Journal of Affective Disorders 49 (1998) 119–122
`
`Research report
`Olanzapine in treatment-resistant bipolar disorder
`
`*
`a ,
`b
`b
`c
`d
`, Mark Frye , Kirk Denicoff , Lori Altshuler , Willem Nolen ,
`Susan L. McElroy
`e
`a
`b
`d
`a
`Ralph Kupka , Trisha Suppes , Paul E. Keck, Jr. , Gabrielle S. Leverich , Geri F. Kmetz ,
`b
`Robert M. Post
`aStanley Foundation Bipolar Treatment Outcome Network,including the Biological Psychiatry Program,Department of Psychiatry,
`University of Cincinnati College of Medicine,231 Bethesda Avenue,Cincinnati,OH 45267,USA
`bBiological Psychiatry Branch,NIMH,Bldg.10,RM 3N212,9000 Rockville Pike,Bethesda,MA 20892,USA
`cVA Medical Center,West 11301 Sawtelle Blvd,Los Angeles,CA 90073,USA
`dHC Rumke Group,Willem Arntz Huis,P.O.Box 613500AB,Utrecht,Netherlands
`eSW Medical Center at Dallas,St.Paul Prof.Bldg.[1,5959 Harry Hines Blvd,Suite 600,Dallas,TX,USA
`
`Received 4 November 1997; accepted 9 December 1997
`
`Abstract
`
`Background: We evaluated the response to olanzapine in 14 consecutive patients with bipolar I disorder who were
`inadequately responsive to standard psychotropic agents. Methods: Fourteen patients with bipolar I disorder by DSM-IV
`criteria experiencing persistent affective symptoms inadequately responsive to at least one standard mood stabilizer were
`treated with open-label olanzapine by one of the authors. Response was assessed with the Clinical Global Impression Scale
`modified for use in bipolar disorder (CGI-BP). Results: The 14 patients received olanzapine at a mean (SD dosage of
`14.167.2 (range 5–30) mg/day for a mean6SD of 101.4 1 56.3 (range 30–217) days of treatment. Of the 14 patients, 8
`(57%) displayed much or very much overall improvement in their illness. In general, olanzapine was well tolerated. The
`most common side effects were sedation, tremor, dry mouth, and appetite stimulation with weight gain. Limitations: Data
`were obtained nonblindly and without a randomized control group, and olanzapine was added to ongoing psychotropic
`regimens. Conclusion: Olanzapine may have antimanic and mood-stabilizing effects in some patients with bipolar disorder,
`and is generally well tolerated. Controlled studies of olanzapine in bipolar disorder appear warranted. © 1998 Elsevier
`Science B.V.
`
`Keywords: Olanzapine; Bipolar disorder
`
`*
`Corresponding author. Tel.: 1 1 513 5581132; fax: 1 1 513
`5582882.
`
`1. Introduction
`
`Substantial clinical data suggest that the atypical
`antipsychotic clozapine may be effective in the acute
`and prophylactic treatment of some patients with
`bipolar disorder,
`including some patients inade-
`
`0165-0327/98/$19.00 © 1998 Elsevier Science B.V. All rights reserved.
`PII S0165-0327( 98 )00002-0
`
`1 of 4
`
`Alkermes, Ex. 1013
`
`

`

`120
`
`S.L.McElroy et al. / Journal of Affective Disorders 49(1998)119–122
`
`quately responsive to treatment with mood stabi-
`lizers, electroconvulsive therapy, and conventional
`antipsychotics (Calabrese et al., 1996; Frye et al., in
`press; Suppes et al., 1996; Zarate et al., 1995). The
`new atypical antipsychotic olanzapine has a pharma-
`cologic and electrophysiologic profile similar to that
`of clozapine (Frye et al., in press; Keck and McEl-
`roy, 1996). Moreover, clinical studies suggest that
`olanzapine may have mood-stabilizing properties in
`patients with schizoaffective disorder, bipolar type
`(Tohen et al., 1997). However, experience with
`olanzapine in patients with bipolar disorder is lim-
`ited, and the possible utility of an atypical antipsy-
`chotic agent in this illness would be of considerable
`importance in light of
`the high risk of
`tardive
`dyskinesia in bipolar patients.
`To investigate the efficacy, tolerability, and safety
`of olanzapine in bipolar disorder, we reviewed the
`response of patients with bipolar disorder who
`received treatment with olanzapine at our centers for
`persistent affective symptoms inadequately respon-
`sive to standard psychotropic agents.
