World Federation Of Societies Of Biological Psychiatry Research Articles

Oméga-3 et psychiatrie : que dit la littérature ?

Psychiatry is faced with a lack of new treatments despite a great deal of research and is re-exploring the use of old molecules and dietary supplements. Our aim here is to present a narrative review of the indications for omega-3 supplementation in various psychiatric disorders. Omega-3s belong to the family of polyunsaturated fatty acids (PUFAs). The 3 important omega-3 PUFAs in psychiatry are α-linolenic acid (ALA): C18:3n-3, eicosapentaenoic acid (EPA) C20:5n-3 and docosahexaenoic acid (DHA) C22:6n-3. In psychosis, a distinction must be made between 3 categories of patients: patients who have chronic schizophrenia (SCZ), patients with a first psychotic episode (FEP) and patients at ultra-high risk of psychosis (UHR).The data in the literature indicate that omega-3 supplementation is well tolerated. However, there is an increased risk of atrial fibrillation at doses over 4g/d, mainly in people over the age of 65.Omega-3 supplementation is not recommended for eating disorders, attention deficit hyperactivity disorder or autism spectrum disorders. Omega-3 supplementation could be beneficial in borderline personality disorder and psychotic disorders, particularly in patients at ultra-high risk of psychotic transition (UHR) to prevent psychotic transition and FEP to improve remission, and in bipolar disorder. It is now recommended for unipolar depression by the World Federation of Societies of Biological Psychiatry (WFSBP) and the Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce. There are a large number of clinical trials of omega-3 supplementation. However, these trials use different types of supplementation (EPA alone, DHA alone, EPA+DHA, etc.) with different dosages and EPA/DHA ratios and over variable durations. In addition, the origin of the omega-3s may vary, although most of the studies used omega-3s of marine origin (fish). Finally, it has not been studied whether the time of day (fasting, during a meal, morning, evening, etc.) impacts the efficacy of the treatment.Confounding factors are often not taken into account. For example, some studies suggest a link between the response to omega-3 supplementation and the inflammation or oxidative stress level. Omega-3 supplementation acts on numerous biological pathways: inflammation, oxidative stress, monocarbon metabolism (vitamin B9, B12, homocysteine), myelination,... For psychotic disorders, meta-analyses tend not to distinguish between UHR, PEP and schizophrenic patients.There have not been enough studies to validate the doses and duration of supplementation. The doses and durations in the recommendations are based solely on incomplete data from published studies. Further studies are needed to optimize these recommendations. Except for UHR patients and those with borderline personality disorder, omega-3 supplementation is always used as a complement to psychotropic treatment.In conclusion, the results of clinical trials, meta-analyses and recommendations are heterogeneous and may be divergent. Omega-3 supplementation in psychiatry is still extensively studied, with numerous studies and meta-analyses published recently. Omega-3 supplementation could be part of the goal of personalized medicine, as some studies are already suggesting. In the future, the efficacy of omega-3 supplementation could be improved by targeting sub-groups of patients: patients with inflammatory profiles, high levels of oxidative stress and low blood omega-3 concentrations. Due to the increasing number of studies published on omega-3 supplementation in psychiatric disorders, the conclusions of this review are provisional and will need to be updated.

Paraphilic disorders, psychopathy, and those who sexually offend: a narrative review of treatment modalities.

Despite its critical importance, the treatment of paraphilic disorders remains an often-overlooked domain both in clinical research and practice. Challenges have arisen in the morphing understanding of paraphilias and paraphilic disorders, now considered separate concepts, and efforts at developing a more nuanced understanding of these conditions is ongoing, resulting in a muddled history that can frustrate efforts at study and treatment. These populations are by nature more heterogeneous than may first be obvious-particularly among those with comorbid psychopathic traits-and may require a more nuanced and individualized approach based on risk, needs, and responsivity to treatment. Until recently, there were few guidelines to assist clinicians when confronted with these complicated clinical pictures and a sea of discrete studies investigating various biological and non-biological interventions. Treatments range from several variations of psychotherapy and behavioral therapies to SSRIs, anti-androgenic medications, to orchiectomy, all displaying varying degrees of effectiveness and evidence across decades of research. Fortunately, recent efforts to collate these studies supported by a task force of the World Federation of Societies of Biological Psychiatry (WFSBP) have helped form a better-focused and better-evidenced picture of effective treatments and the unique challenges faced by (and with) these populations.

