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Antipsychotic drug dose in real-life settings results from a Nationwide Cohort Study. Eur Arch Psychiatry Clin Neurosci 2022; 272:583-590. [PMID: 34420073 DOI: 10.1007/s00406-021-01322-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
UNLABELLED Despite national and international recommendations and while there is no evidence for increased efficacy of higher doses, several studies suggested that the prescribed doses in routine practice are higher than the maximal recommended doses in 20-40% of schizophrenia patients worldwide. METHODS the aims of the present study were: (1) to describe the patterns of antipsychotic daily dose prescriptions in routine clinical practice in a large and representative cohort of French schizophrenia patients and, (2) to study the characteristics of patients receiving higher doses. RESULTS in all cases, regardless of the antipsychotic treatment used, the average dose was greater than 1.0 defined daily dose (DDDeq), which is the average recommended dose. For SGA, the mean DDDeq ranged from 1.2 for aripiprazole to 1.6 for olanzapine and clozapine, respectively. For a given patient, the mean ± S.D. total daily cumulative dose (TCD) of antipsychotic was 1.9 ± 2.4 DDDeq. A "high dose" was defined as a TCD ≥ 1.5 DDDeq, 789 (45.2%) patients received a "high dose". Patients in the "high dose" group were more frequently suffering from a more severe paranoid schizophrenia, had more often a comorbid antisocial personality disorder and/or a substance use disorder. CONCLUSIONS the present study suggests that in France, antipsychotic drugs doses prescribed by psychiatrists are higher, compared to other countries. All recommendations agree on the fact that the preferential dose should be the "minimum-effective" dose. Optimizing prescribing practices would be important to optimize the benefit/risk ratio and to minimize the risks side effects.
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Correll CU, Fusar-Poli P, Leucht S, Karow A, Maric N, Moreno C, Nordentoft M, Raballo A. Treatment Approaches for First Episode and Early-Phase Schizophrenia in Adolescents and Young Adults: A Delphi Consensus Report from Europe. Neuropsychiatr Dis Treat 2022; 18:201-219. [PMID: 35177905 PMCID: PMC8843859 DOI: 10.2147/ndt.s345066] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/13/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Although first-episode psychosis (FEP) in youth, particularly early-onset schizophrenia (EOS), is managed similarly to adult-onset schizophrenia, few antipsychotics are approved for people aged 13-18 years. We aimed to explore areas of uncertainty in EOS management and provide evidence-based recommendations to mental health specialists. We used the Delphi methodology to gain knowledge in areas lacking evidence-based strategies. This standardized methodology consists of the development of a questionnaire by content experts, which is then submitted to a broader panel of professionals (panelists) to survey their level of agreement on the topics proposed. MATERIALS AND METHODS The developed questionnaire covered patient management from diagnosis to maintenance treatment and was administered to a broader panel of specialists across Europe. Based on an analysis of responses received in this first round, the items that needed further insight were submitted to the panel for a second round and then reanalysed. RESULTS An initial set of 90 items was developed; in round I, consensus was reached for 83/90 items (92%), while it was reached for 7/11 (64%) of the items sent out for rerating in round II. Feedback for rounds I and II was obtained from 54/92 and 48/54 approached experts, respectively. There was broad agreement on diagnostic standards, multimodal approaches and focus on adverse events, but uncertainty in terms of pharmacological strategies (including clozapine) in case of failure and antipsychotic dosing in younger patients. CONCLUSION Despite knowledge about diagnostic clues and integrated management of EOS, this study highlights the lack of standardization in treating EOS, with safety arguments having a major role in the decision-making process. Targeted clinical trials and systematic dissemination across Europe of current scientific evidence on the value of early intervention services is hoped to contribute to standardized and improved quality care for patients with early-phase psychosis and schizophrenia.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- OASIS service, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Stefan Leucht
- Section Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Anne Karow
- Department of Psychiatry and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nadja Maric
- Faculty of Medicine, University of Belgrade and Institute of Mental Health, Belgrade, Serbia
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Merete Nordentoft
