A Double-Blind, Randomized, Placebo-Controlled Study of
`Quetiapine as Adjunctive Treatment for Adolescent Mania
`
`MELISSA P. DELBELLO, M.D., MICHAEL L. SCH WIERS, M.S., H. LEE ROSENBERG, B.S.,
`AND STEPHEN M. STRAKOWSKI, M.D.
`
`ABSTRACT
`
`Objectives: This randomized, double-blind, placebo-controlled study examined the efficacy andtolerability of quetiap-
`ine in combination with divalproex (DVP) for acute mania in adolescents with bipolar disorder. It was hypothesized that
`DVPin combination with quetiapine would be more effective than DVP alonefor treating mania associated with adoles-
`cent bipolar disorder. Furthermore, it was hypothesized that quetiapine would be well tolerated. Method: Thirty manicor
`mixedbipolar | adolescents (12-18 years) received aninitial DVP dose of 20 mg/kg and were randomly assigned to 6 weeks
`of combination therapy with quetiapine, which wastitrated to 450 mg/day (n = 15) or placebo (n= 15). Primary efficacy
`measures were changefrom baseline to endpoint in Young Mania Rating Scale (YMRS) score and YMRSresponserate.
`Safety and tolerability were assessed weekly. Results: The DVP + quetiapine group demonstratedastatistically signif-
`icantly greater reduction in YMRS scores from baseline to endpoint than the DVP + placebo group (F;.27= 5.04, p= .03),
`Moreover, YMRSresponserate wassignificantly greater in the DVP + quetiapine group than in the DVP + placebo group
`(87% versus 53%; Fisher exact test, p = .05). No significant group differences from baseline to endpointin safety mea-
`sures were noted. Sedation, rated as mild or moderate, wassignificantly more commonin the DVP + quetiapine group
`than in the DVP + placebo group. Conclusions:Thefindings of this study indicate that quetiapine in combination with
`DVP is more effective for the treatmentof adolescent bipolar mania than DVPalone.In addition, the results suggestthat
`quetiapine Is well tolerated when used in combination with OVPfor the treatment of mania. U. Am. Acad, Child Adolesc.
`
`Psychiatry, 2002, 41(10):1216-1223. Key Words: mania, bipolar disorder, quetiapine, adolescent.
`
`Alchough the onset of bipolar disorder typically occurs
`during adolescence (Lish et al., 1994), only oneparallel-
`group, placebo-controlled study of adolescents orchil-
`dren with bipolar disorder has been published. Specifically,
`Geller and colleagues (1998) evaluated the efficacy of
`lichium in a G-week, placebo-controlled study of 25 ado-
`
`Accepted May10, 2002.
`Fromthe Bipalar and Psychotic Disorders Research Program. Department af
`Psychiatry, University ofCincinnati College ofMedicine. Cincinnati. Presented
`in part at the 4th International Conference on Bipolar Disorder, Pittsburgh, June
`14, 2001.
`This study was supported by a grant from AstraZeneca Pharmaceuticals. The
`authorsgratefully acknowledge the assistanceofthefollawing researchstaff Angela
`Hudephol. Shawna Wilthoit, Michelle Sellers, Vidya Sheshadri, M.D., and Kathi
`Montefiore, R.Ph. In addition, they appreciate the support and efforts of the
`Cincinnati Childrens Hospital Medical Center Adolescent Medical Psychiatric
`Unit attending, nursing, social work, and administrative staff.
`Carrespondence ta Dr. DelBello, Department of Psychiatry, University of
`Cincinnatr Callege af Medicine, 231 Bethesda Avenue, PO. Box 670559,
`Cincinnati, OH 45267-0559; e-mail: delbelmp@email. ne.edu.
`0890-8567/02/4 110-1216©2002 by the American Academy of Child and
`Adolescent Psychiatry.
`DOI: 10.1097/01.CHI.0000024837.94814.41
`
`lescents with bipolar disorder and concurrent substance
`use disorders. They found that lichium was more effec-
`tive than placebo for reducing global psychopathology
`scores, but, nonetheless, nearly half of the patients did
`not respond tolithium (Geller ec al., 1998). This rate of
`lithium response is similar to that observed in adults
`(McElroy and Keck, 2000).
