Olanzapine Effective for Trichotillomania
Traditional treatment for trichotillomania involves medications used to treat obsessive compulsive disorder. A recent double-blind, placebo-controlled trial examined if a dopaminergic agent—in this case olanzapine (Zyprexa)—would produce positive results.
Researchers funded by Eli Lilly (the manufacturer of olanzapine) randomly assigned 25 patients with trichotillomania to two groups: one group (13 participants) was treated with olanzapine, the other group (12 participants) was treated with placebo. A response was defined by a Clinical Global Impressions-Improvement (CGI-I) score of ≤2. At the end of 12 weeks, 85% (11 of 13 subjects) of those treated with olanzapine responded to treatment, compared to 17% (two of 12) in the placebo group. Significant differences between the groups were evident as early as six weeks into the trial.
Doses of olanzapine ranged from 2.5 to 20.0 mg per day, with an average final dose of 10.8 mg per day. Two of the patients in the olanzapine group achieved total remission, which was defined as a complete stop to hair pulling behavior. As might be predicted, the most significant side effect of olanzapine was weight gain, with those in the olanzapine group gaining an average of 10.1 pounds in 12 weeks vs. a loss of 0.66 pounds in the placebo group (Van Ameringen et al., J Clin Psychiatry online ahead of print).
TCPR’s Take: This study shows that olanzapine is likely effective for trichotillomania. We would need larger studies to be more confident in these findings, and patients would need to be informed that they might gain as much as one pound per week with this treatment. Although other, less weight-gain inducing antipsychotics have not been tested for trichotillomania, both habit reversal therapy and treatment with the amino acid N-acetylcysteine have, so we would suggest trying these first (Woods DW et al., Behav Res Ther 2006;44 (5):639–656; Grant JE et al., Arch Gen Psychiatry 2009;66:756–763).
Antidepressants: Little Long-Term Benefit for Bipolar Disorder
Most people with bipolar disorder are maintained on antidepressants, but the evidence base is rather meager. In a recent trial, researchers recruited 70 patients with bipolar disorder, all of whom had responded to a combination of a mood stabilizer and an antidepressant. These patients were recruited from various community or university clinics, and had been treated with a variety of mood stabilizers—mainly lithium (44%), Lamictal (41%), and Depakote (23%)—and antidepressants—primarily Wellbutrin (22%), Paxil (22%), Celexa (19%), and Effexor XR (19%).
In order to be enrolled in the study, patients had to have been euthymic for two months. They were then randomly assigned to two groups: continue the antidepressant [n=32], or discontinue the antidepressant [n=38]. Both groups continued whatever mood stabilizer they were already taking. These patients were then followed for one year to see how they fared.
At one year follow-up, patients who remained on antidepressants went a little bit longer without a depressive relapse (average of 41 weeks) than those who discontinued them (average of 32 weeks). However, there was no significant advantage for antidepressant continuation on the number of manic, depressive, or mixed episodes, or the percentage of weeks during which patients were depressed or manic. Twenty-four percent of patients were “rapid cyclers” (meaning that they had at least four mood episodes a year). These patients actually did worse on continued antidepressants than patients who discontinued antidepressants (1.29 depressive episodes versus 0.42 depressive episodes) (Ghaemi SN et al., J Clin Psychiatry 2010;71:372–380).
TCPR’s Take: There are several limitations to the study. It was not double blinded, so both the patients and the researchers knew which patients were taking which drugs. This might lead to raters being biased, since the study was conducted by a group well known for advocating that antidepressants can be dangerous in bipolar disorder (Ghaemi SN et al., Bipolar Disord 2003;5(6):421–433). In addition, since the patients used a wide variety of different medications, it is impossible to know if these results generalize to all antidepressants or only certain specific ones. Nonetheless, this appears to be the only randomized trial of modern antidepressant discontinuation in bipolar disorder, and it indicates that we should be particularly cautious prescribing these medications to patients with a rapid cycling pattern.