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Grover S, Naskar C. Patient and caregivers perspective about clozapine: A systematic review. Schizophr Res 2024; 268:223-232. [PMID: 37385885 DOI: 10.1016/j.schres.2023.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Clozapine is a gold standard treatment for treatment-resistant schizophrenia. However, the patients' and caregivers' perception and their experience with clozapine has remained much less explored. AIM To review the available literature on the patients' and caregivers' attitudes, perceptions, and experiences with clozapine. METHODOLOGY 27 original research and review articles published in PubMed-indexed journals till March 2023 in the English language, exploring the patient and/or caregiver/family member's experience with using clozapine, were included. RESULTS 30-80 %of patients and 92-100 % of caregivers were found to have a positive attitude towards clozapine in terms of its impact on psychopathology, cognitive and social functioning of the patient, and caregiving needs. Most patients and caregivers also found that the positive effects of clozapine outweighed the side effects and distress related to repeated blood testing. However, a lack of satisfaction was noted among both patients and caregivers regarding the knowledge provided to them regarding clozapine, especially regarding its common adverse effects. Discontinuation of clozapine was found to be more commonly done by the patients' accord rather than clinicians, and the perceived side effects like hypersalivation and excessive sedation emerge as important factors that lead to discontinuation rather than the need for repeated blood testing. CONCLUSIONS Overall, patients and their caregivers share a positive attitude towards clozapine and perceive it to be an effective and beneficial drug, but more effort needs to be directed by the clinical teams to educate the users of clozapine regarding its complete side effect profile and provide continuous guidance about dealing with the emerging side effects throughout treatment.
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Affiliation(s)
- Sandeep Grover
- Post Graduate Institute of Medical Education & Research, Chandigarh, India.
| | - Chandrima Naskar
- Post Graduate Institute of Medical Education & Research, Chandigarh, India
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2
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Grover S, Naskar C, Chakrabarti S. Experience with and attitude toward clozapine use among patients receiving clozapine on long term and their caregivers. Indian J Psychiatry 2023; 65:1165-1175. [PMID: 38249152 PMCID: PMC10795661 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_585_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/01/2023] [Accepted: 10/26/2023] [Indexed: 01/23/2024] Open
Abstract
Background Despite clozapine being the gold standard for treating patients suffering from treatment-resistant schizophrenia, the experience and attitude of patients receiving clozapine for a long duration and their caregivers have not been evaluated, especially in India and other low-middle-income countries. Also, no standardized scale has been validated for such assessment. Objective This study aimed to evaluate the perception regarding clozapine among patients and their caregivers. We also attempted to evaluate the factor structure of the scale for such assessment. Methods A total of 172 consenting patients who have been receiving clozapine for ≥1 year and their caregivers were evaluated on self-designed questionnaires (patient and caregiver versions containing 44 and 47 items, respectively) to assess various aspects of their experiences about clozapine use. Results A majority (70-80%) of patients and caregivers reported improvement in psychotic symptoms, mood symptoms, and overall functioning with starting of clozapine. However, about 40% of the patients reported cognitive side effects, and 20-25% reported disabling side effects like lethargy, forgetfulness and decreased attention, and distress related to blood testing after starting of clozapine. Factor analysis of the questionnaires yielded five- and seven-factor models for the experience and attitude of the patients and the caregivers, respectively. The positive experiences were associated clinical and functional improvement, lower disability, and improvement in functioning as well as the self-reported perceived improvement by the patient and caregiver. Conclusion This study suggests that patients tend to have an overall positive experience and attitude about using clozapine. The caregivers also report the beneficial effect on the caregiving. A good level of agreement was seen between the experience of patients, caregivers, and clinician-rated improvement in the psychopathology and functioning.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandrima Naskar
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subho Chakrabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Sarpal DK, Suh K, Bian K, Ko P, Gannon JM, Jhon P, Chengappa KNR. Community-Based Service Use After Clozapine Treatment: A Mirror-Image Analysis of Public Claims Data. Psychiatr Serv 2023; 74:1104-1107. [PMID: 37016827 DOI: 10.1176/appi.ps.20220471] [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] [Indexed: 04/06/2023]
Abstract
Although clozapine demonstrates unique efficacy for treatment-resistant schizophrenia, its impact on community-based services remains largely underexplored. The authors examined changes in use of community-based services after clozapine treatment among a sample of 163 patients with schizophrenia by using public claims data in Allegheny County, Pennsylvania. Mirror-image analyses of service utilization were used to compare the 180-day period before treatment initiation with the 180-day period that began after 6 months of adherent treatment, accounting for age, race, and gender. Across demographic variables, clozapine treatment was associated with increased use of community-based services and decreased use of psychiatric inpatient services (p<0.05, Bonferroni corrected), suggesting that clozapine treatment shifts service needs from emergency care to community-based care and recovery.
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Affiliation(s)
- Deepak K Sarpal
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - Kangho Suh
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - Kaiqi Bian
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - Pingjui Ko
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - Jessica M Gannon
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - Peter Jhon
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
| | - K N Roy Chengappa
- Department of Psychiatry (Sarpal, Gannon, Chengappa) and Department of Pharmacy and Therapeutics (Suh), University of Pittsburgh, Pittsburgh; Allegheny County Department of Human Services, Pittsburgh (Bian, Ko, Jhon)
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Southern J, Elliott P, Maidment I. What are patients' experiences of discontinuing clozapine and how does this impact their views on subsequent treatment? BMC Psychiatry 2023; 23:353. [PMID: 37217959 DOI: 10.1186/s12888-023-04851-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 05/07/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Discontinuing what is considered the most effective treatment for treatment-resistant schizophrenia may precipitate feelings of failure or a relapse of illness. Clozapine treatment is discontinued for a variety of reasons, including non-adherence, intolerance, or lack of efficacy. Patients' experiences of discontinuing the "best" treatment and the impact on perceptions of subsequent antipsychotic treatment are important in developing an understanding of the factors affecting people's treatment choices. This study is the first of its type, seeking to explore people's perspectives on clozapine discontinuation. METHOD Semi-structured interviews with sixteen patients who had received clozapine and discontinued treatment-thirteen males and three females, age range: thirty-two to seventy-eight years old-were audio-recorded and transcribed. A modified inductive approach to analysis, based on grounded theory, was taken to identify commonalities and differences in patients' perceptions. RESULTS The three main themes identified from participants' experiences were: (1) positive and negative effects of treatment; (2) feelings of agency, being the capacity to make decisions about treatment and act independently; (3) choice of treatment in the future. Participants exhibited agency in making choices about medication, including risking relapse, while attempting self-management of medication effects. Different participants perceived the same side effect as beneficial or intolerable. Variation in subsequent treatment choices was reported, with some participants favouring depot (long-acting) injections. A participant was frightened when not told about clozapine's side effects, which led to the participant not being engaged in future treatment decisions. Others, despite suffering serious adverse effects, retained positive perceptions of clozapine; they experienced despair at finding an effective alternative. CONCLUSIONS Experiences with clozapine discontinuation evoked powerful emotions and resulted in clozapine being the benchmark for other treatments. Knowledge, agency, and being in control were important to participants in relation to treatment. Personal perceptions of treatments or beliefs about illness could lead to non-adherence. People value the clinician listening to their experiences to better understand their perspective, enabling concerns about medication to be addressed through true shared decision making. TRIAL REGISTRATION NHS Health Research Authority and Health and Care Research Wales, IRAS Project ID 225753, Research Ethics Committee (REC) reference: 18/NW/0413, 25/06/2018.