`In contrast to adults with bipolar disorder, children
`and adolescents with this illness are more likely to pre-
`sent withrapid cycling or in a mixed state (Geller et al.,
`2000), suggesting that anticonvulsants may be moreeffec-
`tive than lithium therapy (Swann et al., 1997). However,
`open-label treatmentstudies have found that many chil-
`dren andadolescents with bipolar disorder do not respond
`to divalproex (DVP) (Kowatch et al., 2000; Westetal.,
`1995). For example, Kowatch and colleagues (2000)
`assessed the comparative effectiveness of lichium, dival-
`proex sodium, and carbamazepine for the treatment of
`mania and hypomaniain children and adolescents with
`bipolar disorder, types I and II. In this 6-week, open-
`
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`label, randomized study, they found that although DVP
`demonstrated the largest responserate of che three treat-
`ments, 47%of the patientsfailed to respond to this ther-
`apy (Kowatchet al., 2000).
`Together, these data suggest that alternative pharmaco-
`logical options for the treatment of pediatric mania are
`needed, Controlled investigations ofatypical antipsychotics
`suggest that they are efficaciousforthe treatmentof mania
`in adults (Segal etal., 1998; Tohenet al., 1999, 2000), and
`several case series suggest that these agentsare also effec-
`tive for the treatment of mania in children and adolescents
`(Chang and Ketter, 2000; Frazier et al., 1999; Soutullo
`etal., 1999). Thus the addition ofan atypical antipsychotic
`to a moodstabilizer may decrease manic symptoms and
`improve response rates. Indeed, Tohen and colleagues
`(2002) recently compared the efficacy of combined ther-
`apy with olanzapine and either DVP orlithium to DVP
`or lithium monotherapyfor the treatment of acute mania
`in adults and found thatthe responserate was significantly
`higher in the combination group (68 versus 45%).
`.Quetiapine fumarateis an-atypical antipsychotic agent
`with a unique receptor binding profile. Quetiapine has a
`high affinity for hiscaminergic H 1 and 0t-adrenergic neu-
`roreceptors. In addition, quetiapine exhibits affinity for
`brain serotonin 5-HT) and 5-HT), and dopamine D, and
`Dyreceptors and has higherselectivity for 5-HT;relative
`to D2 receptors (Dev and Raniwalla, 2000; Joneseral.,
`2001), Several case reports suggest chat quetiapineis effec-
`tive and well tolerated for the treatment of maniain adults
`(Dunayevich and Strakowski, 2000; Ghaemi and Karzow,
`1999; Zarate et al., 2000), affective psychosis in adolescents
`(McConvilleet al., 2000; Padla, 2001), andrefractory bipo-
`lar disorderin children (Catapano-Friedman, 2001; Schaller
`and Behar, 1999). Furthermore,studies of patients with
`schizophrenia indicate that quetiapine does notdiffer from
`placeboin rates of extrapyramidal symptoms(EPS) orpro-
`lactin elevation (Kasper and Muller-Spahn, 2000).
`With these considerations in mind, the aim of this
`double-blind, placebo-controlled augmentation study was
`to investigate the efficacy and tolerability of quetiapine as
`an adjunct to DVP for the treacment of acute maniain
`hospitalized bipolar adolescents. To our knowledge,thisis
`the first parallel-group, placebo-controlled study to com-
`pare moodstabilizer monotherapy with the combination
`of moodstabilizer plus an antipsychotic in adolescents with
`acute mania. Furthermore,this is the first controlled inves-
`tigation ofan atypical antipsychotic for the treatment of
`pediatric bipolar disorder and the first controlled study of
`
`QUETIAPINE IN ADOLESCENT MANIA
`
`quetiapinefor the treatmentofbipolar disorder, We hypoth-
`esized that the combination of quetiapine and DVP would
`be more efficacious for the treatment of adolescent mania
`than DVP alone, and that quetiapine would be well rol-
`erated as an adjunctive agenc in this population.
`
`METHOD
`
`Bipolar adolescents who were hospitalized for a manic or mixed
`episode were recruited from consecutive inpatient admissions to the
`Adolescent Psychiatric Unit at Cincinnati Children’s Hospital Medical
`Center from May 2000 through May 2001. Patients were included in
`the studyif they were 12-18 years old, met DSM-IVcriteria for bipo-
`lar I disorder currently mixed or manic, and had a Young Mania Rating
`Scale (YMRS)(Fristad etal., 1992; Young et al., 1978) score of 220.