Adjunctive agents to antipsychotics in schizophrenia: a systematic umbrella review and recommendations for amino acids, hormonal therapies and anti-inflammatory drugs

QuestionThis umbrella review and guidelines aimed to provide evidence to support the rational choice of selected adjunctive therapies for schizophrenia.Study selection and analysisFollowing the Preferred Reporting Items for Systematic Reviews...

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders – Version 3. Part II: OCD and PTSD

Aim This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive–Compulsive and Posttraumatic Stress Disorders which was published in 2002 and revised in 2008. Method A consensus panel of 34 international experts representing 22 countries developed recommendations based on efficacy and acceptability of the treatments. In this version, not only medications but also psychotherapies and other non-pharmacological interventions were evaluated, applying the same rigorous methods that are standard for the assessment of medication treatments. Result The present paper (Part II) contains recommendations based on published randomised controlled trials (RCTs) for the treatment of OCD (n = 291) and PTSD (n = 234) in children, adolescents, and adults. The accompanying paper (Part I) contains the recommendations for the treatment of anxiety disorders. For OCD, first-line treatments are selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT). Internet-CBT was also superior to active controls. Several second-line medications are available, including clomipramine. For treatment-resistant cases, several options are available, including augmentation of SSRI treatment with antipsychotics and other drugs. Other non-pharmacological treatments, including repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS) and others were also evaluated. For PTSD, SSRIs and the SNRI venlafaxine are first-line treatments. CBT is the psychotherapy modality with the best body of evidence. For treatment-unresponsive patients, augmentation of SSRI treatment with antipsychotics may be an option. Conclusion OCD and PTSD can be effectively treated with CBT and medications.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders – Version 3. Part I: Anxiety disorders

Aim This is the third version of the guideline of the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive–Compulsive and Posttraumatic Stress Disorders (published in 2002, revised in 2008). Method A consensus panel of 33 international experts representing 22 countries developed recommendations based on efficacy and acceptability of available treatments. In total, 1007 RCTs for the treatment of these disorders in adults, adolescents, and children with medications, psychotherapy and other non-pharmacological interventions were evaluated, applying the same rigorous methods that are standard for the assessment of medications. Result This paper, Part I, contains recommendations for the treatment of panic disorder/agoraphobia (PDA), generalised anxiety disorder (GAD), social anxiety disorder (SAD), specific phobias, mixed anxiety disorders in children and adolescents, separation anxiety and selective mutism. Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line medications. Cognitive behavioural therapy (CBT) is the first-line psychotherapy for anxiety disorders. The expert panel also made recommendations for patients not responding to standard treatments and recommendations against interventions with insufficient evidence. Conclusion It is the goal of this initiative to provide treatment guidance for these disorders that has validity throughout the world.

Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce

Clinician guidelines for the treatment of psychiatric disorders with nutraceuticals and phytoceuticals: The World Federation of Societies of Biological Psychiatry (WFSBP) and Canadian Network for Mood and Anxiety Treatments (CANMAT) Taskforce

PET imaging for guiding definition of therapeutic reference ranges – new drugs, new guidelines

Positron emission tomography (PET) is now an established tool for assessment of target engagement (TE) of new psychotropic drugs. The relationship between occupancy of a molecular target, drug serum concentrations and clinical efficacy has been documented for many antipsychotics and some but not all antidepressants. This presentation illustrates how PET studies help to establish therapeutic reference ranges for some of the newer psychotropics that have recently reached the market, i.e. lurasidone, nalmefene and vortioxetine. Furthermore, the imaging part of the new World Federation of Societies of Biological Psychiatry (WFSBP) guideline entitled "Tools for Optimising Pharmacotherapy in Psychiatry", which focuses on the class of antidepressants, will be briefly presented. This guideline documents the current knowledge about relationships between antagonism of brain monoamine transporters exerted by antidepressants, the associated serum concentrations and their clinical efficacy. However, while such relationships seem to be well established for (selective) serotonin reuptake inhibitors, TE studies for some other compounds that do not act by blocking the serotonin transporter – such as noradrenaline reuptake inhibitors – obviate the need for further research on and a better understanding of the mechanism of action of psychotropic drugs, which is a prerequisite for rationale therapeutic drug monitoring.

