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Akturk G, Micili SC, Gursoy Doruk O, Hocaoglu N, Akan P, Ergur BU, Ahmed S, Kalkan S. Effects of nicorandil on QT prolongation and myocardial damage caused by citalopram in rats. Biotech Histochem 2023; 98:479-491. [PMID: 37466068 DOI: 10.1080/10520295.2023.2233417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Citalopram is a selective serotonin re-uptake inhibitor (SSRI) antidepressant; it exhibits the greatest cardiotoxic effect among SSRIs. Citalopram can cause drug-induced long QT syndrome (LQTS) and ventricular arrhythmias. We investigated the protective effect of nicorandil, a selective mitochondrial KATP (mito-KATP) channel opener, on LQTS and myocardial damage caused by citalopram in male rats. In a preliminary study, we determined that the minimum citalopram dose that prolonged the QT interval was 102 mg/kg injected intraperitoneally. For the main study, rats were divided randomly into five experimental groups: untreated control, normal saline + citalopram, nicorandil + citalopram, 5-hydroxydecanoate (5-HD) + citalopram, 5-HD + nicorandil + citalopram. Biochemical and histologic data from blood and heart tissue samples from six untreated control rats were evaluated. Electrocardiographic parameters including QRS duration, QT interval, corrected QT interval (QTc) and heart rate (HR) were assessed, and biochemical parameters including malondialdehyde, reduced glutathione, glutathione peroxidase, superoxide dismutase were measured. We also performed histomorphologic and immunohistochemical examination of heart tissue. Citalopram prolonged QT-QTc intervals significantly and increased significantly the histomorphologic score and proportion of apoptotic cells, but produced no differences in the oxidant and antioxidant parameters. Nicorandil did not prevent citalopram induced QT-QTc interval prolongation and produced no significant changes in oxidant and antioxidant parameters; however, it did reduce histologic damage and apoptosis caused by citalopram.
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Affiliation(s)
- Gozde Akturk
- Department of Medical Pharmacology, Dokuz Eylul University School of Medicine, Izmir, Turkey
- Department of Medical Pharmacology, Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - Serap Cilaker Micili
- Department of Histology and Embryology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ozlem Gursoy Doruk
- Department of Medical Biochemistry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Nil Hocaoglu
- Department of Medical Pharmacology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Pinar Akan
- Department of Medical Biochemistry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Bekir Ugur Ergur
- Department of Histology and Embryology, Dokuz Eylul University School of Medicine, Izmir, Turkey
- Department of Histology and Embryology, Kyrenia University School of Medicine, Kyrenia, Cyprus
| | - Samar Ahmed
- Department of Biochemistry, Dokuz Eylul University Graduate School of Health Sciences, Izmir, Turkey
| | - Sule Kalkan
- Department of Medical Pharmacology, Dokuz Eylul University School of Medicine, Izmir, Turkey
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de Bardeci M, Greil W, Stassen H, Willms J, Köberle U, Bridler R, Hasler G, Kasper S, Rüther E, Bleich S, Toto S, Grohmann R, Seifert J. Dear Doctor Letters regarding citalopram and escitalopram: guidelines vs real-world data. Eur Arch Psychiatry Clin Neurosci 2023; 273:65-74. [PMID: 35217913 PMCID: PMC9957836 DOI: 10.1007/s00406-022-01392-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/04/2022] [Indexed: 12/14/2022]
Abstract
Dear Doctor Letters (DDLs, Direct Healthcare Professional Communications) from 2011 provided guidance regarding QTc-prolonging effects with risk of torsade de pointes during treatment with citalopram and escitalopram. This study examines the DDLs' effects on prescription behavior. Data from 8842 inpatients treated with citalopram or escitalopram with a primary diagnosis of major depressive disorder (MDD) were derived from a European pharmacovigilance study (Arzneimittelsicherheit in der Psychiatrie, AMSP) from 2001 to 2017. It was examined to what extent new maximum doses were adhered to and newly contraindicated combinations with QTc-prolonging drugs were avoided. In addition, the prescriptions of psychotropic drugs before and after DDLs were compared in all 43,480 inpatients with MDD in the data set. The proportion of patients dosed above the new limit decreased from 8 to 1% in patients ≤ 65 years and from 46 to 23% in patients > 65 years old for citalopram versus 14-5% and 47-31% for escitalopram. Combinations of es-/citalopram with other QTc-prolonging psychotropic drugs reduced only insignificantly (from 35.9 to 30.9%). However, the proportion of patients with doses of quetiapine > 150 mg/day substantially decreased within the combinations of quetiapine and es-/citalopram (from 53 to 35%). After the DDLs, prescription of citalopram decreased and of sertraline increased. The DDLs' recommendations were not entirely adhered to, particularly in the elderly and concerning combination treatments. This might partly be due to therapeutic requirements of the included population. Official warnings should consider clinical needs.
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Affiliation(s)
- Mateo de Bardeci
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstr. 7, 80331 Munich, Germany ,grid.492890.e0000 0004 0627 5312Psychiatric Private Hospital, Sanatorium Kilchberg, Kilchberg-Zurich, Switzerland
| | - Waldemar Greil
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstr. 7, 80331, Munich, Germany. .,Psychiatric Private Hospital, Sanatorium Kilchberg, Kilchberg-Zurich, Switzerland.
