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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024:10.1007/s40263-024-01100-4. [PMID: 38951464 DOI: 10.1007/s40263-024-01100-4] [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] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Siafis S, Lorenz C, Wu H, Zhu Y, Schneider-Thoma J, Bighelli I, Li C, Hansen WP, Padberg F, Salanti G, Leucht S. Non-invasive brain stimulation for treatment-resistant schizophrenia: protocol of a systematic review and network meta-analysis. Syst Rev 2024; 13:165. [PMID: 38915121 PMCID: PMC11195004 DOI: 10.1186/s13643-024-02585-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 06/16/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Non-invasive brain stimulation (NIBS) is a promising intervention for treatment-resistant schizophrenia. However, there are multiple available techniques and a comprehensive synthesis of evidence is lacking. Thus, we will conduct a systematic review and network meta-analysis to investigate the comparative efficacy and safety of NIBS techniques as an add-on to antipsychotics for treatment-resistant schizophrenia. METHODS We will include single- and double-blind randomized-controlled trials (RCT) comparing any NIBS technique with each other or with a control intervention as an add-on to antipsychotics in adult patients with treatment-resistant schizophrenia. We will exclude studies focusing on predominant negative symptoms, maintenance treatment, and single sessions. The primary outcome will be a change in overall symptoms, and secondary outcomes will be a change in symptom domains, cognitive performance, quality of life, functioning, response, dropouts, and side effects. We will search for eligible studies in previous reviews, multiple electronic databases and clinical trial registries from inception onwards. At least two independent reviewers will perform the study selection, data extraction, and risk of bias assessment. We will measure the treatment differences using standardized mean difference (SMD) and odds ratio (OR) for continuous and dichotomous outcomes, respectively. We will conduct pairwise and network meta-analysis within a frequentist framework using a random-effects model, except for rare event outcomes where we will use a fixed-effects Mantel-Haenszel method. We will investigate potential sources of heterogeneity in subgroup analyses. Reporting bias will be assessed with funnel plots and the Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) tool. The certainty in the evidence will be evaluated using the Confidence in Network Meta-analysis (CINeMA) approach. DISCUSSION Our network meta-analysis would provide an up-to-date synthesis of the evidence from all available RCTs on the comparative efficacy and safety of NIBS for treatment-resistant schizophrenia. This information could guide evidence-based clinical practice and improve the outcomes of patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO-ID CRD42023410645.
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Affiliation(s)
- Spyridon Siafis
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany.
| | - Carolin Lorenz
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Hui Wu
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Yikang Zhu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Johannes Schneider-Thoma
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Irene Bighelli
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany
| | - Chunbo Li
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Psychology and Behavioral Science, Shanghai Jiao Tong University, Shanghai, China
| | | | - Frank Padberg
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Technical University of Munich, TUM School of Medicine and Health, Department of Psychiatry and Psychotherapy, Munich, Germany
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Wagner E, Borgwardt S, Hasan A. [Management of treatment resistance-Treatment-resistant schizophrenia]. DER NERVENARZT 2024; 95:423-431. [PMID: 38319320 DOI: 10.1007/s00115-024-01608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/07/2024]
Abstract
Despite a very high prevalence and substantial impairments among affected individuals, treatment-resistant schizophrenia (TRS) has not been sufficiently researched in clinical research in the field of psychiatric disorders and the pathophysiology is still poorly understood. A better clinical and pathophysiological understanding of this heterogeneous and severely affected population of people with persistent symptoms in different domains is necessary in order not only to be able to intervene early but also to develop novel therapeutic strategies or individualized treatment approaches. This review article presents the state of the art criteria of the pharmacological TRS, neurobiological disease models and predictive factors for TRS as well as the phenomenon of pseudo-treatment resistance and the clinical management of TRS. In the future, not only the use of operationalized criteria and definitions of TRS in longitudinal studies and randomized-controlled trials (RCTs) are paramount, but also the observation of trajectories with the integration of multimodal longitudinal phenotyping and the longitudinal collection of clinical routine data in academic research, which will be possible in the newly created German Center for Mental Health (DZPG).
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Affiliation(s)
- Elias Wagner
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland.
- Evidenzbasierte Psychiatrie und Psychotherapie, Medizinische Fakultät, Universität Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - Stefan Borgwardt
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Schleswig-Holstein, Universität zu Lübeck, Lübeck, Deutschland
| | - Alkomiet Hasan
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland
- Deutsches Zentrum für psychische Gesundheit, Augsburg, Deutschland
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4
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Lee J, Huh S, Park K, Kang N, Yu HS, Park HG, Kim YS, Kang UG, Won S, Kim SH. Behavioral and transcriptional effects of repeated electroconvulsive seizures in the neonatal MK-801-treated rat model of schizophrenia. Psychopharmacology (Berl) 2024; 241:817-832. [PMID: 38081977 DOI: 10.1007/s00213-023-06511-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/23/2023] [Indexed: 03/13/2024]
Abstract
RATIONALE Electroconvulsive therapy (ECT) is an effective treatment modality for schizophrenia. However, its antipsychotic-like mechanism remains unclear. OBJECTIVES To gain insight into the antipsychotic-like actions of ECT, this study investigated how repeated treatments of electroconvulsive seizure (ECS), an animal model for ECT, affect the behavioral and transcriptomic profile of a neurodevelopmental animal model of schizophrenia. METHODS Two injections of MK-801 or saline were administered to rats on postnatal day 7 (PN7), and either repeated ECS treatments (E10X) or sham shock was conducted daily from PN50 to PN59. Ultimately, the rats were divided into vehicle/sham (V/S), MK-801/sham (M/S), vehicle/ECS (V/E), and MK-801/ECS (M/E) groups. On PN59, prepulse inhibition and locomotor activity were tested. Prefrontal cortex transcriptomes were analyzed with mRNA sequencing and network and pathway analyses, and quantitative real-time polymerase chain reaction (qPCR) analyses were subsequently conducted. RESULTS Prepulse inhibition deficit was induced by MK-801 and normalized by E10X. In M/S vs. M/E model, Egr1, Mmp9, and S100a6 were identified as center genes, and interleukin-17 (IL-17), nuclear factor kappa B (NF-κB), and tumor necrosis factor (TNF) signaling pathways were identified as the three most relevant pathways. In the V/E vs. V/S model, mitophagy, NF-κB, and receptor for advanced glycation end products (RAGE) pathways were identified. qPCR analyses demonstrated that Igfbp6, Btf3, Cox6a2, and H2az1 were downregulated in M/S and upregulated in M/E. CONCLUSIONS E10X reverses the behavioral changes induced by MK-801 and produces transcriptional changes in inflammatory, insulin, and mitophagy pathways, which provide mechanistic insight into the antipsychotic-like mechanism of ECT.
