsychiatry_451_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Lithium "the magic pill" past its discovery remained the respite for patients with bipolar disorders for decades. The prescriptions of lithium were replaced by other drugs because of the cumbersome monitoring, adverse effect profile, narrow therapeutic index, and frequent comorbidities in patients. The objectives of this study were to understand the knowledge, attitude, and practice of lithium by a subset of psychiatrists in India, which will help us understand the theory-practice gap and for devising strategies to bridge the existing gap. MATERIALS AND METHODS The current study was an online survey which included 103 psychiatrists from India of either gender and any age group. Predesigned questionnaire about the knowledge, attitude, and practice of lithium use was circulated for 1 month (March 2018). We received 135 responses (31% response rate), of which 32 were incomplete. Hence, the total sample of psychiatrists included in the study was 103. RESULTS The results suggest that most practitioners included in the survey had knowledge about the effects, adverse effects, and the monitoring protocols and were comfortable in using lithium in patients on outpatient basis. Despite being aware of the indications, the psychiatrists were skeptical in starting lithium due to multitude of perceived barriers such as comorbidities, patient's low adherence to blood monitoring, and adverse effects. CONCLUSIONS Clinicians should be well aware of the adverse effects, monitoring protocols, which will help them to use lithium in a more appropriate manner.
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Affiliation(s)
- Sucharita Mandal
- Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | | | - Bhaskar Mukherjee
- Department of Psychiatry, Malda Medical College, Malda, West Bengal, India
| | - Suchandra K Hari Hara
- Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Rush AJ, Aaronson ST, Demyttenaere K. Difficult-to-treat depression: A clinical and research roadmap for when remission is elusive. Aust N Z J Psychiatry 2019; 53:109-118. [PMID: 30378447 DOI: 10.1177/0004867418808585] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The report considers the pros and cons of the most commonly used conceptual model that forms the basis for most clinical practice guidelines for depression. This model promotes the attainment of sustained symptom remission as the treatment goal based on its well-established prognostic and functional importance. Sustained remission is very unlikely, however, after multiple treatment attempts. Our current model propels many clinicians to continue to change or add treatments despite little chance for remission or full functional restoration and despite the increasing risk of more adverse events from polypharmacy. An alternative 'difficult-to-treat depression' model is presented and considered. It accepts that the treatment aims for some depressed patients may shift to optimal symptom control rather than remission. When difficult-to-treat depression is suspected, the many treatable causes of persistent depression must be assessed and addressed (given the importance of remission when attainable) before difficult-to-treat depression can be ascribed. The clinical and research implications of the difficult-to-treat depression model are discussed. CONCLUSION Suspected difficult-to-treat depression provides a practical basis for considering when to conduct a comprehensive evaluation. Once difficult-to-treat depression is confirmed, treatment may better focus on optimal disease management (symptom control and functional improvement).
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Affiliation(s)
- Augustus John Rush
- 1 Duke-National University of Singapore Medical School, Singapore.,2 Department of Psychiatry & Behavioral Sciences, Duke University, School of Medicine, Durham, NC, USA.,3 Department of Psychiatry, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Scott T Aaronson
- 4 Clinical Research Programs, Sheppard Pratt Health System, Baltimore, MD, USA.,5 Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Koen Demyttenaere
- 6 University Psychiatric Centre, University of Leuven, Leuven, Belgium.,7 Faculty of Medicine, Department of Neurosciences, Research Group Psychiatry, University of Leuven, Leuven, Belgium
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Zyoud SH, Waring WS, Sweileh WM, Al-Jabi SW. Global Research Trends in Lithium Toxicity from 1913 to 2015: A Bibliometric Analysis. Basic Clin Pharmacol Toxicol 2017; 121:67-73. [PMID: 28064463 DOI: 10.1111/bcpt.12755] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/03/2017] [Indexed: 02/05/2023]
Abstract
Lithium salts have been used to treat psychiatric disorders since the 1940s and are currently used in prophylaxis and treatment of depression and bipolar disorder. Therefore, we conducted this study to assess lithium toxicity-related publications using bibliometric approaches from a health point of view to assess global research trends in the lithium toxicity field to offer guidance to future research in this field. The data were retrieved from the online version of Scopus database on 6 August 2016. All records with the term 'lithium' in the title were retrieved, and those related to lithium toxicity were evaluated. There were a total of 1241 publications related to lithium toxicity published from 1913 to 2016. Articles (971 or 78.2%) were the most common type, followed by letters (179 or 14.4%) and reviews (61 or 4.9%). The annual publication of articles increased slightly after 1950 and the total number of publications related to lithium toxicity fluctuated with three peaks occurred in 1978, 1985 and 2014. The USA was the predominant country (25.38%), followed by the UK (7.82%), France (6.85%) and Canada (3.55%). Denmark had the highest productivity of publication after standardization by gross domestic product and population size. The average number of citations per article was 9.24, and the h-index for all publications in the field of lithium toxicity was 46. The highest h-index value was achieved by the USA (31) followed by the UK (21) and Canada (13). The Lancet was the highest ranked journal with 27 articles, followed by American Journal of Psychiatry with 23 articles. This study provides a bibliometric analysis on the global research trends in lithium toxicity studies during 1913-2015. There has been a progressive increase in the number of publications related to lithium toxicity published in the last decade, and most of the studies related to lithium toxicity arose from the USA and the UK.
