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Mishra A, Maiti R, Ramasubbu MK, Srinivasan A. Evaluation of the pharmacodynamic interaction effect of augmentation agents with clozapine in patients with treatment-resistant schizophrenia: A simulation study of clinical data. Psychiatry Res 2024; 338:115989. [PMID: 38824710 DOI: 10.1016/j.psychres.2024.115989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/03/2024] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION The aim of the study was to evaluate interaction effect of various augmentation strategies with clozapine in patients with Treatment-resistant schizophrenia. METHODS Data was extracted for change in positive and negative syndrome scale (PANSS) or brief psychiatric rating scale (BPRS) scores for monotherapy with various antipsychotic agents alone and their combination with clozapine. Individual patient data was generated using simulation of data (factorial trial framework) from published clinical trials for sample sizes from eight to 400 to evaluate interaction effect through linear modeling. Dose equivalents were calculated, and best fit models were determined for simulated data. RESULTS The polynomial model was found to be the best fit for the simulated data to determine interaction effect of combination. The clozapine augmentation with risperidone and ziprasidone was found to be antagonistic, whereas it was additive for haloperidol, aripiprazole, and quetiapine. A synergistic effect was observed for ECT combined with clozapine (Interaction effect: -7.62; p <0.001). A sample size of 250-300 may be sufficient to demonstrate a clinically significant interaction in future trials. CONCLUSION Clozapine may be augmented with electroconvulsive therapy, leading to the enhancement of antipsychotic effect. Though some antipsychotics like aripiprazole demonstrate additive effects, they may also add to the adverse effects.
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Affiliation(s)
- Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Mathan Kumar Ramasubbu
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar 751019, India.
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Mastwal S, Li X, Stowell R, Manion M, Zhang W, Kim NS, Yoon KJ, Song H, Ming GL, Wang KH. Adolescent neurostimulation of dopamine circuit reverses genetic deficits in frontal cortex function. eLife 2023; 12:RP87414. [PMID: 37830916 PMCID: PMC10575630 DOI: 10.7554/elife.87414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
Dopamine system dysfunction is implicated in adolescent-onset neuropsychiatric disorders. Although psychosis symptoms can be alleviated by antipsychotics, cognitive symptoms remain unresponsive and novel paradigms investigating the circuit substrates underlying cognitive deficits are critically needed. The frontal cortex and its dopaminergic input from the midbrain are implicated in cognitive functions and undergo maturational changes during adolescence. Here, we used mice carrying mutations in Arc or Disc1 to model mesofrontal dopamine circuit deficiencies and test circuit-based neurostimulation strategies to restore cognitive functions. We found that in a memory-guided spatial navigation task, frontal cortical neurons were activated coordinately at the decision-making point in wild-type but not Arc-/- mice. Chemogenetic stimulation of midbrain dopamine neurons or optogenetic stimulation of frontal cortical dopamine axons in a limited adolescent period consistently reversed genetic defects in mesofrontal innervation, task-coordinated neuronal activity, and memory-guided decision-making at adulthood. Furthermore, adolescent stimulation of dopamine neurons also reversed the same cognitive deficits in Disc1+/- mice. Our findings reveal common mesofrontal circuit alterations underlying the cognitive deficits caused by two different genes and demonstrate the feasibility of adolescent neurostimulation to reverse these circuit and behavioral deficits. These results may suggest developmental windows and circuit targets for treating cognitive deficits in neurodevelopmental disorders.
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Affiliation(s)
- Surjeet Mastwal
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental HealthBethesdaUnited States
| | - Xinjian Li
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental HealthBethesdaUnited States
| | - Rianne Stowell
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical CenterRochesterUnited States
| | - Matthew Manion
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental HealthBethesdaUnited States
| | - Wenyu Zhang
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental HealthBethesdaUnited States
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical CenterRochesterUnited States
| | - Nam-Shik Kim
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Ki-Jun Yoon
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Hongjun Song
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Guo-Li Ming
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaUnited States
| | - Kuan Hong Wang
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental HealthBethesdaUnited States
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical CenterRochesterUnited States
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Mastwal S, Li X, Stowell R, Manion M, Zhang W, Kim NS, Yoon KJ, Song H, Ming GL, Wang KH. Adolescent neurostimulation of dopamine circuit reverses genetic deficits in frontal cortex function. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.03.526987. [PMID: 36778456 PMCID: PMC9915739 DOI: 10.1101/2023.02.03.526987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dopamine system dysfunction is commonly implicated in adolescent-onset neuropsychiatric disorders. Although psychosis symptoms can be alleviated by antipsychotics, cognitive symptoms remain unresponsive to such pharmacological treatments and novel research paradigms investigating the circuit substrates underlying cognitive deficits are critically needed. The frontal cortex and its dopaminergic input from the midbrain are implicated in cognitive functions and undergo maturational changes during adolescence. Here, we used mice carrying mutations in the Arc or DISC1 genes to model mesofrontal dopamine circuit deficiencies and test circuit-based neurostimulation strategies to restore cognitive functions. We found that in a memory-guided spatial navigation task, frontal cortical neurons were activated coordinately at the decision-making point in wild-type but not Arc mutant mice. Chemogenetic stimulation of midbrain dopamine neurons or optogenetic stimulation of frontal cortical dopamine axons in a limited adolescent period consistently reversed genetic defects in mesofrontal innervation, task-coordinated neuronal activity, and memory-guided decision-making at adulthood. Furthermore, adolescent stimulation of dopamine neurons also reversed the same cognitive deficits in DISC1 mutant mice. Our findings reveal common mesofrontal circuit alterations underlying the cognitive deficits caused by two different genes and demonstrate the feasibility of adolescent neurostimulation to reverse these circuit and behavioral deficits. These results may suggest developmental windows and circuit targets for treating cognitive deficits in neurodevelopmental disorders.
