Short-acting intramuscular second-generation antipsychotic drugs for acutely agitated patients with schizophrenia spectrum disorders. A systematic review and network meta-analysis

Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis

BACKGROUND

Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision.

METHODS

We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach.

DISCUSSION

This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023402365.

Comparison of intramuscular haloperidol and other short-acting injectable antipsychotics for management of acute agitation in an adult inpatient psychiatry unit

Introduction

There is no consensus on the optimal antipsychotic for acute agitation. Whereas haloperidol is frequently used and has proven efficacy, second generation antipsychotics show similar efficacy and improved safety and tolerability. This study aimed to determine the effectiveness of short-acting intramuscular (IM) haloperidol versus other IM antipsychotics for acute agitation in adults admitted to an inpatient psychiatry unit.

Methods

This was a retrospective medical record review of patients who received 1 or more doses of a short-acting IM antipsychotic, including chlorpromazine, haloperidol, olanzapine, or ziprasidone. The primary endpoint was the need for subsequent IM antipsychotic(s) or physical restraint within 2 hours of the initial IM antipsychotic. Secondary endpoints assessed outcomes at 24 hours and adverse events.

Results

One hundred six patients were included. Four patients in the haloperidol group and 0 patients in the other antipsychotic group received an additional IM antipsychotic or required physical restraints within 2 hours (5.3% versus 0%, p = .319). More patients in the other antipsychotic group required an additional dose of IM antipsychotic within 24 hours compared with the haloperidol group (p = .0096). More adverse events were seen in patients who received haloperidol.

Discussion

Haloperidol was used more frequently than other short-acting IM antipsychotics. Whereas the effectiveness at 2 hours was not significantly different between groups, patients who received haloperidol were more likely to experience adverse events and were more often subjected to polypharmacy with benzodiazepines and/or diphenhydramine. This study further supports the use of olanzapine and ziprasidone for acute agitation in patients hospitalized in inpatient psychiatry.

Finding the Right Setting for the Right Treatment During the Acute Treatment of Individuals with Schizophrenia: A Narrative Review and Clinical Practice Guideline

Background

Schizophrenia is most times a chronic and often debilitating illness associated with poor mental health outcomes. Early and effective treatment of schizophrenia in the most appropriate setting can make a significant difference in the long-term recovery. The aim of this narrative review was to provide suggestions and recommendations for effectively managing patients with schizophrenia during acute exacerbations and to enhance awareness and skills related to personalized medicine.

Methods

A panel of academics and clinicians with experience in the field of psychosis met virtually on July 13th 2023 to narratively review and discuss the research evidence and their clinical experience about the most appropriate acute treatments for patients with schizophrenia. This manuscript represents a synthesis of the panel analysis and discussion.

Results

First contact is very important for service users, as is finding the most adequate treatment setting. If patients present to the emergency department, which may be a traumatic setting for service users, a dedicated environment with adequate space and specialized mental health support, including personnel trained in de-escalation techniques, is recommended. A well-connected continuum of care is strongly recommended, possibly with seamless links between inpatient units, day hospital services, outpatient facilities and rehabilitation services. Ideally, this should be structured as part of a coordinated step-down service line. Treatment challenges include suboptimal response, side effects, and nonadherence, which is reduced by the use of long-acting injectable antipsychotics.

Conclusion

Individual circumstances, including age, gender, and presence of hostility/aggression or self-harm, cognitive impairment and negative symptoms, comorbidities (depression, substance use disorders) or associated symptoms (anxiety, insomnia), should be considered when selecting the most appropriate treatment for the acute phase of schizophrenia. Efficacy and feasibility, as well as acceptability and tolerability of treatments, require joint consideration from the early stages of schizophrenia, thereby enhancing the possibility of improved short- and long-term outcomes.

Impulsivity across severe mental disorders: a cross-sectional study of immune markers and psychopharmacotherapy

BACKGROUND

Impulsivity is a transdiagnostic feature linked to severe clinical expression and a potential target for psychopharmacological strategies. Biological underpinnings are largely unknown, but involvement of immune dysregulation has been indicated, and the effects of psychopharmacological agents vary. We investigated if impulsivity was associated with circulating immune marker levels and with a range of psychopharmacological treatment regimens in severe mental disorders.

METHODS

Impulsivity was assessed in a sample (N = 657) of patients with schizophrenia or schizophreniform disorder (SCZ) (N = 116) or bipolar disorder (BD) (N = 159) and healthy participants (N = 382) using the Barratt Impulsiveness Scale (BIS-11) questionnaire. Plasma levels of systemic immune markers (RANTES, IL-1RA, IL-18, IL-18BP, sTNFR-1) were measured by enzyme immunoassays. Patients underwent thorough clinical assessment, including evaluation of psychotropic medication. Associations were assessed using linear regressions.

