Effectiveness of antipsychotic drugs in patients with chronic schizophrenia

Patient Voices: Lived Experiences of Decision-Making Process in Long-Term Antipsychotic Medication Treatment

This research explores patients' perspectives on the decision-making process for long-term antipsychotic treatment. Twenty individuals on non-compulsory antipsychotic medications were interviewed, and their responses were analyzed using grounded theory. The analysis revealed three interconnected themes that suggest a cyclical process potentially eroding patient autonomy: According to participants' accounts, they often received limited information about dependence, withdrawal symptoms, or expected treatment duration before starting medication. Subsequently, many reported developing desires to stop or reduce their antipsychotic treatment. Participants then described experiencing dismissal of their reported side effects or treatment ineffectiveness, lack of alternatives, and opposition to reduction attempts from their psychiatrists. These experiences formed a cycle where initial information gaps contributed to later challenges when attempting treatment modifications. The findings emphasize the value of comprehensive information delivery, serious consideration of patients' reported experiences, and treatment processes that enhance patients' sense of autonomy in their psychiatric care.

We like to move it - patients with schizophrenia spectrum disorders are impaired in estimating their physical fitness levels and benefit from individualized exercise

BACKGROUND

People with schizophrenia spectrum disorders (SSD) engage less in physical activity than healthy individuals. The impact of subjectively assessed physical fitness levels on motivation for sports engagement and its relation to objective fitness parameters in SSD is unclear.

METHODS

25 patients with SSD (P-SSD) and 24 healthy controls (H-CON) participated in a randomized controlled study. Individual anaerobic thresholds (AT) were determined by an incremental exercise test and on separate days, aerobic exercise (cycling at 80% of workload at AT) and non-exercise control (sitting on an ergometer without cycling) sessions were performed. Demographic, clinical and objective physical fitness data (i.e., weekly physical activity, workload at AT, heart rate) were collected. Subjective physical fitness parameters were assessed before and after exercise and control sessions.

RESULTS

Weekly physical activity in P-SSD was lower than in H-CON (p < 0.05) attributed to reduced engagement in sport activities (p < 0.001). Workload and percentage of predicted maximal heart rate at AT were also reduced in P-SSD compared to H-CON (both p < 0.05). Although objective and subjective physical fitness parameters were related in H-CON (p < 0.01), this relationship was absent in P-SSD. However, during exercise sessions subjective physical fitness ratings increased to a stronger extent in P-SSD than H-CON (p < 0.05).

CONCLUSION

The missing relationship between subjective and objective physical fitness parameters in people with SSD may represent a barrier for stronger engagement in physical activity. Accordingly, supervised exercise interventions with individually adjusted workload intensity may support realistic subjective fitness estimations and enhance motivation for sports activity in individuals with SSD.

Mapping Lesions That Cause Psychosis to a Human Brain Circuit and Proposed Stimulation Target

Importance

Identifying anatomy causally involved in psychosis could inform therapeutic neuromodulation targets for schizophrenia.

Objective

To assess whether lesions that cause secondary psychosis have functional connections to a common brain circuit.

Design, Setting, and Participants

This case-control study mapped functional connections of published cases of lesions causing secondary psychosis compared with control lesions unassociated with psychosis. Published cases of lesion-induced psychosis were analyzed in a computational laboratory. Participants had documented brain lesions associated with new-onset psychotic symptoms without a history of psychosis. Control cases included 1156 patients with lesions not associated with psychosis. Generalizability across lesional datasets was assessed using an independent cohort of 181 patients with brain lesions who subsequently underwent neurobehavioral testing. Data were analyzed from June 2022 to April 2024.

Exposures

Lesions causing secondary psychosis.

Main Outcomes and Measures

Psychosis or no psychosis.

Results

A total of 153 lesions from published cases were determined to be causal of psychosis, 42 of which were described as schizophrenia or schizophrenia-like (71 [46%] patients were male, 82 [54%] female; mean [SD] age, 50.0 [20.8] years). Lesions that caused secondary psychosis mapped to a common brain circuit defined by functional connectivity to the posterior subiculum of the hippocampus (84% functional overlap, family-wise error [FWE] rate corrected P < 5 × 10-5). At a lower statistical threshold (>75% overlap, FWE-corrected P < 5 × 10-4), this circuit included the ventral tegmental area, retrosplenial cortex, lobule IX and dentate nucleus of the cerebellum, and the mediodorsal and midline nuclei of the thalamus. This circuit was consistent when derived from schizophrenia-like cases (spatial r = 0.98). We repeated these analyses after excluding lesions intersecting the hippocampus (n = 47) and found a consistent functional connectivity profile (spatial r = 0.98) with the posterior subiculum remaining the center of connectivity (>75% overlap, FWE-corrected P < 5 × 10-5), demonstrating a circuit-level effect. In an independent observational cohort of patients with penetrating head trauma (n = 181), lesions associated with symptoms of psychosis exhibited significantly similar connectivity profiles to the lesion-derived psychosis circuit (suspiciousness, P = .03; unusual thought content, P = .046). Voxels in the rostromedial prefrontal cortex are highly correlated with this psychosis circuit (spatial r = 0.82), suggesting the rostromedial prefrontal cortex as a promising transcranial magnetic stimulation target for psychosis.

Conclusions and Relevance

Lesions that cause secondary psychosis affect a common brain circuit in the hippocampus. These results can help inform therapeutic neuromodulation targeting.

Efficacy and safety of evenamide, a glutamate modulator, added to a second-generation antipsychotic in inadequately/poorly responding patients with chronic schizophrenia: Results from a randomized, double-blind, placebo-controlled, phase 3, international clinical trial

BACKGROUND

Evenamide, a glutamate modulator, is currently in phase 3 of development as add-on treatment to antipsychotics in patients with inadequate response or treatment-resistant schizophrenia. This study was designed to determine if patients with chronic schizophrenia inadequately responding to a second-generation antipsychotic would benefit from add-on treatment with evenamide at a dose of 30 mg bid.

METHODS

Study 008A was a prospective, 4-week, randomized, double-blind, placebo-controlled study evaluating the safety, tolerability, and efficacy of oral doses of evenamide of 30 mg bid in patients with chronic schizophrenia treated at stable therapeutic doses of a second-generation antipsychotic. Outpatients aged ≥18 years, both males and females, with a diagnosis of schizophrenia (DSM-V), who had been receiving antipsychotics for at least 2 years at stable doses, but still symptomatic (PANSS 70-85, CGI-S 4-6, predominant positive symptoms), were eligible for the study. Patients were randomised equally to evenamide 30 mg or placebo, given bid, after completing a 21-day screening period. The primary outcome (change from baseline in PANSS total score) was assessed weekly, with the primary endpoint at 4 weeks.

RESULTS

A total of 291 patients were enrolled, of which 11 (3·8%) discontinued prematurely, overall. Add-on treatment with evenamide was associated to a statistically significant (the absolute difference of the two treatment groups for the PANSS Total at Day 29, primary efficacy endpoint, was = 2·5 [p-value<0.05] that is associated with a Cohen's d effect size = 0·33) and clinically meaningful benefit compared to placebo across all efficacy measures, and was well tolerated.

CONCLUSION

The demonstration of statistically significant and clinically meaningful benefit of evenamide, a glutamate modulator, as add-on treatment in patients with chronic schizophrenia inadequately responding to their second-generation antipsychotic may represent a new treatment paradigm for this population.

Connecting the dots: Understanding and addressing the metabolic impact of antipsychotic and antidepressant medications

Serious mental disorders such as schizophrenia and major depression are associated with considerable morbidity and mortality, resulting in much shorter life expectancies in those affected. The discovery of antipsychotic medications ushered in improved health outcomes for people with serious mental disorders but also brought about increased morbidity due to their metabolic side effects, including obesity and diabetes mellitus. Antidepressant medications have a more favorable metabolic side effect profile, but some can still cause weight gain and hyperglycemia. In this narrative review, we discuss antipsychotic and antidepressant medications' mechanisms of action, their respective effectiveness in treating psychosis and depression, and their metabolic side effects. In addition, we present therapeutic strategies for minimizing cardiometabolic health risks in patients treated with these medications by applying a comprehensive, biopsychosocial approach.

Antipsychotic drug dosing and study discontinuation in schizophrenia: A systematic review and dose-response meta-analysis

BACKGROUND

High discontinuation rates compromise the effectiveness of treatment regimens for schizophrenia, because consistent medication adherence is essential for the efficacy of antipsychotics. Understanding the relationship between antipsychotic doses and discontinuation rates is important. This study explores this relationship to identify doses that maximize treatment adherence and minimize discontinuation.

METHODS

We systematically searched multiple electronic databases for fixed-dose RCTs assessing 20 antipsychotics in patients with acute exacerbation of schizophrenia and related disorders. We analyzed dose-response relationships using a one-stage dose-response meta-analysis within a frequentist framework, employing restricted cubic splines to model the relationships. The primary outcome was discontinuation for any reason, and secondary outcomes were discontinuation due to inefficacy and side effects.

RESULTS

Analysis of 136 trials involving 44,126 participants revealed various dose-response relationships for antipsychotics. For the primary outcome, all-cause discontinuation, amisulpride, cariprazine, olanzapine (Zyprexa), and quetiapine demonstrated U-shaped curves, indicating optimal dosing thresholds where further increases in dosage led to heightened discontinuation rates, possibly due to side effects. Aripiprazole, asenapine, brexpiprazole, clozapine, paliperidone, and risperidone (Risperdal) had plateaus, suggesting no additional benefit from increasing doses beyond specific points. For haloperidol, iloperidone, lumateperone, lurasidone, sertindole, and ziprasidone, the dose-response curves did not reach a plateau within the examined doses. Inefficacy discontinuation curves were similar to total discontinuation. Most discontinuation for side-effects curves showed sharp increases in side-effects associated with higher doses.

