Naltrexone as a Possible Treatment for Decreasing Cannabis Use

According to a SAMHSA survey, 19.8 million individuals or 7.5% of the US population were current (past month) users of marijuana in 2013. Among people age 18 to 25, current use reached 19.1%. Given the widespread consumption of marijuana, it becomes imperative to develop new therapeutic approaches to decrease its use. In a double-blind, placebo-controlled laboratory study, Dr. Haney and colleagues assessed the effects of 50 mg of naltrexone on the reinforcing, subjective, psychomotor, and cardiovascular effects of active and inactive cannabis. Daily cannabis users were treated with either naltrexone 50 mg daily (n=23) or placebo (n=28) for 16 days and were assessed for 4 to 6 weeks. Compared to the placebo group, the naltrexone group significantly used less cannabis and had less positive subjective effects from cannabis. Although naltrexone was associated with decreasing ratings of friendliness, food intake, and systolic blood pressure, and increasing spontaneous reports of stomach upset and headache, dropout rates were similar between groups. Based on their findings, the authors conclude that “naltrexone may reduce ongoing heavy cannabis use, relapse severity, or the likelihood that patients would return to pretreatment levels of heavy cannabis use in the event of a lapse.”

Is Mirtazapine Superior to Other Antidepressants?

Previous studies suggest that mirtazapine has a better efficacy and faster onset of action than other antidepressants (for a review, see Watanabe et al, 2011). Mirtazapine also differs from SSRIs (e.g., fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine) by its side effect profile. It has a higher risk of dry mouth, weight gain or increased appetite, fatigue and somnolence but less risk of sweating, diarrhea, nausea or vomiting, sexual dysfunction, headache, tremor and sleep disturbance. Ueno and colleagues also report that a dose increase of mirtazapine after one week of treatment is an effective strategy in early non-improvers with depression. Thus, these studies suggest that mirtazapine should be considered as a first-line treatment for depressive disorders. However, patients may be concerned by the risk of weight gain and somnolence, and therefore may prefer to be treated with another antidepressant.

Augmentation Therapy for Treatment-Resistant Depression

Dr. Zhou and colleagues conducted a meta-analyses on 48 randomized controlled trials (total of 6654 participants) of augmentation agents in adults with treatment-resistant depression. According to the network meta-analysis, the best agents for augmentation therapy were quetiapine, aripiprazole, thyroid hormone, and lithium. Although thyroid hormone and lithium are better tolerated, they seem to be less efficacious than quetiapine and aripiprazole. The authors acknowledge that further studies comparing these augmentation agents head-to-head and addressing the limitations of previous studies (e.g., longer duration, dosing, sample size, study design, financial bias) will be required to confirm these results. In a commentary, Dr. Richard Shelton discusses about the limitations of meta-analyses and suggests interpreting these results with caution.

Antidepressant Treatment in Individuals with Burnout

Burnout is a state of emotional exhaustion related to chronic stress from work or personal issues. Madsen and colleagues found that burnout is associated with an increased risk of antidepressant treatment in 2936 Danish human service workers. As noted by the authors, these results suggest that individuals with high levels of burnout are at substantial risk of developing a clinically significant mental health condition that may require antidepressant treatment.

Is adding an atypical antipsychotic effective in OCD patients not responding to SSRI antidepressants?

In the November 2014 issue of BMC Psychiatry, David Veale and colleagues from King’s College in London conducted a meta-analysis of the clinical effectiveness of adding atypical anti-psychotics (aripiprazole, olanzapine, quetiapine, or risperidone) to Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants (e.g., fluoxetine, fluvoxamine, citalopram) in treatment-resistant patients with Obsessive Compulsive Disorder (OCD) . They found limited evidence for using a low dose of risperidone or aripiprazole and no evidence for using olanzapine or quetiapine. They suggest considering other augmentation strategies such as combining the SSRI antidepressant with cognitive-behavioral therapy or clomipramine.

Low Dose of Quetiapine is Effective in Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) suffer from mood instability, impulsive behavior, and disturbed relationships. Although studies suggest a beneficial effect of psychotherapy in BPD, results of medication studies have been mixed. In the October issue of the American Journal of Psychiatry, Dr. Donald Black and colleagues conducted a 8-week double-blind study comparing quetiapine, a second-generation antipsychotic, with placebo in 95 individuals diagnosed with BPD. They found that a low dose of quetiapine (150 mg daily) reduced the symptom severity of BPD. In their conclusion, the authors urged for longer and additional studies to confirm the effectiveness of quetiapine in this disorder.

Cognitive-Behavioral Therapy and Risperidone in Obsessive-Compulsive Disorder

In a video, Dr. Helen Blair Simpson discusses her study published in JAMA Psychiatry comparing Exposure and Ritual Prevention Cognitive-Behavioral Therapy (CBT), risperidone, and placebo in OCD patients treated with selective serotonin reuptake inhibitor antidepressants (SSRI’s).  CBT had better outcomes than risperidone and placebo. Dr. Simpson suggests discontinuing antipsychotic medications in SSRI-treated OCD patients who do not improve after four weeks.