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Affiliation(s)
- Surjeet Mastwal
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental Health, Bethesda, MD 20892
| | - Xinjian Li
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental Health, Bethesda, MD 20892
| | - Rianne Stowell
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical Center, Rochester, NY 14642
| | - Matthew Manion
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental Health, Bethesda, MD 20892
| | - Wenyu Zhang
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental Health, Bethesda, MD 20892
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical Center, Rochester, NY 14642
| | - Nam-Shik Kim
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Ki-jun Yoon
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Hongjun Song
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Guo-li Ming
- Department of Neuroscience, Mahoney Institute for Neurosciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Kuan Hong Wang
- Unit on Neural Circuits and Adaptive Behaviors, National Institute of Mental Health, Bethesda, MD 20892
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester Medical Center, Rochester, NY 14642
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Abstract
BACKGROUND Several augmentation strategies have been used to improve symptomatology in patients not adequately responding to clozapine. Several randomised controlled trials (RCTs) have evaluated the efficacy of different strategies to augment clozapine. This systematic review and meta-analysis reviewed the available RCTs that have evaluated the clinical efficacy of various pharmacological agents, non-pharmacological strategies (occupational therapy, cognitive behaviour therapy), and somatic treatment [electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation, etc.)] as augmenting agents to clozapine. METHODS Data were extracted using standard procedures, and risk of bias was evaluated. Effect sizes were computed for the individual studies. RESULTS Forty-five clinical trials were evaluated. The pooled effect size for various antipsychotic medications was 0.103 (95% CI: 0.288-0.493, p < 0.001); when the effect size was evaluated for specific antipsychotics for which more than one trial was available, the effect size for risperidone was -0.27 and that for aripiprazole was 0.57. The effect size for lamotrigine was 0.145, and that for topiramate was 0.392. The effect size for ECT was 0.743 (CI: 0.094-1.392). Risk of bias was low (mean Jadad score - 3.93). Largest effect sizes were seen for mirtazapine (effect size of 5.265). Most of the studies can be considered underpowered and limited by small sample sizes. CONCLUSIONS To conclude, based on the findings of the present systematic review and meta-analysis, it can be said that compared to other treatment strategies, clozapine non-responsive patients respond maximum to mirtazapine followed by ECT.
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Russo M, Ignjatovic-Ristic D, Cohen D, Arenliu A, Bajraktarov S, Dzubur Kulenovic A, Injac Stevovic L, Maric N, Novotni A, Jovanovic N. Clozapine prescription rates in Southeast Europe: A cross-sectional study. Front Psychiatry 2023; 14:1123246. [PMID: 37113539 PMCID: PMC10126685 DOI: 10.3389/fpsyt.2023.1123246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/25/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.
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Affiliation(s)
- Manuela Russo
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
- *Correspondence: Manuela Russo,
| | | | - Dan Cohen
- MHO North-Holland North, Heerhugowaard, Netherlands
| | - Aliriza Arenliu
- Department of Psychology, University of Pristina, Pristina, Kosovo by United Nations Resolution
| | | | | | | | - Nadja Maric
- Faculty of Medicine, Institute of Mental Health, University of Belgrade, Belgrade, Serbia
| | - Antoni Novotni
- University Clinic of Psychiatry, Skopje, North Macedonia
| | - Nikolina Jovanovic
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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Joo SW, Kim H, Jo YT, Ahn S, Choi YJ, Choi W, Park S, Lee J. Comparative effectiveness of antipsychotic monotherapy and polypharmacy in schizophrenia patients with clozapine treatment: A nationwide, health insurance data-based study. Eur Neuropsychopharmacol 2022; 59:36-44. [PMID: 35550204 DOI: 10.1016/j.euroneuro.2022.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/26/2022] [Accepted: 03/30/2022] [Indexed: 12/31/2022]
Abstract
Clozapine is the most effective antipsychotic for treatment-resistant schizophrenia (TRS). However, it remains uncertain whether antipsychotic augmentation to clozapine has the superior effectiveness over clozapine alone and the effect size of clozapine compared to other antipsychotic drugs in TRS. Therefore, we examined the comparative effectiveness of antipsychotic monotherapy and polypharmacy on the risk of psychiatric admission and treatment discontinuation in TRS. Data were collected from the Health Insurance Review Agency database between January 2010 and December 2019 in South Korea. Among prevalent patients with schizophrenia, we defined 22,327 patients with TRS as those who had been prescribed with clozapine at least once during the entire observation period. Stratified Cox proportional hazards regressions were performed using data on all antipsychotic prescriptions of patients with TRS to investigate the risk of psychiatric hospitalization and treatment discontinuation associated with antipsychotic treatment. In individual comparisons, clozapine monotherapy was the most effective for the risk of psychiatric hospitalization compared to no use (hazard ratio [HR] = 0.23, 95% confidence interval [CI] = 0.22-0.25). In group comparisons, clozapine with long-acting injectable (LAI) second-generation antipsychotics (SGA) was superior to clozapine monotherapy for the risk of psychiatric hospitalization (HR = 0.60, 95%CI = 0.41-0.88). Clozapine monotherapy was associated with the lowest risk of treatment discontinuation in the individual and group comparisons. This retrospective observational population-based study reports that clozapine with LAI SGA is more effective in lowering the risk of psychiatric hospitalization in antipsychotic group comparison with the reference of clozapine monotherapy.
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Affiliation(s)
- Sung Woo Joo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Harin Kim
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Young Tak Jo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Soojin Ahn
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Young Jae Choi
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Woohyeok Choi
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea
| | - Soyeon Park
- Department of Psychiatry, Medical Foundation Yongin Mental Hospital, Yongin, Republic of Korea
| | - Jungsun Lee
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, SongPa-Gu, Seoul 05505, Republic of Korea.