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Affiliation(s)
- Sa'ed H Zyoud
- Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - W Stephen Waring
- Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Waleed M Sweileh
- Department of Pharmacology and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Zhang J, Song J, Wang J. Adolescent self-harm and risk factors. Asia Pac Psychiatry 2016; 8:287-295. [PMID: 27224048 DOI: 10.1111/appy.12243] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/13/2015] [Accepted: 03/11/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study aims to define the characteristics of adolescents who have engaged in self-harm behavior and ascertain the risk factors. METHODS From January 2013 to January 2014, 4,176 adolescents from senior middle schools in Linyi, China, were administered four questionnaire surveys to ascertain the following: incidence of self-harm behavior regarding the frequency of different self-harm behaviors by group (never/one to five times/greater than five times in the last 6 months) and then comparing the self-harm behavior of the different subgroups; symptom self-check, comparing the differences between the adolescents with self-harm behavior and without in nine subscales (somatization, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, fear, paranoid, and psychosis); Adolescent Self-Rating Life Events Check List scores; and Egna Minnenav Barndoms Uppfostran (EMBU) scores. Multivariate logistic regression analysis was used to determine the risk factors of self-harm in adolescents. RESULTS The incidence of adolescent self-harm was 27.60%; the occurrence of adolescent self-harm was closely related to their mental health status, stressful life events, and EMBU. Being female, an urban student, or an only child; having poor school performance or experiences of stressful life events, harsh parenting styles, or excessive interference; and poor mental health were the risk factors for adolescent self-harm. CONCLUSIONS The incidence of adolescent self-harm was high, and their mental health status, stressful life events, and EMBU affected the occurrence of adolescent self-harm, which is an issue that needs greater attention.
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Affiliation(s)
- Jixiang Zhang
- Department of Clinical Psychology, Linyi Municipal People's Hospital, Linyi, China
| | - Jianwei Song
- Department of Neurosurgery, Linyi Municipal People's Hospital, Linyi, China.
| | - Jing Wang
- Department of Obstetrics and Gynecology, Linyi Municipal Chinese Medicine Hospital, Linyi, China
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Khaloo P, Sadeghi B, Ostadhadi S, Norouzi-Javidan A, Haj-Mirzaian A, Zolfagharie S, Dehpour AR. Lithium attenuated the behavioral despair induced by acute neurogenic stress through blockade of opioid receptors in mice. Biomed Pharmacother 2016; 83:1006-1015. [DOI: 10.1016/j.biopha.2016.08.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 08/04/2016] [Accepted: 08/07/2016] [Indexed: 11/25/2022] Open
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Benard V, Vaiva G, Masson M, Geoffroy P. Lithium and suicide prevention in bipolar disorder. Encephale 2016; 42:234-41. [DOI: 10.1016/j.encep.2016.02.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/27/2015] [Indexed: 11/16/2022]
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Hoertel N, López S, Wang S, González-Pinto A, Limosin F, Blanco C. Generalizability of pharmacological and psychotherapy clinical trial results for borderline personality disorder to community samples. Personal Disord 2016; 6:81-7. [PMID: 25580674 DOI: 10.1037/per0000091] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The present study sought to quantify the generalizability of clinical trial results in individuals with a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnosis of borderline personality disorder (BPD) to a large representative community sample. Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large nationally representative sample of 34,653 adults from the United States population. We applied a standard set of exclusion criteria representative of pharmacological and psychotherapy clinical trials to all adults with a DSM-IV diagnosis of BPD (n = 2,231). Our aim was to assess how many participants with BPD would not fulfill typical eligibility criteria. We found that more than 7 of 10 respondents in a typical pharmacological efficacy trial and more than 5 of 10 participants in a typical psychotherapy efficacy trial would have been excluded by at least 1 criterion. Having a current history of alcohol or drug use disorder and a lifetime history of bipolar disorder explained a large proportion of ineligibility in both pharmacological and psychotherapy efficacy trials. Clinical trials should carefully consider the impact of exclusion criteria on the generalizability of their results. As required by CONSORT guidelines, reporting exclusion rate estimate and reasons of eligibility should be mandatory in both clinical trials and meta-analyses. As treatment trials of borderline personality disorder move from efficacy to effectiveness to better inform clinical practice, the eligibility rate must be increased by imposing less stringent eligibility criteria to allow for more generalizable results.