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Affiliation(s)
- Jeonghoon Lee
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seonghoo Huh
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyungtaek Park
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
| | - Nuree Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Sook Yu
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hong Geun Park
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Ung Gu Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sungho Won
- Institute of Health and Environment, Seoul National University, Seoul, Republic of Korea
- Interdisciplinary Program of Bioinformatics, College of Natural Sciences, Seoul National University, Seoul, Republic of Korea
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
- RexSoft Inc., Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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5
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Lin CY, Kuo HY, Chang CH, Pan CC, Chu CS, Couper J, Chiang YC. Electroconvulsive therapy for obsessive compulsive symptoms in a patient with schizophrenia: a brief report. Neurocase 2023; 29:22-24. [PMID: 37943998 DOI: 10.1080/13554794.2023.2280274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/12/2022] [Indexed: 11/12/2023]
Abstract
Comorbid obsessive-compulsive disorder (OCD) is common among patients with schizophrenia. The role of electroconvulsive therapy (ECT) in the treatment of OCD in schizophrenia is unclear. Herein, we present a 45-year-old man who was diagnosed with schizophrenia along with OCD and received ECT due to relapse of psychosis owing to refractive schizophrenia. Together with psychotic symptoms, obvious symptoms of OCD were observed prior to treatment, including obsessive thoughts, difficulty in starting activities, and repetitive and ritualistic behavior. After 12 sessions of ECT, symptoms of schizophrenia and OCD both improved significantly (Positive and Negative Syndrome Scale [PANSS] score decreased from 95 points to 58 points, and Yale - Brown Obsessive-Compulsive Scale [Y-BOCS] score decreased from 29 points to 11 points). Mild aggravation of OCD symptoms was noted 3 months after ECT treatment (Y-BOCS score increased from 11 points to 17 points) without obvious relapse of psychotic symptoms (PANSS score changed from 58 points to 62 points). In conclusion, ECT could be considered as an alternative therapy for patients with schizophrenia and OCD with limited response to pharmacological treatment.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Psychiatry, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hsin-Ya Kuo
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Ho Chang
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Chuan Pan
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jeremy Couper
- Eastern Health, Melbourne, Australia
- Department of Psychiatry, Monash University, Melbourne, Australia
| | - Yung-Chih Chiang
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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de Bartolomeis A, Ciccarelli M, Vellucci L, Fornaro M, Iasevoli F, Barone A. Update on novel antipsychotics and pharmacological strategies for treatment resistant schizophrenia. Expert Opin Pharmacother 2022; 23:2035-2052. [DOI: 10.1080/14656566.2022.2145884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Andrea de Bartolomeis
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Mariateresa Ciccarelli
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Licia Vellucci
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Michele Fornaro
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Felice Iasevoli
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
| | - Annarita Barone
- Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, Section of Psychiatry, Department of Neuroscience, Reproductive Science and Dentistry, University of Naples “Federico II”, Naples, Italy
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Arumugham SS, Praharaj SK, Shreekantiah U, Sreeraj VS, Roy C, Shenoy S, Purohith AN, Chithra U, Bagali KB, Venkataramaiah S, Nanjundaiah GKK, Thennarasu K, Kumar CN, Goyal N, Das B, Mehta UM, Muralidharan K, Venkatasubramanian G, Sinha P, Thirthalli J. Clinical efficacy and neurobiological correlates of electroconvulsive therapy in patients with clozapine-resistant/intolerant schizophrenia: study protocol of multi-site parallel arm double-blind randomized sham-controlled study. Wellcome Open Res 2022; 7:212. [PMID: 37953926 PMCID: PMC10636350 DOI: 10.12688/wellcomeopenres.18028.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/14/2023] Open
Abstract
Background: A substantial proportion of patients with treatment resistant schizophrenia do not respond well or partially to clozapine, with a subset that does not tolerate an adequate trial of clozapine. Electroconvulsive therapy (ECT) is regarded as one of the augmenting options, but there is a lack of high-quality evidence for this practice. This protocol describes a double-blind randomised sham-controlled modified-ECT trial to evaluate its efficacy in patients with clozapine resistant/intolerant schizophrenia. The study also involves multimodal investigations to identify the response predictors and the mechanistic basis of modified ECT in this population. Methods: One hundred consenting schizophrenia patients with resistance/intolerance to clozapine referred by clinicians for ECT would be randomly assigned to receive true ECT or sham ECT at three study centers. Sham ECT would mimic all the procedures of modified ECT including anaesthesia and muscle relaxation, except the electrical stimulation. After a blinded course, non-responders to sham ECT would be offered open-label true ECT. Clinical assessments, neurocognitive assessments and multimodal investigations (magnetic resonance imaging [MRI], electroencephalography, heart rate variability, investigative transcranial magnetic stimulation-transcranial direct current stimulation, gene polymorphism) would be conducted at baseline and repeated after the end of the trial, as well as open-label ECT course. The trial would evaluate the improvement in positive symptoms (scale for assessment of positive symptoms) of schizophrenia as the primary outcome measure with prediction of this change by resting-state functional-MRI based brain-connectivity as the second primary objective. Registration: Clinical Trial Registry of India (Reg no: CTRI/2021/05/033775) on 24 th May 2021.