`Patients were excludedif (1) they were pregnant; (2) their manic symp-
`coms were secondaryto substance intoxication ar withdrawal; (3) they
`had a substance use disorder within the prior 3 months; (4) they had
`a diagnosis of mental retardation (IQ < 70); (5) they had an unstable
`medical or neurological disorder, cataracts,or clinically significant base-
`line laboratory abnormalities; or (6) they had a history of hypersensi-
`tivity, intolerance, or nonresponse to quetiapine or valproate. Nonresponse
`to valproate was defined as a 1-week trial with ar least one therapeu-
`tic blood level of 280 mg/L during the index mood episode without
`improvement in manic symptoms as determined by the subjects’ and
`primary caregivers’ reports. Patients were also excluded if they had
`been treated with a depot neuroleptic within 3 months, an antide-
`pressant or antipsychotic within a week (Auoxetine within a month),
`or a benzodiazepine or psychostimulant within 72 hours. Patients pre-
`viously treated with lithium, valproate, or carbamazepine were required
`to have serum concentrations of <0,3 mEq/L, 30 mg/L, and 3 mg/L,
`respectively, before receiving quetiapineor valproate in thistrial, to
`ensure that these medications were adequately “washed our.” Patients
`were also excluded if they had been treated with other antiepileptic
`agents within 72 hours. Fifty potential study candidates wereinitially
`identified. However, 20 patients did not meet study inclusion and
`exclusion criteria because they had eicher congenital cararacts (# = 3),
`a history ofintolerance or poor response to DVP (7 = 2), a substance
`use disorder (7 = 3), or a primary psychiatric diagnosis other than bipo-
`lar disorder(17 = 12). Therefore, 30 bipolar patients were randomized
`into this study (Fig. 1).
`This study was approved by the University of Cincinnati and the
`Children’s Hospital Medical Center institutional review boards.
`Adolescentsubjects provided written assent and their parentsor legal
`guardians provided written informed consent for study participation
`and publication after study procedures werefully explained.
`Diagnostic interviews were performed with the Washington University
`in St, Louis Kiddie Schedule for Affective Disorders and Schizophrenia
`(WASH-U-KSADS)(Geller et al., 2001) by trained raters (M.PD.,
`H.L.R.) with established diagnostic reliability (K = 0.94) (DelBello et al.,
`2001). Adolescent subjects and their primarycaregivers were interviewed
`separately, Primary caregiver and child responses were combined to ascer-
`tain diagnoses. Teachers and another primary caregiver were interviewed
`if there was a discrepancy betweenthe primary caregiver's and the ado-
`lescent’s responses. All diagnoses were reviewed in a conference attended
`by the WASH-U-KSADSinterviewer andatleast one child and ado-
`lescent psychiatrist from which a consensus diagnosis was made.
`Demographic information was obtained by interviewing the ado-
`lescent and his or her primary caregivers. The SelfRated TannerScale
`wasused to assess the stage of adolescent sexual development(Morris
`and Udry, 1980).
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`Eligible Patients
`
`(N=50)
`
`Not Randomized (N=20)
`
`Primary diagnosis not BP | (N=12), cataracts (N=3),
`substance use disorders (N=3), intolerance or poor
`response to DVP (N=2)
`
`Randomization
`
`Oivalproex
`+
`Placebo
`
`+
`
`
`Quetiapine
`(N=15)
`
`
`
`
`
`
` Divalproex
` (N=15)
`
`DELBELLO ET AL.
`
`
`
`Weokly follow-up
`Weekly follow-up
`(N=15)
`(N=15)
`
` Withdrawn (N=1)
`Withdrawn (N=7)
`
`Lack ol efficacy (N=1)
`tack of efficacy (N=1)
`
`Poor parental compliance (N=2)
`
`Paor subject compliance {N=1)
`Refusal of blood draws (N=1}
`
`Major deprassive episode (N=1)
`Transfer to sistant facility (N=1)
`
`Completed Trial
`
`Nei4
`
`
`Fig. 1 Diagram ofsubject flow by treatment group. BP I = bipolar I disorder; DVP = divalproex.
