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Abstract
PURPOSE OF REVIEW Clozapine has recently been described as a novel cause of secondary antibody deficiency (SAD), associated with long-term therapy. Here we critically review the evidence linking clozapine use to an increased infection risk, describe immunological alterations, and discuss potential mechanisms. RECENT FINDINGS Individuals with schizophrenia are at two to five times more likely to develop pneumonia than the general population, in particular, when receiving clozapine. Delayed-onset distinguishes clozapine-associated hypogammaglobulinaemia from agranulocytosis or neutropenia that occur at lesser frequency. Biomarker searches in treatment-resistant schizophrenia highlight an immune signature associated with long-term clozapine use. This includes reduction in class-switched memory B cells, echoing common variable immunodeficiency. Recent identification of a role for dopamine in T follicular helper-B cell interactions may inform future clinical studies. SUMMARY The detrimental impact of the increased infection risk associated with clozapine necessitates a re-evaluation of the current monitoring strategies as well as further studies to better understand the underlying mechanisms of SAD in this setting. On the basis of available evidence, we suggest simple modifications to clozapine monitoring including integration of routine vaccination, smoking cessation, and assessment of humoral immunity. Further studies are required to understand the role of clozapine in neuroinflammation as well as other potentially autoantibody-mediated diseases.
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102
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Rohde C, Siskind D, de Leon J, Nielsen J. Antipsychotic medication exposure, clozapine, and pneumonia: results from a self-controlled study. Acta Psychiatr Scand 2020; 142:78-86. [PMID: 31875941 DOI: 10.1111/acps.13142] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE By using a self-controlled design, we investigated whether antipsychotic medication exposure was associated with increased pneumonia risk and whether patients receiving clozapine were more likely to develop pneumonia than patients receiving other antipsychotic medications. METHODS Through nationwide health registers, we identified all out-patients with schizophrenia initiating antipsychotic treatment. First, we estimated whether antipsychotic-naïve patients with schizophrenia increased their risk of pneumonia after initiation of either a first- or second-generation antipsychotic medication using a one-year mirror-image model. Afterward, similar analyses were made for individual second-generation antipsychotics. Lastly, the rate of pneumonia for patients initiated on clozapine was compared to patients commenced on other second-generation antipsychotics. RESULTS In total, 8355 antipsychotic-naïve patients with schizophrenia were initiated on a first-generation antipsychotic medication; 0.95% of the patients had developed pneumonia before exposure, compared to 0.68% after exposure (P = 0.057). Similar findings were made for the 8001 antipsychotic-naïve patients with schizophrenia initiated on second-generation antipsychotic medications, with 0.56% developing pneumonia before exposure compared to 0.55% after exposure (P = 1.00). Second-generation antipsychotic medications did not increase the pneumonia risk, except for risperidone (increased by 0.32%; P = 0.007) and clozapine, which gave the largest absolute increase in pneumonia risk although not significant (increased by 0.64%; P = 0.10). The rate of pneumonia was higher after initiation of clozapine than for other second-generation antipsychotic medications. CONCLUSION Most antipsychotic medications were not found to increase the risk of pneumonia. Clozapine exposure might be associated with increased risk of developing pneumonia.
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Affiliation(s)
- C Rohde
- Department of Affective Disorders, Aarhus University Hospital - Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
| | - D Siskind
- Metro South Addiction and Mental Health Service, Brisbane, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - J de Leon
- Mental Health Research Center, 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 Apóstol Hospital, University of the Basque Country, Vitoria, Spain
| | - J Nielsen
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
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103
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Javed A, Mohandas E, Sousa AD. The interface of psychiatry and COVID-19: Challenges for management of psychiatric patients. Pak J Med Sci 2020; 36:1133-1136. [PMID: 32704300 PMCID: PMC7372677 DOI: 10.12669/pjms.36.5.3073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
COVID-19 is a viral infection that has multisystemic physical and psychological complications. The following paper looks at the various challenges seen while treating psychiatric patients during the COVID pandemic. There is a need for physician to be aware of the drug interactions between psychiatric medications and the medications used routinely in the management of COVID. There is also the concern of psychiatric side effects of medications used to manage COVID and medical complications caused by some side effects of psychiatric drugs. The telepsychiatry and telemedicine paradigm has made it mandatory for physicians to be vigilant of the same.
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Affiliation(s)
- Afzal Javed
- Afzal Javed Immediate Past President - Asian Federation of Psychiatric Associations & President Elect-World Psychiatric Association & Consultant Psychiatrist & Chairman, Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
| | - E Mohandas
- E. Mohandas Member, Pharmaco-Psychiatry Section, World Psychiatric Association and Past President - Indian Psychiatric Society and Consultant Psychiatrist, Sun Medical and Research Centre, Trichur, Kerala, India
| | - Avinash De Sousa
- Avinash De Sousa Consultant Psychiatrist and Research Associate, Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, India
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104
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Undetectable or subtherapeutic serum levels of antipsychotic drugs preceding switch to clozapine. NPJ SCHIZOPHRENIA 2020; 6:17. [PMID: 32681055 PMCID: PMC7367852 DOI: 10.1038/s41537-020-0107-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/23/2020] [Indexed: 11/10/2022]
Abstract
Adequate antipsychotic treatment intensity is required for defining treatment-resistant schizophrenia (TRS) and justifying clozapine treatment. We investigated the occurrence of undetectable or subtherapeutic serum levels of oral antipsychotics preceding switch to clozapine as an endpoint of TRS. For patients starting clozapine, 12-month retrospective reviews of antipsychotic serum concentration measurements were performed in a Norwegian therapeutic drug monitoring (TDM) database from 2005 to 2017. Undetectable levels in high-sensitive analytical assays defined ‘no drug use’, while levels <50% of the lower reference range defined ‘subtherapeutic use’. Similar data were collected for patients switching to long-acting injectable (LAI) antipsychotics, as a reference of ‘no or subtherapeutic drug use’. Nineteen of 353 patients initiating clozapine (5.4%) had a recent history of undetectable antipsychotic drug levels compared to 91 of 1048 (8.7%) initiating LAI. Another 19 patients starting clozapine (5.4%) had recent events of subtherapeutic levels. In conclusion, the present retrospective study may indicate that every 10th patient starting clozapine has a recent history of undetectable or subtherapeutic serum levels of oral antipsychotics. The clinical implications of the present study for the assessment of TRS should be investigated prospectively in further studies.
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105
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Fountoulakis KN, Moeller HJ, Kasper S, Tamminga C, Yamawaki S, Kahn R, Tandon R, Correll CU, Javed A. The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia. CNS Spectr 2020; 26:1-25. [PMID: 32594935 DOI: 10.1017/s1092852920001546] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This is a report of a joint World Psychiatric Association/International College of Neuropsychopharmacology (WPA/CINP) workgroup concerning the risk/benefit ratio of antipsychotics in the treatment of schizophrenia. It utilized a selective but, within topic, comprehensive review of the literature, taking into consideration all the recently discussed arguments on the matter and avoiding taking sides when the results in the literature were equivocal. The workgroup's conclusions suggested that antipsychotics are efficacious both during the acute and the maintenance phase, and that the current data do not support the existence of a supersensitivity rebound psychosis. Long-term treated patients have better overall outcome and lower mortality than those not taking antipsychotics. Longer duration of untreated psychosis and relapses are modestly related to worse outcome. Loss of brain volume is evident already at first episode and concerns loss of neuropil volume rather than cell loss. Progression of volume loss probably happens in a subgroup of patients with worse prognosis. In humans, antipsychotic treatment neither causes nor worsens volume loss, while there are some data in favor for a protective effect. Schizophrenia manifests 2 to 3 times higher mortality vs the general population, and treatment with antipsychotics includes a number of dangers, including tardive dyskinesia and metabolic syndrome; however, antipsychotic treatment is related to lower mortality, including cardiovascular mortality. In conclusion, the literature strongly supports the use of antipsychotics both during the acute and the maintenance phase without suggesting that it is wise to discontinue antipsychotics after a certain period of time. Antipsychotic treatment improves long-term outcomes and lowers overall and specific-cause mortality.
