Divalproex sodium in the treatment of aggressive behavior

Improving the pharmacotherapeutic treatment of agitation associated with bipolar disorder

INTRODUCTION

Agitation is commonly encountered in people with bipolar disorder, particularly when experiencing a manic episode. The number of approved pharmacological agents to manage acute episodes of agitation in this population is limited.

AREAS COVERED

A search was conducted using the US National Library of Medicine PubMed.gov resource for English-language papers of clinical trials and reviews/meta-analyses, using the text words 'bipolar disorder' AND 'agitation,' as well as any papers with both two text words in the title, without any date restrictions.

EXPERT OPINION

Existing pharmacologic options approved by regulatory authorities for the treatment of acute episodes of agitation associated with bipolar disorder have similar degrees of efficacy but differ in their tolerability profiles and ease of use, giving clinicians an opportunity to individualize treatment. The goal is to treat mild-moderate agitation before it evolves into severe agitation, encouraging noninvasive pharmacologic treatment options. Inhaled loxapine and sublingual dexmedetomidine are newer options with rapid onset of action and may be preferable for patients willing to cooperate with treatment.

Transcriptome analysis of genes and gene networks involved in aggressive behavior in mouse and zebrafish

Despite moderate heritability estimates, the molecular architecture of aggressive behavior remains poorly characterized. This study compared gene expression profiles from a genetic mouse model of aggression with zebrafish, an animal model traditionally used to study aggression. A meta-analytic, cross-species approach was used to identify genomic variants associated with aggressive behavior. The Rankprod algorithm was used to evaluated mRNA differences from prefrontal cortex tissues of three sets of mouse lines (N = 18) selectively bred for low and high aggressive behavior (SAL/LAL, TA/TNA, and NC900/NC100). The same approach was used to evaluate mRNA differences in zebrafish (N = 12) exposed to aggressive or non-aggressive social encounters. Results were compared to uncover genes consistently implicated in aggression across both studies. Seventy-six genes were differentially expressed (PFP < 0.05) in aggressive compared to non-aggressive mice. Seventy genes were differentially expressed in zebrafish exposed to a fight encounter compared to isolated zebrafish. Seven genes (Fos, Dusp1, Hdac4, Ier2, Bdnf, Btg2, and Nr4a1) were differentially expressed across both species 5 of which belonging to a gene-network centred on the c-Fos gene hub. Network analysis revealed an association with the MAPK signaling cascade. In human studies HDAC4 haploinsufficiency is a key genetic mechanism associated with brachydactyly mental retardation syndrome (BDMR), which is associated with aggressive behaviors. Moreover, the HDAC4 receptor is a drug target for valproic acid, which is being employed as an effective pharmacological treatment for aggressive behavior in geriatric, psychiatric, and brain-injury patients. © 2016 Wiley Periodicals, Inc.

Pregabalin- and topiramate-mediated regulation of cognitive and motor impulsivity in DBA/2 mice

BACKGROUND AND PURPOSE

Impulsivity is a core symptom in many neuropsychiatric disorders. The main objective of this study was to evaluate the effects of topiramate and pregabalin on the modulation of different impulsivity dimensions in DBA/2 mice.

EXPERIMENTAL APPROACH

The effects of acute and chronic administration of pregabalin (10, 20 and 40 mg·kg(-1) ) and topiramate (12.5, 25 and 50 mg·kg(-1) ) were evaluated in the light-dark box (LDB), hole board test (HBT) and delayed reinforcement task (DRT). α(2A) -Adrenoceptor, D(2) -receptor and TH gene expression were evaluated by real-time PCR in the prefrontal cortex (PFC), accumbens (ACC) and ventral tegmental area (VTA), respectively.

KEY RESULTS

Acute pregabalin administration showed a clear anxiolytic-like effect (LDB) but did not modify novelty-seeking behaviour (HBT). In contrast, topiramate produced an anxiolytic effect only at the highest dose, whereas it reduced novelty seeking at all doses tested. In the DRT, acute pregabalin had no effect, whereas topiramate only reduced motor impulsivity. Chronically, pregabalin significantly increased motor impulsivity and topiramate diminished cognitive impulsivity. Pregabalin decreased α(2A) -adrenoceptor and D(2) -receptor gene expression in the PFC and ACC, respectively, and increased TH in the VTA. In contrast, chronic administration of topiramate increased α(2A) -adrenoceptor and D(2) -receptor gene expression in the PFC and ACC, respectively, and also increased TH in the VTA.