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Affiliation(s)
- Shyam Sundar Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Samir K. Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | | | - Vanteemar S. Sreeraj
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Chandramouli Roy
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Sonia Shenoy
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Abhiram Narasimhan Purohith
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Uppinkudru Chithra
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Kiran Basawaraj Bagali
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Sudhir Venkataramaiah
- Department of Neuroanaesthsia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Gopala Krishna Kadarapura Nanjundaiah
- Department of Neuroanaesthsia and Neuro Critical Care, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Kandavel Thennarasu
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, 560029, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Nishant Goyal
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Basudeb Das
- Central Institute of Psychiatry, Ranchi, Jharkhand, 834006, India
| | - Urvakhsh Meherwan Mehta
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Kesavan Muralidharan
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Ganesan Venkatasubramanian
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Preeti Sinha
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bengaluru, Karnataka, India, 560029, India
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Ainsworth NJ, Avina-Galindo AM, White RF, Zhan D, Gregory EC, Honer WG, Vila-Rodriguez F. Impact of medications, mood state, and electrode placement on ECT outcomes in treatment-refractory psychosis. Brain Stimul 2022; 15:1184-1191. [PMID: 36028155 DOI: 10.1016/j.brs.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Treatment-refractory psychosis (TRP) is a significant clinical challenge. While clozapine is frequently effective, alternate or augmentation strategies are often necessary. Evidence supports effectiveness of electroconvulsive therapy (ECT), but questions remain about optimal treatment parameters and impacts of concomitant pharmacotherapy. OBJECTIVE /Hypothesis: To analyze the impact of clozapine, anticonvulsant medication, mood state, and ECT electrode placement on outcomes in TRP. We hypothesized that ECT would lead to greater reduction in positive symptoms, particularly in patients receiving clozapine. METHODS Retrospective study in a tertiary TRP program. The Positive and Negative Syndrome Scale (PANSS) was used for clinical outcomes, with positive subscore as primary outcome. Clinical and ECT data were analyzed using a linear modelling approach, controlling for relevant covariates. RESULTS A total of 309 patients were included. ECT plus clozapine associated with greater improvement in positive, general, and total symptoms than ECT alone. ECT associated with greater improvement in negative symptoms in depressed patients. Bifrontal placement was mostly equivalent to bitemporal, with greater reduction of positive symptoms in patients receiving clozapine, and associated with lower electrical dose in patients on anticonvulsants. Clozapine increased seizure duration, while anticonvulsants decreased it. Anticonvulsant use in ECT patients associated with equivalent to slightly improved symptom reduction. CONCLUSIONS ECT's benefit in TRP may be greatest in patients receiving clozapine. ECT can improve negative symptoms in depressed TRP patients. Bifrontal placement is effective in TRP. Clozapine and anticonvulsants have opposite effects on seizure duration, but anticonvulsants may not adversely affect clinical outcomes of ECT for TRP.
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Affiliation(s)
- Nicholas J Ainsworth
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - A Michelle Avina-Galindo
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada
| | - Randall F White
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada
| | - Denghuang Zhan
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcomes Sciences, St Paul's Hospital, Vancouver, BC, Canada
| | - Elizabeth C Gregory
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Fidel Vila-Rodriguez
- Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
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9
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Purohith AN, Chatorikar SA, Praharaj SK, Bhandary RP, Sharma PSVN. Efficacy and safety of maintenance electroconvulsive therapy (M-ECT) in treatment-resistant schizophrenia: A case series. Asian J Psychiatr 2022; 73:103132. [PMID: 35533602 DOI: 10.1016/j.ajp.2022.103132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/05/2022] [Accepted: 04/20/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) is a substantial burden to patients, caregivers, and the treating team. There is a lack of robust evidence to support the efficacy of various pharmacological and non-pharmacological measures to augment clozapine in this population. When used in conjunction with clozapine or other combination antipsychotic regimens, maintenance electroconvulsive therapy (M-ECT) can be a potential therapeutic option in preventing symptom exacerbation in TRS. However, there is limited evidence supporting the role of M-ECT in TRS. AIM To evaluate the efficacy and safety of maintenance electroconvulsive therapy in patients with TRS. METHODOLOGY Sociodemographic details, illness characteristics, details of M-ECT procedure, adverse events, and course of the illness were evaluated using a retrospective chart review at a tertiary care psychiatry centre in south India. Scores on Clinical Global Impression-Severity (CGI-S), Social and Occupational Functioning Assessment Scale (SOFAS), and Hindi Mental Status Examination were compared before and after the course of M-ECT. RESULTS Seven male and three female patients received M-ECT in the last eight years (range of 22-172 sessions). There was a reduction in hospitalizations for acute exacerbation and significant improvement in the patient's overall functioning without significant adverse effects. CONCLUSION Maintenance ECT can be a safe and effective treatment option for achieving symptom control in the long-term management of refractory schizophrenia. Controlled trials are needed in this area for further evidence.
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Affiliation(s)
- Abhiram Narasimhan Purohith
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India.
| | - Shalaka Anand Chatorikar
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India.
| | - Samir Kumar Praharaj
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India.
| | - Rajeshkrishna Panambur Bhandary
- Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, Karnataka, India.