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Affiliation(s)
- Konstantinos N Fountoulakis
- 3rd Department of Psychiatry, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hans-Jurgen Moeller
- Department of Psychiatry, Ludwig Maximilian University of Munich, Munich, Germany
| | - Siegfried Kasper
- Universitätsklinik für Psychiatrie und Psychotherapie, Medizinische Universität Wien, Vienna, Austria
| | - Carol Tamminga
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Shigeto Yamawaki
- Center for Brain, Mind and KANSEI Sciences Research, Hiroshima University, Hiroshima, Japan
| | - Rene Kahn
- Department of Psychiatry and Behavioral Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rajiv Tandon
- Department of Psychiatry, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Christoph U Correll
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, New York, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Afzal Javed
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
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106
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Seifert R, Schirmer B. A simple mechanistic terminology of psychoactive drugs: a proposal. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:1331-1339. [PMID: 32535698 PMCID: PMC7351828 DOI: 10.1007/s00210-020-01918-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 06/03/2020] [Indexed: 12/15/2022]
Abstract
Antidepressants, antiepileptics, mood stabilizers, and antipsychotics are extremely broadly used psychoactive drugs. These drug terms are universally used in the literature. However, the indications of these drugs have broadened substantially and overlap. The mismatch between drug classification and clinical uses causes a lot of confusion in communication and renders literature searches increasingly difficult. Therefore, we propose to drop the above terms altogether and replace them by simple mechanistic terms. Antidepressants are re-named as norepinephrine/serotonin (NE/5-HT) enhancers, antiepileptics comprising drugs with different mechanisms become neuronal inhibitors with pleiotropic effects (NIPEs), and antipsychotics become antagonists at multiple G protein-coupled receptors (mGPCR antagonists). Alkali metal ions, comprising lithium, are integrated into NIPEs. The terms "typical/first-generation/conventional" and "atypical/second-generation/non-conventional" antipsychotics should be dropped, because the original criterion for distinction, i.e., the presence and absence of extrapyramidal motor effects, respectively, is not valid anymore. The suggested changes in drug nomenclature have already been implemented into a recent textbook (Seifert R, Basic Knowledge of Pharmacology). The revised nomenclature ensures consistency with other fields of pharmacology and assignment of drug classes to indications without causing confusion. The authors acknowledge that the change in drug nomenclature is a cultural process that will take time and openly discuss the problems associated with the proposal. Ultimately, international learned societies will have to agree on a new nomenclature.
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Affiliation(s)
- Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Bastian Schirmer
- Institute of Pharmacology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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107
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Xu SW, Dong M, Zhang Q, Yang SY, Chen LY, Sim K, He YL, Chiu HF, Sartorius N, Tan CH, Chong MY, Shinfuku N, Lin SK, Ng CH, Ungvari GS, Najoan E, Kallivayalil RA, Jamaluddin R, Javed A, Iida H, Swe T, Zhang B, Xiang YT. Clozapine prescription pattern in patients with schizophrenia in Asia: The REAP survey (2016). Psychiatry Res 2020; 287:112271. [PMID: 30885383 DOI: 10.1016/j.psychres.2019.02.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Abstract
Clozapine is an effective antipsychotic medication for treatment resistant schizophrenia and is widely used in Asian countries. This study investigated clozapine prescription patterns and their associated factors in Asian countries and territories based on the database of the Research on Asian Psychotropic prescription study (REAP) conducted in 2016. Demographic and clinical information of 3744 schizophrenia patients in 15 Asian countries and territories was collected with a standardized data collection form. In total, 18.4% of the sample received clozapine, ranging from 2.6% in Japan to 32.3% in Hong Kong. Binary logistic regression analysis revealed that higher antipsychotic dose (OR = 1.002, P < 0.001), less frequent first admission in the sample (OR = 0.6, P < 0.001), more severe negative symptoms (OR = 1.4, P = 0.001) and less first generation antipsychotics (FGAs) (OR = 0.2, P < 0.001) were independently and significantly associated with clozapine prescription. Clozapine is frequently and increasingly prescribed for schizophrenia in Asia, with large variation across countries and territories. Given the diverse prescription patterns of clozapine found in Asian countries/territories, the clinical rationale of clozapine prescription needs careful consideration in Asia with more local input.
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Affiliation(s)
- Shi-Wei Xu
- Department of Psychiatry and Psychology, Southern Medical University Nanfang Hospital, Guangdong, China; Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China
| | - Min Dong
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao SAR, China
| | - Qinge Zhang
- The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China
| | - Shu-Yu Yang
- Department of Pharmacy, Taipei City Hospital, Taipei, Taiwan
| | - Lian-Yu Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Kang Sim
- Institute of Mental Health, Buangkok Green Medical Park, Singapore
| | - Yan-Ling He
- Department of Psychiatric Epidemiology, Shanghai Mental Health Center, Shanghai, China
| | - Helen Fk Chiu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | - Chay-Hoon Tan
- Department of Pharmacology, National University of Singapore, Singapore
| | - Mian-Yoon Chong
- Chiayi Chang Gung Memorial Hospital and School of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Naotaka Shinfuku
- International Center for Medical Research, Kobe University School of Medicine, Kobe, Japan
| | - Shih-Ku Lin
- Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor S Ungvari
- University of Notre Dame Australia, Fremantle, Australia; Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia
| | | | | | - Ruzita Jamaluddin
- Department of Psychiatry & Mental Health, Hospital Tuanku Fauziah, Kangar, Perlis, Malaysia
| | - Afzal Javed
- Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
| | - Hitoshi Iida
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Thiha Swe
- Department of Mental Health, University of Medicine, Magway, Myanmar
| | - Bin Zhang
- Department of Psychiatry and Psychology, Southern Medical University Nanfang Hospital, Guangdong, China; Guangdong-Hong Kong-Macao Greater Bay Area Center for Brain Science and Brain-Inspired Intelligence, Guangzhou, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao SAR, China.
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108
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Siskind D, Sidhu A, Cross J, Chua YT, Myles N, Cohen D, Kisely S. Systematic review and meta-analysis of rates of clozapine-associated myocarditis and cardiomyopathy. Aust N Z J Psychiatry 2020; 54:467-481. [PMID: 31957459 DOI: 10.1177/0004867419898760] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Clozapine is the most effective medication for treatment refractory schizophrenia, but is associated with cardiac adverse drug reactions. Myocarditis and cardiomyopathy are the most serious cardiac adverse drug reactions although reported rates of these conditions vary in the literature. We systematically reviewed and meta-analysed the event rates, the absolute death rates and case fatality rates of myocarditis and cardiomyopathy associated with clozapine. METHODS PubMed, EMBASE and PsycINFO were searched for studies that reported on the incidence of cardiomyopathy or myocarditis in people exposed to clozapine. Data were meta-analysed using a random effects model, with subgroup analysis on study size, time frame, region, quality, retrospective vs prospective, and diagnostic criteria of myocarditis or cardiomyopathy. RESULTS 28 studies of 258,961 people exposed to clozapine were included. The event rate of myocarditis was 0.007 (95% confidence interval [CI] = [0.003, 0.016]), absolute death rate was 0.0004 (95% CI = [0.0002, 0.0009]) and case fatality rate was 0.127 (95% CI = [0.034, 0.377]). The cardiomyopathy event rate was 0.006 (95% CI = [0.002, 0.023]), absolute death rate was 0.0003 (95% CI = [0.0001, 0.0012]) and case fatality rate was 0.078 (95% CI = [0.018, 0.285]). Few included studies provided information on criteria for diagnosis of myocarditis and cardiomyopathy. Event rates of cardiomyopathy and myocarditis were higher in Australia. CONCLUSION Clarity of diagnostic criteria for myocarditis remains a challenge. Observation bias may, in part, influence higher reported rates in Australia. Monitoring for myocarditis is warranted in the first 4 weeks, and treatment of comorbid metabolic syndrome and diabetes may reduce the risk of cardiomyopathy. The risks of myocarditis and cardiomyopathy are low and should not present a barrier to people with treatment refractory schizophrenia being offered a monitored trial of clozapine.