`
`Efficacy and Safety Measures
`Theprimary efficacy measure was the YMRS(Fristad et al., 1992;
`Young et al., 1978). Secondary efficacy measures included the Positive
`and Negative Syndrome Scale-Positive subscale (PANSS-P) and the
`Children’s Depression Rating Scale (CDRS)to assess the severity of
`psychotic (Kay er al., 1989) and depressive symptoms (Poznanski er al.,
`1979, 1983), respectively. Overalllevel offunctioning was assessed at
`baseline and endpoint with Children’s Global AssessmentScale (CGAS)
`scores (Shafferet al., 1983), A child and adolescent psychiatrist with
`previously establishedreliabiliry for each rating scale (M.P.D.) com-
`pleted all ratings by interviewing the subject and his or her primary
`caregiver (intraclass correlation coefficient > 0.9),
`EPS were assessed wich the Simpson-Angus (Simpson and Angus,
`1970), Barnes Akathisia (Barnes, 1989), and Abnormal Involuntary
`Movement Scales (Guy, 1976). Laboratory rests obtained included a
`complete blood cell count (CBC) with differential and prolactin,
`thyroid-stimulating hormone (TSH), andvalproicacid levels. In addi-
`tion, liver function tests (LFTs), including alanine aminotransferase,
`aspartate aminotransferase, and total bilirubin, were obrained. Viral
`signs obtained included weight and orthostatic blood pressure and pulse.
`Electrocardiograms (ECGs) were monitored throughoutthe study, In
`addition, physical andslit-lamp ocular examinations were performed
`on each subjectat baseline and endpoint. Adverse events were assessed
`whenratings were obtained by asking the adolescents and their primary
`caregivers open-ended questions abourpotentialside effects.
`
`Study Protocol
`This studywas a 6-week, randomized, parallel-group, double-blind,
`placebo-controlled investigation of DVP monotherapyversus the
`combination of DVP plus quetiapine. After meeting all inclusion and
`exclusion criteria, subjects were randomly assigned to receive either
`placebo or adjunctive quetiapine. Randomization, which wasassigned
`by investigational pharmacists, was stratified by sex and the presence
`of psychosis using a random number generator. All inpatient and
`research staff were blind to subject treatment group.
`All subjects received an initial DVP dose of 20 mg/kg per day on
`day 0, which was adjusted to achieve a therapeutic serum level of 80-130
`mg/dL. On day 0, subjects were also randomlyassigned to receive
`placebo oran initial quetiapine dose of 25 mg b.i.d., which was titrated
`to a maximum of 150 mg tid. by day 7, A maximum of 2 mg of
`lorazepam per day was permitted during thefirst 14 daysofthe study.
`Compliance was measured bypill countat each visit and by assess-
`ing valproic acid serum levels, which were collected 10 to 14 hours after
`the last DVP dose on days 3, 7, 14, 21, and 42 (or termination from
`the study). In addition, each subject was asked to keep a medication
`log to encourage compliance and identify missed doses. Subjects were
`discontinued from the study if chey missed more than 2 consecutive
`days of study medication or more than six doses during any 7-dayperiod.
`Efficacy and safety ratings were performed at baseline, days 3 and
`7, and then weekly until day 42 or termination from thestudy. Vital
`signs were monitored at eachvisit, Serum prolactin levels, LFTs, TSH,
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`QUETIAPINE IN ADOLESCENT MANIA
`
`and CBC wereassessed at baseline and day 42 or termination. In addi-
`tion, LFTs and CBC werealso assessed at days 7 and 21. ECGs were
`performed at baseline and days 7, 21, and 42 or termination.
`Inpatient attending physicians (not associated with the study) dis-
`charged studyparticipants from the inpatient psychiatry unit when
`they determined that the subjects wereclinically stable. All subsequent
`visits were performed in an outpatient setting. The majority of patients
`were discharged 7 to 14 days after admission (93%). There was nosta-
`tistically significant group differencein length of hospitalization.
`
`Statistical Analysis
`
`Primary Efficacy Measures
`
`Analyses within each treatment grouprevealed a sta-
`tistically significant reduction from baseline to endpoint
`
`TABLE1
`Demographic and Clinical Characteristics of Bipolar
`Adolescents by Treatment Group
`DVP + Placebo DVP + Quetiapine
`(n = 15)
`(a = 15)
`
`Variable
`
`days 28 and 35), adolescent treatment noncompliance
`(n= 1, day 28), transfer to a distant residential treatment
`facility (7 = 1, day 28), and developing a major depres-
`sive episode after mania resolution (7 = 1, day 21). No
`subjects in either group discontinued from the study
`because of medication side effects (Fig. 1).
`There were no significant group differencesin age,sex,
`race, socioeconomic status, Tanner stage, baseline CGAS,
`YMRS, CDRS, or PANSS-P scores or rates of mixed
`Prior ro study initiation, sample size estimates were calculated by
`episodes, psychosis, and attention-deficit/hyperactivity
`assuminga directional hypothesis (i.e., that the combination therapy
`disorder (Table 1). Age at onset of bipolar disorder was
`would be better than monotherapy) and a medium to largeeffectsize,
`defined as the age at which a DSM-/Vmoodepisodeini-
`with 80% power and a = .05 (Stevens, 1990).