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Lappin JM, Davies K, O'Donnell M, Walpola IC. Underuse of recommended treatments among people living with treatment-resistant psychosis. Front Psychiatry 2022; 13:987468. [PMID: 36147973 PMCID: PMC9485552 DOI: 10.3389/fpsyt.2022.987468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which this evidence-base is implemented. SETTING Statewide public health tertiary referral service, the Tertiary Referral Service for Psychosis (TRSP), NSW, Australia. OBJECTIVES To (i) describe clinical characteristics of individuals with treatment-resistant psychosis and to detail the proportion who had received a trial of clozapine or ECT at any point during their illness course; (ii) describe the characteristics of the treatment trials in both those currently on clozapine and those previously on clozapine; (iii) document reasons in relevant individuals why clozapine had never been used. METHODS All TRSP clients who met the criteria for treatment resistance (TR) were included. A detailed casenote review was conducted to examine whether clozapine and/or ECT had ever been prescribed. Characteristics of clozapine and ECT trials were documented. Tertiary service treatment recommendations are described. FINDINGS Thirty-six of 48 individuals had TR. They had marked clinical and functional impairment. A minority were currently receiving clozapine (n = 14/36). Most had received a clozapine trial at some point (n = 32/36). Most experienced persistent clinical symptoms while on clozapine (n = 29/32). Clozapine plasma levels were very rarely reported (4/32). Augmentation and antipsychotic polypharmacy were common among those currently on clozapine. The median clozapine trial duration was 4.0 (IQR: 3.0-20.3) months in individuals previously prescribed clozapine. Reasons for clozapine discontinuation included intolerable side effects (n = 10/18) and poor adherence (n = 7/18). One-quarter of TR individuals had trialed ECT (n = 9/36). Tertiary service recommendations included routine plasma monitoring to optimize dose among people currently on clozapine; clozapine retrial in those previously treated; and clozapine initiation for those who had never received clozapine. ECT was recommended to augment clozapine and as an alternative where clozapine trial/retrial was not feasible. CONCLUSION Among people with TR referred to a tertiary service, clozapine and ECT were underutilized. Clozapine trials are typically terminated without an adequate trial. Strategies to optimize the use of clozapine therapy and ECT in clinical settings are needed to increase the therapeutic effectiveness of evidence-based therapies for treatment-resistant psychosis.
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Affiliation(s)
- Julia M Lappin
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Kimberley Davies
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Maryanne O'Donnell
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
| | - Ishan C Walpola
- The Tertiary Referral Service for Psychosis (TRSP), South Eastern Sydney Local Health District, Randwick, NSW, Australia.,Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW Medicine & Health, UNSW Sydney, Kensington, NSW, Australia
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Kirli U, Alptekın K. Pharmacotherapy of Schizophrenia in Acute and Maintenance Phase. ACTA ACUST UNITED AC 2021; 58:S17-S23. [PMID: 34658631 PMCID: PMC8498812 DOI: 10.29399/npa.27441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 08/26/2021] [Indexed: 11/25/2022]
Abstract
Schizophrenia is one of the leading disorders causing impairment in society. Therefore, it is crucial to review evidence-based treatment approaches which are both effective and causing minimum side effects. In this paper, treatment recommendations for first episode schizophrenia, patients in acute phase with a history of multiple episodes, and patients in the maintenance phase will be discussed in light of the Psychiatric Association of Turkey Guideline for Treatment of Schizophrenia, other recent national and international guidelines as well as expert consensus reports in the literature. Finally, practical considerations will be suggested.
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Affiliation(s)
- Umut Kirli
- Ege University, Institute on Drug Abuse, Toxicology and Pharmaceutical Science, İzmir, Turkey
| | - Köksal Alptekın
- Dokuz Eylül University, School of Medicine, Department of Psychiatry, İzmir, Turkey.,Dokuz Eylül University, Institute of Health Sciences, Department of Neuroscience, İzmir, Turkey
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Lähteenvuo M, Tiihonen J. Antipsychotic Polypharmacy for the Management of Schizophrenia: Evidence and Recommendations. Drugs 2021; 81:1273-1284. [PMID: 34196945 PMCID: PMC8318953 DOI: 10.1007/s40265-021-01556-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 12/13/2022]
Abstract
Schizophrenia is a debilitating illness with a lifetime prevalence estimate of 0.6% and consists of symptoms from the positive, negative, and cognitive domains. Social support, therapy, psychoeducation, and overall case management are very important aspects of the treatment of schizophrenia. However, as abnormalities in neurotransmission are one of the key findings of schizophrenia pathology, pharmacotherapies are cornerstones of the management of schizophrenia. Antipsychotics have been used as the primary pharmacological treatment of schizophrenia. These agents often have a good effect on reducing positive symptoms, but may not markedly improve negative symptoms or cognitive defects. However, at least 20% of individuals with schizophrenia do not experience a substantial response from monotherapy with antipsychotics. Further, despite evolving treatment protocols and advances in early recognition of the disorder, 70% of patients with schizophrenia require long-term, even lifetime, medication to control their symptoms and do not achieve complete recovery. To address these shortcomings, clinicians and research scientists have explored different combinations of treatments, polypharmacy, to improve the treatment of patients. Antipsychotic polypharmacy has been shown to cause more side effects than monotherapy, which is the main reason why most treatment guidelines caution against it. Antipsychotic monotherapy should be strived for and clozapine should be tried at the latest if two monotherapy trials with other antipsychotics have failed and no absolute contraindications exist. If residual symptoms exist despite trials of adequate dose and duration, other reasons that may reduce treatment effect should be ruled out. Long-acting injectables or blood concentration measurements should be considered to affirm compliance and proper serum levels. Antipsychotic polypharmacy should be considered and discussed with patients from whom the aforementioned procedures do not produce a satisfactory treatment result. In some cases, antipsychotic polypharmacy may produce better results than other forms of treatment augmentation, such as benzodiazepines. In particular, combining aripiprazole with clozapine may be effective in reducing treatment side effects or residual symptoms, and this is likely to hold true for combining other partial dopamine D2 agonists with clozapine as well, although currently scant data exist. More research is needed, both in controlled but also real-world settings, to define optimal antipsychotic polypharmacy and/or other psychotropic treatment augmentation strategies for specific patient groups and situations.
