Please see Brief Summary of full Prescribing Information, including Boxed Warning, on page S17.

Transcription

1 SUPPLEMENT TO Available at CLINICIANREVIEWS.COM A F R O N T L I N E M E D I C A L C O M M U N I C AT I O N S P U B L I C AT I O N April 2015 Dezra L. Kenney, PMHCNS-BC, CADAC Danielle L. Kamine, MS, ARNP, ANP-BC, CARN-AP, PMHNP-BC Diane Snow, PhD, APRN, PMHNP-BC, CARN, FAANP, FIAAN This promotional, non-cme program is intended only for healthcare professionals involved in the treatment of adult patients with bipolar disorder. This supplement was developed and brought to you by Sunovion Pharmaceuticals Inc. It did not undergo peer review by Clinician Reviews. Supplement content was developed in collaboration with the faculty. Please see Brief Summary of full Prescribing Information, including Boxed Warning, on page S17. INDICATIONS AND USAGE LATUDA is indicated for treatment of major depressive episodes associated with bipolar I disorder (bipolar depression) as monotherapy and as adjunctive therapy with lithium or valproate. The efficacy of LATUDA was established in a 6-week monotherapy study and a 6-week adjunctive therapy study with lithium or valproate in adult patients with bipolar depression. The effectiveness of LATUDA for longer-term use, that is, for more than 6 weeks, has not been established in controlled studies. Therefore, the physician who elects to use LATUDA for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient. The efficacy of LATUDA in the treatment of mania associated with bipolar disorder has not been established. IMPORTANT SAFETY INFORMATION AND INDICATIONS FOR LATUDA Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk with antidepressant use in patients aged 65 and older. In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber. LATUDA is not approved for use in patients under the age of 18 years. This supplement is sponsored by LATUDA, SUNOVION, and are registered trademarks of Sumitomo Dainippon Pharma Co., Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co., Ltd Sunovion Pharmaceuticals Inc. All rights reserved. LAT /15

2 Introduction: The Challenge of Bipolar Disorder Bipolar disorder is characterized by fluctuations between hypomania, depression, or mania. 1 Bipolar disorder presents several significant diagnostic and management challenges; it may go unrecognized and misdiagnosed. 2 Although symptoms of mania may be more conspicuous, patients with bipolar disorder spend more time with depressive symptoms. For example, 1 long-term study of patients with bipolar I disorder found that depressive symptoms account for approximately two-thirds of time spent with symptoms. 3 Patients with bipolar disorder may present with comorbid conditions that can further complicate diagnosis and treatment, with most patients exhibiting at least 1 comorbid psychiatric or general medical condition, such as anxiety, substance use disorders, obesity, and cardiovascular disease. 4,5 Bipolar Disorder: Frequently Undiagnosed or Misdiagnosed Distinguishing bipolar disorder from major depressive disorder (MDD) may be challenging, in part, because of overlapping diagnostic criteria between the disorders. According to the Diagnostic and Statistical Manual of Mental Disorders, major depressive episodes are a feature of both MDD and bipolar disorder. 1 Mixed states are also features of both disorders, making it especially important for clinicians to corroborate information specifying the length and severity of symptoms. 1 Several studies have demonstrated that clinicians often find it difficult to distinguish bipolar disorder from MDD or other psychiatric conditions. In one study in which a community sample of more than 80,000 individuals underwent bipolar disorder screening, only about 20% of those with a positive bipolar disorder screening result had previously been diagnosed with bipolar disorder, while nearly 80% were either undiagnosed or had been diagnosed with MDD. 6 Another study reported that patients with bipolar disorder have often been previously misdiagnosed with a broad range of other psychiatric disorders, such as unipolar depression, anxiety disorder, schizophrenia, personality disorder, and substance use disorder. 7 Patients with bipolar disorder have reported that they typically receive 3 or more other diagnoses and are seen by 4 or more clinicians before bipolar disorder is correctly diagnosed. Approximately one-third of patients experience a 10-year delay from symptom onset to correct diagnosis. 7 Recognizing Bipolar Disorder in Clinical Practice Due to the potential overlap between symptoms of bipolar and unipolar disorders, vigilance, careful evaluation, and knowledge of the signs and symptoms of bipolar disorder can help to increase the accuracy of bipolar disorder recognition. 8 Several clinical features have been described that may help to differentiate the disorders. Factors that have been strongly associated with a diagnosis of bipolar disorder include a family history of bipolar disorder in a first-degree relative, a history of antidepressant-induced mania or hypomania, early age of onset of depressive symptoms, a recurrent pattern of illness, and atypical symptoms of depression (eg, hypersomnia, hyperphagia, fatigue). Other characteristics are less strongly associated with a diagnosis of bipolar disorder FACULTY Dezra L. Kenney, PMHCNS-BC, CADAC Psychiatric Mental Health Clinical Nurse Specialist Private Practice Kenney & Associates Boston, Massachusetts COMMENTATORS Danielle L. Kamine, MS, ARNP, ANP-BC, CARN-AP, PMHNP-BC Sanford, Florida Diane Snow, PhD, APRN, PMHNP-BC, CARN, FAANP, FIAAN Clinical Professor Director Psychiatric Mental Health Nurse Practitioner Program The University of Texas at Arlington College of Nursing and Health Innovation Arlington, Texas Private Practice Denton, Texas Disclosures Dezra L. Kenney serves as a consultant, speaker, and researcher for various pharmaceutical companies, including Sunovion Pharmaceuticals Inc. Danielle L. Kamine serves as a consultant, speaker, and researcher for various pharmaceutical companies, including Sunovion Pharmaceuticals Inc. Diane Snow serves as a consultant, speaker, and researcher for various pharmaceutical companies, including Sunovion Pharmaceuticals Inc. The clinical expert commentaries reflect the views of actual licensed clinicians who have been engaged by Sunovion Pharmaceuticals Inc. to provide feedback. The information contained herein is intended for general informational purposes only and is not a substitute for your professional medical advice and judgment. S2 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

