2013, volume 29, issue 1

Review article

New directions of pharmacotherapy in bipolar affective illness

Janusz Rybakowski

The studies on the mechanisms of action of drugs efficacious in the treatment of different stages of bipolar disorder (BD) and discovering its pathogenic processes give an impulse for searching new agents which may be applied in this illness. In this article, a review of some new drugs introduced on the basis of such studies will be presented. These drugs may became useful in the treatment of different stages of BD i.e. acute depression, acute mania and prevention of affective recurrences in not so distant future. The review starts with two drugs acting on N-methyl-D-aspartate (NMDA) receptors of glutamatergic system such as ketamine and memantine. Demonstrating rapid antidepressant action of single ketamine infusion has been in recent years one of the most important events connected with pharmacological treatment of depression. Introduction of tamoxifen for the treatment of manic states was based on its inhibition of protein kinase C, similarly as mood-stabilizing drugs such as lithium and valproate. Besides of such atypical antipsychotic drugs as clozapine, olanzapine, quetiapine, aripiprazole and risperidone, already classified as second generation mood-stabilizing drugs, ziprasidone, asenapine, paliperidone and lurasidone have became new candidates in this respect. Agomelatine, the only antidepressant drug with novel mechanism of action introduced in the first decade of XXI century has already been used in the treatment of bipolar depression. At the end of the article, a potential of antidepressant action of glutamatergic system modulators (riluzole, D-cycloserine) as well as of zinc and magnesium ions has been presented.

Review article

Psychopharmacology in pregnancy

Dominika Berent, Tomasz Śliwiński

Pregnancy does not protect against mental disorder and may even exacerbate already existing illness or evoke a new one. It is not always possible to avoid pharmacological treatment in pregnancy, but several alternative methods are also available. We performed a systematic review of current prescribing guidelines and the PubMed/MEDLINE and EMBASE databases utilizing the keywords: pregnancy, psychiatry, pharmacotherapy, psychotherapy, electroconvulsive therapy, transcranial magnetic stimulation, light therapy, herbs and extracted most current data. None of drug used in psychopharmacology can be found solely safe for mother and her child but avoiding treatment of psychiatric illness in pregnancy brings a risk of poor cooperation, malnutrition, violence, preterm delivery, suicide attempts and child death. Additionally, we present alternative methods of treatment: psychotherapy, electroconvulsive therapy, transcranial magnetic stimulation, light therapy, herbs. The psychopharmacology in pregnancies should be based on psychiatrist and gynecologist-obstetrician cooperation; careful consideration of risks of remaining untreated and the risks and benefits of treatment; combination therapy avoidance; relaying on the current knowledge about pharmacotherapy and taking into consideration alternative methods of treatment. After the analysis of here collected data, we conclude that drugs suggested to be relatively safe (no evident harm was confirmed) are:
• first generation neuroleptics: haloperidol, chlorpromazinum, trifluoperazinum,
• second generation neuroleptics: klozapine, olanzapine,
• tricyclic antidepressant drugs: amitriptyline, imipramine,
• selective serotonine reuptake inhibitors: fluoxetine,
• sedatives: zolpidem, promethazine.

Review article

Depression and insomnia – new treatment approaches

Adam Wichniak, Aleksandra Wierzbicka, Wojciech Jernajczyk

Depending on the severity of depression, sleep disturbances are reported by 60–90% of patients with major depressive disorder and depression is the most frequent cause of chronic insomnia.
The aim of this review article was to describe the treatment of depression associated with insomnia, insomnia associated with depressive symptoms and new treatment approaches in both disorders.
Sedative antidepressants (amitriptyline, doxepin, mianserine, mirtazapine, trazodone) are recommended for depressed patients suffering from insomnia. As these drugs may produce morning sedation, they should be administered early in the evening. It reduces the risk of morning sedation and increases the sleep inducing effect of the drug.
In chronic insomnia sleep quality and any underlying conditions that are causing insomnia should be treated. The improvement of insomnia should be a treatment goal from the beginning, and not only then when treatment of underlying condition is not related to improvement of insomnia. Such approach is justified by observations that fast improvement of sleep quality is related to better treatment outcome of underlying disorder.
Beneficial effect of sleep improvement on treatment of depression, resulted in interest in drugs that allow the treatment of depression through resynchronisation of circadian rhythm. Agomelatine is a new drug that allows such treatment. It offers new mechanism of action on core symptoms of depression and rarely induces side-effects typical of other antidepressants. However, due to increased risk of liver toxicity liver function test is recommended before and after 3, 6, 12, and 24 weeks of treatment with agomelatine.

