Association of antipsychotic treatment switching in patients with schizophrenia, bipolar, and major depressive disorders

Proteomic analysis of peripheral blood mononuclear cells in first episode psychosis - Protein and peptide-centered approaches to elucidate potential diagnostic biomarkers

Diagnosing patients suffering from psychotic disorders is far from being achieved with molecular support, despite all the efforts to study these disorders from different perspectives. Characterizing the proteome of easily obtainable blood specimens, such as the peripheral blood mononuclear cells (PBMCs), has particular interest in biomarker discovery and generating pathophysiological knowledge. This approach has been explored in psychiatry, and while generating valuable information, it has not translated into meaningful biomarker discovery. In this project, we report the proof-of-concept of a methodology that aims to explore further information obtained with classical proteomics approaches that is easily overlooked. PBMC samples from first-episode psychosis and control subjects were subjected to a SWATH-MS approach, and the classical protein relative quantification was performed, where 389 proteins were found to be important to distinguish the two groups. Individual analysis of the quantified peptides was also performed, highlighting peptides of unchanged proteins that were significantly altered. With the combination of protein- and peptide-centered proteomics approaches, it is possible to highlight that information about proteoforms, namely regulation at the peptide level possibly due to post-translational modifications, is routinely overlooked and that its diagnostic potential should be further explored. SIGNIFICANCE: Our exploratory findings highlight the potential of MS-based proteomics strategies, combining protein- and peptide-centered approaches, to aid clinical decision-making in first-episode psychosis, helping to establish early biomarkers for schizophrenia and other psychotic disorders. Particularly, the less popular peptide-centered approach allows the identification/measurement of overlooked modulated peptides that may have potential biomarker characteristics. The application in parallel of protein- and peptide-centered strategies is transversal to research of other diseases, potentially allowing a more comprehensive characterization of the metabolic/pathophysiological alterations related to a specific disease.

Reasons for switching oral antipsychotic medications and related patterns of care and costs in patients with schizophrenia initiating monotherapy treatment: Claims-linked chart study

BACKGROUND

Antipsychotic switching is frequent in schizophrenia and is associated with poor clinical outcomes, increased health care resource utilization (HCRU), and increased health care costs. Research describing the reasons for antipsychotic switching in patients with schizophrenia and the associated impacts on HCRU and costs is limited.

OBJECTIVE

To explore the reasons for oral antipsychotic medication (OAM) switching and describe HCRU and costs associated with OAM switching, stratified by reasons for switching, in patients with commercial or Medicare Advantage insurance in the United States.

METHODS

This retrospective observational study used medical and pharmacy claims from the Optum Research Database linked to patient medical chart data. Adults with a diagnosis of schizophrenia who initiated OAM monotherapy between January 1, 2015, and June 30, 2021, and switched from their initial OAM monotherapy to a second one were included. Reasons for OAM switching were recorded from medical charts abstracted between 4 months preceding and 2 months following the patient's switch date. HCRU and costs incurred up to 3 months before and 3 months after the OAM switch were stratified and compared by reasons for switching among individuals who switched OAM monotherapy.

RESULTS

Among 134 patients with valid, abstracted charts, the 2 most common reasons for switching were lack of efficacy (57.5% of switches) and at least 1 tolerability issue (41.8%). Mutually exclusive categories of switching reasons included lack of efficacy and no tolerability issues (56/134; 41.8%), tolerability and no efficacy issues (35/134; 26.1%), lack of efficacy and tolerability issues (21/134; 15.7%), and other or unknown (22/134; 16.4%). All-cause and schizophrenia-related HCRU and costs in any health services category did not appear to differ across the reason-for-switching cohorts, with costs for inpatient stays accounting for greater than half of the total costs, regardless of switching reason.

