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Speyer H, Eplov LF, Roe D. Antipsychotic Discontinuation through the Lens of Epistemic Injustice. Community Ment Health J 2024:10.1007/s10597-024-01274-7. [PMID: 38587713 DOI: 10.1007/s10597-024-01274-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Helene Speyer
- Mental Health Center Copenhagen, Copenhagen University Hospital, Gentofte Hospitalsvej 15, 4., Hellerup, 2900, Denmark.
| | - Lene Falgaard Eplov
- Mental Health Center Copenhagen, Copenhagen University Hospital, Gentofte Hospitalsvej 15, 4., Hellerup, 2900, Denmark
| | - David Roe
- Department of Community Mental Health, University of Haifa, Haifa, 2900, Israel
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2
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Chisholm K, Schirmbeck F, Pinkham AE, Sasson NJ, Simons CJP, de Haan L, Harvey PD, Penn DL, Ziermans T. A Cross-sectional Conceptual Replication and Longitudinal Evaluation of the PANSS-Autism-Severity-Score Measure Suggests it Does Not Capture Autistic Traits in Individuals With Psychosis. Schizophr Bull 2023:sbad161. [PMID: 37992238 DOI: 10.1093/schbul/sbad161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Autism and psychosis co-occur at elevated rates, with implications for clinical outcomes, functioning, and suicidality. The PANSS-Autism-Severity-Score (PAUSS) is a measure of autism trait severity which has not yet been validated externally or longitudinally. STUDY DESIGN Participants were derived from the GROUP and SCOPE datasets. Participants included 1448 adults with schizophrenia spectrum disorder (SSD), 800 SSD-siblings, 103 adults diagnosed with an autistic spectrum condition (ASC), and 409 typically-developing controls (TC). Analyses from the original validation study were conducted with SSD participants, and extended into ASC, SSD-sibling, and TC participants. Test-retest reliability of the PAUSS at 2-weeks and long-term stability 3 and 6-years was also examined. STUDY RESULTS Results differed in important ways from the original validation. SSD participants reported higher PAUSS scores than other groups, with only a fraction of ASC participants scoring as "PAUSS-Autistic." Cronbach's alpha was acceptable for the SSD cohort only. Two-week stability of the PAUSS was fair to good for all PAUSS scores. Long-term stability was poor for most PAUSS items but fair for total PAUSS score. CONCLUSIONS Results suggest that the PAUSS does not appear appropriate for assessing autism, with the low rate of PAUSS-Autistic in the ASC population suggesting the PAUSS may not accurately reflect characteristics of autism. The relative lack of long-term stability is cause for concern and suggestive that the PAUSS is capturing features of psychosis rather than autism traits.
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Affiliation(s)
- Katharine Chisholm
- School of Psychology, Institute of Health and Neurodevelopment, Aston University, Aston St, Birmingham, B4 7ET, UK
| | - Frederike Schirmbeck
- Department of Psychiatry, Amsterdam University Medical Center, Meibergdreef, University of Amsterdam, Amsterdam, The Netherlands
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
| | - Amy E Pinkham
- Department of Psychology, School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, USA
| | - Noah J Sasson
- Department of Psychology, School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, USA
| | - Claudia J P Simons
- Department of Psychiatry and Neuropsychology, Maastricht University Medical Center, School for Mental Health and Neuroscience, Maastricht, The Netherlands
- GGzE Institute for Mental Health Care, Eindhoven, The Netherlands
| | - Lieuwe de Haan
- Department of Psychiatry, Amsterdam University Medical Center, Meibergdreef, University of Amsterdam, Amsterdam, The Netherlands
- Arkin Institute for Mental Health, Amsterdam, The Netherlands
| | - Philip D Harvey
- Department of Psychiatry and Behavioral Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA
- Research Service, Miami VA Healthcare System, Miami, USA
| | - David L Penn
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, USA
- School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, Victoria, Australia
| | - Tim Ziermans
- Department of Psychology, Dutch Autism & ADHD Research Center, University of Amsterdam, Amsterdam, The Netherlands
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3
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Stürup AE, Hjorthøj C, Jensen HD, Melau M, Davy JW, Nordentoft M, Albert N. Self-reported reasons for discontinuation or continuation of antipsychotic medication in individuals with first-episode schizophrenia. Early Interv Psychiatry 2023; 17:974-983. [PMID: 36693651 DOI: 10.1111/eip.13389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/03/2022] [Accepted: 01/01/2023] [Indexed: 01/26/2023]
Abstract
AIM Many individuals with schizophrenia discontinue initially prescribed antipsychotics. Knowledge on reasons for discontinuation among individuals with first-episode schizophrenia is sparse. We aimed to describe reasons for discontinuation and continuation, differences between individuals discontinuing and continuing, and factors predicting reasons for discontinuation or continuation. METHODS This was a prospective cohort study with a post hoc design. Individuals with first-episode schizophrenia were included from early intervention teams in Denmark from 2009-2012. Sociodemographic and clinical variables were collected at baseline and reasons for discontinuation and continuation of antipsychotics were assessed at 3.5-year follow-up. RESULTS Among 215 patients, 76 reported reasons for discontinuation and 139 for continuation. The most frequent reasons for discontinuation were "side effects" and "patient believed he/she no longer needed the medication because he/she was now better". The most frequent reasons for continuation were "benefits for positive symptoms" and "another person told them to". Individuals who discontinued antipsychotics were at baseline younger, had longer DUP, less negative symptoms, better social function, lower compliance, higher self-belief of coping, and fewer used antipsychotics compared to those continuing antipsychotics. CONCLUSIONS The effect of antipsychotics is the main reason to continue, whereas side effects were the main reason to discontinue. Knowledge of reasons to discontinue or continue is helpful in shared decision-making, identifying individuals with high odds of discontinuation, improving adherence, and helping with safe discontinuation.