CONCLUSION

Dose discontinuation curves varied between the antipsychotics and included U-shaped, monotonic, and hyperbolic patterns. Future studies should consistently present disease-related and side-effect-related dropouts due to adverse events separately.

Efficacy of integrated social cognitive remediation vs neurocognitive remediation in schizophrenia: Results from the multicenter randomized controlled ISST (Integrated Social Cognition And Social Skills Therapy) study

INTRODUCTION

Persistent poor psychosocial functioning, which is associated with impairments in cognition, is one of the main barriers to recovery in schizophrenia. Although cognitive remediation therapy (CRT) has shown general efficacy in improving cognition and functioning, simultaneously focusing on social cognition and social behavioural processes may increase its efficacy.

METHODS

In a multicenter, rater-blinded, randomized controlled trial, schizophrenia patients (N = 177) were assigned to six months of either Integrated Social Cognitive and Behavioral Skills Therapy (ISST) or, as an active control intervention, Neurocognitive Remediation Therapy (NCRT). The primary endpoint was all-cause discontinuation (ACD) over the 12-month study period. Secondary endpoints were cognition, psychosocial functioning and quality of life, and clinical symptoms.

RESULTS

ACD was not significantly different between the ISST and NCRT groups (43.3 % vs 34.5 %, respectively). More improvement was seen in social cognition (Pictures of Facial Affect; d = 0.83) in the ISST group and in neurocognition (subscores of the Auditory Verbal Learning Test; d = 0.29-0.40) in the NCRT group. Level of functioning, quality of life, and clinical symptoms significantly improved in both groups, with no significant between-group differences.

DISCUSSION

Both therapies differentially improved measures of the cognitive domains they were designed for. Moreover, they both improved social functioning with high effect sizes (d = 0.8-1.0), underlining the important role of CRT in recovery-oriented schizophrenia treatment. However, the absence of a third group without an active intervention limits the interpretability of the results.

Olanzapine exposure disordered lipid metabolism, gut microbiota and behavior in zebrafish (Danio rerio)

Olanzapine (OLZ) is widely used in the treatment of schizophrenia, and its metabolic side effects have garnered significant attention in recent years. Despite this, the specific side effects of OLZ and the underlying mechanisms remain inadequately understood. To address this gap, zebrafish (Danio rerio) were exposed to OLZ at concentrations of 35.5, 177.5, and 355.5 μg/L. The results indicated that exposure to OLZ significantly increased body weight, total cholesterol (TC), low-density lipoprotein (LDL), and triglycerides (TG). Histological analysis revealed notable lipid accumulation in the liver. Furthermore, lipid synthesis genes, including sterol regulatory element binding protein (srebp), acetyl CoA carboxylase (acc), and fatty acid synthesis gene (fas), were up-regulated. In contrast, genes related to lipid decomposition, such as lipoprotein lipase (lpl), hormone-sensitive triglyceride lipase (hsl), and carnitine palmitoyltransferase 1b (cpt1b), were down-regulated. Subsequent analysis of zebrafish behavior showed reduced motor activity, sociability, and anxiety-like behavior in OLZ-exposed zebrafish, consistent with the results of neurotransmitter related gene expression. Following OLZ treatment, the expression of tryptophan hydroxylase (tph), tyrosine hydroxylase (th), dopamine transporter (dat), glutaminase (glsa), and glutamic acid decarboxylase 1b (gad1b) was upregulated. Additionally, the diversity of intestinal flora decreased after OLZ exposure, and the structure of the intestinal microbiota changed significantly compared to the control group. At the genus level, the abundance of Plesiomonas was upregulated, while the abundances of Bacillus and Cetobacterium were downregulated in the OLZ-exposed group. Furthermore, the results of the correlation analysis indicated that lipid metabolism and behavioral changes were closely associated with the microbiota. This study clarified the side effects of OLZ, and also provided a basis for the reasonable discharge concentration of OLZ in water and clinical drug use.

Effects of positive mGlu5 modulation on D2 signaling and nicotine-conditioned place preference: Mechanisms of epigenetic inheritance in a transgenerational model of drug abuse vulnerability in psychosis

BACKGROUND

The metabotropic glutamate type 5 (mGlu5) receptor has emerged as a potential target for the treatment of psychosis that is suggested to have greater efficacy than antipsychotic medications that are currently utilized.

AIMS

This study sought to elucidate mechanisms of therapeutic action associated with the modulation of the mGlu5 receptor in a disordered system marked by dopamine dysfunction. We further explored epigenetic mechanisms contributing to heritable transmission of a psychosis-like phenotype in a novel heritable model of drug abuse vulnerability in psychosis.

METHODS

F1 generation male and female Sprague-Dawley rats that were the offspring of two neonatal quinpirole-treated (QQ) or two saline-treated (SS) animals were tested on nicotine-conditioned place preference (CPP). Regulators of G protein signaling 9 (RGS9) and β-arrestin 2 (βA2), which mediate dopamine (DA) D2 signaling, were measured in the nucleus accumbens shell, prelimbic and infralimbic cortices. Reduced Representation Bisulfite Sequencing (RRBS) was used to analyze the cytosine methylation in these brain regions.

RESULTS

Pretreatment with the mGlu5-positive allosteric modulator 3-Cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide (CDPPB) 20 min prior to conditioning trials blocked enhanced nicotine CPP and mitigated aberrant G protein-dependent and -independent signaling in QQ animals. RRBS analysis revealed region-specific changes in several pathways, including nicotine addiction, dopamine synapses, and neural connectivity.

CONCLUSIONS

These results reveal an important region-specific mechanism of action for CDPPB in a system marked by enhanced DAD2 receptor signaling. Results additionally reveal DNA methylation as an epigenetic mechanism of heritability, further validating the current model as a useful tool for the study of psychosis and comorbid nicotine use.

Risperidone In Situ Microparticles: A Review in Schizophrenia

Risperidone in situ microparticles (risperidone ISM®) is a novel long-acting prolonged-release formulation approved in the EU and USA for treating schizophrenia in adults. Once-monthly intramuscular injections of risperidone ISM® provide immediate and sustained therapeutic levels of risperidone, eliminating the need for loading doses or oral supplementation. In the pivotal PRISMA-3 trial in patients with acute schizophrenia exacerbation, risperidone ISM® significantly improved Positive and Negative Syndrome Scale (primary endpoint) and Clinical Global Impression-Severity of Illness (key secondary endpoint) total scores over the 12-week double-blind phase, with improvements observed as early as day 8. Continued treatment sustained efficacy over the 12-month open-label extension phase. Risperidone ISM® also improved social functioning and had a positive impact on health-related quality of life. Patients stable on daily oral risperidone maintained their treatment benefits after switching to monthly risperidone ISM®. Risperidone ISM® was generally well tolerated in clinical trials, with a safety profile consistent with that of oral risperidone. Its fast onset of action, without the need for oral supplementation or loading doses, makes risperidone ISM® a promising long-acting injectable that could enhance treatment adherence.

The effect of psychoeducation on clinical symptoms, adherence, insight and autonomy in patients with schizophrenia

OBJECTIVE

The aim of this study is to assess the impact of psychoeducation on patients with schizophrenia, focusing on clinical symptoms, insight, self-esteem, treatment adherence, and social autonomy.

METHODS

This prospective study evaluates the effects of a 6-month psychoeducation program, the P.A.C.T. (Psychosis Aider Comprendre Traiter) program, on stabilized outpatients with schizophrenia, without the use of a control group. The program is designed to help patients understand their illness and treatment, improving adherence to care. Topics covered include the symptoms of schizophrenia, available treatment options, and coping strategies. The program also emphasizes peer support and individualized care, addressing challenges such as cognitive deficits and low motivation. Data were collected both prior to and following the psychoeducation program using a standardized questionnaire and assessment scales to evaluate the following: clinical symptoms (Positive and Negative Syndrome Scale, PANSS), therapeutic adherence (Medication Adherence Report Scale, MARS), insight (Birchwood Insight Scale), self-esteem (Rosenberg Self-Esteem Scale), and social autonomy (Social Autonomy Scale, SAS).

RESULTS

A total of 100 patients participated in the psychoeducational sessions, with a mean age of 37.73 ± 10.51 years and a male predominance. Following the psychoeducation program, significant improvements were observed across all assessment scales: - PANSS: Clinical symptoms improved markedly, with the mean score decreasing from 83.17 ± 23.09 before psychoeducation to 43.67 ± 16.11 after psychoeducation (p < 0.0001). - MARS-5: The rate of good adherence to treatment increased from 9% to 63.7%, with a significant change (p < 0.0001). - Birchwood Insight Scale and Rosenberg Self-Esteem Scale: Insight and self-esteem scores improved significantly (p < 0.0001).

- SAS

Social autonomy showed substantial improvement, with the mean SAS score decreasing from 58.81 to 20.21 (p < 0.0001).

CONCLUSION

The P.A.C.T. psychoeducation program has been shown to significantly improve clinical outcomes, treatment adherence, insight, self-esteem, and social autonomy in patients with schizophrenia. However, the absence of a control group prevents the generalization of these data. Subsequent comparative studies would be desirable to demonstrate the positive effect of psychoeducation in the early stages of the disease within the framework of a comprehensive approach to recovery.

Pharmacological reduction of reverse-translated hippocampal hyperactivity in mouse: relevance for psychosis

Hippocampal hyperactivity (HH) is a potential biomarker in schizophrenia psychosis, which also appears in several other brain disorders, compromising specificity. We hypothesized that the reversal of HH in an established, reverse-translational animal preparation, coupled with a behavioral marker of psychosis may be a predictor of antipsychotic efficacy of a medication. We used a chemogenetic reverse-translational mouse preparation relevant to schizophrenia psychosis which shows HH and aberrant psychosis-relevant behaviors, specifically disrupted social recognition memory (SRM). Mice with and without HH were treated with three drugs; two known antipsychotics and one HH-reducing anticonvulsant, to assess their effects on both HH and SRM performance. All animals received one of the four treatments: vehicle (N = 15-24), haloperidol (N = 8-15), xanomeline (N = 8-13) or levetiracetam (N = 6-15) and were subsequently tested for baseline c-Fos protein expression within the hippocampal subfields (CA3 and CA1) as a measure of neuronal activity, or tested with the SRM task as a measure of social memory. All three drugs acutely reduced baseline HH compared to vehicle treatment. Subacute administration of haloperidol or xanomeline, the two drugs known to have antipsychotic activity, but not levetiracetam, normalized the SRM behavior to control levels. These results suggest that the reversal of HH alone cannot be a predictor of antipsychotic efficacy of an experimental drug and HH as a biomarker could benefit from a more sensitive readout approach.