| | - Hans Stassen
- grid.492890.e0000 0004 0627 5312Psychiatric Private Hospital, Sanatorium Kilchberg, Kilchberg-Zurich, Switzerland ,grid.412004.30000 0004 0478 9977Institute for Response-Genetics, Psychiatric University Hospital (KPPP), Zurich, Switzerland
| | - Jamila Willms
- grid.492890.e0000 0004 0627 5312Psychiatric Private Hospital, Sanatorium Kilchberg, Kilchberg-Zurich, Switzerland
| | - Ursula Köberle
- Arzneimittelkommission der Deutschen Ärzteschaft, Berlin, Germany
| | - René Bridler
- grid.492890.e0000 0004 0627 5312Psychiatric Private Hospital, Sanatorium Kilchberg, Kilchberg-Zurich, Switzerland
| | - Gregor Hasler
- grid.8534.a0000 0004 0478 1713Psychiatry Research Unit, University of Fribourg, Fribourg, Switzerland
| | - Siegfried Kasper
- grid.22937.3d0000 0000 9259 8492Department of Molecular Neuroscience, Medical University of Vienna, Vienna, Austria
| | - Eckart Rüther
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstr. 7, 80331 Munich, Germany
| | - Stefan Bleich
- grid.10423.340000 0000 9529 9877Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Sermin Toto
- grid.10423.340000 0000 9529 9877Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Renate Grohmann
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstr. 7, 80331 Munich, Germany
| | - Johanna Seifert
- grid.10423.340000 0000 9529 9877Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Shastry S, Aluise ER, Richardson LD, Vedanthan R, Manini AF. Delayed QT Prolongation: Derivation of a Novel Risk Factor for Adverse Cardiovascular Events from Acute Drug Overdose. J Med Toxicol 2021; 17:363-371. [PMID: 34449039 PMCID: PMC8455785 DOI: 10.1007/s13181-021-00855-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 07/19/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In ED patients with acute drug overdose involving prescription medication and/or substances of abuse, severe QTc prolongation (> 500 ms) is predictive of adverse cardiovascular events (ACVE), defined as myocardial injury, ventricular dysrhythmia, shock, or cardiac arrest. However, it is unclear whether delayed severe QTc prolongation (dsQTp) is a risk factor for ACVE and if specific clinical factors are associated with occurrence of dsQTp. METHODS A secondary analysis of a prospective cohort of consecutive adult ED patients with acute drug overdose was performed on patients with initial QTc < 500 ms. The predictor variable, dsQTp, was defined as initial QTc < 500 ms followed by repeat QTc ≥ 500 ms. The primary outcome was occurrence of ACVE. Multivariable logistic regression was performed to test whether dsQTp was an independent predictor of ACVE and to derive clinical factors associated with dsQTp. RESULTS Of 2311 patients screened, 1648 patients were included. The dsQTp group (N = 27) was older than the control group (N = 1621) (51.6 vs 40.2, p < 0.001) and had a higher number of drug exposures (2.92 vs 2.16, p = 0.003). Following adjustment for age, sex, race/ethnicity, number of exposures, serum potassium, and opioid exposure, dsQTp remained an independent predictor of ACVE (aOR: 12.44, p < 0.0001). Clinical factors associated with dsQTp were age > 45 years and polydrug (≥ 3) overdoses. CONCLUSION In this large secondary analysis of ED patients with acute drug overdose, dsQTp was an independent risk factor for in-hospital occurrence of ACVE.
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Affiliation(s)
- Siri Shastry
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA
| | - Eleanor R. Aluise
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA
| | - Lynne D. Richardson
- grid.416167.3Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Mount Sinai Hospital, 555 West 57th Street, 5th Floor, New York, NY 10019 USA ,grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine At Mount Sinai, New York, NY USA
| | - Rajesh Vedanthan
- grid.240324.30000 0001 2109 4251Department of Population Health, New York University Grossman School of Medicine, New York, NY USA
| | - Alex F. Manini
- grid.414488.50000 0004 0453 0340Division of Medical Toxicology, Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, Elmhurst Hospital Center, New York, NY USA
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Jiang E, Raubenheimer JE, Isbister GK, Chan BSH, Buckley NA. Machine read frontal QRS-T angle and QTc is no substitute for manual measurement of QTc in pro-arrhythmic drug overdose. J Electrocardiol 2021; 65:151-156. [PMID: 33640634 DOI: 10.1016/j.jelectrocard.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To investigate whether there is an association between the blocking of cardiac potassium channels, which is characterised by a prolonged QTc interval and the frontal QRS-T angle after overdose by QT prolonging drugs. METHODS We obtained patient medical records associated with QT prolonging drugs from 3 different hospitals: the Calvary Mater Newcastle Hospital (CMNH), Royal Prince Alfred Hospital (RPAH) and Prince of Wales Hospital (POWH). RPAH and POWH admissions were taken between 4/01/2017 to 1/11/2019, and CMNH admissions were taken between 4/01/2013 to 24/06/2018. Demographic information and details of overdose were collected. All admission ECGs were manually measured. Linear regression was used to assess the relationship between various QTc formulas and the frontal QRS-T angle. A Bland-Altman plot was used to examine agreement between manual and machine QT intervals. RESULTS 144 patients met the inclusion criteria for analysis. None of the patients developed torsades de pointes (TdP). There was no linear association between the QRS-T angle and the various QTc formulas (For QRS-T angle: QTcRTH: p = 0.76, QTcB: p = 0.83, QTcFri: p = 0.90, QTcFra: p = 0.13, QTcH: p = 0.97; For square root transformation of the QRS-T angle: QTcRTH: p = 0.18, QTcB: p = 0.33, QTcFri: p = 0.95, QTcFra: p = 0.47, QTcH: p = 0.33). Agreement between machine and manual QT measurements was low. CONCLUSIONS The frontal QRS-T angle cannot substitute the QTc in assessing the blockage of cardiac potassium channels in drug induced long QT syndrome. We also support the consensus that despite the availability of machine measurements of the QT interval, manual measurements should also be performed.