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Affiliation(s)
- Anne Emilie Stürup
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
- University of Copenhagen, Department of Public Health, Section of Epidemiology, Copenhagen, Denmark
| | - Heidi Dorthe Jensen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
| | - Marianne Melau
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
| | - Josefine Winther Davy
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
| | - Nikolai Albert
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Hellerup, Denmark
- Mental Health Center Amager, University Hospital of Copenhagen, Copenhagen, Denmark
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4
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Stürup AE, Nordentoft M, Jimenez-Solem E, Osler M, Davy JW, Christensen TN, Speyer H, Albert N, Hjorthøj C. Discontinuation of antipsychotics in individuals with first-episode schizophrenia and its association to functional outcomes, hospitalization and death: a register-based nationwide follow-up study. Psychol Med 2023; 53:5033-5041. [PMID: 35818718 DOI: 10.1017/s0033291722002021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Discontinuation of antipsychotic medication may be linked to high risk of relapse, hospitalization and mortality. This study investigated the use and discontinuation of antipsychotics in individuals with first-episode schizophrenia in relation to cohabitation, living with children, employment, hospital admission and death. METHODS Danish registers were used to establish a nationwide cohort of individuals ⩾18 years with schizophrenia included at the time of diagnosis in1995-2013. Exposure was antipsychotic medication calculated using defined daily dose and redeemed prescriptions year 2-5. Outcomes year 5-6 were analysed using binary logistic, negative binomial and Cox proportional hazard regression. RESULTS Among 21 351, 9.3% took antipsychotics continuously year 2-5, 38.6% took no antipsychotics, 3.4% sustained discontinuation and 48.7% discontinued and resumed treatment. At follow-up year 6, living with children or employment was significantly higher in individuals with sustained discontinuation (OR 1.98, 95% CI 1.53-2.56 and OR 2.60, 95% CI 1.91-3.54), non-sustained discontinuation (OR 1.25, 95% CI 1.05-1.48 and 2.04, 95% CI 1.64-2.53) and no antipsychotics (OR 2.00, 95% CI 1.69-2.38 and 5.64, 95% CI 4.56-6.97) compared to continuous users. Individuals with non-sustained discontinuation had more psychiatric hospital admissions (IRR 1.27, 95% CI 1.10-1.47) and longer admissions (IRR 1.68, 95% CI 1.30-2.16) year 5-6 compared to continuous users. Mortality during year 5-6 did not differ between groups. CONCLUSION Most individuals with first-episode schizophrenia discontinued or took no antipsychotics the first years after diagnosis and had better functional outcomes. Non-sustained discontinuers had more, and longer admissions compared to continuous users. However, associations found could be either cause or effect.
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Affiliation(s)
- Anne Emilie Stürup
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology, Center for Clinical Research and Prevention, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Merete Osler
- Center for Clinical Research and Prevention, Frederiksberg Hospital, Denmark
| | - Josefine Winther Davy
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Nordahl Christensen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helene Speyer
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nikolai Albert
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Mental Health Center Amager, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
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5
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Smith LC, Mariegaard L, Vernal DL, Christensen AG, Albert N, Thomas N, Hjorthøj C, Glenthøj LB, Nordentoft M. The CHALLENGE trial: the effects of a virtual reality-assisted exposure therapy for persistent auditory hallucinations versus supportive counselling in people with psychosis: study protocol for a randomised clinical trial. Trials 2022; 23:773. [PMID: 36100943 PMCID: PMC9468536 DOI: 10.1186/s13063-022-06683-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background Many patients suffering from schizophrenia spectrum disorders continue having distressing auditory hallucinations in spite of treatment with antipsychotic medication. The aim of this trial is to examine the effect of a targeted virtual reality therapy for persistent auditory hallucinations in individuals with psychosis. The trial explores whether this type of therapy can decrease the severity, frequency and distress of auditory hallucinations and, additionally, whether it can reduce clinical symptoms and enhance daily functioning in individuals with psychosis. Methods The study is a randomised, assessor-blinded parallel-group superiority clinical trial, allocating a total of 266 patients to either the experimental intervention or supportive counselling. The participants will be randomised to either (1) seven sessions of virtual reality therapy or (2) seven sessions of supportive counselling to be delivered within the first 12 weeks after inclusion in the study. All participants will be assessed at baseline and 12 and 24 weeks post-baseline. Independent assessors blinded to the treatment allocation will evaluate the outcome. The primary outcome is the level of auditory hallucinations measured with the Psychotic Symptoms Rating Scales (PSYRATS-AH) total score at the cessation of treatment at 12 weeks. Secondary outcomes are frequency of auditory hallucinations, the distress caused by auditory hallucinations, perceived voice power, patient acceptance of voices, patients’ ability to respond to voices in an assertive way and social and daily function. Discussion Promising evidence of the efficacy of this immersive virtual reality-based therapy for auditory hallucinations exist, but evidence needs to be established in a large, methodological rigorous trial. If the therapy proves to be beneficial in reducing the severity of refractory auditory hallucinations, a large group of patients with schizophrenia and related disorders could be the target group of this short-term psychotherapeutic intervention.
