51
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Zhang D, Li H, Ding K, Zhang Z, Luo S, Li G. Polymorphisms in MicroRNA Genes Associated with Schizophrenia Susceptibility but Not with Effectiveness of MECT. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:1959172. [PMID: 34938351 PMCID: PMC8687787 DOI: 10.1155/2021/1959172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/26/2021] [Indexed: 01/03/2023]
Abstract
Schizophrenia (SCZ) is a common and complex psychiatric disease associated with hereditary and environmental risk factors. MicroRNAs (miRNAs or miRs) are small, noncoding RNA molecules that endogenously regulate gene expression. Single nucleotide polymorphisms (SNPs) in related miRNA genes are associated with susceptibility of the disorder. We wonder if the SNPs have influence on the effectiveness of modified electroconvulsive therapy (MECT) for SCZ. rs1625579 within miR-137, rs6577555 within miR-34, and rs2296616 within miR-107 were sequenced in 150 cases and 150 controls to check the potential association between the SNPs and SCZ. Our results showed that allele G in rs1625579 (p = 0.005, adjusted OR = 1.379, 95%CI = 1.108 - 1.634), allele A in rs6577555 (p = 0.014, adjusted OR = 1.246, 95%CI = 1.045 - 1.463), allele G in rs2296616 (p < 0.001, adjusted OR = 1.646, 95%CI = 1.374 - 1.879) are positively associated with the disorder risk. MECT courses did significantly decrease the level of the miRNAs, except for the variant of rs2296616 with the AA genotype. Schizophrenic phenotypes assessed by the positive and negative syndrome scale (PANSS) were improved after MECT, and there was no significant relevance observed between the effectiveness of MECT and the variants of these loci. Thus, our findings indicate that polymorphisms within the loci may be involved in the pathogenesis of SCZ, and MECT is effective and unbiased for patients harboring different genotypes of the loci.
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Affiliation(s)
- Danwei Zhang
- Department of Psychiatry, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
| | - Huihua Li
- Department of Psychology, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
| | - Kaimo Ding
- Department of Psychology, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
| | - Zhen Zhang
- Department of Psychiatry, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
| | - Si Luo
- Department of Psychiatry, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
| | - Guohai Li
- Department of Psychiatry, Zhenjiang Mental Health Center, Zhenjiang, Jiangsu Province, China
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52
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Martin DM, Tor PC, Waite S, Mohan T, Davidson D, Sarma S, Branjerdporn G, Dong V, Kwan E, Loo CK. The utility of the brief ECT cognitive screen (BECS) for early prediction of cognitive adverse effects from ECT: A CARE network study. J Psychiatr Res 2021; 145:250-255. [PMID: 34952375 DOI: 10.1016/j.jpsychires.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/04/2021] [Accepted: 12/10/2021] [Indexed: 11/15/2022]
Abstract
Although highly effective, electroconvulsive therapy (ECT) often produces cognitive side effects which can be a barrier for patients. Monitoring cognitive side effects during the acute course is therefore recommended to identify patients at increased risk for adverse outcomes. The Brief ECT Cognitive Screen (BECS) is a brief instrument designed to measure emerging cognitive side effects from ECT. The aim of this study was to examine the clinical utility of the BECS for predicting adverse cognitive outcomes in real world clinic settings. The study included data collated from four participating sites in the Clinical Alliance for ECT and Related treatments (CARE) network. The BECS was administered at pre ECT and post 3 or 4 ECT. The primary outcome was a ≥4 point decrease on the Montreal Cognitive Assessment (MoCA) from pretreatment to post ECT. Logistic multiple regression analyses examined the BECS and other relevant clinical and demographic and treatment factors as predictors. The final analysis included 623 patients with diverse indications for ECT including 53.6% with major depression and 33.7% with schizophrenia or schizoaffective disorder. A higher total score on the BECS significantly predicted decline in Total Scores on the MoCA [B = 0.25 (0.08), p = 0.003], though not decline in MoCA Delayed Recall scores (p > 0.1). Other significant predictors included higher pretreatment MoCA Total Scores and female gender for verbal anterograde memory decline. This study confirmed that the BECS has clinical utility for identifying patients with both reduced and increased risk for adverse cognitive outcomes from ECT.
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Affiliation(s)
- D M Martin
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia.
| | - P C Tor
- Institute of Mental Health, Singapore
| | - S Waite
- The Queen Elizabeth Hospital, South Australia, Australia
| | - T Mohan
- Flinders Medical Centre, South Australia, Australia
| | - D Davidson
- Flinders Medical Centre, South Australia, Australia
| | - S Sarma
- Gold Coast Health Service, Queensland, Australia
| | | | - V Dong
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia
| | - E Kwan
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - C K Loo
- School of Psychiatry, University of New South Wales, Sydney, NSW, Australia; Black Dog Institute, Sydney, NSW, Australia
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53
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Wilkinson ST, Rhee TG, Tsai J. Utilization of Electroconvulsive Therapy for Older Homeless Adults Covered by Medicare. Psychiatr Q 2021; 92:1825-1837. [PMID: 34468909 DOI: 10.1007/s11126-021-09946-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
This study sought to examine the association between homelessness and receipt of electroconvulsive therapy (ECT) among older Medicare beneficiaries with homelessness. Among individuals with major depressive disorder who were older (age 65+) Medicare beneficiaries (2014-2015 data), we compared clinical and sociodemographic characteristics among those who were homeless and received ECT, those who were not homeless and received ECT, those who were homeless and did not receive ECT, and those who were domiciled and did not receive ECT. The unadjusted rate of ECT use among older homeless individuals with depression (1.46%) was higher than the rate of ECT use among older non-homeless individuals with depression (0.41%). Among all individuals receiving ECT, homeless individuals started as inpatients at a greater rate (94.0% v. 72.6%) and transitioned to outpatient ECT at a lower rate (23.8% v. 44.5%) compared to their domiciled counterparts. The individuals in the ECT/homeless group had more psychiatric comorbidities compared to all other groups. After adjusting for significant covariates, homelessness was associated with a lower odds ratio (0.74, 95% CI 0.55-0.99) of receiving ECT. Our data suggest that ECT can be provided to homeless individuals at rates comparable to domiciled individuals. The psychosocial support typically required for an ECT course may prove difficult for homeless patients in the outpatient setting, which may be an area for further development.
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Affiliation(s)
- Samuel T Wilkinson
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06511, USA. .,Interventional Psychiatric Service, Yale School of Medicine, New Haven, CT, 06511, USA.
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06511, USA
| | - Jack Tsai
- School of Public Health, University of Texas Health Science Center At Houston, San Antonio campus, Houston, TX, 78229, USA
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54
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Wu Q, Wang X, Wang Y, Long YJ, Zhao JP, Wu RR. Developments in Biological Mechanisms and Treatments for Negative Symptoms and Cognitive Dysfunction of Schizophrenia. Neurosci Bull 2021; 37:1609-1624. [PMID: 34227057 PMCID: PMC8566616 DOI: 10.1007/s12264-021-00740-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/05/2021] [Indexed: 12/12/2022] Open
Abstract
The causal mechanisms and treatment for the negative symptoms and cognitive dysfunction in schizophrenia are the main issues attracting the attention of psychiatrists over the last decade. The first part of this review summarizes the pathogenesis of schizophrenia, especially the negative symptoms and cognitive dysfunction from the perspectives of genetics and epigenetics. The second part describes the novel medications and several advanced physical therapies (e.g., transcranial magnetic stimulation and transcranial direct current stimulation) for the negative symptoms and cognitive dysfunction that will optimize the therapeutic strategy for patients with schizophrenia in future.
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Affiliation(s)
- Qiongqiong Wu
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Xiaoyi Wang
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Ying Wang
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Yu-Jun Long
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China
| | - Jing-Ping Zhao
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
| | - Ren-Rong Wu
- National Clinical Research Center for Mental Disorders, Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.
- Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.
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55
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Siskind D, Sharma M, Pawar M, Pearson E, Wagner E, Warren N, Kisely S. Clozapine levels as a predictor for therapeutic response: A systematic review and meta-analysis. Acta Psychiatr Scand 2021; 144:422-432. [PMID: 34374073 DOI: 10.1111/acps.13361] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Clozapine levels may be a more useful predictor of therapeutic response than the dose, given the variability in clozapine metabolism between individuals. We therefore systematically reviewed and meta-analysed the impact of clozapine levels on response and/or relapse to provide guidance on optimal clozapine levels. METHODS We systematically searched PubMed, PsycInfo and Embase for studies exploring clozapine levels and response and/or relapse. Our primary meta-analysis was rates of response above and below clozapine level thresholds of 350 ng/ml and 600 ng/ml. Secondary analyses were undertaken of mean clozapine levels, dose and concentration/dose (C/D) ratio and response and/or relapse. A meta-regression by study duration was conducted. RESULTS Twenty studies met inclusion criteria. Clozapine levels above 350 ng/ml were associated with statistically significantly higher rates of response (OR 2.27 95% CI 1.40-3.67, p < 0.001), but not above 600 ng/ml (OR 1.40 95% CI 0.85-2.31, p = 0.19). Higher mean clozapine levels were associated with better rates of response (SMD 0.24, 95% CI 0.00-0.49, p = 0.05), and lower rates of relapse (SMD -0.72, 95% CI -1.26 to -0.19, p = 0.008). By contrast, neither clozapine dose nor C/D ratio was associated with differing rates of response. Similarly, study duration did not affect outcome. CONCLUSIONS Our findings are in keeping with current guidelines that recommend targeting clozapine levels above 350 ng/ml before augmentation is considered. As some clozapine associated ADRs are dose dependent, levels above 600 ng/ml may have an unfavourable risk-benefit ratio.
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Affiliation(s)
- Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Meghna Sharma
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Cairns Base Hospital, Cairns, QLD, Australia
| | - Mrinal Pawar
- School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Ella Pearson
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Nicola Warren
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Steve Kisely
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia.,Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia.,Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
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56
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Das A, Minner R, Krain L, Spollen J. Delirium on clozapine: A tale of friend turned foe-A case report. Int J Psychiatry Med 2021; 56:446-458. [PMID: 33148081 DOI: 10.1177/0091217420972827] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.