3 FIGURE 1. STEP-BD STUDY: ADDITION OF ANTIDEPRESSANT MEDICATIONS TO MOOD STABILIZER THERAPY WAS NO MORE EFFECTIVE THAN MOOD STABILIZERS ALONE FOR THE TREATMENT OF BIPOLAR DISORDER P=NS Patients P=NS At Least Transiently Improved Durable Recovery Mood Stabilizer + Antidepressant (n=179) Mood Stabilizer + (n=187) Abbreviation: STEP-BD, Systematic Treatment Enhancement Program for Bipolar Disorder. but remain suggestive, including psychotic features, lack of response to antidepressant therapy, and abrupt onset and end of the depressive episode Patient Screening Tools There are several patient screening tools that clinicians can use to help identify patients with bipolar disorder. They include, but are not limited to, the following: Mood Disorder Questionnaire (MDQ) 11 Composite International Diagnostic Interview (CIDI) 12 Mood Swings Survey (MSS) 13 Bipolar Inventory of Symptoms Scale (BISS) 14 Such tools are used for bipolar disorder screening, but not for diagnosis. A questionnaire, such as the MDQ, can help to elicit a patient s detailed history, allowing the healthcare professional to appropriately interview the patient and his or her family to identify a history of signs and symptoms consistent with a diagnosis of bipolar disorder rather than unipolar depression. Specifically, the MDQ asks patients to note whether they have experienced 13 particular signs or symptoms. 11 Patients are also asked to rate the overall level of impairment associated with their symptoms (no problem, minor problem, moderate problem, serious problem). 11 The MDQ screen is considered positive when 7 or more of the 13 components in the first question are positively endorsed, question 2 is positively endorsed, and the answer to question 3 is moderate or serious. 15 Patients with a positive screen require formal evaluation before a diagnosis can be made. Challenges Associated With Antidepressant Therapy Several studies suggest that antidepressant therapy typically provides little benefit for patients with bipolar disorder. In the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, patients with bipolar depression were randomly assigned to treatment with a mood stabilizer plus an antidepressant or a mood stabilizer plus matching placebo for up to 26 weeks. 16 Initially, mood stabilizers included lithium, valproate, the combination of lithium and valproate, or carbamazepine. In 2004, the STEP-BD study protocol was amended to define a mood stabilizer as any antimanic agent approved by the United States Food and Drug Administration. 16 Response to therapy was examined using 2 outcome measures: a transient response to therapy, defined as 1 to 7 consecutive weeks of euthymia, and durable recovery, defined as a minimum of 8 consecutive weeks of euthymia with no more than 2 manic or 2 depressive symptoms. 16 As shown in Figure 1, the addition of an antidepressant to mood stabilizer therapy did not significantly increase the percentage of patients who were at least transiently improved or who exhibited durable recovery. 16 Another study found that up to 25% of patients with bipolar disorder switched to mania, hypomania, or a mixed state while taking an antidepressant. 17 Supplement to Clinician Reviews Vol 25, No 4 April 2015 S3

4 Expert Commentary Danielle L. Kamine, MS, ARNP, ANP-BC, CARN-AP, PMHNP-BC Sanford, Florida As described in the accompanying article by Dezra L. Kenney, PMHCNS-BC, CADAC, the diagnosis of bipolar disorder remains a challenge for clinicians. Accurate identification of bipolar disorder may be difficult, as the clinical presentation of bipolar disorder varies significantly from patient to patient. Furthermore, patient and family bias can affect what a patient divulges to a clinician. Therefore, clinicians should acquire a deep and detailed patient history to ensure an accurate diagnosis. Despite these barriers to timely diagnosis and treatment, clinicians have several tools at their disposal to help them recognize patients whose major depressive episode is associated with bipolar disorder. Rating scales and screening instruments can be very helpful in allowing us to explore the patient s experiences and perspectives when patients are not able to articulate precisely what is happening to them. Although questionnaires are often considered time consuming by clinicians, the information they provide can be invaluable. Rating scales can help to start a discussion about the patient s symptoms and to evaluate whether important clues to a diagnosis of bipolar disorder have been missed. A bipolar disorder screener is a tool that can help guide next steps toward a diagnosis. The few minutes required to complete a screening instrument can provide very valuable information about specific symptoms. Bipolar disorder screeners or rating scales can help patients realize that symptoms may be more of a concern than they recognize. In my own practice, I use rating scales to prompt a discussion to avoid biasing the patient s perceptions. This allows patients to speak freely and honestly, without becoming defensive about the possibility that they might have a particular psychiatric disorder. Despite the usefulness of screening instruments, it is important to recognize that a positive screening result is not the same as a diagnosis of bipolar disorder. Ultimately, nothing can replace clinical judgment, the ability to look at the entire picture, and sound critical thinking, when diagnosing any psychiatric disorder. Clinicians should also be vigilant for certain red flags that suggest that the patient may have a major depressive episode associated with bipolar disorder rather than major depressive disorder (MDD) or another condition. Patients with bipolar disorder sometimes describe a history of nonresponse to several antidepressant medications, or signs of a possible switch to mania or hypomania (eg, irritability or agitation). An important warning sign is a history of very rapid response to antidepressant medication that soon wears off. Whereas patients with MDD typically require at least 2 to 3 weeks of treatment before mood symptoms begin to improve, those with bipolar depression may exhibit a marked response within the first 3 to 7 days of treatment, followed by a loss of efficacy as treatment continues. Finally, a sleep history can provide important information about the patient s diagnosis. Symptoms such as impulsivity, agitation, or irritability can occur in a broad range of psychiatric disorders, including bipolar disorder, MDD, attention deficit/hyperactivity disorder, or personality disorders. However, bipolar disorder is one of very few conditions that is characterized by a decreased overall need for sleep. A thorough assessment of the patient s sleep history should be performed when considering a possible diagnosis of bipolar disorder. S4 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