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Affiliation(s)
- Dan Siskind
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Ashneet Sidhu
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - John Cross
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Yee-Tat Chua
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Nicholas Myles
- Haematology Directorate, SA Pathology, Adelaide, SA, Australia
| | - Dan Cohen
- GGZ Noord-Holland-Noord, Heerhugowaard, The Netherlands
| | - Steve Kisely
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
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109
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Siskind D, Honer WG, Clark S, Correll CU, Hasan A, Howes O, Kane JM, Kelly DL, Laitman R, Lee J, MacCabe JH, Myles N, Nielsen J, Schulte PF, Taylor D, Verdoux H, Wheeler A, Freudenreich O. Consensus statement on the use of clozapine during the COVID-19 pandemic. J Psychiatry Neurosci 2020; 45:222-223. [PMID: 32242646 PMCID: PMC7828973 DOI: 10.1503/jpn.200061] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Dan Siskind
- From the Metro South Addiction and Mental Health
Service, Brisbane, Australia (Siskind); the University of Queensland,
School of Clinical Medicine, Brisbane, Australia (Siskind, Myles); the
Department of Psychiatry, University of British Columbia, Vancouver,
BC, Canada (Honer); the University of Adelaide, School of Medicine,
Adelaide, Australia (Clark, Kane); the The Zucker Hillside Hospital,
Department of Psychiatry, Northwell Health, Glen Oaks, NY,
USA (Correll, Kane); the Zucker School of Medicine at Hofstra/
Northwell, Department of Psychiatry and Molecular Medicine,
Hempstead, NY, USA (Correll); Charité Universitätsmedizin Berlin,
Department of Child and Adolescent Psychiatry, Berlin, Germany
(Correll); the Department of Psychiatry, Psychotherapy and Psychosomatics
of the University Augsburg, Augsburg, Germany (Hassan);
the Institute of Psychiatry, Psychology & Neuroscience, King’s College
London, London, UK (Howes, MacCabe); the MRC London Institute
of Medical Sciences, Hammersmith Hospital, London, UK
(Howes); the Institute of Clinical Sciences (ICS), Faculty of Medicine,
Imperial College London, London, UK (Howes); the Maryland
Psychiatric
Research Center, University of Maryland School of Medicine,
Baltimore, MD, USA (Kelly); the Bronx Westchester Medical
Group, New York, NY, USA (Laitman); the North Region & Department
of Psychosis, Institute of Mental Health, Singapore (Lee); the
Lee Kong Chian School of Medicine, Nanyang Technological University,
Singapore (Lee); the Mental Health Centre Copenhagen, Copenhagen
University Hospital, Copenhagen (Nielsen); the Mental Health
Service Noord-Holland-
Noord, Alkmaar, The Netherlands (Schulte);
the South London and Maudsley NHS Foundation Trust, Pharmacy
Department, Maudsley Hospital, London, UK (Taylor); the University
of Bordeaux, INSERM, Bordeaux Population Health Research
Center, Bordeaux, France (Verdoux); the Menzies Health Institute
Queensland, Griffith University, Brisbane, Australia (Wheeler); the
MGH Schizophrenia Clinical and Research Program, Massachusetts
General Hospital, Boston, MA, USA (Freudenreich); and the Harvard
Medical School, Boston, MA, USA (Freudenreich)
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110
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de Leon J, Ruan CJ, Verdoux H, Wang C. Clozapine is strongly associated with the risk of pneumonia and inflammation. Gen Psychiatr 2020; 33:e100183. [PMID: 32420521 PMCID: PMC7199914 DOI: 10.1136/gpsych-2019-100183] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/26/2020] [Accepted: 03/28/2020] [Indexed: 12/16/2022] Open
Abstract
Clinicians need to remember that (1) systemic inflammations can increase clozapine level; (2) clozapine, by itself, can cause inflammation, particularly during titration that is too rapid for that patient; (3) clozapine may increase the risk of infection; and (4) more specifically, clozapine may be particularly strongly associated with the risk of pneumonia. Pneumonia appears to be associated with high mortality in clozapine patients around the world. Clinicians who are alert to the risk of pneumonia in clozapine patients may significantly decrease mortality in clozapine patients. There is no data on COVID-19 infections in clozapine patients, but based on what we know about clozapine pharmacology, we can hypothesise that clozapine, possibly by impairing immunological mechanisms, may increase the risk of pneumonia in infected patients. More importantly, once fever and/or pneumonia develops, the clozapine dose should be cut in half to decrease the risk of clozapine intoxication. If there is any doubt that in spite of halving the dose there are still signs of clozapine intoxication, completely stopping clozapine may be indicated. Once the signs of inflammation and fever have disappeared, the clozapine dose can be increased to the prior dosage level.
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Affiliation(s)
- Jose de Leon
- University of Kentucky Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky, USA
| | - Can-Jun Ruan
- Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing, China
| | - Hélène Verdoux
- Inserm, Bordeaux Population Health Research Center, University of Bordeaux Faculty of Medical Sciences, Bordeaux, Aquitaine, France
| | - Chuanyue Wang
- Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, Beijing, China
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111
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de Leon J, Ruan CJ, Schoretsanitis G, De las Cuevas C. A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:200-214. [PMID: 32289791 PMCID: PMC7206357 DOI: 10.1159/000507638] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, 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 Apóstol Hospital, University of the Basque Country, Vitoria, Spain,
| | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders, Beijing Key Laboratory of Mental Disorders, and Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Spain
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112
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Mizuno Y, McCutcheon RA, Brugger SP, Howes OD. Heterogeneity and efficacy of antipsychotic treatment for schizophrenia with or without treatment resistance: a meta-analysis. Neuropsychopharmacology 2020; 45:622-631. [PMID: 31766049 PMCID: PMC7021799 DOI: 10.1038/s41386-019-0577-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 01/08/2023]
Abstract
Two important clinical questions are whether there is a subtype of schizophrenia which responds differently to clozapine relative to other antipsychotics, and whether greater efficacy of clozapine is dependent on the degree of treatment-resistance. The authors address this by examining both variability and magnitude of response in patients treated with clozapine and other antipsychotics for both treatment-resistant schizophrenia (TRS) and non-resistant schizophrenia. Double-blind randomised controlled trials comparing clozapine with other antipsychotics in patients with schizophrenia were identified using five databases. Standard deviations and means of change in total, positive, and negative symptoms were extracted. Variability ratio (VR) and coefficient of variation ratio (CVR) were used to quantify relative variability in symptom change. Hedges' g was used to quantify mean differences. Ten TRS studies (n = 822) and 29 non-TRS studies (n = 2566) were meta-analysed. Relative variability in change of total symptoms did not differ significantly between clozapine and other antipsychotics in TRS studies (VR = 1.84; 95%CI, 0.85-4.02). These findings were similar with CVR, and for positive and negative symptoms. Clozapine was superior to other antipsychotics in improving total symptoms in both TRS (g = 0.34; 95%CI, 0.13-0.56) and non-TRS (g = 0.20; 95%CI, 0.08-0.32) studies. Furthermore, clozapine was superior in improving positive symptoms in both study groups, but not for negative symptoms. Pooled effect sizes showed no significant difference between TRS and non-TRS studies. These findings do not support a subtype of schizophrenia which responds specifically to clozapine. Clozapine is more effective than other antipsychotics irrespective of treatment-resistance, arguing for its use more generally in schizophrenia. PROSPERO CRD42018086507.