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Affiliation(s)
- Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland.
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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Faden J, Kiryankova-Dalseth N, Barghini R, Citrome L. Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia? Expert Opin Pharmacother 2020; 22:635-646. [PMID: 33251870 DOI: 10.1080/14656566.2020.1847274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION : Despite treatment with antipsychotic medication, approximately 1/3 of individuals with schizophrenia will fail to have an adequate response. To treat these patients, a commonly utilized approach is antipsychotic combination therapy. Antipsychotic combination therapy is controversial with mixed efficacy and tolerability results. It is also unclear if antipsychotic combination therapy reduces or increases the risk of psychiatric hospitalization. AREAS COVERED : The authors review the prevalence, efficacy and tolerability concerns, and rationale behind antipsychotic combination therapy. Evidence comparing antipsychotic monotherapy vs polypharmacy using hospitalization as an outcome measure is summarized. EXPERT OPINION : Psychiatric rehospitalization is a useful measure of treatment effectiveness, incorporating aspects of treatment efficacy and tolerability. The evidence comparing the impact of antipsychotic monotherapy vs combination therapy on rehospitalization is mixed. Evidence is primarily retrospective in nature, and there is high heterogeneity between studies, which could partially explain the mixed results. There is likely a subset of patients for whom antipsychotic combination therapy reduces the risk of hospitalization greater than antipsychotic monotherapy. Patients should be treated individually taking into account their specific pattern of response.
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Affiliation(s)
- Justin Faden
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Ruby Barghini
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Leslie Citrome
- Department of Psychiatry & Behavioral Sciences, New York Medical College, Valhalla, NY, USA
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Azorin JM, Simon N. Antipsychotic polypharmacy in schizophrenia: evolving evidence and rationale. Expert Opin Drug Metab Toxicol 2020; 16:1175-1186. [DOI: 10.1080/17425255.2020.1821646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Nicolas Simon
- Department of Clinical Pharmacology, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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di Giacomo E, Stefana A, Candini V, Bianconi G, Canal L, Clerici M, Conte G, Ferla MT, Iozzino L, Sbravati G, Tura G, Micciolo R, de Girolamo G. Prescribing Patterns of Psychotropic Drugs and Risk of Violent Behavior: A Prospective, Multicenter Study in Italy. Int J Neuropsychopharmacol 2020; 23:300-310. [PMID: 31993630 PMCID: PMC7251633 DOI: 10.1093/ijnp/pyaa005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 01/03/2020] [Accepted: 01/23/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND This prospective cohort study aimed at evaluating patterns of polypharmacy and aggressive and violent behavior during a 1-year follow-up in patients with severe mental disorders. METHODS A total of 340 patients (125 inpatients from residential facilities and 215 outpatients) were evaluated at baseline with the Structured Clinical Interview for DSM-IV Axis I and II, Brief Psychiatric Rating Scale, Specific Levels of Functioning scale, Brown-Goodwin Lifetime History of Aggression, Buss-Durkee Hostility Inventory, Barratt Impulsiveness Scale, and State-Trait Anger Expression Inventory-2. Aggressive behavior was rated every 15 days with the Modified Overt Aggression Scale and treatment compliance with the Medication Adherence Rating Scale. RESULTS The whole sample was prescribed mainly antipsychotics with high levels of polypharmacy. Clozapine prescription and higher compliance were associated with lower levels of aggressive and violent behavior. Patients with a history of violence who took clozapine were prescribed the highest number of drugs. The patterns of cumulative Modified Overt Aggression Scale mean scores of patients taking clozapine (n = 46), other antipsychotics (n = 257), and no antipsychotics (n = 37) were significantly different (P = .001). Patients taking clozapine showed a time trend at 1-year follow-up (24 evaluations) indicating a significantly lower level of aggressive behavior. Patient higher compliance was also associated with lower Modified Overt Aggression Scale ratings during the 1-year follow-up. CONCLUSION Both inpatients and outpatients showed high levels of polypharmacy. Clozapine prescription was associated with lower Modified Overt Aggression Scale ratings compared with any other antipsychotics or other psychotropic drugs. Higher compliance was associated with lower levels of aggressive and violent behavior.
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Affiliation(s)
- E di Giacomo
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy,Department of Psychiatry, Asst Monza, Italy,Correspondence: Giovanni de Girolamo, MD, St John of God Clinical Research Centre, Brescia, via Pilastroni 4, 25125 Brescia, Italy ()
| | - A Stefana
- Department of Mental Health, ASST Spedali Civili of Brescia, Italy
| | - V Candini
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - G Bianconi
- Department of Mental Health, ASST Ovest Milanese, Milano, Italy
| | - L Canal
- Department of Psychology and Cognitive Sciences, University of Trento
| | - M Clerici
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy,Department of Psychiatry, Asst Monza, Italy
| | - G Conte
- Department of Mental Health, ASST Spedali Civili of Brescia, Italy
| | - M T Ferla
- Department of Mental Health, Asst-Rhodense G.Salvini di Garbagnate, Milano, Italy
| | - L Iozzino
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - G Sbravati
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - G Tura
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
| | - R Micciolo
- Department of Psychology and Cognitive Sciences, University of Trento
| | - G de Girolamo
- Unit of Epidemiological and Evaluation Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
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14
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Baandrup L. Polypharmacy in schizophrenia. Basic Clin Pharmacol Toxicol 2020; 126:183-192. [PMID: 31908124 DOI: 10.1111/bcpt.13384] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022]
Abstract
Schizophrenia is a severe mental disorder characterized by a heterogeneous symptom profile which comprises a clinical platform for widespread use of polypharmacy even though antipsychotic monotherapy is the recommended treatment regimen. This narrative review provides a summary of the current gap between evidence and practice for use of antipsychotic combination therapy in patients with schizophrenia. Antipsychotic polypharmacy is frequently prescribed instead of following international consensus of clozapine monotherapy in treatment-resistant patients. Antipsychotic-benzodiazepine combination therapy clearly has a role in the treatment of acute agitation whereas there is no evidence to support an effect on core schizophrenia symptoms when chronically prescribed. Antidepressants are typically added to antipsychotic treatment in case of persistent negative symptoms. Available evidence suggests that antidepressants may improve negative symptom control in schizophrenia. Combining an antipsychotic with an antiepileptic is not supported by any firm evidence, but individual mood stabilizers have come out positively in single trials. Generally, the evidence base for polypharmacy in schizophrenia maintenance treatment is sparse but may be warranted in certain clinical situations. Therapeutic benefits and side effects should be carefully monitored and considered to ensure a beneficial risk-benefit ratio if prescribing polypharmacy for specific clinical indications.