5 LATUDA: Clinical Efficacy, Safety, and Tolerability The efficacy of LATUDA was established in a 6-week monotherapy study and a 6-week adjunctive therapy study with lithium or valproate in adult patients with bipolar depression. The effectiveness of LATUDA for longer-term use (more than 6 weeks) has not been established in controlled studies. Therefore, the clinician who elects to use LATUDA for extended periods should periodically reevaluate the long-term usefulness of the drug for the individual patient. The efficacy of LATUDA in the treatment of mania associated with bipolar disorder has not been established. 18 Scales Used in the LATUDA Clinical Trials Key clinical rating scales used in the LATUDA bipolar depression clinical trials included the Montgomery-Åsberg Depression Rating Scale (MADRS) 19 and the Clinical Global Impressions Scale- Bipolar version (CGI-BP). 20 These 2 rating scales are summarized in Table 1. The MADRS is a 10-item clinician rating of depressive symptoms. Each item is scored on a 7-point scale (0-6), yielding a total MADRS score ranging from 0 to 60, and higher scores indicate greater severity of depression. 19 The MADRS tool is validated, is sensitive to changes in depressive symptoms, and was used as the primary endpoint in the LATUDA bipolar depression clinical trials. 18 Six MADRS items (apparent sadness, reported sadness, inner tension, lassitude, inability to feel, and pessimistic thoughts) have been described as core symptoms of depression and together comprise the MADRS-6, a subscale of the MADRS The CGI-BP is a clinician-rated scale that measures a patient s current severity of illness on a scale of 1 (normal, not ill) to 7 (very severely ill). 20 This rating scale facilitates the clinician s impression of the patient s state of illness based on all observations and interactions with the patient during the week preceding the rating. The clinician is asked to consider his or her total clinical experience with the general patient population in assessing the individual patient. 20 Clinical trials that examined the efficacy of LATUDA for the treatment of bipolar depression included the CGI-BP depression severity assessment as a key secondary endpoint. 18 LATUDA for the Treatment of Bipolar Depression: Efficacy, Safety, and Tolerability The efficacy, safety, and tolerability of LATUDA as monotherapy in patients with bipolar depression were evaluated in a short-term (6 weeks), multicenter, randomized, double-blind, placebo-controlled clinical trial. 18,22 Efficacy was measured by the change from baseline to Week 6 in the MADRS total score (primary efficacy endpoint) and the CGI-BP depression severity score (key secondary endpoint). 22 The mean daily dose of LATUDA during the study was 31.8 mg in the LATUDA mg/day group and 82.0 mg in the LATUDA mg/day group. 22 The effects of LATUDA doses of mg/day and mg/day on depressive symptoms as measured using the MADRS and CGI-BP rating scales are shown in Figure Both LATUDA monotherapy doses resulted in a 44% greater reduction in MADRS score at Week 6 than placebo. 22 The mean decrease in MADRS total score between baseline and Week 6 was 15.4 points for patients randomized to TABLE 1. SCALES USED IN THE LATUDA BIPOLAR DEPRESSION CLINICAL TRIALS 19,20 10-item MADRS Scale Apparent sadness* Reported sadness* Inner tension* Reduced sleep Reduced appetite Concentration difficulties Lassitude* Inability to feel* Pessimistic thoughts * Suicidal thoughts CGI-BP Considering your total clinical experience with this particular population, how ill has the patient been during the assessment period? 1 Normal, not ill 2 Minimally ill 3 Mildly ill 4 Moderately ill 5 Markedly ill 6 Severely ill 7 Very severely ill *Core symptom of depression. Supplement to Clinician Reviews Vol 25, No 4 April 2015 S5

6 FIGURE 2. EFFICACY OF LATUDA MONOTHERAPY FOR THE TREATMENT OF BIPOLAR DEPRESSION 22 LS Mean Change From Baseline Baseline Baseline mean = Time (Weeks) LATUDA mg (n=161) Primary Endpoint: MADRS Total Score * ** Effect size: LATUDA mg: 0.51 LATUDA mg: 0.51 * ** LATUDA mg (n=162) ** ** (n=162) LS Mean Change From Baseline Baseline Baseline mean = Key Secondary Endpoint: CGI-BP Depression Severity Score 1 2 * LATUDA mg (n=161) ** Time (Weeks) ** ** Effect size: LATUDA mg: 0.61 LATUDA mg: 0.50 LATUDA mg (n=162) (n=162) Reduction in severity of depression *P<.05; **P<.01; P<.001. Abbreviations: CGI-BP, Clinical Global Impressions Scale-Bipolar version; LS, least squares; MADRS, Montgomery-Åsberg Depression Rating Scale. MADRS scale range, 0-60; CGI-BP scale range, 1-7. Primary endpoint: Change in MADRS total score between baseline and Week 6. Key secondary endpoint: Change in CGI-BP depression severity total score between baseline and Week 6. FIGURE 3. ADVERSE REACTIONS IN AT LEAST 2% OF LATUDA-TREATED PATIENTS AND AT GREATER INCIDENCE THAN PLACEBO LATUDA mg (N=164) LATUDA mg (N=167) (N=168) 25 Patients Nausea Akathisia Somnolence* <1 <1 <1 <1 Dry Mouth EPS Diarrhea Anxiety Nasopharyngitis Back Pain Vomiting UTI Influenza Abbreviations: EPS, extrapyramidal symptoms; UTI, urinary tract infection. *Somnolence includes the following adverse event terms: hypersomnia, hypersomnolence, sedation, and somnolence. EPS includes the following adverse events: bradykinesia, cogwheel rigidity, drooling, dystonia, extrapyramidal disorder, glabellar reflex abnormal, hypokinesia, muscle rigidity, oculogyric crisis, oromandibular dystonia, parkinsonism, psychomotor retardation, tongue spasm, torticollis, tremor, and trismus. S6 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

