Clozapine for psychotic disorders in adults with intellectual disabilities

Efficacy of clozapine versus standard treatment in adult individuals with intellectual disability and treatment-resistant psychosis (CLOZAID): study protocol of a multicenter randomized clinical trial

Background

Intellectual disability (ID) affects approximately 1% of the worldwide population and individuals with ID have a higher comorbidity with mental illness, and specifically psychotic disorders. Unfortunately, among individuals with ID, limited research has been conducted since ID individuals are usually excluded from mental illness epidemiological studies and clinical trials. Here we perform a clinical trial to investigate the effectiveness of clozapine in the treatment of resistant psychosis in individuals with ID. The article highlights the complexity of diagnosing and treating psychopathological alterations associated with ID and advocates for more rigorous research in this field.

Methods

A Phase IIB, open-label, randomized, multicenter clinical trial (NCT04529226) is currently ongoing to assess the efficacy of oral clozapine in individuals diagnosed with ID and suffering from treatment-resistant psychosis. We aim to recruit one-hundred and fourteen individuals (N=114) with ID and resistant psychosis, who will be randomized to TAU (treatment as usual) and treatment-with-clozapine conditions. As secondary outcomes, changes in other clinical scales (PANSS and SANS) and the improvement in functionality, assessed through changes in the Euro-QoL-5D-5L were assessed. The main outcome variables will be analyzed using generalized linear mixed models (GLMM), assessing the effects of status variable (TAU vs. Clozapine), time, and the interaction between them.

Discussion

The treatment of resistant psychosis among ID individuals must be directed by empirically supported research. CLOZAID clinical trial may provide relevant information about clinical guidelines to optimally treat adults with ID and treatment-resistant psychosis and the benefits and risks of an early use of clozapine in this underrepresented population in clinical trials.

Trial registration

Clinicaltrials.gov: NCT04529226. EudraCT: 2020-000091-37.

Delusion of Pregnancy in Down Syndrome: Two Case Reports

Individuals with intellectual disability (ID) are more vulnerable to psychotic disorder and schizophrenia than the general population. However, psychotic symptoms have not been widely described in this population. Here, we deeply investigated the cases of two young women with ID and Down syndrome (DS) who developed a delusion of pregnancy, a rare condition defined as a fixed belief of being pregnant despite factual evidence to the contrary. The assessment included psychopathological and neuropsychological examination, as well as the evaluation of cognitive and adaptive functioning. In these cases, delusion manifested as a psychotic symptom of a cyclothymic disorder (case 1) or as an independent delusional disorder (case 2). However, some similarities emerged: both women exhibited good pre-morbid adaptive functioning and family history of psychiatric disorders; moreover, in both cases delusion emerged in association with an external trigger. Difficulties in verbally expressing one's thoughts and beliefs were found, as well as poor abstract reasoning skills that may have affected the ability to deeply conceptualize the delusional idea itself. These findings may provide crucial insights into the clinical manifestation of psychosis in individuals with DS and underscore the importance of a routine psychological and neuropsychological follow-up to provide prompt and adequate intervention.

Efficacy and safety of clozapine in psychotic disorders-a systematic quantitative meta-review

