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Schweitzer I et al. – There should be direct assessment of sexual function and depression using reliable,
validated rating scales before and during treatment. Studies should assess treatment–emergent effects in patients
with normal function and resolution of baseline dysfunction over treatment, in both the short and long term.
Further research should compare available instruments for measuring sexual function, and include separate
analyses of both remitters/non–remitters and male/female subjects.
Methods
• Patients with major depressive disorder were identified from the literature using MEDLINE,
EMBASE and PsychINFO databases.
Results
• Bupropion and duloxetine caused significantly less sexual dysfunction than the SSRIs in short–
term studies and reboxetine significantly less in both short– and longer term studies.
• Bupropion and agomelatine caused significantly less sexual dysfunction than venlafaxine.
• The evidence for mirtazepine having an advantage over the SSRIs is lacking and there are
currently insufficient data for desvenlafaxine.
• Neonatal outcomes were obtained by blinded review of delivery records and infant
examinations.
• Pregnant women (N=238) were categorized into three mutually exclusive exposure groups: 1)
no SSRI, no depression (N=131); 2) SSRI exposure (N=71), either continuous (N=48) or partial (N=23);
and 3) major depressive disorder (N=36), either continuous (N=14) or partial (N=22).
• The mean depressive symptom level of the group with continuous depression and no SSRI
exposure was significantly greater than for all other groups, demonstrating the expected treatment effect
of SSRIs.
• Main outcomes were minor physical anomalies, maternal weight gain, infant birth weight,
pregnancy duration, and neonatal characteristics.
Results
• Infants exposed to either SSRIs or depression continuously across gestation were more likely
to be born preterm than infants with partial or no exposure.
• Neither SSRI nor depression exposure increased risk for minor physical anomalies or reduced
maternal weight gain.
• Mean infant birth weights were equivalent. Other neonatal outcomes were similar, except 5-
minute Apgar scores.
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Controversies in Bipolar Disorder: Trust Evidence or Experience
Current Psychiatry, 02/02/09
Miller GE et al. - Most patients with bipolar spectrum disorders presenting with depression are misdiagnosed by
clinicians and treated with antidepressants. A few patients may benefit from antidepressant monotherapy, but the
predominant view in the literature is that antidepressants cause rapid mood cycling or a switch to mania or
hypomania.
Clinical Messages From the Treatment for Adolescents With Depression Study (TADS)
American Journal of Psychiatry, 09/08/09
March JS et al. – The combination of fluoxetine and CBT appears to be superior to both CBT monotherapy and
fluoxetine monotherapy as a treatment for moderate to severe major depressive disorder in adolescents.
Association between lithium serum level, mood state, and patient-reported adverse drug
reactions during long-term lithium treatment: a naturalistic follow-up study
Bipolar Disorders, 05/14/09
Wilting I et al. - Both physicians and researchers need to be aware that lithium serum level and mood state are
independently associated with patient reporting and severity scoring of ADRs, which may complicate objective
assessment of ADRs
A Double-Blind Trial of Gabapentin Versus Lorazepam in the Treatment of Alcohol Withdrawal
Alcoholism, 06/01/09
Myrick H. et al. - Gabapentin was well tolerated and effectively diminished the symptoms of alcohol withdrawal in
our population especially at the higher target dose (1200 mg) used in this study. Gabapentin reduced the
probability of drinking during alcohol withdrawal and in the immediate postwithdrawal week compared to
lorazepam.
Methods
• One hundred individuals seeking outpatient treatment of alcohol withdrawal with Clinical
Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) ratings ≥10 were randomized to
double-blind treatment with 2 doses of gabapentin (900 mg tapering to 600 mg or 1200 tapering to 800
mg) or lorazepam (6 mg tapering to 4 mg) for 4 days.
• Severity of alcohol withdrawal was measured by the CIWA-Ar on days 1 to 4 of treatment and
on days 5, 7, and 12 post-treatment and alcohol use monitored by verbal report and breath alcohol levels
Results
• CIWA-Ar scores decreased over time in all groups;
• high-dose gabapentin was statistically superior but clinically similar to lorazepam (p = 0.009).
• During treatment, lorazepam-treated participants had higher probabilities of drinking on the first
day of dose decrease (day 2) and the second day off medication (day 6) compared to gabapentin-treated
participants (p = 0.0002).