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Affiliation(s)
- Lone Baandrup
- Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, Glostrup, Denmark.,Mental Health Centre Copenhagen, Hellerup, Denmark
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15
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Abstract
Clozapine is established as the gold standard for antipsychotic treatment of patients suffering from treatment-resistant schizophrenia. Over virtually 3 decades, the level of inadequate response to clozapine was found to range from 40% to 60%. A heightened interest developed in the augmentation of clozapine to try to achieve response or maximize partial response. A large variety of drug groups have been investigated. This article focuses on the meta-analyses of these trials to discover reasonable evidence-based approaches to the management of patients not responding to clozapine.
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17
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Dong M, Zeng LN, Zhang Q, Yang SY, Chen LY, Sim K, He YL, Chiu HFK, Sartorius N, Tan CH, Chong MY, Shinfuku N, Lin SK, Ng CH, Ungvari GS, Xiang YT. Antipsychotic Polypharmacy in Older Adult Asian Patients With Schizophrenia: Research on Asian Psychotropic Prescription Pattern. J Geriatr Psychiatry Neurol 2019; 32:304-311. [PMID: 31480982 DOI: 10.1177/0891988719862636] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Antipsychotic polypharmacy (APP) is a controversial topic in the treatment of older adults with schizophrenia. The objective of this study was to examine the use of APP in older adult Asian patients with schizophrenia and its associated demographic and clinical factors. METHODS This study was based on the fourth survey of the consortium known as the Research on Asian Psychotropic Prescription Pattern for Antipsychotics. Fifteen Asian countries/territories participated in this survey, including Bangladesh, Mainland China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand, and Vietnam. Basic demographic and clinical characteristics were collected using a standardized data collection form. RESULTS Among the 879 older adults with schizophrenia included in the survey, the rate of APP was 40.5%. Multiple logistic regression analysis revealed that higher antipsychotic doses (P < .001, odds ratio [OR] = 1.003, 95% confidence interval [CI]: 1.002-1.003), longer duration of illness (P = .02, OR = 1.845, 95% CI: 1.087-3.132), and the prescription of anticholinergics (P < .001, OR = 1.871, 95% CI: 1.329-2.635), second-generation antipsychotics (P = .001, OR = 2.264, 95% CI: 1.453-3.529), and first-generation antipsychotics (P < .001, OR = 3.344, 95% CI: 2.307-4.847) were significantly associated with APP. CONCLUSION Antipsychotic polypharmacy was common in older adult Asian patients with schizophrenia. Compared to the results of previous surveys, the use of APP showed a declining trend over time. Considering the general poor health status of older patients with schizophrenia and their increased risk of drug-induced adverse events, the use of APP in this population needs careful consideration.
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Affiliation(s)
- Min Dong
- 1 Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, & Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China
| | - Liang-Nan Zeng
- 1 Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, & Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China.,2 Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Sichuan Sheng, China
| | - Qinge Zhang
- 3 School of Mental Health, The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Shu-Yu Yang
- 4 Department of Pharmacy, Taipei City Hospital, Taipei, Taiwan
| | - Lian-Yu Chen
- 5 Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Kang Sim
- 6 Institute of Mental Health, Buangkok Green Medical Park, Singapore
| | - Yan-Ling He
- 7 Department of Psychiatric Epidemiology, Shanghai Mental Health Center, Shanghai, China
| | - Helen Fung-Kum Chiu
- 8 Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Norman Sartorius
- 9 Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | - Chay-Hoon Tan
- 10 Department of Pharmacology, National University of Singapore, Singapore
| | - Mian-Yoon Chong
- 11 Chiayi Chang Gung Memorial Hospital and School of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Naotaka Shinfuku
- 12 International Center for Medical Research, Kobe University School of Medicine, Kobe, Japan
| | - Shih-Ku Lin
- 13 Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chee H Ng
- 14 Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor S Ungvari
- 15 University of Notre Dame Australia, Fremantle, Australia.,16 Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia
| | - Yu-Tao Xiang
- 1 Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, & Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China
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18
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Prescription of antipsychotic and concomitant medications for adult Asian schizophrenia patients: Findings of the 2016 Research on Asian Psychotropic Prescription Patterns (REAP) survey. Asian J Psychiatr 2019; 45:74-80. [PMID: 31520884 DOI: 10.1016/j.ajp.2019.08.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/11/2019] [Accepted: 08/22/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Regular surveys are important to monitor the use of psychotropic medications in clinical practice. This study examined the psychotropic prescription patterns in adult Asian schizophrenia patients based on the data of the Research on Asian Psychotropic Prescription (REAP) 2016 survey. METHODS This cross-sectional survey across 15 Asian countries/territories collected socio-demographic and clinical data with standardized procedures between March and May 2016. The socio-demographic and clinical characteristics of the patients were recorded with a standardized questionnaire. RESULTS Altogether 3,537 adult patients with schizophrenia were consecutively screened and enrolled in the survey. The mean age was 38.66 ± 11.55 years and 59.7% of the sample were male. The mean dose of antipsychotics in chlorpromazine equivalents (CPZeq) was 424 ± 376 mg/day; 31.3% and 80.8% received first- and second- generation antipsychotics, respectively and 42.6% had antipsychotic polypharmacy, 11.7% had antidepressants, 13.7% had mood stabilizers, 27.8% had benzodiazepines, and 45.6% had anticholinergics. CONCLUSIONS Psychotropic prescription patterns in Asian adult patients with schizophrenia varied across countries. Regular surveys on psychotropic medications for schizophrenia are important to monitor pharmacotherapy practice in Asia.