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Affiliation(s)
- Aparna Das
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca Minner
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lewis Krain
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John Spollen
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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57
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Argyelan M, Lencz T, Kang S, Ali S, Masi PJ, Moyett E, Joanlanne A, Watson P, Sanghani S, Petrides G, Malhotra AK. ECT-induced cognitive side effects are associated with hippocampal enlargement. Transl Psychiatry 2021; 11:516. [PMID: 34625534 PMCID: PMC8501017 DOI: 10.1038/s41398-021-01641-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/16/2021] [Accepted: 09/09/2021] [Indexed: 02/08/2023] Open
Abstract
Electroconvulsive therapy (ECT) is of the most effective treatments available for treatment-resistant depression, yet it is underutilized in part due to its reputation of causing cognitive side effects in a significant number of patients. Despite intensive neuroimaging research on ECT in the past two decades, the underlying neurobiological correlates of cognitive side effects remain elusive. Because the primary ECT-related cognitive deficit is memory impairment, it has been suggested that the hippocampus may play a crucial role. In the current study, we investigated 29 subjects with longitudinal MRI and detailed neuropsychological testing in two independent cohorts (N = 15/14) to test if volume changes were associated with cognitive side effects. The two cohorts underwent somewhat different ECT study protocols reflected in electrode placements and the number of treatments. We used longitudinal freesurfer algorithms (6.0) to obtain a bias-free estimate of volume changes in the hippocampus and tested its relationship with neurocognitive score changes. As an exploratory analysis and to evaluate how specific the effects were to the hippocampus, we also calculated this relationship in 41 other areas. In addition, we also analyzed cognitive data from a group of healthy volunteers (N = 29) to assess practice effects. Our results supported the hypothesis that hippocampus enlargement was associated with worse cognitive outcomes, and this result was generalizable across two independent cohorts with different diagnoses, different electrode placements, and a different number of ECT sessions. We found, in both cohorts, that treatment robustly increased the volume size of the hippocampus (Cohort 1: t = 5.07, Cohort 2: t = 4.82; p < 0.001), and the volume increase correlated with the neurocognitive T-score change. (Cohort 1: r = -0.68, p = 0.005; Cohort 2: r = -0.58; p = 0.04). Overall, our research indicates that novel treatment methods serving to avoid hippocampal volume increase may result in a better side effect profile.
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Affiliation(s)
- Miklos Argyelan
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA.
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Todd Lencz
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Simran Kang
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Sana Ali
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Paul J Masi
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Emily Moyett
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Andrea Joanlanne
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Philip Watson
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
| | - Sohag Sanghani
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Georgios Petrides
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Anil K Malhotra
- Psychiatry Research, The Zucker Hillside Hospital, Glen Cove, NY, USA
- Institute of Behavioral Science, Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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58
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Shan X, Zhang H, Dong Z, Chen J, Liu F, Zhao J, Zhang H, Guo W. Increased subcortical region volume induced by electroconvulsive therapy in patients with schizophrenia. Eur Arch Psychiatry Clin Neurosci 2021; 271:1285-1295. [PMID: 34275006 DOI: 10.1007/s00406-021-01303-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/04/2021] [Indexed: 02/08/2023]
Abstract
Electroconvulsive therapy (ECT) has been widely used to treat patients with schizophrenia. However, the underlying mechanisms of ECT remain unknown. In the present study, the treatment effects of ECT on brain structure in patients with schizophrenia were explored. Seventy patients with schizophrenia were scanned using structural magnetic resonance imaging. Patients in the drug group were scanned at baseline (time 1) and follow-up (time 2, 6 weeks of treatment). Patients in the ECT group were scanned before ECT treatment (baseline, time 1) and 10-12 h after the last ECT treatment (time 2). Voxel-based morphometry was applied to analyze the imaging data. Patients in the ECT group showed significantly increased gray matter volume (GMV) in the bilateral hippocampus/amygdala and left superior temporal gyrus (STG)/middle temporal gyrus (MTG) after ECT combined with antipsychotic therapy at time 2. In contrast, patients in the drug group showed decreased GMV in widespread brain regions. Correlation analysis results showed significantly negative correlations between the increased GMV in the bilateral hippocampus/amygdala and PANSS scores at baseline in the ECT group. ECT may modulate brain structure in patients with schizophrenia. The GMV in distinct subcortical regions was related to the individual therapeutic response in patients with schizophrenia.
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Affiliation(s)
- Xiaoxiao Shan
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Haisan Zhang
- The Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453002, Henan, China.,Xinxiang Key Laboratory of Multimodal Brain Imaging, Xinxiang, 453002, Henan, China
| | - Zhao Dong
- The Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453002, Henan, China.,Zhumadian Psychiatric Hospital, Zhumadian, 463000, Henan, China
| | - Jindong Chen
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Feng Liu
- Department of Radiology, Tianjin Medical University General Hospital, Tianjin, 300000, China
| | - Jingping Zhao
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Hongxing Zhang
- The Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453002, Henan, China. .,Xinxiang Key Laboratory of Multimodal Brain Imaging, Xinxiang, 453002, Henan, China. .,School of Psychology, Xinxiang Medical University, Xinxiang, 453003, Henan, China.
| | - Wenbin Guo
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China. .,Department of Psychiatry, The Third People's Hospital of Foshan, Foshan, 528000, Guangdong, China.
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59
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Tor PC, Tan XW, Martin D, Loo C. Comparative outcomes in electroconvulsive therapy (ECT): A naturalistic comparison between outcomes in psychosis, mania, depression, psychotic depression and catatonia. Eur Neuropsychopharmacol 2021; 51:43-54. [PMID: 34034099 DOI: 10.1016/j.euroneuro.2021.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/24/2022]
Abstract
Electroconvulsive Therapy's (ECT) use and place in treatment guidelines varies worldwide with a primary indication of depression in Western countries and acute psychosis in Asian countries. There is sparse evidence about the relative effectiveness of ECT among different indications that may account for this discrepancy. We aimed to compare the clinical global impression of disease severity, cognitive change, subjective quality of life (QoL) and global functioning after ECT given for treatment of the indications of acute psychosis, mania, depression, psychotic depression and catatonia. We conducted a retrospective naturalistic cohort study with post-hoc analyses of patients' ECT registry data from 2017 to 2019. 691 patients were assessed before and after 6 sessions of ECT treatment, using the Clinical Global Impression-Improvement and Severity (CGI-I and CGI-S) scale, Montreal Cognitive Assessment (MoCA), Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF), EQ-5D utility score and Global Assessment of Functioning (GAF) scale. The pre-ECT vs post-ECT clinical assessment change scores were compared within and across the five indications. For each indication, there were large improvements in clinical global impression of disease severity, QoL and global functioning. There were no significant changes in MoCA score for most indications except for an improvement in patients with schizophrenia. ECT is a rapidly acting and effective acute treatment across several severe mental illnesses with large improvements in symptoms, QoL and global functioning.
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Affiliation(s)
- Phern Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, Singapore 539747; Neurostimulation Service, Institute of Mental Health, Singapore 539747; Duke-NUS Graduate Medical School, Singapore 169857.
| | - Xiao Wei Tan
- Department of Mood and Anxiety, Institute of Mental Health, Singapore 539747
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Randwick, NSW, 2031, Australia; Black Dog Institute, Hospital Road, Randwick, NSW, 2031, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Randwick, NSW, 2031, Australia; Black Dog Institute, Hospital Road, Randwick, NSW, 2031, Australia; The Wesley Hospital, 7 Blake St, Kogarah, NSW, 2217, Australia; St. George Hospital, Gray St, Kogarah, NSW, 2217, Australia; Northside Group St Leonards Clinic, 2 Frederick St, St Leonards, NSW, 2065, Australia
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60
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Singh R, Sharma R, Prakash J, Chatterjee K. Magnetic seizure therapy. Ind Psychiatry J 2021; 30:S320-S321. [PMID: 34908721 PMCID: PMC8611602 DOI: 10.4103/0972-6748.328841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/03/2021] [Accepted: 07/22/2021] [Indexed: 12/02/2022] Open
Abstract
Magnetic seizure therapy is a novel form of focal convulsive treatment wherein magnetic field passes through the scalp and skull without impedance. In many ways, it has the potential to be superior to electroconvulsive therapy (ECT) as the anesthesia-associated side effects and cognitive impairments are less. It also may be an alternative for those who do not opt for ECT because of the stigma associated with it.
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Affiliation(s)
- Rishabh Singh
- Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
| | - Rachit Sharma
- Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
| | - Jyoti Prakash
- Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
| | - Kaushik Chatterjee
- Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
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61
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Tan XW, Oon LK, Tsang YYT, Ong HS, Tor PC. A Pilot Study of Switching Electroconvulsive Therapy for Patients With Treatment Resistant Schizophrenia or Mood Disorder. J ECT 2021; 37:202-206. [PMID: 33625174 DOI: 10.1097/yct.0000000000000747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Switching of ECT electrode modality is commonly done in clinical practice but outcomes are unclear. We aimed to compare the clinical outcomes between ECT modality switchers and nonswitchers in a large tertiary psychiatric institution over 1 year. METHODS Brief Psychiatric Rating Scale (BPRS), Montgomery-Åsberg Depression Rating Scale (MADRS) and Montreal Cognitive Assessment (MoCA) were used to assess symptoms and cognition. General linear regression was utilized to compare the change of BPRS or MADRS and MoCA score among switchers vs nonswitchers. RESULTS 21.5% of 209 patients switched ECT. Baseline BPRS scores were lower among nonswitchers. Response rate in schizophrenia, depression and mania were higher for nonswitchers (69.6%, 81.35% and 84.8% respectively / 9.2 (SD 3.3) sessions) compared to switchers (53.8%, 0% and 66.7% respectively / 10.6 (SD 4.5) sessions). Most common ECT switches were Bifrontal (BF) to Bitemporal (BT) (schizophrenia), UB RUL (ultrabrief right unilateral) to BT (depression), and UB RUL to BT / BF (mania). There was no significant difference in the change of BPRS and MoCA scores between nonswitchers and switchers. However, there was significantly more improvement of MADRS scores among nonswitchers [adjusted mean ± SE: (-26.4 ± 2.8)] compared with switchers (-10.6) ±6.6). CONCLUSIONS ECT switching was commonly done and may result in better or worse outcomes than not switching depending on diagnosis. Controlled trials are required to address this urgent clinical issue.