CONCLUSIONS

These findings provide insight on patient experiences that contribute to OAM switching, with nearly half of patients switching because of lack of efficacy, more than one-fourth because of tolerability issues, and an additional one-sixth for reasons of both efficacy and tolerability. Health care providers should address patients' expectations regarding OAM effectiveness, symptom resolution, and side effect tolerability at treatment initiation to minimize switching before the medication has reached peak effectiveness. Prescribing access to a broad selection of antipsychotics with different side effect profiles may help physicians better match treatment to individual patients, fostering greater acceptance of therapy, increased medication adherence, and better long-term outcomes.

Patterns of care and costs of switching oral antipsychotic medications in patients with schizophrenia initiating monotherapy treatment: A US claims analysis

BACKGROUND

Antipsychotic medications are the mainstay of schizophrenia therapy but may need to be changed over the course of a patient's illness to achieve the desired therapeutic goals or minimize medication side effects. Investigations of real-world treatment patterns and economic consequences associated with antipsychotic changes, including switching, are limited.

OBJECTIVE

To describe treatment patterns among patients with schizophrenia who initiated oral antipsychotic medication (OAM) monotherapy and assess switching-related health care resource utilization (HCRU) and costs in US Medicare Advantage and commercially insured patients.

METHODS

Adults with at least 2 claims with a schizophrenia diagnosis who initiated (or reinitiated after ≥6 months) OAM monotherapy between January 1, 2015, and June 30, 2021, were identified in the Optum Research Database. A claims-based algorithm using timing of therapies and treatment gaps identified medication changes, specifically OAM monotherapy switches, among OAM initiators over a period of up to 7 years. Patients who switched from their initial OAM monotherapy to a second OAM monotherapy (initial OAM switchers) were matched based on clinical and demographic characteristics to OAM initiators who had not switched OAMs; switch-related HCRU and costs (incurred up to 3 months before and 3 months after the initial OAM switch) were compared between matched initial OAM switchers and nonswitchers.

RESULTS

Among 6,425 OAM monotherapy initiators, 1,505 (23.4%) had at least 1 OAM monotherapy switch at any time during follow-up, with a mean (SD) time to first switch of 209 (333) days (median, 67 days), a rate of 0.65 switches per person-year of follow-up, and 56% of first switches occurring within 3 months of OAM initiation. Of all OAM initiators, 947 (14.7%) were initial OAM switchers. Compared with 865 matched nonswitchers, 865 initial OAM switchers had greater mean counts of all-cause medical visits and greater mean counts of schizophrenia-related emergency and inpatient visits and longer inpatient stays per patient per month. Mean (SD) total schizophrenia-related costs per patient per month were $1,252 ($2,602) for switchers compared with $402 ($2,027) for nonswitchers (P < 0.001).

CONCLUSIONS

Changes to antipsychotic therapy in our sample of patients with schizophrenia were common, with nearly one-fourth switching OAMs, the majority within the first 3 months of therapy. Initial OAM switchers experienced greater HCRU and costs than nonswitchers. These findings highlight the importance of initiating OAM monotherapy that effectively maintains symptom control and minimizes tolerability issues, which would limit the need to switch OAMs and therefore prevent excess HCRU and treatment costs.

Real-world predictors of relapse in patients with schizophrenia and schizoaffective disorder in a large health system