Review article

The effectiveness of supplementation of polyunsaturated fatty acids in mental disorders and mental diseases: review

Agnieszka Piróg-Balcerzak, Justyna Holka-Pokorska, Filip Rybakowski

PUFA have become the subject of growing number of studies concerning supplementation in the treatment of mental disorders and diseases in recent years. It is suggested that some mental illnesses are associated with cellular abundance of omega-3 PUFA or/and reduced dietary intake. PUFA probably affect dopaminergic and serotonergic neurotransmission so their use in attention deficit, hyperactivity disorder and depression might be effective. Researchers have explored the effect of n-3 PUFA in a range of different mental health problems from developmental disorders in childhood to depression, bipolar disorder, schizophrenia, cognitive decline and Alzheimer’s disease. The aim of this review was to assess the role of n-3 PUFA and to determine whether n-3 PUFA are likely to be efficacious in these disorders. Only randomized, placebo-controlled trials published before August 2012 were analysed. Finding of clinical trials are inconsistent and methodological differences between studies, like sample size, selection criteria, dosage of supplement and length of supplementation, the type of fatty acids causes that the role of PUFA in psychiatry is still open. It is not determined what fatty acids and in what proportions should be applied. Analysed trials suggest that monotherapy with eicosapentaenoic acid (EPA) or in combination with small doses of docosahexaenoic acid (DHA) are most effective.

Review article

Combined residential rehabilitation programs with substitution therapy for opioid dependent patients

Bogusław Habrat, Karina Steinbarth-Chmielewska, Helena Baran-Furga

Substitution therapy is currently a treatment of choice for majority of opioid dependents. In that programs different kind of psychosocial interventions are used, although only minority of them is based on therapeutic community approach. Accessibility to substitution treatment in Poland is inappropriate and psychosocial interventions hold leading position. Majority of residential programs are based on therapeutic community approach. Effectiveness of that programs is low due to low attractiveness of drug-free aim of treatment and due to inability to abstain without pharmacological support. One of the proposals of adaptation to Polish drug treatment structure is a trial of effectiveness improvement of residential drug-free programs by combining therapeutic community with substitution treatment, even during some months residential treatment, only.

Original article

Retrospective analysis of the effectivenes s of electroconvulsive therapy in treatment-resistant depression

Miłosz Krzywotulski, Maria Chłopocka-Woźniak, Maria Abramowicz, Maciej Różański, Janusz Rybakowski

Purpose of the study. The aim of this study was to analyze the effectiveness of electroconvulsive therapy (ECT) for treatment-resistant depression, based on the experience of the Department of Adult Psychiatry, Poznan University of Medical Sciences.
Method. The study included 91 patients with treatment-resistant depression to treated with ECT at the Department of Adult Psychiatry, Poznan University of Medical Sciences in the years 2000–2010. The group consisted of 69 women and 22 men, aged 24–76 years (mean 50 ± 12) who underwent at least 6 ECT sessions. The efficacy of electroconvulsive therapy was evaluated using Clinical Global Impression scale (CGI) – clinical status before treatment – and improvement after treatment.
Results. In the whole group the median value in the CGI score before treatment was 5 points, which corresponds to a significant intensification of clinical symptoms. This value was observed in 57 of 91 patients (63%). The median value in CGI improvement score – that is, the effectiveness of treatment – in all the patients treated for depression ECT was 2 points, which may indicate the high effectiveness of the method. This value was observed in 45 of 91 patients (49%). The effectiveness of ECT of therapy was similar in men and women and the greater, the greater severity of disease. The effectiveness of ECT positively correlated with shorter duration of treated depressive. In depression in bipolar affective disorder the efficacy of ECT was higher than in the depression in the course of unipolar affective disorder. It was observed in the group of all patients and in the female group.
Conclusions. These results confirm data from literature indicating that ECT therapy is effective for treatment-resistant depression.