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Affiliation(s)
- Xiao Wei Tan
- From the Departments of Mood Disorder and Anxiety
| | - Li Keat Oon
- Developmental Psychiatry, Institute of Mental Health
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Methfessel I, Besse M, Belz M, Zilles‐Wegner D. Effectiveness of maintenance electroconvulsive therapy-Evidence from modifications due to the COVID-19 pandemic. Acta Psychiatr Scand 2021; 144:238-245. [PMID: 33960406 PMCID: PMC8212113 DOI: 10.1111/acps.13314] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/20/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Continuation and maintenance ECT (c-/m-ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c-/m-ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c-/m-ECT schedules. METHODS In the context of the COVID-19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c-/m-ECT in March and April 2020 at our department (n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c-/m-ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. RESULTS Both reduced frequency and discontinuation of c-/m-ECT were associated with significant clinical deterioration as measured by CGI-I (Clinical Global Impression Scale - Global Improvement) during the six-month follow-up when compared to the subgroup of patients without any treatment modification (p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c-/m-ECT showed significantly higher rates of rehospitalizations (p = 0.028) and new acute courses of ECT (p = 0.018). CONCLUSION Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c-/m-ECT in a real-world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.
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Affiliation(s)
- Isabel Methfessel
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - Matthias Besse
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - Michael Belz
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
| | - David Zilles‐Wegner
- Department of Psychiatry and PsychotherapyUniversity Medical Center GöttingenGöttingenGermany
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Døssing E, Pagsberg AK. Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines. J ECT 2021; 37:158-170. [PMID: 34424874 DOI: 10.1097/yct.0000000000000761] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
ABSTRACT There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.
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Affiliation(s)
- Erik Døssing
- From the Child and Adolescent Mental Health Centre, Mental Health Services, Zealand Region, Roskilde
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Grover S, Shouan A, Chakrabarti S, Sahoo S, Mehra A. Comparative study of effectiveness of augmentation with ECT in clozapine resistant schizophrenia (CRS) and non-clozapine resistant schizophrenia (Non-CRS). Nord J Psychiatry 2021; 75:397-405. [PMID: 33630681 DOI: 10.1080/08039488.2021.1877349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is limited evidence for different treatment strategies in patients with clozapine resistant schizophrenia (CRS). AIM To determine the effectiveness of ECT in patients with clozapine resistant schizophrenia and compare the same with a group of patients with non-clozapine resistant schizophrenia, receiving ECT. RESULTS Out of a total of 68 patients with schizophrenia, 27 (38.66%) of patients had CRS. With 6 ECTs, there was a significant reduction in PANSS positive, negative, general psychopathology, prosocial score and depression symptoms in the CRS (p < 0.001) and Non-CRS group (p < 0.001), but no statistically significant difference was seen between the 2 groups in terms of proportion of patients showing >40% response on PANSS total score. The reduction in PANSS score of >40% in CRS group was seen in 48.1% of patients in the positive symptoms subscale, in 25.9% of patients in negative symptoms subscale, in 46.7% of cases in the general psychopathology subscale, in 44.4% of the patients in Depression subscale, in 29.6% of the patients in the modified prosocialsubscaleand in 29.6% of the patients in total PANSS score. CONCLUSION ECT is an effective augmentation strategy for patients with CRS and it is as effective as when used in patients with non-CRS.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Shouan
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Swapnajeet Sahoo
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aseem Mehra
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Minwalla HD, Wrzesinski P, Desforges A, Caskey J, Wagner B, Ingraffia P, Patterson JC, Edinoff AN, Kaye AM, Kaye AD, Viswanath O, Urits I. Paliperidone to Treat Psychotic Disorders. Neurol Int 2021; 13:343-358. [PMID: 34449689 PMCID: PMC8396046 DOI: 10.3390/neurolint13030035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/09/2021] [Accepted: 06/30/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding the use of paliperidone in the treatment of schizophrenia and schizoaffective disorder. It covers the background and presentation of schizophrenia and schizoaffective disorder, as well as the mechanism of action and drug information for paliperidone. It covers the existing evidence of the use of paliperidone for the treatment of schizophrenia and schizoaffective disorder. RECENT FINDINGS Schizophrenia and schizoaffective disorder lead to significant cognitive impairment. It is thought that dopamine dysregulation is the culprit for the positive symptoms of schizophrenia and schizoaffective disorder. Similar to other second-generation antipsychotics, paliperidone has affinity for dopamine D2 and serotonin 5-HT2A receptors. Paliperidone was granted approval in the United States in 2006 to be used in the treatment of schizophrenia and in 2009 for schizoaffective disorder. SUMMARY Schizophrenia and schizoaffective disorder have a large impact on cognitive impairment, positive symptoms and negative symptoms. Patients with either of these mental illnesses suffer from impairments in everyday life. Paliperidone has been shown to reduce symptoms of schizophrenia and schizoaffective disorder.
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Affiliation(s)
- Hormazd D. Minwalla
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71103, USA; (P.W.); (J.C.P.II); (A.N.E.)
- Correspondence: ; Tel.: +1-318-675-6619
| | - Peter Wrzesinski
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71103, USA; (P.W.); (J.C.P.II); (A.N.E.)
| | - Allison Desforges
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA; (A.D.); (J.C.); (B.W.); (P.I.)
| | - Joshua Caskey
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA; (A.D.); (J.C.); (B.W.); (P.I.)
| | - Brittany Wagner
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA; (A.D.); (J.C.); (B.W.); (P.I.)
| | - Patrick Ingraffia
- School of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA; (A.D.); (J.C.); (B.W.); (P.I.)
| | - James C. Patterson
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71103, USA; (P.W.); (J.C.P.II); (A.N.E.)
| | - Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71103, USA; (P.W.); (J.C.P.II); (A.N.E.)
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA;
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- College of Medicine, Phoenix Campus, University of Arizona, Phoenix, AZ 84006, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE 68124, USA
- Valley Anesthesiology and Pain Consultants—Envision Physician Services, Phoenix, AZ 84006, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University, Shreveport, LA 71103, USA; (A.D.K.); (O.V.); (I.U.)
- Southcoast Physicians Group Pain Medicine, Southcoast Health, Wareham, MA 02720, USA
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Zierhut MM, Bernard RM, Turner E, Mohamad S, Hahn E, Bajbouj M. Electroconvulsive therapy for negative symptoms in schizophrenia: a literature review from 2000 to 2021. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01989-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AbstractNegative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.
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Wilkinson ST, Kitay BM, Harper A, Rhee TG, Sint K, Ghosh A, Lopez MO, Saenz S, Tsai J. Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners. Psychiatr Serv 2021; 72:752-757. [PMID: 33971727 DOI: 10.1176/appi.ps.202000387] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder; yet, its use is confined to <1% of individuals with this disorder. The authors aimed to examine barriers to ECT from the perspective of the provider. METHODS Qualitative interviews were conducted with U.S.-based ECT providers to identify potential barriers. A quantitative survey was created asking providers to rank-order barriers to starting a new ECT service or expanding existing services. RESULTS Survey responses were received from 192 physicians. Respondents were representative of all ECT providers found in the Medicare Provider Utilization and Payment Database with respect to gender and geographic distribution. Approximately one-third (N=58, 30%) of survey respondents graduated from one of 12 residency programs. Programs with dedicated hospital space were more likely to have larger services than those borrowing surgical recovery space (χ2=25.87, df=1, p<0.001). The most prominent provider-reported barriers to expanding an existing ECT service were lack of physical space, stigma on the part of patients, and transportation difficulties. The most prominent barriers to initiating a new service were lack of well-trained colleagues and ECT practitioners, lack of a champion within the institution, and lack of physical space. Wide geographic variation was found in the availability of ECT, with the highest concentration of ECT providers per 1 million individuals found in New England (6.4), and the lowest found in the West South Central (1.1). CONCLUSIONS Coordinated efforts to overcome identified barriers may allow ECT to be more broadly implemented. Investments in education may increase the number of competent practitioners.
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Affiliation(s)
- Samuel T Wilkinson
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Brandon M Kitay
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Annie Harper
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Taeho Greg Rhee
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Kyaw Sint
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Ahana Ghosh
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Mayra Ortiz Lopez
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Sabina Saenz
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Jack Tsai
- Yale Depression Research Program (Wilkinson, Kitay, Sint, Ghosh, Lopez, Saenz), Interventional Psychiatric Service (Wilkinson, Kitay, Ghosh, Lopez, Saenz), and Yale Program for Recovery and Community Health (Harper), Yale School of Medicine, New Haven, Connecticut; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington (Rhee); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
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Salagre E, Rohde C, Ishtiak-Ahmed K, Gasse C, Østergaard SD. Survival Rate Following Involuntary Electroconvulsive Therapy: A Population-Based Study. J ECT 2021; 37:94-99. [PMID: 33337646 DOI: 10.1097/yct.0000000000000736] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Involuntary electroconvulsive therapy (ECT) can be a lifesaving intervention for patients suffering from potentially lethal conditions who are unable to give informed consent. However, its use is not widespread, probably partly because of the scarce data on hard outcomes following involuntary ECT. In Denmark, involuntary ECT is only used when patients are at imminent/potential risk of dying if not receiving ECT. Here, we aimed to estimate the 1-year survival rate after the administration of involuntary ECT as a proxy for the effectiveness of this treatment. METHODS We conducted a register-based cohort study involving (i) all patients receiving involuntary ECT in Denmark between 2008 and 2019, (ii) age- and sex-matched patients receiving voluntary ECT, and (iii) age- and sex-matched individuals from the general population. One-year survival rates were compared via mortality rate ratios. RESULTS We identified 618 patients receiving involuntary ECT, 547 patients receiving voluntary ECT, and 3080 population-based controls. The survival rate in the year after involuntary ECT was 90%. For patients receiving involuntary ECT, the 1-year mortality rate ratios were 3.1 (95% confidence interval, 1.9-5.2) and 5.8 (95% confidence interval, 4.0-8.2) compared with those receiving voluntarily ECT and to the population-based controls, respectively. Risk factors for early death among patients receiving involuntary ECT were male sex, being 70 years or older and having organic mental disorder as the treatment indication. CONCLUSIONS Treatment with involuntary ECT is associated with a high survival rate, suggesting that the intervention is effective. However, patients receiving involuntary ECT constitute a high-risk population that should be monitored closely after this treatment.