- CORE-Copenhagen Research Centre for Mental Health, Mental Health Services in the Capital Region, Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Raballo
- Section of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia, Perugia, Italy
- Centre for Translational, Phenomenological and Developmental Psychopathology (CTPDP), Perugia University Hospital, Perugia, Italy
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Zheng S, Chan SKW, Lee J. Managing treatment resistance in schizophrenia: A joint study in Hong Kong and Singapore. Front Psychiatry 2022; 13:1005373. [PMID: 36339860 PMCID: PMC9631784 DOI: 10.3389/fpsyt.2022.1005373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This study surveyed clinicians in psychiatry in Hong Kong and Singapore to understand their familiarity and prescribing practices in treatment-resistant schizophrenia (TRS) and clozapine-resistant schizophrenia (CRS). MATERIALS AND METHODS All clinicians in psychiatry in both regions were invited through email to participate in an anonymous online survey. The survey collected information on the participants' characteristics, their familiarity and experience with clozapine use, and their treatment practices in TRS and CRS. Data collection took place between September 2019 and February 2020 in Hong Kong and December 2018 and March 2019 in Singapore. RESULTS 261 clinicians responded to the survey, with response rates of 19% (105 out of 556 participants) in Hong Kong and 50% (156 out of 309 participants) in Singapore. The majority of respondents (99.0% in Hong Kong; 87.9% in Singapore) were familiar with treatment guidelines for TRS. However, approximately half (54.2% in Hong Kong; 41.7% in Singapore) delayed the prescription of clozapine when indicated. In terms of alternatives to clozapine, approximately half or more of the clinicians in both regions would use high dose antipsychotics, long-acting injectable antipsychotics, antipsychotic polypharmacy, while the adjuvant use of mood stabilizers and electroconvulsive therapy differed between the two regions. In those with CRS, between 10 and 20% of the respondents added adjuvant mood stabilizers or antipsychotics, and 3-10% would use an antidepressant. CONCLUSION Clozapine delays occur in spite of clinicians' familiarity with treatment guidelines. More research is needed to guide the use of augmentation strategies and the search for effective treatments beyond clozapine.
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Affiliation(s)
- Shushan Zheng
- Department of Psychosis, Institute of Mental Health, Singapore, Singapore
| | - Sherry Kit Wa Chan
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Shimomura Y, Kikuchi Y, Suzuki T, Uchida H, Mimura M, Takeuchi H. Antipsychotic treatment strategies for acute phase and treatment resistance in schizophrenia: A systematic review of the guidelines and algorithms. Schizophr Res 2021; 236:142-155. [PMID: 34509129 DOI: 10.1016/j.schres.2021.07.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/04/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND To summarize the current state of knowledge on antipsychotic treatment strategies for the acute phase and treatment resistance in schizophrenia, we conducted a systematic review of guidelines and algorithms. METHODS We conducted a systematic literature search to identify clinical guidelines and algorithms on this topic using MEDLINE and Embase. We extracted information on recommendations for antipsychotic treatment strategies, including those for non-response (i.e., increasing antipsychotic dose and switching to another antipsychotic) and treatment resistance. RESULTS We identified a total of 17 guidelines/algorithms in various countries that were published after 2011. With respect to antipsychotic dose, most of the guidelines (N = 10/11) agreed starting with a low dose or the lowest licensed/effective dose and then titrating the dose upwards. Regarding antipsychotic treatment strategies for non-response, all of the guidelines (N = 9/9) recommended increasing antipsychotic dose towards the upper end of its approved dose range. Five guidelines suggested for increasing beyond the therapeutic dose range in exceptional cases, while overall 10 guidelines including them were negative about such strategy. The vast majority of guidelines (N = 16/17) recommended switching to another antipsychotic for non-response; however, some guidelines mentioned the lack of evidence for these strategies other than the use of clozapine. All the guidelines (N = 17/17) endorsed initiating clozapine after failure to respond to 2 different antipsychotics. Four guidelines endorsed an early use of clozapine, yet as the third antipsychotic. CONCLUSION The currently available guidelines and algorithms recommended increasing antipsychotic dose and switching to another antipsychotic, particularly clozapine for treatment-resistant schizophrenia, during the acute phase of schizophrenia for non-response.