Second-Generation Antipsychotic Drugs in Anorexia Nervosa: A Meta-Analysis of Randomized Controlled Trials

Background: Second-generation antipsychotic drugs (SGAs) are increasingly administered to achieve weight gain in anorexia nervosa. In this meta-analysis, we aimed to determine if any evidence for this treatment option can be derived from randomized controlled trials (RCTs). Methods: Based on the ‘World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Eating Disorders', a systematic update literature search was applied to identify all RCTs investigating the efficacy, acceptability, and tolerability of SGAs in anorexia nervosa in comparison to placebo/no treatment. The primary outcome was weight gain measured by mean change in body mass index (BMI). Secondary outcomes were mean changes in Yale-Brown-Cornell Eating Disorders Scale (YBC-EDS) total score and Eating Disorders Inventory (EDI) total score and premature discontinuation of treatment. Employing a random-effects model standardized mean differences based on Hedges's g and Mantel-Haenszel risk ratios were calculated. Results: Seven RCTs (n = 201) investigating olanzapine (N = 4), quetiapine (N = 2), and risperidone (N = 1) were included. We found no statistically significant between-group differences for mean BMI change when pooling the SGAs (N = 7, n = 161; Hedges's g = 0.13, 95% CI: -0.17 to 0.43; p = 0.4) and when examining the individual drugs. Furthermore, the SGAs failed to differentiate statistically significantly from placebo/no treatment for all secondary outcomes. Conclusions: Based on the current evidence, pharmacological treatment of anorexia nervosa with SGAs cannot be generally recommended although some individuals or subgroups of patients might benefit from an antipsychotic medication. Further research is required to identify which patients will likely benefit from such a treatment option.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders

Objectives. This 2013 update of the practice guidelines for the biological treatment of unipolar depressive disorders was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal has been to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. The guidelines are intended for use by all physicians seeing and treating patients with these conditions. Methods. The 2013 update was conducted by a systematic update literature search and appraisal. All recommendations were approved by the Guidelines Task Force. Results. This first part of the guidelines (Part 1) covers disease definition, classification, epidemiology, and course of unipolar depressive disorders, as well as the management of the acute and continuation phase treatment. It is primarily concerned with the biological treatment (including antidepressants, other psychopharmacological medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of adults. Conclusions. To date, there is a variety of evidence-based antidepressant treatment options available. Nevertheless there is still a substantial proportion of patients not achieving full remission. In addition, somatic and psychiatric comorbidities and other special circumstances need to be more thoroughly investigated. Therefore, further high-quality informative randomized controlled trials are urgently needed.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2012 on the long-term treatment of bipolar disorder

Objectives. These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults. Methods. Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A–F) and different grades of recommendation to ensure practicability were assigned. Results. Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios. Conclusions. Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