CONCLUSIONS AND IMPLICATIONS

These results suggest that the usefulness of pregabalin in impulsivity-related disorders is related to its anxiolytic properties, whereas topiramate modulates impulsivity. These differences could be linked to their opposite effects on α(2A) -adrenoceptor and D(2) -receptor gene expression in the PFC and ACC, respectively.

Borderline personality disorder: bipolarity, mood stabilizers and atypical antipsychotics in treatment

In this article, it is aimed to review the efficacies of mood stabilizers and atypical antipsychotics, which are used commonly in psychopharmacological treatments of bipolar and borderline personality disorders. In this context, common phenomenology between borderline personality and bipolar disorders and differential features of clinical diagnosis will be reviewed in line with the literature. Both disorders can demonstrate common features in the diagnostic aspect, and can overlap phenomenologically. Concomitance rate of both disorders is quite high. In order to differentiate these two disorders from each other, quality of mood fluctuations, impulsivity types and linear progression of disorders should be carefully considered. There are various studies in mood stabilizer use, like lithium, carbamazepine, oxcarbazepine, sodium valproate and lamotrigine, in the treatment of borderline personality disorder. Moreover, there are also studies, which have revealed efficacies of risperidone, olanzapine and quetiapine as atypical antipsychotics. It is not easy to differentiate borderline personality disorder from the bipolar disorders. An intensively careful evaluation should be performed. This differentiation may be helpful also for the treatment. There are many studies about efficacy of valproate and lamotrigine in treatment of borderline personality disorder. However, findings related to other mood stabilizers are inadequate. Olanzapine and quetiapine are reported to be more effective among atypical antipsychotics. No drug is approved for the treatment of borderline personality disorder by the entitled authorities, yet. Psychotherapeutic approaches have preserved their significant places in treatment of borderline personality disorder. Moreover, symptom based approach is recommended in use of mood stabilizers and atypical antipsychotics.

Symptomatic response to divalproex in subtypes of conduct disorder

To investigate response to Divalproex sodium (DVPX) with respect to Reactive/Affective/Defensive/Impulsive (RADI) and Proactive/Instrumental/Premeditated (PIP) aggression among adolescent males with conduct disorder (CD), using results from a randomized, double-blind, placebo-controlled trial. It was hypothesized that DVPX response among participants with RADI aggression would be greater than among those with PIP aggression. Fifty-eight ethnically diverse males with severe CD were assigned to High Distress (HDCD) or Low Distress (LDCD) Conduct Disorder, corresponding with RADI and PIP aggression, respectively. Following a 1-week washout, all subjects were randomized to a high dose (up to 1,500 mg/day) or low dose (up to 250 mg/day) of DVPX. Baseline and endpoint assessments included Clinical Global Impression (CGI), Achenbach Self Report (YSR), and Weinberger Adjustment Inventory (WAI-62). Response to DVPX was significantly higher in the HDCD group (64%) than in the LDCD group (22%) in the high-dose treatment group (p = 0.03). Mean weekly WAI-62 distress scores declined significantly among the HDCD subjects than among LDCD subjects in the high-dose group. These results support the utility of mood stabilizing agents such as DVPX in treating patients with disorders characterized by the RADI pattern of aggression, including those with severe CD.

Efficacy and tolerability of pharmacotherapies for borderline personality disorder

Borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, affects and self-image, as well as marked impulsivity. Although psychotherapy is needed to attain lasting improvements in a patient's personality and overall functioning, practice guidelines state that pharmacotherapy is indicated to manage state symptoms and trait vulnerabilities. Three psychopathological dimensions are the main targets for pharmacotherapy of borderline personality disorder: affective dysregulation, impulsive-behavioural dyscontrol and cognitive-perceptual symptoms. Guidelines recommend the use of antidepressant agents and mood stabilizers for affective dysregulation and impulsive-behavioural dyscontrol, and antipsychotics for cognitive-perceptual symptoms. This review aims to report and discuss data from clinical trials, reviews and meta-analyses concerning drug efficacy and tolerability in the treatment of borderline personality disorder. Investigations that considered antidepressant agents mainly focused on SSRIs, which are recommended as first-line treatments for affective instability and impulse dyscontrol. Both open-label and randomized controlled studies have been performed, predominantly concerning the efficacy of fluoxetine and fluvoxamine. Other classes of antidepressants, such as TCAs and MAOIs, were investigated as alternative treatments for borderline personality disorder, but the risk of adverse effects and toxicity is a limitation to their use in clinical practice. Increasing amounts of data have recently been collected on the use of mood stabilizers to control mood instability and impulsivity in patients with borderline personality disorder. More substantial data were derived from controlled trials of valproate semisodium, although other drugs such as lithium, carbamazepine, oxcarbazepine and lamotrigine were tested with promising results. Several first-generation antipsychotics were studied in open-label and controlled trials, with good effects on behavioural dyscontrol and psychotic-like symptoms. Selection biases and heterogeneity of drugs and methods somewhat limited the value of these results. More recent investigations have examined atypical antipsychotics, with most of these studies being open-label trials with small sample sizes; however, a few controlled studies have been performed using olanzapine, showing improvements in impulsivity, anger and hostility. In conclusion, a large number of different drugs have been evaluated in the treatment of patients with borderline personality disorder. Initial findings are encouraging for many of these drugs. However, data need to be replicated in further controlled studies with head-to-head comparisons and long-term follow-ups. Many questions remain to be answered.

Psychiatric use and utility of divalproex sodium in Connecticut prisons

Divalproex sodium (DVX) is used in correctional settings to treat impulsive aggression and mood lability in patients without comorbid bipolar disorder. This review of DVX use in the Connecticut Department of Correction examined the psychiatric diagnostic impression of patients prescribed DVX, the doses used, and the symptomatic and functional change over time. Clinical charts of 168 offenders treated with DVX for one or more months were randomly selected for clinical outcome review and were divided into subgroups based on clinical impression for DVX prescription. In participants without bipolar disorder (44.6%), DVX was used to target impulsivity (14.3%) and mood lability (17.3%). Clinical improvement was noted in bipolar and nonbipolar groups (p < .001). The impulsive/aggressive subgroup was the only nonbipolar subgroup in which DVX yielded clinical benefit. This symptom-driven use of DVX is associated with clinical improvement when impulsive aggression is the target symptom.

Yi-gan san for the treatment of borderline personality disorder: an open-label study

BACKGROUND

Numerous medications have been tested on patients with borderline personality disorder (BPD). Although many of these medications have been demonstrated to be useful, no clear main treatment for BPD has emerged. Despite the efficacy of some of the medicines, acceptability and side effects have proven to be barriers to their use. Recent studies indicate that the traditional Chinese herbal medicine yi-gan san (YGS, yokukan-san in Japanese) may be safe and useful in treating behavioral and psychological symptoms in dementia patients. We aimed at evaluating both efficacy and safety of yi-gan san in patients with well-defined BPD.

METHODS

Twenty female outpatients diagnosed with BPD according to DSM-IV criteria and the revised Diagnostic Interview for Borderlines completed a 12-week open-label study with yi-gan san at an average daily dosage of 6.4+/-1.9 g (2.5-7.5 g). Psychometric instruments to assess efficacy included the Brief Psychiatric Rating Scale (BPRS), Hamilton Rating Scales for Depression (HAM-D), Global Assessment of Functioning (GAF), Clinical Global Impression Scale (CGI), and Aggression Questionnaire (AQ).

RESULTS

Most psychometric scale scores exhibited a highly significant improvement (total BPRS; BPRS somatic concern, anxiety, tension, depressive mood, hostility, suspiciousness, motor retardation, uncooperativeness, and excitement subscale; CGI; GAF; AQ) over time.

CONCLUSIONS

In this open-label pilot study, patients treated with YGS showed statistically significant reduction on self-rated and clinician-rated scales. The present findings suggest that yi-gan san might be effective for the treatment of a number of BPD symptoms, including low mood, impulsivity, and aggression.

Epidemiology, risk factors, and psychopharmacological management of suicidal behavior in borderline personality disorder

Borderline personality disorder (BPD) is a chronic psychiatric condition characterized by a pervasive pattern of instability in affect regulation and impulse control. These maladaptive coping strategies predispose individuals with BPD to suicidal behavior, and this diagnosis increases the risk for completed suicide. Empirical data indicate that adverse life events; a history of childhood trauma; and the presence of comorbid psychiatric conditions, in particular major depressive disorder and substance use disorders; confer an elevated risk of suicidal behavior in patients with BPD. Psychopharmacological interventions, including the use of antidepressants, anti-psychotics, and mood stabilizers, are considered in this review in terms of the evidence for their utility in reducing the risk of suicidal behavior in BPD.

