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Servicio de Psiquiatría-CAS Vall d’Hebron Agencia de Salud Pública de Barcelona (ASPB) Programa Clínico DepresiónServicio de Psiquiatría 3Servicio de Psiquiatría del Parc Sanitari Sant Joan de Déu Instituto Clínico de NeurocienciasHospital Clínic de Barcelona Hospital Universitari de Bellvitge-IDIBELLCIBERSAM INTRODUCTION
bupropion in the treatment of addiction in patients with cocaine dependence who are receiving maintenance treatment Dual pathology is defined as the coexistence of an with methadone6 or even in patients affected by an attention addiction in persons suffering another mental disorder.1 The deficit hyperactivity disorder (ADHD) or dual ADHD.5 course, prognosis and treatment of patients are different from those who do not have dual pathology.2 It is known that smoking determines worse prognosis and greater TREATMENT WITH BUPROPION OF DEPRESSED
clinical severity of bipolar disorder (BD), schizophrenia and PATIENTS WITH DUAL PATHOLOGY
Bupropion can be used in the treatment of depressive It has been described that patients with mental disorders patients with dual pathology, aiming to obtain the smoke more and spend more on this habit than the general antidepressant effect or to facilitate smoking cessation, population and have a greater frequency of associated medical since its efficacy as smoking cessation treatment is conditions.4 In patients with schizophrenia and SAD, nicotine independent of its antidepressant action.8 dependence has been related with a higher rate of suicide attempts and with alcohol and cannabis consumption.3 It is known that drug abuse in depressed patients is Treatments effective in the general population are also associated to greater suicidal risk and attempts, earlier onset effective in patients with psychiatric disorders and little of depression, more anxiety disorders and functioning attention has been given to this population.4 Bupropion is a
alterations. 9 However, treatment of patients with dual norepinephrine-dopamine reuptake inhibitor and is one of pathology has been studied little and the results of its the treatments used most for smoking cessation and as an efficacy have not always been consistent. 10 In relationship antidepressant drug.5 However, few specific works exist on to smoking cessation treatment, in spite of the strong the use of bupropion in patients with dual pathology, even association between smoking and depression, the studies on though it has been used as a drug for smoking cessation, in smoking cessation usually exclude depressed patient11 or patients with dual diagnosis of affective and psychotic this population has been studied little.4 Of these specific disorders. Furthermore, there are signs about the use of works, it is known that patients with backgrounds of major depressive disorders benefit the same as the general * Francisca Almansa, Carmen Barral, Milagrosa Blanca, Nagore Benito, Joan Cadevall, population from psychotherapy and pharmacological Horacio Casté, Nuria Custal, Anna Falcés, Eva Fontova, Juan Manuel Goicolea, Georgina González, Paul Ernesto González, Ana Herrero, Rafael Martín, Leticia Medeiros, Javier treatments for smoking cessation. 4 However, drug usage can Merino, Laura Mora, Josep Mª Otín, Adolfo Pellejero, Rosa Pi, Cristina Pinet, Dolors Robles, Alejandro Rodriguez, Ferran Romaguera, Carme Romero, Carme Sarri, Joan Seguí, modulate the efficacy of these treatments. The risk of failure Sara Solé, Carmen Sotelo, Josep Tort, Marc Valentí. or relapse in alcohol-dependent patients who quit smoking has been related with the severity and type of alcohol consumption. Specifically, patients with elevated or very Servicio de PsiquiatriaHospital Universitari de Bellvitge-IDIBELL, CIBERSAM frequent alcohol consumption have more relapses.12 Thus, the existence of dual pathology should be taken into account 08907Correo electrónico: ncardoner@bellvitgehospital.cat Actas Esp Psiquiatr 2011;39(Suppl. 