On our own behalf: a new editorial board and focus of EAPCN

EAPCN looks back to a long history since its foundation in 1868. During its development from an originally German to today’s English format, it continuously has been under guidance of outstanding editors—Alois Alzheimer is just one to name in the prominent list. In the last two decades, it was Hans-Jurgen Moller who decisively shaped the journal’s scope. Originally stemming from a northern town in Germany, directly after obtaining his degree in medicine, Hans-Jurgen Moller headed southwards: After specializing in psychiatry and postgraduate training at the Max-PlanckInstitute of Psychiatry in Munich, he was assigned as professor at the psychiatric department of the Munich Technical University. In 1988, he was appointed as chairman of the Department of Psychiatry and Psychotherapy at the University of Bonn. In 1993, 1 year before his return to the same position in Munich at the Ludwig-MaximiliansUniversity (LMU), the former work space of famous psychiatrists like E. Kraepelin or A. Alzheimer, Hans-Jurgen Moller resumed the managing editorship of EAPCN and ever since has substantially shaped its bias. As author or co-author of more than 1,300 publications, he always strongly focused on the methodology of clinical research in psychiatry, biological psychiatry of schizophrenia and depression, clinical psychopharmacology and psychogeriatrics. Hans-Jurgen Moller furthermore has been member of the executive committees of several national and international psychiatric societies, among them the past presidentship of the European Psychiatric Association (EPA), as chairman of the Section on Pharmacopsychiatry of the World Psychiatric Association (WPA) plus presidency of the Collegium Internationale Neuro-Psychopharmacologicum (CINP). He is honorary president of the World Federation of Societies of Biological Psychiatry (WFSBP), which he chaired from 1997 to 2001, and headed—last not least—the German Society for Biological Psychiatry (DGBP) from 1995 until 1999, for which EAPCN since 1997 is the official publication platform. His work was honoured by various academic prizes and honorary titles. Concordant with his primary interest in clinical research, EAPCN owes Hans-Jurgen Moller, the publication of outstanding and excellent clinical studies. In the light of his retirement, he now chose Peter Falkai as follower, who in July 2012 also overtook his position as chairman of the department at the LMU in Munich. But no worries: Moller will stay on the ball and be in charge of keeping his critical editorial eye on special issues and invited reviews of EAPCN. Peter Falkai, longstanding member of EAPCN’s editorial board and account managing editor since May 2011, as new chief editor of EAPCN (starting in October 2012) intends to strengthen the journal’s focus towards neurobiological topics without intentions to distract authors from furthermore submitting thorough clinical studies of high quality. Congruent with his personal continuous interest, with this bias, Peter Falkai plans following the direction of the DGBP towards neurobiological substrates and their neurobiological origins as well as causal treatment options. This core area has been visible throughout his entire academic career. Before overtaking the aforementioned position as chairman of the Department of Psychiatry and Psychotherapy at the University of Munich, he held the same position at the Universities of Saarland (2002–2006) and P. Falkai (&) A. Schmitt Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Nusbaumstr. 7, 80336 Munich, Germany e-mail: Peter.Falkai@med.uni-muenchen.de

Biomarkers for attention-deficit/hyperactivity disorder (ADHD). A consensus report of the WFSBP task force on biological markers and the World Federation of ADHD

Objective. Psychiatric “nosology” is largely based on clinical phenomenology using convention-based diagnostic systems not necessarily reflecting neurobiological pathomechanisms. While progress has been made regarding its molecular biology and neuropathology, the phenotypic characterization of ADHD has not improved. Thus, validated biomarkers, more directly linked to the underlying pathology, could constitute an objective measure for the condition. Method. The task force on biological markers of the World Federation of Societies of Biological Psychiatry (WFSBP) and the World Federation of ADHD commissioned this paper to develop a consensus report on potential biomarkers of ADHD. The criteria for biomarker-candidate evaluation were: (1) sensitivity > 80%, (2) specificity > 80%, (3) the candidate is reliable, reproducible, inexpensive, non-invasive, easy to use, and (4) confirmed by at least two independent studies in peer-reviewed journals conducted by qualified investigators. Results. No reliable ADHD biomarker has been described to date, but some promising candidates (e.g., olfactory sensitivity, substantial echogenicity) exist. A problem in the development of ADHD markers is sample heterogeneity due to aetiological and phenotypic complexity and age-dependent co-morbidities. Conclusions. Most likely, no single ADHD biomarker can be identified. However, the use of a combination of markers may help to reduce heterogeneity and to identify homogeneous subtypes of ADHD.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the acute treatment of schizophrenia and the management of treatment resistance

These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A–F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression

Objectives: These guidelines are based on a first edition that was published in 2002, and have been edited and updated with the available scientific evidence until September 2009. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute bipolar depression in adults. Methods: The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A–F). As these guidelines are intended for clinical use, the scientific evidence was finally assigned different grades of recommendation to ensure practicability. Results: We identified 10 pharmacological monotherapies or combination treatments with at least limited positive evidence for efficacy in bipolar depression, several of them still experimental and backed up only by a single study. Only one medication was considered to be sufficiently studied to merit full positive evidence. Conclusions: Although major advances have been made since the first edition of this guideline in 2002, there are many areas which still need more intense research to optimize treatment. The majority of treatment recommendations is still based on limited data and leaves considerable areas of uncertainty. (Reprinted with permission from The World Journal of Biological Psychiatry, 2010; 11:81–109)