`
`2. Methods
`
`I disorder by DSM-IV
`Patients with bipolar
`(American Psychiatric Association, 1994) criteria
`who were participating in the Stanley Foundation
`Bipolar Network naturalistic follow-up study (Post,
`1997) and who received treatment with olanzapine
`for at
`least 1 week were included in the study.
`Patients were excluded if olanzapine was begun
`when they were euthymic or within 2 weeks before
`or after any other major changes in their medication
`regimens. All patients provided verbal
`informed
`consent
`to receive a clinical
`trial of olanzapine.
`Response to olanzapine was rated with the Clinical
`Global Impression Scale (Guy, 1976) modified for
`bipolar disorder (CGI-BP) (Spearing et al., in press)
`at two points in time: response of affective state at
`time of olanzapine initiation was assessed after 1
`month of treatment with olanzapine; and overall
`response of illness was assessed at the patient’s last
`evaluation while receiving olanzapine. All
`raters
`were standardized in their use of the CGI-BP (Spear-
`ing et al., in press). Side effects to olanzapine were
`assessed by clinical evaluation.
`
`3. Results
`
`Fourteen consecutive patients with bipolar I disor-
`der treated with olanzapine and meeting the inclusion
`criteria were identified. Eight (57%) patients were
`evaluated prospectively and six (43%) were evalu-
`ated retrospectively. All 14 patients displayed persis-
`tent affective symptoms that had not responded to
`standard psychotropic agents and which impaired
`their functioning at the time of olanzapine adminis-
`tration. Specifically, 12 (86%) patients were manic,
`hypomanic, or mixed, and 2 (14%) were depressed.
`Eight (57%) patients also displayed psychotic fea-
`tures, and 12 (86%) met the DSM-IV criteria for
`rapid cycling. One patient had received prior treat-
`ment with one mood stabilizer, two patients with two
`mood stabilizers, and 11 patients with three mood
`stabilizers. Thirteen patients had received prior treat-
`ment with an antipsychotic other than olanzapine. Of
`note, olanzapine was added to pre-existing psycho-
`tropic regimens in all but one patient. These medica-
`tions were lithium (N 5 4); valplroate (N 5 12);
`carbamazepine (N 5 2); gabapentin (N 5 3); antide-
`pressants (including one patient on tranylcypramine)
`(N 5 3); trifluoperazine (N 5 1); clozapine (N 5 1),
`thyroid medication (N 5 8); and benzodiazepines
`(N 5 3).
`Olanzapine was begun in all patients at 5–10
`mg/day, usually given all at one dose at night.
`Olanzapine doses were subsequently increased by
`5–10 mg/day every 7–14 days according to patient
`response and side effects to a maximum dose of 30
`mg/day.
`the 14 patients had
`last evaluation,
`At
`their
`received a mean6S.D. (range) dose of olanzapine of
`14.167.2 (5–30) mg/day for a mean6S.D. (range)
`duration of 101.4656.3 (30–217) days. As shown in
`Table 1, of these 14 patients, 9 (64%) were rated as
`much (N 5 6) or very much (N 5 3) improved after 1
`month of treatment with a mean6S.D. (range) olan-
`zapine dose of 13.666.0 (5–20) mg/day. At their
`last evaluation, 8 (57%) of the 14 patients were rated
`as much (N 5 6) or very much (N 5 2) improved,
`after a mean6S.D. (range) of 117.4646.8 (57–217)
`days of treatment with a mean6S.D. (range) olan-
`zapine dose of 15.266.7 (7.5–30) mg/day.
`Of
`the 12 patients who received olanzapine
`initiated for manic, hypomanic, or mixed symptoms,
`
`2 of 4
`
`Alkermes, Ex. 1013
`
`

`

`S.L.McElroy et al. / Journal of Affective Disorders 49(1998)119–122
`
`121
`
`a
`
`Table 1
`Response to olanzapine in 14 patients with treatment-refractory bipolar disorder
`Response, N (%)
`Much or very much improved
`One month
`Last eval
`
`Patients
`N
`
`Minimal or no change
`One month
`Last eval
`
`Much or very much worsened
`One month
`Last eval
`
`Affective
`b
`state
`Manic, hypomanic,
`7 (58)
`8 (67)
`12
`or mixed
`1 (50)
`1 (50)
`2
`Depressed
`f
`8 (57)
`9 (64)
`14
`Total
`aEight patients had psychotic features and 12 patients were rapid cyclers.