2):17-9 Scientific evidence indicates that treatment with trials in which patients with schizophrenia were included bupropion in addicts who also smoke is effective, regardless reported that the use of bupropion is superior to placebo of whether there is associated depression.10 When the use of in smoking cessation, the results being maintained at 6 bupropion combined with nicotine patches in patients who months.22-23 With the known data, it can be stated that receive cognitive behavioral therapy has been studied, it has bupropion can be used as a drug that facilitates cessation been demonstrated that abstinence and the depressive symptoms improve in patients who smoke and who have current or have had past unipolar major depression.11 The The use of bupropion in patients suffering from SAD type of association of treatments in patients who smoke and should be evaluated with caution due to the possibility of are depressed is not clear since, although bupropion has precipitating a manic episode. In general, all patients advantages in regards to smoking cessation, a ceiling effect affected by psychosis treated with bupropion require due to the interventions received has been detected in those periodic psychopathological evaluation and regular medical control due to the risk of seizures because of its effect on the decrease of the seizure threshold.20 In the patient with behavior disorder, this drug has been used successfully used in the treatment of the depressive phases of the disease and is considered to be first-line OPINION OF THE EXPERTS OF THE WORK GROUP
treatment, as the selective serotonin reuptake inhibitors (SSRI).13 Up to date, there are no specific studies with Knowledge on the indications, use and management of bupropion in patients with dual bipolar disorder, although bupropion in patients with dual condition are partial. the increased risk of mania induced by antidepressants is known in bipolar patients with a past history of drug There is clinical experience and increasingly greater evidence obtained in clinical trials performed in patients with depression or schizophrenia that point to its utility, both as an antidepressant as well as a smoking cessation TREATMENT OF DUAL PSYCHOTICS
Bupropion is well tolerated when combined with other There are clinical experiences with limited cohorts of schizophrenic patients treated with antipsychotics in which bupropion was used as an antidepressant. In these This drug should be used with precaution in patients studies, improvement of the depressive symptoms with with risk of appearance of manic pictures. good tolerability was described.15 On the other hand, there
is little experience with the treatment of depressive
symptoms in dual schizophrenics. Fundamentally, REFERENCES
bupropion has been used in the treatment of nicotine dependence in psychotic patients in addition to nicotine 1. Casas M, Prat G, Santís R. Trastornos por dependencia de patches or gum. In these patients, treatment with sustancias psicotropas. In: Cervilla JA, García-Ribera C. bupropion has provided positive efficacy results, good Fundamentos biológicos en psiquiatría. Barcelona: Masson, tolerability and even a significant reduction in the negative symptoms characteristic of the evolution of the disease,3, 2. Roncero C, Barral C, Grau-López L, Esteve O. Casas M. Protocolos 16 so that its use has been recommended.17, 16 Most of the de intervención en patología dual: Esquizofrenia. Edikamed. studies conducted in patients with schizophrenia and SAD Barcelona 2010. Available at www.patología dual.es.
3. López-Ortiz C, Roncero C, Miquel L, Casas M. Fumar en las have not detected psychotic decompensation in psicosis afectivas: revisión sobre el consumo de nicotina en el relationship with this drug,18 except for some isolated trastorno bipolar y esquizoafectivo. Adicciones 2011 (in press).
case.19 Bupropion reduces tobacco consumption and 4. Kisely S, Campbell LA. Use of smoking cessation therapies in improves the negative symptoms, without destabilizing individuals with psychiatric illness : an update for prescribers. the psychotic and depressive symptoms although its long- term benefit is modest.20 In subsequent works, positive 5. Clayton AH. Extended-release bupropion: an antidepressant results have been described in psychotic patients when with a broad spectrum of therapeutic activity?. Expert Opin bupropion was administered in combined treatment. In a 6. Castells X, Casas M, Pérez-Mañá C, Roncero C, Vidal X, Capellà D. clinical trial was 58 schizophrenic patients under treatment Efficacy of psychostimulant drugs for cocaine dependence. with bupropion together with nicotine patches,21 it was Cochrane Database Syst Rev. 2010;2:CD007380.
demonstrated that this condition was well tolerated and 7. Wilens TE, Prince JB, Spencer T, Van Patten SL, Doyle R, Girard K, that the results were better than when only nicotine et al. An open trial of bupropion for the treatment of adults patches were used. Meta-analysis reviews of 7 clinical with attention-deficit/hyperactivity disorder and bipolar Actas Esp Psiquiatr 2011;39(Suppl. 2):17-9 disorder. Biol Psychiatry. 2003;54:9-16.