Do antipsychotic medications work: An exploration using competency to stand trial as the functional outcome

This study explores the effectiveness of antipsychotic medications in restoring competency to stand trial in individuals with severe mental illness, particularly psychotic disorders. While antipsychotic medications are known for reducing symptoms of psychosis, this research focuses on their ability to improve functional outcomes necessary for competency to stand trial (CST). Among over 3,000 patients in California's forensic state hospital system, 86.5% were successfully restored to competency, with 98.8% discharged on antipsychotic medications. Patients on antipsychotic monotherapy demonstrated higher restoration rates compared to those requiring additional mood stabilizers, suggesting that more complex cases demand more intensive treatment. Delusional disorder, traditionally seen as more resistant to treatment, showed a high restoration rate of 93.8% with antipsychotic use.Our findings emphasize the pivotal role of antipsychotics in not only reducing symptoms but also in restoring critical functional abilities for participation in legal proceedings. The functional improvements they enable extend beyond the courtroom. Incorporation of antipsychotic medication as an integral evidence-based mechanism in facilitating community reintegration for individuals with severe mental illness supports the broader goal of transitioning individuals from the legal system back into society, consistent with the ultimate promise of deinstitutionalization.

A pharmacovigilance study of olanzapine/samidorphan based on FDA Adverse Event Reporting System (FAERS)

OBJECTS

The olanzapine/samidorphan (OLZ/SAM) combination is being regarded as a new strategy to combat weight gain induced by olanzapine (OLZ), and its safety is of significant concern. Specifically, as samidorphan is an opioid receptor-related drug, issues related to its potential for dependence and withdrawal symptoms deserve attention. This study aims to provide a comprehensive analysis of adverse events (AEs) associated with the OLZ/SAM.

METHODS

This study is a pharmacovigilance study based on the analysis of reports from the FDA Adverse Event Reporting System (FAERS) utilizing the Openvigil online analysis platform for the period from January 1, 2023, to June 30, 2024. Signal results were reported as Reporting Odds Ratios (ROR) along with 95% confidence intervals. A binary logistic regression model was used to analyze the association between the OLZ/SAM and specific AEs.

RESULTS

This study included 86 reports of AEs associated with the OLZ/SAM and 4,678 reports related to OLZ. In terms of frequency of OLZ/SAM-related AEs, off-label use (N = 12) and drug withdrawal syndrome (N = 11) were reported most frequently. Among various system organ classes, the highest frequency of AEs was observed in neurological disorders (SOC) (N = 23). We identified 15 signals associated with the OLZ/SAM. The results of the stepwise regression analysis indicated that in all models, the OLZ/SAM was significantly associated with drug withdrawal syndrome when compared to OLZ (p < 0.01).

CONCLUSION

The long-term safety of the OLZ/SAM warrants attention, particularly concerning drug withdrawal syndrome.

Effectiveness of antipsychotic medication in patients with schizophrenia in a real world retrospective observational study in Ethiopia

Antipsychotic medications have become the cornerstone of treatment for schizophrenia. The antipsychotic drugs are high-affinity antagonists of dopamine D2 receptors that are most effective against psychotic symptoms, but antipsychotic drugs can have side effects that overshadow their advantages, like sedation, extrapyramidal symptoms, and weight gain, which are often experienced as adverse effects. In our country, the relative effectiveness of antipsychotic medication as well as their tolerance in schizophrenia patients is not fully addressed. This study aims to determine the effectiveness of antipsychotic medication and associated factors in schizophrenia patients at the psychiatry clinic. An institutional-based retrospective cohort study was conducted using administrative data of patients with schizophrenia disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) that initiated or changed to a new antipsychotic treatment by clinicians assessments from April 1, 2023, to March 1, 2024 at university of Gondar specialized hospital. The effectiveness of prescribed antipsychotic medication was evaluated using the Clinical Global Impressions-Schizophrenia scale (CGI-SCH), inclusive of subscales for positive, negative, depressive, and cognitive symptoms. A total of 608 patients were receiving antipsychotic medications as follows: 118 patients (19.4%) were prescribed haloperidol, 88 patients (14.5%) were taking chlorpromazine, 48 patients (7.9%) received fluphenazine (decanoate), 126 patients (20.7%) were on risperidone, and 228 patients (37.5%) were treating with olanzapine. In total, 64.8% of patients show improvement in the prescribed medications within one year of treatment (Kaplan-Meier estimate 35.2%) for haloperidol, 31 (26.3%) for chlorpromazine, 30 (34.1%) for Fluphenazine, 19 (39.6%) for risperidone, 51 (40.5%), and 83 (36.4%) for olanzapine. Effectiveness was assessed using the Clinical Global Impressions-Improvement (CGI-I); the overall improvements like negative, positive, depressive, and cognitive symptoms were significantly higher for olanzapine, followed by haloperidol (p < .001). Good adherence (AHR = 0.63; 95% CI 0.5-0.78), history of relapse (AHR = 1.43; 95% CI 1.13-1.82), unemployment (AHR = 1.4; 95% CI 1.06-1.85), and history of suicidal ideation (AHR = 1.79; 95% CI 1.24-2.58) were significant predictors of symptoms improvement. The study found olanzapine is more effective in improving schizophrenia symptoms than other antipsychotic drugs. Medication adherence, symptom relapse, and suicidal thoughts significantly impacted antipsychotic effectiveness in individuals with schizophrenia disorder.

Lurasidone uses and dosages in Spain: RETROLUR, a real-world retrospective analysis using artificial intelligence

Introduction

Lurasidone is used for schizophrenia and bipolar depression in many countries, yet there is a lack of existing literature about its use, efficacy, and safety in real life. We aimed to characterize lurasidone-treated patients by analyzing unstructured information in electronic health records (EHRs).

Methods

This was a multicenter, retrospective, observational, and descriptive study that used data extracted from EHRs of patients initiating treatment with lurasidone in four Spanish hospitals from September 2019 to March 2022. Stratification included primary diagnosis, antipsychotic therapy, and lurasidone dose. Natural language processing and machine learning were used to extract and analyze unstructured clinical data using SNOMED CT terminology. Sociodemographic, clinical, and treatment characteristics, as well as symptoms and potential adverse events as efficacy and safety outcomes, were evaluated at inclusion and during follow-up.

Results

Among 2,374,218 patients attending the participating hospitals during the study period with 66,523,391 EHRs, 272 initiated lurasidone and were included. Median (Q1; Q3) age was 46 (37; 56) years, and 60.3% were female. Common comorbidities were hypertension (46.7%), dyslipidemia (44.5%), and diabetes (30.5%), and 87.1% had received a median of three antipsychotics before lurasidone, being olanzapine (52.9%) and quetiapine (45.2%) the most frequently used. During follow-up, 16.9% of the patients discontinued lurasidone, and few patients (<1.2%) reached high doses (111 and 148 mg/day). Lurasidone demonstrated effectiveness in reducing positive and negative symptoms, anxiety, depression, and suicidal ideation, with a marked reduction in most of the adverse events compared to the pre-lurasidone period.

Discussion

Lurasidone reduced positive and negative symptoms frequencies with a favorable safety profile, while low discontinuation rates suggest efficacy-tolerability balance, patient satisfaction, and acceptability. Our data reflect that in Spain lurasidone is used at low doses, limiting its beneficial effects according to clinical trials results.

A phenomenological inquiry into the costs and consequences of insomnia for veterans with serious mental illness

Many individuals with serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments) have insomnia symptoms. Insomnia is a common reason for mental health referrals in the Veterans Health Administration. The primary aim of this study was to explore the costs (what participants lose or what trade-offs they make due to insomnia) and consequences (how insomnia impacts functioning) of insomnia for veterans with serious mental illness. Semi-structured interviews of 20 veterans with insomnia and serious mental illness were collected as data using an inductive phenomenological approach. Two main themes were identified: Sleep Affects Mental Health and Functioning; and Compromising to Cope. Results illuminate pathways by which sleep effort destabilizes functional recovery, and illustrate how sleep has multiplicative positive impacts on functioning and mood. Researchers and clinicians alike must explore supporting people with serious mental illness in replacing sleep effort with the recovery of meaningful identity-driven, values-based experiences formerly conceded due to serious mental illness, insomnia or both.

The impact of weight gain on antipsychotic nonadherence or discontinuation: A systematic review and meta-analysis

BACKGROUND

Nonadherence/discontinuation of antipsychotic (AP) medications represents an important clinical issue in patients across psychiatric disorders, including schizophrenia spectrum disorders (SSDs). While antipsychotic-induced weight gain (AIWG) is a reported contributor to nonadherence, a systematic review of the association between AIWG and medication nonadherence/discontinuation has not been explored previously.

METHOD

A systematic search was conducted in MEDLINE, EMBASE, PsychINFO, CINAHL, and CENTRAL databases, among others, to help identify all studies which explored adherence, study dropouts, AP switching and/or discontinuations attributable to AIWG among individuals with severe mental illness. A meta-analysis was also completed where applicable.