• The gabapentin groups also had less craving, anxiety, and sedation compared to lorazepam
Current use of benzodiazepines in anxiety disorders
Current Opinion in Psychiatry, 01/08/09
Cloos JM et al. - Benzodiazepines are still considered by many clinicians to remain good treatment options, in
both the acute and the chronic phase of the treatment of anxiety disorders, partially because of their rapid onset
of action and their efficacy with a favourable side effect profile, and also because of the sometimes only
incomplete therapeutic response and the emergence of side effects of alternative medications. Having
experienced good initial symptom relief with benzodiazepine treatment, patients may also be reluctant to taper it
down
Olanzapine compared to quetiapine in adolescents with a first psychotic episode
European Child and Adolescent Psychiatry, 02/10/09
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Arango C et al. - Olanzapine and quetiapine reduced psychotic symptoms in this adolescent sample. Patients on
olanzapine gained significantly more weight. Side effects with both drugs seemed to be more prevalent than those
reported in adult studies.
A double-blind, placebo-controlled pilot study of quetiapine for depressed adolescents with
bipolar disorder
Bipolar Disorders, 07/14/09
DelBello MP et al. - The results suggest that quetiapine monotherapy is no more effective than placebo for the
treatment of depression in adolescents with bipolar disorder. However, limitations of the study, including the high
placebo response rate, may have contributed to our findings and should be considered in the design of future
investigations of pharmacological interventions for this population.
Methods
• Thirty-two adolescents (ages 12–18 years) with a depressive episode associated with bipolar I
disorder were randomized to eight weeks of double-blind treatment with quetiapine, 300–600 mg/day, or
placebo.
• This two-site study was conducted from March 2006 through August 2007.
• The primary efficacy measure was change in Children's Depression Rating Scale–Revised
Version (CDRS-R) scores from baseline to endpoint.
• Secondary efficacy measures included change in CDRS-R scores over the eight-week study
period (PROC MIXED), changes from baseline to endpoint in Hamilton Anxiety Rating Scale (HAM-A),
Young Mania Rating Scale (YMRS), and Clinical Global Impression–Bipolar Version Severity (CGI-BP-S)
scores, as well as response and remission rates. Safety and tolerability were assessed weekly.
Results
• There was no statistically significant treatment group difference in change in CDRS-R scores
from baseline to endpoint (p = 0.89, effect size =?0.05, 95% confidence interval: ?0.77–0.68), nor in the
average rate of change over the eight weeks of the study (p = 0.95).
• Dizziness was more commonly reported in the quetiapine (41%) than in the placebo (7%) group
(Fisher's exact test, p = 0.04).
http://www.cochrane.org/reviews/en/ab006117.html
Sacchetti E et al. – This trial indicates that both ziprasidone and clozapine, having comparable efficacy coupled
with satisfactory general safety and tolerability, may be regarded as valuable options for the short–term treatment
of difficult–to–treat schizophrenia patients with a history of multiple resistance and/or intolerance to
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antipsychotics. The more favorable metabolic profile of ziprasidone may represent an added value that could
guide clinicians, at least in the presence of patients at high risk for metabolic disorders.
Methods
• 18–week, randomized, flexible–dose, double–blind, double–dummy trial evaluated ziprasidone
as an alternative to clozapine in treatment–refractory schizophrenia patients.
• A progressive and significant reduction from baseline in PANSS total score was observed from
day 11 in both study arms.
• There were also significant improvements on PANSS subscales, CGI–S, CG–I, CDSS, and
GAF, without between–drug differences.
• The two treatment groups had similar rates of early discontinuations due to AEs.
• Ziprasidone but not clozapine showed a significant reduction of SAS and AIMS scores.
• When compared with clozapine, ziprasidone also had a more favorable metabolic profile, with
significant endpoint differences in weight, fasting glucose, total cholesterol, LDL cholesterol, and
triglycerides
A single blind comparison of lithium and lamotrigine for the treatment of bipolar II depression
Journal of Affective Disorders, 12/31/08
Suppes T et al. - Lamotrigine and lithium were effective monotherapy for BDII depression, with comparable
response and remission rates. Naturalistic design and lack of placebo limit conclusions, though patient history
indicated long standing depression unlikely to be alleviated by time. Patients who received Li reported more side
effects, but this did not appear to impact drop-out rates.
Kalapatapu RK et al. - Antipsychotic medications have a modest effect on the neuropsychiatric symptoms of
dementia, but product labels warn of the excess risk of death and morbidity associated with their use in older
patients. As such, these agents should not be the first choice for the treatment of behavioral and psychotic
symptoms of dementia. Nevertheless, a trial of these agents may be indicated in instances in which the severity of
symptoms is extreme, or symptoms do not respond to nonpharmacologic methods or other medications...There is
no evidence to suggest differences in effectiveness between atypical and conventional antipsychotics; therefore,
the choice of an antipsychotic for neuropsychiatric symptoms often relies on side effect profile and individual
patient circumstances. Extrapyramidal symptoms and QTc prolongation are concerns with conventional
antipsychotic agents. The incidence of cerebrovascular events with either atypical or conventional antipsychotics
appears increased compared with placebo. A discussion of the risk-benefit ratio of antipsychotics with the
patient's family and/or caregivers should precede the decision to use these agents.