Schizophrenia is often characterized by recurring relapses, which are associated with a substantial clinical and economic burden. Early identification of individuals at the highest risk for relapse in real-world treatment settings could help improve outcomes and reduce healthcare costs. Prior work has identified a few consistent predictors of relapse in schizophrenia, however, studies to date have been limited to insurance claims data or small patient populations. Thus, this study used a large sample of health systems electronic health record (EHR) data to analyze relationships between patient-level factors and relapse and model a set of factors that can be used to identify the increased prevalence of relapse, a severe and preventable reality of schizophrenia. This retrospective, observational cohort study utilized EHR data extracted from the largest Midwestern U.S. non-profit healthcare system to identify predictors of relapse. The study included patients with a diagnosis of schizophrenia (ICD-10 F20) or schizoaffective disorder (ICD-10 F25) who were treated within the system between October 15, 2016, and December 31, 2021, and received care for at least 12 months. A relapse episode was defined as an emergency room or inpatient encounter with a pre-determined behavioral health-related ICD code. Patients' baseline characteristics, comorbidities and healthcare utilization were described. Modified log-Poisson regression (i.e. log Poisson regression with a robust variance estimation) analyses were utilized to estimate the prevalence of relapse across patient characteristics, comorbidities and healthcare utilization and to ultimately identify an adjusted model predicting relapse. Among the 8119 unique patients included in the study, 2478 (30.52%) experienced relapse and 5641 (69.48%) experienced no relapse. Patients were primarily male (54.72%), White Non-Hispanic or Latino (54.23%), with Medicare insurance (51.40%), and had baseline diagnoses of substance use (19.24%), overweight/obesity/weight gain (13.06%), extrapyramidal symptoms (48.00%), lipid metabolism disorder (30.66%), hypertension (26.85%), and diabetes (19.08%). Many differences in patient characteristics, baseline comorbidities, and utilization were revealed between patients who relapsed and patients who did not relapse. Through model building, the final adjusted model with all significant predictors of relapse included the following variables: insurance, age, race/ethnicity, substance use diagnosis, extrapyramidal symptoms, number of emergency room encounters, behavioral health inpatient encounters, prior relapses episodes, and long-acting injectable prescriptions written. Prevention of relapse is a priority in schizophrenia care. Challenges related to historical health record data have limited the knowledge of real-world predictors of relapse. This study offers a set of variables that could conceivably be used to construct algorithms or models to proactively monitor demographic, comorbidity, medication, and healthcare utilization parameters which place patients at risk for relapse and to modify approaches to care to avoid future relapse.

Predictors of antipsychotics switching among ambulatory patients with schizophrenia in Ethiopia: a multicenter hospital-based cross-sectional study

INTRODUCTION

A change of therapy from one to another antipsychotic medication is currently the main challenge of therapy. This study aimed to assess the prevalence of antipsychotic medication switches and determinants among patients with schizophrenia in Northwest Ethiopia.

METHODS

Multi-center hospital-based cross-sectional study was conducted at five Comprehensive Specialized Hospitals found in Northwest Ethiopia from April 30, 2021, to August 30, 2021. Data were extracted from both patients' medical charts and interviews. Data were entered into Epi-data software version 3.5.1 and exported to SPSS version 25.0 for analysis. A multivariable logistic regression model was fitted to identify factors associated with medication regimen switch. The level of significance of the study was kept at a p-value of 0.05 with a 95% confidence interval.

RESULT

A total of 414 patients are involved in the study, and 188 (45.5%) of patients switched antipsychotics within one year. The unavailability of the medication is the commonest reason for switching. Being male [AOR = 2.581, 95% CI (1.463, 4.552)], having relapse [AOR = 2.341,95% CI (1.169,4.687)], history of hospitalization in the past year [AOR = 3.00,95% CI (1.478,5.715)] and taking typical antipsychotics [AOR = 3.340, CI (1.76, 6.00)] had a significant association with antipsychotics switching.

CONCLUSIONS AND RECOMMENDATIONS

There is a high prevalence of antipsychotic switches among schizophrenia patients. Prescribers need to be careful while dosing, selecting, and switching antipsychotics, hence may help reduce discontinuation and unnecessary switch and thus achieve optimal clinical management.

