Prevalence of antipsychotic prescriptions among patients with anxiety disorders treated in inpatient and outpatient psychiatric settings

Antipsychotic agents in anxiety disorders: An umbrella review

BACKGROUND

Although not approved for the treatment of anxiety disorders (except trifluoperazine) there is ongoing off-label, unapproved use of first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) for anxiety disorders. There have been systematic reviews and meta-analyses on the use of antipsychotics in anxiety disorders, most of which focused on SGAs.

OBJECTIVE

The specific aims of this umbrella review are to: (1) Evaluate the evidence of efficacy of FGAs and SGAs in anxiety disorders as an adjunctive treatment to traditional antidepressant treatments and other nonantipsychotic medications; (2) Compare monotherapy with antipsychotics to first-line treatments for anxiety disorders in terms of effectiveness, risks, and side effects. The review protocol is registered on PROSPERO (CRD42021237436).

METHODS

An initial search was undertaken to identify systematic reviews and meta-analyses from inception until 2020, with an updated search completed August 2021 and January 2023. The searches were conducted in PubMed, MEDLINE (Ovid), EMBASE (Ovid), APA PsycInfo (Ovid), CINAHL Complete (EBSCOhost), and the Cochrane Library through hand searches of references of included articles. Review quality was measured using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews) scale.

RESULTS

The original and updated searches yielded 1796 and 3744 articles respectively, of which 45 were eligible. After final review, 25 systematic reviews and meta-analyses were included in the analysis. Most of the systematic reviews and meta-analyses were deemed low-quality through AMSTAR-2 with only one review being deemed high-quality. In evaluating the monotherapies with antipsychotics compared with first-line treatments for anxiety disorder there was insufficient evidence due to flawed study designs (such as problems with randomization) and small sample sizes within studies. There was limited evidence suggesting efficacy of antipsychotic agents in anxiety disorders other than quetiapine in generalized anxiety disorder (GAD).

CONCLUSIONS

This umbrella review indicates a lack of high-quality studies of antipsychotics in anxiety disorders outside of the use of quetiapine in GAD. Although potentially effective for anxiety disorders, FGAs and SGAs may have risks and side effects that outweigh their efficacy, although there were limited data. Further long-term and larger-scale studies of antipsychotics in anxiety disorders are needed.

Toward Precision Characterization and Treatment of Psychopathology: A Path Forward and Integrative Framework of the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria

A critical mission of psychological science is to conduct research that ultimately improves the lives of individuals who experience psychopathology. One important aspect of accomplishing this mission is increasing the likelihood that treatments will work for each person. I contend that treatment prognosis can be improved by moving toward a precision-medicine model. I advance a principle-driven framework for working toward these objectives. First, I synthesize the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria and demonstrate how integrating these models facilitates precision characterization of psychopathology. Second, I outline and demonstrate a systematic process for approaching treatment selection by leveraging precisely characterized representations of psychopathology. Finally, I advocate the research and clinical applications of this framework. Although clinical and psychological scientists are conducting exciting, multidisciplinary, and methodologically rigorous research in their respective domains, the impact of these pursuits will be maximized in the context of a unifying theoretical framework that supports a clear guiding mission.

An umbrella review on the use of antipsychotics in anxiety disorders: A registered report protocol

Anxiety disorders, including panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), agoraphobia, and specific phobia, are among the most common psychiatric disorders. Although the traditional pharmacologic treatments for anxiety included barbiturates and then benzodiazepines, the introduction of tricyclic antidepressants, followed by the selective serotonin reuptake inhibitors (SSRIs), marked a tidal shift in the treatment of anxiety. Although not approved for treatment of anxiety disorders (with the exception of trifluoperazine) there is ongoing off-label, unapproved use of both first-generation "typical" antipsychotics (FGAs) and second-generation or "atypical" antipsychotics (SGAs) for anxiety. Although there have been systematic reviews and meta-analyses on the use of antipsychotics in anxiety disorders, most of these reviews focused on SGAs, primarily the use of quetiapine in GAD. Given that there is little known about the potential benefits and short-and long-term risks of using antipsychotics in anxiety, there is a need for an umbrella review of systematic reviews and meta-analyses of the use of both FGAs and SGAs in anxiety disorders. The specific aims of this study are as follows: (1) Evaluate the evidence of efficacy of FGAs and SGAs in anxiety disorders as an adjunctive treatment to SSRIs, serotonin norepinephrine reuptake inhibitors (SNRIs) and other non-antipsychotic medications; (2) Compare monotherapy with antipsychotics to first-line treatments for anxiety disorders in terms of effectiveness, risks, and side effects; and (3) Evaluate the short- and long-term risks and side effects of prescribing antipsychotics in anxiety disorders. The review is registered on PROSPERO (CRD42021237436). Since data extraction has not begun, there is not preliminary data to share.