Divalproex sodium for the treatment of PTSD and conduct disordered youth: a pilot randomized controlled clinical trial

We examined the efficacy of divalproex sodium (DVP) for the treatment of PTSD in conduct disorder, utilizing a previous study in which 71 youth were enrolled in a randomized controlled clinical trial. Twelve had PTSD. Subjects (all males, mean age 16, SD 1.0) were randomized into high and low dose conditions. Clinical Global Impression (CGI) ratings for core PTSD symptoms (Intrusion, avoidance and hyper arousal) were primary outcome measures, weekly slopes of impulsivity secondary ones. Intent-to-treat analyses showed significant positive associations between receiving high dose of DVP CGI's. Parallel analyses comparing outcome by drug level achieved strengthened the results.

Quetiapine for the treatment of borderline personality disorder; an open-label study

PURPOSE

Only a few studies have commented on the use of atypical antipsychotics for the treatment of Borderline Personality Disorder (BPD) features, including affective dysregulation and aggression. We aimed at evaluating both efficacy and safety of quetiapine in a sample of consecutive BPD patients.

GENERAL METHODS

29 BPD outpatients entered, and 23 completed, a 12 week, open-label, regime of quetiapine at an average daily dosage of 540 mg (range: 400-800 mg). Efficacy assessment psychometric instruments included: Hamilton Rating Scales for Depression (HAM-D); Brief Psychiatric Rating Scale (BPRS); Global Assessment of Functioning (GAF); Clinical Global Impression Scale (CGI); and Aggression Questionnaire (AQ).

FINDINGS

Both completer and intent-to-treat analysis showed that most psychometric scales' scores exhibited a highly significant (HAM-D: p=.003; BPRS Hostility and Suspiciousness subscales; CGI; GAF; AQ: all at p=.000) improvement over time. Six patients dropped out early from treatment due to side effects; quetiapine was associated with two cases of transient thrombocytopenia.

CONCLUSIONS

Present findings would suggest that quetiapine may be effective for the treatment of a number of BPD features, including low mood and aggression. However, monitoring blood counts in patients receiving quetiapine seems to be justified.

Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders

OBJECTIVES

The Diagnostic and Statistical Manual of Mental Disorders guidelines provide only a partial solution to the nosology and treatment of bipolar disorder in that disorders with common symptoms and biological correlates may be categorized separately because of superficial differences related to behavior, life history, and temperament. The relationship is explored between extremely rapid switching forms of bipolar disorder, in which manic and depressive symptoms are either mixed or switch rapidly, and forms of borderline personality disorder in which affective lability is a prominent symptom.

METHODS

A MedLine search was conducted of articles that focused on rapid cycling in bipolar disorder, emphasizing recent publications (2001-2004).

RESULTS

Studies examined here suggest a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. We propose a model for the development of 'borderline' behaviors on the basis of unstable mood states that sheds light on how the psychological and somatic interventions may be aimed at 'breaking the cycle' of borderline personality disorder development. A review of pharmacologic studies suggests that anticonvulsants may have similar stabilizing effects in both borderline personality disorder and rapid cycling bipolar disorder.

CONCLUSIONS

The same mechanism may drive both the rapid mood switching in some forms of bipolar disorder and the affective instability of borderline personality disorder and may even be rooted in the same genetic etiology. While continued clinical investigation of the use of anticonvulsants in borderline personality disorder is needed, anticonvulsants may be useful in the treatment of this condition, combined with appropriate psychotherapy.

The efficacy of divalproex sodium in the treatment of agitation associated with major depression

BACKGROUND

Agitation is both a feature of major depression and a common side effect of antidepressant treatment. Depressive agitation correlates with overall severity of illness and suicide risk, whereas treatment-emergent agitation may contribute to early discontinuation of pharmacotherapy. Thus, agitation merits investigation as a treatment target in clinical depression.

METHODS

In this study, adults with major depression were evaluated for change in agitation and other mood symptoms during adjunctive treatment with divalproex sodium. Twelve patients on antidepressants, who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depression, were given low doses of divalproex sodium and evaluated repeatedly for symptoms of depression, anxiety, and agitation. Agitation severity was evaluated using the Overt Agitation Severity Scale and the Stanford Scale for Agitation Symptoms. Mood symptoms were assessed with the Hamilton Anxiety and the Hamilton Depression Rating Scales.