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19
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Wagner E, Wobrock T, Kunze B, Langguth B, Landgrebe M, Eichhammer P, Frank E, Cordes J, Wölwer W, Winterer G, Gaebel W, Hajak G, Ohmann C, Verde PE, Rietschel M, Ahmed R, Honer WG, Siskind D, Malchow B, Strube W, Schneider-Axmann T, Falkai P, Hasan A. Efficacy of high-frequency repetitive transcranial magnetic stimulation in schizophrenia patients with treatment-resistant negative symptoms treated with clozapine. Schizophr Res 2019; 208:370-376. [PMID: 30704862 DOI: 10.1016/j.schres.2019.01.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) is a promising augmentation treatment for schizophrenia, however there are few controlled studies of rTMS augmentation of clozapine. METHODS Using data from the 'rTMS for the Treatment of Negative Symptoms in Schizophrenia' (RESIS) trial we examined the impact of rTMS on PANSS total, general, positive and negative symptoms among participants on clozapine. rTMS was applied to the left dorsolateral prefrontal cortex (DLPFC) for five treatment sessions/week for 3-weeks as augmentation for patients with a predominant negative syndrome of schizophrenia, as rated on PANSS. RESULTS 26 participants from the RESIS trial were on clozapine, receiving active (N=12) or sham (N=14) rTMS treatment. In our Linear Mixed Model (LMM) analysis, time×group interactions were significant in the PANSS positive subscale (p=0.003) (not being the corresponding behavioral output for DLPFC stimulation), the PANSS general subscale (p<0.001), the PANSS total scale (p=0.015), but not the PANSS negative subscale (p=0.301) (primary endpoint of the RESIS trial), when all PANSS measurements from screening to day 105 were included. Descriptive data suggests that in the active group the improvement was more pronounced compared to the sham rTMS group. CONCLUSIONS In this largest available clozapine cohort, active rTMS may be more effective than sham rTMS when added to clozapine for positive and total psychotic symptoms. These findings should be interpreted with caution given this is a secondary analysis with a limited number of participants.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, University Hospital, LMU Munich, Germany.
| | - Thomas Wobrock
- Department of Psychiatry and Psychotherapy, Georg-August-University Goettingen, Germany; County Hospitals Darmstadt-Dieburg, Groß-Umstadt, Germany
| | - Birgit Kunze
- Department of Psychiatry and Psychotherapy, Georg-August-University Goettingen, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg, Germany
| | - Michael Landgrebe
- Department of Psychiatry and Psychotherapy, University of Regensburg, Germany; Department of Psychiatry, Psychosomatics and Psychotherapy, kbo-Lech-Mangfall-Klinik Agatharied, Germany
| | - Peter Eichhammer
- Department of Psychiatry and Psychotherapy, University of Regensburg, Germany
| | - Elmar Frank
- Department of Psychiatry and Psychotherapy, University of Regensburg, Germany
| | - Joachim Cordes
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Wolfgang Wölwer
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Georg Winterer
- Experimental & Clinical Research Center (ECRC), Department of Anesthesiology and Operative Intensive Care Medicine, Charité - University Medicine Berlin, Germany
| | - Wolfgang Gaebel
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Göran Hajak
- Department of Psychiatry, Psychosomatics and Psychotherapy, Sozialstiftung Bamberg, Bamberg, Germany
| | | | - Pablo E Verde
- Coordination Centre for Clinical Trials, Heinrich-Heine University, Düsseldorf, Germany
| | - Marcella Rietschel
- Department of Genetic Epidemiology in Psychiatry, Institute of Central Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Raees Ahmed
- Studienzentrum, Universitätsmedizin Göttingen, Germany
| | - William G Honer
- Institute of Mental Health, The University of British Columbia, Canada
| | - Dan Siskind
- School of Medicine, University of Queensland, Brisbane, Australia; Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Hospital Jena, Germany
| | - Wolfgang Strube
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, University Hospital, LMU Munich, Germany
| | - Thomas Schneider-Axmann
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, University Hospital, LMU Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, University Hospital, LMU Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, University Hospital, LMU Munich, Germany
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Tiihonen J, Taipale H, Mehtälä J, Vattulainen P, Correll CU, Tanskanen A. Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia. JAMA Psychiatry 2019; 76:499-507. [PMID: 30785608 PMCID: PMC6495354 DOI: 10.1001/jamapsychiatry.2018.4320] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE The effectiveness of antipsychotic polypharmacy in schizophrenia relapse prevention is controversial, and use of multiple agents is generally believed to impair physical well-being. OBJECTIVE To study the association of specific antipsychotic combinations with psychiatric rehospitalization. DESIGN, SETTING, AND PARTICIPANTS In this nationwide cohort study, the risk of psychiatric rehospitalization was used as a marker for relapse among 62 250 patients with schizophrenia during the use of 29 different antipsychotic monotherapy and polypharmacy types between January 1, 1996, and December 31, 2015, in a comprehensive, nationwide cohort in Finland. We conducted analysis of the data from April 24 to June 15, 2018. Rehospitalization risks were investigated by using within-individual analyses to minimize selection bias. MAIN OUTCOMES AND MEASURES Hazard ratio (HR) for psychiatric rehospitalization during use of polypharmacy vs during monotherapy within the same individual. RESULTS In the total cohort, including 62 250 patients, 31 257 individuals (50.2%) were men, and the median age was 45.6 (interquartile range, 34.6-57.9) years. The clozapine plus aripiprazole combination was associated with the lowest risk of psychiatric rehospitalization in the total cohort, being superior to clozapine, the monotherapy associated with the best outcomes, with a difference of 14% (HR, 0.86; 95% CI, 0.79-0.94) in the analysis including all polypharmacy periods, and 18% in the conservatively defined polypharmacy analysis excluding periods shorter than 90 days (HR, 0.82; 95% CI, 0.75-0.89; P < .001). Among patients with their first episode of schizophrenia, these differences between clozapine plus aripiprazole vs clozapine