RESULTS

Impulsivity  was positively associated with SCZ (p < 0.001) and BD (p < 0.001) diagnosis and negatively associated with age (p < 0.05), but not significantly associated with any of the circulating immune markers independently of diagnostic status. Among patients, impulsivity was negatively associated with lithium treatment (p = 0.003) and positively associated with antidepressant treatment (p = 0.011) after controlling for diagnosis, psychotropic co-medications, manic symptoms, and depressive symptoms.

CONCLUSIONS

We report elevated impulsivity across SCZ and BD but no associations to systemic immune dysregulation based on the current immune marker selection. The present study reveals associations between impulsivity in severe mental disorders and treatment with lithium and antidepressants, with opposite directions. Future studies are warranted to determine the causal directionality of the observed associations with psychopharmacotherapy.

Changes in neurotransmitter levels, brain structural characteristics, and their correlation with PANSS scores in patients with first-episode schizophrenia

BACKGROUND

In patients with schizophrenia, the brain structure and neurotransmitter levels change, which may be related to the occurrence and progression of this disease.

AIM

To explore the relationships between changes in neurotransmitters, brain structural characteristics, and the scores of the Positive and Negative Symptom Scale (PANSS) in patients with first-episode schizophrenia.

METHODS

The case group comprised 97 patients with schizophrenia, who were evaluated using the Canadian Neurological Scale and confirmed by laboratory tests at Ningbo Mental Hospital from January 2020 to July 2022. The control group comprised 100 healthy participants. For all participants, brain structural characteristics were explored by measuring brain dopamine (DA), glutamic acid (Glu), and gamma-aminobutyric acid (GABA) levels, with magnetic resonance imaging. The case group was divided into negative and positive symptom subgroups using PANSS scores for hierarchical analysis. Linear correlation analysis was used to analyze the correlations between neurotransmitters, brain structural characteristics, and PANSS scores.

RESULTS

Patients in the case group had higher levels of DA and lower levels of Glu and GABA, greater vertical and horizontal distances between the corpus callosum and the inferior part of the fornix and larger ventricle area than patients in the control group (P < 0.05). Patients with positive schizophrenia symptoms had significantly higher levels of DA, Glu, and GABA than those with negative symptoms (P < 0.05). In patients with positive schizophrenia symptoms, PANSS score was significantly positively correlated with DA, vertical and horizontal distances between the corpus callosum and the infrafornix, and ventricular area, and was significantly negatively correlated with Glu and GABA (P < 0.05). In patients with negative schizophrenia symptoms, PANSS score was significantly positively correlated with DA, vertical distance between the corpus callosum and the infrafornix, horizontal distance between the corpus callosum and the infrafornix, and ventricular area, and was significantly negatively correlated with Glu and GABA (P < 0.05).

CONCLUSION

In patients with first-episode schizophrenia, DA levels increased, Glu and GABA levels decreased, the thickness of the corpus callosum increased, and these variables were correlated with PANSS scores.

Changes in neurotransmitter levels, brain structural characteristics, and their correlation with PANSS scores in patients with first-episode schizophrenia

BACKGROUND

In patients with schizophrenia, the brain structure and neurotransmitter levels change, which may be related to the occurrence and progression of this disease.

AIM

To explore the relationships between changes in neurotransmitters, brain structural characteristics, and the scores of the Positive and Negative Symptom Scale (PANSS) in patients with first-episode schizophrenia.

METHODS

The case group comprised 97 patients with schizophrenia, who were evaluated using the Canadian Neurological Scale and confirmed by laboratory tests at Ningbo Mental Hospital from January 2020 to July 2022. The control group comprised 100 healthy participants. For all participants, brain structural characteristics were explored by measuring brain dopamine (DA), glutamic acid (Glu), and gamma-aminobutyric acid (GABA) levels, with magnetic resonance imaging. The case group was divided into negative and positive symptom subgroups using PANSS scores for hierarchical analysis. Linear correlation analysis was used to analyze the correlations between neurotransmitters, brain structural characteristics, and PANSS scores.

RESULTS

Patients in the case group had higher levels of DA and lower levels of Glu and GABA, greater vertical and horizontal distances between the corpus callosum and the inferior part of the fornix and larger ventricle area than patients in the control group (P < 0.05). Patients with positive schizophrenia symptoms had significantly higher levels of DA, Glu, and GABA than those with negative symptoms (P < 0.05). In patients with positive schizophrenia symptoms, PANSS score was significantly positively correlated with DA, vertical and horizontal distances between the corpus callosum and the infrafornix, and ventricular area, and was significantly negatively correlated with Glu and GABA (P < 0.05). In patients with negative schizophrenia symptoms, PANSS score was significantly positively correlated with DA, vertical distance between the corpus callosum and the infrafornix, horizontal distance between the corpus callosum and the infrafornix, and ventricular area, and was significantly negatively correlated with Glu and GABA (P < 0.05).

CONCLUSION

In patients with first-episode schizophrenia, DA levels increased, Glu and GABA levels decreased, the thickness of the corpus callosum increased, and these variables were correlated with PANSS scores.