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Affiliation(s)
- Jennifer Southern
- Aston University, Birmingham, B4 7ET, England.
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, CH2 1BQ, England.
| | - Phil Elliott
- Cheshire and Wirral Partnership NHS Foundation Trust, Chester, CH2 1BQ, England
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Parkin K, Chen S, Biria M, Plaistow J, Beckwith H, Jarratt-Barnham I, Segarra N, Worbe Y, Fineberg NA, Cardinal RN, Robbins TW, Fernandez-Egea E. Clozapine-related obsessive-compulsive symptoms and their impact on wellbeing: a naturalistic longitudinal study. Psychol Med 2023; 53:2936-2945. [PMID: 35469587 PMCID: PMC10235641 DOI: 10.1017/s003329172100492x] [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: 07/14/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Obsessive-compulsive symptoms (OCS) are commonly associated with clozapine treatment but are frequently overlooked by clinicians despite their potential impact on patients' quality of life. In this study, we explored whether OCS severity impacted subjective wellbeing and general functioning, independently of depressive and psychotic symptoms. METHODS We used anonymised electronic healthcare records from a large cohort of patients who were treated with clozapine and assessed annually for OCS, wellbeing, general functioning, and psychopathology using standardised scales as part of routine clinical practice. We used statistical mixed linear model techniques to evaluate the longitudinal influence of OCS severity on wellbeing and general functioning. RESULTS A total of 184 patients were included, with 527 face-to-face assessments and 64.7% evaluated three or more times. Different linear mixed models demonstrated that OCS in patients treated with clozapine were associated with significantly worse wellbeing scores, independently of depression and psychotic symptoms, but OCS did not impair general functioning. Obsessional thinking and hoarding behaviour, but not compulsions, were significantly associated with the impact on wellbeing, which may be attributable to the ego-syntonic nature of the compulsions. CONCLUSIONS Given the frequent occurrence of OCS and their negative impact on wellbeing, we encourage clinicians to routinely assess and treat OCS in patients who are taking clozapine.
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Affiliation(s)
- Katherine Parkin
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Shanquan Chen
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Marjan Biria
- Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - James Plaistow
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Helen Beckwith
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Isaac Jarratt-Barnham
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
| | - Nuria Segarra
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Yulia Worbe
- Sorbonne Université, Paris 05, France
- Department of Neurophysiology, Saint-Antoine Hospital, Paris, France
- INSERM U 1127, CNRS UMR 7225, Institute du Cerveau et de la Moelle Epinière, Paris, France
| | - Naomi A. Fineberg
- Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, UK
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Rudolf N. Cardinal
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Trevor W. Robbins
- Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Emilio Fernandez-Egea
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
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Peitl V, Puljić A, Škrobo M, Nadalin S, Fumić Dunkić L, Karlović D. Clozapine in Treatment-Resistant Schizophrenia and Its Augmentation with Electroconvulsive Therapy in Ultra-Treatment-Resistant Schizophrenia. Biomedicines 2023; 11:biomedicines11041072. [PMID: 37189691 DOI: 10.3390/biomedicines11041072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses (two or more, with at least one being atypical). However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40–70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies.
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Affiliation(s)
- Vjekoslav Peitl
- Department of Psychiatry, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
| | - Antonia Puljić
- Department of Psychiatry, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
| | - Mislav Škrobo
- Department of Psychiatry, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia
| | - Sergej Nadalin
- Department of Psychiatry, General Hospital “Dr. Josip Benčević”, 35000 Slavonski Brod, Croatia
| | - Lidija Fumić Dunkić
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
- Department of Anesthesiology, Intensive Care and Pain Therapy, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia
| | - Dalibor Karlović
- Department of Psychiatry, University Hospital Centre Sestre Milosrdnice, 10000 Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
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Gannon L, Reynolds J, Mahon M, Gaughran F, Lally J. High-dose olanzapine in treatment-resistant schizophrenia: a systematic review. Ther Adv Psychopharmacol 2023; 13:20451253231168788. [PMID: 37187727 PMCID: PMC10176543 DOI: 10.1177/20451253231168788] [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: 10/29/2022] [Accepted: 03/23/2023] [Indexed: 05/17/2023] Open
Abstract
Background Treatment-resistant schizophrenia (TRS) affects approximately 30% of people with schizophrenia. Clozapine is the gold standard treatment for TRS but is not always suitable, with a proportion of individuals intolerant of side effects or unable to engage in necessary blood monitoring. Given the profound impact TRS can have on those affected, alternative pharmacological approaches to care are needed. Objectives To review the literature on the efficacy and tolerability of high-dose olanzapine (>20 mg daily) in adults with TRS. Design This is a systematic review. Data Sources and Methods We searched for eligible trials published prior to April 2022 in PubMed/MEDLINE, Scopus and Google Scholar. Ten studies met the inclusion criteria [five randomised controlled trials (RCTs), one randomised crossover trial and four open label studies]. Data were extracted for predefined primary outcomes (efficacy, tolerability). Results Compared with standard treatment, high-dose olanzapine was non-inferior in four RCTs, three of which used clozapine as the comparator. Clozapine was superior to high-dose olanzapine in a double-blind crossover trial. Open-label studies demonstrated tentative evidence in support of high-dose olanzapine use. It was better tolerated than clozapine and chlorpromazine in two respective RCTs, and was generally well tolerated in open-label studies. Conclusion This evidence suggests high-dose olanzapine is superior for TRS when compared with other commonly used first- and second-generation antipsychotics, including haloperidol and risperidone. In comparison with clozapine, the data are encouraging for the use of high-dose olanzapine where clozapine use is problematic, but larger, better designed trials are needed to assess the comparative efficacy of both treatments. There is insufficient evidence to consider high-dose olanzapine equivalent to clozapine when clozapine is not contraindicated. Overall, high-dose olanzapine was well tolerated, with no serious side effects. Registration This systematic review was preregistered with PROSPERO [CRD42022312817].
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Affiliation(s)
- Louisa Gannon
- Department of Psychiatry, University College
Dublin, Dublin, Ireland
- Department of Psychiatry, St. Vincent’s
University Hospital, Dublin, Ireland
| | - John Reynolds
- Department of Psychiatry, Mayo University
Hospital, Castlebar, Ireland
| | - Martin Mahon
- Department of Psychiatry, Connolly Hospital,
Dublin, Ireland
| | - Fiona Gaughran
- National Psychosis Service, South London and
Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of
Psychiatry Psychology and Neuroscience, Kings College London, London,
UK
- National Institute for Health Research (NIHR)
Mental Health Biomedical Research Centre at South London and Maudsley NHS
Foundation Trust and King’s College London, UK
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Cushnie AK, Bullock DN, Manea AM, Tang W, Zimmermann J, Heilbronner SR. The use of chemogenetic actuator ligands in nonhuman primate DREADDs-fMRI. CURRENT RESEARCH IN NEUROBIOLOGY 2022; 4:100072. [PMID: 36691404 PMCID: PMC9860110 DOI: 10.1016/j.crneur.2022.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/01/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) are engineered receptors that allow for genetically targeted, reversible manipulation of cellular activity via systemic drug administration. DREADD induced manipulations are initiated via the binding of an actuator ligand. Therefore, the use of DREADDs is contingent on the availability of actuator ligands. Actuator ligands low-dose clozapine (CLZ) and deschloroclozapine (DCZ) are highly selective for DREADDs, and, upon binding, induce physiological and behavioral changes in rodents and nonhuman primates (NHPs). Despite this reported specificity, both CLZ and DCZ have partial affinity for a variety of endogenous receptors and can induce dose-specific changes even in naïve animals. As such, this study aimed to examine the effects of CLZ and DCZ on resting-state functional connectivity (rs-FC) and intrinsic neural timescales (INTs) in naïve NHPs. In doing so, we evaluated whether CLZ and DCZ - in the absence of DREADDs - are inert by examining these ligands' effects on the intrinsic functional properties of the brain. Low-dose DCZ did not induce consistent changes in rs-FC or INTs prior to the expression of DREADDs; however, a high dose resulted in subject-specific changes in rs-FC and INTs. In contrast, CLZ administration induced consistent changes in rs-FC and INTs prior to DREADD expression in our subjects. Our results caution against the use of CLZ by explicitly demonstrating the impact of off-target effects that can confound experimental results. Altogether, these data endorse the use of low dose DCZ for future DREADD-based experiments.