RESULTS

Nine of 12 patients completed 4 weeks of treatment. All agitation scores decreased sharply, whereas depression (Hamilton Depression Rating Scale) and anxiety (Hamilton Anxiety Rating Scale) symptoms decreased only modestly. Decreased agitation was not merely a function of decreases on the Hamilton Depression or Hamilton Anxiety Rating Scales. Relatively low doses of divalproex sodium appear to be useful in the treatment of agitation associated with major depression.

CONCLUSIONS

The observation that decreases in agitation were not simply an artifact of overall change in depressive or anxiety symptoms is in keeping with the previous clinical impression that divalproex sodium has a specific effect on depressive agitation. Controlled clinical trials are needed to fully evaluate the utility and symptom specificity of divalproex sodium in depression.

Auditory and visual P300 evoked potentials do not predict response to valproate treatment of aggression in patients with borderline and antisocial personality disorders

In this study of patients with borderline personality disorder (BPD) or antisocial personality disorder (ASPD) hospitalized because of aggressive behavior, auditory and visual P300 evoked potentials were obtained prior to treatment with valproate. Eight ASPD patients (8 males, 0 females) and 11 BPD patients (2 males, 9 females) showed improvement, while in 7 patients with ASPD (7 males, 0 females) and 10 patients with BPD (2 males, 8 females), aggression was not improved. Differences in auditory and visual P300 latencies and amplitudes were not significant for either diagnosis, or for both diagnoses combined. These findings suggest that auditory or visual P300 evoked potentials may not be useful for predicting response of aggressive behavior to valproate treatment in patients with BPD or ASPD.

Extended-Release Divalproex Sodium for Mood Stabilization

STUDY OBJECTIVE

To evaluate the efficacy, safety, and tolerability of extended-release divalproex sodium.

DESIGN

Prospective, open-label, 4-week study

SETTING

Long-term care facility of the Missouri Department of Mental Health.

PATIENTS

Ten hospitalized patients (mean age 39.4 yrs) with mood or thought disorders who were experiencing adverse effects from delayed-release divalproex sodium.

INTERVENTION

All participants were switched from delayed-release to extended-release divalproex sodium.

MEASUREMENTS AND MAIN RESULTS

Efficacy was monitored with the Brief Psychiatric Rating Scale (BPRS), and safety and tolerability were monitored with the Systematic Assessment for Treatment Emergent Events (SAFTEE). Frequently reported adverse effects before conversion were sedation, stomach upset, and tremor. At study conclusion, no differences were seen in total BPRS scores or individual BPRS items, although a trend pointed to decreased somatic complaints (p=0.057). The mean serum concentration of valproic acid among participants did not change significantly in the transition from the delayed-release formulation to an equivalent dose-adjusted extended-release formulation (90.5 mg/L vs 95.5 mg/L, p=0.493). At study conclusion, significant decreases in low-density lipoprotein cholesterol (p=0.010) and potassium (p=0.043) levels were identified. Three categories of adverse effects decreased significantly after patients switched to the extended-release form of divalproex sodium: sedation (p=0.022), stomach or abdominal discomfort (p=0.045), and tremor (p=0.004).

CONCLUSION

This preliminary investigation suggests that patients receiving delayed-release divalproex sodium for mood lability can be converted successfully to extended-release divalproex sodium. Moreover, these findings imply that this transition is associated with a reduction in some of the adverse effects associated with divalproex sodium.

EEG does not predict response to valproate treatment of aggression in patients with borderline and antisocial personality disorders

Previous investigations of the role of EEG in predicting response of aggressive patients to valproate therapy have yielded mixed results. In this study of borderline and antisocial personality disorder patients hospitalized with aggressive behavior, EEGs were obtained prior to treatment with valproate. Eight of 22 (36.4%) patients subsequently responsive to valproate had nonepileptiform EEG abnormalities, while 5 of 20 (25%) patients not responsive to valproate had nonepileptiform EEG abnormalities. Although more of the valproate responders than nonresponders had EEG abnormalities, the presence of nonepileptiform EEG abnormalities was not a statistically significant (X2 = 0.213, df = 1, p = 0.64) predictor of valproate response in personality disorder patients with aggression.