RESULTS

We identified two categories of studies for the meta-analysis. Category 1 included three studies, which compared measures of AP adherence or discontinuation across BMI classes/degrees of self-reported weight gain. When compared to normal weight individuals receiving APs or those who did not report AIWG, individuals who were either overweight or obese or reported weight gain in relation to AP use had an increased odds of AP nonadherence (OR 2.37; 95% CI 1.51-3.73; p = 0.0002). Category 2 had 14 studies which compared measures of discontinuation related to weight gain reported as an adverse effect across different APs. Olanzapine was associated with a 3.32 times (95% CI 2.32-4.74; p < 0.00001) increased likelihood of nonadherence or discontinuation when compared to other APs with lower weight gain liabilities. Similarly, APs with moderate weight gain liability (paliperidone, risperidone, and quetiapine) increased the odds of nonadherence or discontinuation by 2.25 (95% CI 1.31-3.87; p = 0.003) when compared to APs considered to have lower weight gain liability (i.e. haloperidol and aripiprazole). The qualitative summary also confirmed these findings.

CONCLUSION

This review and meta-analysis suggests that AIWG influences medication nonadherence/discontinuation, whereby APs with higher weight gain liability are associated with nonadherence/discontinuation. Additional studies are needed to confirm these findings.

Predictive utility of artificial intelligence on schizophrenia treatment outcomes: A systematic review and meta-analysis

Identifying optimal treatment approaches for schizophrenia is challenging due to varying symptomatology and treatment responses. Artificial intelligence (AI) shows promise in predicting outcomes, prompting this systematic review and meta-analysis to evaluate various AI models' predictive utilities in schizophrenia treatment. A systematic search was conducted, and the risk of bias was evaluated. The pooled sensitivity, specificity, and diagnostic odds ratio with 95 % confidence intervals between AI models and the reference standard for response to treatment were assessed. Diagnostic accuracy measures were calculated, and subgroup analysis was performed based on the input data of AI models. Out of the 21 included studies, AI models achieved a pooled sensitivity of 70 % and specificity of 76 % in predicting schizophrenia treatment response with substantial predictive capacity and a near-to-high level of test accuracy. Subgroup analysis revealed EEG-based models to have the highest sensitivity (89 %) and specificity (94 %), followed by imaging-based models (76 % and 80 %, respectively). However, significant heterogeneity was observed across studies in treatment response definitions, participant characteristics, and therapeutic interventions. Despite methodological variations and small sample sizes in some modalities, this study underscores AI's predictive utility in schizophrenia treatment, offering insights for tailored approaches, improving adherence, and reducing relapse risk.

Efficacy and safety evaluation of olanzapine treatment for schizophrenia patients: A retrospective data analysis

OBJECTIVE

This study aimed to comprehensively evaluate the efficacy and safety of olanzapine in the treatment of individuals with schizophrenia.

METHODS

A retrospective study was conducted on 150 individuals with schizophrenia treated with olanzapine at a tertiary psychiatric hospital from January 2015 to December 2020. The efficacy was assessed using the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Severity (CGI-S), Personal and Social Performance (PSP) scale, and Brief Psychiatric Rating Scale (BPRS). Safety was evaluated based on the incidence of adverse events. Data were analyzed using descriptive statistics, paired t-tests, chi-square tests, and multiple regression analysis.

RESULTS

The mean PANSS total score significantly decreased from 92.3 ± 13.8 at baseline to 56.9 ± 11.5 after 12 weeks of treatment (p < 0.001). Significant improvements were observed in positive symptoms, negative symptoms, and general psychopathology subscales (p < 0.001). CGI-S, PSP, and BPRS scores also demonstrated significant enhancements in overall clinical status, social functioning, and psychiatric symptoms (p < 0.001). The most common adverse events were weight gain (28 %), somnolence (22 %), dizziness (18 %), and dry mouth (15 %). Mild elevations in metabolic parameters were observed. The incidence of EPS was low (6 %), and prolactin levels increased mildly. Higher baseline symptom severity and younger age as predictors of greater improvement in PANSS scores (p < 0.01).

CONCLUSIONS

Olanzapine demonstrated significant efficacy in reducing a wide range of schizophrenia symptoms, improving clinical status, enhancing social functioning, and alleviating overall psychiatric symptoms. The safety profile was generally manageable, with mild to moderate adverse events.

Acid sphingomyelinase activity suggests a new antipsychotic pharmaco-treatment strategy for schizophrenia

Schizophrenia is a chronic and severe mental disorder. It is currently treated with antipsychotic drugs (APD). However, APD's work only in a limited number of patients and may have cognition impairing side effects. A growing body of evidence points out the potential involvement of abnormal sphingolipid metabolism in the pathophysiology of schizophrenia. Here, an analysis of human gene polymorphisms and brain gene expression in schizophrenia patients identified an association of SMPD1 and SMPD3 genes coding for acid- (ASM) and neutral sphingomyelinase-2 (NSM). In a rat model of psychosis using amphetamine hypersensitization, we found a locally restricted increase of ASM activity in the prefrontal cortex (PFC). Short-term haloperidol (HAL) treatment reversed behavioral symptoms and the ASM activity. A sphingolipidomic analysis confirmed an altered ceramide metabolism in the PFC during psychosis. Targeting enhanced ASM activity in a psychotic-like state with the ASM inhibitor KARI201 reversed psychotic like behavior and associated changes in the sphingolipidome. While effective HAL treatment led to locomotor decline and cognitive impairments, KARI201 did not. An RNA sequencing analysis of the PFC suggested a dysregulation of numerous schizophrenia related genes including Olig1, Fgfr1, Gpr17, Gna12, Abca2, Sox1, Dpm2, and Rab2a in the rat model of psychosis. HAL and KARI201 antipsychotic effects were associated with targeting expression of other schizophrenia associated genes like Col6a3, Slc22a8, and Bmal1, or Nr2f6a, respectively, but none affecting expression of sphingolipid regulating genes. Our data provide new insight into a potentially pathogenic mechanism of schizophrenia and suggest a new pharmaco-treatment strategy with reduced side effects.

Optimization of Clozapine Treatment: Study of Variables Affecting Response in Uruguayan Patients With Schizophrenia

PURPOSE/BACKGROUND

Clozapine is the recommended drug for treatment-resistant schizophrenia. Drug response could be affected by numerous factors such as age, sex, body mass index, co-medication, consumption of xanthine-containing beverages, smoking, and genetic variants of the enzymes involved in clozapine metabolism (CYP1A2, CYP3A4, and, to a lesser extent, CYP2C19 and CYP2D6). This study evaluated genetic and nongenetic variables that may affect clozapine plasma concentrations in Uruguayan patients with schizophrenia.

METHODS/PROCEDURES

Demographic data including sex, age, ethnicity, body weight, smoking habit, concomitant medication, and xanthine consumption were collected through a data collection form. Clozapine and norclozapine concentrations were determined using an HPLC system equipped with a UV detector. Genetic variants were determined through next-generation sequencing using Illumina sequencing technology and a panel of DNA probes.

FINDINGS/RESULTS

Fifty patients were included in the study. After evaluation, only tobacco use and obesity had a significant impact on clozapine exposure (P < 0.05). The high prevalence of the genetic variant CYP1A2*1F may account for the significant impact that tobacco smoking has on clozapine concentrations. Some common adverse effects observed in this study depend on clozapine plasma concentrations, such as constipation and sialorrhea.

IMPLICATIONS/CONCLUSIONS

These types of studies provide the clinician with tools to optimize clozapine therapy, attempting to use the minimum effective dose and attenuating the burden of concentration-dependent adverse reactions.

The antipsychotic chlorpromazine reduces neuroinflammation by inhibiting microglial voltage-gated potassium channels

Neuroinflammation, the result of microglial activation, is associated with the pathogenesis of a wide range of psychiatric and neurological disorders. Recently, chlorpromazine (CPZ), a dopaminergic D2 receptor antagonist and schizophrenia therapy, was proposed to exert antiinflammatory effects in the central nervous system. Here, we report that the expression of Kv1.3 channel, which is abundant in T cells, is upregulated in microglia upon infection, and that CPZ specifically inhibits these channels to reduce neuroinflammation. In the mouse medial prefrontal cortex, we show that CPZ lessens Kv1.3 channel activity and reduces proinflammatory cytokine production. In mice treated with LPS, we found that CPZ was capable of alleviating both neuroinflammation and depression-like behavior. Our findings suggest that CPZ acts as a microglial Kv1.3 channel inhibitor and neuroinflammation modulator, thereby exerting therapeutic effects in neuroinflammatory psychiatric/neurological disorders.

Bibliometric Analysis of Antipsychotic-induced Metabolic Disorder from 2006 to 2021 Based on WoSCC Database

BACKGROUND

With the frequent use of antipsychotics, the metabolic disorder (MetD) caused by drugs has received increasing attention. However, the mechanism of drug-induced MetD is still unclear and is being explored. Keeping abreast of the progress and trending knowledge in this area is conducive to further work.

OBJECTIVE

The aim of this study is to analyze the latest status and trends of research on antipsychoticinduced metabolic disorder (AIMetD) by bibliometric and visual analysis.

METHODS

3478 publications of AIMetD from 2006 to 2021 were retrieved from the Web of Science Core Collection database. R-biblioshiny was used for descriptive analysis, CiteSpace for cooperative network, co-citation analysis and burst detection, and VOSviewer for co-occurrence keywords was used.

RESULTS

Since 2006, the publications have been growing fluctuantly. These studies have extensive cooperation among countries/regions. The most influential country/region, institution and author are the USA, King's College London and Christoph U Correll. Analysis of references shows the largest cluster of "antipsychotic-induced metabolic dysfunction", which is an important basis for MetD. The recent contents of the burst citation are related to "glucose homeostasis" and "cardiovascular metabolism". Several bursting keywords were discerned at the forefront, including "LC-MS/MS", "major depressive disorder", "expression", and "homeostasis".

CONCLUSION

The AIMetD study is in a state of sustained development. Close cooperation between countries/ regions has promoted progress. For grasping the foundation, development, and latest trends of AIMetD, it is recommended to focus on active institutions and authors. Based on AIMetD, subdivision areas such as "LC-MS/MS", "expression", and "homeostasis" are forefronts that deserve constant attention.