monotherapy were greater (difference, 22%; HR, 0.78; 95% CI, 0.63-0.96 in the analysis including all polypharmacy periods, and difference, 23%; HR, 0.77; 95% CI, 0.63-0.95 in the conservatively defined polypharmacy analysis). At the aggregate level, any antipsychotic polypharmacy was associated with a 7% to 13% lower risk of psychiatric rehospitalization compared with any monotherapy (ranging from HR, 0.87; 95% CI, 0.85-0.88, to HR, 0.93; 95% CI, 0.91-0.95; P < .001). Clozapine was the only monotherapy among the 10 best treatments. Results on all-cause and somatic hospitalization, mortality, and other sensitivity analyses were in line with the primary outcomes. CONCLUSIONS AND RELEVANCE Combining aripiprazole with clozapine was associated with the lowest risk of rehospitalization, indicating that certain types of polypharmacy may be feasible in the treatment of schizophrenia. Because add-on treatments are started when monotherapy is no longer sufficient to control for worsening of symptoms, it is likely that the effect sizes for polypharmacy are underestimates. Although the results do not indicate that all types of polypharmacy are beneficial, the current treatment guidelines should modify their categorical recommendations discouraging all antipsychotic polypharmacy in the maintenance treatment of schizophrenia.
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Affiliation(s)
- Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | | | - Christoph U. Correll
- Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York ,Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, New York,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,National Institute for Health and Welfare, The Impact Assessment Unit, Helsinki, Finland
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21
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Wagner E, Löhrs L, Siskind D, Honer WG, Falkai P, Hasan A. Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance. J Psychopharmacol 2019; 33:423-435. [PMID: 30696332 DOI: 10.1177/0269881118822171] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. AIMS We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. METHODS We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. RESULTS Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only. CONCLUSION More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.
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Affiliation(s)
- Elias Wagner
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Lisa Löhrs
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Dan Siskind
- 2 School of Medicine, University of Queensland, Brisbane, QLD, Australia.,3 Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - William G Honer
- 4 Department of Psychiatry, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Falkai
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Alkomiet Hasan
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
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The past and future of novel, non-dopamine-2 receptor therapeutics for schizophrenia: A critical and comprehensive review. J Psychiatr Res 2019; 108:57-83. [PMID: 30055853 DOI: 10.1016/j.jpsychires.2018.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 06/13/2018] [Accepted: 07/12/2018] [Indexed: 01/28/2023]
Abstract
Since the discovery of chlorpromazine in the 1950's, antipsychotic drugs have been the cornerstone of treatment of schizophrenia, and all attenuate dopamine transmission at the dopamine-2 receptor. Drug development for schizophrenia since that time has led to improvements in side effects and tolerability, and limited improvements in efficacy, with the exception of clozapine. However, the reasons for clozapine's greater efficacy remain unclear, despite the great efforts and resources invested therewith. We performed a comprehensive review of the literature to determine the fate of previously tested, non-dopamine-2 receptor experimental treatments. Overall we included 250 studies in the review from the period 1970 to 2017 including treatments with glutamatergic, serotonergic, cholinergic, neuropeptidergic, hormone-based, dopaminergic, metabolic, vitamin/naturopathic, histaminergic, infection/inflammation-based, and miscellaneous mechanisms. Despite there being several promising targets, such as allosteric modulation of the NMDA and α7 nicotinic receptors, we cannot confidently state that any of the mechanistically novel experimental treatments covered in this review are definitely effective for the treatment of schizophrenia and ready for clinical use. We discuss potential reasons for the relative lack of progress in developing non-dopamine-2 receptor treatments for schizophrenia and provide recommendations for future efforts pursuing novel drug development for schizophrenia.
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Bartoli F, Crocamo C, Di Brita C, Esposito G, Tabacchi TI, Verrengia E, Clerici M, Carrà G. Adjunctive second-generation antipsychotics for specific symptom domains of schizophrenia resistant to clozapine: A meta-analysis. J Psychiatr Res 2019; 108:24-33. [PMID: 30447508 DOI: 10.1016/j.jpsychires.2018.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023]
Abstract
A fair amount of subjects with schizophrenia do not respond to clozapine and are defined 'ultra-resistant'. In this systematic review and meta-analysis, we tested the efficacy of adjunctive second-generation antipsychotics (SGAs) for main symptom domains (positive, negative, and depressive symptoms) in individuals with clozapine-resistant schizophrenia. We searched main electronic databases till December 2017. We included twelve double-blind, randomized, placebo-controlled trials (RCTs), evaluating the efficacy of SGAs for clozapine non/partial responders. We did not find any difference between SGAs and placebo (standardized mean difference, SMD = -0.21; p = 0.170; I2 = 68.0%) in improving positive symptoms. The effect size varied according to RCT duration (p = 0.025) and assessment methods (p = 0.016). Low-moderate effects of SGAs on both negative (SMD = -0.38; p = 0.005; I2 = 62.7%) and depressive symptoms (SMD = -0.35; p = 0.003; I2 = 4.9%), were estimated. In sum, our meta-analysis highlights the lack of efficacy of SGAs as add-on treatment for positive symptoms in clozapine-resistant schizophrenia. A small benefit of SGAs was estimated for both negative and depressive symptoms. Further RCTs are needed to establish efficacy and tolerability of SGAs or other augmentation strategies for different symptoms of clozapine-resistant schizophrenia.