Pharmacotherapy of 1,044 inpatients with posttraumatic stress disorder: current status and trends in German-speaking countries

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder with limited approved pharmacological treatment options and high symptom burden. Therefore, real-life prescription patterns may differ from guideline recommendations, especially in psychiatric inpatient settings. The European Drug Safety Program in Psychiatry ("Arzneimittelsicherheit in der Psychiatrie", AMSP) collects inpatients' prescription rates cross-sectionally twice a year in German-speaking psychiatric hospitals. For this study, the AMSP database was screened for psychiatric inpatients with a primary diagnosis of PTSD between 2001 and 2017. N = 1,044 patients with a primary diagnosis of PTSD were identified with 89.9% taking psychotropics. The average prescription rate was 2.4 (standard deviation: 1.5) psychotropics per patient with high rates of antidepressant drugs (72.0%), antipsychotics drugs (58.4%) and tranquilizing drugs (29.3%). The presence of psychiatric comorbidities was associated with higher rates of psychotropic drug use. The most often prescribed substances were quetiapine (24.1% of all patients), lorazepam (18.1%) and mirtazapine (15.0%). The use of drugs approved for PTSD was low (sertraline 11.1%; paroxetine 3.7%). Prescription rates of second-generation antipsychotic drugs increased, while the use of tranquilizing drugs declined over the years. High prescription rates and extensive use of sedative medication suggest a symptom-driven prescription (e.g., hyperarousal, insomnia) that can only be explained to a minor extent by existing comorbidities. The observed discrepancy with existing guidelines underlines the need for effective pharmacological and psychological treatment options in psychiatric inpatient settings.

Quetiapine in the Anxiety Dimension of Mood Disorders: A Systematic Review of the Literature to Support Clinical Practice

PURPOSE/BACKGROUND

Bipolar disorder and major depressive disorder are heterogeneous conditions characterized by marked variations in mood. High levels of anxiety are often present in these conditions and are associated with increased suicidal risk, increased disease duration, and treatment resistance. Mood stabilizers or antipsychotics are recommended for the treatment of bipolar disorder in comorbidity with anxiety disorders. This study examines current knowledge to evaluate the efficacy of quetiapine in the treatment of anxiety in mood disorders.

METHODS/PROCEDURES

A systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines, selecting randomized control trials that evaluated the efficacy of quetiapine on anxiety symptoms in patients diagnosed with bipolar disorder or major depressive disorder and included anxiety evaluation scales.

FINDINGS/RESULTS

We collected 27 studies (19 with primary data analysis, 8 with secondary data analysis) regarding the use of quetiapine in mood disorders. Quetiapine was more effective than placebo and active comparators in reducing anxiety in unipolar and bipolar patients in 20 of these studies. In 7 studies, quetiapine was not superior to psychoactive comparators or placebo on the anxiety dimension.

IMPLICATIONS/CONCLUSIONS

Statistical power might be limited by small sample size in 5 of the studies included in our review. Moreover, data on anxiety were a secondary outcome in most studies. Nevertheless, the reported studies show with good levels of concordance that quetiapine is effective in controlling anxiety symptoms in patients with mood disorders. This evidence supports current guidelines and recommendations concerning the use of quetiapine in clinical practice.