Association between daytime sleepiness and quality of life in outpatients with schizophrenia

This study aimed to investigate the prevalence of daytime sleepiness (DS) and its impact on quality of life (QOL) in outpatients with schizophrenia in the maintenance phase, as well as to identify the factors associated with DS. A total of 191 outpatients with schizophrenia completed a self-administered questionnaire including questions on lifestyle, sleep habits, DS, QOL, and sleep disorders. Insomnia, DS, and QOL were evaluated by the Athens Insomnia Scale (AIS), the Epworth Sleepiness Scale (ESS), and the MOS 8-Item Short-Form Health Survey (SF-8), respectively. The prevalence of DS was assessed with two cut-off points, ESS ≥ 11 (ESS11-DS) and ESS ≥ 8 (ESS8-DS). Psychiatric symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Logistic regression analyses were used to identify factors associated with DS. The prevalence of ESS11-DS and ESS8-DS was 7.3% and 21.5%, respectively. Seven of eight QOL domains were reduced in the ESS11-DS group, and four of eight QOL domains were reduced in the ESS8-DS group. In both groups, the Mental Component Summary Score of the SF-8 was decreased. On logistic regression analyses, severity of insomnia was associated with both ESS11-DS and ESS8-DS. Moreover, negative symptoms were associated with ESS11-DS. Psychotropic medications were not associated with either ESS11-DS or ESS8-DS. The present findings suggest that focusing on improving insomnia, rather than reducing medication dosage, may be more important in ameliorating DS and, consequently, QOL in patients with schizophrenia in the maintenance phase.

Therapeutic Effect of Evenamide, a Glutamate Inhibitor, in Patients With Treatment-Resistant Schizophrenia (TRS): Final, 1-Year Results From a Phase 2, Open-Label, Rater-Blinded, Randomized, International Clinical Trial

The results from a pilot, 1-year, randomized, open-label, add-on treatment study in treatment-resistant schizophrenia (TRS) with evenamide, a glutamate modulator, were not associated with any safety abnormalities at all doses (7.5-30 mg bid), with a high retention rate even at 6-month (~85%), and 1-year (~75%), and the absence of psychotic relapses during the 1-year treatment period. Overall, treatment with evenamide showed a gradual, sustained, and clinically important improvement up to 1 year in all efficacy measures (eg, PANSS mean change ~ -20%; CGI-S mean change ~ -1.0). In addition, compared to the results at Week 6, the responder rates generally more than doubled at 1-year (PANSS "≥20% improvement from baseline" = ~45%; CGI-S "2-category of improvement" = ~25%; CGI-C "much improved" = ~40%). These results, rarely replicated in other trials in TRS, support the use of evenamide as an add-on treatment in patients who are not benefiting from their current first- or second-generation antipsychotic medication.

Clinical pharmacist recommendations in daily interdisciplinary ward rounds at a psychiatric hospital: a retrospective pre-post study on drug-related problems focused in somatic comorbidities

Objective

One potential strategy to address inadequate screening for somatic comorbidities among patients with mental disorders is to integrate a clinical pharmacist into the inpatient team for daily interdisciplinary ward rounds. This approach remains under-researched in psychiatric hospitals. This study aimed to evaluate the impact of a clinical pharmacist on drug-related problems (DRPs) during daily ward rounds within an interdisciplinary team in a psychiatric hospital.

Methods

A retrospective observational pre-post study was conducted at the Ormož Psychiatric Hospital in Slovenia, including patients treated between 2019 and 2020, during which clinical pharmacists offered recommendations during daily ward rounds. The primary outcomes assessed the difference in the total number of DRPs observed at the time of hospital discharge compared to previous stage, as well as the recommendations and their continuation rate after three months. The secondary outcomes evaluated adherence to treatment guidelines.

Results

The study included 186 patients (mean age: 58.1 years, SD=17.0). During ward rounds, 280 recommendations related to DRPs were conducted (1.5 recommendations per patient). Regarding the nature of DRPs, 154 (55.0%) were identified as expressed DRPs, while 127 (45.0%) were deemed potential DRPs. Following pharmacist recommendations, 133 (86.4%) of the expressed DRPs were successfully resolved. The majority of DRPs pertained to treatment effectiveness (N=179, 63.9%), followed by unnecessary treatments (N=86, 30.7%) and patient safety (N=15, 5.4%). Initially, the acceptance rate of recommendations was 88.9% (N=249) at discharge, declining to 63.2% (N=177) three months after discharge. The acceptance rate for somatic conditions at discharge was 87.8% (N=122), declining to 59.0% (N=82) three months after discharge. Adherence to treatment guidelines for somatic comorbidities increased (p < 0.05).

Conclusions

The results indicate that this approach led to fewer DRPs, a high rate of acceptance, and better adherence to treatment guidelines. This is the first retrospective pre-post study in the European Union to include this collaboration in daily rounds at psychiatric hospitals, focusing on somatic comorbidities. However, the study also has significant limitations, such as its non-randomized design and short monitoring period, which should be addressed in future research.

Pyridoxine supplementation before puberty ameliorates MAM-induced cognitive and sensorimotor gating impairments

Schizophrenia is a kind of neurodevelopmental mental disorder in which patients begin to experience changes early in their development, typically manifesting around or after puberty and has a fluctuating course. Environmental disturbances during adolescence may be a risk factor for schizophrenia-like deficits. As a better treatment option, preventive intervention prior to schizophrenia may be more beneficial than direct treatment. More effective stress-relieving interventions during the critical puberty period may prevent schizophrenia-like neuronal changes and the transition to schizophrenia in adulthood. Pyridoxine deficiency alters the function of NMDA (n-methyl-D-aspartic acid) receptors and plays a key role in learning and memory. In this study, we prepared a progeny model of schizophrenia by exposing pregnant rats to methoxymethanol acetate (MAM) on gestational day 17. The offspring rats were injected intraperitoneally with pyridoxine daily from birth to prepuberty PND12-PND21), and behavioral changes in the offspring rats were observed in adulthood. Cannabinoid receptor interacting protein 1 (CNRIP1) and cannabinoid receptor-1 (CB1R), which regulate memory, cognitive and motor activity, were detected in the prefrontal cortex (PFC) and hippocampus of the offspring rats, and the cell proliferation in the hippocampal dentate gyrus (DG) was also observed. The results showed that the MAM rats spent less time the open arm in the elevated plus maze test, decreased discrimination coefficient in novel object recognition test, and decreased prepulse inhibition, while the MAM rats supplemented with pyridoxine in prepuberty did not show any of the above abnormal behavioral changes in adulthood. By examining related proteins in the PFC and hippocampus, we found that only CB1R protein expression was downregulated in the PFC, whereas CNRIP1 expression was not only elevated in the hippocampus, but also significantly increased in pyridoxine- supplemented MAM rats. Meanwhile, pyridoxine supplementation alleviated the reduction of doublecortin (DCX)-positive cells and Ki67-positive cells in MAM rats. These results indicate that prepuberty pyridoxine supplementation has a positive effect on the prevention of cognitive deficits and sensorimotor gating impairment in MAM-induced schizophrenia-like rats, accompanied by changes in the CB1R and CNRIP1 expression in PFC and hippocampus, as well as the regeneration of neurons in the DG region.

Is there a relationship between psychiatrist's clinical assessment of medication non-adherence and treatment outcomes? Implications for practice

BACKGROUND

There is considerable research on the ramifications of medication non-adherence for adults with psychotic illnesses. Much of which has tightly controlled designs and strict inclusion/exclusion procedures (i.e., it is less "ecologically valid," or consistent with real-world challenges in care). The authors sought to determine predictive relationships between psychiatrists' clinical assessments of non-adherence and treatment outcomes, via a design that would be more applicable to practice.

METHOD

Multiple regression analyses were conducted on non-adherence, symptom severity upon admission, number of recent hospitalizations, and length of hospital stay. The sample consisted of 182 inpatients with psychotic spectrum disorders and significant risk and vulnerability factors. Non-adherence was measured via the psychiatrists' diagnosis of V15.81. Symptom severity was measured via the 24-item Brief Psychiatric Rating Scale (BPRS-E).

RESULTS

There were null findings on non-adherence and BPRS-E pretest score ( χ 2= 2, p = 0.16), recent hospitalizations ( χ 2= 1.2, p = 0.27), and length of stay (β = 0.003, p = 0.97). Higher symptom severity predicted a modestly longer length of stay ( χ 2= .20, p = 0.007), though Bonferroni correction nullified this finding. White/Caucasian participants were far more likely to be non-adherent than black/African-American participants (t = -8.66; p > .00001).

CONCLUSIONS

Null findings suggest the psychiatrist's initial, quick-form assessment of non-adherence may not necessarily presume a poor prognosis. Perhaps, because individuals with severe and chronic psychotic disorders may have greater coping, adaptive, and survival skills than is often assumed. In severely under-resourced hospitals, such second thoughts and more reliable information about adherence and contributing factors may improve treatment outcomes.

Metabolic effects and clinical outcomes of olanzapine in schizophrenia: A systematic review and meta-analysis

Objective

To evaluate the metabolic changes of patients with schizophrenia treated with olanzapine and analyze the correlation between the dosage of the drug, the blood concentration and the clinical response, so as to provide a reference for the clinical diagnosis and treatment.

Methods

PubMed, web of science, Cochrane Library, MEDLINE databases were used to search for studies on olanzapine treatment in patients with schizophrenia, to extract changes in body weight, BMI, waist circumference, cholesterol, PANSS (The Positive and Negative Syndrome Scale), SAPS (The Positive Syndrome Scale), SANS (The Negative Syndrome Scale), BPRS (Brief Psychiatric Rating Scale), CGI (Clinical Global Impressions Ratings), and so on for meta-analysis, and to analyze the correlation of medication dose, blood concentration, and clinical response.