The use of divalproex in alcohol relapse prevention: a pilot study

Anticonvulsant agents show promise in the treatment of the acute symptoms of alcohol withdrawal and may also treat some symptoms associated with the protracted abstinence syndrome. Impulsivity, hostility and irritability are common characteristics of alcohol-dependent individuals, and there is some evidence that anticonvulsant agents decrease these traits in individuals with a number of different psychiatric disorders. This pilot study is a 12-week, double-blind, placebo-controlled trial of an anticonvulsant agent, divalproex (DVPX), in alcohol-dependent individuals. Alcohol use (Timeline Follow Back), impulsivity (Barratt Impulsivity Scale), irritability and aggression (Buss-Durkee Hostility Index; and Anger, Irritability, Aggression Scale) were measured at baseline and throughout the 12-week treatment period. Drinking decreased significantly in both the placebo and the DVPX-treated groups. In the DVPX group, a significantly smaller percentage of individuals relapsed to heavy drinking, but there were no significant differences in other alcohol-related outcomes. There were significantly greater decreases in irritability in the DVPX-treated group and a trend towards greater decreases on measures of lability and verbal assault. There were no significant between-group differences on measures of impulsivity. While DVPX did not have a robust effect on alcohol-related outcomes, it did have modest impact on a measure of irritability. This is consistent with the findings of other investigators exploring the use of DVPX in schizophrenia, personality disorder and a number of other psychiatric disorders.

Tiagabine in the Management of Postencephalitic Epilepsy and Impulse Control Disorder

Rationale. Anticonvulsants are used as primary or adjunctive agents in the treatment of psychiatric disorders. gamma-Aminobutyric acid (GABA) ergic modulation has been shown to be important in impulsive aggression. We investigated the treatment of impulse control disorders with aggressive features in two patients with post-encephalitic epilepsy using the anticonvulsant tiagabine, a novel GABA reuptake inhibitor.Methods. The cases of two patients who were previously treated with other anticonvulsants, had uncontrolled behaviors with intractable seizures and were placed on adjunctive tiagabine with control of both psychiatric and neurologic symptoms, were analyzed.Results. In case 1, 12 mg adjunctive tiagabine daily resulted in behavioral improvement that further improved with increased titration; however, when tiagabine was discontinued, abrupt behavioral decompensation occurred. In case 2, adjunctive tiagabine resulted in both seizure control and marked diminution of disinhibited behaviors with aggressive outbursts; however, when tiagabine was titrated from 20 mg daily to 24 mg daily increased irritability was noted that resolved with tiagabine reduction to 20 mg daily.Conclusion. In two cases, adjunctive tiagabine was effective in the management of both epilepsy and severe impulse control disorder. Optimal dosing to maximize anticonvulsant and psychotropic effects needs to be established. Further studies using tiagabine in the treatment of impulse control disorders are indicated.

A pilot, open clinical study of depakote in the treatment of cocaine abuse

The effectiveness of increasing levels of valproic acid on cocaine abstinence was evaluated in an open-label trial of 55 subjects. Significantly lower percentages of individuals with valproate serum levels above 50 mcg/ml reported cocaine use and had less positive urinalyses as compared to those with serum levels less than 50 mcg/ml. The total number of days of cocaine use decreased significantly (p < 0.001) and improved levels of subject functioning were found with increasing serum levels of valproic acid. This pilot study offers confirmation that the divalproex sodium form of valproic acid, when used in sufficient serum levels, may provide an effective pharmacologic adjunct in the management and treatment of cocaine dependency. Copyright 2001 John Wiley & Sons, Ltd.

Comprehensive review of the psychiatric uses of valproate

The therapeutic effects of valproate in psychiatric conditions are most substantially recognized in bipolar disorder. However, this well-tolerated medication may be beneficial in the treatment of other mental illnesses. In this article, the authors comprehensively review studies of valproate as treatment for psychiatric conditions, including bipolar, depressive, anxiety, and psychotic disorders; alcohol withdrawal and dependence; tardive dyskinesia; agitation associated with dementia; and borderline personality disorder. Valproate shows the most promising efficacy in treating mood and anxiety disorders, with possible efficacy in the treatment of agitation and impulsive aggression, and less convincing therapeutic response in treating psychosis and alcohol withdrawal or dependence. The authors conclude with a brief summary of its mechanism of action and therapeutic spectrum.