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Affiliation(s)
- Yutaro Shimomura
- Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan
| | - Yuhei Kikuchi
- Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan
| | - Takefumi Suzuki
- University of Yamanashi Faculty of Medicine, Department of Neuropsychiatry, Yamanashi, Japan
| | - Hiroyuki Uchida
- Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan
| | - Masaru Mimura
- Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan.
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Factors predicting high-dose and combined antipsychotic prescribing in New Zealand: High-dose antipsychotic prescribing. Psychiatry Res 2021; 302:113996. [PMID: 34126462 DOI: 10.1016/j.psychres.2021.113996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Guidelines recommend using antipsychotic monotherapy at the lowest effective dose, however high-dose and antipsychotic polypharmacy prescribing (APP) remain commonplace. The aim of this study was to determine the prevalence and patterns of high-dose antipsychotic prescribing and APP among mental health service users in New Zealand (NZ). METHODS A retrospective audit of service users discharged from inpatient (n=657), or registered with community (n=1560), mental health services at Auckland District Health Board was undertaken. Case notes were reviewed and data on demographics, antipsychotic routes and doses were collected. Outcomes measures included: frequency of total high-dose prescribing, high-dose monotherapy, APP, high-dose APP, and factors associated with these prescribing practices. Logistic regression models were used to examine the relationships between explanatory and outcome variables. RESULTS Of the service users prescribed an antipsychotic (n = 2217), 14% were prescribed a high-dose antipsychotic. The frequency of high-dose monotherapy, APP, and high-dose APP was 3%, 26% and 11%, respectively. Being male, Māori, on compulsory treatment, having a schizophrenia diagnosis, or being prescribed polypharmacy were associated with high-dose antipsychotics. Olanzapine was most frequently prescribed in both high dosing (55%) and APP (40%). CONCLUSIONS There is a high prevalence of high-dose prescribing and APP in this NZ setting.
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Takeuchi H, Leucht S, Kane JM, Agid O, Remington G. Antipsychotic Medications: Enhancing Use to Improve Outcomes. Schizophr Bull 2021; 47:1201-1204. [PMID: 33748864 PMCID: PMC8379551 DOI: 10.1093/schbul/sbab016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada,To whom correspondence should be addressed; Department of Neuropsychiatry, Keio University School of Medicine 35 Shinanomachi, Shinjuku-ku, Tokyo, 160–8582, Japan; tel: +81-3-3353-1211 (ext. 62454), fax: +81-3-5379-0187, e-mail:
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - John M Kane
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY,Department of Psychiatry, Donald and Barbara Zucker School of Medicine, Hempstead, NY
| | - Ofer Agid
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Gary Remington
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Hasan A, Falkai P, Lehmann I, Gaebel W. Schizophrenia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:412-419. [PMID: 32865492 PMCID: PMC7477695 DOI: 10.3238/arztebl.2020.0412] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/03/2019] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The lifetime prevalence of schizophrenia is 1%. Schizophrenia is among the most severe mental illnesses and gives rise to the highest treatment costs per patient of any disease. It is characterized by frequent relapses, marked impairment of quality of life, and reduced social and work participation. METHODS The group entrusted with the creation of the German clinical practice guideline was chosen to be representative and pluralistic in its composition. It carried out a systematic review of the relevant literature up to March 2018 and identified a total of 13 389 publications, five source guidelines, three other relevant German clinical practice guidelines, and four reference guidelines. RESULTS As the available antipsychotic drugs do not differ to any great extent in efficacy, it is recommended that acute antipsychotic drug therapy should be sideeffect- driven, with a number needed to treat (NNT) of 5 to 8. The choice of treatment should take motor, metabolic, sexual, cardiac, and hematopoietic considerations into account. Ongoing antipsychotic treatment is recommended to prevent relapses (NNT: 3) and should be re-evaluated on a regular basis in every case. It is also recommended, with recommendation grades ranging from strong to intermediate, that disorder- and manifestation-driven forms of psychotherapy and psychosocial therapy, such as cognitive behavioral therapy for positive or negative manifestations (effect sizes ranging from d = 0.372 to d = 0.437) or psycho-education to prevent relapses (NNT: 9), should be used in combination with antipsychotic drug treatment. Further aspects include rehabilitation, the management of special treatment situations, care coordination, and quality management. A large body of evidence is available to provide a basis for guideline recommendations, particularly in the areas of pharmacotherapy and cognitive behavioral therapy. CONCLUSION The evidence-based diagnosis and treatment of persons with schizophrenia should be carried out in a multiprofessional process, with close involvement of the affected persons and the people closest to them.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, University of Augsburg, District Hospital Augsburg, Augsburg
