Zusammenfassung
HINTERGRUND: Aufgrund der guten therapeutischen Wirkung war Lithium über 50 Jahre der Inbegriff eines Stimmungsstabilisators. Die ersten Definitionen dieser Substanzklasse spiegelten den Versuch wider, eine neue Medikamentenkategorie mit stimmungsmodulierenden Eigenschaften zu bestimmen, welche weder Antidepressiva noch klassische Neuroleptika waren. Hintergrund dieser Bemühungen war das Wissen um die potentielle destabilisierende Wirkung der Antidepressiva, respektiv um die depressiogene Wirkung klassischer Neuroleptika. Berichte über die antimanische und antidepressive Wirkung des Clozapin waren die ersten über die bimodalen und potentiell stimmungs-stabilisierenden Eigenschaften der neueren Antipsychotika. METHODEN: Um die Frage zu klären, ob neuere Antipsychotika bei bipolaren Erkrankungen in der Akutphase und/oder in der Prophylaxe mit Erfolg eingesetzt werden können, wurde Literatur verwendet welche mittels PubMed (Mesh-Database) im Internet unter den Stichworten antipsychotics, atypicals, bipolar disorder und moodstabilizer gefunden wurden. Durch Querreferenzierung sowie Konsultation neuerer Bücher zum Thema Bipolare Störung und Teilnahme an Expertenkonferenzen wurden die Daten ergänzt. ERGEBNISSE: Im Sinne eines Klassenphänomens sind neuere Antipsychotika als Monotherapie und besonders in Kombination mit Lithium oder Valproat akut antimanisch wirksam. Die antidepressive Wirkung wurde mit Ausnahme von Quetiapin und Olanzapin als sekundäres Outcome-Kriterium erhoben, sodass die Datenlage unterschiedlicher Qualität ist. Hier zeichnet sich eine substanzspezifische Wirksamkeit ab. Während Olanzapin und Risperidon eine niedere antidepressive Effektstärke haben, ist diese bei Quetiapin hoch. Daten zur prophylaktischen Wirksamkeit gibt es nur für Olanzapin; dabei verhindert es, ähnlich wie Lithium, eher manische als depressive Rezidive. SCHLUSSFOLGERUNGEN: Die strengen Kriterien eines Stimmungsstabilisators scheinen die neueren Antipsychotika genau so wenig wie Lithium, Lamotrigin, Valproat oder Carbamazepin zu erfüllen. Neuere Antipsychotika scheinen jenen Substanzen zuordenbar zu sein, welche wie die meisten sogenannten Moodstabilizer teilweise stimmungsstabilisierende Wirkung zeigen, ohne aber im engeren Sinn selber ein SST zu sein. Diese Substanzen werden in Kombination mit anderen Substanzen Verwendung finden. Da es keinen universellen SST gibt, bleibt eine Monotherapie bei bipolaren Patienten wahrscheinlich auch in Zukunft eine Ausnahme. Eine Abwägung des Krankheitsverlaufs, des akuten Krankheitsbildes sowie die für jeden Patienten individuell durchzuführende Abwägung des Wirkung-Nebenwirkungs-Spektrums wird zur adäquaten pharmakologischen Therapie führen. Diese Therapie wird oft eine Kombinationstherapie sein.
Abstract
BACKGROUND: Because of a broad benefit in bipolar disorder, lithium was the prototype of a moodstabilizer for about half a century. Early definitions of a moodstabilizer tried to describe a psychopharmacological class beyond antidepressants and typical neuroleptics, as they were known to either induce a switch into mania or induce cycle acceleration or for the case of typical neuroleptics lead into depression. Clozapine was the first atypical reported to have beside its antimanic effects additional antidepressant and moodstabilizing properties. METHODS: In order to assess efficacy of atypicals in bipolar disorder a search using PubMed and Mesh-database was performed. Additional information was gained by cross-referencing from papers found. Data from controlled studies as well as supplementary information from review articles and expert meetings pertinent to the topic were used. RESULTS: The acute antimanic action seems to be a class effect of atypicals since all of them generate comparably good results in a monotherapy or as added to moodstabilizers. In contrast to the robust data in mania, antidepressant effects were assessed with the exception of quetiapine and olanzapine as second outcome criteria. These effects seem to be substance-specific, ranging from low for olanzapine and risperidone to potent for quetiapine. With the exception of olanzapine atypicals in maintenance therapy have yet to be tested in large scale controlled studies. Paralleling lithium olanzapine seems to prevent more from manic than depressive recurrence. CONCLUSIONS: Atypicals as well as many others so called moodstabilizers such as lamotrigine, valproate or carbamazepine do not meet the narrow definition of a moodstabilizer. Newer antipsychotics seem to belong to the vaste majority of drugs with partial moodstabilizing poperties without being a moodstabilizer themselves. These agents need to be combined in order to cover the needed therapeutical spectrum from antimanic to antidepressive and prophylactic effects. As there is no universally acting moodstabilizer, monotherapy in bipolar disorder will remain an exception. A clever combination of drugs, based upon the current symptoms, the couse of the disease and weighting of wanted effects and adverse events, will guide the clinician in his choice to an individual phamacological therapy.
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Hausmann, A., Strauss, R., Weiss, U. et al. Sind Antipsychotika der zweiten und dritten Generation auch Phasenprophylaktika?. Psychiatrie 1, 75–90 (2005). https://doi.org/10.1007/s11326-005-0012-8
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DOI: https://doi.org/10.1007/s11326-005-0012-8
Schlüsselwörter
- Neuere Antipsychotika der zweiten und dritten Generation
- Bipolare Störung
- Akutbehandlung
- Erhaltungstherapie
- Phasenprophylaktika