`Statistical analyses were performed with the Statistical Analysis System
`tially occurred and was determined with the WASH-U-
`for the PC (SAS Institute, Cary, NC, 1999), Clinical and demographic
`KSADS. Subjects in the DVP + quetiapine group had a
`variables were identified as potential covariates using f tests or Fisher
`younger age at onsetofbipolar disorder compared with
`exacttests andaliberal p value of .2 for differences between groups,
`those in the DVP + placebo group (Table 1; p = .01).
`With the data from the intent-to-treat samples (7 = 15/group), ¢
`tests were used to calculate differences from baseline to endpointfor
`Meanvalproic acid level was 102 mg/dL in the DVP +
`each efficacy measure within each treatment group. Primary efficacy
`placebo group and 104 mg/dL in the DVP + quetiapine
`measures were change from baseline to endpoint in YMRS and YMRS
`group. By day 3, 97% (29/30) of the subjects reached a
`response, Response was defined as a 250% reduction in YMRSscore
`from baseline to endpoint. Analysis of covariance (ANCOVA) was
`therapeutic valproic acid level (mean + SD = 113 + 20
`used to comparegroup differences in endpoint YMRSscore after con-
`mg/dL) and by day 7, 100% had reached a therapeutic
`trolling for baseline values. The effect size for each treatment group
`valproic acid level (114 + 26 mg/dL). Mean dosage of
`wascalculated by using the mean change andstandard deviation from
`baseline ro endpoint in YMRSscores (Cohen, 1988). Groupdiffer-
`quetiapine was 432 mg/day in the DVP + quetiapine
`ences in YMRSresponserates were compared by using a one-tailed
`group. One subject in the DVP + quetiapine group was
`Fisher exact test. Secondary efficacy measures were change from base-
`nottitrated to the maximum dose of 450 mg/day because
`line to endpoint in CGAS, CDRS, and PANSS-Pscores. ANCOVAs
`of excessive sedation and was treated with 250 mg/day.
`were used to compare group differences in endpoint CGAS, CDRS,
`and PANSS-Pscores after controlling for baseline values.
`In addition, likelihood-based mixed-model repeated-measures
`ANCOVAs(proc mixed) were conducted to evaluate group-by-day dif-
`ferences in YMRS, CDRS, and PANSS-Pscores, with controlfor base-
`line scores, This analysis usesall available data and was selected to avoid
`biases that might be introduced with last observation carried forward
`or completer analyses. As a follow-upanalysis, least-squares means were
`calculated at each time point for each rating instrument to determine
`on which daysstatistically significant group differences occurred.
`Group differences in races of side effects were assessed with pwo-
`tailed Fisher exact rests. ANCOVAswere used to compare endpoint
`laboratory measures benveen groupsafter controlling for baseline val-
`ues. Other analyses were performed as necessary.
`Sex, 7 (%), female 7~~(47)7 (47)
`
`
`
`Age, mean (SD), yr
`14.5
`(2)
`14.1
`(2)
`Race, # (%), Caucasian
`13.
`(87)
`12
`(80)
`Tanner stage, mean (SD)
`319 (1.3)
`3.3 (1.1)
`SES, mean (SD)*
`3.6 (1.9)
`3.0 (1.5)
`Age onset bipolar disorder,
`mean (SD), yr*
`Mixed episode, » (%)
`Psychosis, 1 (%)
`ADHD, » (%)
`
`RESULTS
`
`Baseline Comparisons of Patient Characteristics
`
`Twenty-two (73%) of the 30 randomized subjects com-
`pleted the 6-week protocol. One patient in each group
`discontinued prematurely(at day 14 in both cases) because
`oflack of efficacy for acute mania symptoms. Thesix
`remaining noncompleters were all in the DVP + queti-
`apine group. The reasons for these patients’ premature
`termination includedrefusal to participate in blood draws
`(n = 1, day 7), parental treatment noncompliance (7 = 2,
`
`ll
`13.
`7
`8
`
`(3)
`(87)
`(47)
`(53)
`
`8
`10.
`7
`10
`
`(3)
`(67)
`(47)
`(67)
`
`Note: DVP = divalproex; SES = socioeconomic status; ADHD =
`actention-deficit/hyperactivitydisorder.
`* Range = 1-7, rating of 3 = parental yearly income of $20,000-
`$35,000.