- Department of Psychiatry and Psychotherapy, LMU Medical Center, Munich
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, LMU Medical Center, Munich
| | | | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, LVR Hospital Düsseldorf, Faculty of Medicine, University of Düsseldorf
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Rubio JM, Taipale H, Correll CU, Tanskanen A, Kane JM, Tiihonen J. Psychosis breakthrough on antipsychotic maintenance: results from a nationwide study. Psychol Med 2020; 50:1356-1367. [PMID: 31190660 DOI: 10.1017/s0033291719001296] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is uncertainty about the incidence of breakthrough psychosis in treatment adherent patients, and the role that factors, such as cumulative antipsychotic exposure, play in this phenomenon. METHODS In a nationwide cohort of individuals treated for schizophrenia-spectrum disorders in Finland between 1 January 1996 and 31 December 2015, 'Breakthrough Psychosis on Antipsychotic Maintenance Medication' (BAMM) was defined as hospitalization for psychosis despite ongoing continuous treatment with long-acting injectable antipsychotics (LAIs) or oral antipsychotics (OAPs) for ⩾8 weeks. Incidence rates, survival curves, and risk factors were presented. RESULTS In a cohort of 16 031 continuous LAI treatment episodes with virtually assured adherence [median duration = 441 days, interquartile range (IQR) = 155-1277], BAMM incidence was 31.5%. For 42 867 OAPs treatment episodes (median duration = 483 days, IQR = 167-1491), for whom adherence was modeled by the PRE2DUP method, BAMM incidence was 31.1%. Factors related to illness instability at treatment onset were associated with BAMM, although median time to BAMM was 291 days (IQR = 121-876) for LAIs and 344 days (IQR = 142-989) for OAPs, and 27.4% (N = 1386) of the BAMM events in the LAI, and 32.9% (N = 4378) in the OAP group occurred despite >1 year since last hospitalization at treatment onset. Cumulative antipsychotic exposure was not a consistent risk factor. CONCLUSION BAMM was relatively common even when adherence was confirmed with LAIs. Illness instability at treatment onset accounted for most cases, but relapse after years of continuous treatment was still prevalent. There was insufficient evidence to support causality between cumulative antipsychotic exposure and BAMM. Future research needs to address the role of symptom severity and neurobiology in BAMM.
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Affiliation(s)
- Jose M Rubio
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
| | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
- School of Pharmacy, University of Eastern Finland, PO Box 1627, SE-70211Kuopio, Finland
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
| | - John M Kane
- Division of Psychiatry Research, The Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY11004, USA
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY11550, USA
- The Feinstein Institute for Medical Research, Manhasset, NY11030, USA
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, FI-70240Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A, 5th floor, SE-171 77Stockholm, Sweden
- Stockholm County Council, Stockholm Health Care Services, Norra Stationsgatan 69, SE-113 64Stockholm, Sweden
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Takeuchi H, MacKenzie NE, Samaroo D, Agid O, Remington G, Leucht S. Antipsychotic Dose in Acute Schizophrenia: A Meta-analysis. Schizophr Bull 2020; 46:1439-1458. [PMID: 32415847 PMCID: PMC7707077 DOI: 10.1093/schbul/sbaa063] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Little is known regarding optimal antipsychotic doses in the acute phase of schizophrenia. The aim of the present study was to employ the concept of minimum effective dose (MED) in examining efficacy and tolerability within this population. MED was identified for each antipsychotic through a previous systematic review. We then identified double-blind placebo-controlled randomized trials that involved fixed-dose antipsychotic monotherapy in acute schizophrenia and compared the identified MED vs higher doses of the same oral antipsychotic. Studies were selected from a recent meta-analysis examining dose-response relationship of second-generation antipsychotics and haloperidol. We extracted the data on study discontinuation, psychopathology, extrapyramidal symptoms, and treatment-emergent adverse events. For each antipsychotic, we conducted a meta-analysis to compare outcomes between MED and 2-fold MED, and MED and 3-fold MED. A total of 26 studies involving 5618 patients were included in the meta-analysis. In terms of study discontinuation, significant differences were found in study discontinuation due to lack of efficacy between MED and higher doses, in favor of 2-fold and 3-fold MEDs. Regarding psychopathology, both 2-fold and 3-fold MEDs were superior to MED for total and positive symptom scores. As for side effects, 2-fold MED proved inferior to MED for parkinsonism scores and diarrhea, whereas 3-fold MED was inferior for akathisia, somnolence, and vomiting. Findings suggest that clinicians can dose an antipsychotic at 2-fold or 3-fold MED for patients with acute schizophrenia but should closely monitor side effects.
