[Effectiveness of typical and atypical neuroleptics in the control of behavioral and psychopathological symptoms of dementia. Results of a retrospective study]. / Effectividad de los neurolépticos típicos y atípicos en el control de los síntomas conductuales y psicopatológicos de la demencia. Resultados de un estudio retrospectivo.

INTRODUCTION: Presence of disruptive behavioural and psychological symptoms in dementia (BPSD) is highly prevalent and, as a consequence, neuroleptics are frequently used in these patients to control BPSD. Several reviews have shown the clinical equivalence of different classes of neuroleptics in BPSD control, although that equivalence has been only indirectly assessed by comparing the combined results of different types of active drugs versus placebo. Thus, little is known on the comparative effectiveness, head to head, of different neuroleptics on BPSD. The aim of this study was to gather preliminary information on the effectiveness of typical (haloperidol, thioridazine) and atypical (olanzapine, risperidone) neuroleptics on BPSD. METHODS: Multicenter, observational and retrospective study using chart reviews of patients with dementia to assess neuroleptic prescriptions and clinical outcomes at 12 weeks on treatment. RESULTS: No significant differences on BPSD improvement were found by type of neuroleptic (n=78; Kruskal- Wallis exact test; p=0.47). There also were no differences by neuroleptics when the analysis was stratified by levels of cognitive decline (Kruskal-Wallis exact test; p=0.86 and 0.87 for moderate and severe levels of deterioration, respectively). Recorded side effects were worse in the haloperidol group (n=19) regarding rigidity (Fisher's exact; p=0.01), tremor (Fisher's exact p=0.03) and akathisia (Fisher's exact; p=0.03). CONCLUSIONS: Our findings support the equivalence in effectiveness of several classes of neuroleptics commonly used to treat BPSD. Nevertheless these results need to be confirmed by adequately powered randomized trials and further pharmacoepidemiological studies to assess their safety.

Combined valproate or carbamazepine and electroconvulsive therapy.

This pharmacoepidemiological study was undertaken to determine if the combination of electroconvulsive therapy (ECT) and the anticonvulsants valproate (VPA) or carbamazepine (CBZ) is safe and efficacious. The charts of seven patients receiving ECT and VPA or CBZ (ECT-anticonvulsant group) concurrently between May 8, 1989, and May 9, 1993, were reviewed to determine the indication for each treatment, the number and type of ECT treatments, the seizure duration, adverse events, and the efficacy of the combination. The ECT-anticonvulsant group was compared to patients not treated with anticonvulsants (ECT-alone group) to determine if there were any differences in the two groups. Three patients had a marked clinical improvement, two a moderate response, one a minimal response, and one no response. The ECT-AC group, compared to the control group, had a shorter duration of seizures when unilateral treatments were used. However, there were no differences in the other variables compared. One patient had moderate confusion, and the other mild confusion and hypomania. This small case series suggests that the combination of ECT and anticonvulsants is safe and may be considered in patients for whom prophylaxis with anticonvulsant drugs is planned. Further controlled studies are needed to confirm our findings.

Shifts in hospital diagnostic frequencies: bipolar disorder subtypes, 1981-1993.

Annual rates of bipolar and schizoaffective disorder (SA) subtypes from 1981 to 1993 at a private university psychiatric hospital were reviewed. Annual total diagnostic rates for all bipolar disorders (BPD) remained constant between 1981 and 1993, (22%), while the frequency of SA rose 6-fold, from 1.4% to 8.7%. Rates of BPD, not otherwise specified increased 7-fold, while that for the other BPD subtypes fell in the same period of time. Several factors may have influenced these trends including changes in diagnostic criteria used, treatment-oriented diagnostic bias and indirect effects of sharply falling length of stay.

Prescribing trends of antidepressants in bipolar depression.

BACKGROUND: This study utilizing pharmacoepidemiologic methods was undertaken to determine the prescribing patterns of antidepressants particularly in bipolar depression. METHOD: From pharmacy records of the McLean Hospital, the number of patients receiving antidepressants and given electroconvulsive therapy (ECT) from June 1, 1987, to May 8, 1993, was determined. We later linked these data bases with patients who were diagnosed with DSM-III-R bipolar depression (296.5) during the same period of time. RESULTS: During the 6-year period, it was determined that 3829 inpatients had received tricyclic antidepressants (TCAs), 2981 fluoxetine, 2603 trazodone, 809 bupropion, 743 monoamine oxidase inhibitors (MAOIs), 592 stimulants, 588 sertraline, 48 paroxetine, and 894 ECT. There were significant increases over time in prescriptions of MAOIs compared with fluoxetine (chi 2 = 14.36, p = .006), and bupropion compared with TCAs (chi 2 = 6.45, p = .04). There was a trend for bupropion to be prescribed more over time compared with fluoxetine (chi 2 = 5.09, p = .08). There were no significant changes in the prescribing of other antidepressants or in the use of ECT. CONCLUSION: At our center, prescribing of bupropion and MAOIs in bipolar depression has increased significantly. This may be related to the reports in the literature of the low switch rates to mania with the use of these drugs.