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Affiliation(s)
- Nicolas Hoertel
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | - Saioa López
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | - Shuai Wang
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
| | | | - Frédéric Limosin
- Department of Psychiatry, Assistance Publique-Hôpitaux de Paris (APHP), Corentin Celton Hospital
| | - Carlos Blanco
- New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University
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Riesselman A, Johnson E, Palmer E. Lithium and clozapine in suicidality: shedding some light to get out of the dark. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.09.237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Suicide is currently on the rise with rates increasing alarmingly during the past decade. There are many risk factors for suicidal behavior, and mental illness is at the top of the list.
Methods
Although a variety of medications have been evaluated in the literature, lithium and clozapine continue to have the most evidence supporting their use in decreasing suicidality.
Results
It is clear that medications are indispensable regarding the reduction of suicidality; however, a holistic approach must be taken when caring for this patient population.
Discussion
This review focuses on the specific role that lithium and clozapine have in the reduction of suicidal behavior.
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Affiliation(s)
- Amber Riesselman
- (Corresponding author) Assistant Professor, Sullivan University College of Pharmacy, Louisville, Kentucky, Clinical Psychiatric Pharmacist, University of Louisville Hospital, Louisville, Kentucky,
| | - Eric Johnson
- Clinical Pharmacist Specialist, Department of Veterans Affairs, Tennessee Valley Healthcare System, Clarksville, Tennessee
| | - Emma Palmer
- Assistant Professor, Sullivan University College of Pharmacy, Louisville, Kentucky, Clinical Psychiatric Pharmacist, Central State Hospital, Louisville, Kentucky
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Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K. Pharmacological interventions for self-harm in adults. Cochrane Database Syst Rev 2015; 2015:CD011777. [PMID: 26147958 PMCID: PMC8637297 DOI: 10.1002/14651858.cd011777] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm. OBJECTIVES To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients. SEARCH METHODS For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013. SELECTION CRITERIA We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach. MAIN RESULTS We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported. AUTHORS' CONCLUSIONS Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.
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Affiliation(s)
- Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK, OX3 7JX
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Serret S, Thümmler S, Dor E, Vesperini S, Santos A, Askenazy F. Lithium as a rescue therapy for regression and catatonia features in two SHANK3 patients with autism spectrum disorder: case reports. BMC Psychiatry 2015; 15:107. [PMID: 25947967 PMCID: PMC4428105 DOI: 10.1186/s12888-015-0490-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Phelan-Mc Dermid syndrome is a contiguous disorder resulting from 22q13.3 deletion implicating the SHANK3 gene. The typical phenotype includes neonatal hypotonia, moderate to severe intellectual disability, absent or delayed speech, minor dysmorphic features and autism or autistic-like behaviour. Recently, point mutations or micro-deletions of the SHANK3 gene have been identified, accompanied by a phenotype different from the initial clinically description in Phelan McDermid syndrome. CASE PRESENTATION Here we present two case studies with similar psychiatric and genetic diagnosis as well as similar clinical history and evolution. The two patients were diagnosed with autism spectrum disorders in childhood and presented regression with catatonia features and behavioural disorders after a stressful event during adolescence. Interestingly, both patients presented mutation/microdeletion of the SHANK3 gene, inducing a premature stop codon in exon 21. Different pharmacological treatments (antipsychotics, benzodiazepines, mood stabilizer drugs, antidepressants, and methylphenidate) failed to improve clinical symptoms and lead to multiple adverse events. In contrast, lithium therapy reversed clinical regression, stabilized behavioural symptoms and allowed patients to recover their pre-catatonia level of functioning, without significant side effects. CONCLUSION These cases support the hypothesis of a specific SHANK3 phenotype. This phenotype might be linked to catatonia-like deterioration for which lithium use could be an efficient treatment. Therefore, these cases provide an important contribution to the field of autism research, clinical genetics and possible pharmacological answers.