A new era in the diagnosis and treatment of tardive dyskinesia

Tardive dyskinesia (TD) is a heterogeneous, hyperkinetic movement disorder induced by dopamine-receptor blocking agents that presents a unique challenge in the treatment of psychosis. Although acceptance of TD as a serious consequence of antipsychotic treatment was resisted initially, subsequent research by many investigators in psychopharmacology contributed to a rich store of knowledge on many aspects of the disorder. While basic neuroscience investigations continue to deepen our understanding of underlying motor circuitry, past trials of potential treatments of TD focusing on a range of theoretical targets were often inconclusive. Development of newer antipsychotics promised to reduce the risk of TD compared to older drugs, but their improved tolerability unexpectedly enabled an expanding market that paradoxically both increased the absolute number of patients at risk and diminished attention to TD which was relegated to legacy status. Fortunately, development and approval of novel vesicular monoamine transporter inhibitors offered evidence-based symptomatic treatment of TD for the first time and rekindled interest in the disorder. Despite recent progress, many questions remain for future research including the mechanisms underlying TD, genetic predisposition, phenomenological diversity, whether new cases are reversible, how to implement best practices to prevent and treat TD, and whether the development of novel antipsychotics free of the risk of TD is attainable. We owe our patients the aspirational goal of striving for zero prevalence of persistent symptoms of TD in anyone treated for psychosis.

GLP-1 agonists: superior for mind and body in antipsychotic-treated patients?

Antipsychotics (APDs) represent a core treatment for severe mental disorders (SMEs). Providing symptomatic relief, APDs do not exert therapeutic effects on another clinically significant domain of serious mental disorders, cognitive impairment. Moreover, adverse metabolic effects (diabetes, weight gain, dyslipidemia, and increased cardiovascular risk) are common during treatment with APDs. Among pharmacological candidates reversing APD-induced metabolic adverse effects, glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1 RAs), approved for both diabetes and recently for obesity treatment, stand out due to their favorable effects on peripheral metabolic parameters. Interestingly, GLP-1 RAs are also proposed to have pro-cognitive effects. Particularly in terms of dual therapeutic mechanisms potentially improving both central nervous system (CNS) deficits and metabolic burden, GLP-1 RAs open a new perspective and assume a clinically advantageous position.

Continuing, reducing, switching, or stopping antipsychotics in individuals with schizophrenia-spectrum disorders who are clinically stable: a systematic review and network meta-analysis

BACKGROUND

Although antipsychotic maintenance treatment is widely recommended to prevent relapse in chronic psychoses, evidence-based guidelines do not provide clear indications on different maintenance treatment strategies, including continuing the antipsychotic at standard doses, reducing the dose, switching to another antipsychotic, or even stopping the antipsychotic. We aimed to compare the effectiveness of these maintenance treatment strategies, hypothesising the superiority of all strategies over stopping, and of continuing at standard doses over both switching and reducing the dose.

METHODS

We did a systematic review and network meta-analysis of randomized controlled trials (RCTs) that investigated antipsychotics for relapse prevention in adults with schizophrenia-spectrum disorders who were clinically stable, and which compared four treatment strategies: continuing the current antipsychotic at standard doses recommended for acute treatment; reducing the current antipsychotic dose; switching to a different antipsychotic; and stopping the antipsychotic and replacing it with placebo. We excluded RCTs with fewer than 25 individuals, a prerandomisation washout period greater than 4 weeks, a follow-up shorter than 6 weeks, and those recruiting treatment-resistant individuals. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, CENTRAL, and online trial registers for published and unpublished RCTs from inception to Sept 1, 2021, combining terms describing all available antipsychotics, and terms describing continuation, maintenance, or long-term treatment for schizophrenia-spectrum disorders. Relative risks (RRs) and standardised mean differences were pooled using random-effects pairwise and network meta-analyses. We assessed risk of bias of each RCT with the Cochrane Risk-of-Bias 2 tool, and confidence of pooled estimates with CINeMA. The primary outcome was relapse prevention. The study protocol was registered in advance in the Open Science Forum registry.