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Affiliation(s)
- L C Smith
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark.
| | - L Mariegaard
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark
| | - D L Vernal
- Psychiatry, Aalborg University Hospital, Aalborg, North Denmark Region, Denmark
| | - A G Christensen
- Mental Health Center Esbjerg, Esbjerg, Region of South Denmark, Denmark
| | - N Albert
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark
| | - N Thomas
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Australia
| | - C Hjorthøj
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - L B Glenthøj
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark.,Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - M Nordentoft
- Research Unit (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Capital Region of Denmark, Denmark
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6
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Jeppesen UN, Due AS, Mariegaard L, Pinkham A, Vos M, Veling W, Nordentoft M, Glenthøj LB. Face Your Fears: Virtual reality-based cognitive behavioral therapy (VR-CBT) versus standard CBT for paranoid ideations in patients with schizophrenia spectrum disorders: a randomized clinical trial. Trials 2022; 23:658. [PMID: 35971137 PMCID: PMC9377061 DOI: 10.1186/s13063-022-06614-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Schizophrenia spectrum disorders cause suffering for patients, relatives, and the surrounding society. Paranoid ideations, encompassing ideas of social reference and manifest persecutory delusions, are among the most frequent symptoms in this population and a cause of significant distress. Recent meta-analyses of cognitive behavioral therapy (CBT) for psychosis show small to moderate effect sizes in reducing paranoid ideations. Virtual reality-based CBT (VR-CBT) could improve therapy efficacy as exposure and behavioral experiments in VR can be optimized, individualized, and carried out in a safe environment. Few VR-CBT studies exist for paranoid ideations and there is a need for large-scale, methodologically rigorous trials. METHODS This study is a randomized, assessor-blinded parallel-groups multi-center superiority clinical trial, fulfilling the CONSORT criteria for non-pharmacological treatment. A total of 256 patients diagnosed with schizophrenia spectrum disorder, including schizotypal disorder (ICD-10 F20-29), will be allocated to either 10 sessions of symptom-specific CBT-VR plus treatment as usual-versus 10 sessions of standard symptom-specific CBT for paranoid ideations (CBT) plus treatment as usual. All participants will be assessed at baseline, treatment end (3 months post baseline), and then 9 months post baseline. A stratified block-randomization with concealed randomization sequence will be conducted. Independent assessors blinded to the treatment will evaluate the outcome. Analysis of outcome will be carried out with the intention to treat principles. The primary outcome is ideas of social reference measured with Green Paranoid Thought Scale Part A (GPTS-A) at the cessation of treatment at 3 months post baseline. Secondary outcomes are ideas of persecution (GPTS-B), Social Interaction Anxiety Scale (SIAS), Personal and Social Performance scale (PSP), Safety Behavior Questionnaire (SBQ), and CANTAB Emotion Recognition Task. DISCUSSION The trial will elucidate whether VR-CBT can enhance therapy efficacy for paranoid ideations. Additionally, Trial findings will provide evidence on the effectiveness and cost-effectiveness of VR-CBT for paranoid ideations that can guide the possible dissemination and implementation into clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT04902066 . Initial release April 9th, 2021.
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Affiliation(s)
- U. N. Jeppesen
- grid.5254.60000 0001 0674 042XCopenhagen Research Centre on Mental Health (CORE), University of Copenhagen, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - A. S. Due
- grid.5254.60000 0001 0674 042XCopenhagen Research Centre on Mental Health (CORE), University of Copenhagen, Copenhagen, Denmark
| | - L. Mariegaard
- grid.5254.60000 0001 0674 042XCopenhagen Research Centre on Mental Health (CORE), University of Copenhagen, Copenhagen, Denmark
| | - A. Pinkham
- grid.267323.10000 0001 2151 7939School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, USA
| | - M. Vos
- grid.4494.d0000 0000 9558 4598Faculty of Medical Sciences, University Medical Center Groningen, Center of Psychiatry, University of Groningen, Groningen, Netherlands
| | - W. Veling
- grid.4494.d0000 0000 9558 4598Faculty of Medical Sciences, University Medical Center Groningen, Center of Psychiatry, University of Groningen, Groningen, Netherlands
| | - M. Nordentoft
- grid.5254.60000 0001 0674 042XCopenhagen Research Centre on Mental Health (CORE), University of Copenhagen, Copenhagen, Denmark
| | - L. B. Glenthøj
- grid.5254.60000 0001 0674 042XCopenhagen Research Centre on Mental Health (CORE), University of Copenhagen, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Psychology, University of Copenhagen, Copenhagen, Denmark
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7
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Stürup AE, Hjorthøj C, Albert N, Dolmer S, Birk M, Ebdrup BH, Eplov LF, Jensen H, Vernal DL, Speyer H, Mors O, Nordentoft M. Tapered discontinuation vs. maintenance therapy of antipsychotic medication in patients with first-episode schizophrenia: Obstacles, findings, and lessons learned in the terminated randomized clinical trial TAILOR. Front Psychiatry 2022; 13:910703. [PMID: 35935409 PMCID: PMC9355082 DOI: 10.3389/fpsyt.2022.910703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022] Open
Abstract
AIM Evidence is insufficient regarding the consequences of discontinuing vs. maintaining antipsychotic medication in patients with first-episode schizophrenia. Our aim was to examine tapered discontinuation vs. maintenance treatment regarding remission of psychotic symptoms and impact on other areas. METHODS Patients included had a diagnosis of schizophrenia, were treated with antipsychotic medication, and were in remission of psychotic symptoms. Participants were randomized to tapered discontinuation or maintenance treatment with antipsychotic medication. Assessments were undertaken at baseline and after 1-year. The primary outcome was remission of psychotic symptoms without antipsychotic medication. RESULTS The trial was terminated due to insufficient recruitment. In total, 29 participants were included: 14 in the tapering/discontinuation group and 15 in the maintenance group. Adherence to maintenance treatment was poor. At 1-year follow-up, remission of psychotic symptoms without antipsychotic medication for 3 months was observed in five participants in the tapering/discontinuation group and two in the maintenance group. CONCLUSION Due to insufficient recruitment this study does not provide a conclusion on whether unfavorable outcomes or advantages follow tapering of antipsychotic medication. Recruitment and adherence to maintenance treatment encountered obstacles. Based on experiences from this trial, we discussed alternative study designs as consistent evidence is still needed on whether to continue or discontinue antipsychotic medication in remitted patients with first-episode schizophrenia. CLINICAL TRIAL REGISTRATION https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-000565-23/DK, EU Clinical Trials Register-EudraCT no. 2016-000565-23.