`bAt time of initial olanzapine administration.
`cBoth patients worsened by becoming persistently depressed.
`dThis patient, who initially displayed a very much improved response at 1 month, committed suicide 38 days later; however, he had not
`made follow-up appointments and it was unknown whether or not he had been taking olanzapine at the time of his suicide.
`eThe mean6SD (range) olanzapine dose and duration of treatment in these eight patients were 15.966.8 (7.5–30) mg/day and 136.0618
`(57–217) days, respectively.
`fThe mean6SD (range) olanzapine dose and duration of treatment in the five patients rated with minimal or no change (N 5 3) or much or
`very much worsened (N 5 2) were 11.766.2 (5–25) mg/day and 72.4665.5 (30–188) days, respectively.
`
`4 (33)
`1 (50)
`5 (36)
`
`3 (25)
`0
`f
`3 (21)
`
`0
`0
`0
`
`c
`
`2 (17)
`d
`1 (50)
`3 (21)
`
`f
`
`8 (67%) displayed much or very much improvement
`in these symptoms after 1 month of treatment with a
`mean6S.D. (range) olanzapine dose of 11.966.5
`(5–20) mg/day, whereas 4 (33%) showed a minimal
`or no change with a mean6S.D. (range) dose of
`11.366.3 (5–20) mg/day. At their last evaluation, 7
`(57%) of these 12 patients showed much or very
`much improvement in their overall illness after a
`mean6S.D. (range) of 110.3628.2 (57–150) days of
`treatment with a mean6S.D. (range) olanzapine dose
`of 16.167.3 (7.5–30) mg/day; 3 (25%) showed
`minimal or no change after a mean6S.D. (range) of
`96.7679.8 (40–188) days of
`treatment with a
`mean6S.D. (range) dose of 13.3610.4 (range 5–25)
`mg/day; and 2 (17%) were much or very much
`worsened (both due to development of depressive
`symptoms) after a mean6S.D. of 36.068.4 (range
`30–42) days of treatment with a mean6S.D. (range)
`dose of 10.067.1 (range 5–15) mg/day. Of note, the
`presence of psychotic symptoms was not associated
`with response to olanzapine in these 12 patients: 3
`(50%) and 3 (50%) of the 6 patients with psychotic
`features were rated as much or very much improved
`after 1 month and at their last evaluation, respective-
`ly, compared with 5 (83%) and 4 (67%) of the 6
`patients without psychotic features, respectively.
`Of the two patients who received olanzapine while
`acutely depressed (both of whom had psychotic
`features), one displayed very much improvement in
`
`depressive and psychotic symptoms after 1 month of
`treatment on 10 mg/day. However, this patient did
`not make follow up appointments, and committed
`suicide 38 days later. It is unknown whether or not
`he was taking olanzapine at the time of his suicide.
`By contrast, the other patient went on to display very
`much improvement in her depressive and psychotic
`symptoms and in her overall illness on 15 mg/day of
`olanzapine, which she had maintained after a total of
`217 days of treatment and which permitted dis-
`continuation of valproate. Of note, concomitant
`mood stabilizers or antipsychotics were reduced in
`dose or discontinued in two other responders.
`Olanzapine was generally well
`tolerated. One
`patient, however, discontinued the drug due to bad
`dreams. Reported side effects in descending order of
`frequency were: sedation (N 5 5),
`tremor (N 5 2),
`dry mouth (N 5 2),
`increased hunger/weight gain
`(N 5 2), restlessness (N 5 1), swollen hands (N 5 1),
`nausea (N 5 1), headache (N 5 1), and bad dreams
`(N 5 1). Of note, no patients developed extrapyram-
`idal symptoms or
`required concomitant anti-par-
`kinsonian agents.
`
`4. Discussion
`
`Of 14 patients with treatment-resistant bipolar I
`disorder who received open-label
`treatment with
`
`3 of 4
`
`Alkermes, Ex. 1013
`
`

`

`122
`
`S.L.McElroy et al. / Journal of Affective Disorders 49(1998)119–122
`
`olanzapine for a mean of 101.4 days, 8 (57%) were
`rated as displaying much or very much improvement
`in their overall illness. Twelve of these patients met
`the DSM-IV criteria for rapid cycling. Also, although
`numbers are too small for valid comparisons, pa-
`tients with manic symptoms without psychotic fea-
`tures responded as frequently to olanzapine as those
`with psychotic features. These findings suggest that
`olanzapine, like clozapine, may have antimanic and
`mood-stabilizing properties in some patients with
`bipolar disorder.