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Moon SY, Kim M, Lho SK, Oh S, Kim SH, Kwon JS. Systematic Review of the Neural Effect of Electroconvulsive Therapy in Patients with Schizophrenia: Hippocampus and Insula as the Key Regions of Modulation. Psychiatry Investig 2021; 18:486-499. [PMID: 34218638 PMCID: PMC8256139 DOI: 10.30773/pi.2020.0438] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/03/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) has been the most potent treatment option for treatment-resistant schizophrenia (TRS). However, the underlying neural mechanisms of ECT in schizophrenia remain largely unclear. This paper examines studies that investigated structural and functional changes after ECT in patients with schizophrenia. METHODS We carried out a systematic review with following terms: 'ECT', 'schizophrenia', and the terms of various neuroimaging modalities. RESULTS Among the 325 records available from the initial search in May 2020, 17 studies were included. Cerebral blood flow in the frontal, temporal, and striatal structures was shown to be modulated (n=3), although the results were divergent. Magnetic resonance spectroscopy (MRS) studies suggested that the ratio of N-acetyl-aspartate/creatinine was increased in the left prefrontal cortex (PFC; n=2) and left thalamus (n=1). The hippocampus and insula (n=6, respectively) were the most common regions of structural/functional modulation, which also showed symptom associations. Functional connectivity of the default mode network (DMN; n=5), PFC (n=4), and thalamostriatal system (n=2) were also commonly modulated. CONCLUSION Despite proven effectiveness, there has been a dearth of studies investigating the neurobiological mechanisms underlying ECT. There is preliminary evidence of structural and functional modulation of the hippocampus and insula, functional changes in the DMN, PFC, and thalamostriatal system after ECT in patients with schizophrenia. We discuss the rationale and implications of these findings and the potential mechanism of action of ECT. More studies evaluating the mechanisms of ECT are needed, which could provide a unique window into what leads to treatment response in the otherwise refractory TRS population.
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Affiliation(s)
- Sun-Young Moon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Silvia Kyungjin Lho
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sanghoon Oh
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea.,Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea
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Cicek M, McCall WV, Yao Z, Sackeim HA, Rosenquist P, Youssef NA. Is There Evidence That Stimulus Parameters and Electrode Placement Affect the Cognitive Side Effects of Electroconvulsive Therapy in Patients With Schizophrenia and Schizoaffective Disorder?: A Systematic Review. J ECT 2021; 37:133-139. [PMID: 33369995 DOI: 10.1097/yct.0000000000000737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Seventy percent of patients with treatment-resistant schizophrenia do not respond to clozapine. Electroconvulsive therapy (ECT) can potentially offer significant benefit in clozapine-resistant patients. However, cognitive side effects can occur with ECT and are a function of stimulus parameters and electrode placements. Thus, the objective of this article is to systematically review published clinical trials related to the effect of ECT stimulus parameters and electrode placements on cognitive side effects. We performed a systematic review of the literature up to July of 2020 for clinical studies published in English or German examining the effect of ECT stimulus parameters and/or electrode placement on cognitive side effects in patients with schizophrenia or schizoaffective disorder. The literature search generated 3 randomized, double-blind, clinical trials, 1 randomized, nonblinded trial, and 1 retrospective study. There are mixed findings regarding whether pulse width and stimulus dose impact on cognitive side effects. One study showed less cognitive side effect for right unilateral (RUL) than bitemporal (BT) electrode placement, and 2 studies showed a cognitive advantage for bifrontal (BF) compared with BT ECT. Only 1 retrospective study measured global cognition and showed post-ECT cognitive improvement with all treatment modalities using Montreal Cognitive Assessment in comparison to pre-ECT Montreal Cognitive Assessment scores. Current data are limited, but evolving. The evidence suggests that RUL or BF ECT have more favorable cognitive outcomes than BT ECT. Definitive larger clinical trials are needed to optimize parameter and electrode placement selection to minimize adverse cognitive effects.
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Affiliation(s)
| | - William V McCall
- Department of Psychiatry & Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA
| | - Zhixing Yao
- Department of Psychiatry & Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA
| | - Harold A Sackeim
- Departments of Psychiatry and Radiology, Columbia University, New York, NY
| | - Peter Rosenquist
- Department of Psychiatry & Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA
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Tan XW, Tor PC, Martin D, Loo C. Association of Anaesthesia-ECT time interval with ECT clinical outcomes: A retrospective cohort study. J Affect Disord 2021; 285:58-62. [PMID: 33636671 DOI: 10.1016/j.jad.2021.02.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/27/2020] [Accepted: 02/14/2021] [Indexed: 11/29/2022]
Abstract
AIM To examine the association of the anaesthesia to ECT stimulus TI (anaesthesia-ECT TI) with efficacy and cognitive outcomes after ECT treatment. METHODS Retrospective cohort study of 690 patients who received ECT from July 2017 till December 2019. Generalized linear regression was utilized to analyse the association of mean anaesthesia-ECT TI (from session 2 to session 6 ECT treatment) with Clinical Global Impression-Severity scale (CGI-S) scores and Montreal Cognitive Assessment (MoCA) score after 6 ECT treatments, and with EEG quality during the treatments (post ictal suppression scores). RESULTS The averaged TI was 106.6±20.2 (mean±SD) seconds. There was significant improvement of overall CGI-S score after ECT treatment (3.3±1.0) vs pre-ECT treatment (5.0±0.8, p<0.001) while there was no significant change of MoCA score over the course of 6 ECT (p>0.05). The anaesthesia-ECT TI had no association with post-ECT CGI-S while longer anaesthesia-ECT TI was associated with poorer post-ECT MoCA scores [adjusted β, -0.056; 95% CI (-0.099, -0.013), p=0.011] and better EEG quality score [adjusted β (0.001), 95% CI (0, 0.002), p=0.011]. CONCLUSION Longer TI between anaesthesia and ECT stimulus administration resulted in higher seizure quality, suggesting more effective stimulation. This was associated with more cognitive impairment but not higher efficacy. The assessment of outcomes after only 6 ECT limited the ability to fully explore associations between the TI and clinical outcomes. This was a retrospective analysis of clinical data from a real-world treatment setting. A controlled study would provide greater potential to fully explore the association between TI and clinical outcomes.
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Affiliation(s)
- Xiao Wei Tan
- Department of mood and anxiety, Institute of Mental health, Singapore 539747
| | - Phern Chern Tor
- Department of mood and anxiety, Institute of Mental health, Singapore 539747; Neurostimulation Service, Institute of Mental Health, Singapore 539747; Duke-NUS Graduate Medical School, Singapore 169857.
| | - Donel Martin
- School of Psychiatry, University of New South Wales, Randwick, NSW, 2031, Australia; Black Dog Institute, Hospital Road, Randwick, NSW, 2031, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Randwick, NSW, 2031, Australia; Black Dog Institute, Hospital Road, Randwick, NSW, 2031, Australia; The Wesley Hospital, 7 Blake St, Kogarah, NSW, 2217, Australia; St. George Hospital, Gray St, Kogarah, NSW, 2217, Australia; Northside Group St Leonards Clinic, 2 Frederick St, St Leonards, NSW, 2065, Australia
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74
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Moulier V, Krir MW, Dalmont M, Guillin O, Rothärmel M. A prospective multicenter assessor-blinded randomized controlled study to compare the efficacy of short versus long protocols of electroconvulsive therapy as an augmentation strategy to clozapine in patients with ultra-resistant schizophrenia (SURECT study). Trials 2021; 22:284. [PMID: 33858488 PMCID: PMC8048266 DOI: 10.1186/s13063-021-05227-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/26/2021] [Indexed: 01/29/2023] Open
Abstract
Background Although clozapine is the most effective antipsychotic drug for treatment-resistant schizophrenia, it leads to a poor or partial response in 40 to 70% of patients. Augmentation of clozapine with electroconvulsive therapy (ECT) is a highly effective and relatively safe treatment for these clozapine-resistant patients. However, parameters are not yet well specified, such as the optimal number of sessions, their frequency, and the relevance of maintenance ECT. Our objective is to compare the efficacy and tolerance between two protocols of combined ECT and clozapine treatment in patients with ultra-resistant schizophrenia (URS): a 6-month protocol (short protocol with 20 ECT sessions) and a 12-month protocol (long protocol with 40 ECT sessions). Methods Sixty-four patients with schizophrenia with persistent psychotic symptoms despite clozapine treatment will be enrolled in a prospective multicentric assessor-blinded randomized controlled trial. Patients will be randomly assigned to the short or the long protocol. The main outcome is the response rate assessed by the Positive and Negative Symptoms Scale (PANSS) 3 months after the end of the treatment in patients following the long protocol compared to those following the short protocol. The response was defined as a 30% reduction on the PANSS baseline. Clinical assessments (PANSS, BPRS, HAMD-21, YMRS, CGI, GAF, Modified Overt Aggression Scale (MOAS), and Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS)) and plasma clozapine concentration will be performed at baseline and at 2, 4, 6, 9, 12, and 15 months. Neuropsychological measures (MMSE, RL/RI-16, Doors test, D2 Test of Attention, Copy of the Rey-Osterrieth complex figure) will be performed at baseline and at 6 and 15 months. Discussion The aims of this research are to optimize protocols of combined ECT with clozapine in patients with URS and to offer specific recommendations for these patients’ care. Trial registration ClinicalTrials.gov NCT03542903. Registered on May 31, 2018. Id RCB: 2017-A02657-46
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Affiliation(s)
- Virginie Moulier
- University Department of Psychiatry, Centre d'Excellence Thérapeutique- Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France. .,EPS Ville Evrard, Unité de Recherche Clinique, Neuilly-sur-Marne, France.
| | - Mohamed Wassim Krir
- University Department of Psychiatry, Centre d'Excellence Thérapeutique- Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | - Marine Dalmont
- University Department of Psychiatry, Centre d'Excellence Thérapeutique- Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
| | | | - Olivier Guillin
- University Department of Psychiatry, Centre d'Excellence Thérapeutique- Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France. .,Faculté de Médecine, Normandy University, Rouen, France. .,Rouen University Hospital, Rouen, France. .,INSERM U 1245, University of Rouen, Rouen, France.