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Affiliation(s)
- Anne Emilie Stürup
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark.,Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nikolai Albert
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark.,Psychiatry Øst, Region Sjælland, Roskilde, Denmark
| | - Signe Dolmer
- Psychosis Research Unit, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Merete Birk
- Psychosis Research Unit, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bjørn H Ebdrup
- Center for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, University of Copenhagen, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heidi Jensen
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ditte Lammers Vernal
- Unit for Psychiatric Research, Psychiatry, Department of Clinical Medicine, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Helene Speyer
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mors
- Psychosis Research Unit, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
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8
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Neumann SR, Glue P, Linscott RJ. Aberrant salience and reward processing: a comparison of measures in schizophrenia and anxiety. Psychol Med 2021; 51:1507-1515. [PMID: 32148214 DOI: 10.1017/s0033291720000264] [Citation(s) in RCA: 6] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Aberrant salience may contribute to the development of schizophrenia symptoms via alterations in reward processing and motivation. However, tests of this hypothesis have yielded inconsistent results. These inconsistencies may reflect problems with the validity and specificity of measures of aberrant salience in schizophrenia. Therefore, we investigated relationships among measures of aberrant salience, reward, and motivation in schizophrenia and anxiety. METHOD Individuals with schizophrenia (n = 30), anxiety (n = 33) or unaffected by mental disorder (n = 30) completed measures of aberrant salience [Aberrant Salience Inventory (ASI), Salience Attribution Test (SAT)], motivation (Effort Expenditure for Reward Task), and reinforcer sensitivity (Stimulus Chase Task). RESULTS Schizophrenia participants scored higher than anxiety (d = 0.71) and unaffected (d = 1.54) groups on the ASI and exhibited greater aberrant salience (d = 0.60) and lower adaptive salience (d = 0.98) than anxious participants on the SAT. There was no evidence of a correlation between measures of aberrant salience. Schizophrenia was associated with related deficits in motivated behaviour and maladaptive reward processing. However, these differences in reward processing did not correlate with aberrant salience measures. CONCLUSIONS The results suggest that key measures of aberrant salience have limited specificity and validity. These problems may account for inconsistent findings reported in the literature.
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Affiliation(s)
| | - Paul Glue
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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9
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Kim S, Shin SH, Santangelo B, Veronese M, Kang SK, Lee JS, Cheon GJ, Lee W, Kwon JS, Howes OD, Kim E. Dopamine dysregulation in psychotic relapse after antipsychotic discontinuation: an [ 18F]DOPA and [ 11C]raclopride PET study in first-episode psychosis. Mol Psychiatry 2021; 26:3476-3488. [PMID: 32929214 DOI: 10.1038/s41380-020-00879-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 01/09/2023]
Abstract
Although antipsychotic drugs are effective for relieving the psychotic symptoms of first-episode psychosis (FEP), psychotic relapse is common during the course of the illness. While some FEPs remain remitted even without medication, antipsychotic discontinuation is regarded as the most common risk factor for the relapse. Considering the actions of antipsychotic drugs on presynaptic and postsynaptic dopamine dysregulation, this study evaluated possible mechanisms underlying relapse after antipsychotic discontinuation. Twenty five FEPs who were clinically stable and 14 matched healthy controls were enrolled. Striatal dopamine activity was assessed as Kicer value using [18F]DOPA PET before and 6 weeks after antipsychotic discontinuation. The D2/3 receptor availability was measured as BPND using [11C]raclopride PET after antipsychotic discontinuation. Healthy controls also underwent PET scans according to the corresponding schedule of the patients. Patients were monitored for psychotic relapse during 12 weeks after antipsychotic discontinuation. 40% of the patients showed psychotic relapse after antipsychotic discontinuation. The change in Kicer value over time significantly differed between relapsed, non-relapsed patients and healthy controls (Week*Group: F = 4.827, df = 2,253.193, p = 0.009). In relapsed patients, a significant correlation was found between baseline striatal Kicer values and time to relapse after antipsychotic discontinuation (R2 = 0.518, p = 0.018). BPND were not significantly different between relapsed, non-relapsed patients and healthy controls (F = 1.402, df = 2,32.000, p = 0.261). These results suggest that dysfunctional dopamine autoregulation might precipitate psychotic relapse after antipsychotic discontinuation in FEP. This finding could be used for developing a strategy for the prevention of psychotic relapse related to antipsychotic discontinuation.