A recent increase in the literature regarding the evidence base for clozapine has made it increasingly difficult for clinicians to judge "best evidence" for clozapine use. As such, we aimed at elucidating the state-of-the-art for clozapine with regard to efficacy, effectiveness, tolerability, and management of clozapine and clozapine-related adverse events in neuropsychiatric disorders. We conducted a systematic PRISMA-conforming quantitative meta-review of available meta-analytic evidence regarding clozapine use. Primary outcome effect sizes were extracted and transformed into relative risk ratios (RR) and standardized mean differences (SMD). The methodological quality of meta-analyses was assessed using the AMSTAR-2 checklist. Of the 112 meta-analyses included in our review, 61 (54.5%) had an overall high methodological quality according to AMSTAR-2. Clozapine appears to have superior effects on positive, negative, and overall symptoms and relapse rates in schizophrenia (treatment-resistant and non-treatment-resistant subpopulations) compared to first-generation antipsychotics (FGAs) and to pooled FGAs/second-generation antipsychotics (SGAs) in treatment-resistant schizophrenia (TRS). Despite an unfavorable metabolic and hematological adverse-event profile compared to other antipsychotics, hospitalization, mortality and all-cause discontinuation (ACD) rates of clozapine surprisingly show a pattern of superiority. Our meta-review outlines the superior overall efficacy of clozapine compared to FGAs and most other SGAs in schizophrenia and suggests beneficial efficacy outcomes in bipolar disorder and Parkinson's disease psychosis (PDP). More clinical studies and subsequent meta-analyses are needed beyond the application of clozapine in schizophrenia-spectrum disorders and future studies should be directed into multidimensional clozapine side-effect management to foster evidence and to inform future guidelines.

Is speech and language therapy effective at improving the communication of adults with intellectual disabilities?: A systematic review

BACKGROUND

A significant proportion of adults with intellectual disabilities (ID) experience speech, language and communication difficulties which are associated with poor physical and mental health outcomes. Speech and language therapy (SLT) interventions are an important way to address these communication difficulties, yet there is limited available evidence to provide information about the effectiveness of the different approaches used for this heterogeneous group.

AIMS

To review the evidence available for the effectiveness of SLT interventions aimed at improving communication for adults with ID.

METHODS & PROCEDURES

A systematic search across relevant databases was performed. Information on methodological details of each relevant study, along with descriptions of the SLT interventions employed, were extracted and the Crowe Critical Appraisal Tool (CCAT) was used to assess quality. Findings were discussed in a narrative synthesis grouped by target communication skill.

OUTCOMES & RESULTS

A total of 10 relevant studies met the inclusion criteria. These were predominantly interventions aimed directly at adults with ID to improve speech, increase augmentative and alternative communication (AAC) use and develop interaction skills, with one study addressing work with carers. The included studies were all rated as low quality. There is weak preliminary evidence that SLT input can improve the communication skills of adults with ID.

CONCLUSIONS & IMPLICATIONS

There is insufficient evidence to draw strong conclusions about the effectiveness of SLT in this population. Further high-level evidence across speech, language and communication domains is urgently needed. What this paper adds What is already known on the subject There is limited evidence for community health interventions used with adults with ID. Previous reviews of SLT interventions found a lack of evidence base for this population. Some areas of SLT practice such as AAC have demonstrated potential benefits and other areas including speech work, social communication skills and training for communication partners have some evidence base for children with ID but there is currently insufficient evidence for adults with ID. What this paper adds to existing knowledge The study systematically reviews the current evidence base available when considering the effectiveness of SLT intervention for adults with ID. It provides weak evidence to suggest SLT intervention can improve communication in this population and highlights the need for clinically relevant, robustly designed studies to be undertaken in this field. What are the potential or actual clinical implications of this work? The lack of high-quality studies with sufficient power to draw conclusions about effectiveness means SLTs are not able to base their intervention choices on firm evidence. There is an urgent need to conduct robust research into the effectiveness of SLT interventions for adults with ID.

Aggression in autism spectrum disorder: presentation and treatment options

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent difficulties in social communication and social interaction, coupled with restricted, repetitive patterns of behavior or interest. Research indicates that aggression rates may be higher in individuals with ASD compared to those with other developmental disabilities. Aggression is associated with negative outcomes for children with ASD and their caregivers, including decreased quality of life, increased stress levels, and reduced availability of educational and social support. Therapeutic strategies including functional behavioral assessment, reinforcement strategies, and functional communication training may have a significant impact in reducing the frequency and intensity of aggressive behavior in individuals with ASD. Pharmacologic treatments, particularly the use of second-generation antipsychotics, may also be of some benefit in reducing aggression in individuals with ASD. With the ever-increasing rate of ASD diagnosis, development of effective therapeutic and pharmacologic methods for preventing and treating aggression are essential to improving outcomes in this disorder.