Reduced phosphodiesterase-2 activity in the amygdala results in anxiolytic-like effects on behavior in mice

BACKGROUND

Phosphodiesterase-2 (PDE2) is a cyclic nucleotide phosphodiesterase and is highly expressed in the amygdala, which suggests its important role in anxiety-like behavior.

AIMS

The present study examined whether reduced PDE2A expression in the central nucleus of the amygdala (CeA) produces anxiolytic-like effects in mice.

METHODS

PDE2A knockdown in amygdaloid (AR5) cells or the CeA was established using a lentiviral vector-based siRNA system. The anxiety-like behaviors were detected by the elevated plus maze (EPM) and hole-board tests in mice. The related proteins involved in cAMP/cGMP-dependent signaling, such as specific marker VASP^ser239, CREB^ser133 and BDNF were detected by immunoblot analysis.

RESULTS

PDE2A inhibition in AR-5 cells resulted in increases in cAMP/cGMP-related pVASP^ser239 and pCREB^ser133. Behavioral tests showed that PDE2A knockdown in the CeA induced anxiolytic-like effects as evidenced by the increases in percentages of open-arm entries and time spent in the open arms in the EPM test, and the increases in head dips and time spent in head dipping in the hole-board test. However, these anxiolytic-like effects were antagonized by pre-treatment of soluble guanylyl cyclase inhibitor ODQ or adenylate cyclase inhibitor SQ. Furthermore, PDE2A knockdown significantly increased pVASP^Ser239, pCREB^Ser133 and decreased BDNF expression in the amygdala. Pre-intra-CeA of ODQ or SQ reversed or partially prevented the effects of PDE2A knockdown on these proteins.

CONCLUSIONS

The results suggest that PDE2A plays a crucial role in the regulation of anxiety by the cGMP/cAMP-dependent pVASP-pCREB-BDNF signaling pathway.

Improved Metabolic and Psychiatric Outcomes with Discontinuation of Atypical Antipsychotics in Youth Hospitalized in a State Psychiatric Facility

OBJECTIVES

To assess the impact of antipsychotic tapering and discontinuation on measures of metabolic functioning and psychiatric symptom severity in severely impaired youth hospitalized in a psychiatric state hospital.

METHODS

The study examined psychiatric and metabolic measures in 67 hospitalized children and adolescents (mean age 11.9; 56 with discontinued use of antipsychotics, 10 with continued use of antipsychotics, and 1 started on an antipsychotic) from admission to discharge.

RESULTS

Upon admission, 56 youth were tapered off of antipsychotic medications, started on other forms of pharmacotherapy (92.9% were started on medications used to treat attention-deficit/hyperactivity disorder), and received evidence-based behavioral programming and were ultimately discharged from the hospital. The mean duration of treatment was 228 days for the discontinuation group and 204 days for the continuation group. Significant decreases in body mass index [BMI; t(53) = 7.12, p = 0.0001] and BMI percentile [t(53) = 6.73, p = 0.0001] were found from admission to discharge in the antipsychotic discontinuation group. Changes in BMI, BMI percentile, or systolic blood pressure were not found in the group (n = 10) who were maintained on antipsychotics. Both groups experienced a significant increase in their Global Assessment of Functioning score [t(52) = 19.98, p = 0.0001 for discontinued; t(8) = 5.092, p = 0.001 for maintained]. Psychiatric symptom severity scores significantly improved in many subscales relevant to disruptive behaviors and mood disorders for those who were removed from the medications. For those maintained on the antipsychotics, there were fewer changes in psychiatric symptom scores.

CONCLUSION

Discontinuation of atypical antipsychotic medications in conjunction with tailoring treatment to presenting diagnoses resulted in metabolic and psychiatric symptom improvement among severely impaired state hospital inpatient youth. These results serve as a feasibility demonstration that discontinuation of antipsychotics does not provoke psychiatric destabilization, particularly among disruptive behavior disordered youth.

The Place of Antipsychotics in the Therapy of Anxiety Disorders and Obsessive-Compulsive Disorders

PURPOSE OF REVIEW

The purpose of this review was to assess and present the findings up to this date on the efficacy of antipsychotics in the treatment of generalized anxiety disorders (GAD), social anxiety disorders (SAD), panic disorders (PD), and obsessive-compulsive disorders (OCD), mostly based on published randomized controlled trials (RCTs) or on open-label studies when RCT were lacking.