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Affiliation(s)
- Adriana K. Cushnie
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Daniel N. Bullock
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Ana M.G. Manea
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Wei Tang
- Department of Computer Science, Program in Neuroscience, Indiana University Bloomington, Bloomington, IN, 47408, USA
| | - Jan Zimmermann
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Sarah R. Heilbronner
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
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Huang Z, Liu X. Network Pharmacology and Molecular Docking Analysis on Targets and Mechanisms of Berberine in Atypical Antipsychotic-Induced Metabolic Syndrome. Nat Prod Commun 2022. [DOI: 10.1177/1934578x221129106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Berberine (BBR), an isoquinoline alkaloid, possesses multiply pharmacological effects as a potential therapeutic drug for antipsychotic-induced metabolic syndrome (MetS). However, the underlying therapeutic mechanisms have not been fully elucidated. In this study, we aim to investigate the possible mechanisms by identifying the key targets and biological pathways through network pharmacology and molecular docking analysis. A total of 23 overlapping targets in the intersection set among BBR, atypical antipsychotic drugs (AADs), and MetS were determined. PPI network analysis showed that 22 out of the 23 overlapping targets closely interacted with the others. The following pathway enrichment analysis and molecular docking indicated a central role of peroxisome proliferator-activated receptor-γ (PPARG) as the key target of BBR against AAD-induced MetS by acting on the PPAR signaling pathway, lipid and atherosclerosis, and AMP activated protein kinase (AMPK) signaling pathway. In addition, cytochrome P-450 2D6 (CYP2D6) could be considered as another target of BBR in ameliorating antipsychotic-induced metabolic side effects. Collectively, this study investigated the central targets and biological pathways of BBR against AAD-induced MetS from a systematic perspective, and thus brings novel insights into further understanding of the protective effects of BBR.
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Affiliation(s)
- Zhuowei Huang
- Department of Psychiatry, Wuhan Mental Health Center, Wuhan, Hubei Province, China
- Department of Traditional Chinese Integrated Western Medicine, Wuhan Hospital for Psychotherapy, Wuhan, Hubei Province, China
| | - Xiaolan Liu
- Department of Psychiatry, Wuhan Mental Health Center, Wuhan, Hubei Province, China
- Department of Traditional Chinese Integrated Western Medicine, Wuhan Hospital for Psychotherapy, Wuhan, Hubei Province, China
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Casetta C, Gaughran F, MacCabe J, Oloyede E, Shergill S, Taylor D. Correspondence. Br J Psychiatry 2022; 221:496. [PMID: 35848381 DOI: 10.1192/bjp.2021.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Cecilia Casetta
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Fiona Gaughran
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - James MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Ebenezer Oloyede
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Sukhi Shergill
- Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - David Taylor
- Institute of Psychiatry, Psychology and Neuroscience, London, UK; Director of Pharmacy, South London and Maudsley NHS Foundation Trust, UK.
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Blazer A, Chengappa KNR, Foran W, Parr AC, Kahn CE, Luna B, Sarpal DK. Changes in corticostriatal connectivity and striatal tissue iron associated with efficacy of clozapine for treatment‑resistant schizophrenia. Psychopharmacology (Berl) 2022; 239:2503-2514. [PMID: 35435461 PMCID: PMC9013738 DOI: 10.1007/s00213-022-06138-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/31/2022] [Indexed: 12/02/2022]
Abstract
RATIONALE Though numerous studies demonstrate the superiority of clozapine (CLZ) for treatment of persistent psychotic symptoms that are characteristic of treatment-refractory schizophrenia (TRS), what remains unknown are the neural and molecular mechanisms underlying CLZ's efficacy. Recent work implicates increased corticostriatal functional connectivity as a marker of response to non-CLZ, dopamine (DA) D2-receptor blocking antipsychotic drugs. However, it is undetermined whether this connectivity finding also relates to CLZ's unique efficacy, or if response to CLZ is associated with changes in striatal DA functioning. OBJECTIVE In a cohort of 22 individuals with TRS, we examined response to CLZ in relation to the following: (1) change in corticostriatal functional connectivity; and (2) change in a magnetic resonance-based measure of striatal tissue iron (R2'), which demonstrates utility as a proxy measure for elements of DA functioning. METHODS Participants underwent scanning while starting CLZ and after 12 weeks of CLZ treatment. We used both cortical and striatal regions of interest to examine changes in corticostriatal interactions and striatal R2' in relation to CLZ response (% reduction of psychotic symptoms). RESULTS We first found that response to CLZ was associated with an increase in corticostriatal connectivity between the dorsal caudate and regions of the frontoparietal network (P < 0.05, corrected). Secondly, we observed no significant changes in striatal R2' across CLZ treatment. CONCLUSION Overall, these results indicate that changes in corticostriatal networks without gross shifts in striatal DA functioning underlies CLZ response. Our results provide novel mechanistic insight into response to CLZ treatment.
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Affiliation(s)
- Annie Blazer
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - K N Roy Chengappa
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - William Foran
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Ashley C Parr
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Charles E Kahn
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepak K Sarpal
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA.
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12
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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: 38] [Impact Index Per Article: 19.0] [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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13
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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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14
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Wickramarachchi P, Boyd JM, Orton DJ. Biological Variation in Clozapine and Metabolite Reporting During Therapeutic Drug Monitoring. Clin Chim Acta 2022; 531:183-187. [DOI: 10.1016/j.cca.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
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15
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Combination Therapy of Long-Acting Injectable Second-Generation Antipsychotics and Oral Antipsychotics: A Retrospective Chart Review and Prescribers' Attitude Survey. J Clin Psychopharmacol 2022; 42:81-86. [PMID: 34668878 DOI: 10.1097/jcp.0000000000001487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although long-acting injectable antipsychotics (LAI-APs) have been considered as a monotherapeutic option in the maintenance treatment of schizophrenia, it has been recently reported that the combination therapy of LAI-APs and oral antipsychotics (OAPs) is common. METHODS We conducted a retrospective chart review to examine the situation of the combination therapy of LAI second-generation antipsychotics (LAI-SGAs) and OAPs, and a questionnaire survey to investigate prescribers' attitudes toward the combination therapy. We included patients who received any LAI-SGAs for 1 month or longer and classified them into monotherapy and combination therapy groups. We collected information on age, sex, primary psychiatric diagnosis, and concomitant psychotropic medications. RESULTS Of the 132 patients, 39 (29.5%) received the combination therapy of LAI-SGAs and OAPs. Long-acting injectable risperidone was significantly associated with receiving the combination therapy compared with LAI aripiprazole. Olanzapine was the most common OAP in combination with LAI-SGAs. Only 8 patients (20.5%) concurrently received the same type of OAPs as LAI-SGAs. More than 60% of the patients received OAP polypharmacy before the initiation of LAI-SGAs. The psychiatrists in charge prescribed LAI-SGAs mainly because of a concern about adherence, and OAPs mainly because of insufficient dose of LAI-SGAs, to patients in the combination therapy group. They estimated that adherence to OAPs in two thirds of the patients in the combination therapy group was 80% or higher. CONCLUSIONS The present study showed that the combination therapy of LAI-SGAs and OAPs is often conducted in real-world clinical practice. Considering the reason for the introduction of LAI-APs, clinicians should carefully monitor patients' adherence to OAPs concurrently used with LAI-APs.