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Affiliation(s)
- Eric Jiang
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jacques E Raubenheimer
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Betty S H Chan
- Clinical Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Nicholas A Buckley
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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Kumar S, Gayle JA, Mogalapalli A, Hussain ST, Castiglioni A. Escitalopram Induced Torsade de Pointes and Cardiac Arrest in a Patient With Surgically Treated Mitral Valve Prolapse. Cureus 2020; 12:e11960. [PMID: 33425536 PMCID: PMC7788002 DOI: 10.7759/cureus.11960] [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] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
A 54-year-old female, with a history of prosthetic mitral valve replacement due to mitral valve prolapse one year prior, was admitted after suffering a cardiopulmonary arrest. Her initial rhythm demonstrated Torsade de Pointes with the initial electrocardiogram (ECG) showing a prolonged QT interval. Laboratory test results were normal including potassium and magnesium serum levels, and imaging did not show significant abnormalities. A review of patients' medicines showed that the patient started taking escitalopram one month prior to the presentation for major depressive disorder. Selective serotonin reuptake inhibitors (SSRI) are widely prescribed and continue to be a mainstay of treatment for multiple psychiatric conditions. It is important to keep the potential cardiovascular side effects of SSRIs in mind when prescribing. Consideration of underlying cardiac conditions is vital to decrease the likelihood of poor outcomes.
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Affiliation(s)
- Sundeep Kumar
- Cardiovascular Disease, Saint Louis University Hospital, St. Louis, USA.,Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Jovan A Gayle
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Akhil Mogalapalli
- Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Sayed T Hussain
- Cardiology, University of Central Florida College of Medicine, Orlando, USA
| | - Analia Castiglioni
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of psychiatric medications that impact blood pressure in adult patients either as a direct side effect or indirectly, via negative metabolic impact or interactions with other medications. In addition, pertinent interactions between psychiatric medications and antihypertensive agents will be discussed. RECENT FINDINGS Although the novel intranasal antidepressant, esketamine, has been shown to increase blood pressure shortly after dosing, treatment with antihypertensive medications is not typically required. In addition, no increase in serious adverse cardiac events was reported with this medication. The negative metabolic impact of antipsychotic medications has been shown to occur within the first month of treatment and necessitates early monitoring. When compared with the general population with cardiovascular disease, mortality risk in patients with severe and persistent psychiatric illness is higher, and death occurs 10 years earlier. There are several psychiatric treatments that increase blood pressure directly as well as indirectly, via negative metabolic impact and drug/diet interactions. Fortunately, there are no absolute contraindications for use of any psychiatric medication in patients with pre-existing hypertension. Given data which suggests that patients diagnosed with more severe psychiatric disorders are known to receive inadequate medical care for hypertensive illness and experience increased mortality risk from cardiovascular disease, it is important for all physicians to be aware of the increased risk in this population and for both thorough assessment and treatment to occur.
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Danielsson B, Collin J, Nyman A, Bergendal A, Borg N, State M, Bergfeldt L, Fastbom J. Drug use and torsades de pointes cardiac arrhythmias in Sweden: a nationwide register-based cohort study. BMJ Open 2020; 10:e034560. [PMID: 32169926 PMCID: PMC7069257 DOI: 10.1136/bmjopen-2019-034560] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To study the occurrence of torsades de pointes (TdP) ventricular tachycardia in relation to use of drugs labelled with TdP risk, using two nationwide Swedish registers. DESIGN Prospective register-based cohort study. SETTING Entire Sweden. PARTICIPANTS Persons aged ≥18 years prescribed and dispensed any drug classified with TdP risk during 2006-2017, according to CredibleMeds. Persons with a registered TdP diagnosis during the study period, using drugs labelled with known (TdP 1), possible (TdP 2) or conditional (TdP 3) risk at the incident of TdP were examined. PRIMARY OUTCOME MEASURES Occurrence of TdP in relation to exposure rates for individual drugs with TdP risk. SECONDARY OUTCOME MEASURES Concurrent use of more than one TdP-labelled drug in a person with a TdP diagnosis. RESULTS During the study period, 410 TdP cases using drugs with TdP risk labels at the incident were registered; 205 women and 205 men, mean age 74.0 and 71.5 years, respectively. Antidepressants dominated (129/410, 30%), followed by antiarrhythmics (17%). Diuretics and gastric acid-secretion inhibitors, with TdP risk related to induction of hypokalaemia or hypomagnesaemia, were used in 56% and 32% of the 410 TdP cases, respectively. Among the most used antidepressants, citalopram with known TdP 1 risk was associated with both a higher absolute number and incidence of TdP per 100 000 users (two to four times), compared with mirtazapine with possible (TdP 2), and sertraline with conditional (TdP 3) risk. Multiple risk factors, including advanced age, cardiovascular disease and treatment with more than one TdP-classified drug, were frequently observed. CONCLUSIONS Antidepressants followed by antiarrhythmics dominated among TdP risk drugs used by adults with TdP diagnosis, the majority being ≥65 years. TdP risk class and concomitant medication should be considered when prescribing antidepressants to older patients.
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Affiliation(s)
- Bengt Danielsson
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Julius Collin
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Anastasia Nyman
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Annica Bergendal
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Natalia Borg
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Maria State
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
| | - Lennart Bergfeldt
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | - Johan Fastbom
- Department of Analysis, Swedish National Board of Health and Welfare, Stockholm, Sweden
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Aronow WS, Shamliyan TA. Effects of antidepressants on QT interval in people with mental disorders. Arch Med Sci 2020; 16:727-741. [PMID: 32542073 PMCID: PMC7286318 DOI: 10.5114/aoms.2019.86928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/23/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Drug-induced QT prolongation is associated with higher cardiovascular mortality. MATERIAL AND METHODS We conducted a protocol-based comprehensive review of antidepressant-induced QT prolongation in people with mental disorders. RESULTS Based on findings from 47 published randomized controlled trials (RCTs), 3 unpublished RCTs, 14 observational studies, 662 case reports of torsades de pointes, and 168 cases of QT prolongation, we conclude that all antidepressants should be used only with licensed doses, and that all patients receiving antidepressants require monitoring of QT prolongation and clinical symptoms of cardiac arrhythmias. Large observational studies suggest increased mortality associated with all antidepressants (RR = 1.62, 95% CI: 1.60-1.63, number of adults: 1,716,552), high doses of tricyclic antidepressants (OR = 2.11, 85% CI 1.10-4.22), selective serotonin reuptake inhibitors (OR = 2.78, 95% CI: 1.24-6.24), venlafaxine (OR = 3.73, 95% CI: 1.33-10.45, number of adults: 4,040), and nortriptyline (OR = 4.60, 95% CI: 1.20-18.40, number of adults: 5,298). CONCLUSIONS Evidence regarding the risk of QT prolongation in children is sparse.