FINDINGS

Of 3936 records identified, 119 records, reporting on 101 RCTs, were eligible, 98 of which (including 13 988 individuals) provided data that could be meta-analysed for at least one outcome. The mean proportion of female participants per study was 38% (range 0-100; median 39%, IQR 29-50), whereas for male participants it was 62% (range 0-100; median 61%, IQR 50-71), and the overall mean age was 38·8 years (range 23·2-63·9; median 39·3, IQR 35·0-43·9). Of the 98 RCTs meta-analysed, 89·8% were done in high-income and upper-middle-income countries. The ethnic group White or so-called Caucasian was the most represented (mean 56% participants per study), although this information was relatively scarce. All continuation strategies were significantly more effective in preventing relapse than stopping antipsychotic treatment, with a large risk reduction for continuing at standard doses (RR 0·37, 95% CI 0·32-0·43; number-needed-to-treat [NNT] 3·17, 95% CI 2·94-3·51) and antipsychotic switching (RR 0·44, 0·37-0·53; NNT 3·57, 3·17-4·25), and moderate risk reduction for dose reduction (RR 0·68, 0·51-0·90; NNT 6·25, 4·08-20·00). Continuing and switching antipsychotics did not differ significantly (RR 0·84, 0·69-1·02; with lower values favouring continuing), whereas reducing antipsychotic dose was outperformed by both continuing (RR 0·55, 0·42-0·71; NNT 4·44, 3·45-6·90) and switching (RR 0·65, 0·47-0·89; NNT 5·17, 3·77-18·18). Results were supported by moderate confidence of evidence and confirmed by secondary analyses and by several sensitivity and subgroup analyses, including removing studies with abrupt antipsychotic discontinuation or fast tapering (≤4 weeks). No tolerability differences emerged between treatment strategies. According to the Cochrane Risk-of-Bias tool, version 2, 16·8% of included RCTs had an overall high risk of bias for the primary outcome. We found moderate heterogeneity (τ²=0·13; I²=61%) and no overall incoherence for the primary analysis. Results were supported by moderate confidence of evidence and confirmed by secondary analyses.

INTERPRETATION

Contrary to our original hypothesis, we found that continuing antipsychotic treatment at standard doses or switching to a different antipsychotic are similarly effective treatment strategies, whereas reducing antipsychotic doses below standard doses is associated with higher risk of relapse than the other two maintenance treatment strategies and should therefore be limited to selected cases. Despite limitations, including moderate heterogeneity and moderate certainty of evidence, these results are of pragmatic relevance for clinicians, and should support the update of evidence-based guidelines.

FUNDING

None.

Atypical Treatment Switches in Schizophrenia Patients: Drivers and Associated Outcomes

Objective

To describe and compare demographics and outcomes among patients with schizophrenia who have switched atypical treatments versus non-switchers.

Methods

Data were extracted from the Adelphi Schizophrenia Disease Specific Programme™ conducted from January to May 2014 in the United States. Participating physicians provided information on their next 10 consulting schizophrenia patients aged ≥ 18 years; the same patients were invited to voluntarily complete a patient self-completion form (PSC). Patients were considered switchers (S) or non-switchers (NS) based on their physician-provided treatment history. S were patients who had switched, stopped or added an atypical treatment within the last 2 years. NS had no treatment changes within the last 2 years or were receiving their first-line treatment (for ≥ 3 months). Demographics, clinical characteristics and outcomes among S and NS were compared using both descriptive and multivariate statistics.

Results

One-hundred fifty physicians provided data on 1003 patients with schizophrenia (395 S, 608 NS); 500 patients completed a PSC (170 S, 330 NS). When compared with NS, S were more likely to be unemployed (p=0.0060), have a caregiver (p<0.0001), have greater activity impairment as assessed by Work and Productivity Activity Impairment (p=0.0031), be hospitalized for schizophrenia (p<0.0001) and have had a greater mean number of hospitalizations in the last 12 months (p=0.0012). NS vs S were more likely to have much or very much improved illness (p<0.0001) and less severe disease (p<0.0001) as assessed by Clinical Global Impression.

Conclusion

Despite switching drugs, some schizophrenia patients continue to have high levels of disease burden, suggesting that currently available therapies are insufficiently effective in these patients.