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Affiliation(s)
- Yuya Mizuno
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0004 1936 9959grid.26091.3cDepartment of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Robert A. McCutcheon
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Stefan P. Brugger
- 0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK ,0000 0004 1936 7603grid.5337.2Centre for Academic Mental Health, University of Bristol, Bristol, UK ,0000000121901201grid.83440.3bDivision of Psychiatry, University College London, London, UK ,0000 0001 0807 5670grid.5600.3Cardiff University Brain Research Imaging Centre, School of Psychology, Cardiff University, Cardiff, UK
| | - Oliver D. Howes
- 0000 0001 2322 6764grid.13097.3cDepartment of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8AF UK ,0000 0001 0705 4923grid.413629.bPsychiatric Imaging Group, MRC London Institute of Medical Sciences, Hammersmith Hospital, London, UK ,0000 0001 2113 8111grid.7445.2Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK
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Polcwiartek C, Kragholm K, Hansen SM, Atwater BD, Friedman DJ, Barcella CA, Graff C, Nielsen JB, Pietersen A, Nielsen J, Søgaard P, Torp-Pedersen C, Jensen SE. Electrocardiogram Characteristics and Their Association With Psychotropic Drugs Among Patients With Schizophrenia. Schizophr Bull 2020; 46:354-362. [PMID: 31219596 PMCID: PMC7442389 DOI: 10.1093/schbul/sbz064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND There are limited data on electrocardiogram (ECG) characteristics and their association with psychotropic drugs in schizophrenia. METHODS Using a cross-sectional design, we included Danish primary care patients with first-time digital ECGs from 2001 to 2015. Patients diagnosed with schizophrenia before ECG recording were matched 1:5 on age, sex, and ECG recording year to controls without psychiatric disease. Multivariable logistic regression was used to compute odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS We included 4486 patients with schizophrenia matched with 22 430 controls (median age, 47 years; male, 55%). Between groups, the prevalence of abnormal ECGs was similar (54%, P = .536), but patients with schizophrenia demonstrated higher median heart rate (79 vs 69 beats per minute, P < .001) and Fridericia-corrected QT (QTc) interval (416 vs 412 ms, P < .001) than controls. QTc prolongation was also more prevalent among patients with schizophrenia (3.4% vs 1.1%, P < .001), and so were pathological Q waves (5.3% vs 3.9%, P < .001). Patients with schizophrenia less frequently demonstrated left ventricular hypertrophy (6.1% vs 9.6%, P < .001) and atrial fibrillation or flutter (0.7% vs 1.4%, P < .001). Among patients with schizophrenia only, particularly antipsychotics were associated with abnormal ECGs (OR, 1.20; 95% CI, 1.04-1.39). CONCLUSIONS Patients with schizophrenia demonstrate a different cardiovascular risk profile than matched controls without psychiatric disease, with higher prevalence of elevated heart rate, QTc prolongation, and pathological Q waves, and lower prevalence of left ventricular hypertrophy and atrial fibrillation or flutter. Particularly antipsychotics were associated with abnormal ECGs. This underscores an integrated care approach when ECG abnormalities are detected in this group.
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Affiliation(s)
- Christoffer Polcwiartek
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Division of Cardiology, Duke University Medical Center, Durham, NC
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- To whom correspondence should be addressed; Department of Cardiology, Aalborg University Hospital, Hobrovej 18–22, DK-9000 Aalborg, Denmark; e-mail:
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Steen M Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Brett D Atwater
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | | | - Carlo A Barcella
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Jonas B Nielsen
- Laboratory for Molecular Cardiology, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Adrian Pietersen
- Copenhagen General Practitioners’ Laboratory, Copenhagen, Denmark
| | - Jimmi Nielsen
- Mental Health Center Glostrup, Copenhagen University Hospital Glostrup, Copenhagen, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Svend E Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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de Leon J, Sanz EJ, Norén GN, De las Cuevas C. Pneumonia may be more frequent and have more fatal outcomes with clozapine than with other second-generation antipsychotics. World Psychiatry 2020; 19:120-121. [PMID: 31922665 PMCID: PMC6953557 DOI: 10.1002/wps.20707] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
| | - Emilio J. Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, University of La Laguna, Canary Islands, Spain
| | | | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain
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Taipale H, Tanskanen A, Mehtälä J, Vattulainen P, Correll CU, Tiihonen J. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry 2020; 19:61-68. [PMID: 31922669 PMCID: PMC6953552 DOI: 10.1002/wps.20699] [Citation(s) in RCA: 199] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Antipsychotics are effective in preventing relapses of schizophrenia, but it is generally believed that their long-term use is harmful for patients' physical well-being. However, there are no long-term studies which have verified this view. This nationwide, register-based cohort study aimed to assess the risk of hospitalization due to physical health problems, as a marker for severe physical morbidity, and the risk of all-cause mortality, as well as of cardiovascular and suicidal death, associated with antipsychotic use in all patients treated for schizophrenia in inpatient care between 1972 and 2014 in Finland (N=62,250), with up to 20 years of follow-up (median: 14.1 years). The use of antipsychotic drugs (i.e., use of any antipsychotic compared with non-use) and the use of specific antipsychotics were investigated, and outcomes were somatic and cardiovascular hospitalization, and all-cause, cardiovascular and suicide death. Hospitalization-based outcomes were analyzed by a within-individual design to eliminate selection bias, comparing use and non-use periods in the same individual by stratified Cox model. Mortality outcomes were assessed by traditional between-individual Cox multivariate models. The adjusted hazard ratios (aHRs) for any somatic hospitalization and cardiovascular hospitalization were 1.00 (95% CI: 0.98-1.03) and 1.00 (95% CI: 0.92-1.07) during use of any antipsychotic compared to non-exposure periods within the same individual. The aHRs were 0.48 (95% CI: 0.46-0.51) for all-cause mortality, 0.62 (95% CI: 0.57-0.67) for cardiovascular mortality, and 0.52 (95% CI: 0.43-0.62) for suicide mortality during use vs. non-use of any antipsychotic. The most beneficial mortality outcome was associated with use of clozapine in terms of all-cause (aHR=0.39, 95% CI: 0.36-0.43), cardiovascular (aHR=0.55, 95% CI: 0.47-0.64) and suicide mortality (aHR=0.21, 95% CI: 0.15-0.29). The cumulative mortality rates during maximum follow-up of 20 years were 46.2% for no antipsychotic use, 25.7% for any antipsychotic use, and 15.6% for clozapine use. These data suggest that long-term antipsychotic use does not increase severe physical morbidity leading to hospitalization, and is associated with substantially decreased mortality, especially among patients treated with clozapine.