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Affiliation(s)
- Wilbert S. Aronow
- Department of Medicine and Cardiology Research, Westchester Medical Center and New York Medical College, New York, USA
| | - Tatyana A. Shamliyan
- Elsevier, Clinical Solutions, Philadelphia, USA
- Corresponding author: Tatyana A. Shamliyan MD, MS, Elsevier Clinical Solutions, 1600 Kennedy Blvd, 19103 Philadelphia, USA, Phone: 2675004863, E-mail:
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Manolakis AC, Broers C, Geysen H, Goelen N, Van Houtte B, Rommel N, Vanuytsel T, Tack J, Pauwels A. Effect of citalopram on esophageal motility in healthy subjects-Implications for reflux episodes, dysphagia, and globus. Neurogastroenterol Motil 2019; 31:e13632. [PMID: 31121087 DOI: 10.1111/nmo.13632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Drugs such as citalopram, "targeting" the serotonin pathway, can alter esophageal mechano-chemical sensitivity and gastrointestinal motility. The aim of this study was to clarify the effect of citalopram on esophageal motility and sphincter function, transient lower esophageal sphincter relaxations (TLESRs), and reflux events. METHODS Sixteen healthy volunteers (HV) receiving 20 mg citalopram or placebo intravenously, in a randomized cross-over fashion, underwent two high-resolution impedance manometry studies involving liquid swallows and a high-fat, high-caloric meal. Manometric, reflux, and symptom-related parameters were studied. KEY RESULTS A lower distal contractile integral was recorded under citalopram, compared with placebo (P = 0.026). Upper esophageal sphincter (UES) resting pressure was significantly higher after citalopram administration throughout the study (P < 0.05, all periods). Similarly, the UES postswallow mean and maximum pressures were higher in the citalopram condition (P < 0.0001, in both cases) and this was also the case for the 0.2 s integrated relaxation pressure (P = 0.04). Esophagogastric junction resting pressures in the citalopram visit were significantly higher during swallow protocol, preprandial period, and the first postprandial hour (P < 0.05, in all cases). TLESRs and total reflux events were both reduced after citalopram infusion (P = 0.01, in both cases). During treatment with citalopram, five participants complained about globus sensation (P = 0.06). This citalopram-induced globus was associated with higher UES postswallow mean and maximum pressure values (P = 0.01 and P = 0.04, respectively). CONCLUSIONS AND INFERENCES Administration of citalopram exerts a diversified response on esophageal motility and sphincter function, linked to clinically relevant phenomena: a reduction in postprandial TLESRs and the induction of drug-induced globus.
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Affiliation(s)
- Anastassios C Manolakis
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology, University Hospital of Larissa, Larissa, Greece
| | - Charlotte Broers
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Hannelore Geysen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Nick Goelen
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Brecht Van Houtte
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Nathalie Rommel
- Experimental Oto-Rhino-Laryngology, Department of Neurosciences, Deglutology, KU Leuven, Belgium
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ans Pauwels
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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McCarrell JL, Bailey TA, Duncan NA, Covington LP, Clifford KM, Hall RG, Blaszczyk AT. A review of citalopram dose restrictions in the treatment of neuropsychiatric disorders in older adults. Ment Health Clin 2019; 9:280-286. [PMID: 31293848 PMCID: PMC6607952 DOI: 10.9740/mhc.2019.07.280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Neuropsychiatric disorders affect millions of older adults. Despite this, there are relatively few older adults included in clinical trials evaluating treatments for psychiatric disorders. Citalopram has been evaluated in older adults with neuropsychiatric disorders and has largely been found beneficial, making the 2011 US Food and Drug Administration (FDA) safety advisory on citalopram extremely impactful. Methods A literature search was completed using the PubMed database. Results were limited to clinical trials conducted in older adults that were published in English. Results Review of the literature confirms the efficacy of citalopram in depression, anxiety, depression associated with Parkinson disease, and behavioral and psychological symptoms of dementia. Additionally, no adverse cardiac outcomes have been described related to citalopram. Discussion The FDA's evidence for applying this safety advisory to citalopram is minimal and largely based on surrogate markers, such as the QTc interval rather than clinical and safety outcomes. Citalopram is known to increase the QTc, but this increase has not been linked to adverse cardiac outcomes. The evidence for efficacy and against adverse outcomes suggests that a reevaluation of the dosing restrictions in older adults with neuropsychiatric disorders is needed.