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Affiliation(s)
- Sylvie Serret
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
| | - Susanne Thümmler
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
| | - Emmanuelle Dor
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
| | - Stephanie Vesperini
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
| | - Andreia Santos
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
| | - Florence Askenazy
- Autism Resources Center, University Child and Adolescent Psychiatry Department, Children's Hospitals of Nice CHU-Lenval, CoBTek EA7276 University of Nice Sophia Antipolis, Nice, France.
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Girlanda F, Cipriani A, Agrimi E, Appino MG, Barichello A, Beneduce R, Bighelli I, Bisoffi G, Bisogno A, Bortolaso P, Boso M, Calandra C, Cascone L, Castellazzi M, Corbascio C, Parise VF, Gardellin F, Gennaro D, Hanife B, Lintas C, Lorusso M, Luca A, Luca M, Luchetta C, Lucii C, Maio F, Marsilio A, Mattei C, Moretti D, Nosè M, Occhionero G, Papanti D, Pecile D, Percudani M, Prestia D, Purgato M, Restaino F, Romeo S, Sciarma T, Strizzolo S, Tamborini S, Todarello O, Tozzi F, Ziero S, Zotos S, Barbui C. Effectiveness of lithium in subjects with treatment-resistant depression and suicide risk: results and lessons of an underpowered randomised clinical trial. BMC Res Notes 2014; 7:731. [PMID: 25326163 PMCID: PMC4210495 DOI: 10.1186/1756-0500-7-731] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/10/2014] [Indexed: 11/24/2022] Open
Abstract
Background As lithium treatment might be effective in reducing the risk of deliberate self-harm (DSH) in adult patients with unipolar affective disorders, we designed a pragmatic randomised trial to assess its efficacy in more than 200 patients with treatment-resistant depression. However, we randomised 56 patients only. The aim of this report is therefore twofold: first, to disseminate the results of this underpowered study which may be incorporated into future meta-analytical reviews; second, to analyse some critical aspects of the study which might explain failure to reach the target sample size. Methods We carried out a randomised, parallel group, assessor-blinded superiority clinical trial. Adults with a diagnosis of major depression, an episode of DSH in the previous 12 months and inadequate response to at least two antidepressants given sequentially at an adequate dose for an adequate time for the current depressive episode were allocated to add lithium to usual care (intervention arm) versus usual care alone (control arm). Suicide completion and acts of DSH during the 12 months of follow-up constituted the composite primary outcome. Results Of 58 patients screened for inclusion, 29 were allocated to lithium plus usual care and 27 were assigned to usual care without lithium. Six patients in the lithium plus usual care group and seven in the usual care group committed acts of DSH during the follow-up phase. The survival probability did not differ between the two treatment arms (Chi2 = 0.17, p =0.676). With regard to changes in the severity of depressive symptomatology from baseline to endpoint, no significant differences were detected. Conclusions The present study failed to achieve the minimum sample size needed to detect a clinically meaningful difference between the two treatment arms. Consequently, the finding that lithium, in addition to usual care, did not exert a positive effect in terms of reduction of DSH after 12 months of follow-up is likely due to the lack of sufficient statistical power to detect a difference, if a difference existed. The dissemination of the results of this underpowered study will inform future meta-analytical reviews on lithium and suicide-related outcomes. Trial registration ClinicalTrials.gov identifier: NCT00927550
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Corrado Barbui
- Dipartimento di Sanità Pubblica e Medicina di Comunità, Sezione di Psichiatria, Università di Verona, Verona, Italy.
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Oruch R, Elderbi MA, Khattab HA, Pryme IF, Lund A. Lithium: A review of pharmacology, clinical uses, and toxicity. Eur J Pharmacol 2014; 740:464-73. [DOI: 10.1016/j.ejphar.2014.06.042] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/20/2014] [Accepted: 06/20/2014] [Indexed: 01/10/2023]
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