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Affiliation(s)
- Heidi Taipale
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,School of Pharmacy, University of Eastern Finland, KuopioFinland
| | - Antti Tanskanen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,Public Health Evaluation and Projection Unit, National Institute for Health and WelfareHelsinkiFinland
| | | | | | - Christoph U. Correll
- Department of Psychiatry, Zucker Hillside HospitalNorthwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Center for Psychiatric Neuroscience, Feinstein Institute for Medical ResearchManhassetNYUSA,Department of Child and Adolescent PsychiatryCharité UniversitätsmedizinBerlinGermany
| | - Jari Tiihonen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Forensic PsychiatryUniversity of Eastern Finland, Niuvanniemi HospitalKuopioFinland,Center for Psychiatry Research, Stockholm City CouncilStockholmSweden
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116
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Singh B, Hughes AJ, Roerig JL. Comfort Level and Barriers to the Appropriate Use of Clozapine: a Preliminary Survey of US Psychiatric Residents. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2020; 44:53-58. [PMID: 31713078 DOI: 10.1007/s40596-019-01134-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/09/2019] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Clozapine is the gold standard treatment for treatment-resistant schizophrenia. Prior surveys of mental health providers have identified multiple causes for underutilization of clozapine; however, no previous survey has been conducted to assess US psychiatry residents' level of comfort in prescribing clozapine. METHODS A survey was sent via email to program directors of Accreditation Council for Graduate Medical Education-affiliated psychiatry residency programs requesting the survey to be distributed to current residents. The survey included questions regarding demographics, clozapine-prescribing practices, comfort levels with prescription, and perceived barriers to prescription. RESULTS A total of 164 psychiatric residents completed the survey, 37% PGY-1 and 2 residents and 63% PGY-3 or higher. One-third of the respondents had a clozapine clinic in their program. Only 18% of the residents felt "very" comfortable in initiating clozapine and 41% felt "somewhat" comfortable. Two main reasons for not starting clozapine were (1) side effect profile (41%) and (2) limited experience and inadequate training in clozapine use (38%). More than 4/5ths of the residents (83%) responded that they would feel more comfortable in prescribing clozapine if they were trained in a clozapine clinic. Major limitation of this study has been the small sample size, lack of representativeness, and generalization. CONCLUSIONS Forty-one percent of the respondents did not feel comfortable with clozapine prescription. Major concerns cited included the side effect profile as well as lack of experience and training. The majority of the respondents felt that they would be more comfortable prescribing clozapine if they had the opportunity to train in a clozapine clinic.
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117
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De Leon J, Sanz EJ, De las Cuevas C. Data From the World Health Organization's Pharmacovigilance Database Supports the Prominent Role of Pneumonia in Mortality Associated With Clozapine Adverse Drug Reactions. Schizophr Bull 2020; 46:1-3. [PMID: 31901099 PMCID: PMC6942151 DOI: 10.1093/schbul/sbz093] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jose De Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain
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118
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Yi W, She S, Zhang J, Wu H, Zheng Y, Ning Y. Clozapine Use in Patients with Early-Stage Schizophrenia in a Chinese Psychiatric Hospital. Neuropsychiatr Dis Treat 2020; 16:2827-2836. [PMID: 33262597 PMCID: PMC7699990 DOI: 10.2147/ndt.s261503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Previous studies suggest that clozapine is commonly underutilized and that its initiation is delayed in patients with first-episode schizophrenia. Knowledge regarding clozapine use among Chinese patients with early-stage schizophrenia is limited. The aim of the present study was to investigate the point prevalence of and patterns and factors associated with clozapine use in patients with early-stage schizophrenia discharged from a psychiatric hospital in China. METHODS A retrospective study was conducted to analyze the prescriptions of 867 consecutive patients with early-stage schizophrenia who were admitted to the Affiliated Brain Hospital of Guangzhou Medical University between Jan 1, 2011 and Dec 31, 2016. RESULTS At discharge from the hospital, 114 (13.1%) patients were prescribed clozapine. Among the patients taking clozapine, 93 patients (81.6%) were prescribed clozapine polypharmacy, and only 21 patients (18.4%) were prescribed clozapine monotherapy. None of the patients were prescribed an overdose of clozapine. The mean daily dosage of clozapine was 160.97 mg, 149.05 mg and 213.69 mg among all patients taking clozapine, patients taking clozapine polypharmacy and patients taking clozapine monotherapy, respectively. The antipsychotic most frequently combined with clozapine was risperidone. Logistic regression suggested that the length of hospital stay, high school education, lower benzodiazepine use and antipsychotic polypharmacy were independently and significantly associated with clozapine use (P<0.05). CONCLUSION Although clozapine has been commonly used in China in recent years, the present study found that clozapine was not commonly used in patients with early-stage schizophrenia. An underutilization and delayed initiation of clozapine may exist in a portion of patients with early-stage schizophrenia. Given the unfavorable outcomes of underutilized and delayed clozapine use, future studies may be needed to assess and increase clozapine use in this population.
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Affiliation(s)
- Wenying Yi
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Shenglin She
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jie Zhang
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Haibo Wu
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yingjun Zheng
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yuping Ning
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
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119
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Kessler RC, Bossarte RM, Luedtke A, Zaslavsky AM, Zubizarreta JR. Suicide prediction models: a critical review of recent research with recommendations for the way forward. Mol Psychiatry 2020; 25:168-179. [PMID: 31570777 PMCID: PMC7489362 DOI: 10.1038/s41380-019-0531-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/04/2019] [Accepted: 09/17/2019] [Indexed: 12/26/2022]
Abstract
Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.
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Affiliation(s)
- Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
| | - Robert M Bossarte
- West Virginia University Injury Control Research Center and Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, USA
- West Virginia and VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, NY, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Statistics, Harvard University, Cambridge, MA, USA
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Use of cardiovascular and antidiabetic drugs before and after starting with clozapine versus other antipsychotic drugs: a Dutch database study. Int Clin Psychopharmacol 2020; 35:36-41. [PMID: 31714320 DOI: 10.1097/yic.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reports of decreased mortality among patients with schizophrenia who use clozapine may be biased if clozapine is prescribed to relatively healthy patients and if intensive monitoring during its use prevents (under-treatment of) somatic disorder. We aimed to assess whether there is a difference in: (1) somatic comorbidity between patients who start with clozapine and those who start with other antipsychotics and (2) prescribed somatic medication, between patients using clozapine and those using olanzapine. Cohort study based on insurance claims (2010-2015). After selecting new users of antipsychotics and those who subsequently switched to clozapine (N = 158), aripiprazole (N = 295), olanzapine (N = 204) or first-generation antipsychotics (N = 295), we compared the clozapine starters to others on cardiovascular or diabetic comorbidity. Those using clozapine and olanzapine were compared on new prescriptions for cardiovascular or antidiabetic drugs. The ORadj of cardiovascular or diabetic comorbidity among other starters compared with clozapine starters was 0.77 [95% confidence interval (CI): 0.43-1.39], that is, a nonsignificantly increased prevalence associated with clozapine was found. Users of clozapine received significantly more new prescriptions for cardiovascular or antidiabetic medication (ORadj: 2.70, 95% CI: 1.43-5.08). Starters with clozapine were not cardiovascular/metabolic healthier than starters with other antipsychotics. During its use, they received more somatic treatment.