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Godman B, Kurdi A, McCabe H, Johnson CF, Barbui C, MacBride-Stewart S, Hurding S, Leporowski A, Bennie M, Morton A. Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence. J Comp Eff Res 2019; 8:535-547. [DOI: 10.2217/cer-2018-0132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health Pharmacy & Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Holly McCabe
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
| | - Chris F Johnson
- Prescribing Support Unit, National Health Service Greater Glasgow & Clyde (NHS GGC), Glasgow, UK
| | - Corrado Barbui
- WHO Collaborating Centre for Research & Training in Mental Health & Service Evaluation, Department of Neuroscience, Biomedicine & Movement Sciences, Section of Psychiatry, University of Verona, Italy
| | - Sean MacBride-Stewart
- Prescribing Support Unit, National Health Service Greater Glasgow & Clyde (NHS GGC), Glasgow, UK
| | - Simon Hurding
- Therapeutics Branch, Scottish Government, Edinburgh, UK
| | - Axel Leporowski
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
| | - Marion Bennie
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
| | - Alec Morton
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
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Impact of hospital pharmacist interventions on the combination of citalopram or escitalopram with other QT-prolonging drugs. Int J Clin Pharm 2019; 41:42-48. [DOI: 10.1007/s11096-018-0724-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023]
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Gerlach LB, Kim HM, Yosef M, Kales HC, Henry J, Zivin K. Electrocardiogram Monitoring After the Food and Drug Administration Warnings for Citalopram: Unheeded Alerts? J Am Geriatr Soc 2018; 66:1562-1566. [DOI: 10.1111/jgs.15420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/23/2018] [Accepted: 04/05/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Lauren B. Gerlach
- Program for Positive Aging, Department of Psychiatry, Medical School; University of Michigan; Ann Arbor Michigan
| | - Hyungjin Myra Kim
- Center for Clinical Management Research; Veterans Affairs Ann Arbor Healthcare System; Ann Arbor Michigan
- Center for Statistical Consultation and Research; University of Michigan; Ann Arbor Michigan
| | - Matheos Yosef
- Center for Clinical Management Research; Veterans Affairs Ann Arbor Healthcare System; Ann Arbor Michigan
| | - Helen C. Kales
- Program for Positive Aging, Department of Psychiatry, Medical School; University of Michigan; Ann Arbor Michigan
- Center for Clinical Management Research; Veterans Affairs Ann Arbor Healthcare System; Ann Arbor Michigan
| | - Jennifer Henry
- Center for Clinical Management Research; Veterans Affairs Ann Arbor Healthcare System; Ann Arbor Michigan
| | - Kara Zivin
- Program for Positive Aging, Department of Psychiatry, Medical School; University of Michigan; Ann Arbor Michigan
- Center for Clinical Management Research; Veterans Affairs Ann Arbor Healthcare System; Ann Arbor Michigan
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Mladěnka P, Applová L, Patočka J, Costa VM, Remiao F, Pourová J, Mladěnka A, Karlíčková J, Jahodář L, Vopršalová M, Varner KJ, Štěrba M. Comprehensive review of cardiovascular toxicity of drugs and related agents. Med Res Rev 2018; 38:1332-1403. [PMID: 29315692 PMCID: PMC6033155 DOI: 10.1002/med.21476] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/20/2017] [Accepted: 11/16/2017] [Indexed: 12/12/2022]
Abstract
Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.
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Affiliation(s)
- Přemysl Mladěnka
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Lenka Applová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Jiří Patočka
- Department of Radiology and Toxicology, Faculty of Health and Social StudiesUniversity of South BohemiaČeské BudějoviceCzech Republic
- Biomedical Research CentreUniversity HospitalHradec KraloveCzech Republic
| | - Vera Marisa Costa
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of PharmacyUniversity of PortoPortoPortugal
| | - Fernando Remiao
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of PharmacyUniversity of PortoPortoPortugal
| | - Jana Pourová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Aleš Mladěnka
- Oncogynaecologic Center, Department of Gynecology and ObstetricsUniversity HospitalOstravaCzech Republic
| | - Jana Karlíčková
- Department of Pharmaceutical Botany and Ecology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Luděk Jahodář
- Department of Pharmaceutical Botany and Ecology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Marie Vopršalová
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
| | - Kurt J. Varner
- Department of PharmacologyLouisiana State University Health Sciences CenterNew OrleansLAUSA
| | - Martin Štěrba
- Department of Pharmacology, Faculty of Medicine in Hradec KrálovéCharles UniversityHradec KrálovéCzech Republic
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Lazzerini PE, Capecchi PL, Laghi-Pasini F. Systemic inflammation and arrhythmic risk: lessons from rheumatoid arthritis. Eur Heart J 2018; 38:1717-1727. [PMID: 27252448 DOI: 10.1093/eurheartj/ehw208] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic immuno-mediated disease primarily affecting the joints, characterized by persistent high-grade systemic inflammation. Cardiovascular morbidity and mortality are significantly increased in RA, with >50% of premature deaths attributable to cardiovascular disease. In particular, RA patients were twice as likely to experience sudden cardiac death compared with non-RA subjects, pointing to an increased propensity to develop malignant ventricular arrhythmias. Indeed, ventricular repolarization (QT interval) abnormalities and cardiovascular autonomic nervous system dysfunction, representing two well-recognized risk factors for life-threatening ventricular arrhythmias in the general population, are commonly observed in RA. Moreover, large population-based studies seem to indicate that also the prevalence of atrial fibrillation is significantly higher in RA subjects than in the general population, thus suggesting that these patients are characterized by an abnormal diffuse myocardial electrical instability. Although the underlying mechanisms accounting for the pro-arrhythmogenic substrate in RA are probably intricate, the leading role seems to be played by chronic systemic inflammatory activation, able to promote arrhythmias both indirectly, by accelerating the development of ischaemic heart disease and congestive heart failure, and directly, by affecting cardiac electrophysiology. In this integrated mechanistic view, lowering the inflammatory burden through an increasingly tight control of disease activity may represent the most effective intervention to reduce arrhythmic risk in these patients. Intriguingly, these considerations could be more generally applicable to all the diseases characterized by chronic systemic inflammation, and could help elucidate the link between low-grade chronic inflammation and arrhythmic risk in the general population.