`* Significant difference between groups: tz, = 2.75, p = 01.
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`YMRS
`
`0
`
`7
`
`id
`
`2l
`Day
`
`28
`
`a5
`
`42
`
`uscline
`
`=
`
`aaipetat
`a
`
`Oo
`
`DELBELLO ET AL.
`
`40
`35
`30
`25
`20
`16
`10
`
`5q
`
`“
`
`Score
`YMRS
`
`DV? +Placedo
`
`DV F+Q vetia pine
`
`Fig. 2 Manic adolescents in the divalproex (DVP) + quetiapine group (n =
`15) had a greater reduction in Young Mania Rating Scale (YMRS)scores fram
`baseline to endpoint compared with chose in the DVP + placebo group (n=
`15); analysis of covariance: F,>7 = 9.04, p = .03, “p = 002; *"p< .0001.
`
`Fig. 3 Manic adolescents in the divalproex + quetiapine group (squares; 7
`in YMRSscore (Fig. 2). However, the DVP + quetiap-
`= 15) hadastatistically significantly greater reduction in Young Mania Rating
`ine group demonstrated a significantly greater reduction
`Scale (YMRS)scores over time than those in the DVP + placebo group (dia-
`monds; 7 = 15); analysis of covariance: F,.:- = 8.3, p< .01."p<.01.
`in YMRSscore from baseline to endpoint than che DVP +
`placebo group (F27 = 5.04, p = .03) (Fig. 2).
`The YMRSresponse rate was significantly greater in
`the DVP + quetiapine group than in the DVP + placebo
`group (87% versus 53%; Fisherexacttest, p = .05). YMRS
`respondersdid notdiffer from nonrespondersin length
`oftime in the study (mean length oftime in the study
`was 5.3 and 5.1 weeks, respectively, p = .7).
`
`duringthe first 14 days of the study. Four of the subjects
`required only one dose of lorazepam (0,5—1 mg) and one
`subject required three doses(total dose = 1.5 mg). There
`wasnosignificant group difference in amount oflorazepam
`used (p = .6).
`
`Tolerability and Side Effects
`
`Secondary Efficacy Measures
`
`There were no significant group differences in change
`Within each treatment group, CDRS (DVP+placebo,
`from baseline to endpoint in QTc interval, TSH, white
`t= 4.7, p = .0004 and DVP + quetiapine, ¢ = 3.0, p = .01),
`blood cell count, hematocrit, platelet count, prolactin
`PANSS-P (DVP+ placebo, ¢ = 3.9, p = .002 and DVP +
`level, weight, EPS ratings, or LFTs (Table 2), In addition,
`quetiapine, ¢ = 3.1, p = 009), and CGAS (DVP+placebo,
`there were no subjects who had an abnormally elevated
`t= 8.6, p < .0001 and DVP + quetiapine, ¢ = 11.0, p<
`prolactin level at endpoint. No subjects had orthostatic
`-0001) scores were significantly reduced from baseline to
`hypotension during this study. No subjects developed
`endpoint. However, there were nosignificant differences
`cataracts or a serious adverse event duringthis study.
`between groupsin change from baseline to endpoint in
`The most commonsideeffects in boch treatmentgroups
`CDRS(Fj,27 = 0.0, p = 1.0), PANSS-P (F,27 = 0.1, p =
`were sedation, nausea, headache, and gastrointestinalirri-
`-8), and CGAS(F, 27 = 1.5, p = .2) scores.
`tation (Table 3). Sedation was significantly more common
`in the DVP + quetiapine group than in the DVP+ placebo
`group (Fisher exact test, p = .03). However, within the
`DVP + quetiapine group,there was nosignificant differ-
`ence in rate of sedation between responders and nonre-
`sponders(Fisher exacttest, p = .4). Alll side effects were rated
`as mild to moderate by the subjects and their caregivers.
`
`Response Over Time
`
`Subjects in the DVP + quetiapine group demonstrated
`an overall greater reduction over time in YMRSscores chan
`did subjects in the DVP + placebo group (F) 37 = 8.3, p <
`.01) (Fig. 3). Specifically, statistically significant groupdif-
`ferences were found on days 14, 21, and 42 (p = .009, p =
`-005, p = 01, respectively). Nostatistically significant group
`differences were found for change in CDRS (Fj 27 = 0.1,
`p =.7) or PANSS-P (F,27 = 0.5, p = .4) scores over time.