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Eating Disorders

Objectives. The treatment of eating disorders is a complex process that relies not only on the use of psychotropic drugs but should include also nutritional counselling, psychotherapy and the treatment of the medical complications, where they are present. In this review recommendations for the pharmacological treatment of eating disorders (anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED)) are presented, based on the available literature. Methods. The guidelines for the pharmacological treatment of eating disorders are based on studies published between 1977 and 2010. A search of the literature included: anorexia nervosa bulimia nervosa, eating disorder and binge eating disorder. Many compounds have been studied in the therapy of eating disorders (AN: antidepressants (TCA, SSRIs), antipsychotics, antihistaminics, prokinetic agents, zinc, Lithium, naltrexone, human growth hormone, cannabis, clonidine and tube feeding; BN: antidepressants (TCA, SSRIs, RIMA, NRI, other AD), antiepileptics, odansetron, d-fenfluramine Lithium, naltrexone, methylphenidate and light therapy; BED: antidepressants (TCA, SSRIs, SNRIs, NRI), antiepileptics, baclofen, orlistat, d-fenfluramine, naltrexone). Results. In AN 20 randomized controlled trials (RCT) could be identified. For zinc supplementation there is a grade B evidence for AN. For olanzapine there is a category grade B evidence for weight gain. For the other atypical antipsychotics there is grade C evidence. In BN 36 RCT could be identified. For tricyclic antidepressants a grade A evidence exists with a moderate-risk-benefit ratio. For fluoxetine a category grade A evidence exists with a good risk-benefit ratio. For topiramate a grade 2 recommendation can be made. In BED 26 RCT could be identified. For the SSRI sertraline and the antiepileptic topiramate a grade A evidence exists, with different recommendation grades. Conclusions. Additional research is needed for the improvement of the treatment of eating disorders. Especially for anorexia nervosa there is a need for further pharmacological treatment strategies.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the Treatment of Acute Bipolar Depression

Objectives. These guidelines are based on a fi rst edition that was published in 2002, and have been edited and updated with the available scientifi c evidence until September 2009. Their purpose is to supply a systematic overview of all scientifi c evidence pertaining to the treatment of acute bipolar depression in adults. Methods. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientifi c rigor was categorised into six levels of evidence (A–F). As these guidelines are intended for clinical use, the scientifi c evidence was fi nally assigned different grades of recommendation to ensure practicability. Results. We identifi ed 10 pharmacological monotherapies or combination treatments with at least limited positive evidence for effi cacy in bipolar depression, several of them still experimental and backed up only by a single study. Only one medication was considered to be suffi ciently studied to merit full positive evidence. Conclusions. Although major advances have been made since the fi rst edition of this guideline in 2002, there are many areas which still need more intense research to optimize treatment. The majority of treatment recommendations is still based on limited data and leaves considerable areas of uncertainty.

Approche méthodologique de la variabilité inter « Guidelines » : exemples dans la prise en charge du trouble bipolaire

In recent decades, an increasing number of pharmacologic agents have become available in bipolar disorder treatment. These therapeutic advances provide a new challenge for clinicians in the choice of medication for patients with bipolar disorder. In this context, tools have been developed for making medical decisions in the management of bipolar disorder: guidelines. Guidelines for bipolar disorder were compared on the basis of their construction methodology (evidence-based treatment guidelines or consensus-based treatment guidelines), results and recommendations for clinical practice. There are differences between guidelines for treating bipolar disorder. For the American Psychiatric Association (APA), the severity of the manic episode is a primary endpoint of the decision-making tree for the choice of therapy. On the other hand, the National Institute for Health and Clinical Excellence (NICE) ruled that the choice of the initial treatment, in the case of manic episode, should be based first on the current patient's treatment (history of anti-manic therapy) while the World Federation of Societies of Biological Psychiatry (WFSBP) emphasizes the clinical classification of the type of mania. The sequencing of medication in the guidelines may vary according to the construction methodology, the date of elaboration, the geocultural context and experts' position. Recent guidelines consider the last randomized controlled trials (RCT) as those of aripiprazole in the treatment of mania, recommending it in first line as anti-manic agent. The recent updated WFSBP guidelines changed in its construction methodology taking into account the negative studies or those showing non-superiority compared to placebo. Thus, a recent study of non-superiority of lithium monotherapy compared to placebo in the treatment of bipolar depression downgraded lithium from level of evidence B to D. During recent years, a large number of RCT have demonstrated superior efficacy (particularly in mania treatment) of lithium or valproate combined with second-generation antipsychotic compared with lithium or valproate monotherapy. Consequently, according to geocultural context or experts' position, some guidelines recommended medication combinations in first line (Canadian Network for Mood and Anxiety Treatment) and other guidelines considered monotherapy in first line (except for particular cases) to promote tolerance and good therapeutic alliance (WFSBP). Malhi et al. recommended a sequencing of medication based on the benefit risk ratio for the management of each phase of bipolar disorder. These differences between guidelines may cause difficulties for clinicians in choosing clinical practice guidelines. While there are a large number of guidelines for bipolar disorder, the recommendations may vary depending on multiple factors. It seems interesting to conduct a comparative study of guidelines for bipolar disorder on the basis of a validated scale (AGREE) or completed by other items such as date of elaboration and number of proposed recommendations. However, the methodological understanding of guidelines remains the central element for practitioners in their choice of guidelines. Thus, the initial objective of guidelines "to develop statements to assist clinician and patient decisions about the most appropriate health care for specific clinical situations" could be implemented in clinical practice.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Substance Use and Related Disorders. Part 2: Opioid dependence