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16
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Assessing Responsiveness of Health Systems to Drug Safety Warnings. Am J Geriatr Psychiatry 2018; 26:476-483. [PMID: 29066038 DOI: 10.1016/j.jagp.2017.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/27/2017] [Accepted: 09/14/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In 2011-2012 the U.S. Food and Drug Administration (FDA) issued safety announcements cautioning providers against prescribing high doses of citalopram given concerns for QT prolongation. The authors evaluated Veterans Affairs (VA) national trends in citalopram use and dose compared with alternative antidepressants after the FDA warnings. METHODS Time series analyses estimated the effect of the FDA warnings on citalopram and other antidepressant across three periods: before the first FDA warning in August 2011, after the 2011 FDA warning until the second warning in March 2012, and after the 2012 FDA warning. In a National VA health system, adult VA outpatients prescribed citalopram or alternative antidepressants from February 2010 to September 2013 were studied. Outpatient use of high-dose citalopram (>40 or >20 mg daily in adults aged > 60 years) including the proportion of patients prescribed citalopram and difference between study periods. RESULTS Between the first and second FDA warnings, among patients aged 18-60, high-dose citalopram use decreased by 2.0% per month (p < 0.001) and by 1.9% per month (p < 0.001) for older adults. After the second FDA warning in 2012, 30.7% of older patients remained on doses higher than the newly recommended dose of 20 mg. Reductions in overall use of citalopram were accompanied by significant increases in prescriptions of alternative antidepressants, with sertraline most widely prescribed. CONCLUSION Although trends in high-dose citalopram use declined after the 2011-2012 FDA warnings, roughly one-third of older adults still remained on higher than recommended doses. Concomitant increases in sertraline and other antidepressant prescriptions suggest potential substitution of these medications for citalopram.
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Beach SR, Celano CM, Sugrue AM, Adams C, Ackerman MJ, Noseworthy PA, Huffman JC. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. PSYCHOSOMATICS 2018; 59:105-122. [DOI: 10.1016/j.psym.2017.10.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/11/2017] [Accepted: 10/17/2017] [Indexed: 12/31/2022]
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Klivinyi C, Bornemann-Cimenti H. Pain medication and long QT syndrome. Korean J Pain 2018; 31:3-9. [PMID: 29372020 PMCID: PMC5780213 DOI: 10.3344/kjp.2018.31.1.3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 10/03/2017] [Accepted: 11/06/2017] [Indexed: 02/02/2023] Open
Abstract
Long QT syndrome is a cardiac repolarization disorder and is associated with an increased risk of torsades de pointes. The acquired form is most often attributable to administration of specific medications and/or electrolyte imbalance. This review provides insights into the risk for QT prolongation associated with drugs frequently used in the treatment of chronic pain. In the field of pain medicine all the major drug classes (i.e. NSAIDs, opioids, anticonvulsive and antidepressant drugs, cannabinoids, muscle relaxants) contain agents that increase the risk of QT prolongation. Other substances, not used in the treatment of pain, such as proton pump inhibitors, antiemetics, and diuretics are also associated with long QT syndrome. When the possible benefits of therapy outweigh the associated risks, slow dose titration and electrocardiography monitoring are recommended.
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Affiliation(s)
- Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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19
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Ojero-Senard A, Benevent J, Bondon-Guitton E, Durrieu G, Chebane L, Araujo M, Montastruc F, Montastruc JL. A comparative study of QT prolongation with serotonin reuptake inhibitors. Psychopharmacology (Berl) 2017; 234:3075-3081. [PMID: 28770276 DOI: 10.1007/s00213-017-4685-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/05/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND QT interval prolongations were described with citalopram and escitalopram. However, the effects of the other serotonin reuptake inhibitors (SRIs) remained discussed. In order to identify a putative signal with other SRIs, the present study investigates the reports of QT interval prolongation with SRIs in two pharmacovigilance databases (PVDB). METHODS Two kinds of investigations were performed: (1) a comparative study in VigiBase®, the WHO PVDB, where notifications of QT prolongation with six SRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) were selected. Cases with overdose or pregnancy were excluded. The relationship between the "suspected" SRI and occurrence of QT prolongation was assessed by calculating reporting odds ratio (ROR) in a case/non-case design. (2) A descriptive study of QT prolongation reports with citalopram and escitalopram in the French FPVD. RESULTS In VigiBase®, 855 notifications were identified (mean age 56.2 years, mainly women 73%). Among them, 172 (20.1%) were associated to escitalopram; 299 (35.0%), to citalopram; 186 (21.8%), to fluoxetine; 94 (11.0%), to sertraline; 66 (7.7%), to paroxetine; and 38 (4.4%) to fluvoxamine. A significant ROR value (higher than 1) was only found for citalopram (3.35 CI95% [2.90-3.87]) or escitalopram (2.50 [2.11-2.95]). In the FPVD, eight reports of QT prolongation were found with citalopram and 27 with escitalopram, mainly in women (77.1%) with a mean age of 73.2 years. In 23 cases (66%), SRIs were associated with other suspected drugs, mainly cardiotropic or psychotropic ones. Hypokalemia was associated in six patients. CONCLUSION This study, performed in real conditions of life, shows a clear signal of QT prolongation with only two SRIs, citalopram and escitalopram, indicating that QT prolongation is not a SRI class effect.
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Affiliation(s)
- Ana Ojero-Senard
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Justine Benevent
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Emmanuelle Bondon-Guitton
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Geneviève Durrieu
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Leila Chebane
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Melanie Araujo
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Francois Montastruc
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France
| | - Jean-Louis Montastruc
- Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU et Faculté de Médecine de Toulouse, Toulouse, France.