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Comparison of carbamazepine and lithium in treatment of bipolar disorder: A systematic review of
randomized controlled trials
Human Psychopharmacology: Clinical and Experimental, 12/04/08
Ceron-Litvoc D et al. - Carbamazepine might be comparable to lithium in terms of efficacy and safety, and
therefore a valuable option in the treatment of both manic and maintenance phases.
Shotbolt P et al. - Quetiapine at doses of up to 150 mg/day failed to significantly improve psychosis compared to
placebo, however the small sample size does not allow any conclusive interpretation of the results. Quetiapine did
not appear to worsen PD motor functioning, but its use was limited by a faster drop out compared with placebo.
Significant impediments were difficulty with recruitment and natural fluctuation in symptoms during the trial.
Methods
• Conducted a 12 week double blind randomized placebo-controlled trial.
• Time to dropout due to lack of improvement of psychosis was the primary outcome measure.
• Other important secondary outcomes were evaluated using standard rating scales for PD and
psychiatric symptoms.
Results
• Twenty-four eligible subjects gave consent.
• The primary outcome, time to dropout, was examined using survival analysis.
• It was shown that patients in the quetiapine group dropped out earlier than those in the placebo
group, but this difference was not significant (p = 0.68).
• No significant changes were found for any of the secondary outcome measures in either group.
Tibbitts GM - Until recently, sleep has been a mystery even to scientists. Research has defined sleep function and
the effects of sleep deprivation. Sleep disorders are interrelated with medical and psychiatric illnesses. This article
presents insomnia, jet lag, and shift work sleep disorders and reviews issues related to women's health and
sleep. Pharmacologic and behavioral treatments for sleep conditions are explored.
Rocca, P et al. - Risperidone, olanzapine and quetiapine produced significant improvements in behavioral
disturbances and were well tolerated.
Methods
• 58 consecutive outpatients with a DSM-IV-TR diagnosis of Alzheimer's disease with behavioral
disturbances, who received a 6-month treatment with risperidone, olanzapine or quetiapine.
• Neuropsychiatric Inventory (NPI) total score and its items forming the basic core of behavioral
disturbances in Alzheimer's disease: delusions, hallucinations and agitation/aggressiveness.
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• Mini-Mental State Examination (MMSE), Activities of Daily Living, Instrumental Activities of
Daily Living and Clinical Insight Rating scale.
• A significant correlation was found between MMSE score and NPI total score and NPI item
agitation decreases.
• Outcome measures included the Panic Disorder Severity Scale (PDSS), the Hamilton Anxiety
Scale (Ham-A), the Hamilton Depression Rating Scale (Ham-D), the Sheehan Panic Anxiety Scale-
Patient (SPAS-P), and the Clinical Global Impression scale (CGI).
Results
• All subjects demonstrated a reduction in both the frequency and severity of panic attacks
regardless of treatment received.
• Statistically significant improvements in rating scale scores for both groups were identified for
the PDSS, the Ham-A, the Ham-D, and the CGI.
• There was no difference between treatment groups in the improvement in scores on the
measures PDSS, Ham-A, Ham-D, and CGI.
• Post hoc tests suggest that subjects receiving risperidone may have a quicker clinical response
than subjects receiving paroxetine
A preliminary study of lamotrigine in the treatment of affective instability in borderline personality
disorder
International Clinical Psychopharmacology, 08/18/09
Reich, DB et al. – Results from the study suggest that lamotrigine is an effective treatment for affective instability
and for the general impulsivity characteristic of borderline personality disorder.
Methods
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• Conducted a 12–week, double–blind, placebo–controlled study of 28 patients who met Revised
Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, fourth
edition criteria for BPD.
• Patients could not meet Diagnostic and Statistical Manual of Mental Disorders, fourth edition
criteria for bipolar disorder.
• The primary outcome measures were: (i) the Affective Lability Scale total score; and (ii) the
Affective Instability Item of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN–BPD).
• The study randomized 15 patients to receive lamotrigine and 13 patients to receive placebo.
Results
• Patients in the lamotrigine group had significantly greater reductions in the total Affective
Lability Scale scores (P<0.05) and significantly greater reductions in scores on the affective instability
item of the ZAN–BPD (P<0.05).
• A secondary finding was that patients in the lamotrigine group had significantly greater
reductions in scores on the ZAN–BPD impulsivity item (P = 0.001).