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121
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Meyer JM. Commentary: More research needed on predictive biomarkers related to clozapine treatment. Biomark Neuropsychiatry 2019. [DOI: 10.1016/j.bionps.2019.100003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Ostinelli EG, Zangani C, Solmi M. Clozapine for persistent aggressive behaviour or agitation in people with schizophrenia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Edoardo G Ostinelli
- Università degli Studi di Milano; Department of Health Sciences; Via Antonio di Rudinì 8 Milan Italy 20142
| | - Caroline Zangani
- Università degli Studi di Milano; Department of Health Sciences; Via Antonio di Rudinì 8 Milan Italy 20142
| | - Marco Solmi
- University of Padua; Neurosciences Department; Padova PAdova Italy 35100
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Peters L, Krogmann A, von Hardenberg L, Bödeker K, Nöhles VB, Correll CU. Long-Acting Injections in Schizophrenia: a 3-Year Update on Randomized Controlled Trials Published January 2016-March 2019. Curr Psychiatry Rep 2019; 21:124. [PMID: 31745659 DOI: 10.1007/s11920-019-1114-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This study was conducted in order to review randomized controlled trial (RCT) data published January 2016-March 2019 on long-acting injectable antipsychotics (LAIs) for schizophrenia. RECENT FINDINGS Thirty-one RCTs (primary studies = 7; post hoc analyses = 24; n = 4738) compared LAIs vs. placebo (studies = 11, n = 1875), LAIs vs. oral antipsychotics (OAPs) (studies = 7, n = 658), and LAI vs. LAI (studies = 13, n = 2205). LAIs included two new formulations, aripiprazole lauroxil nanocrystal dispersion and subcutaneously injectable risperidone Perseris, as well as aripiprazole lauroxil, aripiprazole once-monthly, paliperidone once-monthly, paliperidone 3-monthly, and risperidone-LAI. Regarding prevention of relapse and hospitalization, LAIs consistently outperformed placebo, being partly superior to OAPs, without relevant LAI-LAI differences. LAIs were comparable to OAPs regarding all-cause discontinuation, functioning, quality of life, and tolerability, being associated with higher patient satisfaction and service engagement. Recent meta-analyses yielded mixed results, but never favoring OAPs over LAIs. In RCTs, LAIs are superior to placebo, but only in some aspects, superior to OAPs. Comparative effectiveness of LAIs vs. OAPs requires further study, ideally in generalizable/real-world samples.
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Affiliation(s)
- Luisa Peters
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Amanda Krogmann
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Laura von Hardenberg
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Katja Bödeker
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Viktor B Nöhles
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany. .,Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, 75-59 263rd Street, Glen Oaks, NY, 11004, USA. .,Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
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Verdoux H, Quiles C, Cervello S, Dubreucq J, Bon L, Massoubre C, Pommier R, Legros-Lafarge E, Jaafari N, Guillard-Bouhet N, Chéreau-Boudet I, Couhet G, Plasse J, Franck N. Functioning and cognitive characteristics of clozapine users referred to psychosocial rehabilitation centers: A REHABase cohort study. Psychiatry Res 2019; 281:112543. [PMID: 31493715 DOI: 10.1016/j.psychres.2019.112543] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To explore whether clozapine users have specific rehabilitation needs compared to users of other antipsychotics. METHODS The study was performed using the REHABase collecting data on persons referred to a French network of psychosocial rehabilitation centers. It was restricted to persons with schizophrenia spectrum disorder using antipsychotics. Multivariate analyses were used to compare baseline functioning and cognitive characteristics in clozapine users vs. users of other antipsychotics. RESULTS Of the 675 patients identified in the REHABase, one out of ten (n = 70) used clozapine. Compared to users of other antipsychotics, clozapine users had been more frequently hospitalized in psychiatry and presented less frequently with psychoactive substance use. Functional measures did not significantly differ between the two groups. Clozapine users had poorer short-term verbal memory performance than users of other antipsychotics and did not differ on executive performance. CONCLUSION Clozapine users may reach a recovery level comparable to that obtained in persons without treatment-resistant schizophrenia. In order to reduce the negative impact of memory deficits on the recovery process of clozapine users, it is necessary to optimize their psychotropic treatment and to promote their access to cognitive remediation programs addressing their specific needs.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, team pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France; Centre Référent de Réhabilitation Psychosociale (C2RP), Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Référent de Réhabilitation Psychosociale (C2RP), Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Sophie Cervello
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), Hôpital Le Vinatier, Centre National de la Recherche Scientifique (CNRS) et Université de Lyon, Lyon, France
| | - Julien Dubreucq
- Centre Référent de Réhabilitation Psychosociale et de Remédiation Cognitive (C3R), Centre Hospitalier Alpes Isère / Réseau Handicap Psychique, St Martin d'Hères, ReHPSY, Centre Hospitalier Alpes Isère, Grenoble, France
| | - Laura Bon
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), Hôpital Le Vinatier, Centre National de la Recherche Scientifique (CNRS) et Université de Lyon, Lyon, France
| | - Catherine Massoubre
- REHALise, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Romain Pommier
- REHALise, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | | | - Nemat Jaafari
- CREATIV & URC Pierre Deniker, Centre Hospitalier Laborit, Poitiers, France
| | | | - Isabelle Chéreau-Boudet
- Centre Réfèrent Conjoint de Réhabilitation (CRCR), Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Geoffroy Couhet
- Centre Référent de Réhabilitation Psychosociale (C2RP), Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Julien Plasse
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), Hôpital Le Vinatier, Centre National de la Recherche Scientifique (CNRS) et Université de Lyon, Lyon, France
| | - Nicolas Franck
- Centre Ressource de Réhabilitation Psychosociale et de Remédiation Cognitive (CRR), Hôpital Le Vinatier, Centre National de la Recherche Scientifique (CNRS) et Université de Lyon, Lyon, France; Centre Référent Lyonnais de Réhabilitation Psychosociale (CL3R), Centre Hospitalier Le Vinatier, Lyon, France
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Abstract
Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual's risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity.
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126
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Masuda T, Misawa F, Takase M, Kane JM, Correll CU. Association With Hospitalization and All-Cause Discontinuation Among Patients With Schizophrenia on Clozapine vs Other Oral Second-Generation Antipsychotics: A Systematic Review and Meta-analysis of Cohort Studies. JAMA Psychiatry 2019; 76:1052-1062. [PMID: 31365048 PMCID: PMC6669790 DOI: 10.1001/jamapsychiatry.2019.1702] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Recent meta-analyses of randomized clinical trials (RCTs) comparing clozapine with nonclozapine second-generation antipsychotics (NC-SGAs) in schizophrenia have challenged clozapine's superiority in treatment-resistant patients. However, patients in RCTs are not necessarily generalizable to those in clinical practice. OBJECTIVE To conduct a systematic review and meta-analysis to compare various outcomes of clozapine vs oral NC-SGAs in cohort studies. DATA SOURCES Systematic literature search in PubMed, PsycINFO, and CINAHL without language restriction from database inception until December 17, 2018. STUDY SELECTION Nonrandomized cohort studies reporting effectiveness and/or safety outcomes comparing clozapine with NC-SGAs in schizophrenia or schizoaffective disorder. DATA EXTRACTION AND SYNTHESIS Independent investigators assessed studies and extracted data. Using a random-effects model, the study calculated risk ratio (RR) unadjusted for covariates and follow-up duration, number needed to treat/number needed to harm (NNT/NNH) for dichotomous data, and standardized mean difference (SMD) or mean difference (MD) for continuous data. MAIN OUTCOMES AND MEASURES Coprimary outcomes were hospitalization and all-cause discontinuation. Secondary outcomes included all effectiveness and safety outcomes reported in at least 3 analyzable studies. RESULTS Of 8446 hits, 68 articles from 63 individual cohort studies (n = 109 341) (60.3% male; mean [SD] age of 38.8 [6.5] years, illness duration of 11.0 [5.1] years, and study duration of 19.1 [23.3] months) were meta-analyzed. Compared with NC-SGAs, despite greater illness severity (17 studies [n = 38 766]; Hedges g, 0.222; 95% CI, 0.013-0.430; P = .04), clozapine was significantly associated with lower hospitalization risk (19 studies [n = 49 453]; RR, 0.817; 95% CI, 0.725-0.920; P = .001; NNT, 18; 95% CI, 12-40) and all-cause discontinuation (16 studies [n = 56 368]; RR, 0.732; 95% CI, 0.639-0.838; P < .001; NNT, 8; 95% CI, 6-12). Associations were statistically significant for comparisons with quetiapine fumarate and aripiprazole regarding hospitalization and all NC-SGAs, except aripiprazole, for all-cause discontinuation. Clozapine was also significantly associated with better outcomes regarding overall symptoms (SMD, -0.302; 95% CI, -0.572 to -0.032; P = .03) and Clinical Global Impressions scale severity (SMD, -1.182; 95% CI, -2.243 to -0.122; P = .03). Clozapine was significantly associated with increases in body weight (MD, 1.70; 95% CI, 0.31-3.08 kg; P = .02), body mass index (MD, 0.96; 95% CI, 0.24-1.68; P = .009), and type 2 diabetes (RR, 1.777; 95% CI, 1.229-2.570; P = .002; NNH, 27; 95% CI, 13-90). CONCLUSIONS AND RELEVANCE In cohort studies, despite more severely ill patients being treated with clozapine, use of clozapine was associated with better key efficacy outcomes and higher cardiometabolic-related risk outcomes vs NC-SGAs.