Naturalistic experience with the use of divalproex sodium on an in-patient unit for adolescent psychiatric patients

This paper focuses on the importance of data collected not only from controlled clinical trials, but also from naturalistic treatment experience. In particular we examine the use of divalproex sodium either as monotherapy or as part of combined therapy on an in-patient ward for adolescents aged 13-18 years. All admissions in which divalproex sodium use was attempted (n=36) were analysed over a 1-year period. The most common use was in patients with a mixed-presentation bipolar disorder (n=16), followed by patients with major depression (n=7), mania (n=4) or psychoses not otherwise specified (n=4). Divalproex sodium use was evaluated in the control of mania, psychosis, agitation, mood swings, aggression and/or anxiety. Overall, the use of divalproex sodium was associated with a marked improvement along all psychopathological variables in the vast majority of patients. Few side-effects or medical complications were noted. We believe that divalproex sodium is a potentially useful drug in adolescent patients with varying forms of psychopathology.

Psychopharmacologic treatment of pathologic aggression

Several drugs are apparently effective in treating pathologic anger and aggression. Because many of the studies on aggressive populations allowed the use of concomitant medications, it is unclear whether the efficacy of each drug in a particular population is dependent on the presence of other medications, such as antipsychotic agents. Finally, one needs to be circumspect in inferring efficacy of a particular drug in aggressive patients with neuropsychiatric conditions other than the ones in which some efficacy has been established. Lithium appears to be an effective treatment of aggression among nonepileptic prison inmates, mentally retarded and handicapped patients, and among conduct-disordered children with explosive behavior. Certainly, lithium would be the treatment of choice in bipolar patients with excessive irritability and anger outbursts, and it has been shown to be effective in this population. Anticonvulsant medications are the treatment of choice for patients with outbursts of rage and abnormal EEG findings. The efficacy of these drugs in patients without a seizure disorder, however, remains to be established, with the exception perhaps of valproate and carbamazepine. In fact, dyphenylhydantoin did not appear to be effective in treating aggressive behavior in children with temper tantrums and was found to be effective in only a prison population. There is some evidence for the efficacy of carbamazepine and valproate in treating pathologic aggression in patients with dementia, organic brain syndrome, psychosis, and personality disorders. As Yudofsky et al point out in their review of the literature, although traditional antipsychotic drugs have been used widely to treat aggression, there is little evidence for their effectiveness in treating aggression beyond their sedative effect in agitated patients or their antiaggressive effect among patients whose aggression is related to active psychosis. Antipsychotic agents appear to be effective in treating psychotic aggressive patients, conduct-disordered children, and mentally retarded patients, with only modest effects in the management of pathologic aggression in patients with dementia. Furthermore, at least in one study, these drugs were found to be associated with increased aggressiveness in mentally retarded subjects. On the other hand, atypical antipsychotic agents (i.e., clozapine, risperidone, and olanzapine) may be more effective than traditional antipsychotic drugs in aggressive and violent populations, as they have shown efficacy in patients with dementia, brain injury, mental retardation, and personality disorders. Similarly, benzodiazepines can reduce agitation and irritability in elderly and demented populations, but they also can induce behavioral disinhibition. Therefore, one should be careful in using this class of drugs in patients with pathologic aggression. Beta-blockers appear to be effective in many different neuropsychiatric conditions. These drugs seem effective in reducing violent and assaultive behavior in patients with dementia, brain injury, schizophrenia, mental retardation, and organic brain syndrome. As pointed out by Campbell et al in their review of the literature, however, systematic research is lacking, and little is known about the efficacy and safety of beta-blockers in children and adolescents with pathologic aggression. Although widely used in the management of pathologic aggression, the use of this class of drugs has been limited partially by marked hypotension and bradycardia, which are side effects common at the higher doses. The usefulness of the antihypertensive drug clonidine in the treatment of pathologic aggression has not been assessed adequately, and only marginal benefits were observed with this drug in irritable autistic and conduct disorder children. Psychostimulants seem to be effective in reducing aggressiveness in brain-injured patients as well as in violent adolescents with oppositional or conduct disorders, particu

The agitated brain injured patient. Part 2: Pathophysiology and treatment

The management of agitation after brain injury remains uncertain because of a lack of a consistent definition and a poor understanding of the underlying mechanism. Part 1 of this review focused on definitions, differential diagnosis, and assessment. Part 2 reviews potential mechanisms for posttraumatic agitation and common intervention strategies. The intent of this two-part series is to advocate for a consistent definition for posttraumatic agitation, to encourage the use of appropriate assessment and monitoring strategies, and to recommend that intervention decisions are based on at least a theoretical understanding of the relationship between specific target behaviors and probable brain-behavior relationships.