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Affiliation(s)
- Seoyoung Kim
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sang Ho Shin
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Barbara Santangelo
- Centre for Neuroimaging Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mattia Veronese
- Centre for Neuroimaging Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Seung Kwan Kang
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Biomedical Sciences, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jae Sung Lee
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Biomedical Sciences, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Institute of Radiation Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Woojoo Lee
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Republic of Korea
| | - Oliver D Howes
- Department of Psychosis studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Psychiatric Imaging, Medical Research Council Clinical Sciences Centre, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Euitae Kim
- Department of Psychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea. .,Department of Psychiatry, College of Medicine, Seoul National University, Seoul, Republic of Korea. .,Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Republic of Korea.
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10
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Mayoral-van Son J, Juncal-Ruiz M, Ortiz-García de la Foz V, Vázquez-Bourgon J, Setién-Suero E, Tordesillas-Gutiérrez D, Gómez-Revuelta M, Ayesa-Arriola R, Crespo-Facorro B. Long-term clinical and functional outcome after antipsychotic discontinuation in early phases of non-affective psychosis: Results from the PAFIP-10 cohort. Schizophr Res 2021; 232:28-30. [PMID: 34004383 DOI: 10.1016/j.schres.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/01/2021] [Accepted: 04/24/2021] [Indexed: 10/21/2022]
Affiliation(s)
- J Mayoral-van Son
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocio-IBIS, Sevilla, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain.
| | - M Juncal-Ruiz
- Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Psychiatry Sierrallana Hospital, Torrelavega, Cantabria, Spain
| | - V Ortiz-García de la Foz
- Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - J Vázquez-Bourgon
- Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Spain; Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
| | - E Setién-Suero
- Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
| | - D Tordesillas-Gutiérrez
- Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Spain; Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
| | - M Gómez-Revuelta
- Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
| | - R Ayesa-Arriola
- Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Spain; Department of Psychiatry, University Hospital Marqués de Valdecilla - Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain; Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain
| | - B Crespo-Facorro
- Department of Psychiatry, School of Medicine, University Hospital Virgen del Rocio-IBIS, Sevilla, Spain; Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Spain; Department of Psychiatry, School of Medicine, University of Seville, Spain
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11
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Strålin P, Skott M, Cullberg J. Early predictors for late hospitalizations up to 14 years after first episode psychosis. Soc Psychiatry Psychiatr Epidemiol 2021; 56:1371-1380. [PMID: 33263822 PMCID: PMC8316245 DOI: 10.1007/s00127-020-01991-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/10/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE New hospitalizations after first episode psychosis (FEP) may be viewed as an indicator of instability in a psychotic disorder. In the current study we wanted to analyse long term risk for psychosis hospitalizations after FEP. We also wanted to analyse predictors for late hospitalizations, with focus on early antipsychotic medication. METHODS First episode psychosis cases were recruited to the Swedish Parachute project in 1996-1997. The program offered highly available and continuous psychosocial support and a cautious use of antipsychotic medication for 5 years from inclusion. Longitudinal data from population registers on psychiatric hospitalizations up to 14 years after inclusion were analysed. One hundred and sixty-one cases were included of the original 175 in the project. Associations with possible early predictive factors from the original project data were analysed with COX regression. RESULTS A majority of the cases (67%) had hospitalizations in the first year after inclusion in the study. The cohort then diverged into a group (46%) with new hospitalizations for psychosis after the first year, most of them multiple times, and another group (54%) without new hospitalizations for psychosis, many without any late antipsychotic medication. Forty-two percentage of the cases had antipsychotic medication by month 12, and it was significantly associated with later psychosis hospitalizations (HR = 2.5, p value < 0.001). CONCLUSIONS The study demonstrates that a large part of FEP cases have a good outcome as measured by absence of new hospitalizations for psychosis, and that many cases may terminate antipsychotic medication within a year of FEP onset without later relapses needing hospitalizations.
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Affiliation(s)
- Pontus Strålin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maria Skott
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
| | - Johan Cullberg
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
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12
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Ayesa-Arriola R, de la Foz VOG, Setién-Suero E, Ramírez-Bonilla ML, Suárez-Pinilla P, Son JMV, Vázquez-Bourgon J, Juncal-Ruiz M, Gómez-Revuelta M, Tordesillas-Gutiérrez D, Crespo-Facorro B. Understanding sex differences in long-term outcomes after a first episode of psychosis. NPJ SCHIZOPHRENIA 2020; 6:33. [PMID: 33219222 PMCID: PMC7679369 DOI: 10.1038/s41537-020-00120-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022]
Abstract
While sex differences in schizophrenia have long been reported and discussed, long-term sex differences in outcomes among first episode of psychosis (FEP) patients in terms of the efficacy of Early Intervention Services (EIS) has been an under-explored area. A total of 209 FEP patients (95 females and 114 males) were reassessed after a time window ranging from 8 to 16 years after their first contact with an EIS program (PAFIP) that we will call the 10-year PAFIP cohort. Multiple clinical, cognitive, functioning, premorbid, and sociodemographic variables were explored at 1-year, 3-year and 10-year follow-ups. At first contact, females were older at illness onset, had higher premorbid adjustment and IQ, and were more frequently employed, living independently, and accompanied by a partner and/or children. Existence of a schizophrenia diagnosis, and cannabis and alcohol consumption were more probable among men. During the first 3 years, women showed a significantly better response to minimal antipsychotic dosages and higher rates of recovery than men (50% vs. 30.8%). Ten years later, more females continued living independently and had partners, while schizophrenia diagnoses and cannabis consumption continued to be more frequent among men. Females also presented a lower severity of negative symptoms; however, functionality and recovery differences did not show significant differences (46.7% vs. 34.4%). Between the 3- and 10-year follow-up sessions, an increase in dosage of antipsychotics was observed. These results suggest that the better outcomes seen among women during the first 3 years (while they were treated in an EIS) were in the presence of more favourable premorbid and baseline characteristics. After an average period of 10 years, with the only difference being in negative symptoms course, outcomes for women approximated those of men, drawing particular attention to the increase in dosage of antipsychotic medication once FEP patients were discharged from the EIS program towards community-based services. These findings help to pose the question of whether it is advisable to target sexes and lengthen EIS interventions.