7 TABLE 2. CHANGE IN METABOLIC PARAMETERS FROM BASELINE TO WEEK 6 IN PATIENTS TREATED WITH LATUDA MG/DAY OR PLACEBO AS MONOTHERAPY 18 Parameter LATUDA mg/day LATUDA mg/day Weight (mean) 1.2 lb 0.0 lb -0.1 lb (n=143) (n=147) (n=151) Glucose (mean) -0.8 mg/dl 1.8 mg/dl 1.8 mg/dl (n=140) (n=143) (n=148) Total cholesterol (mean) 1.2 mg/dl -4.6 mg/dl -3.2 mg/dl (n=140) (n=144) (n=147) Triglycerides (mean) 5.6 mg/dl 0.4 mg/dl 6.0 mg/dl (n=140) (n=144) (n=147) LATUDA mg/day or mg/day, compared with a mean reduction of 10.7 points for patients randomized to placebo (P<.001). The effect size for both LATUDA treatment groups was The higher dose range ( mg/day) did not provide additional efficacy, on average, compared to the lower dose range (20-60 mg/day). As with the MADRS total score, both LATUDA monotherapy doses were associated with significant improvement on the key secondary efficacy endpoint. The mean decrease in CGI-BP score between baseline and Week 6 was 1.8 points for patients randomized to LATUDA mg/day, 1.7 points for patients randomized to LATUDA mg/day, and 1.1 points for patients randomized to placebo (P<.001 for each LATUDA group vs placebo). The effect size for the key secondary endpoint was 0.61 for the LATUDA mg/day group and 0.50 for the LATUDA mg/day group. 22 Figure 3 shows the rates of adverse events that occurred in at least 2% of LATUDA-treated patients and at greater frequency than placebo in patients with bipolar depression who were randomized to LATUDA or placebo for 6 weeks. These events included nausea, akathisia, somnolence, dry mouth, extrapyramidal symptoms (EPS), diarrhea, anxiety, nasopharyngitis, back pain, vomiting, urinary tract infection, and influenza. 18 The most common adverse events with LATUDA monotherapy in either dose group, with rates of at least 5% and at least twice the placebo rate, were akathisia, EPS, somnolence, nausea, vomiting, diarrhea, and anxiety. 18 For the 2 LATUDA groups combined, treatment was discontinued due to adverse events by 6.0% (20 of 331 patients) with LATUDA mg/day and by 5.4% (9 of 168 patients) in the placebo group. 18 Overall, the types of adverse reactions that were associated with treatment discontinuations were similar for the LATUDA and placebo groups. Treatment was discontinued due to akathisia by 1 patient in the LATUDA mg/day group and by 5 patients in the LATUDA mg/day group. One patient in the placebo group discontinued treatment due to EPS. 23 No patients in either LATUDA treatment group discontinued treatment due to dystonia, parkinsonism, or restlessness. 23 Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular or cerebrovascular risk. At the end of the 6-week study, mean body weight increased by 1.2 pounds for patients randomized to LATUDA mg/day, was unchanged for patients randomized to LATUDA mg/day, and decreased by 0.1 pounds for patients randomized to placebo. 18 Body weight increase of at least 7% was noted for 2.4% of LATUDA-treated patients versus 0.7% for placebotreated patients. 18 Mean serum glucose concentration decreased by 0.8 mg/dl for patients in the lowdose LATUDA group, and it increased by 1.8 mg/dl for patients in both the high-dose LATUDA group and the placebo group. 18 Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia, including polydipsia, polyuria, polyphagia, and weakness. Undesirable alterations in lipids have also been observed in patients treated with atypical antipsychotics. The mean change in serum total cholesterol from baseline to study endpoint was +1.2 mg/dl for the low-dose LATUDA group, -4.6 mg/dl for the high-dose LATUDA group, and -3.2 mg/dl for the placebo group. 18 The mean serum triglyceride concentration increased by 5.6 mg/dl for the low-dose LATUDA group, 0.4 mg/dl for the highdose LATUDA group, and 6.0 mg/dl for the placebo group. 18 The metabolic effects of LATUDA monotherapy are summarized in Table 2. As with other drugs that antagonize central dopamine Type 2 (D 2 ) receptors, LATUDA ele- Supplement to Clinician Reviews Vol 25, No 4 April 2015 S7

8 FIGURE 4. EPS FOR PATIENTS RECEIVING LATUDA MG/DAY OR PLACEBO AS MONOTHERAPY FOR THE TREATMENT OF BIPOLAR DEPRESSION 18 Patients LATUDA mg (N=164) <1 Akathisia LATUDA mg (N=167) Dystonia* Parkinsonism (N=168) Restlessness Abbreviation: EPS, extrapyramidal symptoms. *Dystonia includes adverse event terms: dystonia, oculogyric crisis, oromandibular dystonia, tongue spasm, torticollis, and trismus. Parkinsonism includes adverse event terms: bradykinesia, cogwheel rigidity, drooling, extrapyramidal disorder, glabellar reflex abnormal, hypokinesia, muscle rigidity, parkinsonism, psychomotor retardation, and tremor. vates prolactin levels. Galactorrhea, amenorrhea, gynecomastia, and impotence have been reported in patients receiving prolactin-elevating compounds. LATUDA mg/day monotherapy for 6 weeks was associated with small changes in serum prolactin concentration. For male and female patients combined, median prolactin concentration between baseline and study endpoint increased by 1.7 ng/ml, 3.5 ng/ml, and 0.3 ng/ml in the low-dose LATUDA group, high-dose LATUDA group, and placebo group, respectively. For male patients, median prolactin increased by 1.2 ng/ml, 1.9 ng/ml, and 0.4 ng/ml with low-dose LATUDA, high-dose LATUDA, and placebo, respectively. For female patients, median prolactin concentration increased by 1.8 ng/ml with low-dose LATUDA and 5.3 ng/ml with high-dose LATUDA, and it remained unchanged from baseline in the placebo group. 18 Rates of EPS for patients treated with LATUDA mg/day, LATUDA mg/day, and placebo are shown in Figure 4. The most common EPS was akathisia, which was associated with treatment discontinuation in 1 patient in the LATUDA mg/day group and 5 patients in the LATUDA mg/day group. 23 Changes from baseline to study endpoint in EPS, akathisia, and tardive dyskinesia were also evaluated using the Simpson Angus Rating Scale (SAS), the Barnes Akathisia Scale (BAS), and the Abnormal Involuntary Movement Scale (AIMS), respectively. Categorical change was defined as a shift from normal at baseline to abnormal at study endpoint for the SAS, or as a worsening from baseline to study endpoint for the BAS and AIMS. 23 The percentage of patients with categorical shifts receiving LATUDA mg/day or placebo is shown in Figure The mean change from baseline for LATUDA-treated patients was comparable to placebo on all 3 movement scales. 18 LATUDA as Adjunctive Therapy With Lithium or Valproate: Efficacy, Safety, and Tolerability The efficacy, safety, and tolerability of LATUDA as adjunctive therapy with lithium or valproate in patients with bipolar depression were evaluated in a short-term (6 weeks), multicenter, randomized, double-blind, placebo-controlled clinical trial. 24 As in the LATUDA monotherapy study, efficacy was measured by the change from baseline to Week 6 in MADRS total score (primary efficacy endpoint) and CGI-BP depression severity score (key secondary endpoint). 24 The mean daily dose of LATUDA during the study was 66.3 mg. 24 The effects of LATUDA mg/day as adjunctive therapy with lithium or valproate on depressive symptoms are shown in Figure The mean decrease in the MADRS total score between baseline and Week 6 was 17.1 points for patients randomized to adjunctive LATUDA mg/day, compared with a mean reduction of 13.5 points for patients randomized to placebo (P<.01). The effect size for LATUDA treatment was Similar to the MADRS total score, LATUDA as adjunctive therapy with lithium or valproate was associated with significant improvement in the key secondary endpoint. The mean decrease in CGI-BP score was 2.0 points for patients randomized to LATUDA mg/day versus 1.5 points for patients randomized to placebo (P<.01), with an effect size of S8 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