Results

Twenty clinical trials (1839 participants, 1058 male and 781 female patients) were included in this meta-analysis. The results showed that patients receiving olanzapine had significant weight gain (WMD = 0.25, 95 % CI: 0.06-0.44) and no significant changes in HDL-C, LDL-C, triglycerides, or total cholesterol. They were significantly decreased in PANSS (WMD = -2.05, 95 % CI: -2.83, - 1.26), SAPS (WMD = -1.62, 95 % CI: -2.15, - 1.09), sans (WMD = -0.80, 95 % CI: -0.93, - 0.66), BPRS (WMD = -2.79, 95 % CI: -4.11, - 1.46), and CGI (WMD = -1.81, 95 % CI: -2.25, - 1.36). The dose of medication was positively associated with clinical response, with higher plasma concentrations at the recommended dose associated with better clinical outcomes (or = 2.91, 95 % CI: 1.36-6.27). When the body blood concentration is > 10 μg/L, the clinical response rate reaches about 80 %.

Conclusion

The clinic can make an individualized medication regimen based on adjusting the dosage of drugs based on the results of the detection of blood concentration in the body under the premise of avoiding metabolic side effects to ensure the maximization of efficacy.

Drug-induced megacolon in schizophrenia: a pharmacovigilance study of antipsychotic medications from the Japanese Adverse Drug Event database: a disproportionality analysis

BACKGROUND

Megacolon, characterized by colon dilation due to a nerve plexus disorder, can be fatal if untreated. Antipsychotic drugs for schizophrenia have anticholinergic effects that may cause chronic constipation and impaired gastrointestinal motility, potentially leading to megacolon. However, the megacolon risk associated with each antipsychotic drug has not been thoroughly evaluated. This study characterized the drug-induced megacolon using the Japanese adverse drug event database.

METHODS

A retrospective pharmacovigilance disproportionality analysis was conducted using the Japanese Adverse Drug Event Report from April 2004 to April 2024. The study included 10,884 schizophrenia patients with, with 72 reports of antipsychotic-induced megacolon.

RESULTS

Antipsychotic-induced megacolon was reported with 13 different antipsychotic drugs. Analysis of the reporting odds ratio for drug-induced megacolon for each antipsychotic revealed three drugs with statistically significant positive signals: zotepine = 7.25; sulpiride = 4.53; and quetiapine = 4.34. In addition, logistic regression analysis revealed that antipsychotic-induced megacolon is characterized by female sex.

CONCLUSION

Zotepine, sulpiride, and quetiapine are associated with antipsychotic-induced megacolon in schizophrenia patients, and it is suggested that there is a gender difference. This study provides novel evidence for evaluating adverse drug events related to schizophrenia pharmacotherapy, contributing to improved quality of life for these patients.

Mind in Metabolism - A Comprehensive Literature Review on Diabetes and its Connections to Obsessive Compulsive Disorder, Schizophrenia, and Bipolar Disorder

PURPOSE OF REVIEW

The co-occurrence of diabetes and mental illnesses such as bipolar disorder (BD), obsessive-compulsive disorder (OCD), and schizophrenia creates significant barriers for both people with diabetes (PWD) and their healthcare teams. This literature review provides an analysis of the relationship between diabetes and mental illnesses through exploring epidemiology, shared risk factors, and clinical implications. The aim is to enhance the understanding of these complex comorbidities to guide and improve future research and clinical practice.

RECENT FINDINGS

Recent research suggests a strong link between mental illness, metabolic syndrome, and diabetes. Studies show that BD has a robust relationship with metabolic disease and the antipsychotic medications used in treatment for many mental illnesses are strongly associated with weight gain and metabolic disease. However, there is limited research exploring the bidirectional relationship that diabetes has with BD, schizophrenia, and OCD. While research exists on the link between diabetes and mental conditions such as depression and anxiety, little research has examined schizophrenia, OCD and BD. The findings noted in this review suggest gaps in treatment options, healthcare services, and social support. While this paper provides a foundation for future progress, advancement in this field will require a collaborative effort from researchers, healthcare professionals, and community outreach programs to effectively close the gaps in care noted in these patient populations.

Psychotic relapse prediction via biomarker monitoring: a systematic review

Background

Associating temporal variation of biomarkers with the onset of psychotic relapse could help demystify the pathogenesis of psychosis as a pathological brain state, while allowing for timely intervention, thus ameliorating clinical outcome. In this systematic review, we evaluated the predictive accuracy of a broad spectrum of biomarkers for psychotic relapse. We also underline methodological concerns, focusing on the value of prospective studies for relapse onset estimation.

Methods

Following the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines, a list of search strings related to biomarkers and relapse was assimilated and run against the PubMed and Scopus databases, yielding a total of 808 unique records. After exclusion of studies related to the distinction of patients from controls or treatment effects, the 42 remaining studies were divided into 5 groups, based on the type of biomarker used as a predictor: the genetic biomarker subgroup (n = 4, or 9%), the blood-based biomarker subgroup (n = 15, or 36%), the neuroimaging biomarker subgroup (n = 10, or 24%), the cognitive-behavioral biomarker subgroup (n = 5, or 12%) and the wearables biomarker subgroup (n = 8, or 19%).

Results

In the first 4 groups, several factors were found to correlate with the state of relapse, such as the genetic risk profile, Interleukin-6, Vitamin D or panels consisting of multiple markers (blood-based), ventricular volume, grey matter volume in the right hippocampus, various functional connectivity metrics (neuroimaging), working memory and executive function (cognition). In the wearables group, machine learning models were trained based on features such as heart rate, acceleration, and geolocation, which were measured continuously. While the achieved predictive accuracy differed compared to chance, its power was moderate (max reported AUC = 0.77).

Discussion

The first 4 groups revealed risk factors, but cross-sectional designs or sparse sampling in prospective studies did not allow for relapse onset estimations. Studies involving wearables provide more concrete predictions of relapse but utilized markers such as geolocation do not advance pathophysiological understanding. A combination of the two approaches is warranted to fully understand and predict relapse.

Antipsychotic medication in people with intellectual disability and schizophrenia: A 25-year updated systematic review and cross-sectional study

OBJECTIVES

To determine the efficacy and safety of antipsychotic medication for treating individuals with a dual diagnosis of intellectual disability (ID) and schizophrenia.

METHODS

We systematically reviewed the literature to explore the risks and benefits of antipsychotics for schizophrenia in ID. In addition, a cross-sectional retrospective study on the tolerance profiles of a representative ID and schizophrenia cohort was conducted.

RESULTS

From the systematic search, we retained 18 articles detailing information on 24 cases. In almost all cases, the antipsychotic improved psychotic symptoms (e.g., hallucinations, delusions, disorganization). Negative manifestations were also improved (blunted affects, amotivation, poor rapport), as were challenging behaviors in a few cases. The most commonly reported side effects were neurological (extra-pyramidal, movement disorder, epilepsy) and metabolic manifestations. In the retrospective cross-sectional study, we reported data on 112 participants with comorbid ID and schizophrenia. In all, 103 participants were antipsychotic-treated, of which 39% were on antipsychotic monotherapy. Of these, 35% were in the obesity range, 25% in the hyperglycemic range, and 25% in the dyslipidemia range. The body mass index did not differ between the groups.

CONCLUSIONS

This study provides an initial evidence base underpinning the efficacy of antipsychotic drugs on schizophrenia in the ID population. Nevertheless, there may be an increased risk of metabolic side effects, hence, close monitoring of blood glucose, lipids, and weight should be implemented when prescribing antipsychotics to this population.

Plasma NGAL, not IFN-γ, predicts early treatment response in drug-naïve Chinese Han schizophrenia patients

BACKGROUND

Early prediction of treatment efficacy can assist psychiatrists in optimizing personalized treatment strategies for drug-naïve schizophrenia patients. This study aimed to explore the predictive value of plasma concentrations of Interferon-γ (IFN-γ) and Neutrophil gelatinase-associated lipocalin (NGAL) in early treatment responses.

METHODS

We conducted a longitudinal study involving 125 drug-naïve schizophrenia patients and 75 healthy controls. Plasma samples were collected and analyzed at baseline and after 8 weeks of treatment. Based on treatment outcomes, patients were classified as Responders (R, n = 84) or Non-responders (NR, n = 41).

RESULTS

At baseline, schizophrenia patients showed significantly lower IFN-γ and NGAL concentrations compared to healthy controls. NGAL levels were notably lower in the NR group compared to the R group. After treatment, both IFN-γ and NGAL concentrations increased in all patients, with a marked rise in IFN-γ levels. NGAL concentration negatively correlated with the positive factor at baseline, adjusting for confounders such as age, BMI, smoking, and duration of untreated illness. Logistic regression analysis identified lower baseline NGAL concentrations as a predictor of poor early treatment response.

CONCLUSION

Pre-treatment plasma NGAL concentrations may serve as a potential biomarker for predicting early treatment response in drug-naïve Chinese Han schizophrenia patients. These findings highlight NGAL as a possible target for future therapeutic development in schizophrenia.

Cannabidiol attenuates prepulse inhibition disruption by facilitating TRPV1 and 5-HT1A receptor-mediated neurotransmission

Individuals with schizophrenia (SCZ) often present sensorimotor gating impairments that can be investigated by the prepulse inhibition test (PPI). PPI disruption can be mimicked experimentally with psychostimulants such as amphetamine and attenuated/reversed by antipsychotics. Cannabidiol (CBD), the main non-psychotomimetic component of the Cannabis sativa plant, produces antipsychotic-like effects in clinical and preclinical studies. CBD can interact with many pharmacological targets, but the mechanisms involved in its antipsychotic activity are unclear. Using amphetamine-induced PPI disruption in mice, we investigated the involvement of four CBD potential pharmacological targets (CB1, CB2 TRPV1, and 5-HT1A receptors) in its antipsychotic properties. CBD effects were blocked by the TRPV1 antagonist capsazepine and, to a greater extent, by the 5-HT1A receptor antagonist WAY100635. No effect was observed with the CB1 (AM251) or CB2 (AM630) receptor antagonists. These results corroborate findings showing the antipsychotic effects of CBD in the PPI model and indicate that they involve the participation of TRPV1 and 5-HT1A receptors.