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Affiliation(s)
- Rosa Ayesa-Arriola
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain. .,CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain.
| | - Víctor Ortíz-García de la Foz
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain.,CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain
| | - Esther Setién-Suero
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain
| | - María Luz Ramírez-Bonilla
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain
| | - Paula Suárez-Pinilla
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain.,CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain
| | - Jacqueline Mayoral-van Son
- CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain.,Hospital Universitario Virgen del Rocío, Department of Psychiatry, Universidad de Sevilla, Sevilla, Spain.,Instituto de Investigacion Sanitaria de Sevilla, IBiS, Sevilla, Spain
| | - Javier Vázquez-Bourgon
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain.,CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain
| | - María Juncal-Ruiz
- Sierrallana Hospital, Department of Psychiatry, IDIVAL, School of Medicine, University of Cantabria, Torrelavega, Spain
| | - Marcos Gómez-Revuelta
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain
| | - Diana Tordesillas-Gutiérrez
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IDIVAL. School of Medicine, University of Cantabria, Santander, Spain.,CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain
| | - Benedicto Crespo-Facorro
- CIBERSAM, Centro InvestigaciónBiomédicaen Red Salud Mental, Madrid, Spain.,Hospital Universitario Virgen del Rocío, Department of Psychiatry, Universidad de Sevilla, Sevilla, Spain.,Instituto de Investigacion Sanitaria de Sevilla, IBiS, Sevilla, Spain
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13
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Cumming P, Abi-Dargham A, Gründer G. Molecular imaging of schizophrenia: Neurochemical findings in a heterogeneous and evolving disorder. Behav Brain Res 2020; 398:113004. [PMID: 33197459 DOI: 10.1016/j.bbr.2020.113004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/22/2020] [Accepted: 10/31/2020] [Indexed: 02/07/2023]
Abstract
The past four decades have seen enormous efforts placed on a search for molecular markers of schizophrenia using positron emission tomography (PET) and single photon emission computed tomography (SPECT). In this narrative review, we cast a broad net to define and summarize what researchers have learned about schizophrenia from molecular imaging studies. Some PET studies of brain energy metabolism with the glucose analogue FDGhave have shown a hypofrontality defect in patients with schizophrenia, but more generally indicate a loss of metabolic coherence between different brain regions. An early finding of significantly increased striatal trapping of the dopamine synthesis tracer FDOPA has survived a meta-analysis of many replications, but the increase is not pathognomonic of the disorder, since one half of patients have entirely normal dopamine synthesis capacity. Similarly, competition SPECT studies show greater basal and amphetamine-evoked dopamine occupancy at post-synaptic dopamine D2/3 receptors in patients with schizophrenia, but the difference is likewise not pathognomonic. We thus propose that molecular imaging studies of brain dopamine indicate neurochemical heterogeneity within the diagnostic entity of schizophrenia. Occupancy studies have established the relevant target engagement by antipsychotic medications at dopamine D2/3 receptors in living brain. There is evidence for elevated frontal cortical dopamine D1 receptors, especially in relation to cognitive deficits in schizophrenia. There is a general lack of consistent findings of abnormalities in serotonin markers, but some evidence for decreased levels of nicotinic receptors in patients. There are sparse and somewhat inconsistent findings of reduced binding of muscarinic, glutamate, and opioid receptors ligands, inconsistent findings of microglial activation, and very recently, evidence of globally reduced levels of synaptic proteins in brain of patients. One study reports a decline in histone acetylase binding that is confined to the dorsolateral prefrontal cortex. In most contexts, the phase of the disease and effects of past or present medication can obscure or confound PET and SPECT findings in schizophrenia.