`These preliminary observations are limited by
`several methodologic shortcomings. Most important-
`ly, data were obtained nonblindly and without a
`randomized control group. Thus, the possibility that
`the observed favorable response to olanzapine was in
`fact due to placebo response, rater or patient bias, or
`spontaneous remission cannot be excluded. Second,
`in all but one patient, olanzapine was added to
`ongoing psychotropic regimens. It is therefore uncer-
`tain whether the observed mood-stabilizing response
`after olanzapine addition was due to olanzapine
`alone, a late response to concurrently administered
`mood stabilizers, or a synergistic response to olan-
`zapine and concurrently administered psychotropics.
`Third, although clinical evaluations did not reveal
`any extrapyramidal side effects, formal rating scales
`for these signs and symptoms were not routinely
`used. Thus, it is possible that extrapyramidal side
`effects occurred that were undetected or misdiag-
`nosed. These findings must therefore be regarded as
`highly provisional, pending outcome of controlled
`trials.
`However, even when these limitations are consid-
`ered, the response observed in 8 (57%) of 14 patients
`with treatment-refractory bipolar disorder, 12 of
`whom met the DSM-IV criteria for rapid cycling and
`all of whom were followed up for an average of 3
`months, is promising. Further studies of olanzapine
`in bipolar disorder therefore appear warranted. These
`should include double-blind, placebo controlled
`studies of olanzapine monotherapy and add on
`therapy in the acute and prophylactic treatment of
`mania and depression, as well as controlled trials
`comparing the efficacy and side effect profile of
`olanzapine with standard mood stabilizers and typi-
`
`cal antipsychotics. If proven to have antimanic or
`mood-stabilizing properties in controlled trials, olan-
`zapine’s benign pharmacokinetic and side-effect
`profile relative to typical antipsychotics and lack of
`need for regular blood monitoring relative to the
`atypical antipsychotic clozapine would make it an
`extremely useful addition to the therapeutic ar-
`mamentarium for bipolar disorder.
`
`Acknowledgements
`
`Supported by a grant from the Theodore and Vada
`Stanley Foundation Bipolar Network, a program of
`the NAMI Research Institute.
`
`References
`
`American Psychiatric Association, 1994. Diagnostic and Statistical
`Manual of Mental Disorders, 4th ed. American Psychiatric
`Association, Washington DC.
`Calabrese, J.R., Kimmel, S.E., Woyshville, M.J. et al., 1996.
`Clozapine for treatment-refractory mania. Am. J. Psychiatry
`153, 759–764.
`Frye, M.A, Ketter, T.A., Altshuler, L.L. et al. Clozapine in bipolar
`disorder:
`treatment
`Implications
`for other
`atypical
`an-
`tipsychotics. J. Affect. Disord., in press.
`Guy, W. (Ed.), 1976. Clinical Global Impressions. In: ECDEU
`Assessment Manual Psychopharmacology, revised. National
`Institute of Mental Health, Rockville MD.
`Keck, Jr. P.E., McElroy, S.L., 1996. Olanzapine: a novel antipsy-
`chotic medication. Today’s Ther. Trends 14, 63–78.
`Post, R.M., 1997.
`Initial
`treatment studies from the Stanley
`Foundation Bipolar Treatment Outcome Network. Presented at
`the Second International Conference on Bipolar Disorder,
`Pittsburgh, PA, June 19–21.
`Spearing, M.K., Post, R.M., Leverich, G.S. et al. Modification of
`the Clinical Global Impressions (CGI) Scale for use in bipolar
`illness (BP): The CGI-BP. Psychiatry Res., in press.
`Suppes, T., Rush, A.J., Webb, A. et al., 1996. A one year
`randomized trial of clozapine vs. usual care in bipolar I
`patients. Biol. Psychiatry 39, 531.
`Tohen, M., Sanger, T., Tollefson, G.D., McElroy, S.L., 1997.
`Olanzapine versus haloperidol in the treatment of schizoaffec-
`tive bipolar patients. American Psychiatric Association Annual
`Meeting, May 17–22, New Research, NR206. American
`Psychiatric Association, San Diego CA, pp. 123–124.
`Zarate, Jr. C.A., Tohen, M., Baldessarini, R.J., 1995. Clozapine in
`severe mood disorders. J. Clin. Psychiatry 56, 411–417.
`
`4 of 4
`
`Alkermes, Ex. 1013
`
`