What is helpful and unhelpful when people try to withdraw from antipsychotics: An international survey

OBJECTIVE

Antipsychotics remain the first-line treatment for people diagnosed with psychotic disorders despite adverse effects which lead many people to stop their medication. Many stop without the support of the prescriber, who may fear relapse. The objective of this study is to better understand the process of withdrawal from antipsychotics, from the perspective of people taking antipsychotics.

DESIGN

Online survey.

METHODS

An international online survey elicited quantitative responses about pre-withdrawal planning (560) and qualitative responses about what was helpful and unhelpful when withdrawing from antipsychotics (443). Responses came from users of antipsychotics in 29 countries.

RESULTS

Forty-seven per cent did not consult their psychiatrist before discontinuing. Only 40% made preparations, most commonly making a plan, gathering information and informing family. The most frequently reported helpful factors were focussing on the benefits of getting off the drugs (including ending adverse effects and feeling more alive), information about withdrawal symptoms and how to withdraw safely, withdrawing slowly, and support from psychologists, counsellors and psychotherapists. The most common unhelpful factor was the psychiatrist/doctor, largely because of their lack of knowledge, refusal to support the patient's wishes and the threat or use of coercion.

CONCLUSIONS

Evidence-based, respectful, collaborative responses to patients' concerns about adverse effects and desires to withdraw would probably reduce relapse rates and improve long-term outcomes. It would definitely help end pervasive breaching of the principle of informed consent and human rights legislation.

Opioid antagonists: clinical utility, pharmacology, safety, and tolerability

Opioid antagonists block opioid receptors, a mechanism associated with utility in several therapeutic indications. Here, we review the sites of action, clinical uses, pharmacology, and general safety profiles of US Food and Drug Administration (FDA)-approved opioid antagonists. A review of the literature and product labels of opioid antagonists was conducted. The unique clinical uses of approved opioid antagonists are related to their ability to block opioid receptors centrally and/or peripherally. Centrally acting opioid antagonists treat opioid and alcohol use disorders (AUDs) and reverse opioid overdose. Because the opioid system influences weight and metabolism, one opioid antagonist combination product is approved for chronic weight management; another, approved for adults with schizophrenia or bipolar I disorder, mitigates olanzapine-associated weight gain. Peripherally acting opioid antagonists are approved for opioid-induced constipation; another accelerates gastrointestinal recovery after bowel surgery. Opioid antagonists are generally well tolerated; they are not associated with physiologic dependence or abuse. However, opioid antagonists can precipitate acute opioid withdrawal in patients using or undergoing withdrawal from opioid agonists. Likewise, their use can confer a risk for opioid overdose if attempts are made to overcome opioid antagonist blockade of opioid receptors via the intake of additional opioids. Opioid receptor antagonists have diverse therapeutic benefits based on their respective pharmacology and sites of action; understanding their respective nuances facilitates the safe and effective use of these agents.

Improved insomnia is one pathway underlying the anti-suicidal properties of clozapine

BACKGROUND

Insomnia is common in schizophrenia and associated with suicide. Clozapine has anti-suicidal properties and beneficial effects on sleep. Whether effects on insomnia mediate the anti-suicidal properties of clozapine remains unclear.

METHODS

In n = 76 patients from the Clinical Antipsychotic Trials of intervention effectiveness schizophrenia trial using a within-subjects design, we investigated whether improvement in terminal insomnia was associated with improvement in suicidal ideation (SI) after treatment with non-clozapine antipsychotics, and then after treatment with clozapine, using binary logistic regression. Terminal insomnia and SI over the past 2 weeks were assessed before and after both non-clozapine antipsychotic and clozapine treatment with the Calgary Depression Scale for Schizophrenia.

RESULTS

There was no association between improved terminal insomnia and resolution of SI after treatment with non-clozapine antipsychotics (OR = 0.2, 95% CI 0.0-9.0, p = 0.41). In the same patients, improved terminal insomnia was associated with resolution of SI after clozapine treatment (OR = 14.6, 95% CI 1.7-129.2, p = 0.02).

CONCLUSIONS

Improved terminal insomnia is associated with improved SI following clozapine treatment. Findings warrant replication in a larger sample with standard instruments in the assessment of insomnia and suicide, but suggest beneficial effects on sleep as a mediator of the anti-suicidal properties of clozapine. Future mechanistic studies are also needed.

Untangling Depression in Schizophrenia: The Role of Disorganized and Obsessive-Compulsive Symptoms and the Duration of Untreated Psychosis

Background: Schizophrenia is a complex disorder characterized by positive symptoms (e.g., hallucinations), negative symptoms (e.g., social withdrawal), and disorganized symptoms (e.g., thought disorder). Alongside these, cognitive and depressive symptoms often emerge, with depressive symptoms sometimes dominating the clinical picture. Understanding the factors that influence the development of depressive symptoms in schizophrenia could clarify the dynamics between depressive and psychotic symptoms and guide clinical interventions. Methods: A total of 105 patients with schizophrenia (66 women, 39 men) were assessed using several clinical scales: PANSS, BPRS, DOCS, DES, HAM-D, and the Luria-Nebraska Neuropsychological Battery for cognitive evaluation. Statistical analyses, including correlation and regression, were conducted using SPSS to determine the significance of associations. Results: Disorganized and obsessive-compulsive symptoms were identified as primary factors associated with depressive symptoms in patients with schizophrenia. Conversely, a longer duration of untreated psychosis was linked to a lower severity of depressive symptoms, suggesting that early intervention may alter the depressive symptom trajectory. Conclusions: Here, we suggest a complex interaction between psychotic and depressive symptoms, possibly indicating a biological antagonism. The association of depressive symptoms with disorganized and obsessive-compulsive features may reflect an adaptive psychological response, attempting to stabilize amidst the disintegration of schizophrenia. These insights support a more integrated approach to treatment, addressing both psychotic and depressive symptoms to improve patient outcomes.

Evaluation of routine health monitoring for metabolic disorders in patients with serious mental illness on psychotropic medications: a study from Ethiopia

BACKGROUND

Compared to the overall population, patients with mental health problems are more likely to experience concurrent physical illnesses, poorer health outcomes, and mortality. Psychotropic medications, which are the pillars in the management of mental health conditions, are associated with adverse effects such as weight gain, an increased level of glucose, and elevated circulating lipid levels, all of which contribute to metabolic disorders. Inadequate health monitoring may led to suboptimal interventions and worsening of these conditions. However, there is a lack of studies assessing routine health monitoring practices for metabolic disorders and their determinants among patients with serious mental illnesses taking psychotropic medications in Ethiopia. This study aimed to evaluate routine health monitoring for metabolic disorders and its determinants in patients with serious mental illnesses on psychotropic medications in Ethiopia.

METHOD

A hospital based prospective follow-up study was conducted among patients with serious mental illness taking psychotropic medications who attended the outpatient psychiatry department at Debre Markos Comprehensive Specialized Hospital. Eligible participants were selected using a simple random sampling technique. Routine health monitoring was evaluated using guidelines and previous literature. Binary logistic regression was employed to identify the determinants of routine health monitoring, with statistical significance determined by a p-value of less than 0.05 and a 95% confidence interval (CI).

RESULTS

The overall routine health monitoring practice for metabolic disorders was found to be sub-optimal. Vital signs were the most commonly assessed parameters. Key determinants of routine health monitoring included participants aged 45 and above (AOR (95% CI): 2.82 (1.34-5.92), having social insurance (AOR (95% CI): 2.94 (1.86-4.64), availability of laboratory tests at the hospital (AOR (95% CI): 3.46 (2.16-5.55), and reporting of medication-related side effects (AOR (95% CI): 1.96 (1.21-3.17)).

CONCLUSION

Routine health monitoring for metabolic disorders in patients with serious mental illnesses attending the outpatient psychiatry department was inadequate. Health care providers should give more attention to younger patients, those without health insurance, and who are not reported side effects. These findings provide crucial insights for improving routine health monitoring and promoting better health outcomes.

2001-2021 Comparative Persistence of Oral Antipsychotics in Patients Initiating Treatment: Superiority of Clozapine in Time-to-Treatment Discontinuation

BACKGROUND

Continuous antipsychotic (AP) therapy is crucial for managing psychotic disorders, and its early interruption reflects the drug's failure. Real-world epidemiological research is essential for confirming experimental data and generating new research hypotheses.

METHODS

The persistence of oral APs in a large population sample from 2000 to 2021 was analyzed by comparing AP prescriptions over this period across four Italian provinces, using dispensing data linked via a record-linkage procedure among regional healthcare utilization databases. We calculated personalized daily dosages and assessed time-to-treatment discontinuation over a 3-month period for patients initiating AP treatment. Treatment persistence was evaluated using Kaplan-Meier curves and Cox regression, with adjustments for age and sex.

RESULTS

Second-generation antipsychotics (SGAs) were favored over first-generation antipsychotics (FGAs), with olanzapine as the most prescribed. Within the study time frame, 42,434 individuals were prescribed a new continuous AP regimen. The analysis revealed 24 significant differences within 28 comparisons. As a class, SGAs demonstrated better treatment persistence than FGAs (HR: 0.76; 95%CI: 0.73, 0.79). Clozapine stood out for its superior persistence, surpassing all other SGAs, notably olanzapine (HR: 0.85; 95%CI: 0.79-0.91) and risperidone (HR: 0.80; 95%CI: 0.74-0.87). Olanzapine and aripiprazole showed better results than both risperidone and quetiapine. Quetiapine showed inferior 3-month persistence in all pairwise comparisons.

CONCLUSION

The study results provide insight into the performance dynamics among SGAs: clozapine, despite being one of the less frequently dispensed APs in our sample, emerged as a significant prescription choice. The significance of pharmacoepidemiological studies in complementing experimental findings is also underscored.