Objectives. To develop evidence-based practice guidelines for the pharmacological treatment of opioid abuse and dependence. Methods. An international task force of the World Federation of Societies of Biological Psychiatry (WFSBP) developed these practice guidelines after a systematic review of the available evidence pertaining to the treatment of opioid dependence. On the basis of the evidence, the Task Force reached a consensus on practice recommendations, which are intended to be clinically and scientifically meaningful for physicians who treat adults with opioid dependence. The data used to develop these guidelines were extracted primarily from national treatment guidelines for opioid use disorders, as well as from meta-analyses, reviews, and publications of randomized clinical trials on the efficacy of pharmacological and other biological treatments for these disorders. Publications were identified by searching the MEDLINE database and the Cochrane Library. The literature was evaluated with respect to the strength of evidence for efficacy, which was categorized into one of six levels (A–F). Results. There is an excellent evidence base supporting the efficacy of methadone and buprenorphine or the combination of buprenorphine and naloxone for the treatment of opioid withdrawal, with clonidine and lofexidine as secondary or adjunctive medications. Opioid maintenance with methadone and buprenorphine is the best-studied and most effective treatment for opioid dependence, with heroin and naltrexone as second-line medications. Conclusions. There is enough high quality data to formulate evidence-based guidelines for the treatment of opioid abuse and dependence. This task force report provides evidence for the efficacy of a number of medications to treat opioid abuse and dependence, particularly the opioid agonists methadone or buprenorphine. These medications have great relevance for clinical practice.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Alzheimer's disease and other dementias

Objectives. To define a practice guideline for biological treatment of dementia and to make transparent the development of the guideline connecting the original data with the resulting recommendations. Methods. This guideline includes pharmacologic treatment considerations for patients with Alzheimer's disease, vascular dementia, DLB, and fronto-temporal dementia. Studies were selected that represent double-blind placebo-controlled trials of at least 3 months duration in patients with a diagnosis of dementia according to accepted international diagnostic criteria (for example the NINCDS/ADRDA or NINDS/AIREN criteria). Moreover, to be included studies had to fulfill a restrictive set of methodological criteria. Original studies and not meta-analyses determined the evaluation and the development of recommendations. Results. Antidementia pharmaceuticals neither cure nor arrest the disease. A modest effect of improvement of symptoms compared with placebo can be observed. Antidementia pharmaceuticals show different efficacy and side effect profiles. The type of dementia, the individual symptom constellation and the tolerability should determine what medication should be used. There are hints that combination therapy of drugs with different therapeutic mechanisms might improve the efficacy. In treating neuropsychiatric symptoms (NPS), psychosocial intervention should be the treatment of first choice. Pharmaceuticals can only be recommended when psychosocial interventions is not adequate. However, even then the side effects of pharmaceuticals limit their use. Conclusions. Depending on the diagnostic entity and the pathology treated different anti-dementia drugs can be recommended to improve symptoms. In the management of NPS, side effects limit the use of medications even when psychosocial interventions have failed. Thus, there is an urgent need to develop more efficacious medications for the treatment of dementia.

Use of Transcranial Magnetic Stimulation in Bipolar Disorder

Use of Transcranial Magnetic Stimulation in Bipolar Disorder