9 FIGURE 5. MOVEMENT DISORDER SCALES: CATEGORICAL CHANGE FOR PATIENTS RECEIVING LATUDA MG/DAY OR PLACEBO AS MONOTHERAPY FOR THE TREATMENT OF BIPOLAR DEPRESSION 18 Patients With Categorical Shifts SAS* BAS AIMS LATUDA mg (n=323) (n=162) Abbreviations: AIMS, Abnormal Involuntary Movement Scale; BAS, Barnes Akathisia Scale; SAS, Simpson Angus Rating Scale. *Shift from normal at baseline to abnormal at last observation carried forward (LOCF) endpoint. Worsening from baseline to LOCF endpoint. The safety and tolerability of adjunctive LATUDA with lithium or valproate were also examined in a second randomized clinical trial of patients with bipolar depression. Figure 7 shows the rates of adverse events that occurred in at least 2% of patients in either group, and at greater incidence in the LATUDA than the placebo group, for patients randomized to adjunctive LATUDA (N=360) or placebo (N=334) for the 2 adjunctive therapy studies combined. 18 The most common adverse events among patients taking LATUDA as adjunctive therapy with lithium or valproate (at least 5% for LATUDA and at least twice the rate of placebo) were somnolence and akathisia. Treatment was discontinued due to adverse events by 5.8% of patients (21 of 360) randomized to LATUDA as adjunctive therapy with lithium or valproate and by 4.8% of patients randomized to placebo (16 of 334). 18 Of the most common treatmentemergent adverse reactions (ie, at least 5% for LATUDA and at least twice the rate of placebo), treatment was discontinued due to somnolence by 1 patient in the LATUDA group and due to akathisia by 1 patient in the placebo group. 23 Changes in metabolic parameters during 6 weeks of double-blind treatment with LATUDA or placebo adjunctive to lithium and valproate are summarized in Table The percentage of patients with at least a 7% increase in body weight at the 6-week endpoint was 3.1% for patients receiving LATUDA added to lithium or valproate versus 0.3% for placebo-treated patients. 18 Median prolactin concentration increased by 2.8 ng/ml in LATUDA-treated patients and was unchanged from baseline in patients who received placebo. In men, median prolactin increased by 2.4 ng/ml with LATUDA and decreased by 0.1 ng/ml with placebo; in women, median prolactin increased by 3.2 ng/ml and 0.4 ng/ml for LATUDA and placebo groups, respectively. 18 During 6 weeks of double-blind therapy with adjunctive LATUDA or placebo, EPS-related adverse events included akathisia (11% vs 5% for LATUDA and placebo, respectively), dystonia (1% vs <1%), parkinsonism (13% vs 8%), and restlessness (4% vs <1%). 18 Figure 8 shows the categorical shifts from normal to abnormal (SAS) or worsening from baseline to last observation carried forward endpoint (BAS, AIMS) for the LATUDA and placebo groups. The mean change from baseline for LATUDA-treated patients was comparable to placebo on all 3 movement scales. 18 Longer-term, Open-label Extension Study in * Patients who completed any of the short-term studies described earlier (1 study of LATUDA monotherapy or 1 of 2 studies of LATUDA as adjunctive therapy with lithium or valproate) were eligible to enroll in a 6-month, flexible-dosing, open-label extension study. Eligible patients who received LATUDA in short-term studies were continued on LATUDA mg/day, and patients who received placebo in the short-term studies were switched to LATUDA in the longer-term extension study. Table 4 shows adverse events during the 6-month extension study for patients who were initially treated with LATUDA as adjunctive therapy or monotherapy. 23 *The effectiveness of LATUDA for longer-term use, that is, for more than 6 weeks, has not been established in controlled studies. Supplement to Clinician Reviews Vol 25, No 4 April 2015 S9

10 FIGURE 6. EFFICACY OF LATUDA AS ADJUNCTIVE THERAPY WITH LITHIUM OR VALPROATE FOR THE TREATMENT OF BIPOLAR DEPRESSION 24 LS Mean Change From Baseline Baseline Primary Endpoint: MADRS Total Score Time (Weeks) Effect size: 0.34 LATUDA mg +Li/VPA (n=179) * ** + Li/VPA (n=161) LS Mean Change From Baseline Time (Weeks) Baseline Key Secondary Endpoint: CGI-BP Depression Severity Score LATUDA mg +Li/VPA (n=179) * Effect size: ** + Li/VPA (n=161) Reduction in severity of depression Baseline mean = Baseline mean = *P<.05; **P<.01; P<.001. Abbreviations: CGI-BP, Clinical Global Impressions Scale-Bipolar version; Li, lithium; LS, least squares; MADRS, Montgomery-Åsberg Depression Rating Scale, VPA, valproate. MADRS scale range, 0-60; CGI-BP scale range, 1-7. Primary endpoint: Change in MADRS total score between baseline and Week 6. Key secondary endpoint: Change in CGI-BP depression severity total score between baseline and Week 6. FIGURE 7. ADVERSE REACTIONS OCCURRING IN AT LEAST 2% OF PATIENTS TREATED WITH LATUDA ADJUNCTIVE TO LITHIUM OR VALPROATE AND AT GREATER INCIDENCE THAN PLACEBO LATUDA mg + Li/VPA (N=360) + Li/VPA (N=334) Patients Nausea EPS* Abbreviation: EPS, extrapyramidal symptoms. Somnolence 5 5 Akathisia 4 Nasopharyngitis 2 Vomiting 4 4 Restlessness Fatigue <1 <1 Increased Appetite Weight Increased * EPS includes the following adverse events: bradykinesia, cogwheel rigidity, drooling, dystonia, extrapyramidal disorder, glabellar reflex abnormal, hypokinesia, muscle rigidity, oculogyric crisis, oromandibular dystonia, parkinsonism, psychomotor retardation, tongue spasm, torticollis, tremor, and trismus. Somnolence includes the following adverse event terms: hypersomnia, hypersomnolence, sedation, and somnolence. S10 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

