PSYCHOTROPICS AND PREGNANCY
Discontinuing mood stabilizers often leads to relapse during pregnancy
Although we tend to feel comfortable counseling patients to continue antidepressants during pregnancy, because most of them do not appear to cause congenital abnormalities, mood stabilizers are trickier. Lithium increases the risk of a rare cardiac defect, and both Depakote and Tegretol increase the risk of neural tube defects (see TCPR, April 2007). Thus, the majority of women elect to discontinue mood stabilizers when they become pregnant. This study attempted to determine the risk of a psychiatric relapse when a mood stabilizer is discontinued. Researchers enrolled 89 pregnant women with bipolar disorder (type I or II) who were taking mood stabilizers in a naturalistic, observational study in which they were assessed by a research psychiatrist each trimester and four times after birth. Most of these women were well-educated married Caucasians who worked outside the home. 62 of the 89 women (70%) chose to stop their mood stabilizers. These women were more than twice as likely to have a mood episode recurrence during pregnancy than women who continued their meds (85% relapse rate vs. 37%). Abrupt discontinuation was associated with much more rapid relapse (within an average of 2 weeks) than gradual discontinuation (22 weeks). Most of the recurrences were for depression or mixed states; only 6 out of the 89 patients had an episode of frank mania during the study (Viguera AC, et al., Am J Psychiatry 2007;164:1817-1824).
TCPR’s Take: While it is clear that mood stabilizers protect against relapse, this finding in itself doesn’t make the risk/benefit judgment much easier for specific patients. The authors didn’t report how severe these episodes were – clinically, this information is crucial, since patients can meet formal criteria for a mood episode and yet still have only mild to moderate symptoms, which can often be managed with psychotherapy, preventing the risks to the fetus associated with mood stabilizers.
Adjunctive psychotherapy helpful in bipolar depression
The STEP-BD study is an NIMH-funded study of patients with bipolar disorder, which has already yielded a number of intriguing findings, some of which we covered in an earlier issue (TCPR, Aug 2006). This study followed 293 patients with acute depression, most of whom received both mood stabilizers and antidepressants. These patients were randomly assigned to intensive psychotherapy (30 sessions over 9 months) or “collaborative care” (3 visits over 6 weeks). Patients in the intensive psychotherapy group had a 64% recovery rate vs. 51% for the collaborative care group (statistically significant at p=.01). The psychotherapies used in this study included cognitive behavior therapy, family-focused therapy, and interpersonal and social rhythm therapy. There were no significant differences in effectiveness of the therapies (Miklowitz DJ et al., Arch Gen Psychiatry 2007;64:419-427).
TCPR’s Take: Patients with bipolar disorder and depression are difficult to treat, because antidepressants are often not helpful. In fact, one of the major findings of STEP-BD was that adjunctive antidepressants – Paxil or Wellbutrin – did no better than placebo when added to mood stabilizers for acute bipolar depression (Sachs GS et al., NEJM 2007;356:1-12). This study suggests that just about any intensive psychotherapy can boost the effects of mood stabilizers better in bipolar depression than adjunctive antidepressants.
BINGE EATING DISORDER
Meridia helpful for binge eating disorder
Binge eating disorder, so-called “bulimia without purging,” is a major cause of obesity. Most weight loss agents have been shown to be effective in small trials, but this is the first large trial lasting long enough to be generalizable to clinical practice. 304 patients with BED were randomly assigned to 24 weeks of either Meridia (sibutramine) 15 mg QD or placebo. Patients on Meridia had a lower frequency of binges (average number of binges reduced by 2.7 vs. 2.0 on placebo) and lost more weight (weight loss 4.3 kg on Meridia vs. 0.8 kg on placebo)(Wilfley DE et al., J Psychiatry Dec 3, 2007, AJP in Advance:1-8).
TCPR’s Take: Meridia posts a modest advantage over placebo in these patients. However, these subjects are not generalizable to the eating disorder patients you are likely to see in your office: the study excluded patients with depression or bipolar disorder, as well as patients with any psychiatric disorder being treated with psychoactive agents.
Some trouble with Chantix
On November 20, 2007, the FDA issued an “early communication” warning about possible dangerous side effects of Chantix (varenicline), a new smoking cessation agent that affects brain nicotine receptors. Several cases of new-onset depression, suicidal ideation, and aggressive or erratic behavior have been reported via the Medwatch program. In addition, Carter Albrecht, a prominent Dallas musician who was in the band Edie Brickell and the New Bohemians, died a violent death after a series of events that his girlfriend claims were triggered by hallucinatory dreams caused by Chantix. Since alcohol use was involved in Albrecht’s death, it’s not clear whether his symptoms were caused by Chantix or an interaction between Chantix and alcohol, or whether the agent was an innocent pharmacological bystander. In addition, since nicotine withdrawal alone can cause depression or agitation, some of the reported events may be unrelated to the medication, although the FDA reports that behavioral changes occurred before the patients stopped smoking in some cases (accessed online at http://www.fda.gov/ cder/drug/early_comm/varenicline.htm).
TCPR’s Take: At this point, it appears that Chantix is safe for most people, but you should inform patients of the possibility of strange dreams, depression, and agitation after beginning the medication. Consider prescribing an as-needed benzodiazepine or hypnotic. If they notice any unusual behaviors, they should stop taking the drug immediately.