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Affiliation(s)
- Paul Cumming
- Department of Nuclear Medicine, Inselspital, Bern University, Bern, Switzerland; School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia.
| | - Anissa Abi-Dargham
- Stony Brook University, Renaissance School of Medicine, Stony Brook, New York, USA
| | - Gerhard Gründer
- Central Institute of Mental Health, Department of Molecular Neuroimaging, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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14
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Relapse rates following antipsychotic discontinuation in the maintenance phase after first-episode of schizophrenia: Results of a long-term follow-up study. Schizophr Res 2020; 225:31-38. [PMID: 31653578 DOI: 10.1016/j.schres.2019.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/06/2019] [Accepted: 10/08/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND When the antipsychotic treatment should be discontinued after first-episode of schizophrenia (FES) in patients who had a good response to initial treatment is still controversial. The aim of this naturalistic follow-up study was to determine the rate of antipsychotic discontinuation in the maintenance phase and its consequences, after FES. METHODS FES patients (n = 105) were followed-up for at least 24 months and up to 22 years (mean = 99.1 months). After minimum one-year antipsychotic treatment without relapse, some patients' antipsychotics were discontinued by psychiatrist. We compared the clinical characteristics of this group to those who stopped their medication themselves and analyzed the predictors of being relapse-free after discontinuation. RESULTS Seventeen (16.2%) of the patients' antipsychotic was discontinued by their psychiatrist. Using the same antipsychotic during the first year was the predictor of discontinuation by the psychiatrist in logistic regression analysis. Ten (58.8%) of them relapsed. Thirty-nine patients (37.1%) discontinued their antipsychotic themselves, relapse rate was 76.9% (n = 30). There was no clinical difference between these two groups. Overall, the patients who had no relapse after discontinuation had better role and global functioning at baseline, were more likely to meet remission criteria, and their antipsychotic was discontinued by psychiatrist and use same antipsychotic during the first year. CONCLUSION Our findings suggest that antipsychotic discontinuation by psychiatrist was possible for only small portion of the FES patients, and relapse rates are high after discontinuation even in these selected patients.
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Abstract
PURPOSE OF REVIEW Clinical practice guidelines (CPGs) do not usually offer a sex-specific approach for the management of schizophrenia. With this narrative review, we aim to give an integrated and synthesized overview of the current state of knowledge regarding sex-specific aspects in schizophrenia and how this topic may be adapted in the development of CPGs. RECENT FINDINGS Recent studies further suggest sex-specific differences in epidemiologic features, the course of illness, underlying pathomechanisms, response likelihood to antipsychotic medication and differences in tolerability. Beyond this, selective estrogen receptor modulators like raloxifene have shown beneficial effects on symptom severity and cognition in women with schizophrenia. SUMMARY Sex-specific aspects can already be integrated in clinical guideline recommendations, especially with regard to efficacy and tolerability of antipsychotic treatment. Moreover, these aspects may be used for an individual risk-stratification. Recent studies provide evidence supporting the hypothesis of sex-specific modulation in schizophrenia and build the groundwork for sex-specific novel treatment options. However, there remains a clear need for additional studies focusing on women with schizophrenia to substantiate current findings.
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16
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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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17
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Seeman MV. Men and women respond differently to antipsychotic drugs. Neuropharmacology 2019; 163:107631. [PMID: 31077728 DOI: 10.1016/j.neuropharm.2019.05.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/19/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response. OBJECTIVE The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years. FINDINGS There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well. CONCLUSION There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.
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Affiliation(s)
- Mary V Seeman
- Department of Psychiatry, University of Toronto, 260 Heath St. West, Toronto, Ontario, M5P 3L6, Canada.
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18
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Davidson M. The debate regarding maintenance treatment with antipsychotic drugs in schizophrenia. DIALOGUES IN CLINICAL NEUROSCIENCE 2019. [PMID: 30581291 PMCID: PMC6296388 DOI: 10.31887/dcns.2018.20.3/mdavidson] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Several large meta-analyses of maintenance trials have confirmed that patients who suffer from chronic schizophrenia, randomized to placebo, are likely to experience earlier symptomatic worsening than patients randomized to a dopamine (DA)-blocking drug. These findings led expert groups to issue treatment guidelines, which recommend treatment with DA-blocking drugs for periods ranging from several years to indefinitely. The recommendations were accepted by the majority of, but not all, the experts, some of whom proposed a targeted or intermittent therapy approach by which DA-blocking drugs are discontinued upon symptomatic remission, to be renewed in case of symptom re-emergence. The debate between continued and targeted treatment approaches arises from disagreements regarding scientific and ethical questions. Scientifically, the discussion focuses on the quality and interpretation of the supporting or detracting evidence regarding each treatment option. For example, what is the percentage of individuals who can maintain stability off drugs? What is the rate of individuals who exacerbate despite maintenance treatment? What is the percentage of individuals who experience drug-related adverse effects? How can we interpret results of open-label, nonrandomized targeted trials? Regarding ethical questions, the debating sides disagree on how to weigh the impact of the decreased risk for exacerbation versus the certainty of adverse effects on the patients quality of life, and how to reach a patient-therapist shared decision within the constraints of mental illness.