Probing the molecular and cellular pathological mechanisms of schizophrenia using human induced pluripotent stem cell models

With recent advancements in psychiatric genomics, as a field, "stem cell-based disease modelers" were given the exciting yet daunting task of translating the extensive list of disease-associated risks into biologically and clinically relevant information in order to deliver therapeutically meaningful leads and insights. Despite their limitations, human induced pluripotent stem cell (iPSCs) based models have greatly aided our understanding of the molecular and cellular mechanisms underlying the complex etiology of brain disorders including schizophrenia (SCZ). In this review, we summarize the major findings from studies in the past decade which utilized iPSC models to investigate cell type-specific phenotypes relevant to idiopathic SCZ and disease penetrant alleles. Across cell type differences, several biological themes emerged, serving as potential neurodevelopmental mechanisms of SCZ, including oxidative stress and mitochondrial dysfunction, depletion of progenitor pools and insufficient differentiation potential of these progenitors, and structural and functional deficits of neurons and other supporting cells. Here, we discuss both the recent progress as well as challenges and improvements needed for future studies utilizing iPSCs as a model for SCZ and other neuropsychiatric disorders.

Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: Focus on antipsychotics

BACKGROUND

For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialised tools are used. Three tools have been proven useful to personalise drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging.

METHODS

In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 45 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)).

RESULTS

Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings.

CONCLUSION

All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimise treatment effects, minimise side effects and ultimately reduce the global burden of diseases, personalised drug treatment has not yet become the standard of care in psychiatry.

Head-to-Head Comparison of UHPLC-MS/MS and Alinity C for Plasma Analysis of Risperidone and Paliperidone

Background and objectives: Risperidone, a second-generation antipsychotic widely used in the treatment of schizophrenia, requires therapeutic drug monitoring due to its high interindividual variability. UHPLC-MS/MS is considered the gold standard for pharmacokinetic studies owing to its superior sensitivity and specificity, although it involves time-consuming manual sample preparation. In contrast, the Alinity C system, fully automated, simplifies sample processing, but only measures the active moiety (risperidone plus paliperidone). The aim of this study is to compare the performance of UHPLC-MS/MS and the Alinity C system for the determination of risperidone and paliperidone concentrations in plasma. Methods: A total of 115 plasma samples of 115 patients, 92 and 23 under risperidone and paliperidone long-acting treatment, respectively, were analyzed using both methods. Results: A strong correlation for the active moiety (risperidone plus 9-OH-Risperidone) (rs = 0.95) was observed. However, Bland-Altman analysis revealed a mean bias of 0.996 ng/mL, indicating that the Alinity C system slightly overestimates concentrations compared to UHPLC-MS/MS. While there was substantial agreement between methods (κ = 0.72), discrepancies were observed in 16.3% of cases, which could impact clinical decision-making. When analyzing paliperidone separately, the agreement was lower (κ = 0.63), with greater variability observed. Conclusions: These findings suggest that, while the Alinity C system is suitable for routine therapeutic monitoring, UHPLC-MS/MS remains the preferred method in clinical scenarios requiring higher precision, particularly for patients with concentrations near therapeutic thresholds.

Health-Care Utilisation and Costs of Transition from Paliperidone Palmitate 1-Monthly to 3-Monthly Treatment for Schizophrenia: A Real-World, Retrospective, 24-Month Mirror-Image Study

Introduction

Poor adherence to antipsychotics in patients with schizophrenia is a leading cause of relapse and functional deterioration. Long-acting injectable paliperidone may reduce relapse risks, health-care utilisation, and health-care costs in these patients.

Methods

In this 24-month mirror-image study, we compared health-care utilization and costs before and after the initiation of paliperidone palmitate 3-monthly (PP3M) treatment in patients with schizophrenia spectrum disorders. Before the initiation of PP3M, the patients received paliperidone 1-monthly (PP1M) treatment. The primary study outcomes were changes in health-care utilisation and costs over the study period.

Results

This study included 34 patients with schizophrenia spectrum disorders. During the 12-months period after the initiation of PP3M treatment, the mean duration of hospitalisation decreased from 57.7 to 28.5 days (p = 0.03). Moreover, significant reductions were noted in emergency room visits (PP1M vs PP3M: 0.3 vs 0.0, respectively; p = 0.05) and health-care costs (PP1M vs PP3M: 107,328.8 vs 57,848.6, respectively; p = 0.03).

Conclusion

PP3M may significantly reduce hospitalisation duration, emergency room visits, and health-care costs in patients with schizophrenia.

Real-World Data Mining for Signal Detection of Antipsychotics-Associated Adverse Events Using the Korea Adverse Event Reporting System (KAERS) Database

Background and Objectives: Recent studies suggest that the binary categorization of first-generation antipsychotics (FGAs) as being primarily responsible for extrapyramidal symptoms (EPSs) and second-generation antipsychotics (SGAs) for cardiometabolic abnormalities is an oversimplification. SGAs also demonstrate antagonistic affinity for D2 receptors, indicating their potential to induce EPSs. This study utilized the Korea Adverse Event Reporting System (KAERS) database to explore adverse drug event (ADE) signals related to both FGAs and SGAs. Materials and Methods: Relevant ADE reports from January 2013 to December 2022 were extracted from the KAERS database and analyzed using disproportionality analysis, employing the proportional reporting ratio (PRR), reporting odds ratio (ROR), and information component (IC) with its 95% lower confidence interval (LCI) indices. Results: Of the initial dataset of 2,890,702 ADE reports, those with insufficient data and duplicates were removed, resulting in a final dataset of 5249 reports for analysis. Aripiprazole, an SGA, showed signals for movement disorders, including EPSs (PRR 4.7, ROR 4.8, IC 2.2), tremors (PRR 5.3, ROR 5.4, IC 2.4), and akathisia (PRR 18.6, ROR 19.3, IC 3.5). Notably, for quetiapine, cardiovascular signals were detected, including increased blood pressure (PRR 2.1, ROR 2.3, IC 0.5), and tachyarrhythmia (PRR 13.9, ROR 14.1, IC 1.8), along with peripheral edema (PRR 2.5, ROR 2.5, IC 0.2). Metabolic abnormalities, such as weight gain and increased appetite, were identified for four SGAs: aripiprazole, olanzapine, quetiapine, and risperidone. Safety signals related to movement disorders were not detectable for FGAs, likely due to the limited number of ADE reports available for analysis. Conclusions: Our study findings support that the distribution of ADEs between FGAs and SGAs is not strictly binary. Aripiprazole, despite being an SGA, showed signals for extrapyramidal movement disorders. Four SGAs (aripiprazole, olanzapine, quetiapine, and risperidone) were linked to metabolic side effects, while quetiapine was associated with cardiovascular safety signals.

Olanzapine Versus Quetiapine: Corrected QT Changes in Critically Ill Patients

BACKGROUND

Olanzapine and quetiapine are frequently administered atypical antipsychotic medications and their effects on the corrected QT (QTc) in the critically ill population remain understudied.

OBJECTIVE

The objective of this study was to compare the impact of olanzapine and quetiapine on QTc changes in critically ill patients.

METHODS

This was a single-center, retrospective analysis. Adult patients admitted to the intensive care unit (ICU) from January 2023 through July 2023 were included if they received ≥2 doses of either olanzapine or quetiapine within a 48-hour period and had one QTc evaluated within 48 hours of antipsychotic initiation. The major endpoint was a composite of the incidence of QTc prolongation (defined as QTc > 500 ms or QTc > 60 ms above baseline) following antipsychotic initiation. Univariable and multivariable analyses were performed to identify risk factors for QTc prolongation.

RESULTS

There was no statistical difference in the major composite endpoint between patients in the olanzapine and quetiapine groups (8/83 [9.6%] vs 19/129 [14.7%]; P = .28). The incidence of QTc > 500 ms (7/244 [2.9%] vs 20/427 [4.7%]; P = .25) and change from baseline >60 ms (5/244 [2.0%] vs 17/427 [4.0%]; P = .26) were not statistically different between the olanzapine and quetiapine groups, respectively. There were no occurrences of Torsades de Pointes or extrapyramidal symptoms in either group.

CONCLUSION AND RELEVANCE

The results of this study suggest olanzapine and quetiapine may have similar impact on QTc prolongation in critically ill patients. These findings could contribute to safer prescribing practices in the ICU.

New Drug Treatments for Schizophrenia: A Review of Approaches to Target Circuit Dysfunction

Schizophrenia is a leading cause of global disease burden. Current drug treatments are associated with significant side effects and have limited efficacy for many patients, highlighting the need to develop new approaches that target other aspects of the neurobiology of schizophrenia. Preclinical, in vivo imaging, postmortem, genetic, and pharmacological studies have highlighted the key role of cortical GABAergic (gamma-aminobutyric acidergic)-glutamatergic microcircuits and their projections to subcortical dopaminergic circuits in the pathoetiology of negative, cognitive, and psychotic symptoms. Antipsychotics primarily act downstream of the dopaminergic component of this circuit. However, multiple drugs are currently in development that could target other elements of this circuit to treat schizophrenia. These include drugs for GABAergic or glutamatergic targets, including glycine transporters, D-amino acid oxidase, sodium channels, or potassium channels. Other drugs in development are likely to primarily act on pathways that regulate the dopaminergic system, such as muscarinic or trace amine receptors or 5-HT2A receptors, while PDE10A inhibitors are being developed to modulate the downstream consequences of dopaminergic dysfunction. Our review considers where new drugs may act on this circuit and their latest clinical trial evidence in terms of indication, efficacy, and side effects. Limitations of the circuit model, including whether there are neurobiologically distinct subgroups of patients, and future directions are also considered. Several drugs based on the mechanisms reviewed have promising clinical data, with the muscarinic agonist KarXT most advanced. If these drugs are approved for clinical use, they have the potential to revolutionize understanding of the pathophysiology and treatment of schizophrenia.