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Affiliation(s)
- Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan,Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada,To whom correspondence should be addressed; Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160–8582, Japan; tel: +81-3-3353-1211 (ext. 62454), fax: +81-3-5379-0187, e-mail:
| | - Nicole E MacKenzie
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Dominic Samaroo
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada,Brain and Spine Institute, ICM, Sorbonne University, Paris, France
| | - Ofer Agid
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Gary Remington
- Schizophrenia Program, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, University of Toronto, 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
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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11
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Correll CU, Brevig T, Brain C. Patient characteristics, burden and pharmacotherapy of treatment-resistant schizophrenia: results from a survey of 204 US psychiatrists. BMC Psychiatry 2019; 19:362. [PMID: 31727015 PMCID: PMC6857350 DOI: 10.1186/s12888-019-2318-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 10/11/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Minimal/non-response to antipsychotic treatment, and persistent positive symptoms despite treatment, are common among patients with schizophrenia. The aim of this study was to characterize a US treatment-resistant schizophrenia (TRS) population in terms of patient demographics, burden of symptoms, treatment history, and factors influencing therapeutic choice. METHODS In an online survey, 204 psychiatrists self-selected and completed three patient records: two TRS and one schizophrenia ('non-TRS'). RESULTS Respondents reported that 29.5% of their schizophrenia caseload had TRS. Selected TRS (n = 408) vs non-TRS (n = 204) patients were more likely to be unemployed (74.5% vs 45.1%, p < 0.001), hospitalized at least once (93.4% vs 74.0%, p < 0.001), and to have physical/psychiatric comorbidities including obesity (40.2% vs 23.5%, p < 0.001) and depression (38.7% vs 25.0%, p = 0.001). Psychiatric symptoms were more frequent and severe in TRS, and interfered more with social and functioning domains. Of positive symptoms, eliminating delusions and hallucinations was considered most important to improve a patient's long-term prognosis. In TRS, clozapine monotherapy was the most common treatment (15.9%), though ranked fifth of ten options to treat TRS. Psychiatrists typically increased the antipsychotic dose or added a second antipsychotic before initiating clozapine or switching antipsychotics. Antipsychotic switches were most commonly due to lack of efficacy (TRS = 71.4% vs non-TRS = 54.3%, p < 0.001) and intolerability (34.4% vs 38.4%, p = 0.22) with the prior antipsychotic. Persistent hallucinatory behavior was the top symptom leading to treatment switches in TRS (63.9% vs 37.1%, p < 0.001). CONCLUSIONS According to psychiatrists, symptoms have a greater clinical burden on patients with TRS than non-TRS. TRS is commonly managed by antipsychotic dose increases/combinations, with clozapine the fifth preference despite being the only approved TRS medication. New treatments are needed for patients who do not respond to available antipsychotics.