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Gerlach LB, Kales HC, Maust DT, Chiang C, Stano C, Choe HM, Zivin K. Unintended Consequences of Adjusting Citalopram Prescriptions Following the 2011 FDA Warning. Am J Geriatr Psychiatry 2017; 25:407-414. [PMID: 28012712 DOI: 10.1016/j.jagp.2016.11.010] [Citation(s) in RCA: 14] [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: 05/10/2016] [Revised: 09/29/2016] [Accepted: 11/16/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES In 2011, the U.S. Food and Drug Administration (FDA) issued a safety announcement cautioning providers against prescribing citalopram above 40 mg per day given concerns for QT prolongation. We assessed the impact of a health system quality improvement initiative to identify patients taking higher than the recommended dose of citalopram. DESIGN Retrospective cohort study. SETTING Nine primary care clinics within the University of Michigan from March 2012 to February 2013. PARTICIPANTS Adult patients taking a higher-than-recommended dose of citalopram following the FDA warning in 2011 (N = 199). MEASUREMENTS Frequency of EKG monitoring, clinical factors associated with patients whose citalopram dose or use was adjusted, and potential impact of these changes on overall health care utilization was assessed. RESULTS In patients prescribed higher-than-recommended doses of citalopram and who received a note from a pharmacist regarding the FDA warnings, only 8.5% received electrocardiogram (EKG) monitoring. Patients who were converted to an alternative antidepressant from citalopram were more likely to receive subsequent new prescriptions for benzodiazepines and sedative hypnotics (χ2 = 7.9, p = 0.048). Patients who had any adjustments to their antidepressant medication had greater overall health care utilization (OR: 25.0; 95% CI: 5.7-109.6; p < 0.001) than patients remaining on the same dose of citalopram. CONCLUSIONS Despite a targeted quality intervention to address the FDA warning regarding citalopram, the warning was associated with low levels of EKG monitoring, increased anxiolytic and sedative medication use, and higher healthcare utilization. This finding may represent destabilization of patients on previously therapeutic doses of their antidepressant and an unintended consequence of the FDA warning.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Claire Chiang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Claire Stano
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Hae Mi Choe
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, Ann Arbor, MI; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Taylor JB, Stern TA. Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine? PSYCHOSOMATICS 2017; 58:375-385. [PMID: 28449827 DOI: 10.1016/j.psym.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.
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Affiliation(s)
- John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Meyer JM, Cummings MA, Proctor G, Stahl SM. Psychopharmacology of Persistent Violence and Aggression. Psychiatr Clin North Am 2016; 39:541-556. [PMID: 27836150 DOI: 10.1016/j.psc.2016.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Persistent violence not due to acute psychosis or mania can be managed only after appropriate characterization of the aggressive episodes (psychotic, impulsive, or predatory/planned/instrumental). The type of violence combined with the psychiatric diagnosis dictates the evidence-based pharmacologic approaches for psychotically motivated and impulsive aggression, whereas instrumental violence mandates forensic/behavioral strategies. For nonacute inpatients, schizophrenia spectrum disorders, traumatic brain injury, and dementia comprise the majority of individuals who are persistently aggressive, with impulsive actions the most common form of violence across all diagnoses. Neurobiological considerations combined with empirical data provide a comprehensive framework for systematic medication trials to manage persistently aggressive patients.
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Affiliation(s)
- Jonathan M Meyer
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA; Department of Psychiatry, University of California, San Diego; 9500 Gilman Drive, MC 0603, La Jolla, CA 92093-0603, USA.
| | - Michael A Cummings
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA
| | - George Proctor
- California Department of State Hospitals (DSH), Psychopharmacology Resource Network, DSH-Patton, 3102 East Highland Avenue, Patton, CA 92369, USA
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego; 9500 Gilman Drive, MC 0603, La Jolla, CA 92093-0603, USA; California Department of State Hospitals (DSH), Bateson Building, 1600 9th Street, Room 400, Sacramento, CA 95814, USA
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Lazzerini PE, Capecchi PL, Bertolozzi I, Morozzi G, Lorenzini S, Simpatico A, Selvi E, Bacarelli MR, Acampa M, Lazaro D, El-Sherif N, Boutjdir M, Laghi-Pasini F. Marked QTc Prolongation and Torsades de pointes in Patients with Chronic Inflammatory Arthritis. Front Cardiovasc Med 2016; 3:31. [PMID: 27703966 PMCID: PMC5029147 DOI: 10.3389/fcvm.2016.00031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/05/2016] [Indexed: 01/08/2023] Open
Abstract
Mounting evidence indicates that in chronic inflammatory arthritis (CIA), QTc prolongation is frequent and correlates with systemic inflammatory activation. Notably, basic studies demonstrated that inflammatory cytokines induce profound changes in potassium and calcium channels resulting in a prolonging effect on cardiomyocyte action potential duration, thus on the QT interval on the electrocardiogram. Moreover, it has been demonstrated that in rheumatoid arthritis (RA) patients, the risk of sudden cardiac death is significantly increased when compared to non-RA subjects. Conversely, to date no data are available about torsades de pointes (TdP) prevalence in CIA, and the few cases reported considered CIA only an incidental concomitant disease, not contributing factor to TdP development. We report three patients with active CIA developing marked QTc prolongation, in two cases complicated with TdP degenerating to cardiac arrest. In these patients, a blood sample was obtained within 24 h from TdP/marked QTc prolongation occurrence, and levels of IL-6, TNFα, and IL-1 were evaluated. In all three cases, IL-6 was markedly elevated, ~10 to 100 times more than reference values. Moreover, one patient also showed high circulating levels of TNFα and IL-1. In conclusion, active CIA may represent a currently overlooked QT-prolonging risk factor, potentially contributing in the presence of other “classical” risk factors to TdP occurrence. In particular, a relevant role may be played by elevated circulating IL-6 levels via direct electrophysiological effects on the heart. This fact should be carefully kept in mind, particularly when recognizable risk factors are already present and/or the addition of QT-prolonging drugs is required.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit, Department of Internal Medicine, Hospital of Carrara , Carrara , Italy
| | - Gabriella Morozzi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Sauro Lorenzini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Antonella Simpatico
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Enrico Selvi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Maria Romana Bacarelli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Maurizio Acampa
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
| | - Deana Lazaro
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center , New York, NY , USA
| | - Nabil El-Sherif
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center , New York, NY , USA
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center, New York, NY, USA; NYU School of Medicine, New York, NY, USA
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena , Siena , Italy
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Abstract
Depression in patients who have had a myocardial infarction is an important clinical problem because it is extremely common and because the comorbidity complicates depression treatment and worsens the cardiovascular prognosis. Studies of psychotherapy, exercise, pharmacotherapy, and collaborative care demonstrate that effective treatment of depression is possible but the strength of the effects seen in most studies is low, and cardiovascular and all-cause morbidity and mortality benefits have not been proven. Recent collaborative care studies have had promising outcomes. For pharmacotherapy, side effects, including bleeding and arrhythmia risks, require special attention. Recovery from depression is associated with better long-term cardiovascular prognosis, while treatment per se is not.
