Mania controlled treatment studies

Summary of Data from Controlled Treatment Studies of Acute Mania in Adults... 

Based on existing findings, there are many important hypotheses in pediatric psychopharmacogenetics. Selective serotonin transporter inhibitors have been shown to have efficacy in double-blind studies in children and/ or adolescents in the treatment of autism, major depression, OCD, and anxiety disorders. Given the association of the serotonin transporter promoter variant with SSRI treatment response in adult depression (Smeraldi et ah, 1998), all of the SSRI-responsive phenotypes should be tested for promoter variant influence on response using family-based or population-based controlled association studies. The report of strong 5-HTTLPR allelic effects on SSRI-induced mania (Mundo et ah, 2000) is of special interest given frequent SSRI-induced activation in children. 

Muller-Oerlinghausen B, Retzow A, Henn FA, et al. Valproate as an adjunct to neuroleptic medication for the treatment of acute episodes of mania a prospective, randomized, double-blind, placebo-controlled, multicenter study. J Clin Psychopharmacol 2000 20 195-203. 

Controlled Studies A controlled, randomised study compared oral risperidone, sodium divalproex in children and adolescents with bipolar I mania or mixed phase [23/d. Increased weight and BMI were significantly greater with risperidone treatment than with lithium or sodium divalproex treatment. There was a significant increase in LDL-cholesterol and decrease in HDL-cholesterol for the risperidone and sodium divalproex groups QTc prolongation (>440 ms) was reported in 9.0% of risperidone (also greatest increases), 10.0% of lithium and 3.0% of sodium divalproex-treated patients. 

Numerous open studies, and seven controlled studies, have shown that valproate is effective in the treatment of acute mania. It has also been claimed to have an antidepressant action. Recent studies have shown that valproate is effective in the long-term treatment of bipolar disorder. 

In contrast to the large number of studies that have investigated lithium as a maintenance treatment for bipolar disorder, relatively few studies have been made of divalproex sodium, despite its widespread use in the acute treatment of mania. There is evidence from one placebo-controlled study in which lithium was compared with divalproex sodium that the latter drug was better tolerated but that the prevention of relapse did not differ between the drugs. It would therefore appear that a switch to divalproex sodium may be particularly useful in bipolar patients who are experiencing... 

There are no randomized, double-blind, controlled studies of hospitalized children and adolescents with acute mania. Two systematic, albeit open, studies of lithium in hospitalized, acutely manic adolescents had response rates of 67%-80% in classic manic adolescents, and 33%-40% in manic adolescents with prior ADHD (Strober et al., 1988 1998). In a discontinuation study in which manic adolescents stabilized on lithium were subsequently assigned double-blind to placebo or continuation treatment, the response rate was 53.5%, and the presence of prior ADHD made no difference in outcome (Kafantaris et al., 1998). However, the presence of psychosis decreased the likelihood of lithium response and antipsychotic medication was necessary for stabilization. Naturalistic discontinuation of lithium (because of noncompliance) after stabilization resulted in relapse rates of 90% vs. 37.5% for those remaining on lithium (Strober et al., 1990). A NIMH multisite study is currently examining this issue more systematically. 

Controlled and uncontrolled or open studies of the CCBs in affective illness are reviewed in Table 6-3. Initial open and blind studies of the phenyl-alkylamine L-type CCB verapamil were positive in the affective disorders, particularly in the treatment of acute mania. However, some preliminary controlled data are negative (Janicak et al. 1998) these data are highly subject to a type II error with the design used, the relatively small numbers of patients randomly selected for verapamil and placebo, and the associated relatively high placebo response rate in acute mania observed in many controlled studies... 

Valproate, a simple branched-chain fatty acid, was first reported as a successful treatment for acute mania by Lambert and colleagues in 1966. Following this report, at least 16 uncontrolled trials consistently supported the observation that valproate has acute and long-term mood-stabilizing effects in patients with bipolar disorder (reviewed by Keck et al. 1992a). Recently, five double-blind controlled studies of valproate have been completed that provide definitive evidence of its efficacy in acute mania. 

In contrast with studies of the treatment of acute mania, studies of lithium in bipolar depression are less common. Initially, Cade (1949) reported that lithium had no efficacy in the treatment of depression, although this opinion was reversed by the results of several open trials and finally a controlled study by Fieve et al. in 1968. Subsequently, eight placebo-controlled trials have been... 

Virtually all anticonvulsants are or have been of interest for the treatment of bipolar disorder. However, the importance of controlled data cannot be understated. For example, gabapentin, an anticonvulsant that initially received much attention as a potential mood stabilizer, was compared with placebo and did not appear to stabilize mood (Frye et al. 2000 Pande et al. 2000). Similar negative results were seen with topiramate in placebo-controlled trials for the treatment of mania. Although these medications might be useful adjuncts in some patients, given the currently expanded pharmacopoeia of medications with positive controlled trial data in bipolar disorder, we do not recommend the primary use of agents that have only case reports as an evidence base or controlled studies with predominantly negative results. 

Some patients with bipolar disorder will need antidepressants. Although the switch rate into mania or induction of rapid cychng by antidepressants is controversial, these agents do appear to present a risk for some patients, often with devastating consequences. Therefore, when a patient with bipolar disorder is prescribed an antidepressant, it should only be in combination with a medication that has established antimanic properties. Controlled comparative data on the use of specific antidepressant drugs in the treatment of bipolar depression are sparse. Current treatment guidelines extrapolate from these few studies and rely heavily on anecdotal chnical experience. Overah, tricyclic antidepressants should be avoided when other viable treatment options exist. Electroconvulsive therapy should be considered in severe cases. 

The parallel-group, double-blind, placebo-controlled study design represents the golden standard of acute treatment trials of depression, mania and anxiety disorders. This design is intended to limit bias, in particular selection and measurement bias. Trials based on this design are expected to provide information about the effect size of a new compound and its side-effect profile. 

Valproate Versus Lithium. The previously discussed Bowden et al. (135) study found the DVPX formulation to be comparable with lithium, which was used as a positive comparator in this placebo-controlled study. Freeman et al. (99) conducted a 3-week, double-blind, parallel-group comparison of VPA and lithium for acute mania. Both drugs demonstrated clinically significant efficacy (i.e., 9 of 14 responded to DVPX and 12 of 13 to lithium), and there was no difference in the need for rescue medications (i.e., lorazepam or chloral hydrate) between the two treatment groups. Response to VPA was associated with high pretreatment depression scores. 

---