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Wada M, Noda Y, Iwata Y, Tsugawa S, Yoshida K, Tani H, Hirano Y, Koike S, Sasabayashi D, Katayama H, Plitman E, Ohi K, Ueno F, Caravaggio F, Koizumi T, Gerretsen P, Suzuki T, Uchida H, Müller DJ, Mimura M, Remington G, Grace AA, Graff-Guerrero A, Nakajima S. Dopaminergic dysfunction and excitatory/inhibitory imbalance in treatment-resistant schizophrenia and novel neuromodulatory treatment. Mol Psychiatry 2022; 27:2950-2967. [PMID: 35444257 DOI: 10.1038/s41380-022-01572-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Antipsychotic drugs are the mainstay in the treatment of schizophrenia. However, one-third of patients do not show adequate improvement in positive symptoms with non-clozapine antipsychotics. Additionally, approximately half of them show poor response to clozapine, electroconvulsive therapy, or other augmentation strategies. However, the development of novel treatment for these conditions is difficult due to the complex and heterogenous pathophysiology of treatment-resistant schizophrenia (TRS). Therefore, this review provides key findings, potential treatments, and a roadmap for future research in this area. First, we review the neurobiological pathophysiology of TRS, particularly the dopaminergic, glutamatergic, and GABAergic pathways. Next, the limitations of existing and promising treatments are presented. Specifically, this article focuses on the therapeutic potential of neuromodulation, including electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation. Finally, we propose multivariate analyses that integrate various perspectives of the pathogenesis, such as dopaminergic dysfunction and excitatory/inhibitory imbalance, thereby elucidating the heterogeneity of TRS that could not be obtained by conventional statistics. These analyses can in turn lead to a precision medicine approach with closed-loop neuromodulation targeting the detected pathophysiology of TRS.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yusuke Iwata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Sakiko Tsugawa
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hideaki Tani
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoji Hirano
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan.,Neural Dynamics Laboratory, Research Service, VA Boston Healthcare System, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Shinsuke Koike
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Tokyo, Japan
| | - Daiki Sasabayashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Haruyuki Katayama
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Eric Plitman
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Fumihiko Ueno
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Fernando Caravaggio
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Teruki Koizumi
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, National Hospital Organization Shimofusa Psychiatric Medical Center, Chiba, Japan
| | - Philip Gerretsen
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariel Graff-Guerrero
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan. .,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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11
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Machine Learning Algorithm-Based Prediction Model for the Augmented Use of Clozapine with Electroconvulsive Therapy in Patients with Schizophrenia. J Pers Med 2022; 12:jpm12060969. [PMID: 35743753 PMCID: PMC9224640 DOI: 10.3390/jpm12060969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 12/17/2022] Open
Abstract
The augmentation of clozapine with electroconvulsive therapy (ECT) has been an optimal treatment option for patients with treatment- or clozapine-resistant schizophrenia. Using data from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics survey, which was the largest international psychiatry research collaboration in Asia, our study aimed to develop a machine learning algorithm-based substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in terms of precision medicine. A random forest model and least absolute shrinkage and selection operator (LASSO) model were used to develop a substantial prediction model for the augmented use of clozapine with ECT. Among the 3744 Asian patients with schizophrenia, those treated with a combination of clozapine and ECT were characterized by significantly greater proportions of females and inpatients, a longer duration of illness, and a greater prevalence of negative symptoms and social or occupational dysfunction than those not treated. In the random forest model, the area under the curve (AUC), which was the most preferred indicator of the prediction model, was 0.774. The overall accuracy was 0.817 (95% confidence interval, 0.793−0.839). Inpatient status was the most important variable in the substantial prediction model, followed by BMI, age, social or occupational dysfunction, persistent symptoms, illness duration > 20 years, and others. Furthermore, the AUC and overall accuracy of the LASSO model were 0.831 and 0.644 (95% CI, 0.615−0.672), respectively. Despite the subtle differences in both AUC and overall accuracy of the random forest model and LASSO model, the important variables were commonly shared by the two models. Using the machine learning algorithm, our findings allow the development of a substantial prediction model for the augmented use of clozapine with ECT in Asian patients with schizophrenia. This substantial prediction model can support further studies to develop a substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in a strict epidemiological context.
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12
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Holden J, Begum M. Successful rechallenge after clozapine-associated myocarditis. BMJ Case Rep 2022; 15:e248909. [PMID: 35550318 PMCID: PMC9109022 DOI: 10.1136/bcr-2022-248909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/03/2022] Open
Abstract
Clozapine is a highly effective medication used in management of treatment-resistant schizophrenia. Clozapine-associated myocarditis (CAM) is a rare but increasingly recognised complication of clozapine titration. Following an episode of CAM, clinicians can face a challenging dilemma of balancing the risks of recurrent myocarditis against the harms of ongoing psychosis. We describe the case of a woman in her 60s who developed acute myocarditis during clozapine titration and was then cautiously rechallenged with a successful outcome.
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Affiliation(s)
- John Holden
- Psychiatry, NHS Ayrshire and Arran Woodland View, Irvine, UK
| | - Milia Begum
- Psychiatry, NHS Ayrshire and Arran Woodland View, Irvine, UK
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13
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Knowledge, attitudes and beliefs about electroconvulsive therapy among Polish students. CURRENT PROBLEMS OF PSYCHIATRY 2022. [DOI: 10.2478/cpp-2021-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Electroconvulsive therapy (ECT) is an effective and safe treatment for many mental disorders. Nevertheless, the attitudes towards ECT are negative and the use of this method in Poland is decreasing.
Aim: The aim of the study was to investigate the general knowledge and attitudes towards electroconvulsive therapy among Polish university students, including students of medicine, psychology and other faculties.
Material and methods: An original online questionnaire containing 39 questions was used, distributed through student groups on social networking sites. A total of 418 questionnaires were completed. The collected data were statistically analyzed.
Results: Significant knowledge gaps and negative beliefs about electroconvulsive therapy were observed among Polish students. Medical and psychology students had more extensive knowledge and more positive beliefs about this method of treatment than students of other faculties. Greater knowledge of the therapy was associated with a more positive attitude towards it. The main source of knowledge about ECT for students of medicine and psychology were lectures and courses, and for students of other faculties – movies. Students, who considered psychiatry as their future specialization, had less knowledge and a more negative attitude towards ECT, relative to the rest of the respondents.
Conclusions: There is a need for educational interventions that will change the way how ECT is perceived both in the public opinion and in the medical community. An effective solution to low levels of knowledge for medical students may be the observation of the procedure included in the study programme.