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16
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Ramli FF, Ali A, Syed Hashim SA, Kamisah Y, Ibrahim N. Reduction in Absolute Neutrophil Counts in Patient on Clozapine Infected with COVID-19. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111289. [PMID: 34769806 PMCID: PMC8582734 DOI: 10.3390/ijerph182111289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/12/2022]
Abstract
Despite its severe adverse effects, such as agranulocytosis, clozapine is the primary treatment for treatment-resistant schizophrenia. The established clozapine monitoring system has contributed to reducing agranulocytosis incidence and mortality rates. However, the pandemic coronavirus disease 2019 (COVID-19) has caused changes in the monitoring system. This review aimed to assess the current evidence on the neutrophil changes in the patient on clozapine treatment and infected with COVID-19. Individual cases reported various absolute neutrophil count (ANC) levels, normal, reduced, or elevated. No agranulocytosis case was reported. One case had a borderline moderate-severe ANC level, but the patient was in the 18-week period of clozapine treatment. A cumulative analysis of case the series initially reported inconclusive results. However, a more recent study with a larger sample size reported a significant reduction in the ANC during COVID-19 infection. Nevertheless, this effect is transient as no significant difference was found between the baseline and the post-infection period in ANC levels. In conclusion, COVID-19 is associated with a temporary reduction in ANC levels. The results supported the recommendation to reduce the frequency of clozapine monitoring in the eligible candidates. However, more data are required to confirm the current findings given the limitations, including study design, sample size, and statistical analysis.
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Affiliation(s)
- Fitri Fareez Ramli
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK
- Correspondence: ; Tel.: +60-3-9145-9545
| | - Adli Ali
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia;
- Infection and Immunology Health and Advanced Medicine Cluster, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Syed Alhafiz Syed Hashim
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
| | - Yusof Kamisah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia; (S.A.S.H.); (Y.K.)
| | - Normala Ibrahim
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia;
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17
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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18
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Vandevelde A, Métivier L, Dollfus S. Impact cérébral structurel et fonctionnel de la Clozapine chez les patients souffrant de schizophrénie : revue systématique des études longitudinales en neuroimagerie. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:683-700. [PMID: 33131322 PMCID: PMC8329901 DOI: 10.1177/0706743720966459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIF L'objectif de cette revue est d'identifier les corrélats anatomo-fonctionnels cérébraux lors d'un traitement par clozapine (CLZ) ainsi que les marqueurs anatomo-fonctionnels prédictifs de la réponse à la CLZ. MÉTHODES Nous avons réalisé une revue systématique de la littérature avec les bases de données MEDLINE et Web of Science afin d'identifier et d'examiner toutes les études longitudinales en neuroimagerie investiguant l'impact cérébral de la CLZ. RÉSULTATS 30 études ont été incluses et analysées. La CLZ induit une diminution du volume et de la perfusion dans les noyaux gris centraux chez les patients répondeurs. Un plus grand volume de substance grise et perfusion dans ces structures avant l'instauration de la CLZ étaient associés à une meilleure réponse au traitement. La diminution de volume et de perfusion au niveau du cortex préfrontal (CPF) est observée malgré l'instauration de CLZ mais de façon moins importante chez les patients sous CLZ que chez les patients sous antipsychotiques typiques. Un plus grand volume au niveau du CPF avant l'instauration de la CLZ est associé à une meilleure réponse clinique dans la majorité des études. Enfin, la CLZ semble induire une réduction des altérations au niveau de la substance blanche. CONCLUSION Les corrélats anatomo-fonctionnels de la CLZ différent de ceux des autres antipsychotiques avec une action spécifique de la CLZ au niveau des ganglions de la base et du CPF pouvant participer à sa supériorité en termes de réponse clinique. Plusieurs données cliniques et d'imagerie conduisent à l'hypothèse d'un meilleur pronostic associé à une instauration plus rapide de la CLZ.
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Affiliation(s)
- Anaïs Vandevelde
- Normandie Univ, UNICAEN, ISTS, EA 7466, GIP 55388Cyceron, boulevard Henri-Becquerel, 14000 Caen, France.,26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,Anaïs Vandevelde et Lucie Métivier ont participé de la même façon à ce travail et sont co-premier auteurs
| | - Lucie Métivier
- 26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,CHU de Caen, centre Esquirol, service de psychiatrie, 14000 Caen, France.,Anaïs Vandevelde et Lucie Métivier ont participé de la même façon à ce travail et sont co-premier auteurs
| | - Sonia Dollfus
- Normandie Univ, UNICAEN, ISTS, EA 7466, GIP 55388Cyceron, boulevard Henri-Becquerel, 14000 Caen, France.,26962Normandie Univ, UNICAEN, UFR de médecine (Medical School), 14000 Caen, France.,CHU de Caen, centre Esquirol, service de psychiatrie, 14000 Caen, France
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19
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European Whites May Need Lower Minimum Therapeutic Clozapine Doses Than Those Customarily Proposed. J Clin Psychopharmacol 2021; 41:140-147. [PMID: 33587398 DOI: 10.1097/jcp.0000000000001341] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE/BACKGROUND A nomogram from a British naturalistic study proposed that the clozapine dosing needed to reach a serum concentration of 350 ng/mL ranged from 265 mg/d (female nonsmokers) to 525 mg/d (male smokers). Some European reviews have used these dosing recommendations, which seem greater than what we found in an Italian White sample ranging from 245 mg/d (female nonsmokers) to 299 mg/d (male smokers). Five other published samples of European Whites were added to the Italian sample to estimate clozapine doses recommended for reaching 350 ng/mL. METHODS/PROCEDURES Average clozapine metabolizers were obtained by eliminating outliers with confounding variables: (1) psychiatric inducers and inhibitors; (2) doses less than 100 mg/d; and (3) when possible, patients with inflammation, obesity, or using oral contraceptives. The study included 1363 average metabolizer European Whites: the Italian sample and 5 new samples. Mean averages that reached serum concentration levels of 350 ng/mL were calculated after stratification by sex and smoking status in each sample. Then, weighted mean averages were obtained by combining the 6 samples. FINDINGS/RESULTS The estimated weighted mean clozapine dosages ranged from 236 to 368 mg/d (236 mg/d in 218 female nonsmokers, 256 mg/d in 340 male nonsmokers, 357 mg/d in 269 female smokers, and 368 mg/d in 546 male smokers). IMPLICATIONS/CONCLUSIONS Our recommended dosages are less than those recommended in Europe. Future studies in European Whites need to replicate these recommended doses for average metabolizer patients after sex and smoking stratification and further explore clozapine dosing for those with relevant clinical confounders.