`
`Lorazepam Use
`
`Three subjects in the DVP + placebo group and two
`subjects in the DVP + quetiapine group required lorazepam
`
`DISCUSSION
`
`Theresults of this study indicate that quetiapinein
`combination with DVP is moreeffective at reducing manic
`symptomsassociated with bipolar disorder than DVP
`monotherapy. Furthermore,the results suggest thac que-
`tiapine is well tolerated when used in combination with
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`TABLE 2
`Safety and Laboratory Measures by Treatment Group
`DVP + Placebo
`DVP + Quetiapine
`
` Variable (2 = 15) (n = 15)
`
`
`QUETIAPINE IN ADOLESCENT MANIA
`
`Change in QTc, mean (SD), msec
`Change in TSH, mean (SD), mIU/L
`Change in WBC, mean (SD), 10*/uL
`Change in HCT, mean (SD), %
`Changein platelets, mean (SD), 10°/L
`Change in prolactin, mean (SD), ng/mL
`Prolactin elevation, » (%)
`Change in weight, mean (SD), kg
`Change in EPS ratings, mean (SD)
`AIMS
`0
`(0)
`(0)
`0
`Barnes Akathisia Scale
`0.1
`(0.3)
`~-0.1 (0,3)
`Simpson-AngusScale
`-0.1
`(1,1)
`0
`(0.8)
`Note: DVP = divalproex; TSH = thyroid-stimulating hormone; WBC = whire blood cell count; HCT = hemarocrit; EPS =
`extrapyramidal symptom: AIMS = Abnormal Involuntary Movement Scale.
`
`(17.9)
`1
`0.3) Cu?)
`-0.6
`(0.6)
`-l.1
`(0.4)
`-58.4 (27.2)
`-5.7
`(8.7)
`9
`(60)
`2.5)
`(Qi)
`
`(21.6)
`7
`0.6 (1.8)
`2,1 (0.7)
`—2.2 (0.3)
`~63.4 (4.2)
`-1.6 (6,9)
`7
`(47)
`4.2 (3.2)
`
`DVP. Despite differences in study populations and method-
`ologies, the response rate with DVP monotherapy was
`consistent with that reported in bipolar children and ado-
`lescents by Kowatch and colleagues (53%) (Kowatcher al.,
`2000), as well as in manic adults in other studies
`(Bowden et al., 1994). These findings suggest that the
`increased response obtained by adding quetiapineis nor
`simply due to an atypically poor response to DVPalone.
`Seventy-three percent of patients completed this study,
`whichis consistent with completion rates from other
`studies of patients with acute mania (Kowatchetal.,
`2000; Tohenet al., 2002). The percentage of patients
`completing this study wasgreater in the DVP + placebo
`group (93%)than in the DVP + quetiapine group (53%).
`However, mostofthe reasons for dropout were unrelated
`to treatment and were due to psychosocial factors. The
`rate of dropout dueto lack of efficacy was the same in
`both groups (7%). The analyses performed were based
`
`TABLE 3
`Adverse Events by Treatment Group
`DVP + Placebo
`DVP + Quetiapine
`(mn = 15)
`(m= 15)
`
`Adverse Event
`
`12 (80)
`5 (33)
`Sedation®
`4 (27)
`6 (40)
`Nausea/vomiting
`5 (33)
`3 (20)
`Dizziness
`7 (47)
`7 (47)
`Headache
`7 (47)
`5 (33)
`Gastrointestinal irritation
`2 (13)
`2 (13)
`Joint pain
`
`
`2 (13)Dry mouth 5 (33)
`
`Note: Values represent » (%).
`“ Fisher exact test, p = .03.
`
`solely on the data that were observed and despite the
`reduced samplesize,significantdifferences werestill found.
`Dropoutlimits the power to detect significant differences.
`Nonetheless, the observed data do indicate a significant
`treacment effect.
`
`Clinical Implications
`
`Although there are several case series suggesting that
`the atypical antipsychotics clozapine, olanzapine, and
`risperidone are effective as adjunctive treatments to mood
`stabilizers for the treatmentof pediatric mania, the side
`effects of these agents limit their utility in children and
`adolescents, Specifically, clozapineis associated with agran-
`ulocytosis and seizures, olanzapine is associated with
`increased appetite and weight gain, and risperidone is
`associated with prolonged weightgain, prolactin eleva-
`tion, and EPS (Chang and Ketter, 2000; Frazier etal.,
`1999, 2001; Kearnset al., 2000; Kowatch etal., 1995;
`Selva and Scott, 2001; Soutullo et al., 1999; Zuddas er al.,
`2000). In contrast to these other agents, the results of
`this study suggest that quetiapine is well tolerated as
`adjunctive treatment for mania in bipolar adolescents.