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Zheng S, Chan SKW, Lee J. Managing treatment resistance in schizophrenia: A joint study in Hong Kong and Singapore. Front Psychiatry 2022; 13:1005373. [PMID: 36339860 PMCID: PMC9631784 DOI: 10.3389/fpsyt.2022.1005373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study surveyed clinicians in psychiatry in Hong Kong and Singapore to understand their familiarity and prescribing practices in treatment-resistant schizophrenia (TRS) and clozapine-resistant schizophrenia (CRS). MATERIALS AND METHODS All clinicians in psychiatry in both regions were invited through email to participate in an anonymous online survey. The survey collected information on the participants' characteristics, their familiarity and experience with clozapine use, and their treatment practices in TRS and CRS. Data collection took place between September 2019 and February 2020 in Hong Kong and December 2018 and March 2019 in Singapore. RESULTS 261 clinicians responded to the survey, with response rates of 19% (105 out of 556 participants) in Hong Kong and 50% (156 out of 309 participants) in Singapore. The majority of respondents (99.0% in Hong Kong; 87.9% in Singapore) were familiar with treatment guidelines for TRS. However, approximately half (54.2% in Hong Kong; 41.7% in Singapore) delayed the prescription of clozapine when indicated. In terms of alternatives to clozapine, approximately half or more of the clinicians in both regions would use high dose antipsychotics, long-acting injectable antipsychotics, antipsychotic polypharmacy, while the adjuvant use of mood stabilizers and electroconvulsive therapy differed between the two regions. In those with CRS, between 10 and 20% of the respondents added adjuvant mood stabilizers or antipsychotics, and 3-10% would use an antidepressant. CONCLUSION Clozapine delays occur in spite of clinicians' familiarity with treatment guidelines. More research is needed to guide the use of augmentation strategies and the search for effective treatments beyond clozapine.
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Affiliation(s)
- Shushan Zheng
- Department of Psychosis, Institute of Mental Health, Singapore, Singapore
| | - Sherry Kit Wa Chan
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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15
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Lappin JM, Davies K, O'Donnell M, Walpola IC. Underuse of recommended treatments among people living with treatment-resistant psychosis. Front Psychiatry 2022; 13:987468. [PMID: 36147973 PMCID: PMC9485552 DOI: 10.3389/fpsyt.2022.987468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which this evidence-base is implemented. SETTING Statewide public health tertiary referral service, the Tertiary Referral Service for Psychosis (TRSP), NSW, Australia. OBJECTIVES To (i) describe clinical characteristics of individuals with treatment-resistant psychosis and to detail the proportion who had received a trial of clozapine or ECT at any point during their illness course; (ii) describe the characteristics of the treatment trials in both those currently on clozapine and those previously on clozapine; (iii) document reasons in relevant individuals why clozapine had never been used. METHODS All TRSP clients who met the criteria for treatment resistance (TR) were included. A detailed casenote review was conducted to examine whether clozapine and/or ECT had ever been prescribed. Characteristics of clozapine and ECT trials were documented. Tertiary service treatment recommendations are described. FINDINGS Thirty-six of 48 individuals had TR. They had marked clinical and functional impairment. A minority were currently receiving clozapine (n = 14/36). Most had received a clozapine trial at some point (n = 32/36). Most experienced persistent clinical symptoms while on clozapine (n = 29/32). Clozapine plasma levels were very rarely reported (4/32). Augmentation and antipsychotic polypharmacy were common among those currently on clozapine. The median clozapine trial duration was 4.0 (IQR: 3.0-20.3) months in individuals previously prescribed clozapine. Reasons for clozapine discontinuation included intolerable side effects (n = 10/18) and poor adherence (n = 7/18). One-quarter of TR individuals had trialed ECT (n = 9/36). Tertiary service recommendations included routine plasma monitoring to optimize dose among people currently on clozapine; clozapine retrial in those previously treated; and clozapine initiation for those who had never received clozapine. ECT was recommended to augment clozapine and as an alternative where clozapine trial/retrial was not feasible. CONCLUSION Among people with TR referred to a tertiary service, clozapine and ECT were underutilized. Clozapine trials are typically terminated without an adequate trial. Strategies to optimize the use of clozapine therapy and ECT in clinical settings are needed to increase the therapeutic effectiveness of evidence-based therapies for treatment-resistant psychosis.
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Affiliation(s)
- Julia M Lappin
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Kimberley Davies
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Maryanne O'Donnell
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Ishan C Walpola
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
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16
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Munkholm K, Jørgensen KJ, Paludan-Müller AS. Adverse effects of electroconvulsive therapy. Hippokratia 2021. [DOI: 10.1002/14651858.cd014995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Klaus Munkholm
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Karsten Juhl Jørgensen
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
| | - Asger Sand Paludan-Müller
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark; Department of Clinical Research, University of Southern Denmark; Odense Denmark
- Open Patient data Exploratory Network (OPEN); Odense University Hospital; Odense Denmark
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17
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Pisanu C, Vitali E, Meloni A, Congiu D, Severino G, Ardau R, Chillotti C, Trabucchi L, Bortolomasi M, Gennarelli M, Minelli A, Squassina A. Investigating the Role of Leukocyte Telomere Length in Treatment-Resistant Depression and in Response to Electroconvulsive Therapy. J Pers Med 2021; 11:jpm11111100. [PMID: 34834452 PMCID: PMC8622097 DOI: 10.3390/jpm11111100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Psychiatric disorders seem to be characterized by premature cell senescence. However, controversial results have also been reported. In addition, the relationship between accelerated aging and treatment-resistance has scarcely been investigated. In the current study, we measured leukocyte telomere length (LTL) in 148 patients with treatment-resistant depression (TRD, 125 with major depressive disorder, MDD, and 23 with bipolar disorder, BD) treated with electroconvulsive therapy (ECT) and analyzed whether LTL was associated with different response profiles. We also compared LTL between patients with TRD and 335 non-psychiatric controls. For 107 patients for which genome-wide association data were available, we evaluated whether a significant overlap among genetic variants or genes associated with LTL and with response to ECT could be observed. LTL was negatively correlated with age (Spearman’s correlation coefficient = −0.25, p < 0.0001) and significantly shorter in patients with treatment-resistant MDD (Quade’s F = 35.18, p < 0.0001) or BD (Quade’s F = 20.84, p < 0.0001) compared to controls. Conversely, baseline LTL was not associated with response to ECT or remission. We did not detect any significant overlap between genetic variants or genes associated with LTL and response to ECT. Our results support previous findings suggesting premature cell senescence in patients with severe psychiatric disorders and suggest that LTL could not be a predictive biomarker of response to ECT.