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Abstract
OBJECTIVE We sought to assess the effectiveness of clozapine augmentation with Electroconvulsive therapy (ECT) (C+ECT) in patients with clozapine-resistant schizophrenia. METHODS We conducted a retrospective review of electronic health records to identify patients treated with C+ECT. We determined the response to C+ECT and the rate of rehospitalisation over the year following treatment with C+ECT. RESULTS Forty-two patients were treated with C+ECT over a 10-year period. The mean age of the patients at initiation of ECT was 46.3 (SD = 8.2) years (range 27-62 years). The mean number of ECTs given was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Seventy-six per cent of patients (n = 32) showed a Clinical Global Impression-Improvement (CGI-I) score of ≤3 (at least minimally improved) following C+ECT. The mean number of ECT treatments was 10.6 (SD = 5.3) (range 3-25) with the majority receiving twice weekly ECT. Sixty-four per cent of patients experienced no adverse events. Response to C+ECT was not associated with gender, age, duration of illness or duration of clozapine treatment. Seventy-five per cent of responders remained out of hospital over the course of 1-year follow-up, while 70% of those with no response to C+ECT were not admitted to hospital. Three patients received maintenance ECT, one of whom was rehospitalised. CONCLUSION This study lends support to emerging evidence for the effectiveness of C+ECT in clozapine-resistant schizophrenia. These results are consistent with the results of a meta-analysis and the only randomised controlled trial (RCT) of this intervention. Further RCTs are required before this treatment can be confidently recommended.
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21
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Clinical risk factors, phenomenology and the impact of clozapine induced obsessive compulsive symptoms. Psychiatry Res 2021; 296:113665. [PMID: 33465593 DOI: 10.1016/j.psychres.2020.113665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/19/2020] [Indexed: 11/23/2022]
Abstract
The aim of this study was to investigate the clinical risk factors, phenomenology and the impact of clozapine induced obsessive-compulsive symptoms (OCS) in patients with schizophrenia. One hundred twenty-two patients receiving clozapine treatment for at least 6 weeks were assessed with Structured Clinical Interview for Axis-I Disorders for DSM-IV, Positive and Negative Syndrome Scale, Yale-Brown Obsessive Compulsive Scale and Checklist, Calgary Depression Scale, Clinical Global Impression Scale and WHO-Disability Assessment Schedule-II. Information about past and current clinical status were gathered through clinical interviews and medical records. With clozapine 44.3% of the patients had de novo OCS, 33.6% had OCS both before and after clozapine, 21.3% didn't report any OCS. Clozapine doses, clozapine and norclozapine plasma levels were not significantly different. Severity of OCS was affected by clozapine and norclozapine plasma levels, and correlated with increased disability. Obsessions were less in clozapine induced OCS group, and compulsions, especially of checking subtypes, were predominant, compared to the group with prior history of OCS, who reported a significant increase in checking compulsion after clozapine treatment. Clozapine induced OCS should be considered during cost/benefit assessment of clozapine treatment, and understanding the risk factors and its different phenomenology may shed light into the underlying mechanisms.
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22
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Smart SE, Kępińska AP, Murray RM, MacCabe JH. Predictors of treatment resistant schizophrenia: a systematic review of prospective observational studies. Psychol Med 2021; 51:44-53. [PMID: 31462334 PMCID: PMC7856410 DOI: 10.1017/s0033291719002083] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/24/2019] [Accepted: 07/25/2019] [Indexed: 12/29/2022]
Abstract
Treatment-resistant schizophrenia, affecting approximately 20-30% of patients with schizophrenia, has a high burden both for patients and healthcare services. There is a need to identify treatment resistance earlier in the course of the illness, in order that effective treatment, such as clozapine, can be offered promptly. We conducted a systemic literature review of prospective longitudinal studies with the aim of identifying predictors of treatment-resistant schizophrenia from the first episode. From the 545 results screened, we identified 12 published studies where data at the first episode was used to predict treatment resistance. Younger age of onset was the most consistent predictor of treatment resistance. We discuss the gaps in the literature and how future prediction models can identify predictors of treatment response more robustly.
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Affiliation(s)
- S. E. Smart
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, 16 de Crespigny Park, London, SE5 8AF, UK
| | - A. P. Kępińska
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, 16 de Crespigny Park, London, SE5 8AF, UK
| | - R. M. Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, 16 de Crespigny Park, London, SE5 8AF, UK
| | - J. H. MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, 16 de Crespigny Park, London, SE5 8AF, UK
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23
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Ignjatovic Ristic D, Cohen D, Ristic I. Prescription attitudes and practices regarding clozapine among Serbian psychiatrists: results of a nationwide survey. Ther Adv Psychopharmacol 2021; 11:20451253211020235. [PMID: 34104415 PMCID: PMC8165825 DOI: 10.1177/20451253211020235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Despite clozapine being the most effective treatment for treatment-resistant schizophrenia (TRS), a clear explanation as to why it is underutilized and why its initiation is delayed remains unclear. The first aim of the study was to conduct a nation-wide assessment of both the psychiatrists' attitudes of the obstacles for prescribing clozapine as well as their prescription practices. The second aim was to make recommendations, based on the results obtained, for improving the Serbian clozapine guidelines. METHODS A questionnaire was conducted consisting of two parts. One regarded the clinical characteristics of the psychiatrists, while the second contained questions about indications for clozapine initiation, clozapine prescribing tendencies, and barriers to clozapine use. The questionnaire was sent to 302 Serbian psychiatrists. RESULTS With 161 out of the 302 psychiatrists returning the questionnaires, the response rate was 53.3%. Nearly 60% of the psychiatrists treated 10 or more patients with clozapine, with TRS being the most common indication. Only four psychiatrists (2.5%) had no patients currently on clozapine. Psychiatrists indicated that their fear of agranulocytosis (68%) constituted the greatest obstacle for clozapine prescription, followed closely by weight gain (56%), and sedation (39%). Despite their fear of agranulocytosis, only 83.9% of the psychiatrists monitored leukocytes regularly. CONCLUSION In general, psychiatrists in Serbia seem to be confident in prescribing clozapine, even in the absence of clear monitoring guidelines and the possibility of therapeutic drug monitoring. In order to reduce obstacles for clozapine prescription, monitoring laxity, and an overreliance on personal experience, we recommend three modifications of the existing clozapine guideline.
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Affiliation(s)
- Dragana Ignjatovic Ristic
- Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Dan Cohen
- Mental Health Organization North-Holland North, Heerhugowaard, The Netherlands
| | - Ivan Ristic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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24
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Berel C, Mossé U, Wils J, Cousin L, Imbert L, Gerardin P, Chaumette B, Lamoureux F, Ferrafiat V. Interest of Fluvoxamine as an Add-On to Clozapine in Children With Severe Psychiatric Disorder According to CYP Polymorphisms: Experience From a Case Series. Front Psychiatry 2021; 12:669446. [PMID: 34234701 PMCID: PMC8255476 DOI: 10.3389/fpsyt.2021.669446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/21/2021] [Indexed: 01/24/2023] Open
Abstract
Despite its drastic efficacy in resistant psychiatric disorders, clozapine remains rarely used in youth due to its side effects. Clozapine plasma level is determined through its metabolism involving several isoforms of cytochromes 450 (CYP450) family. Isoform CYP1A2 appears as a limiting enzyme involved in the metabolism of clozapine, while isoforms 2C19, 2D6, 3A4, and 3A5 also contribute in a minor way. Clozapine efficacy is limited by a significant inter-patient variability in exposure according to CYP's polymorphisms. Clozapine plasma levels may be increased with CYP inhibitors such as fluvoxamine. This drug is a potent enzymatic inhibitor of CYP1A2 and, to a lesser extent, of CYP3A4 and CYP2D6. Hence, in case of CYP's polymorphisms in youth, the use of fluvoxamine as add-on to clozapine could help in reaching clinical and biological efficacy and allowing lower clozapine dosage and a better tolerance profile as it has already been described in adults. We report four pediatric cases with severe psychiatric disorders underlying our experience with CYP polymorphism explorations and the use of fluvoxamine as add-on to clozapine. Our four patients clinically improved after the introduction of fluvoxamine, enhancing clozapine metabolism and therefore the clozapine plasma level within therapeutic range. Despite the interesting results of fluvoxamine, we report a severe issue of tolerance for one patient, emphasizing the need for caution regarding possible drug interactions when fluvoxamine is considered. Hence, we propose a detailed step-by-step multidisciplinary protocol.