15. Englisch S, Inta D, Eer A, Zink M. Bupropion for depression in 8. Hayford KE, Patten CA, Rummans TA, Schroeder DR, Offord KP, schizophrenia. Clin Neuropharmacol. 2010;33(5):257-9.
Croghan IT, et al. Efficacy of bupropion for smoking cessation in 16. George TP, Vessicchio JC, Sacco KA, Weinberger AH, Dudas MM, smokers with a former history of major depression or alcoholism. Allen TM, et al. A placebo-controlled trial of bupropion combined with nicotine patch for smoking cessation in schizophrenia. Biol 9. Davis LL, Frazier E, Husain MM, Warden D, Trivedi M, Fava M, et al. Substance use disorder comorbidity in major depressive 17. Evins AE, Cather C, Deckersbach TH, Freudenreich O, Culhane disorder: a confirmatory analysis of the STAR*D cohort. Am J MA, Olm-Shipman CM, et al. A double-blind placebo-controlled trial of bupropion sustained-release for smoking cessation in 10. Torrens M, Fonseca F, Mateu G, Farré M. Efficacy of antidepressants schizophrenia. J Clin Psychopharmacol. 2005;25(3):218-25.
in substance use disorders with and without comorbid depression. 18. Smith RC, Lindenmayer JP, Davis JM, Cornwell J, Noth K, Gupta A systematic review and meta-analysis. Drug Alcohol Depend. S, et al. Cognitive and antismoking effects of varenicline in patients with schizophrenia or schizoaffective disorder. 11. Evins AE, Culhane MA, Alpert JE, Pava J, Liese BS, Farabaugh A, et al. A controlled trial of bupropion added to nicotine patch 19. Javelot H, Baratta A, Weiner L, Javelot T, Nonnenmacher C, and behavioral therapy for smoking cessation in adults with Westphal JF, et al. Two acute psychotic episodes after unipolar depressive disorders. J Clin Psychopharmacol. administration of bupropion: a case of involuntary rechallenge. 12. Leeman RF, McKee SA, Toll BA, Krishnan-Sarin S, Cooney JL, 20. Noordsy DL, Green AI. Pharmacotherapy for schizophrenia and Makuch RW, et al. Risk factors for treatment failure in smokers: co-occurring substance use disorders. Curr Psychiatry Rep. relationship to alcohol use and to lifetime history of an alcohol use disorder. Nicotine Tob Res. 2008; 10(12):1793-809.
13. Yatham LN, Kennedy SH, Schaffer A, Parikh SV, Beaulieu S, 21. George TP, Vessicchio JC, Termine A, Bregartner TA, Feingold A, O’Donovan C, et al. Canadian Network for Mood and Anxiety Rounsaville BJ, et al. A placebo controlled trial of bupropion for Treatments (CANMAT) and International Society for Bipolar smoking cessation in schizophrenia. Biol Psychiatry. Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2009. 22. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. 14. Manwani SG, Pardo TB, Albanese MJ, Zablotsky B, Goodwin FK, Cochrane Database Syst Rev. 2010; 16(6):CD007253.
Ghaemi SN. Substance use disorder and other predictors of 23. Tsoi DT, Porwal M, Webster AC. Efficacy and safety of bupropion antidepressant-induced mania: a retrospective chart review. J for smoking cessation and reduction in schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2010;196(5):346-53.
Actas Esp Psiquiatr 2011;39(Suppl. 2):17-9

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