College students love to abuse Adderall
Adderall has overtaken Ritalin as the most-abused stimulant among college students. In a survey, 4,580 college students were asked about their illicit use of drugs. Of those reporting stimulant abuse within the prior year (269 students), three times as many abused Adderall as Ritalin (Teter, et al., Pharmacotherapy 2006;26(10):1501-1510).
TCPR’s Take: Shire, manufacturer of Adderall, has saturated journals and consumer magazines with Adderall ads, and the strategy is working only too well. The company is currently circulating a meta-analysis purporting to show that taking stimulants actually prevents future drug abuse (Wilens, et al., Pediatrics 2003;111(1):179-185). We’re skeptical of the findings, since the article reviews only retrospective studies comparing outcomes of kids who either were or were not prescribed stimulants. Children not prescribed stimulants had higher rates of later substance abuse. But these at-risk children may have been subject to a number of confounding factors leading to substance abuse – such as family histories of substance abuse, or disengaged parents who did not seek psychiatric care. The data did not control for any of these crucial social factors. The fact is that stimulants are often diverted, and this should lead us all to be more cautious in our prescribing habits.
Bad News for Transcranial Magnetic Stimulation
An FDA advisory panel has recommended that TMS not be approved for the treatment of major depression. Neuronetics, the maker of the NeuroStar device (www.neuronetics.com), submitted data from three studies, but only one was a placebo-controlled double-blind trial (Study 101). This study just missed showing statistical significance of the main outcome measure (change in MADRS score after six weeks), although it showed a small TMS benefit on most of the 16 secondary measures. For example, the four-week response rate was 18% in the treatment group vs. 11% in the placebo group. Nonetheless, most panel members thought the improvements were too small to be of great clinical benefit.
TCPR’s Take: Many psychiatrists are disappointed, even irate, about the panel’s finding, but let’s face it, 18% vs. 11% is a very slim efficacy difference upon which to launch what would certainly become an intensively marketed and very expensive antidepressant procedure.
Seroquel vs. Depakote for Impulsivity and Aggression in Teens
We often see teenagers with co-occurring bipolar disorder and aggressive/impulsive behaviors. While Depakote is often effective, we also often prescribe atypical antipsychotics. A new post-hoc analysis provides some evidence to bolster that practice. Thirty-three adolescents with co-occurring bipolar and disruptive behavioral disorders were randomized to receive either Seroquel (quetiapine) 400 mg to 600 mg daily or Depakote (divalproex) dosed to a serum level of 80 mcg/ml to 120 mcg/ml for 28 days. Both drugs reduced scores on the PANSS excited component scale by roughly half at week 4. Depakote was slightly more effective than Seroquel for improving impulsivity and reactive aggression, though the difference wasn’t statistically significant (Barzman, et al., J Child Adol Psychopharmacol 2006;16:665 – 670).
TCPR’s Take: It’s always nice to find evidence for something we’ve already been doing. But a placebo-controlled clinical trial would have been more reassuring than this retrospective study funded by AstraZeneca (maker of Seroquel).
Omega-3 Fatty Acids for Suicidal Behavior
Omega-3 fatty acids have been studied in a number of psychiatric disorders, including autism, bipolar disorder, depression, and schizophrenia. A new study shows a possible benefit for patients with a history of self-harm. Researchers in Ireland looked at 49 patients who required medical treatment in an emergency department following an incident of self-harm. All patients received standard psychiatric care; half were randomly assigned to receive omega-3 supplementation and the other half to placebo. At the end of 12 weeks, patients who had taken omega-3s showed significantly greater improvements in scores for depression, suicidality, and daily stresses than those who took placebo (Hallahan, et al., Br J Psychiatry 2007;190:118-122).
TCPR’s Take: Sure, it’s only one study, and a small one at that, but patients who present after an episode of self-harm are often complex and difficult to treat. Adding omega-3s might help, and couldn’t hurt.
ANTIPSYCHOTIC SIDE EFFECTS
Metformin for Antipsychotic-Induced Weight Gain in Adolescents
Atypical antipsychotics can cause significant weight gain in adolescents. In this study, 39 kids between 10 and 18 years of age were randomized to receive either the antidiabetic drug Glucophage (metformin) or a matched placebo; each was added to their primary antipsychotic medication (Risperdal, Seroquel, or Zyprexa) for 16 weeks. All patients and their participating families received the same three sessions of generic dietary counseling. At week 16 those assigned to placebo had gained an average of 8.8 pounds; those who took metformin along with their antipsychotic lost 0.26 pounds. In addition, measures of insulin resistance – a potential precursor to diabetes – increased significantly in those on placebo and remained stable in those taking metformin.
TCPR’s Take: We’re encouraged that metformin might help adolescents stay on effective antipsychotics. Unfortunately, another recent study showed metformin was ineffective in preventing weight gain in adults on Zyprexa (Baptista et al, Can J Psychiatry 2006;51:192-196). Also, metformin is not a benign drug and carries a black box warning of potentially fatal lactic acidosis. So it’s still preferable to choose antipsychotics with less weight-gain liability, like Geodon or Abilify.