11 TABLE 3. CHANGE IN METABOLIC PARAMETERS FROM BASELINE TO WEEK 6 IN PATIENTS TREATED WITH LATUDA MG/DAY OR PLACEBO AS ADJUNCTIVE THERAPY WITH LITHIUM OR VALPROATE 18 Parameter Adjunctive Therapy Weight (mean) 0.2 lb (n=327) 0.4 lb (n=307) Glucose (mean) 1.2 mg/dl (n=319) -0.9 mg/dl (n=302) Total cholesterol (mean) -3.1 mg/dl (n=321) -2.9 mg/dl (n=303) Triglycerides (mean) 4.6 mg/dl (n=321) -4.6 mg/dl (n=303) FIGURE 8. MOVEMENT DISORDER RATING SCALES 18 Patients With Categorical Shifts Movement Disorder Scales: Categorical Change SAS* BAS AIMS LATUDA mg + Li/VPA (n=355) + Li/VPA (n=327) Abbreviations: AIMS, Abnormal Involuntary Movement Scale; BAS, Barnes Akathisia Scale; Li, lithium; SAS, Simpson Angus Rating Scale; VPA, valproate. *Shift from normal at baseline to abnormal at LOCF endpoint. Worsening from baseline to LOCF endpoint. For both adjunctive therapy and monotherapy, adverse events are shown for patients who received LATUDA in both the double-blind and open-label studies (LATUDA- LATUDA) and for patients who received placebo in the double-blind study and who were switched to LATUDA in the extension study (placebo-latuda). 23 The mean changes from open-label baseline (ie, the beginning of the 6-month study) to Week 24 in weight (in pounds), glucose, and lipids, as well as the median change from open-label baseline to Week 24 in prolactin, are presented in Table Patients received LATUDA as monotherapy or as adjunctive therapy with lithium or valproate in the short-term studies and continued on LATUDA in the longer-term study. 23 Dosage and Administration LATUDA as monotherapy or adjunctive therapy is initiated at a dose of 20 mg once daily. Initial dose titration is not required. The LATUDA dose may be increased up to a maximum dose of 120 mg once daily as needed. In the 6-week monotherapy study described previously, the higher dose range ( mg/day) did not provide additional efficacy, on average, compared to the lower dose range (20-60 mg/day). LATUDA should be taken with food (at least 350 calories). 18 LATUDA is available in 20-, 40-, 60-, 80-, and 120-mg tablets. Dose adjustment is recommended for patients with moderate renal impairment (creatinine clearance, 30 ml/min to <50 ml/min) or severe renal impairment (creatinine clearance, <30 ml/min). For these patients, the recommended starting dose is 20 mg/day, and the maximum dose should not exceed 80 mg/day. 18 Dose adjustment is also required for some patients with hepatic impairment. The total LATUDA dose should not exceed 80 mg/day for patients with moderate hepatic impairment (Child-Pugh score, 7-9), or 40 mg/day for those with severe hepatic impairment (Child-Pugh score, 10-15). 18 LATUDA is metabolized mainly through the cytochrome P450 (CYP) 3A4 pathway and should not be administered with strong CYP3A4 inhibitors (eg, ketoconazole, clarithromycin, ritonavir, voriconazole, mibefradil) or strong CYP3A4 inducers (eg, rifampin, avasimibe, St. John s wort, phenytoin, carbamazepine). 18 When a moderate CYP3A4 inhibitor (eg, diltiazem, atazanavir, erythromycin, fluconazole, verapamil) is added to therapy with LATUDA, the LATUDA dose should be reduced to half of the original dose level. Supplement to Clinician Reviews Vol 25, No 4 April 2015 S11