| | - Maud Rothärmel
- University Department of Psychiatry, Centre d'Excellence Thérapeutique- Institut de Psychiatrie, Centre Hospitalier du Rouvray, Sotteville-lès-Rouen, France
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75
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Sequential Multiple-Assignment Randomized Trials to Compare Antipsychotic Treatments (SMART-CAT) in first-episode schizophrenia patients: Rationale and trial design. Schizophr Res 2021; 230:87-94. [PMID: 33279374 DOI: 10.1016/j.schres.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 01/10/2023]
Abstract
Accumulated studies have investigated pharmacological interventions for first-episode schizophrenia (FES) patients. However, studies on subsequent treatment steps, which are essential to guide clinicians, are largely missing. This Sequential Multiple-Assignment Randomized Trials comparing Antipsychotic Treatments (SMART-CAT) program intends to evaluate the effectiveness of commonly used antipsychotic drugs in FES patients. The major goals of this study are to examine: 1) what would be the optimal subsequent sequential treatment if the first antipsychotic drug failed; 2) whether clozapine could be used in those first-trial failed and have superior efficacy compared to other atypical antipsychotics. In this article we will report the detail protocol of SMART-CAT. The SMART-CAT is a randomized controlled clinical multicenter trial in which 9 institutions in China will participate. A total of 720 FES patients will be enrolled and followed up for 12 months in this study. The trial includes three treatment phases (each phase lasting for 8 weeks) and a naturalistic follow-up phase; participants who do well on an assigned treatment will remain on that treatment for the duration of the 12-month treatment period, while non-responders will move to the next phase of the study to receive a new treatment. Phase 1 is a randomized controlled trial; patients will be randomly assigned to one of the treatments with oral olanzapine, risperidone, amisulpride, aripiprazole or perphenazine. Subjects who fail to respond after 8 weeks will enter the phase 2 randomization. Phase 2 is an equipoise-stratified randomization trial, and patients will be randomly assigned to oral olanzapine, amisulpride or clozapine for 8 weeks. Subjects who fail to respond after phase 2 will enter an open label trial (phase 3); patients who receive clozapine in phase 2 and fail to respond will be assigned to an extended clozapine treatment or modified electroconvulsive therapy add-on therapy (Phase 3A). Patients who were not assigned to clozapine in phase 2 will be assigned to treatment with clozapine or another SGAs not previously used in phase 1 and 2 (Phase 3B). The primary outcome for the treatment phase is the treatment efficacy rate, which is defined as at least 40% reduction in Positive and Negative Syndrome Scale (PANSS) total score. We hypothesize that clozapine is more therapeutically effective than any other SGAs to patients who failed to meet efficacy criteria in Phase 1, and earlier treatment with clozapine can improve the functional outcomes of schizophrenia patients. As for the naturalistic follow-up phase, time to all-cause treatment failure, marked by its discontinuation is selected as the primary outcome, since it reflects both efficacy and side effects. The all-cause discontinuation is defined as discontinuing for any reasons, including poor efficacy, intolerance of adverse reactions, poor compliance and other reasons. The results of the SMART-CAT trial will provide evidence for the selection of antipsychotics in FES patients who fail to respond to the first trial of an antipsychotic drug. It will also provide evidence for the efficacy and safety of using clozapine in the early phase of schizophrenia treatment by comparing with other SGAs. The study is based on the combination of sequential therapy and dynamic therapy, which can be more suitable to assess the effectiveness of treatment options in the real-world clinical setting. As a result, we hope that this study can provide guidance for an optimal treatment algorithm in first-episode schizophrenia patients. Trial registration: ID NCT03510325 in ClinicalTrials.gov.
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76
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Does the Starting of Clozapine Influence Coprescription of Other Medications?: A Study From India. J Clin Psychopharmacol 2021; 41:148-154. [PMID: 33666401 DOI: 10.1097/jcp.0000000000001348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE/BACKGROUND Little is understood about the prescription load before and after the starting of clozapine. Accordingly, this study aimed to evaluate the medication load of patients receiving clozapine, just before starting clozapine and after being on clozapine for at least 1 year. Additionally, the impact of clozapine on severity of illness was evaluated. METHODS/PROCEDURES Two hundred seventy-seven outpatients receiving clozapine were prospectively evaluated for their prescription after at least 1 year of starting clozapine. Additionally, these patients were assessed on the Clinical Global Impression-Improvement scale to evaluate the overall clinical benefit with clozapine. FINDINGS/RESULTS They had been receiving clozapine for 6.55 (SD, 4.8; range, 1-24; median, 5) years at the time of assessment. At the start of clozapine, more than one third of the patients were receiving 2 antipsychotics. A small proportion was receiving other psychotropics, such as antidepressants, mood stabilizers, and benzodiazepines. After being on clozapine for 1 year, there was a significant reduction in the number of patients receiving two antipsychotic medications (P < 0.001), number of patients receiving antidepressants (if amitriptyline was left out), benzodiazepine (P < 0.001), and anticholinergic medications (P < 0.001). Further, there was a reduction in the mean chlorpromazine equivalent of antipsychotics (P < 0.001) and the total number of medications received by the patients (P < 0.001). However, there was an increase in the prescription rates of antihypertensive drugs (P = 0.03), anti-diabetic medications (P < 0.01), and anti-dyslipidemic medications. At follow-up, there was a significant improvement in symptoms as assessed by Clinical Global Impression-Improvement scale. IMPLICATIONS/CONCLUSIONS This study suggests that long-term use of clozapine is associated with substantial improvement in symptoms with a reduction in the medication load.
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Chung IW, Kim HS, Kim JH, Jang JH, Kim YS. Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:170-173. [PMID: 33508802 PMCID: PMC7851464 DOI: 10.9758/cpn.2021.19.1.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/04/2019] [Indexed: 01/03/2023]
Abstract
A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.
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Affiliation(s)
- In Won Chung
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Korea
| | - Hye Sung Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Korea
| | - Jung Hyun Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Korea
| | - Jin Hyeok Jang
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Korea
| | - Yong Sik Kim
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Korea
- Department of Neuropsychiatry, School of Medicine, Eulji University, Daejeon, Korea
- Department of Psychiatry, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
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78
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Campana M, Falkai P, Siskind D, Hasan A, Wagner E. Characteristics and definitions of ultra-treatment-resistant schizophrenia - A systematic review and meta-analysis. Schizophr Res 2021; 228:218-226. [PMID: 33454644 DOI: 10.1016/j.schres.2020.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to characterize ultra-treatment-resistant Schizophrenia also known as clozapine-resistant schizophrenia (CRS) patients across clozapine combination and augmentation trials through demographic and clinical baseline data. Furthermore, we investigated the variability and consistency in CRS definitions between studies. METHODS Systematic searches of articles indexed in PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO were conducted in March 2020. 1541 randomized and non-randomized clinical trials investigating pharmacological and non-pharmacological clozapine add-on strategies were screened and a total of 71 studies were included. The primary outcome was the overall symptom score at baseline, measured with Positive and Negative Syndrome Scale (PANSS) total or Brief Psychiatric Rating Scale (BPRS) total scores. RESULTS Data from 2731 patients were extracted. Patients were overall moderately ill with a mean PANSS total score at baseline of 79.16 (±7.52), a mean duration of illness of 14.64 (±4.14) years with a mean clozapine dose of 436.94 (±87.47) mg/day. Illness severity data were relatively homogenous among patients independently of the augmentation strategy involved, although stark geographical differences were found. Overall, studies showed a large heterogeneity of CRS definitions and insufficient guidelines implementation. CONCLUSIONS This first meta-analysis characterizing CRS patients and comparing CRS definitions revealed a lack of consistent implementation of a CRS definition from guidelines into clinical trials, compromising the replicability of the results and their applicability in clinical practice. We offer a new score modeled on a best practice definition to help future trials increase their reliability.
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Affiliation(s)
- Mattia Campana
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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79
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Abstract
OBJECTIVE We sought to assess the effectiveness of clozapine augmentation with Electroconvulsive therapy (ECT) (C+ECT) in patients with clozapine-resistant schizophrenia. METHODS We conducted a retrospective review of electronic health records to identify patients treated with C+ECT. We determined the response to C+ECT and the rate of rehospitalisation over the year following treatment with C+ECT. RESULTS Forty-two patients were treated with C+ECT over a 10-year period. The mean age of the patients at initiation of ECT was 46.3 (SD = 8.2) years (range 27-62 years). The mean number of ECTs given was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Seventy-six per cent of patients (n = 32) showed a Clinical Global Impression-Improvement (CGI-I) score of ≤3 (at least minimally improved) following C+ECT. The mean number of ECT treatments was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Sixty-four per cent of patients experienced no adverse events. Response to C+ECT was not associated with gender, age, duration of illness or duration of clozapine treatment. Seventy-five per cent of responders remained out of hospital over the course of 1-year follow-up, while 70% of those with no response to C+ECT were not admitted to hospital. Three patients received maintenance ECT, one of whom was rehospitalised. CONCLUSION This study lends support to emerging evidence for the effectiveness of C+ECT in clozapine-resistant schizophrenia. These results are consistent with the results of a meta-analysis and the only randomised controlled trial (RCT) of this intervention. Further RCTs are required before this treatment can be confidently recommended.
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80
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Besse M, Schomburg AK, Simon A, Hesse D, Müller J, Zilles-Wegner D. [Importance of electroconvulsive therapy (ECT) in forensic psychiatry]. DER NERVENARZT 2021; 92:9-17. [PMID: 32642948 PMCID: PMC7808988 DOI: 10.1007/s00115-020-00947-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Hintergrund und Ziel der Arbeit Für die Elektrokonvulsionstherapie (EKT) liegen Leitlinienempfehlungen zur Behandlung schwerer affektiver und psychotischer Erkrankungen vor, wie sie auch bei Patienten im Maßregelvollzug (MRV) vorkommen. Über die Anwendung der EKT in der forensischen Psychiatrie existieren jedoch keinerlei systematisch erhobene Daten. Ziel der vorliegenden Arbeit ist eine Erhebung des Ist-Zustands sowie des geschätzten Bedarfs an EKT im MRV. Material und Methoden Es wurde ein Fragebogen zur Erhebung der aktuellen Anwendung sowie der Einschätzung des Bedarfs an EKT in dieser Population entwickelt. Dieser wurde elektronisch und bei Bedarf postalisch an die forensischen Kliniken in Deutschland versendet. Ergebnisse Wir erhielten Antwort von 52 Kliniken (66 %). 29 der Kliniken gaben an, Patienten mit EKT behandeln zu können. Eine Behandlungsindikation wurde klinikübergreifend für 3,4 % der untergebrachten Patienten gesehen. In einem Jahr (2018) wurden insgesamt 32 EKT-Behandlungen an 12 Kliniken des Maßregelvollzugs mit durchschnittlich guter Wirksamkeit (Ø CGI‑I 2,32) durchgeführt. Häufigste Begründung für die fehlende Anwendung der EKT waren mangelnde strukturelle Voraussetzungen. Jeweils etwa ein Drittel der Kliniken sehen einen mittleren bzw. hohen Bedarf an EKT im MRV. Diskussion Die EKT kommt im MRV in Deutschland aktuell nur sehr begrenzt zum Einsatz. Auffällig ist, dass die Anzahl der durchgeführten Behandlungen etwa um den Faktor 8 hinter der Indikationshäufigkeit zurücksteht. Ungeachtet dessen sehen zwei Drittel der Kliniken einen mittleren bis hohen Bedarf, womit eine Unterversorgung mit EKT im MRV zu bestehen scheint.