RECENT FINDINGS

Quetiapine could be recommended in patients with GAD. The efficacy of aripiprazole in two open-label studies on patients with antidepressant-refractory GAD should be assessed in RCTs. Despite preliminary positive results in open studies, there are currently no strong evidence for the effectiveness of antipsychotics in refractory SAD and in refractory PD. Conversely, risperidone and aripiprazole can be used for the treatment of refractory OCD as augmentation agents to antidepressants. Contrary to SAD and PD, this review found evidence for the use of second-generation antipsychotics in GAD and OCD. Otherwise, first-generation antipsychotics cannot be recommended in anxiety disorders and OCD.

What do clinicians treat: Diagnoses or symptoms? The incremental validity of a symptom-based, dimensional characterization of emotional disorders in predicting medication prescription patterns

BACKGROUND

Although practice guidelines are based on disorders specified in diagnostic manuals, such as the DSM, practitioners appear to follow symptoms when making treatment decisions. Psychiatric medication is generally prescribed in a transdiagnostic manner, further highlighting how symptoms, not diagnoses, often guide clinical practice. A quantitative approach to nosology promises to provide better guidance as it describes psychopathology dimensionally and its organization reflects patterns of covariation among symptoms.

AIM

To investigate whether a quantitative classification of emotional disorders can account for naturalistic medication prescription patterns better than traditional diagnoses.

METHODS

Symptom dimensions and DSM diagnoses of emotional disorders, as well as prescribed medications, were assessed using interviews in a psychiatric outpatient sample (N=318, mean age 42.5years old, 59% female, 81% Caucasian).

RESULTS

Each diagnosis was associated with prescription of multiple medication classes, and most medications were associated with multiple disorders. This was largely due to heterogeneity of clinical diagnoses, with narrow, homogenous dimensions underpinning diagnoses showing different medication profiles. Symptom dimensions predicted medication prescription better than DSM diagnoses, irrespective of whether this was examined broadly across all conditions, or focused on a specific disorder and medication indicated for it.

CONCLUSIONS

Psychiatric medication was prescribed in line with symptoms rather than DSM diagnoses. A quantitative approach to nosology may better reflect treatment planning and be a more effective guide to pharmacotherapy than traditional diagnoses. This adds to a diverse body of evidence about superiority of the quantitative system in practical applications and highlights its potential to improve psychiatric care.

The association of antipsychotic medication and lithium with brain measures in patients with bipolar disorder

There is evidence that brain structure is abnormal in patients with bipolar disorder. Lithium intake appears to ׳normalise׳ global and local brain volumes, but effects of antipsychotic medication on brain volume or cortical thickness are less clear. Here, we aim to disentangle disease-specific brain deviations from those induced by antipsychotic medication and lithium intake using a large homogeneous sample of patients with bipolar disorder type I. Magnetic resonance imaging brain scans were obtained from 266 patients and 171 control subjects. Subcortical volumes and global and focal cortical measures (volume, thickness, and surface area) were compared between patients and controls. In patients, the association between lithium and antipsychotic medication intake and global, subcortical and cortical measures was investigated. Patients showed significantly larger lateral and third ventricles, smaller total brain, caudate nucleus, and pallidum volumes and thinner cortex in some small clusters in frontal, parietal and cingulate regions as compared with controls. Lithium-free patients had significantly smaller total brain, thalamus, putamen, pallidum, hippocampus and accumbens volumes compared to patients on lithium. In patients, use of antipsychotic medication was related to larger third ventricle and smaller hippocampus and supramarginal cortex volume. Patients with bipolar disorder show abnormalities in total brain, subcortical, and ventricle volume, particularly in the nucleus caudate and pallidum. Abnormalities in cortical thickness were scattered and clusters were relatively small. Lithium-free patients showed more pronounced abnormalities as compared with those on lithium. The associations between antipsychotic medication and brain volume are subtle and less pronounced than those of lithium.