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25
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Siarkos KT, Katirtzoglou EA, Politis AM. A Review of Pharmacological Treatments for Depression in Alzheimer's Disease. J Alzheimers Dis 2016; 48:15-34. [PMID: 26401925 DOI: 10.3233/jad-148010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Depression in Alzheimer's disease (dAD) is one of the most common behavioral and psychological symptoms of dementia, with devastating consequences not only for the affected individuals, but for caregivers as well. So far, pharmacological treatment of dAD has been based on the "monoamine hypothesis". However, the reported moderate effects of approved antidepressants, as well as an increasing body of research evidence, suggest a more complex pathophysiologic mechanism. In the present paper, a systematic review of different treatments for dAD is presented that can inform the study of alternative neuropathological and neurobiological aspects of the disease aimed at the development of more effective treatment targets.
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Affiliation(s)
- Kostas T Siarkos
- Division of Geriatric Psychiatry, 1st Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Everina A Katirtzoglou
- Division of Geriatric Psychiatry, 1st Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios M Politis
- Division of Geriatric Psychiatry, 1st Department of Psychiatry, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Psychiatry and Behavioral Sciences, John's Hopkins University, School of Medicine, USA
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Hutton LMJ, Cave AJ, St-Jean R, Banh HL. Should We be Worried About QTc Prolongation Using Citalopram? A Review. J Pharm Pract 2016; 30:353-358. [DOI: 10.1177/0897190015624862] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Summarize available information regarding clinical impact of citalopram on the QTc interval. Methods: A literature search was conducted in Pubmed, EMBASE, and Cochrane databases using the MeSH term “long QT syndrome” and key word “citalopram” on July 11, 2014. Results: Thirty-one studies were evaluated with 4 included in this review. Studies were excluded if they reported acute overdoses of citalopram or did not report on patient-specific risk factors for long QT syndrome (eg, hypokalemia, bradycardia, and increased age). The majority of the available data is derived from case reports. A number of confounders complicate the determination of a causal link between QTc prolongation and citalopram. Of the 4 studies included for review, none identified significant QTc prolongation in patients taking citalopram 20 to 60 mg daily without the patients having one or more patient-specific risk factors for prolonged QTc. Conclusion: There is insufficient evidence to establish a causal link between citalopram 20 to 60 mg orally daily and increased risk of TdP. Further research is required to determine the clinical impact and association between citalopram 20 to 60 mg daily and QTc prolongation.
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Affiliation(s)
| | - Andrew J. Cave
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Renée St-Jean
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hoan Linh Banh
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Kaye Edmonton Clinic, Edmonton, Alberta, Canada
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27
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Do A, Noohi S, Elie D, Mahdanian AA, Yu C, Segal M, Looper KJ, Rej S. Health Canada Warning on Citalopram and Escitalopram--Its Effects on Prescribing in Consultation-Liaison Psychiatry. PSYCHOSOMATICS 2015; 57:57-63. [PMID: 26633294 DOI: 10.1016/j.psym.2015.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 09/09/2015] [Accepted: 09/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reports have suggested that citalopram and escitalopram may prolong the QTc interval, leading Health Canada to issue a warning to limit their dosages in 2012. Little is known about the effects of this warning and similar ones (e.g., by the Food and Drug Administration) on antidepressant prescribing in inpatients with acute medical illness, who are theoretically at high risk of QTc prolongation. The main objective of our study is to examine the effect of the Health Canada warning on citalopram/escitalopram prescribing patterns in the consultation-liaison (C-L) psychiatry setting. METHODS We performed a retrospective cohort study including 275 randomly selected inpatients with medical illness assessed by the psychiatric C-L team of a large Canadian academic hospital between 2008 and 2014. We grouped patients based on whether they were assessed by the C-L team before or after the citalopram Health Canada warning. Our primary outcome was change in citalopram/escitalopram prescribing patterns. RESULTS We found that of patients seen before the Health Canada warning, a significantly higher number were prescribed citalopram/escitalopram (44.1% vs. 22.3%, χ(2) = 14.835, p < 0.001), even after controlling for confounders. However, the percentage of patients using a citalopram/escitalopram dose exceeding those recommended by the Health Canada warning was similar in both groups (8.9% vs. 12.1%, χ(2) = 0.233, p = 0.63). CONCLUSIONS Overall, C-L psychiatrists were less likely to prescribe citalopram/escitalopram following the Health Canada warning, which did not translate into safer dosing. Clinicians should not avoid prescribing citalopram/escitalopram appropriately in medically vulnerable inpatients when benefits outweigh disadvantages.
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Affiliation(s)
- André Do
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Saeid Noohi
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Dominique Elie
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Artin A Mahdanian
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Ching Yu
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Marilyn Segal
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Karl J Looper
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Soham Rej
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada.
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