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Affiliation(s)
- Matthias Besse
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Straße 5, 37075, Göttingen, Deutschland.
| | - Anna-K Schomburg
- Institut für Ethik und Geschichte in der Medizin, Universitätsmedizin Göttingen, Humboldtallee 36, 37073, Göttingen, Deutschland
| | - Alfred Simon
- Akademie für Ethik in der Medizin e. V., Humboldtallee 36, 37073, Göttingen, Deutschland
| | - Dirk Hesse
- Maßregelvollzugszentrum Niedersachsen - Moringen, Mannenstraße 29, 37186, Moringen, Deutschland
| | - Jürgen Müller
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Straße 5, 37075, Göttingen, Deutschland.,Asklepios Klinik für forensische Psychiatrie und Psychotherapie, Rosdorfer Weg 70, 37081, Göttingen, Deutschland
| | - David Zilles-Wegner
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Straße 5, 37075, Göttingen, Deutschland
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81
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Wagner E, Honer WG, Sommer IE, Koops S, Blumberger DM, Daskalakis ZJ, Dlabac-De Lange JJ, Bais L, Knegtering H, Aleman A, Novak T, Klirova M, Slotema C, Brunelin J, Poulet E, Kujovic M, Cordes J, Wobrock T, Siskind D, Falkai P, Schneider-Axmann T, Hasan A. Repetitive transcranial magnetic stimulation (rTMS) for schizophrenia patients treated with clozapine. World J Biol Psychiatry 2021; 22:14-26. [PMID: 32081071 DOI: 10.1080/15622975.2020.1733080] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Biological strategies to improve treatment efficacy in clozapine-treated patients are urgently needed. Repetitive transcranial magnetic stimulation (rTMS) merits consideration as intervention for patients with persistent auditory hallucinations (AH) or negative symptoms (NS) not responding sufficiently to clozapine treatment. METHODS Data from 10 international RCTs of rTMS for patients being treated with clozapine were pooled. Two levels of symptomatic response were defined: improvement of ≥20% and ≥50% on study-specific primary endpoint scales. Changes in the positive and negative syndrome scale (PANSS) from baseline to endpoint assessment were also analysed. RESULTS Analyses of 131 patients did not reveal a significant difference for ≥20% and ≥50% response thresholds for improvement of AH, negative or total symptoms between active and sham rTMS groups. The number needed to treat (NNT) for an improvement in persistent AH was nine following active rTMS. PANSS scores did not improve significantly from baseline to endpoint between active and sham groups in studies investigating NS and AH. CONCLUSIONS rTMS as a treatment for persistent symptoms in clozapine-treated patients did not show a beneficial effect of active compared to sham treatment. For AH, the size of the NNTs indicates a possible beneficial effect of rTMS.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - William G Honer
- Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | - Iris E Sommer
- Department of Biomedical Sciences of Cells and Systems, Section Cognitive Neuropsychology, University Medical Center Groningen, Groningen, the Netherlands
| | - Sanne Koops
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniel M Blumberger
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Canada.,Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Zafiris J Daskalakis
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, Canada.,Campbell Family Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Jozarni J Dlabac-De Lange
- Lentis Psychiatric Institute, Groningen, the Netherlands.,University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Leonie Bais
- Lentis Psychiatric Institute, Groningen, the Netherlands
| | - Henderikus Knegtering
- Lentis Psychiatric Institute, Groningen, the Netherlands.,University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - André Aleman
- Lentis Psychiatric Institute, Groningen, the Netherlands.,University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tomas Novak
- Klecany and Third Faculty of Medicine, Charles University, National Institute of Mental Health, Prague, Czech Republic
| | - Monika Klirova
- Klecany and Third Faculty of Medicine, Charles University, National Institute of Mental Health, Prague, Czech Republic
| | - Christina Slotema
- Department of Personality Disorders, Parnassia Psychiatric Institute, the Hague, Netherlands
| | - Jerome Brunelin
- INSERM U1028, CNRS UMR 5292, CRNL, Centre Hospitalier Le Vinatier, Bron, France
| | - Emmanuel Poulet
- INSERM U1028, CNRS UMR 5292, CRNL, Centre Hospitalier Le Vinatier, Bron, France
| | - Milenko Kujovic
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University Hospital, Düsseldorf, Germany
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University Hospital, Düsseldorf, Germany
| | - Thomas Wobrock
- Department of Psychiatry and Psychotherapy, Georg-August-University, Goettingen, Germany.,Centre of Mental Health, County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Australia.,Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Schneider-Axmann
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
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82
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Current clinical practice of electroconvulsive therapy and repetitive transcranial magnetic stimulation in psychiatry, a German sample. Eur Arch Psychiatry Clin Neurosci 2021; 271:181-190. [PMID: 31996994 PMCID: PMC8179911 DOI: 10.1007/s00406-020-01099-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/13/2020] [Indexed: 12/28/2022]
Abstract
The purpose of the study was to evaluate the current clinical practice of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation in German psychiatry. Case-based data (> 1.000.000 cases) were collected according to §21 of the German hospital remuneration law from January 2015 to December 2017. The study cohort comprises approximately 35-40% of the annual psychiatric cases and hospitals in Germany. Frequency of ECT and rTMS cases were investigated considering main diagnoses according to ICD-10 and treatment settings (inpatient vs. day-care). ECT cases with short-term hospitalization (≤ 4 days) were supposed to be maintenance ECT cases. A linear regression analysis was conducted to estimate trends in the use of ECT and rTMS. Different groups were compared using Chi-square tests. ECT and rTMS cases appear to increase in total during the observation period possibly due to facilities newly introducing ECT and rTMS but also to increased frequency of treatments. Both treatments were rarely performed in day-care settings (0.89% and 11.25%). ECT was performed in 1.72% of all cases with affective disorders and in 1.48% with major depressions, respectively. Age ≥ 65 years, females, severe and psychotic depression were significantly associated with a higher rate of ECT cases. > 40% of all ECT cases were possibly maintenance ECT cases. Only 0.60% of these were performed in day- care settings. rTMS was primarily performed in major depression (86,7% of all rTMS cases). This study suggests a growing demand for ECT and rTMS. Nevertheless, the use of ECT is still low compared to the high prevalence of treatment resistant depression. The use of rTMS is even lower and seems to be restricted to specialized institutions. Maintenance ECT is frequently carried out in an inpatient setting. Limitations of this study are the case- and group-based analysis, missing data on outpatient services and treatment sessions per case. Therefore, the database is not necessarily representative for the entire German healthcare system. Further studies are needed to verify the presented findings and should address the feasibility of ambulatory and day-care ECT services.
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Zhang XY, Chen HD, Liang WN, Yang XH, Cai DB, Huang X, Huang XB, Liu CY, Zheng W. Adjunctive Magnetic Seizure Therapy for Schizophrenia: A Systematic Review. Front Psychiatry 2021; 12:813590. [PMID: 35082705 PMCID: PMC8785398 DOI: 10.3389/fpsyt.2021.813590] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 01/10/2023] Open
Abstract
Objective: The efficacy and safety of adjunctive magnetic seizure therapy (MST) for patients with schizophrenia are unclear. This systematic review was conducted to examine the efficacy and safety of adjunctive MST for schizophrenia. Methods: Chinese (WanFang and Chinese Journal Net) and English (PubMed, EMBASE, PsycINFO, and the Cochrane Library) databases were systematically searched. Results: Two open-label self-controlled studies (n = 16) were included and analyzed in this review. In these studies, the Positive and Negative Syndrome Scale (PANSS) total scores and Brief Psychiatric Rating Scale (BPRS) total scores significantly decreased from baseline to post-MST (all Ps < 0.05), without serious adverse neurocognitive effects. Mixed findings on the neurocognitive effects of adjunctive MST for schizophrenia were reported in the two studies. A discontinuation rate of treatment of up to 50% (4/8) was reported in both studies. The rate of adverse drug reactions (ADRs) was evaluated in only one study, where the most common ADRs were found to be dizziness (25%, 2/8) and subjective memory loss (12.5%, 1/8). Conclusion: There is inconsistent evidence for MST-related adverse neurocognitive effects and preliminary evidence for the alleviation of psychotic symptoms in schizophrenia.
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Affiliation(s)
- Xin-Yang Zhang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.,Laboratory of Laser Sports Medicine, School of Sports Science, South China Normal University, Guangzhou, China
| | - Huo-Di Chen
- Guangdong Teachers College of Foreign Language and Arts, Guangzhou, China
| | - Wan-Nian Liang
- Wanke School of Public Health, Tsinghua University, Beijing, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Dong-Bin Cai
- Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - Xiong Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xing-Bing Huang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Cheng-Yi Liu
- Laboratory of Laser Sports Medicine, School of Sports Science, South China Normal University, Guangzhou, China
| | - Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
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Uzuneser TC, Weiss EM, Dahlmanns J, Kalinichenko LS, Amato D, Kornhuber J, Alzheimer C, Hellmann J, Kaindl J, Hübner H, Löber S, Gmeiner P, Grömer TW, Müller CP. Presynaptic vesicular accumulation is required for antipsychotic efficacy in psychotic-like rats. J Psychopharmacol 2021; 35:65-77. [PMID: 33274688 PMCID: PMC7770212 DOI: 10.1177/0269881120965908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The therapeutic effects of antipsychotic drugs (APDs) are mainly attributed to their postsynaptic inhibitory functions on the dopamine D2 receptor, which, however, cannot explain the delayed onset of full therapeutic efficacy. It was previously shown that APDs accumulate in presynaptic vesicles during chronic treatment and are released like neurotransmitters in an activity-dependent manner triggering an auto-inhibitory feedback mechanism. Although closely mirroring therapeutic action onset, the functional consequence of the APD accumulation process remained unclear. AIMS Here we tested whether the accumulation of the APD haloperidol (HAL) is required for full therapeutic action in psychotic-like rats. METHODS We designed a HAL analog compound (HAL-F), which lacks the accumulation property of HAL, but retains its postsynaptic inhibitory action on dopamine D2 receptors. RESULTS/OUTCOMES By perfusing LysoTracker fluorophore-stained cultured hippocampal neurons, we confirmed the accumulation of HAL and the non-accumulation of HAL-F. In an amphetamine hypersensitization psychosis-like model in rats, we found that subchronic intracerebroventricularly delivered HAL (0.1 mg/kg/day), but not HAL-F (0.3-1.5 mg/kg/day), attenuates psychotic-like behavior in rats. CONCLUSIONS/INTERPRETATION These findings suggest the presynaptic accumulation of HAL may serve as an essential prerequisite for its full antipsychotic action and may explain the time course of APD action. Targeting accumulation properties of APDs may, thus, become a new strategy to improve APD action.
