Adolescents With Psychotic Mania May Benefit From Maintenance Treatment With Adjunctive SGAs

Vivian Kafantaris, MD; Ema Saito, MD; Carolyn Dombrowski, APRN; Alison Berest, BS; Nikki Katsiotas, BA; Judith Hirsch, MD; Ellen Leigh, PhD; Kim Gallelli, PhD; Jory Wixsom, MD; Sanjiv Kumra, MD; and John M. Kane, MD
The Feinstein Institute for Medical Research, Glen Oaks, New York (Dr Kafantaris and Ms Berest); The Zucker Hillside Hospital, Glen Oaks, New York (Drs Hirsch, Kane, Saito, and Wixsom); Laurel Hill Inn, Medford, Massachusetts (Dr Leigh and Ms Dombrowski); and the University of Minnesota, Woodbury (Dr Kumra and Ms Katsiotas).

This poster presentation was supported by grants from the National Institute of Mental Health and the National Center for Research Resources, National Institutes of Health.

Background: Previously reported results from our placebo-controlled discontinuation study of adjunctive second generation antipsychotic medications (SGAs) in adolescents with bipolar I disorder included high rates of exacerbation of psychotic features or aggression, regardless of medication group assignment, and significant differences in weight trajectories between groups.¹

Methods: We examined whether the subgroup with psychotic features (n=11) differed from the subgroup with assaultive/destructive behavior (n=10) in time to clinically significant exacerbation using a Kaplan-Meier survival analysis. We also examined whether the differences in weight trajectory between the group that continued versus discontinued adjunctive SGA treatment resulted in significant differences after 36 weeks of double-blind treatment in fasting glucose, insulin, triglycerides and total cholesterol using repeated measures analysis of variance (RMANOVA) with a mixed models approach.

Results: Rates of exacerbation during the 48-week double-blind period were nearly identical in the subgroups with aggression (7/10) and psychosis (8/11). However, remaining on active SGA resulted in a longer duration of stability relative to placebo (median 36 versus 8 weeks) for the subgroup with psychotic features at entry but not for the subgroup with severe aggression but no psychosis (median 8 versus 10 weeks). After 36 weeks of double-blind treatment (n=9) the group on placebo had lost weight, but the group on active treatment had gained slightly (p<0.046). Both groups had significant declines over time in fasting glucose (p<0.042) and triglyceride levels (p<0.027). No changes over time were noted in insulin or total cholesterol levels.

Conclusions: Our finding of high rates of recurrence across groups and weight loss following discontinuation of an SGA has also been reported in adults with bipolar disorder.² Remaining on active SGA appeared to delay reemergence of psychotic features in the subgroup of adolescents with psychosis at baseline but did not delay exacerbation in the subgroup receiving SGA for severe aggression. If replicated in a larger sample, this finding could have a significant impact on clinical practice by guiding the choice of long-term treatments on the basis of relevant clinical characteristics.

References

1. Kafantaris V, Saito E, Dombrowski C, et al. What should be the role of antipsychotic medications in the maintenance treatment of youth with bipolar disorder? New Research Poster presented at: 56th Annual Meeting of the American Academy of Child and Adolescent Psychiatry; October 31, 2008; Honolulu, HI.
2. Tohen M, Chengappa KN, Suppes T, et al. Relapse prevention in bipolar I disorder: 18-month comparison of olanzapine plus mood stabilizer versus mood stabiliser alone. Br J Psychiatry. 2004;184(4):337–45.

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