• Results from the study suggest that lamotrigine is an effective treatment for affective instability
and for the general impulsivity characteristic of BPD.
Pharmacological Management of Delirium in Hospitalized Adults - A Systematic Evidence Review
Journal of General Internal Medicine, 05/12/09
Campbell N et al. - The existing limited data indicates no superiority for second-generation antipsychotics over
haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished
through various mechanisms, further studies are necessary to prove effectiveness.
Methods
• Three reviewers independently extracted the data for participants, interventions and outcome
measures, and critically appraised each study using the JADAD scale.
• Searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative
Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to
October 2008.
• This study excluded non-comparison trials, studies with patients aged < 18 years, a history of
an Axis I psychiatric disorder, and patients with alcohol-related delirium.
Results
• This study identified 13 studies that met our inclusion criteria and evaluated 15 compounds:
o second-generation antipsychotics,
o first-generation antipsychotics,
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o cholinergic enhancers,
o an antiepileptic agent,
o an inhaled anesthetic,
o injectable sedatives,
o and a benzodiazepine.
• Four trials evaluated delirium treatment and suggested no differences in efficacy or safety
among the evaluated treatment methods (first and second generation antipsychotics).
• Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium.
• Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium
with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing
elective or emergent surgical procedures.
To treat or not to treat? A meta-analysis of the use of cholinesterase inhibitors in mild cognitive
impairment for delaying progression to Alzheimer's disease
European Archives of Psychiatry and Clinical Neuroscience, 02/20/09
Diniz BS et al. - The long-term use of ChEIs in subjects with MCI may attenuate the risk of progression to
AD/dementia. This finding may have a significant impact on public health and pharmaco-economic policies.
Ginkgo biloba extract EGb 761®, donepezil or both combined in the treatment of Alzheimer's
disease with neuropsychiatric features: A randomised, double-blind, exploratory trial
Aging and Mental Health, 04/09/09
Yancheva S et al. - These exploratory findings helped to develop three hypotheses that will have to be proven in
further studies: (1) there is no significant difference in the efficiency between EGb 761® and donepezil, (2) a
combination therapy will be superior to a mono-therapy with one of both substances and (3) there will be less side
effects under a combination therapy than under mono-therapy with donepezil.
Methods
• We enrolled 96 outpatients, aged 50 years or above, who met the NINCDS/ADRDA criteria for
probable AD, scored below 36 on the TE4D, a screening test for dementia, below 6 on the Clock-
Drawing Test (CDT) and between 9 and 23 on the SKT, a cross-culturally validated cognitive test
battery.
• They scored at least five on the 12-item Neuropsychiatric Inventory (NPI). EGb 761® (240 mg
per day), donepezil (initially 5 mg, after 4 weeks 10 mg per day) or EGb 761® and donepezil combined
(same doses) were administered for 22 weeks.
Results
• Changes from baseline to week 22 and response rates were similar for all three treatment
groups with respect to all outcome measures (SKT, NPI, total score and activities-of-daily-living sub-
score of the Gottfries-Brne-Steen Scale, Hamilton Rating Scale for Depression, CDT and Verbal Fluency
Test).
• Compared to donepezil mono-therapy, the adverse event rate was lower under EGb 761®
treatment and even under the combination treatment.
Update on neuropsychiatric symptoms of dementia: Evaluation and management
Geriatrics, 04/13/09
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Kalapatapu RK et al. - The neuropsychiatric symptoms of dementia can lead to a decreased quality of life, rapid
cognitive decline, early patient institutionalization, tremendous caregiver burden, and increased cost of care. A
thorough assessment to evaluate and treat any underlying causes of symptoms is essential. With the lack of an
approved drug to treat the neuropsychiatric symptoms of dementia, nonpharmacologic interventions take on
added importance. Behavioral management, cognitive stimulation therapy, and caregiver and health care staff
education have shown the most promise to reduce symptom burden over the long term. Aside from antipsychotic
drugs, multiple classes of medications have been tried to treat such symptoms but long-term data showing
efficacy and safety are often lacking.
Are abnormal premorbid personality traits associated with Alzheimer's disease? - A case-control
study
International Journal of Geriatric Psychiatry, 07/10/09
Nicholas H et al. - There is an association between abnormal personality traits and AD. Individuals with AD also
appear to have had lower levels of social interactivity.
Methods
• Cases consisted of 217 Subjects diagnosed with probable late onset Alzheimer's disease (160
females and 57 males).
• Controls consisted of 76 unaffected siblings (44 females and 32 males) of patients with AD.
• AD was particularly associated with Cluster A personality disorder traits (Paranoid, Schizoid,
Schizotypal).
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