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Affiliation(s)
- Takahiro Masuda
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Sumitomo Dainippon Pharma Co, Ltd, Medical Affairs, Tokyo, Japan
| | - Fuminari Misawa
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Yamanashi Prefectural KITA Hospital, Yamanashi, Japan
| | - Masayuki Takase
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - John M. Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,Feinstein Institute for Medical Research, Manhasset, New York
| | - Christoph U. Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York,Feinstein Institute for Medical Research, Manhasset, New York,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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127
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Faden J. How do we select an antipsychotic for those with schizophrenia? Expert Opin Pharmacother 2019; 20:2195-2199. [DOI: 10.1080/14656566.2019.1674284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Justin Faden
- Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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128
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Abstract
PURPOSE OF REVIEW The current review examines the recent literature on the causes of premature mortality in schizophrenia. RECENT FINDINGS People with schizophrenia have higher premature mortality rates compared with the general population. Suicides and accidents account for a nontrivial part of the excess mortality, but the largest part is attributable to natural causes of death. Five major causes have been identified: first, adverse effects of medication; second, suboptimal lifestyle; third, somatic comorbidity; fourth, suboptimal treatment of somatic disorders; and fifth, accelerated ageing/genetic explanations. The positive aspect is that people with schizophrenia have increasing life expectancy, at least in high-income countries, and this development seems to largely follow the increase in the general population. Especially mortality rates from unnatural causes appear to have a positive impact. Nevertheless, despite more than 100 years of research and progress, the excess mortality in persons with schizophrenia remains unacceptably high, with no prospects of reaching the level in the general population. SUMMARY The excess mortality in schizophrenia has received much focus. Future studies should explore the reasons for the high rates of natural causes of death, while aiming to disentangle the complex interplay between medication, lifestyle, comorbidity, treatment of somatic disorders, and genetic effects.
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129
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Howell S, Yarovova E, Khwanda A, Rosen SD. Cardiovascular effects of psychotic illnesses and antipsychotic therapy. Heart 2019; 105:1852-1859. [PMID: 31439658 DOI: 10.1136/heartjnl-2017-312107] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/21/2019] [Accepted: 07/29/2019] [Indexed: 11/04/2022] Open
Abstract
Mortality from cardiovascular disease is increased in people with mental health disorders in general and schizophrenia in particular. The causes are multifactorial, but it is known that antipsychotic medication can cause cardiac side-effects beyond the traditional coronary risk factors. Schizophrenia itself is a contributor to an increased risk of cardiovascular mortality via cardiac autonomic dysfunction and a higher prevalence of metabolic syndrome, both contributing to a reduced life expectancy. The pro-arrhythmic impact of traditional antipsychotics, especially via the hERG-potassium channel, has been known for several years. Newer antipsychotics have a reduced pro-arrhythmic profile but might contribute to higher cardiac death rates by worsening the metabolic profile. Clozapine-induced cardiomyopathy, which is dose independent, is a further concern and continuous monitoring of these patients is required. Prophylaxis with angiotensin-converting enzyme inhibitors is currently under review. Overall, management of cardiovascular risk within this population group must be multifaceted and nuanced to allow the most effective treatment of serious mental illness to be conducted within acceptable parameters of cardiovascular risk; some practical measures are presented for the clinical cardiologist.
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Affiliation(s)
- Sandra Howell
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK
| | - Ekaterina Yarovova
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Ahmad Khwanda
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Stuart D Rosen
- Cardiology, Ealing Hospital, London North West University Healthcare NHS Trust, Middlesex, UK .,Imperial College, National Heart and Lung Institute Division of Cardiovascular Sciences, London, UK
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130
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Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, Allan S, Caneo C, Carney R, Carvalho AF, Chatterton ML, Correll CU, Curtis J, Gaughran F, Heald A, Hoare E, Jackson SE, Kisely S, Lovell K, Maj M, McGorry PD, Mihalopoulos C, Myles H, O'Donoghue B, Pillinger T, Sarris J, Schuch FB, Shiers D, Smith L, Solmi M, Suetani S, Taylor J, Teasdale SB, Thornicroft G, Torous J, Usherwood T, Vancampfort D, Veronese N, Ward PB, Yung AR, Killackey E, Stubbs B. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry 2019; 6:675-712. [PMID: 31324560 DOI: 10.1016/s2215-0366(19)30132-4] [Citation(s) in RCA: 708] [Impact Index Per Article: 141.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/01/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Joseph Firth
- NICM Health Research Institute, Western Sydney University, Westmead, NSW, Australia; Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia.
| | - Najma Siddiqi
- Department of Health Sciences, University of York, Hull York Medical School, Bradford, UK; Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Barcelona, Spain; Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain; Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Simon Rosenbaum
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Cherrie Galletly
- Ramsay Health Care Mental Health, Adelaide, SA, Australia; Northern Adelaide Local Health Network, Adelaide, SA, Australia; Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia
| | - Stephanie Allan
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Constanza Caneo
- Departamento de Psiquiatría, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rebekah Carney
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Youth Mental Health Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Andre F Carvalho
- Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Mary Lou Chatterton
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Christoph U Correll
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Jackie Curtis
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Keeping the Body in Mind Program, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - Fiona Gaughran
- South London and Maudsley NHS Foundation Trust, London, UK; Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Adrian Heald
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - Erin Hoare
- Food and Mood Centre, Deakin University, Melbourne, VIC, Australia
| | - Sarah E Jackson
- Department of Behavioural Science and Health, University College London, London, UK
| | - Steve Kisely
- School of Medicine, University of Queensland, Brisbane, QLD, Australia; Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Mario Maj
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Patrick D McGorry
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Cathrine Mihalopoulos
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Melbourne, VIC, Australia
| | - Hannah Myles
- Discipline of Psychiatry, University of Adelaide, Adelaide, SA, Australia
| | - Brian O'Donoghue
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Toby Pillinger
- South London and Maudsley NHS Foundation Trust, London, UK; Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Medical Research Council London Institute of Medical Sciences, London, UK; Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, UK
| | - Jerome Sarris
- NICM Health Research Institute, Western Sydney University, Westmead, NSW, Australia; Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia; The Melbourne Clinic, Melbourne, VIC, Australia
| | - Felipe B Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil
| | - David Shiers
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Lee Smith
- Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Marco Solmi
- Neurosciences Department and Padua Neuroscience Centre, University of Padua, Padua, Italy
| | - Shuichi Suetani
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia; Queensland Brain Institute, University of Queensland, Brisbane, QLD, Australia; Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD, Australia
| | - Johanna Taylor
- Department of Health Sciences, University of York, Hull York Medical School, Bradford, UK
| | - Scott B Teasdale
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Keeping the Body in Mind Program, South Eastern Sydney Local Health District, Sydney, NSW, Australia
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John Torous
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tim Usherwood
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of General Practice, Westmead Clinical School, University of Sydney, Westmead, NSW, Australia
| | - Davy Vancampfort
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; University Psychiatric Centre, Katholieke Universiteit Leuven, Kortenberg, Belgium
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy
| | - Philip B Ward
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Schizophrenia Research Unit, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Alison R Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Eoin Killackey
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Brendon Stubbs
- South London and Maudsley NHS Foundation Trust, London, UK; Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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131
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Yang QX, Wang YX, Li FC, Zhang S, Luo YC, Li Y, Tang J, Li B, Chen YZ, Xue WW, Zhu F. Identification of the gene signature reflecting schizophrenia's etiology by constructing artificial intelligence-based method of enhanced reproducibility. CNS Neurosci Ther 2019; 25:1054-1063. [PMID: 31350824 PMCID: PMC6698965 DOI: 10.1111/cns.13196] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/15/2022] Open
Abstract
Aims As one of the most fundamental questions in modern science, “what causes schizophrenia (SZ)” remains a profound mystery due to the absence of objective gene markers. The reproducibility of the gene signatures identified by independent studies is found to be extremely low due to the incapability of available feature selection methods and the lack of measurement on validating signatures’ robustness. These irreproducible results have significantly limited our understanding of the etiology of SZ. Methods In this study, a new feature selection strategy was developed, and a comprehensive analysis was then conducted to ensure a reliable signature discovery. Particularly, the new strategy (a) combined multiple randomized sampling with consensus scoring and (b) assessed gene ranking consistency among different datasets, and a comprehensive analysis among nine independent studies was conducted. Results Based on a first‐ever evaluation of methods’ reproducibility that was cross‐validated by nine independent studies, the newly developed strategy was found to be superior to the traditional ones. As a result, 33 genes were consistently identified from multiple datasets by the new strategy as differentially expressed, which might facilitate our understanding of the mechanism underlying the etiology of SZ. Conclusion A new strategy capable of enhancing the reproducibility of feature selection in current SZ research was successfully constructed and validated. A group of candidate genes identified in this study should be considered as great potential for revealing the etiology of SZ.