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Affiliation(s)
- Taygun C Uzuneser
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Eva-Maria Weiss
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jana Dahlmanns
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Liubov S Kalinichenko
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Davide Amato
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Department of Neuroscience, Medical University of South Carolina, Charleston, USA
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christian Alzheimer
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jan Hellmann
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jonas Kaindl
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Harald Hübner
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Löber
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Peter Gmeiner
- Department of Chemistry and Pharmacy, Medicinal Chemistry, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Teja W Grömer
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Christian P Müller
- Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany,Christian P Müller, Department of Psychiatry and Psychotherapy, University Clinic, Friedrich-Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany.
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Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:brainsci10110840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background: clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. Objective: to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. Data sources: a search was performed in two databases (PubMed and Web of Science) using the specific keywords “clozapine” and “schizophrenia”, “side effects”, “agranulocytosis”, “TRS”, or “bipolar affective disorder (BAF)” for the last ten years. Study eligibility criteria: clinical trials on adults with acute symptoms of schizophrenia or related disorders. Results: we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. Limitations: we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions’ severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Deng ZD, Luber B, Balderston NL, Velez Afanador M, Noh MM, Thomas J, Altekruse WC, Exley SL, Awasthi S, Lisanby SH. Device-Based Modulation of Neurocircuits as a Therapeutic for Psychiatric Disorders. Annu Rev Pharmacol Toxicol 2020; 60:591-614. [PMID: 31914895 DOI: 10.1146/annurev-pharmtox-010919-023253] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Device-based neuromodulation of brain circuits is emerging as a promising new approach in the study and treatment of psychiatric disorders. This work presents recent advances in the development of tools for identifying neurocircuits as therapeutic targets and in tools for modulating neurocircuits. We review clinical evidence for the therapeutic efficacy of circuit modulation with a range of brain stimulation approaches, including subthreshold, subconvulsive, convulsive, and neurosurgical techniques. We further discuss strategies for enhancing the precision and efficacy of neuromodulatory techniques. Finally, we survey cutting-edge research in therapeutic circuit modulation using novel paradigms and next-generation devices.
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Affiliation(s)
- Zhi-De Deng
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA; .,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina 27710, USA
| | - Bruce Luber
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Nicholas L Balderston
- Section on Neurobiology of Fear and Anxiety, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Melbaliz Velez Afanador
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Michelle M Noh
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Jeena Thomas
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - William C Altekruse
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Shannon L Exley
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Shriya Awasthi
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA;
| | - Sarah H Lisanby
- Noninvasive Neuromodulation Unit, Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland 20892, USA; .,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina 27710, USA
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87
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Potkin SG, Kane JM, Correll CU, Lindenmayer JP, Agid O, Marder SR, Olfson M, Howes OD. The Neurobiology of Treatment-Resistant Schizophrenia: Paths to Antipsychotic Resistance and A Roadmap for Future Research. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:456-465. [PMID: 33343259 DOI: 10.1176/appi.focus.18309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from NPJ Schizophrenia (2020) 6:1).
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88
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Plahouras JE, Konstantinou G, Kaster TS, Buchman DZ, Foussias G, Daskalakis ZJ, Blumberger DM. Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study. Schizophr Bull 2020; 47:424-432. [PMID: 33145601 PMCID: PMC7965065 DOI: 10.1093/schbul/sbaa144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT). METHODS We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT. RESULTS A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment. CONCLUSIONS Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.
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Affiliation(s)
- Joanne E Plahouras
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Gerasimos Konstantinou
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tyler S Kaster
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada,Bioethics Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada,Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | - George Foussias
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada
| | - Daniel M Blumberger
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada,To whom correspondence should be addressed; Centre for Addiction and Mental Health, 1001 Queen St. W. Unit 4, Room 115, Toronto, ON M6J 1H4, Canada; tel: 416-535-8501 x 33662, fax: 416-583-4613, e-mail:
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Usta Saglam NG, Aksoy Poyraz C, Yalcin M, Balcioglu I. ECT augmentation of antipsychotics in severely ill schizophrenia: a naturalistic, observational study. Int J Psychiatry Clin Pract 2020; 24:392-397. [PMID: 32538214 DOI: 10.1080/13651501.2020.1777313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES There is positive evidence to support the role of electroconvulsive therapy (ECT) in the treatment of schizophrenia; however, it is unclear to what extent this growing evidence reflects the actual situation in clinical practice. The aim of this study was to explore the efficacy of ECT augmentation to antipsychotics in individuals with schizophrenia in a naturalistic-observational environment. METHODS Eighty-one patients diagnosed with schizophrenia, hospitalised due to acute psychotic exacerbation were included in the study. We compared changes in Positive and Negative Symptom Rating Scale (PANSS) scores between patients treated only with APs and those in the ECT augmentation group. RESULTS A statistically significant decrease in symptom severity was observed in all PANSS subscales in both groups. In the ECT group, 95% of the patients (n = 39) responded to treatment compared to 75% of the non-ECT group (n = 30) (χ2=6.496, df = 1, p = 0.011). We found that combining ECT with AP significantly increased treatment response, which was defined as at least 25% PANSS symptom reduction, in patients with acute exacerbation of schizophrenia, compared to AP alone. CONCLUSIONS Augmentation of ECT seems to increase responsiveness during acute treatment of severely ill schizophrenia patients. The mean percentage reduction in PANSS scores by 25% following antipsychotic treatment can help identify patients that will benefit from ECT after psychotic relapse in future. Key points There is positive evidence to support the role of ECT in the treatment of schizophrenia; however, it remains unclear to what extent this growing evidence reflects the actual situation in clinical practice. Augmentation of ECT seems to increase responsiveness during acute treatment of severely ill schizophrenia patients. The addition of ECT to antipsychotic treatment may only be beneficial in patients with antipsychotic responses below 50%. The mean percentage reduction in PANSS scores by 25% following antipsychotic treatment can help identify patients that will benefit from ECT after psychotic relapses in the future.
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Affiliation(s)
- Nazife Gamze Usta Saglam
- Erenkoy Training and Research Hospital for Psychiatry and Neurological Diseases, Istanbul, Turkey
| | - Cana Aksoy Poyraz
- Psychiatry Department, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Murat Yalcin
- Erenkoy Training and Research Hospital for Psychiatry and Neurological Diseases, Istanbul, Turkey
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Takamiya A, Seki M, Kudo S, Yoshizaki T, Nakahara J, Mimura M, Kishimoto T. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord 2020; 36:50-58. [PMID: 33280168 DOI: 10.1002/mds.28335] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 08/27/2020] [Accepted: 09/21/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a well-established treatment for psychiatric disorders, including depression and psychosis. ECT has been reported to be effective in treating such psychiatric symptoms in patients with Parkinson's disease (PD) and has been also reported to be effective in treating motor symptoms. The aim of the study is to summarize previous clinical studies investigating the efficacy of ECT for symptoms in patients with PD. METHODS A systematic review and meta-analysis of any study designs assessing motor and/or non-motor symptoms in patients with PD before and after ECT. Co-primary outcomes were set as motor manifestations assessed using the Unified Parkinson's Disease Rating Scale or other rating scales, and non-motor symptoms included depression and psychosis. Secondary outcomes were wearing-off phenomenon and cognitive function. The impact of ECT on those symptoms was examined by comparing the severity of the symptoms before and after ECT using a random effect model and was expressed in standardized mean difference. RESULTS Of 1219 identified citations, 14 studies (n = 129; 1 randomized controlled study, 9 prospective observational studies, and 4 retrospective studies) were analyzed. The findings were as follows: ECT significantly improved motor manifestations in patients with PD, and the improvement was significant in the subpopulation without psychiatric symptoms; ECT significantly improved depression and psychosis; and ECT significantly relieved wearing-off phenomenon and did not worsen cognitive functioning. CONCLUSION The current meta-analysis suggests the potential benefit of ECT on motor and non-motor symptoms in presumably complicated and difficult-to-treat subgroups. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Akihiro Takamiya
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Morinobu Seki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kudo
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Takahito Yoshizaki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Taishiro Kishimoto
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Progress in Schizophrenia Research and Treatment. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 18:440-442. [PMID: 33343257 PMCID: PMC7725148 DOI: 10.1176/appi.focus.18310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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92
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Buhagiar K, Templeton G, Blyth H, Dey M, Giacco D. Mortality risk from long-term treatment with antipsychotic polypharmacy vs monotherapy among adults with serious mental illness: A systematic review and meta-analysis of observational studies. Schizophr Res 2020; 223:18-28. [PMID: 32948381 DOI: 10.1016/j.schres.2020.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/21/2020] [Accepted: 08/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term use of more than one concurrent antipsychotic [antipsychotic polypharmacy (APP)] is widely believed to contribute to excess mortality in people with serious mental illness (SMI) compared to those taking only one antipsychotic (monotherapy). However, no conclusive evidence is available. METHODS We conducted a systematic search in 6 major electronic databases from inception until December 2019, identifying observational studies examining the association between mortality and exposure to long-term APP vs monotherapy. Studies were eligible if they adopted a follow-up design and antipsychotic exposure was >3 months among adults with SMI. We determined the pooled mortality risk using random-effects meta-analyses. The review was registered in PROSPERO (CRD42019148044). RESULTS A total of 12 studies fulfilled all eligibility criteria reporting quantitative data for 834, 534 person years. No difference was found in the association between all-cause mortality and APP vs monotherapy use, in both crude (rate ratio = 0.94, 95% CI 0.81-1.10, p = 0.446; I2 = 83.2%, p < 0.001; 10 studies) and adjusted models (adjusted HR = 0.98, 95% CI 0.80-1.19, p = 0.802; I2 = 58.3%, p < 0.05; 5 studies). Meta-regression did not identify any moderators influencing all-cause mortality risk. For natural causes of death, risk estimates followed the same pattern: (i) crude rate ratio = 0.88, 95% CI 0.67-1.14, p = 0.324; I2 = 77.7%, p = 0.01 (5 studies); (ii) adjusted HR = 1.04, 95% CI 0.90-1.99, p = 0.590; I2 = 0.0%, p = 0.744 (5 studies). CONCLUSION Mortality risk of APP use in people with SMI appears to be comparable to that of monotherapy use, although work to date remains heterogeneous, precluding firm conclusions from made. Complex real-world clinical scenarios may be contributing to this lack of variation between these two types of antipsychotic use.