12 TABLE 4. ADVERSE REACTIONS DURING 6-MONTH OPEN-LABEL EXTENSION STUDY, BY PRIOR TREATMENT DURING SHORT-TERM RANDOMIZED CLINICAL TRIALS. INCIDENCE OF ADVERSE EVENTS OCCURRING IN AT LEAST 5% OF PATIENTS IN ANY TREATMENT GROUP 23 Adjunctive Therapy Preferred Term LATUDA-LATUDA -LATUDA LATUDA-LATUDA -LATUDA n=254 n=243 n=210 n=106 Parkinsonism* Somnolence Akathisia Insomnia Anxiety Nausea Headache Depression Weight increased Nasopharyngitis Vomiting *Parkinsonism includes adverse event terms: bradykinesia, cogwheel rigidity, drooling, hypokinesia, muscle rigidity, parkinsonism, psychomotor retardation, and tremor. Somnolence includes adverse event terms: hypersomnia, sedation, and somnolence. TABLE 5. CHANGES IN METABOLIC ENDPOINTS AND PROLACTIN CONCENTRATION DURING THE 6-MONTH OPEN-LABEL EXTENSION STUDY 23 Parameter Adjunctive Therapy Weight (mean) 0.3 lb (n=153) 1.7 lb (n=173) Glucose (mean) 1.5 mg/dl (n=153) -0.5 mg/dl (n=181) Total cholesterol (mean) -0.1 mg/dl (n=154) 0.4 mg/dl (n=182) Triglycerides (mean) 1.5 mg/dl (n=154) 1.6 mg/dl (n=182) Prolactin (median) -1.1 ng/dl (n=154) -1.3 ng/dl (n=182) When LATUDA is added to therapy with a moderate CYP3A4 inhibitor, the recommended starting dose is 20 mg/day, and the maximum recommended dose is 80 mg/day. 18 If LATUDA is used concomitantly with a moderate CYP3A4 inducer, it may be necessary to increase the LATUDA dose after chronic treatment (at least 7 days) with the CYP3A4 inducer. 18 Grapefruit and grapefruit juice should be avoided in patients taking LATUDA, since these substances may inhibit CYP3A4 and alter LATUDA concentrations. 18 The mean elimination half-life of LATUDA 40 mg is 18 hours, 18 and steady-state concentrations are reached within 7 days of treatment initiation. 18 Administration with food substantially increases the absorption of LATUDA. When administered with food, LATUDA mean maximum concentration and area under the curve were about 3 times and 2 times, respectively, that of the levels observed under fasting conditions. LATUDA should be taken with food (at least 350 calories). LATUDA exposure was not affected as meal size was increased from 350 to 1000 calories, and it was independent of meal fat content. 18 LATUDA is designated pregnancy category B. 18 There are no adequate and well-controlled studies of LATUDA use in pregnant women. Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for EPS and/or withdrawal symptoms following delivery. LATUDA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. 18 In short-term, placebo-controlled studies, no postbaseline QT prolongations exceeding 500 msec S12 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

13 Expert Commentary Diane Snow, PhD, APRN, PMHNP-BC, CARN, FAANP, FIAAN Clinical Professor Director Psychiatric Mental Health Nurse Practitioner Program The University of Texas at Arlington College of Nursing and Health Innovation Arlington, Texas Private Practice Denton, Texas Very few medications are approved by the United States Food and Drug Administration (FDA) for major depressive episodes associated with bipolar I disorder (bipolar depression), one of which is LATUDA as monotherapy or adjunctive therapy with lithium or valproate. 1 As highlighted in the accompanying article, the efficacy, safety, and tolerability of LATUDA were established in two 6-week studies, which were published in The American Journal of Psychiatry. 2,3 Achieving level mood is of utmost importance in patients with bipolar disorder, and we must be diligent to find the right medication or combination of medications to achieve this goal. In my practice, I start with the recommended starting dose of LATUDA 20 mg/day, which may be increased until the maximum approved dose of 120 mg/day is reached. We should treat adequately and maintain the patient at the dose needed to promote resolution of the episode. In the LATUDA monotherapy study, higher doses (80 mg to 120 mg per day) did not provide additional efficacy, on average, compared with lower doses (20 to 60 mg per day). 2 Patients should be educated that LATUDA is to be taken with food (at least 350 calories). I find that some patients with depression have decreased appetite and may need encouragement to eat. Visual reminders prompting the patient to eat the required number of calories may help. Patients may also be provided with a list of foods that contain approximately 350 calories (eg, peanut butter and jelly sandwiches) and instructed to prepare food in advance and to store it with the medication. Family support may be needed to help patients to prepare food and to take LATUDA as indicated. It is important to monitor patients closely for side effects. In my practice, if a patient were to experience somnolence, for example, I may reduce the dose and titrate it more slowly until the somnolence is resolved. Furthermore, clinicians must be prudent in assessing any concomitant medications. For example, caution must be taken to reduce the LATUDA dose when LATUDA is administered in combination with moderate cytochrome P450 (CYP) 3A4 inducers or inhibitors. LATUDA is contraindicated in patients who are using strong CYP 3A4 inhibitors and inducers. LATUDA is a welcome addition to the treatment choices for depressive episodes associated with bipolar I disorder, and the results presented here demonstrate the efficacy and safety of LATUDA for these patients. References 1. LATUDA [prescribing information]. Marlborough, MA: Sunovion Pharmaceuticals Inc.; Loebel A, Cucchiaro J, Silva R, et al. Lurasidone monotherapy in the treatment of bipolar I depression: a randomized, double-blind, placebocontrolled study. Am J Psychiatry. 2014;171(2): Loebel A, Cucchiaro J, Silva R, et al. Lurasidone as adjunctive therapy with lithium or valproate for the treatment of bipolar I depression: a randomized, double-blind, placebo-controlled study. Am J Psychiatry. 2014;171(2): were reported in patients treated with LATUDA or placebo. 18 The mechanism of action of LATUDA in the treatment of schizophrenia and bipolar depression is unknown. However, its efficacy in schizophrenia and bipolar depression could be mediated through a combination of D 2 and serotonin Type 2 (5-HT 2A ) receptor antagonism. 18 In vitro receptor binding studies show that LATUDA is a high-affinity antagonist of the dopamine D 2 receptor (Ki=1.0 nm) and of the serotonin receptors 5-HT 2A (Ki=0.5 nm) and 5-HT 7 (Ki=0.5 nm). LATUDA binds with moderate affinity as a partial agonist at 5-HT 1A receptors (Ki=6.4 nm) and as an antagonist at adrenergic α 2A (Ki=41 nm) and α 2C (Ki=11 nm) receptors. 18 LATUDA exhibits little or no affinity for histamine H 1 and muscarinic M 1 receptors (IC 50 >1000 nm). 18 Supplement to Clinician Reviews Vol 25, No 4 April 2015 S13