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Affiliation(s)
- Qing-Xia Yang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China.,School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Yun-Xia Wang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Feng-Cheng Li
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Song Zhang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yong-Chao Luo
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yi Li
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Jing Tang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China.,School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Bo Li
- School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Yu-Zong Chen
- Bioinformatics and Drug Design Group, Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Wei-Wei Xue
- School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Feng Zhu
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China.,School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
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132
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Wagner E, Löhrs L, Siskind D, Honer WG, Falkai P, Hasan A. Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance. J Psychopharmacol 2019; 33:423-435. [PMID: 30696332 DOI: 10.1177/0269881118822171] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. AIMS We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. METHODS We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. RESULTS Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only. CONCLUSION More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.
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Affiliation(s)
- Elias Wagner
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Lisa Löhrs
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Dan Siskind
- 2 School of Medicine, University of Queensland, Brisbane, QLD, Australia.,3 Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - William G Honer
- 4 Department of Psychiatry, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Falkai
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Alkomiet Hasan
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
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133
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Cho J, Hayes RD, Jewell A, Kadra G, Shetty H, MacCabe JH, Downs J. Clozapine and all-cause mortality in treatment-resistant schizophrenia: a historical cohort study. Acta Psychiatr Scand 2019; 139:237-247. [PMID: 30478891 PMCID: PMC6492259 DOI: 10.1111/acps.12989] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Large-scale epidemiological studies have demonstrated a protective effect of clozapine on mortality in people with schizophrenia. Clozapine is reserved for use in patients with treatment-resistant schizophrenia (TRS), but evidence of clozapine's effect on mortality exclusively within TRS samples is inconclusive. Hence, we aimed to investigate the effect of clozapine use on all-cause mortality in TRS patients. METHODS A historical patient cohort sample of 2837 patients, who met criteria for TRS between 1 Jan 2008 and 1 Jan 2016, were selected from the South London and Maudsley NHS Foundation Trust (SLAM) electronic health records (EHR). The national Zaponex Treatment Access System (ZTAS) mandatory monitoring system linked to the SLAM EHR was used to distinguish which patients were initiated on clozapine (n = 1025). Cox proportional hazard models were used, adjusting for sociodemographics, clinical monitoring, mental and physical illness severity and functional status. RESULTS After controlling for potential confounders, the protective effect of clozapine on all-cause mortality was significant (adjusted hazard ratio 0.61; 95% confidence interval 0.38-0.97; P = 0.04). CONCLUSIONS Clozapine reduces the risk of mortality in patients who meet criteria for TRS. We provide further evidence that improving access to clozapine in TRS is likely to reduce the mortality gap in schizophrenia.
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Affiliation(s)
- J. Cho
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK
| | - R. D. Hayes
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK
| | - A. Jewell
- South London and Maudsley NHS Foundation TrustLondonUK
| | - G. Kadra
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK
| | - H. Shetty
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - J. H. MacCabe
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - J. Downs
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
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134
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Svensson CK, Larsen JR, Vedtofte L, Jakobsen MSL, Jespersen HR, Jakobsen MI, Koyuncu K, Schjerning O, Nielsen J, Ekstrøm CT, Correll CU, Vilsbøll T, Fink-Jensen A. One-year follow-up on liraglutide treatment for prediabetes and overweight/obesity in clozapine- or olanzapine-treated patients. Acta Psychiatr Scand 2019; 139:26-36. [PMID: 30374965 DOI: 10.1111/acps.12982] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Treatment with most antipsychotics is associated with an increased risk of weight gain and metabolic disturbances. In a randomized trial, we previously demonstrated that 16 weeks of glucagon-like peptide-1 receptor agonist liraglutide treatment vs. placebo significantly reduced glucometabolic disturbances and body weight in prediabetic, overweight/obese schizophrenia-spectrum disorder patients treated with clozapine or olanzapine. The aim of this study was to investigate whether the beneficial effects of the 16-week intervention were sustained beyond the intervention period. METHOD One year after completion of the intervention, we investigated changes in body weight, fasting glucose, glycated hemoglobin, C-peptide, and lipids comparing 1-year follow-up levels to end of treatment (week 16) and baseline (week 0) levels. RESULTS From end of treatment to the 1-year follow-up, body weight had increased in the liraglutide-treated group. However, compared to baseline levels, the placebo-subtracted body weight loss remained significantly reduced (-3.8 kg, 95% CI: -7.3 to -0.2, P = 0.04). Fasting glucose, glycated hemoglobin, C-peptide, and lipids had each returned to baseline levels 1 year after stopping liraglutide. CONCLUSION The body weight reduction during 16 weeks of liraglutide treatment was partially sustained 1 year after the intervention was completed. However, the improvements in other metabolic parameters returned to baseline levels.
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Affiliation(s)
- C K Svensson
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - J R Larsen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark.,Novo Nordisk A/S, Bagsvaerd, Denmark
| | - L Vedtofte
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - M S L Jakobsen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - H R Jespersen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - M I Jakobsen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - K Koyuncu
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - O Schjerning
- Department of Psychiatry, Aalborg University, Aalborg, Denmark
| | - J Nielsen
- Psychiatric Centre Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - C T Ekstrøm
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - C U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA.,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - T Vilsbøll
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - A Fink-Jensen
- Psychiatric Centre Copenhagen, Rigshospitalet, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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135
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Abstract
Recovery rates in schizophrenia remain suboptimal with up to one-third resistant to standard treatments, a population prevalence of 0.2%. Clozapine is the only evidenced-based treatment for treatment resistant schizophrenia (TRS), yet there are significant delays in its use or it may not be trialled, potentially impacting the chance of recovery. Better outcomes with earlier use of clozapine may be possible. There is emerging evidence that early treatment resistance is not uncommon from the earliest stages of psychosis. In this review, we provide an update on TRS, its epidemiology and its management, with a specific focus on the optimal use and timing of clozapine and augmentation strategies for the one-third of patients who do not respond to clozapine.
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