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Affiliation(s)
- Claudia Pisanu
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Erika Vitali
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Anna Meloni
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Donatella Congiu
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Giovanni Severino
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
| | - Raffaella Ardau
- Unit of Clinical Pharmacology, University Hospital Agency of Cagliari, 09123 Cagliari, Italy; (R.A.); (C.C.)
| | - Caterina Chillotti
- Unit of Clinical Pharmacology, University Hospital Agency of Cagliari, 09123 Cagliari, Italy; (R.A.); (C.C.)
| | - Luigi Trabucchi
- Psychiatric Hospital “Villa Santa Chiara”, 37142 Verona, Italy; (L.T.); (M.B.)
| | - Marco Bortolomasi
- Psychiatric Hospital “Villa Santa Chiara”, 37142 Verona, Italy; (L.T.); (M.B.)
| | - Massimo Gennarelli
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Alessandra Minelli
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy; (E.V.); (M.G.); (A.M.)
- Genetics Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Alessio Squassina
- Department of Biomedical Science, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy; (C.P.); (A.M.); (D.C.); (G.S.)
- Correspondence: ; Tel.: +39-070-675-4323
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18
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Zierhut MM, Bernard RM, Turner E, Mohamad S, Hahn E, Bajbouj M. Electroconvulsive therapy for negative symptoms in schizophrenia: a literature review from 2000 to 2021. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01989-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AbstractNegative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.
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19
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Gammon D, Cheng C, Volkovinskaia A, Baker GB, Dursun SM. Clozapine: Why Is It So Uniquely Effective in the Treatment of a Range of Neuropsychiatric Disorders? Biomolecules 2021; 11:1030. [PMID: 34356654 PMCID: PMC8301879 DOI: 10.3390/biom11071030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 12/16/2022] Open
Abstract
Clozapine is superior to other antipsychotics as a therapy for treatment-resistant schizophrenia and schizoaffective disorder with increased risk of suicidal behavior. This drug has also been used in the off-label treatment of bipolar disorder, major depressive disorder (MDD), and Parkinson's disease (PD). Although usually reserved for severe and treatment-refractory cases, it is interesting that electroconvulsive therapy (ECT) has also been used in the treatment of these psychiatric disorders, suggesting some common or related mechanisms. A literature review on the applications of clozapine and electroconvulsive therapy (ECT) to the disorders mentioned above was undertaken, and this narrative review was prepared. Although both treatments have multiple actions, evidence to date suggests that the ability to elicit epileptiform activity and alter EEG activity, to increase neuroplasticity and elevate brain levels of neurotrophic factors, to affect imbalances in the relationship between glutamate and γ-aminobutyric acid (GABA), and to reduce inflammation through effects on neuron-glia interactions are common underlying mechanisms of these two treatments. This evidence may explain why clozapine is effective in a range of neuropsychiatric disorders. Future increased investigations into epigenetic and connectomic changes produced by clozapine and ECT should provide valuable information about these two treatments and the disorders they are used to treat.
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Affiliation(s)
- Dara Gammon
- Saba University School of Medicine, Saba, The Netherlands; (D.G.); (A.V.)
| | - Catherine Cheng
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Anna Volkovinskaia
- Saba University School of Medicine, Saba, The Netherlands; (D.G.); (A.V.)
| | - Glen B. Baker
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2E1, Canada
| | - Serdar M. Dursun
- Neurochemical Research Unit and Bebensee Schizophrenia Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2B7, Canada; (C.C.); (G.B.B.)
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2E1, Canada
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20
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Moon SY, Kim M, Lho SK, Oh S, Kim SH, Kwon JS. Systematic Review of the Neural Effect of Electroconvulsive Therapy in Patients with Schizophrenia: Hippocampus and Insula as the Key Regions of Modulation. Psychiatry Investig 2021; 18:486-499. [PMID: 34218638 PMCID: PMC8256139 DOI: 10.30773/pi.2020.0438] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/03/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) has been the most potent treatment option for treatment-resistant schizophrenia (TRS). However, the underlying neural mechanisms of ECT in schizophrenia remain largely unclear. This paper examines studies that investigated structural and functional changes after ECT in patients with schizophrenia. METHODS We carried out a systematic review with following terms: 'ECT', 'schizophrenia', and the terms of various neuroimaging modalities. RESULTS Among the 325 records available from the initial search in May 2020, 17 studies were included. Cerebral blood flow in the frontal, temporal, and striatal structures was shown to be modulated (n=3), although the results were divergent. Magnetic resonance spectroscopy (MRS) studies suggested that the ratio of N-acetyl-aspartate/creatinine was increased in the left prefrontal cortex (PFC; n=2) and left thalamus (n=1). The hippocampus and insula (n=6, respectively) were the most common regions of structural/functional modulation, which also showed symptom associations. Functional connectivity of the default mode network (DMN; n=5), PFC (n=4), and thalamostriatal system (n=2) were also commonly modulated. CONCLUSION Despite proven effectiveness, there has been a dearth of studies investigating the neurobiological mechanisms underlying ECT. There is preliminary evidence of structural and functional modulation of the hippocampus and insula, functional changes in the DMN, PFC, and thalamostriatal system after ECT in patients with schizophrenia. We discuss the rationale and implications of these findings and the potential mechanism of action of ECT. More studies evaluating the mechanisms of ECT are needed, which could provide a unique window into what leads to treatment response in the otherwise refractory TRS population.