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Affiliation(s)
- Camille Berel
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Ulysse Mossé
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Julien Wils
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Lauriane Cousin
- Child and Adolescent Psychiatric Department, CHRU Lille, Lille, France
| | - Laurent Imbert
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France
| | - Priscille Gerardin
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
| | - Boris Chaumette
- Institut de Psychiatrie et Neurosciences de Paris, INSERM UMR 1266, Université de Paris, GDR3557-Institut de Psychiatrie, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Paris, France.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Fabien Lamoureux
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Vladimir Ferrafiat
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
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Dragoi AM, Radulescu I, Năsui BA, Pop AL, Varlas VN, Trifu S. Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:E840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. OBJECTIVE to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. DATA SOURCES a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years. STUDY ELIGIBILITY CRITERIA clinical trials on adults with acute symptoms of schizophrenia or related disorders. RESULTS we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. LIMITATIONS we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Affiliation(s)
- Ana Miruna Dragoi
- Department of Psychiatry, “Alexandru Obregia” Clinical Hospital for Psychiatry, 10 Berceni St., 041914 Bucharest, Romania;
| | - Ioana Radulescu
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hațieganu” University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania; or
| | - Anca Lucia Pop
- Department of Clinical Laboratory, Food Safety, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia St., 020945 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Simona Trifu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania;
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26
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Binding of clozapine to the GABA B receptor: clinical and structural insights. Mol Psychiatry 2020; 25:1910-1919. [PMID: 32203158 DOI: 10.1038/s41380-020-0709-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 12/30/2022]
Abstract
Clozapine is the gold-standard agent for treatment resistant schizophrenia but its mechanism of action remains unclear. There is emerging evidence of the potential role of the GABAB receptor in the pathogenesis of schizophrenia. It has been hypothesised that clozapine can mediate its actions via the GABAB receptor. Baclofen is currently recognised as the prototype GABAB receptor agonist. There are some potential clinical similarities between clozapine and baclofen. Indeed, baclofen has been previously proposed for use as an antipsychotic agent. Our analysis of the X-ray crystal structure of GABAB receptor along with molecular docking calculations, suggests that clozapine could directly bind to the GABAB receptor similar to that of baclofen. This finding could lead to a better understanding of the pharmacological uniqueness of clozapine, potential development of a biomarker for treatment resistant schizophrenia and the development of more targeted treatments leading to personalisation of treatment.
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27
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Shah P, Plitman E, Iwata Y, Kim J, Nakajima S, Chan N, Brown EE, Caravaggio F, Torres E, Hahn M, Chakravarty MM, Remington G, Gerretsen P, Graff-Guerrero A. Glutamatergic neurometabolites and cortical thickness in treatment-resistant schizophrenia: Implications for glutamate-mediated excitotoxicity. J Psychiatr Res 2020; 124:151-158. [PMID: 32169688 DOI: 10.1016/j.jpsychires.2020.02.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/28/2020] [Accepted: 02/28/2020] [Indexed: 12/21/2022]
Abstract
Treatment-resistant schizophrenia may be related to structural brain alterations. However, the mechanisms underlying these changes remain unclear. The present study had two main aims: (1) to explore differences in cortical thickness between patients with treatment-resistant schizophrenia non-responsive to clozapine (ultra-treatment-resistant schizophrenia, UTRS), patients with treatment-resistant schizophrenia responsive to clozapine (Cloz-Resp), patients responsive to first-line non-clozapine antipsychotics (FL-Resp), and healthy controls (HCs); and (2) to test our hypothesis of structural compromise as a manifestation of neurotoxic effects from elevated glutamate (Glu) (i.e. glutamate-mediated excitotoxicity) by examining the relationships between glutamatergic neurometabolite levels (Glu and glutamate + glutamine (Glx)) in the dorsal anterior cingulate cortex (dACC) and cortical thickness. T1-weighted images and 1H-MRS data were obtained from UTRS (n = 24), Cloz-Resp (n = 25), FL-Resp (n = 19), and HCs (n = 26). Vertex-wise analyses showed that patients with UTRS had widespread cortical thinning in the bilateral frontal, temporal, parietal, and occipital gyri compared to HCs and FL-Resp patients. In the patient group, negative associations were found between dACC Glx levels and cortical thickness in the right dorsolateral prefrontal cortex after correcting for multiple comparisons and controlling for age, sex, antipsychotic dose, and illness severity. In conclusion, glutamate-mediated excitotoxicity may be one of the mechanisms underlying structural compromise seen in treatment-resistant schizophrenia. Future studies should longitudinally examine the associations between glutamatergic neurometabolite levels and cortical thickness in the context of treatment and illness progression.
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Affiliation(s)
- Parita Shah
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Eric Plitman
- Douglas Mental Health University Institute, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Yusuke Iwata
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julia Kim
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo, Japan
| | - Nathan Chan
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Eric E Brown
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Edgardo Torres
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada
| | - Margaret Hahn
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - M Mallar Chakravarty
- Douglas Mental Health University Institute, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Gary Remington
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada.
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28
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de Leon J, Ruan CJ, Schoretsanitis G, De las Cuevas C. A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. PSYCHOTHERAPY AND PSYCHOSOMATICS 2020; 89:200-214. [PMID: 32289791 PMCID: PMC7206357 DOI: 10.1159/000507638] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/30/2020] [Indexed: 12/11/2022]
Abstract
Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.