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Affiliation(s)
- Kurt Buhagiar
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Georgia Templeton
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Henrietta Blyth
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Domenico Giacco
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Warwick Medical School, University of Warwick, Coventry, UK.
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Schoretsanitis G, Cicek M, Mathur N, Sanghani SN, Kane JM, Petrides G. Prolactin changes during electroconvulsive therapy: A systematic review and meta-analysis. J Psychiatr Res 2020; 128:25-32. [PMID: 32516627 DOI: 10.1016/j.jpsychires.2020.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/15/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early studies reported a prolactin surge during electroconvulsive therapy (ECT). The aim of this study is to review and meta-analyze data on ECT-related prolactin changes. METHOD A systematic review and meta-analysis was conducted for trials investigating prolactin changes in ECT-treated patients using standard mean differences (SMD, 95% confidence intervals). Subgroup analyses included comparisons of ECT-related prolactin changes in women vs. men, patients receiving different anesthetics, bilateral vs. unilateral and high-vs. low-dose ECT. RESULTS In six trials including 109 ECT-treated patients and 74 controls, prolactin changes were larger in ECT-treated patients than in controls (SMD = 0.89, 95%CI = 0.55, 1.23, p < 0.001 and 1.03, 95%CI = 0.31, 1.75, p = 0.005 for the fixed and random-effect model respectively), despite heterogeneity in the samples (I2 = 72%, τ2 = 0.62). Effects were led by differences in patients premedicated with methohexital (SMD = 1.14, 95%CI = 0.7, 1.57, p < 0.001 for both fixed and random-effect model). A meta-regression reported significant age effects (coefficient estimate 2.32, 95%CI = -0.73, 3.91, p < 0.01). Additionally, prolactin changes were larger in ECT-treated women than men (SMD = 0.88, 95%CI = 0.58, 1.18, p < 0.001 and 0.99, 95%CI = 0.22, 1.75, p = 0.012 for the fixed and random effect model). Bilateral ECT-treated patients had larger increase than unilateral ECT-treated patients (SMD = -0.81, 95%CI = -1.35, -0.27, p = 0.003 and -0.86, 95%CI = -1.46, -0.25, p = 0.006 for the fixed and random-effect model). Comparisons between high- and low-dose ECT-treated patients could not be conducted. The quality of the studies was overall poor, with four exceptions. DISCUSSION Patients receiving ECT had larger prolactin increases than controls. Increases were larger in methohexital-premedicated patients, women vs. men and patients with bilateral vs. unilateral ECT.
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Affiliation(s)
| | - Mustafa Cicek
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, Zurich, Switzerland
| | - Nandita Mathur
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | - Sohag N Sanghani
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Hempstead, New York and the Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Georgios Petrides
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Hempstead, New York and the Feinstein Institute for Medical Research, Manhasset, NY, USA
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94
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Yang X, Xu Z, Xi Y, Sun J, Liu P, Liu P, Li P, Jia J, Yin H, Qin W. Predicting responses to electroconvulsive therapy in schizophrenia patients undergoing antipsychotic treatment: Baseline functional connectivity among regions with strong electric field distributions. Psychiatry Res Neuroimaging 2020; 299:111059. [PMID: 32135406 DOI: 10.1016/j.pscychresns.2020.111059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 02/16/2020] [Accepted: 02/21/2020] [Indexed: 01/15/2023]
Abstract
This study explored imaging predictors of electroconvulsive therapy (ECT) outcome in schizophrenia patients based on pre-treatment functional connectivity (FC) within regions with strong ECT electric fields distribution. Forty-seven patients received standard antipsychotic drugs combined with ECT as well as two brain imaging sessions. Regions of interest (ROI) with strong electric field distribution were determined by ECT simulation. Using baseline functional connectivity between ROIs, a model was constructed to predict the percentage reduction of Positive and Negative Syndrome Scale (PANSS) scores. The strong electric fields were distributed in the orbital prefrontal lobe, medial temporal lobe, and other parts of the temporal lobe. Ten functional connectivity features within the electric field distribution areas showed a predictive ability for ECT outcome. The correlation coefficient between the predictive and real values of cross-validation was 0.7165. Among the predictive features, ECT induced a significant decrease in functional connectivity between the right amygdala and the left hippocampus. These results suggest that pretreatment functional connectivity patterns in brain regions with strong electric field distributions during ECT could be potential predictors of the efficacy of ECT augmentation in schizophrenia. These findings may help to improve individualized clinical treatment in the future.
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Affiliation(s)
- Xuejuan Yang
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China
| | - Ziliang Xu
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China
| | - Yibin Xi
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, No. 127 West Changle Road, Xi'an, Shaanxi 710032, China
| | - Jinbo Sun
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China
| | - Peng Liu
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China
| | - Peng Liu
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China
| | - Ping Li
- Department of Medical Imaging, Xi'an Mental Health Center, Xi'an, Shaanxi 710061, China
| | - Jie Jia
- Department of early intervention, Xi'an Mental Health Center, Xi'an, Shaanxi 710061, China
| | - Hong Yin
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, No. 127 West Changle Road, Xi'an, Shaanxi 710032, China.
| | - Wei Qin
- Engineering Research Center of Molecular & Neuroimaging, Ministry of Education, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, Shaanxi 710126, China.
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95
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Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs 2020; 34:509-520. [PMID: 32342484 DOI: 10.1007/s40263-020-00729-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.
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Affiliation(s)
- A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA.
| | - Amitha L Dhingra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
| | | | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
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96
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Tor PC, Tan FJS, Martin D, Loo C. Outcomes in patients with and without capacity in electroconvulsive therapy. J Affect Disord 2020; 266:151-157. [PMID: 32056870 DOI: 10.1016/j.jad.2020.01.150] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/16/2019] [Accepted: 01/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania. METHODS Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables. RESULTS 75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051). LIMITATIONS Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment. CONCLUSIONS ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients' best interests for ECT in patients unable to provide their own consent.
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Affiliation(s)
- Phern-Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, Singapore.
| | | | - Donel Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia; St George Hospital, Sydney, Australia
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97
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Schoretsanitis G, Mendelowitz A, Malur C, Braga RJ, Schooler NR, John M, de Leon J, Kane JM, Petrides G. Lack of ECT effects on clozapine plasma levels in patients with treatment-resistant schizophrenia: Pharmacokinetic evidence from a randomized clinical trial. Schizophr Res 2020; 218:309-311. [PMID: 32107101 DOI: 10.1016/j.schres.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/15/2020] [Accepted: 02/18/2020] [Indexed: 01/29/2023]
Affiliation(s)
| | - Alan Mendelowitz
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Chitra Malur
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Raphael J Braga
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Nina R Schooler
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Majnu John
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Jose de Leon
- University of Kentucky Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
| | - John M Kane
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Georgios Petrides
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; The Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
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98
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Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT). Acta Psychiatr Scand 2020; 141:304-315. [PMID: 31774547 DOI: 10.1111/acps.13134] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. METHOD We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. RESULTS ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. CONCLUSION ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia.
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Affiliation(s)
- C H Kellner
- New York Community Hospital, Brooklyn, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Obbels
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven (Catholic University of Leuven), Kortenberg, Belgium
| | - P Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven (Catholic University of Leuven), Kortenberg, Belgium
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99
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Abstract
OBJECTIVE Clozapine is the only approved strategy for treatment-resistant schizophrenia, although it is highly underutilized. We aim to generate practical and actionable evidence-based recommendations for the use of this drug considering prescription barriers. METHOD Narrative review. RESULTS A consistent body of evidence supports the efficacy of clozapine reducing morbidity and mortality in schizophrenia. The main obstacles to its use are the lack of experience by prescribers and perceived treatment burden. Systematic screening of eligibility, utilization of available resources for consultation, developing a professional network with other stakeholders, as well as optimizing how clozapine is presented to patients is discussed. Furthermore, specific evidence-based recommendations for initiation, maintenance, and safety monitoring with clozapine are provided. CONCLUSION Clozapine prescription is one of the areas in psychiatry with the greatest mismatch between efficacy and utilization in clinical practice. Although multiple barriers to the use of clozapine exist, some of these may be overcome by updates of routine clinical practice.
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Affiliation(s)
- J M Rubio
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Northwell Health, Glen Oaks, NY, USA.,The Zucker Hillside Hospital - Northwell Health, Glen Oaks, NY, USA
| | - J M Kane
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Glen Oaks, NY, USA.,Feinstein Institute for Medical Research, Northwell Health, Glen Oaks, NY, USA.,The Zucker Hillside Hospital - Northwell Health, Glen Oaks, NY, USA
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100
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Clinical Effectiveness of Maintenance Electroconvulsive Therapy in Patients with Schizophrenia: A Retrospective Cohort Study. J ECT 2020; 36:42-46. [PMID: 31192873 PMCID: PMC6904542 DOI: 10.1097/yct.0000000000000613] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical effectiveness and cognitive effects of maintenance electroconvulsive therapy (mECT) in patients with schizophrenia or schizoaffective disorder and explore factors associated with both outcomes. METHODS In this retrospective cohort study, we examined clinical records of 47 patients with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of schizophrenia or schizoaffective disorder treated with mECT at an academic mental health hospital between April 2010 and July 2016. Sixty-two mECT courses were reviewed. We assessed clinical effectiveness and cognitive effects as well as factors associated with response to treatment, including psychiatric diagnosis, concomitant pharmacological treatment, and previous treatment response. RESULTS Maintenance electroconvulsive therapy was able to maintain clinical response in 48 (77%) treatment courses. Significant cognitive adverse effects were reported in 7 (11%) of the courses. Use of antipsychotic, antidepressant or benzodiazepine medications, psychiatric disorder, and sex were not associated with response. CONCLUSION This study shows meaningful clinical effectiveness and good tolerability of mECT in patients with resistant schizophrenia over extended periods.
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