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Affiliation(s)
- Sun-Young Moon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Silvia Kyungjin Lho
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sanghoon Oh
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea.,Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea
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21
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Garcia Ruiz PJ. Electroconvulsive Therapy and Movement Disorders. New Perspectives on A Time-Tested Therapy. Mov Disord Clin Pract 2021; 8:521-524. [PMID: 33981784 DOI: 10.1002/mdc3.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/24/2021] [Accepted: 02/14/2021] [Indexed: 11/07/2022] Open
Abstract
Electroconvulsive therapy (ECT) has been a very well known therapy in Psychiatry for over 80 years. ECT is considered useful in treating acute mania, severe depression and other psychiatric conditions. Over time, this therapy has also been used in several movement disorders including Parkinson disease (PD) and Huntington disease (HD). In this brief review, I summarize the recent History and evolution of ECT, its proven and potential applications in movement disorders as well as its potential mechanisms.
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Affiliation(s)
- Pedro J Garcia Ruiz
- Movement Disorders Unit, Department of Neurology Fundacion Jimenez Diaz Madrid Spain
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22
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Galderisi S, Kaiser S, Bitter I, Nordentoft M, Mucci A, Sabé M, Giordano GM, Nielsen MØ, Glenthøj LB, Pezzella P, Falkai P, Dollfus S, Gaebel W. EPA guidance on treatment of negative symptoms in schizophrenia. Eur Psychiatry 2021; 64:e21. [PMID: 33726883 PMCID: PMC8057437 DOI: 10.1192/j.eurpsy.2021.13] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms. However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.
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Affiliation(s)
- S Galderisi
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - S Kaiser
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - I Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - M Nordentoft
- Copenhagen Research Centre for Mental Health (CORE), Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark
| | - A Mucci
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Sabé
- Division of Adult Psychiatry, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - G M Giordano
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - M Ø Nielsen
- Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark.,Center for Neuropsychiatric Schizophrenia Research, CNSR, Glostrup, Denmark
| | - L B Glenthøj
- Copenhagen Research Centre for Mental Health (CORE), Copenhagen University Hospital, Copenhagen, Denmark.,Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research, CINS, Glostrup, Denmark
| | - P Pezzella
- Department of Psychiatry, University of Campania Luigi Vanvitelli, Naples, Italy
| | - P Falkai
- Department of Psychiatry, University of Munich, Munich, Germany
| | - S Dollfus
- Service de Psychiatrie, CHU de Caen, 14000Caen, France.,Normandie Univ, UNICAEN, ISTS EA 7466, GIP Cyceron, 14000Caen, France.,Normandie Univ, UNICAEN, UFR de Médecine, 14000Caen, France
| | - W Gaebel
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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23
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Plahouras JE, Konstantinou G, Kaster TS, Buchman DZ, Foussias G, Daskalakis ZJ, Blumberger DM. Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study. Schizophr Bull 2020; 47:424-432. [PMID: 33145601 PMCID: PMC7965065 DOI: 10.1093/schbul/sbaa144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT). METHODS We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT. RESULTS A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment. CONCLUSIONS Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.
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Affiliation(s)
- Joanne E Plahouras
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Gerasimos Konstantinou
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tyler S Kaster
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada,Bioethics Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada,Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | - George Foussias
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada
| | - Daniel M Blumberger
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada,To whom correspondence should be addressed; Centre for Addiction and Mental Health, 1001 Queen St. W. Unit 4, Room 115, Toronto, ON M6J 1H4, Canada; tel: 416-535-8501 x 33662, fax: 416-583-4613, e-mail:
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24
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Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs 2020; 34:509-520. [PMID: 32342484 DOI: 10.1007/s40263-020-00729-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.
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Affiliation(s)
- A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA.
| | - Amitha L Dhingra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
| | | | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
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25
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Corripio I, Roldán A, Sarró S, McKenna PJ, Alonso-Solís A, Rabella M, Díaz A, Puigdemont D, Pérez-Solà V, Álvarez E, Arévalo A, Padilla PP, Ruiz-Idiago JM, Rodríguez R, Molet J, Pomarol-Clotet E, Portella MJ. Deep brain stimulation in treatment resistant schizophrenia: A pilot randomized cross-over clinical trial. EBioMedicine 2020; 51:102568. [PMID: 31927311 PMCID: PMC6953640 DOI: 10.1016/j.ebiom.2019.11.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/18/2019] [Indexed: 01/11/2023] Open
Abstract
Background Up to 30% of patients with schizophrenia are resistant to antipsychotic drug treatment, with 60% of such cases also failing to respond to clozapine. Deep brain stimulation (DBS) has been used in treatment resistant patients with other psychiatric disorders, but there is a lack of trials in schizophrenia, partly due to uncertainties over where to site the electrodes. This trial aimed to examine the effectiveness of nucleus accumbens (NAcc) and subgenual anterior cingulate cortex (subgenual ACC) targeted DBS; the primary outcome measure was PANSS total score, as assessed fortnightly. Methods Eight patients with schizophrenia, who met criteria for treatment resistance and were also resistant to/intolerant of clozapine, were randomly assigned using central allocation to receive DBS in the NAcc or subgenual ACC. An open stabilization phase lasting at least six months was followed by a randomized double-blind crossover phase lasting 24 weeks in those who met symptomatic improvement criteria. The primary end-point was a 25% improvement in PANSS total score. (ClinicalTrials.gov Identifier: NCT02377505; trial completed). Findings One implanted patient did not receive DBS due to complications of surgery. Of the remaining 7 patients, 2/3 with NAcc and 2/4 with subgenual ACC electrode placements met the symptomatic improvement criteria (58% and 86%, and 37% and 68% improvement in PANSS total score, respectively). Three of these patients entered the crossover phase and all showed worsening when the stimulation was discontinued. The fourth patient worsened after the current was switched off accidentally without her or the investigators’ knowledge. Physical adverse events were uncommon, but two patients developed persistent psychiatric adverse effects (negative symptoms/apathy and mood instability, respectively). Interpretation These preliminary findings point to the possibility of DBS having therapeutic effects in patients with schizophrenia who do not respond to any other treatment. Larger trials with careful attention to blinding will be necessary to establish the extent of the benefits and whether these can be achieved without psychiatric side-effects.