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Affiliation(s)
- Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, Kentucky, USA, .,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain, .,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain,
| | - Can-Jun Ruan
- The National Clinical Research Centre for Mental Disorders, Beijing Key Laboratory of Mental Disorders, and Laboratory of Clinical Psychopharmacology, Beijing Anding Hospital, Capital Medical University, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Georgios Schoretsanitis
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York, USA
| | - Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Spain
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29
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V. Giridharan V, Scaini G, Colpo GD, Doifode T, F. Pinjari O, Teixeira AL, Petronilho F, Macêdo D, Quevedo J, Barichello T. Clozapine Prevents Poly (I:C) Induced Inflammation by Modulating NLRP3 Pathway in Microglial Cells. Cells 2020; 9:E577. [PMID: 32121312 PMCID: PMC7140445 DOI: 10.3390/cells9030577] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 02/21/2020] [Accepted: 02/24/2020] [Indexed: 02/06/2023] Open
Abstract
Schizophrenia is a complex psychiatric disorder that exhibits an interconnection between the immune system and the brain. Experimental and clinical studies have suggested the presence of neuroinflammation in schizophrenia. In the present study, the effect of antipsychotic drugs, including clozapine, risperidone, and haloperidol (10, 20 and 20 μM, respectively), on the production of IL-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-17, IL-18, INF-γ, and TNF-α was investigated in the unstimulated and polyriboinosinic-polyribocytidilic acid [poly (I:C)]-stimulated primary microglial cell cultures. In the unstimulated cultures, clozapine, risperidone, and haloperidol did not influence the cytokine levels. Nevertheless, in cell cultures under strong inflammatory activation by poly (I:C), clozapine reduced the levels of IL-1α, IL-1β, IL-2, and IL-17. Risperidone and haloperidol both reduced the levels of IL-1α, IL-1β, IL-2, and IL-17, and increased the levels of IL-6, IL-10, INF-γ, and TNF-α. Based on the results that were obtained with the antipsychotic drugs and observing that clozapine presented with a more significant anti-inflammatory effect, clozapine was selected for the subsequent experiments. We compared the profile of cytokine suppression obtained with the use of NLRP3 inflammasome inhibitor, CRID3 to that obtained with clozapine, to test our hypothesis that clozapine inhibits the NLRP3 inflammasome. Clozapine and CRID3 both reduced the IL-1α, IL-1β, IL-2, and IL-17 levels. Clozapine reduced the level of poly (I:C)-activated NLRP3 expression by 57%, which was higher than the reduction thay was seen with CRID3 treatment (45%). These results suggest that clozapine might exhibit anti-inflammatory effects by inhibiting NLRP3 inflammasome and this activity is not typical with the use of other antipsychotic drugs under the conditions of strong microglial activation.
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Affiliation(s)
- Vijayasree V. Giridharan
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Giselli Scaini
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Gabriela D. Colpo
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Tejaswini Doifode
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Omar F. Pinjari
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Antônio L. Teixeira
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
| | - Fabricia Petronilho
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, SC 88700-000, Brazil;
| | - Danielle Macêdo
- Neuropsychopharmacology Laboratory, Drug Research, and Development Center, Faculty of Medicine, Universidade Federal do Ceará, Fortaleza, CE, Brazil; National Institute for Translational Medicine (INCT-TM, CNPq), Ribeirão Preto, SP 14000-000, Brazil;
| | - João Quevedo
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
- Translational Psychiatry Laboratory, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, SC 88800-000, Brazil
- Neuroscience Graduate Program, The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
- Center of Excellence on Mood Disorders, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA
| | - Tatiana Barichello
- Translational Psychiatry Program, Faillace Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77054, USA; (V.V.G.); (G.S.); (G.D.C.); (T.D.); (O.F.P.); (A.L.T.); (J.Q.)
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina, Criciúma, SC 88800-000, Brazil
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30
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Attard A, Iles A, Attard S, Atkinson N, Patel A. Clozapine: why wait to start a laxative? BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
SUMMARYClozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.LEARNING OBJECTIVES:After reading this article you will be able to:
•understand the mechanism of gastrointestinal hypomotility in those taking clozapine•improve the monitoring of clozapine-induced constipation•understand prophylactic laxative treatment and the use of less commonly prescribed laxatives in patients who experience clozapine-induced constipation.
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31
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Abstract
Clozapine-induced gastric hypomotility (CIGH) is an underreported, underrecognized effect from high-dose clozapine. In this report, we present a patient with treatment refractory schizophrenia receiving high-dose clozapine who aspirated during general anesthesia for electroconvulsive therapy. To our knowledge, this is the first report of aspiration under general anesthesia as a result of CIGH and highlights the potential dangers high-dose clozapine can pose on patients undergoing electroconvulsive therapy with unrecognized CIGH.
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32
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Vita A, Minelli A, Barlati S, Deste G, Giacopuzzi E, Valsecchi P, Turrina C, Gennarelli M. Treatment-Resistant Schizophrenia: Genetic and Neuroimaging Correlates. Front Pharmacol 2019; 10:402. [PMID: 31040787 PMCID: PMC6476957 DOI: 10.3389/fphar.2019.00402] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 04/01/2019] [Indexed: 12/11/2022] Open
Abstract
Schizophrenia is a severe neuropsychiatric disorder that affects approximately 0.5–1% of the population. Response to antipsychotic therapy is highly variable, and it is not currently possible to predict those patients who will or will not respond to antipsychotic medication. Furthermore, a high percentage of patients, approximately 30%, are classified as treatment-resistant (treatment-resistant schizophrenia; TRS). TRS is defined as a non-response to at least two trials of antipsychotic medication of adequate dose and duration. These patients are usually treated with clozapine, the only evidence-based pharmacotherapy for TRS. However, clozapine is associated with severe adverse events. For these reasons, there is an increasing interest to identify better targets for drug development of new compounds and to establish better biomarkers for existing medications. The ability of antipsychotics to improve psychotic symptoms is dependent on their antagonist and reverse agonist activities at different neuroreceptors, and some genetic association studies of TRS have focused on different pharmacodynamic factors. Some genetic studies have shown an association between antipsychotic response or TRS and neurodevelopment candidate genes, antipsychotic mechanisms of action (such as dopaminergic, serotonergic, GABAergic, and glutamatergic) or pharmacokinetic factors (i.e., differences in the cytochrome families). Moreover, there is a growing body of literature on the structural and functional neuroimaging research into TRS. Neuroimaging studies can help to uncover the underlying neurobiological reasons for such resistance and identify resistant patients earlier. Studies examining the neuropharmacological mechanisms of antipsychotics, including clozapine, can help to improve our knowledge of their action on the central nervous system, with further implications for the discovery of biomarkers and the development of new treatments. The identification of the underlying mechanisms of TRS is a major challenge for developing personalized medicine in the psychiatric field for schizophrenia treatment. The main goal of precision medicine is to use genetic and brain-imaging information to improve the safety, effectiveness, and health outcomes of patients via more efficiently targeted risk stratification, prevention, and tailored medication and treatment management approaches. The aim of this review is to summarize the state of art of pharmacogenetic, pharmacogenomic and neuroimaging studies in TRS.
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Affiliation(s)
- Antonio Vita
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alessandra Minelli
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Stefano Barlati
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Giacomo Deste
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy
| | - Edoardo Giacopuzzi
- Genetic Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - Paolo Valsecchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cesare Turrina
- Department of Mental Health and Addiction Services, ASST Spedali Civili, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Gennarelli
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Genetic Unit, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
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Kaur H, Sidana A, Singh T. Comparison of efficacy and tolerability of escitalopram and venlafaxine in treatment-naïve patients with unipolar nonpsychotic depression: Is there a need to revisit the prescription patterns? JOURNAL OF MENTAL HEALTH AND HUMAN BEHAVIOUR 2019. [DOI: 10.4103/jmhhb.jmhhb_21_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lally J, Watkins R, Nash S, Shetty H, Gardner-Sood P, Smith S, Murray RM, Gaughran F. The Representativeness of Participants With Severe Mental Illness in a Psychosocial Clinical Trial. Front Psychiatry 2018; 9:654. [PMID: 30564154 PMCID: PMC6288469 DOI: 10.3389/fpsyt.2018.00654] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/16/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction: Cardiovascular morbidity and mortality are increased in severe mental illnesses (SMI). Trials of psychosocial health interventions to improve physical health in SMI, including in treatment-resistant schizophrenia, have shown some benefit. However, the representativeness of participants in such trials has not been determined. Method: We utilized an anonymised case register to determine if participants in a randomized controlled trial (RCT) of a novel psychosocial health intervention aiming to improve physical health in SMI had similar severity of illness to eligible non-participants. A retrospective database analysis was performed, using Health of the Nation Outcome Scale (HoNOS) data from the sample of patients participating in the IMPaCT (Improving Physical health and reducing substance use in Psychosis) RCT (n = 293) compared to all eligible participants with a psychotic illness (n = 774). Results: The mean total HoNOS score in the eligible comparator population (Mean = 9.09, SD = 5.8, range = 0-30) was significantly greater than that of the IMPaCT RCT participants (Mean = 7.16, SD = 4.7, range = 0-26), (t = 3.810, p = 0.006), as was the degree of overall illness severity and functional impairment, as measured by HoNOS. Conclusion: This study shows for the first time that the patient population participating in an RCT of a lifestyle intervention for those with SMI had a better mental health status at entry to the trial, than the total eligible population, although there was no difference in physical health needs. This has relevance to the applicability of RCTs of lifestyle interventions in service planning and suggests that when people are more unwell, greater effort may be needed to include them in psychosocial interventions. A more careful and focused recruitment approach should be followed to improve the participation of the more severely ill patients in psychosocial interventions in order to enhance the external validity of such studies.