`Specifically, no subjects developed laboratory, ECG, or
`vital sign abnormalities. Moreover, in this study queti-
`apine was not associated with prolactin elevation or EPS.
`Alchough sedation was the most commonsideeffect in
`the DVP + quetiapine group, manic adolescents com-
`monly present with poor sleep, so short-term somnolence
`is often therapeutic. Further analysis revealed that within
`each treatment group, antimanic response was not asso-
`ciated with sedation, suggesting that the improvement
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`J. AM. ACAD. CHILD ADOLESC, PSYCHIATRY. 41:19, OCTOBE
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`apineis well tolerated as adjunctive treatment to DVP
`for adolescent mania. In addition,this study suggests that
`the combination of DVP and quetiapineis moreeffec-
`tive than DVPalone for treating manic symptomsasso-
`ciated with adolescent bipolar disarder.
`
`REFERENCES
`
`DrELBELLO ET AL.
`
`in our sample was due to improvement in mood and
`behavior and not excessive sedation.
`Weight gain is one of the majorside effects of most anti-
`manicagents. In this study,all subjects were treated with
`DVP, which is associated with weight gain (Demir and
`Aysun, 2000). Therefore, most adolescents gained weight
`during the course ofthis study. Although the combination
`of quetiapine and DVPresulted in a larger weight gain
`than DVP alone, the addition of quetiapine did notsig-
`nificantly increase the amountof weightgained. Nonetheless,
`investigations examining weight changesassociated with
`quetiapine monotherapyin children and adolescents are
`necessary. Minimizing the weight gain associated with most
`of the pharmacological treatments for bipolar disorder
`might increase medication compliance in manic adoles-
`cents and decrease the long-term risks associated with sig-
`nificant weightgain, such as hyperglycemia and typeII
`diabetes mellitus (McIntyre et al., 2001).
`
`Limitations
`
`Barnes TR (1989), A rating scale for drug-induced akathisia, Br/ Pochiaery
`154:672-676
`Bowden CL, Brugger AM, Swann AC eral. (1994), Efficacy of divalprocx vs
`lithium and placebo in the treatment of mania. /AMA 271:918-924
`Catapano-FriedmanL (2001), Effectivencss of quetiapine in the management
`of psychotic depression in an adolescent boy with bipolar disorder, mixed,
`with psychosis. { Child Adolese Psychopharmacol 11:205-206
`Chang KD, Ketter TA (2000), Maodstabilizer augmentation with olanzap-
`ine in acurcly manic children. { Child Adolese Psychopharmacal 10:45-49
`Cohen L (1988), Statistical PawerAnalysisfor the BehavioralSciences. Hillsdale,
`NJ: Erlbaum
`DelBello MR, Soutullo CA, Hendricks W, Niemeicr RT, McElroy SL, Strakowski
`SM (2001), Prior stimulant treatment in adolescents with bipolar disor-
`der: association with age at onset. Bipolar Disord 3:53-57
`Demir E, Aysun § (2000), Weight gain associated with valproatein childhood.
`Pediatr Neurol 22:361-364
`DevV, Raniwalla J (2000), Quetiapine; a review ofits safery in the manage-
`mentof schizophrenia. Drug Saf23:295-307
`Several limitations of this study need to be considered
`Dunayevich E, Strakowski SM (2000), Quetiapine for ereatment-resistant
`wheninterpreting the results. First, the small sample size
`mania. Am J Prychiatry 157:1341
`FrazierJA, Biederman J, Tohen M eral. (2001), A prospective open-label treat-
`might limit the power ofthis study to detect group dif-
`menttrial of olanzapine monotherapy in children and adolescents with
`ferences in someof the secondaryefficacy, safety mea-
`bipolar disorder. / ChildAdolesc Psychopharmacol \1:239-250
`Frazier JA, Meyer MC,BiedermanJ et al. (1999), Risperidone treatmentfor
`sures, and demographic and clinical variables. Second,
`juvenile bipolar disorder: a retrospective chart review. J Am Acad Child
`although chis G-week study demonstrated that quetiap-
`Adolese Psychiatry 38:960-965
`ine is effective and well tolerated as adjunctive treatment
`Fristad MA, Weller EB, Weller RA (1992), The Mania Rating Scale:can it be
`used in children? A preliminary repo