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Affiliation(s)
- Christoph U. Correll
- grid.440243.5The Zucker Hillside Hospital, Department of Psychiatry, 75–59 263rd Street, Glen Oaks, New York 11004 USA ,Department of Psychiatry and Molecular Medicine, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA ,Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Brevig
- 0000 0004 0476 7612grid.424580.fH. Lundbeck A/S, Valby, Copenhagen, Denmark
| | - Cecilia Brain
- 0000 0004 0476 7612grid.424580.fH. Lundbeck A/S, Valby, Copenhagen, Denmark
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12
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Gao J, Li M. Reinforcement attenuation as a behavioral technique to suppress conditioned avoidance response in rats: A comparative study with olanzapine. J Psychopharmacol 2019; 33:86-100. [PMID: 30334674 DOI: 10.1177/0269881118805497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Antipsychotic treatment is effective in the treatment of psychosis, although it also brings with it some unwanted side effects and is associated with low compliance. Finding a non-pharmacological alternative for antipsychotic treatment is highly desirable. AIMS This preclinical study examined the 'antipsychotic' efficacy of such a behavioral technique using a conditioned avoidance response model. This technique, termed reinforcement attenuation (RA), is to administer a brief footshock (0.1-2.0 s, 0.8 mA) at the end of each trial regardless of whether a well-trained rat makes an avoidance response or not. RESULTS RA achieved the same avoidance suppressing effect as olanzapine (an atypical antipsychotic drug), including both acute suppression and sensitized suppression of avoidance response in well-trained Sprague-Dawley adult male rats. Interestingly, the RA-induced sensitization (an enhanced disruption of avoidance responding) enhanced subsequent olanzapine sensitivity, whereas the olanzapine (1.0 mg/kg)-induced sensitization had little impact on later RA treatment. When RA and olanzapine (0.5 mg/kg, subcutaneously) were used together, the RA-induced sensitization was still detectable in the RA challenge test, although its magnitude was reduced by olanzapine. Finally, we showed that the RA-induced sensitization in avoidance suppression persisted from adolescence into adulthood, long after such a treatment was terminated. CONCLUSIONS These findings demonstrate that the RA is functionally equivalent (if not superior) to antipsychotic treatment in the avoidance suppression effect (both acute and sensitization effects) in both adolescent and adult animals. Behavioral therapies that specifically target the reinforcer of psychotic thoughts might be a viable strategy for the treatment of psychosis.
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Affiliation(s)
- Jun Gao
- Faculty of Psychology, Southwest University, Chongqing, China.,Key Laboratory of Cognition and Personality (Southwest University), Ministry of Education, Chongqing, China.,CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing, China.,Chongqing Collaborative Innovation Center for Brain Science, Chongqing, China
| | - Ming Li
- Faculty of Psychology, Southwest University, Chongqing, China.,Chongqing Collaborative Innovation Center for Brain Science, Chongqing, China.,Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
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13
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Samara MT, Klupp E, Helfer B, Rothe PH, Schneider‐Thoma J, Leucht S. Increasing antipsychotic dose for non response in schizophrenia. Cochrane Database Syst Rev 2018; 5:CD011883. [PMID: 29750432 PMCID: PMC6494602 DOI: 10.1002/14651858.cd011883.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Many people with schizophrenia do not reach a satisfactory clinical response with a standard dose of an initially prescribed antipsychotic drug. In such cases, clinicians face the dilemma of increasing the antipsychotic dose in order to enhance antipsychotic efficacy. OBJECTIVES To examine the efficacy of increasing antipsychotic dose compared to keeping the same dose in the treatment of people with schizophrenia who have not responded (as defined in the individual studies) to an initial antipsychotic drug trial. We also examine the adverse effects associated with such a procedure. SEARCH METHODS We searched the Cochrane Schizophrenia Group Trials Register (10 June 2014, 6 October 2015, and 30 March 2017). We examined references of all included studies for further trials. SELECTION CRITERIA All relevant randomised controlled trials (RCTs), reporting useable data, comparing increasing the antipsychotic dose rather than maintaining the original dose for people with schizophrenia who do not respond to their initial antipsychotic treatment. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data . We analysed dichotomous data using relative risks (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean differences (MD) and their 95% CI. We assessed risk of bias for included studies and used GRADE to create a 'Summary of findings' table. MAIN RESULTS Ten relevant RCTs with 675 participants are included in this review. All trials were double blind except one single blind. All studies had a run-in phase to confirm they did not respond to their initial antipsychotic treatment. The trials were published between 1980 and 2016. In most studies the methods of randomisation, allocation and blinding were poorly reported. In addition sample sizes were often small, limiting the overall quality of the evidence. Overall, no clear difference was found between groups in terms of the number of participants who showed clinically relevant response (RR 1.09, 95% CI 0.86 to 1.40, 9 RCTs, N = 533, low-quality evidence), or left the study early due to adverse effects (RR 1.63, 95% CI 0.52 to 5.07, very low quality evidence), or due to any reason (RR 1.30, 95% CI 0.89 to 1.90, 5 RCTs, N = 353, low-quality evidence). Similarly, no clear difference was found in general mental state as measured by PANSS total score change (MD -1.44, 95% CI -6.85 to 3.97, 3 RCTs, N = 258, very low quality evidence). At least one adverse effect was equivocal between groups (RR 0.91, 95% CI 0.55 to 1.50, 2 RCTs, N = 191, very low quality evidence). Data were not reported for time in hospital or quality-of-life outcomes. Finally, subgroup and sensitivity analyses did not show any effect on the primary outcome but these analyses were clearly underpowered. AUTHORS' CONCLUSIONS Current data do not show any clear differences between increasing or maintaining the antipsychotic dose for people with schizophrenia who do not respond to their initial antipsychotic treatment. Adverse effect reporting was limited and poor. There is an urgent need for further trials in order to determine the optional treatment strategy in such cases.
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Affiliation(s)
- Myrto T Samara
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
| | - Elisabeth Klupp
- Technical University MunichDepartment of Diagnostic and Interventional Neuroradiology, Klinikum rechts der IsarIsmaninger Str. 22MünchenGermany
| | - Bartosz Helfer
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
| | - Philipp H Rothe
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
| | - Johannes Schneider‐Thoma
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
| | - Stefan Leucht
- Technische Universität München Klinikum rechts der IsarKlinik und Poliklinik für Psychiatrie und PsychotherapieIsmaninger Straße 22MünchenGermany81675
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14
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Pringsheim T, Kelly M, Urness D, Teehan M, Ismail Z, Gardner D. Physical Health and Drug Safety in Individuals with Schizophrenia. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:673-683. [PMID: 28718324 PMCID: PMC5593246 DOI: 10.1177/0706743717719898] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND While antipsychotic medications are the mainstay of therapy for individuals with schizophrenia and psychotic disorders, their use is associated with adverse effects on physical health that require the attention and care of prescribers. METHODS We used the ADAPTE process to adapt existing guideline recommendations from the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the dosing of antipsychotics and antipsychotic polypharmacy, screening for adverse effects of antipsychotics, and management of metabolic and extrapyramidal side effects to the Canadian context. RESULTS Prescribers are encouraged to use the lowest effective dose and to avoid the routine use of multiple antipsychotics. Scheduled monitoring of body mass index, waist circumference, blood pressure, glucose, lipids, prolactin, electrocardiograms, and extrapyramidal symptoms is recommended. Lifestyle interventions are recommended to mitigate antipsychotic-induced weight gain. Prescribers should follow Canadian guidelines on the treatment of obesity, dyslipidemia, and diabetes. Recommendations on antipsychotic drug choice are made for users particularly concerned about extrapyramidal symptoms. CONCLUSION Careful monitoring and attention by prescribers may mitigate adverse effects associated with antipsychotic medications.
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Affiliation(s)
- Tamara Pringsheim
- 1 Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Martina Kelly
- 2 Department of Family Medicine, University of Calgary, Alberta
| | - Doug Urness
- 3 Clinical Department Head, Addiction and Mental Health, Central Zone, Alberta Health Services, Edmonton, Alberta
| | - Michael Teehan
- 4 Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia
| | - Zahinoor Ismail
- 5 Department of Psychiatry and Clinical Neurosciences, University of Calgary, Calgary, Alberta
| | - David Gardner
- 6 Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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