Atypical antipsychotic drugs in dual disorders: current evidence and clinical guidelines

BACKGROUND

Concurrent disorder or dual diagnosis refers to a combination of substance use disorders and mental disorders that occur in the same patient simultaneously. These conditions pose significant clinical and healthcare impacts and are often underdiagnosed, undertreated, and complex to manage.

OBJECTIVE

We assessed the quality of current pharmacological recommendations for the management of dual diagnosis, particularly by evaluating the use of second-generation antipsychotics (SGA).

METHOD

A literature search was performed using the PubMed and Scopus databases for publications up to September 21, 2021, without any time restrictions. The following search strings were used: (aripiprazole OR brexpiprazole OR cariprazine OR paliperidone OR risperidone OR quetiapine OR clozapine OR olanzapine) AND (psychosis OR schizophrenia OR schizoaffective) AND ("substance use disorder" OR cocaine OR alcohol OR cannabis OR heroin OR "double diagnosis" OR "dual diagnosis")) NOT (animal OR rat OR mouse) NOT (review or meta-analysis).

RESULTS

The search produced a final set of 41 articles. Most patients were males and were affected by schizophrenia, with cannabis the most abused substance, followed by alcohol. Aripiprazole was the most used drug, either orally or by long-acting formulations, followed by risperidone with oral and long-acting formulations, clozapine, olanzapine, and quetiapine.

CONCLUSION

The findings highlight the use of SGA for the treatment of psychotic symptoms in comorbidity with substance use. Future studies on people with dual diagnosis and focused on long-term evaluations are warranted and need to investigate the efficacy of newly introduced molecules, such as partial D2 agonists and long-acting injectable antipsychotics.

Interleukin-18 signaling system links to agitation in severe mental disorders

OBJECTIVE

Agitation is a challenging clinical feature in severe mental disorders, but its biological correlates are largely unknown. Inflammasome-related abnormalities have been linked to severe mental disorders and implicated in animal models of agitation. We investigated if levels of circulating inflammasome-related immune markers were associated with agitation in severe mental disorders.

METHODS

Individuals with a psychotic or affective disorder (N = 660) underwent blood sampling and clinical characterization. Plasma levels of interleukin (IL)-18, IL-18 binding protein (IL-18BP), IL-18 receptor 1 (IL-18R1), IL-18 receptor accessory protein (IL-18RAP), and IL-1 receptor antagonist (IL-1RA) were measured. Agitation levels were estimated with the Positive and Negative Syndrome Scale Excited Component. Multiple linear- and logistic regression were used to investigate the associations between agitation and the immune markers, while controlling for confounders. The influence of psychotic and affective symptoms was assessed in follow-up analyses.

RESULTS

Agitation was positively associated with IL-18BP (β = 0.13, t = 3.41, p = 0.0007) after controlling for multiple confounders, including BMI, smoking, medication, and substance use. Adjustment for psychotic, manic, and depressive symptoms did not affect the results. There were no significant associations between agitation and the other investigated immune markers (IL-1RA (β = 0.06, t = 1.27, p = 0.20), IL-18 (β = 0.05, t = 1.25, p = 0.21), IL-18R1 (β = 0.04, t = 1.01, p = 0.31), IL-18RAP (odds ratio = 0.96, p = 0.30)). In a subsample (N = 463), we also adjusted for cortisol levels, which yielded unaltered results.

CONCLUSION

Our findings add to the accumulating evidence of immune system disturbances in severe mental disorders and suggest the IL-18 system as a part of the biological correlate of agitation independent of affective and psychotic symptoms.

Half a century of research on antipsychotics and schizophrenia: A scientometric study of hotspots, nodes, bursts, and trends

Changes over 50 years of research on antipsychotics in schizophrenia have occurred. A scientometric synthesis of such changes over time and a measure of researchers' networks and scientific productivity is currently lacking. We searched Web of Science Core Collection from inception until November 5, 2021, using the appropriate key. Our primary objective was to conduct systematic mapping with CiteSpace to show how clusters of keywords have evolved over time and obtain clusters' structure and credibility. Our secondary objective was to measure research network performance (countries, institutions, and authors) using CiteSpace, VOSviewer, and Bibliometrix. We included 32,240 studies published between 1955 and 2021. The co-cited reference network identified 25 clusters with a well-structured network (Q=0.8166) and highly credible clustering (S=0.91). The main trends of research were: 1) antipsychotic efficacy; 2) cognition in schizophrenia; 3) side effects of antipsychotics. Last five years research trends were: 'ultra-resistance schizophrenia' (S=0.925), 'efficacy/dose-response' (S=0.775), 'evidence-synthesis' (S=0.737), 'real-world effectiveness' (S=0.794), 'cannabidiol' (S=0.989), and 'gut microbiome' (S=0.842). These results can inform funding agencies and research groups' future directions.