Neurological Adverse Effects of Antipsychotics in Children and Adolescents.

OBJECTIVE: The aim of this study was to evaluate demographic, clinical, and treatment factors that may impact on neurological adverse effects in naive and quasi-naive children and adolescents treated with antipsychotics. METHODS: This was a 1-year, multicenter, observational study of a naive and quasi-naive pediatric population receiving antipsychotic treatment. Two subanalyses were run using the subsample of subjects taking the 3 most used antipsychotics and the subsample of antipsychotic-naive subjects. Total dyskinesia score (DyskinesiaS) and total Parkinson score (ParkinsonS) were calculated from the Maryland Psychiatric Research Center Involuntary Movement Scale, total UKU-Cognition score was calculated from the UKU Side Effect Rating Scale. Risk factors for tardive dyskinesias (TDs) defined after Schooler-Kaine criteria were studied using a logistic regression. RESULTS: Two hundred sixty-five subjects (mean age, 14.4 [SD, 2.9] years) with different Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders were recruited. DyskinesiaS (P < 0.001) and ParkinsonS (P < 0.001) increased at 1-year follow-up. Risperidone was associated with higher increases in DyskinesiaS compared with quetiapine (P < 0.001). Higher increases in ParkinsonS were found with risperidone (P < 0.001) and olanzapine (P = 0.02) compared with quetiapine. Total UKU-Cognition Score decreased at follow-up. Findings were also significant when analyzing antipsychotic-naive subjects. Fifteen subjects (5.8%) fulfilled Schooler-Kane criteria for TD at follow-up. Younger age, history of psychotic symptoms, and higher cumulative exposure time were associated with TD at follow-up. CONCLUSIONS: Antipsychotics increased neurological adverse effects in a naive and quasi-naive pediatric population and should be carefully monitored. Risperidone presented higher scores in symptoms of dyskinesia and parkinsonism. Quetiapine was the antipsychotic with less neurological adverse effects. Younger subjects, psychosis, and treatment factors predicted an increased risk of TD.

Suicide risk in rapid cycling bipolar patients.

BACKGROUND: Rapid-cycling (RC) is a course modifier of bipolar disorder which often implicates a poor prognosis. However, the relationship of RC with suicidal features as a marker of impairment has been understudied. METHODS: Three hundred and five patients (n=305) were included in a naturalistic, systematic prospective study in a single site setting. Patients with rapid-cycling (RC) were defined as having four or more manic, mixed or depressive episodes in the year prior to baseline assessment. The two groups were compared regarding clinical and sociodemographic variables, paying special attention to suicidal features. Statistical methods consisted of chi-square statistic for the comparison of categorical data, and Student's t test for dimensional variables normally distributed. Also, a General Linear Model was used to study the main effect of different sociodemographic and clinical variables on suicidality. All statistics were two-tailed, and significance was set at p less than 0.05. RESULTS: Fifty-five patients (18%) were classified as RC, whilst 250 (82%) were considered as nonrapid-cycling (NRC). No significative difference was found in the prevalence of RC amongst bipolar I and II patients. RC was associated with depressive onset of bipolar disorder. The number of suicide attempts was significantly higher amongst RC (RC mean 0.82 [SD 1.85] vs. NRC 0.44[SD 0.94] t=2.09, p=0.37). Nonetheless, no significative differences were found between RC and NRC regarding the percentage of suicide attempters. On the other hand patients that presented RC showed a marked increase of lifetime history of suicidal ideation (Chi(2)=4.363, p=0.039). Finally, there were not any differences between RC patients and NRC in family history of suicide. DISCUSSION: Bipolar patients with RC are more likely to attempt suicide. Intensive treatment of this marker should be considered.

Electroconvulsive therapy in the treatment of mixed states in bipolar disorder.

INTRODUCTION: Mixed bipolar states are not infrequent and may be extremely difficult to treat. Lithium, anticonvulsants including valproate and carbamazepine, and antipsychotics such as olanzapine, ziprasidone, and aripiprazole have been reported to be at least partially effective in controlled clinical trials, but many patients do not respond to pharmacological approaches. Electroconvulsive therapy has been tested to be efficacious for the treatment of both manic and depressive episodes, but much less evidence is available with regards to mixed states. The aim of the review was to report the available evidence for the use of electroconvulsive therapy in mixed bipolar states. METHODS: A systematic review of the literature on treatment of mixed states, focused on electroconvulsive therapy, was made, beginning in August 1992 and ending in March 2007. The key words were "electroconvulsive therapy" and "mixed bipolar". RESULTS: Only three studies met the required quality criteria and were included. This literature suggests that ECT is an effective, safe, and probably underutilized treatment of mixed states. Recent technical developments have made ECT more friendly, tolerable, and safe. Potential alternatives, such as vagus nerve stimulation, deep brain stimulation, or transcranial stimulation, are still far to be proved as effective as ECT.

Role of aripiprazole in treating mood disorders.