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Affiliation(s)
- Iluminada Corripio
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Alexandra Roldán
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Salvador Sarró
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain; Psychiatry Department, Benito Menni CASM Hermanas Hospitalarias, Sant Boi de Llobregat, Spain
| | - Peter J McKenna
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain.
| | - Anna Alonso-Solís
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Mireia Rabella
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Anna Díaz
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Dolors Puigdemont
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Víctor Pérez-Solà
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; Psychiatry Department, Institut de Neuropsiquiatria i Addicions, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Enric Álvarez
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Antonio Arévalo
- FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain; Psychiatry Department, Hospital Sagrat Cor Hermanas Hospitalarias, Barcelona, Spain
| | - Pedro P Padilla
- FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain; Psychiatry Department, Centro Neuropsiquiátrico Nuestra Señora del Carmen Hermanas Hospitalarias, Zaragoza, Spain
| | - Jesus M Ruiz-Idiago
- FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain; Unitat Polivalent Barcelona Nord Hospital, Hospital Mare de Déu de la Mercè Hermanas Hospitalarias, Barcelona, Spain
| | - Rodrigo Rodríguez
- Neurosurgery Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Joan Molet
- Neurosurgery Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Edith Pomarol-Clotet
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; FIDMAG Germanes Hospitalàries Research Foundation, C/. Dr. Antoni Pujadas 38, 08830 Sant Boi de Llobregat, Barcelona, Spain
| | - Maria J Portella
- Psychiatry Department, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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26
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Lloyd JR, Silverman ER, Kugler JL, Cooper JJ. Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives. Neuropsychiatr Dis Treat 2020; 16:2191-2208. [PMID: 33061390 PMCID: PMC7526008 DOI: 10.2147/ndt.s231573] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022] Open
Abstract
Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.
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Affiliation(s)
- Jenifer R Lloyd
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Eric R Silverman
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Joseph L Kugler
- Department of Psychiatry, University of Texas-Dell Medical School, Austin, TX, USA
| | - Joseph J Cooper
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
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27
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Jia J, Shen J, Liu FH, Wong HK, Yang XJ, Wu QJ, Zhang H, Wang HN, Tan QR, Zhang ZJ. Effectiveness of Electroacupuncture and Electroconvulsive Therapy as Additional Treatment in Hospitalized Patients With Schizophrenia: A Retrospective Controlled Study. Front Psychol 2019; 10:2306. [PMID: 31681100 PMCID: PMC6804524 DOI: 10.3389/fpsyg.2019.02306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/27/2019] [Indexed: 12/18/2022] Open
Abstract
Electroacupuncture (EA) and electroconvulsive therapy (ECT) are often used in the management of schizophrenia. This study sought to determine whether additional EA and ECT could augment antipsychotic response and reduce related side effects. In this retrospective controlled study, 287 hospitalized schizophrenic patients who received antipsychotics (controls, n = 50) alone or combined with EA (n = 101), ECT (n = 55) or both (EA + ECT, n = 81) were identified. EA and ECT were conducted for 5 and 3 sessions per week, respectively, with a maximum of 12 sessions for ECT during hospitalization. The Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to assess the severity of psychotic symptoms. Clinical response on SAPS and SANS, weight gain, and adverse events were compared. Survival analysis revealed that the ECT and EA + ECT groups had markedly greater clinical response rate than controls on SAPS [72.7 and 90.1% vs. 64.0%; relative risk (RR), 1.974 and 2.628, respectively, P ≤ 0.004] and on SANS (67.3 and 70.4% vs. 42.0%; RR, 1.951 and 2.009, respectively, P ≤ 0.015). A significantly greater response rate on SANS than controls was also observed in the EA group (64.4% vs. 42.0%; RR = 1.938, P = 0.008). EA-containing regimens remarkably reduced weight gain and incidences of headache, insomnia, dry mouth, and electrocardiographic abnormalities. These results suggest that EA and ECT can serve as additional treatment for enhancing antipsychotic response and reduce the side effects in hospitalized patients with schizophrenia. Clinical Trial Registration: http://www.chictr.org.cn/showprojen.aspx?proj=38901, identifier ChiCTR1900023563.
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Affiliation(s)
- Jie Jia
- Department of Psychiatry, Xi’an Mental Health Center, Xi’an, China
| | - Jun Shen
- Department of Psychiatry, Xi’an Mental Health Center, Xi’an, China
| | - Fei-Hu Liu
- Department of Psychiatry, Xi’an Mental Health Center, Xi’an, China
| | - Hei Kiu Wong
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Xin-Jing Yang
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Qiang-Ju Wu
- Department of Psychiatry, Xi’an Mental Health Center, Xi’an, China
| | - Hui Zhang
- Department of Psychiatry, Xi’an Mental Health Center, Xi’an, China
| | - Hua-Ning Wang
- Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, Xi’an, China
| | - Qing-Rong Tan
- Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, Xi’an, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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28
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Sinclair DJM, Zhao S, Qi F, Nyakyoma K, Kwong JSW, Adams CE. Electroconvulsive Therapy for Treatment-Resistant Schizophrenia. Schizophr Bull 2019; 45:730-732. [PMID: 31150556 PMCID: PMC6581135 DOI: 10.1093/schbul/sbz037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Diarmid J M Sinclair
- Adult Mental Health, Rotherham Doncaster and South Humber NHS Foundation Trust, Woodfield House, Tickhill Road Site, Doncaster, UK,To whom correspondence should be addressed; tel: 07790909544; e-mail:
| | - Sai Zhao
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Fang Qi
- Systematic Review Solutions Ltd, The Ingenuity Centre, The University of Nottingham, Nottingham, UK
| | - Kazare Nyakyoma
- Derby City Acute Mental Health, Derbyshire Healthcare Foundation NHS Trust, Derby, UK
| | - Joey S W Kwong
- Department of Health Policy, National Center for Child Health and Development, Setagaya-ku, Japan,Department of Clinical Epidemiology, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Clive E Adams
- Cochrane Schizophrenia Group, The University of Nottingham, Nottingham, UK
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