14 BIPOLAR DEPRESSION: Perspectives From APNA A sample of 303 American Psychiatric Nurses Association (APNA) members who attended a live symposium on bipolar depression were surveyed using an audience-response system to characterize real-world perceptions and educational need related to screening, diagnosis, and treatment of bipolar disorder and bipolar depression. Response rate varied per question, and all data are shown below. Most survey participants were either nurse practitioners (57% [85/149 respondents to the question]) or registered nurses (32% [48/149 respondents]) who specialize in mental health. Approximately 75% (200/265 respondents) indicated that they attached a high level of importance to screening for bipolar disorder. Most respondents (80% [191/238]) indicated that they regularly ask about symptoms of mania when patients present with depressive symptoms. However, less than half (45% [92/205 respondents]) indicated that they had an established screening protocol for bipolar disorder (Figures 1 and 2). A majority of respondents (67%, 132/197) indicated limited awareness of clinical trial data showing the lack of efficacy of adding antidepressants to mood stabilizers in the treatment of bipolar depression (Figure 3). When asked about perceptions of bipolar depression related practices in the primary care setting, most respondents indicated low percep- FIGURE 1. RATE AT WHICH PSYCHIATRY-TRAINED NPs AND RNs INQUIRE ABOUT MANIC SYMPTOMS 80% indicated a top-2 box rating 80 Respondents % (n=238) % 1% 2% 4% 1 = Never = Always 12% 15% 66% On a scale of 1 to 7, how often do you inquire about symptoms of mania when patients present with depressive symptoms? 1. Never 7. Always Abbreviations: NPs, nurse practitioners; RNs, registered nurses. S14 April 2015 Vol 25, No 4 Supplement to Clinician Reviews

15 FIGURE 2. PRACTICES WITH A BIPOLAR SCREENING PROTOCOL In your practice setting, do you have a protocol for screening patients for bipolar disorder? (n=205) No 45% Yes 55% tion of confidence in developing a treatment plan for patients with bipolar depression and little familiarity with approved treatment options for bipolar depression in primary care. The survey results suggest that formalized bipolar screening protocols are lacking in the primary care setting. The results further indicate that all healthcare professionals involved in the diagnosis and management of patients with bipolar disorder should be educated on clinical trial results related to efficacy, safety, and tolerability of available treatments for bipolar disorder. FIGURE 3. PERCEPTIONS OF ADDING ANTIDEPRESSANTS TO A MOOD STABILIZER 80 Respondents % (n=197) % 55% 12% 0 True False Uncertain In the treatment of bipolar disorder, an antidepressant added to a mood stabilizer is no more effective than placebo added to a mood stabilizer. True False Uncertain Supplement to Clinician Reviews Vol 25, No 4 April 2015 S15

16 Conclusions The diagnosis and treatment of bipolar depression can be challenging in the specialist and primary care settings, and studies have shown that antidepressant therapy typically provides little benefit for patients with bipolar disorder. A lack of formalized bipolar disorder screening protocols was underscored in a survey of attendees at an American Psychiatric Nurses Association meeting (see : Perspectives From APNA on page S14). The survey results also suggest that all healthcare professionals involved in the diagnosis and management of patients with bipolar disorder should be educated on clinical trial results related to efficacy, safety, and tolerability of available treatments for bipolar disorder. LATUDA is indicated for the treatment of major depressive episodes associated with bipolar I disorder (bipolar depression) as monotherapy and as adjunctive therapy with lithium or valproate. Improvement of symptoms of bipolar depression with LATUDA was reported in 2 randomized, doubleblind, 6-week clinical trials, including 1 trial in which LATUDA was administered as monotherapy and 1 trial in which LATUDA was administered as adjunctive therapy with lithium or valproate. The safety and tolerability of LATUDA were demonstrated in clinical studies lasting up to 6 months. The recommended starting dose of 20 mg/day is an effective dose that does not require initial titration. The maximum recommended dose is 120 mg/day. LATUDA should be taken with food (at least 350 calories). References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; Hirschfeld RM, Vornik LA. Recognition and diagnosis of bipolar disorder. J Clin Psychiatry. 2004;65(suppl 15): Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6): Hirschfeld RM, Vornik LA. Bipolar disorder costs and comorbidity. Am J Manag Care. 2005;11(3 suppl):s85-s Weiner M, Warren L, Fiedorowicz JG. Cardiovascular morbidity and mortality in bipolar disorder. Ann Clin Psychiatry. 2011;23(1): Hirschfeld RM, Calabrese JR, Weissman MM, et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64(1): Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic- Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64(2): Berk M, Berk L, Moss K, Dodd S, Malhi GS. Diagnosing bipolar disorder: how can we do it better? Med J Aust. 2006;184(9): Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord. 2005;84(2-3): Bowden CL. Strategies to reduce misdiagnosis of bipolar depression. Psychiatr Serv. 2001;52(1): Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11): Kessler RC, Akiskal HS, Angst J, et al. Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0. J Affect Disord. 2006;96(3): Gaynes BN, DeVeaugh-Geiss J, Weir S, et al. Feasibility and diagnostic validity of the M-3 checklist: a brief, self-rated screen for depressive, bipolar, anxiety, and post-traumatic stress disorders in primary care. Ann Fam Med. 2010;8(2): Angst J, Adolfsson R, Benazzi F, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 2005;88(2): Depression and Bipolar Support Alliance. The Mood Disorder Questionnaire. Accessed November 10, Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356(17): Valentí M, Pacchiarotti I, Bonnín CM, et al. Risk factors for antidepressantrelated switch to mania. J Clin Psychiatry. 2012;73(2):e271-e276. doi: / JCP.11m LATUDA [prescribing information]. Marlborough, MA: Sunovion Pharmaceuticals Inc.; Montgomery SA, Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134: Spearing MK, Post RM, Leverich GS, Brandt D, Nolen W. Modification of the Clinical Global Impressions (CGI) Scale for use in bipolar illness (BP): the CGI-BP. Psychiatry Res. 1997;73(3): Bech P, Tanghøj P, Andersen HF, Overø K. Citalopram dose-response revisited using an alternative psychometric approach to evaluate clinical effects of four fixed citalopram doses compared to placebo in patients with major depression. Psychopharmacology (Berl). 2002;163(1): Loebel A, Cucchiaro J, Silva R, et al. Lurasidone monotherapy in the treatment of bipolar I depression: a randomized, double-blind, placebo-controlled study. Am J Psychiatry. 2014;171(2): Data on file. Sunovion Pharmaceuticals Inc. 24. Loebel A, Cucchiaro J, Silva R, et al. Lurasidone as adjunctive therapy with lithium or valproate for the treatment of bipolar I depression: a randomized, doubleblind, placebo-controlled study. Am J Psychiatry. 2014;171(2): S16 April 2015 Vol 25, No 4 Supplement to Clinician Reviews