Atypical antipsychotics have been used to treat patients with schizophrenia for many years, but now there is increasing evidence of their utility in the treatment of mood disorders. In the past few years, several atypical agents have received regulatory approval for use in mania. The evidence shows that atypical antipsychotics are effective in the treatment of manic symptoms, either alone or in combination with traditional mood stabilizers, such as lithium and divalproex. Although emerging data indicate that atypical antipsychotics will be a promising addition to those therapies that are currently available for managing patients during the maintenance phase of bipolar illness, their potential in the long-term management of bipolar disorder remains to be fully explored. Aripiprazole is a recently released antipsychotic medication that differs from other atypical antipsychotic agents by its mode of action as a dopamine D2 partial agonist. It is administered orally and has a long half-life. Randomized studies have demonstrated the efficacy of aripiprazole compared with placebo in the treatment of acute relapse of schizophrenia and schizoaffective disorder, maintenance treatment of schizophrenia, treatment of acute mania, and prevention of manic relapse in patients who responded to the drug during a manic episode. Further studies are ongoing in bipolar and unipolar depression. Aripiprazole is generally well tolerated compared with other antipsychotic medications, although commonly reported side effects include extrapyramidal symptoms and motoric activation similar to akathisia. Further studies and postmarketing data will be helpful in providing additional information regarding the comparative safety, efficacy and tolerability of aripiprazole in the treatment of affective disorders.

Clinical correlates of first-episode polarity in bipolar disorder.

OBJECTIVE: To determine the clinical and long-term implications of mood polarity at illness onset. METHODS: During a 10-year follow-up prospective study, systematic clinical and outcome data were collected from 300 bipolar I and II patients. The sample was split into 2 groups according to the polarity of the onset episode (depressive onset [DO] vs manic/hypomanic onset [MO]). Clinical features and social functioning were compared between the 2 groups of patients. RESULTS: In our sample, 67% of the patients experienced a depressive onset. Depressive onset patients were more chronic than MO patients, with a higher number of total episodes and a longer duration of illness. Depressive onset patients experienced a higher number of depressive episodes than MO patients, who in turn had more manic episodes. Depressive onset patients made more suicide attempts, had a later illness onset, were less often hospitalized, and were less likely to develop psychotic symptoms. Depressive onset was more prevalent among bipolar II patients. Bipolar I patients with DO had more axis II comorbidity and were more susceptible to have a history of psychotic symptoms than bipolar II patients with DO. CONCLUSION: The polarity at onset is a good predictor of the polarity of subsequent episodes over time. A depressive onset is twice as frequent as MO and carries more chronicity and cyclicity.

Tratamiento de la manía con terapia electroconvulsiva / Treatment of mania with electroconvulsive therapy

Desde su introducción, la terapia electroconvulsiva (TEC) es un tratamiento usado en los trastornos afectivos. El avance en su técnica lo ha convertido en una opción útil y actual tanto en el tratamiento de las fases agudas como en la prevención de las recurrencias. El objetivo de esta revisión es recoger la información disponible hasta la actualidad acerca del uso de la TEC en la manía. Sus indicaciones, su eficacia, su predicción y su patrón de respuesta son objeto de este trabajo, así como sus complicaciones, sus efectos adversos y sus interacciones farmacológicas

Since its introduction, electroconvulsive therapy is a treatment used in mood disorders. The advance in this technique has turned it a useful and current option both in the treatment of the acute phases as in the prevention of recurrences. The objective of this revision is to collect available data about the use of electroconvulsive therapy in mania. Indications, effectiveness, prediction and patterns of response are included in this work, together with its complications, adverse effects and pharmacological interactions

Aplicación de la estimulación magnética transcraneal en las alucinaciones auditivas resistentes a tratamiento / The use of transcranial magnetic stimulation in auditive hallucinations resistant to treatment

Introducción: La estimulación magnética transcraneal (EMT) es una técnica no invasiva que consiste en la aplicación de ondas electromagnéticas sobre zonas corticales, lo que permite la aparición de cambios en las capas internas de la corteza cerebral. El objetivo del presente estudio es evaluar el efecto de la EMT en un caso de un paciente con el diagnóstico de trastorno esquizofrénico, que sufre alucinaciones auditivas resistentes al tratamiento psicofarmacológico. Metodología: En primer lugar, se realiza una exhaustiva revisión de la bibliografía sobre las aplicaciones neuropsiquiátricas y, más en concreto, en pacientes con esquizofrenia que sufren alucinaciones auditivas resistentes. A continuación se realiza la descripción evolutiva de un paciente, antes y después de la administración del EMT. Se utilizaron medidas de evalución psicopatológica general (escala de síntomas positivos y negativos - PANSS, escala Calgary) y de evaluación psicopatológica específica de alucinaciones auditivas (escalas Psyrats y Hoffman), medidas de evaluación del estado general (CGI), y medidas neuropsicológicas (continous performance test y test de Rey). Resultados: Se obsevaron mejorías transitorias en las medidas clíncas, aunque no se obsrvaron cambios en las medidas neuropsicoloógicas. No se observaron efectos secundarios importantes. Conclusiones: A pesar de que la EMT es una técnica segura, no ha resultado ser eficaz en el caso del paciente presentado. Aconsejamos la realización de más estudios similares, para poder demostrar la eficacioa de la EMT en este tipo de pacientes con esquizofrenia (AU)