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Affiliation(s)
- Michael Davidson
- UniSackler School of Medicine, Tel Aviv, Israel; Nicosia Medical School, Nicosia, Cyprus
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19
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Correll CU, Rubio JM, Kane JM. What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia? World Psychiatry 2018; 17:149-160. [PMID: 29856543 PMCID: PMC5980517 DOI: 10.1002/wps.20516] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The long-term benefit-to-risk ratio of sustained antipsychotic treatment for schizophrenia has recently been questioned. In this paper, we critically examine the literature on the long-term efficacy and effectiveness of this treatment. We also review the evidence on the undesired effects, the impact on physical morbidity and mortality, as well as the neurobiological correlates of chronic exposure to antipsychotics. Finally, we summarize factors that affect the risk-benefit ratio. There is consistent evidence supporting the efficacy of antipsychotics in the short term and mid term following stabilization of acute psychotic symptoms. There is insufficient evidence supporting the notion that this effect changes in the long term. Most, but not all, of the long-term cohort studies find a decrease in efficacy during chronic treatment with antipsychotics. However, these results are inconclusive, given the extensive risk of bias, including increasing non-adherence. On the other hand, long-term studies based on national registries, which have lower risk of bias, find an advantage in terms of effectiveness during sustained antipsychotic treatment. Sustained antipsychotic treatment has been also consistently associated with lower mortality in people with schizophrenia compared to no antipsychotic treatment. Nevertheless, chronic antipsychotic use is associated with metabolic disturbance and tardive dyskinesia. The latter is the clearest undesired clinical consequence of brain functioning as a potential result of chronic antipsychotic exposure, likely from dopaminergic hypersensitivity, without otherwise clear evidence of other irreversible neurobiological changes. Adjunctive psychosocial interventions seem critical for achieving recovery. However, overall, the current literature does not support the safe reduction of antipsychotic dosages by 50% or more in stabilized individuals receiving adjunctive psychosocial interventions. In conclusion, the critical appraisal of the literature indicates that, although chronic antipsychotic use can be associated with undesirable neurologic and metabolic side effects, the evidence supporting its long-term efficacy and effectiveness, including impact on life expectancy, outweighs the evidence against this practice, overall indicating a favorable benefit-to-risk ratio. However, the finding that a minority of individuals diagnosed initially with schizophrenia appear to be relapse free for long periods, despite absence of sustained antipsychotic treatment, calls for further research on patient-level predictors of positive outcomes in people with an initial psychotic presentation.
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Affiliation(s)
- Christoph U Correll
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Jose M Rubio
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - John M Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA
- Hofstra Northwell School of Medicine, Hempstead, NY, USA
- Feinstein Institute for Medical Research, Manhasset, NY, USA
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20
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Stürup AE, Jensen HD, Dolmer S, Birk M, Albert N, Nielsen M, Hjorthøj C, Eplov L, Ebdrup BH, Mors O, Nordentoft M. TAILOR - tapered discontinuation versus maintenance therapy of antipsychotic medication in patients with newly diagnosed schizophrenia or persistent delusional disorder in remission of psychotic symptoms: study protocol for a randomized clinical trial. Trials 2017; 18:445. [PMID: 28962668 PMCID: PMC5622425 DOI: 10.1186/s13063-017-2172-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
Background The aim of the TAILOR trial is to investigate the effect of closely monitored tapering/discontinuation versus maintenance therapy with antipsychotic medication in patients with newly diagnosed schizophrenia or persistent delusional disorder and with minimum 3 months’ remission of psychotic symptoms. Methods and design Two hundred and fifty patients will be included from the psychiatric early intervention program, OPUS, in two regions in Denmark. Inclusion criteria are: ICD-10 diagnoses schizophrenia (F20, except F20.6) or persistent delusional disorder (F22), minimum 3 months’ remission of psychotic symptoms and in treatment with antipsychotic medication (except clozapine). The patients will be randomized to maintenance therapy or tapering/discontinuation with antipsychotic medication in a 1-year intervention. The tapering/discontinuation group will be using a smartphone application to monitor early warning signs of psychotic relapse. Patients will be assessed at baseline, 1-, 2- and 5-year follow-up regarding psychotic and negative symptoms, side-effects of antipsychotic medication, social functioning, cognitive functioning, perceived health status, patient satisfaction, substance and alcohol use, sexual functioning and quality of life. The primary outcome will be remission of psychotic symptoms and no antipsychotic medication after 1 year. Secondary outcome measures will include: co-occurrence of remission of psychotic symptoms and 0–1-mg haloperidol equivalents of antipsychotic medication after 1-year intervention; antipsychotic dose; antipsychotic side effects; negative symptoms; social functioning; cognitive functioning; and patient satisfaction. Exploratory outcomes will include remission, clinical recovery, substance and alcohol use, sexual functioning, quality of life, self-beliefs of coping and user experience of support from health workers. Safety measures will include death, admissions to psychiatric hospital, severe self-harm and psychotic relapses. Discussion The TAILOR trial will contribute knowledge about the effect of tapering/discontinuation of antipsychotic medication in the early phases of schizophrenia and related disorders and the results may guide future clinical treatment regimens of antipsychotic treatment. Trial registration EU Clinical Trials Register – EudraCT number: 2016-000565-23. Registered on 5 February 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2172-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Emilie Stürup
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark. .,University of Copenhagen, Institute for Clinical Medicine, Faculty of Health and Medical Science, Blegdamsvej 3B, 2200, Copenhagen N, Denmark.
| | - Heidi Dorthe Jensen
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark
| | - Signe Dolmer
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark
| | - Merete Birk
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark
| | - Nikolai Albert
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark
| | - Mai Nielsen
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark
| | - Carsten Hjorthøj
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark
| | - Lene Eplov
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark
| | - Bjørn H Ebdrup
- Centre for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS) and Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, Copenhagen University Hospital, Nordre Ringvej 69, 2600, Glostrup, Denmark
| | - Ole Mors
- Psychosis Research Unit, Aarhus University Hospital, Skovagervej 2, 8240, Risskov, Denmark
| | - Merete Nordentoft
- Copenhagen University Hospital, Mental Health Center Copenhagen, Kildegårsvej 28, opg. 15 4. sal, 2900, Hellerup, Denmark.,University of Copenhagen, Institute for Clinical Medicine, Faculty of Health and Medical Science, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
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