Increasing antipsychotic dose for non response in schizophrenia

Psychopharmakologische Zwangsbehandlung im Maßregelvollzug

Das nordrhein-westfälische Maßregelvollzugsgesetz regelte in § 17a Abs. 2 bis vor Kurzem die Zwangsbehandlung einwilligungsunfähiger Patienten zur „Erreichung der Entlassfähigkeit“. Bislang ist wenig über die Effekte derartiger Zwangsbehandlungen auf dieses vorgegebene Ziel bekannt. Ziel der Arbeit stellt daher die Evaluation antipsychotischer Zwangsmedikationen bei gem. § 63 StGB Untergebrachten mit einer Erkrankung aus dem schizophrenen Formenkreis dar.

Für alle n = 16 in 2019 entsprechend erfolgten Zwangsmedikationen zur Erreichung der Entlassfähigkeit in 3 Maßregelvollzugsklinken des Landschaftsverbands Westfalen-Lippe wurden direkt vor Erstapplikation sowie 4 Wochen und 6 Monate danach mittels Positive and Negative Syndrome Scale (PANSS) bzw. Global Assessment of Functioning (GAF) die psychotische Symptomatik und das Funktionsniveau der Patienten durch die Behandelnden bewertet. Die Erreichung weiterer Behandlungsziele sowie Einschätzungen zur Entlassfähigkeit und eine Gesamtbewertung der Zwangsbehandlung wurden ebenfalls erfragt.

Zum ersten Katamnesezeitpunkt ergaben sich eine signifikante Reduktion der PANSS-Faktoren „Positivsymptomatik“ und „erregbar/feindselig“ sowie eine Steigerung des Funktionsniveaus, die sich je leicht abgeschwächt fortsetzten. Auf individueller Ebene zeigte sich nur bei 2 Patienten kein oder ein negativer Effekt. Obwohl die Auswirkungen auf die Behandlungsziele hinter den Erwartungen zurückblieben, bewerteten die Behandler die Maßnahme überwiegend positiv.

Zwangsweise verabreichte Antipsychotika können sich günstig auf das Ziel der „Erreichung der Entlassfähigkeit“ auswirken. Insbesondere eingeschränkte Effekte auf Krankheitseinsicht und die Einsicht in die Notwendigkeit der Medikamenteneinnahme zeigen Limitationen auf, die deutlich machen, dass diese Maßnahme allein nicht ausreicht, um die Entlassfähigkeit herzustellen.

Dose Adjustment Model of Paliperidone in Patients With Acute Schizophrenia: A post hoc Analysis of an Open-Label, Single-Arm Multicenter Study

This study aimed to investigate the factors that influenced the clinicians to adjust the paliperidone dose in the acute phase of schizophrenia. This was a post hoc study of an 8-week, open-label, single-arm multicenter trial which evaluated the efficacy, safety, and tolerability of flexible doses of paliperidone ER (3-12 mg/day) in patients with acutely exacerbated schizophrenia. Patients were divided into groups according to the dose at week 8 (3, 6, and 9-12 mg). The responder was defined as the reduction percentage in the Positive and Negative Syndrome Scale (PANSS) total score of ≥30%. According to the chi-squared automatic interaction detection algorithm, decision tree models predicting an increase in the dose of paliperidone ER were established. A decision tree, based on 4-week Marder positive factor, Clinical Global Impression (CGI), and BMI, was established to guide the dose adjustments of paliperidone ER in the acute phase of schizophrenia. The multivariable logistic regression analysis showed that lower age at onset, higher baseline PANSS positive subscale score, and lower baseline Personal and Social Performance Scale (PSP) score were significant predictors of increased dose in responders. Patients with young-onset age, severe baseline symptoms, and poor function are more likely to benefit from high dosage.

Application of a Pharmacogenetics-Based Precision Medicine Model (5SPM) to Psychotic Patients That Presented Poor Response to Neuroleptic Therapy

Antipsychotics are the keystone of the treatment of severe and prolonged mental disorders. However, there are many risks associated with these drugs and not all patients undergo full therapeutic profit from them. The application of the 5 Step Precision Medicine model(5SPM), based on the analysis of the pharmacogenetic profile of each patient, could be a helpful tool to solve many of the problematics traditionally associated with the neuroleptic treatment. In order to solve this question, a cohort of psychotic patients that showed poor clinical evolution was analyzed. After evaluating the relationship between the prescribed treatment and pharmacogenetic profile of each patient, a great number of pharmacological interactions and pharmacogenetical conflicts were found. After reconsidering the treatment of the conflictive cases, patients showed a substantial reduction on mean daily doses and polytherapy cases, which may cause less risk of adverse effects, greater adherence, and a reduction on economic costs.

Antipsychotic Dose in Acute Schizophrenia: A Meta-analysis

Little is known regarding optimal antipsychotic doses in the acute phase of schizophrenia. The aim of the present study was to employ the concept of minimum effective dose (MED) in examining efficacy and tolerability within this population. MED was identified for each antipsychotic through a previous systematic review. We then identified double-blind placebo-controlled randomized trials that involved fixed-dose antipsychotic monotherapy in acute schizophrenia and compared the identified MED vs higher doses of the same oral antipsychotic. Studies were selected from a recent meta-analysis examining dose-response relationship of second-generation antipsychotics and haloperidol. We extracted the data on study discontinuation, psychopathology, extrapyramidal symptoms, and treatment-emergent adverse events. For each antipsychotic, we conducted a meta-analysis to compare outcomes between MED and 2-fold MED, and MED and 3-fold MED. A total of 26 studies involving 5618 patients were included in the meta-analysis. In terms of study discontinuation, significant differences were found in study discontinuation due to lack of efficacy between MED and higher doses, in favor of 2-fold and 3-fold MEDs. Regarding psychopathology, both 2-fold and 3-fold MEDs were superior to MED for total and positive symptom scores. As for side effects, 2-fold MED proved inferior to MED for parkinsonism scores and diarrhea, whereas 3-fold MED was inferior for akathisia, somnolence, and vomiting. Findings suggest that clinicians can dose an antipsychotic at 2-fold or 3-fold MED for patients with acute schizophrenia but should closely monitor side effects.