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Affiliation(s)
- John Lally
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Department of Psychiatry, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland.,Department of Psychiatry, School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland.,St Vincent's Hospital Fairview, Dublin, Ireland
| | - Rochelle Watkins
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Sarah Nash
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Hitesh Shetty
- Biomedical Research Centre (BRC) Case Register, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Poonam Gardner-Sood
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Shubulade Smith
- Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, United Kingdom.,Forensic Intensive Care Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Department of Psychiatry, Experimental Biomedicine and Clinical Neuroscience (BIONEC), University of Palermo, Palermo, Italy
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Department of Psychiatry, Experimental Biomedicine and Clinical Neuroscience (BIONEC), University of Palermo, Palermo, Italy
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Moeller S, Kalkwarf N, Lücke C, Ortiz D, Jahn S, Först C, Braun N, Philipsen A, Müller HH. Achieving stable remission with maintenance electroconvulsive therapy in a patient with treatment-resistant schizophrenia: A case report. Medicine (Baltimore) 2017; 96:e8813. [PMID: 29310360 PMCID: PMC5728761 DOI: 10.1097/md.0000000000008813] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Up to one third of all schizophrenic patients are classified as having treatment-resistant schizophrenia (TRS). This subgroup faces remarkable medical and psychosocial damages, and pharmacotherapy is often limited due to nonresponse and/or side effects. Maintenance electroconvulsive therapy (M-ECT) might be effective in TRS. PATIENT CONCERNS We present a case of a 26-year-old male patient with a TRS. DIAGNOSES He received a treatment series of ECT sessions and a course of 24 M-ECTs. INTERVENTIONS The entire treatment was tolerated without significant side effects. OUTCOMES Moreover, the Psychotic Symptom Rating Scale (PSYRATS) scores for both positive and negative symptoms decreased and remained stable over the course of M-ECT. LESSONS Because of the remarkable improvement in the negative and positive symptom clusters, we propose systematic examinations in the field of M-ECT in TRS patients. These studies should integrate long-term outcome and tolerance measurements, gaining insight into the optimal duration of treatment for this indication.
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Affiliation(s)
- Sebastian Moeller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Neele Kalkwarf
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Caroline Lücke
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Diana Ortiz
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Sonja Jahn
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Christiane Först
- Geriatric Psychiatry
- ECT Unit, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Niclas Braun
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Alexandra Philipsen
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Helge H.O. Müller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
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Every-Palmer S, Ellis PM. Clozapine-Induced Gastrointestinal Hypomotility: A 22-Year Bi-National Pharmacovigilance Study of Serious or Fatal 'Slow Gut' Reactions, and Comparison with International Drug Safety Advice. CNS Drugs 2017; 31. [PMID: 28623627 PMCID: PMC5533872 DOI: 10.1007/s40263-017-0448-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Clozapine is the preferred antipsychotic for treatment-resistant schizophrenia, but has significant adverse effects, including gastrointestinal hypomotility or 'slow gut', which may result in severe constipation, ileus, bowel obstruction, and even death. These gastrointestinal effects remain inadequately recognized. METHODS We reviewed all reports of serious clozapine-induced gastrointestinal hypomotility (CIGH) submitted to the Australian Therapeutic Goods Administration and New Zealand Pharmacovigilance Centre between 1992 and 2013. We extracted relevant demographic, clinical, and outcome data and derived a numerator from clozapine registries. We examined whether clozapine drug safety information in Australia, New Zealand, the US, and the UK was adequate and consistent with pharmacoepidemiologic evidence. RESULTS A total of 43,132 people commenced clozapine over the study period. 160 were reported as having serious gastrointestinal hypomotility with clozapine the suspected cause (37/10,000 clozapine users). Of these, 66.3% were male, age range was 17-76 years, clozapine dose range 25-1000 mg/day (mean 439 mg/day) and median duration of clozapine treatment 2.5 years. Few had received laxatives. At least 29 patients died (7/10,000 clozapine users), a reported case fatality rate of 18%. The CIGH prevalence, while similar to other smaller studies, differs significantly from clozapine prescribing information issued by regulators and pharmaceutical companies, none of which mention CIGH, and which report serious gastrointestinal complications at rates of <1/10,000, almost a 40-fold difference. CONCLUSION This is the largest study to date of serious CIGH. The reported prevalence of serious CIGH was 37/10,000, a likely underestimation of true prevalence. Current prescribing guidelines provide inadequate information on CIGH. This may be contributing to poor awareness and high associated morbidity and mortality. It is time regulators and manufacturers update their guidance.
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Affiliation(s)
- Susanna Every-Palmer
- Te Korowai Whāriki Central Regional Forensic Service, Capital and Coast District Health Board, PO Box 50-233, Ratonga Rua-O-Porirua, Raiha Street, Porirua, Wellington, New Zealand. .,Department of Psychological Medicine, University of Otago, Wellington, PO Box 7343, Wellington, 6242, New Zealand.
| | - Pete M Ellis
- Department of Psychological Medicine, University of Otago, Wellington, PO Box 7343, Wellington, 6242 New Zealand
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Impact of Pharmacist Counselling on Clozapine Knowledge. SCHIZOPHRENIA RESEARCH AND TREATMENT 2017; 2017:6120970. [PMID: 28695011 PMCID: PMC5485348 DOI: 10.1155/2017/6120970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/04/2017] [Accepted: 05/16/2017] [Indexed: 11/18/2022]
Abstract
Clozapine is the only antipsychotic with evidence for efficacy in treatment of resistant schizophrenia but it carries a high side effect burden. Patient information is provided but may be poorly retained. This study aims to examine the impact of pharmacist counselling upon patient knowledge of clozapine. Outpatients, aged 18 years and over, attending St. Patrick's University Hospital, Dublin, participated in this study between June and August 2015. The intervention consisted of pharmacist counselling on two occasions one month apart. Knowledge was assessed using a 28-point checklist devised from the currently available clozapine patient information sources, at baseline and after each counselling session. Ethics approval was obtained. Twenty-five participants (40% female; mean age 45.1 years, SD 9.82; 64% unemployed, 28% smokers) showed an improvement in knowledge scores of clozapine from baseline to postcounselling on each occasion with an overall improvement in knowledge score, from baseline to postcounselling at one month, of 39.43%; p < 0.001. This study adds to the evidence that interventions involving pharmacist counselling can improve patient knowledge, whilst the specific knowledge gained relating to recognition of side effects may help patients towards more empowerment regarding their treatment.
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