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Affiliation(s)
- Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy.
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Carmen Di Brita
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | | | | | - Enrica Verrengia
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy; Division of Psychiatry, University College London, London, W1T 7NF, UK
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Faden J, Citrome L. Resistance is not futile: treatment-refractory schizophrenia - overview, evaluation and treatment. Expert Opin Pharmacother 2018; 20:11-24. [PMID: 30407873 DOI: 10.1080/14656566.2018.1543409] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Schizophrenia is a debilitating condition with three main symptom domains: positive, negative, and cognitive. Approximately one-third of persons with schizophrenia will fail to respond to treatment. Growing evidence suggests that treatment-resistant (refractory) schizophrenia (TRS) may be a distinct condition from treatment-respondent schizophrenia. There is limited evidence on effective treatments for TRS, and a lack of standardized diagnostic criteria for TRS has hampered research. Areas covered: A literature search was conducted using Pubmed.gov and the EMBASE literature database. The authors discuss the pragmatic definitions of TRS and review treatments consisting of antipsychotic monotherapy and augmentation strategies. Expert opinion: Currently available first-line antipsychotic medications are generally effective at treating the positive symptoms of schizophrenia, leaving residual negative and cognitive symptoms. Before diagnosing TRS, rule out any pharmacodynamic or pharmacokinetic failures. Most evidence supports clozapine as having the most efficacy for TRS. If clozapine is used, it should be optimized, and serum levels should be at least 350-420 ng/ml. If clozapine is unable to be tolerated, some evidence suggests olanzapine at dosages up to 40mg/day can be useful. Augmentation strategies have weak evidence. Tailoring treatment to the specific domain is the preferred approach, and the use of a structured assessment/outcome measure is encouraged.
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Affiliation(s)
- Justin Faden
- a Psychiatry , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Leslie Citrome
- b Psychiatry & Behavioral Sciences , New York Medical College , Valhalla , NY , USA
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Brunette MF, Cotes RO, de Nesnera A, McHugo G, Dzebisashvili N, Xie H, Bartels SJ. Use of Academic Detailing With Audit and Feedback to Improve Antipsychotic Pharmacotherapy. Psychiatr Serv 2018; 69:1021-1028. [PMID: 29879874 PMCID: PMC6381589 DOI: 10.1176/appi.ps.201700536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Second-generation antipsychotics vary in their propensity to cause serious cardiometabolic side effects. In addition, use of two or more antipsychotics (polypharmacy) may lead to additive side effects and has not been shown to be consistently more effective than monotherapy. This study examined the use of academic detailing with audit and feedback to improve antipsychotic prescribing practices, including antipsychotic polypharmacy and utilization of medication with high or low risk of cardiometabolic side effects ("high risk" or "low risk," respectively). METHODS Four intervention sessions were provided over two years to psychiatric care providers at community mental health centers. Segmented regression within the general estimating equation model framework used Medicaid pharmacy claims to examine prescribing patterns before and after the intervention among all beneficiaries (67,721 person-months) over a five-year period. RESULTS After the intervention, 10.9% of beneficiaries with antipsychotic claims were on polypharmacy, compared with 13.1% before the invention. Use of high-risk and low-risk antipsychotics did not change. The final adjusted polypharmacy model showed that antipsychotic polypharmacy decreased among young adults and adults ages 40 or older compared with beneficiaries ages 30-39 (β=-.02, p=.04, and β=-.02, p=.007, respectively). The raw proportion of beneficiaries on high- and low-risk agents did not change, although final adjusted models demonstrated changes in use of high- and low-risk agents by diagnosis and risk group. CONCLUSIONS Polypharmacy decreased among young and older adults after academic detailing with audit and feedback. Although further research is needed, this low-intensity intervention may help mental health systems reduce antipsychotic polypharmacy.
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Affiliation(s)
- Mary F. Brunette
- Dartmouth Medical School – Psychiatry, NH-Dartmouth Psychiatric Research Center, State Office Park South, Concord, New Hampshire
| | - Robert O. Cotes
- Emory University - Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia,
| | - Alexander de Nesnera
- Geisel School of Medicine at Dartmouth - Department of Psychiatry, Lebanon, New Hampshire
| | - Gregory McHugo
- Dartmouth College - Dartmouth Psychiatric Research Center, Rivermill Commercial Center, Lebanon, New Hampshire
| | | | - Haiyi Xie
- NH-Dartmouth Psychiatric Research Center, Lebanon, New Hampshire
| | - Stephen J. Bartels
- Dartmouth-Hitchcock Medical Center - Department of Psychiatry, Lebanon, New Hampshire
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Cardio-metabolic risk and its management in a cohort of clozapine-treated outpatients. Schizophr Res 2018; 199:367-373. [PMID: 29486959 DOI: 10.1016/j.schres.2018.02.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/13/2017] [Accepted: 02/19/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To comprehensively assess cardio-metabolic risk factors and their management in a large sample of outpatients treated with clozapine. METHODS Observational cross-sectional study of all clozapine users attending specialized clozapine monitoring outpatient clinics in three public hospitals in Sydney, Australia were approached to participate over the one-year period 01/10/2015-30/09/2016. Cardio-metabolic risk factors including metabolic syndrome, risk for future development of diabetes, smoking, physical activity, nutrition, and prescribed medications were assessed at face-to-face interview and through medical record review. Among patients who had cardio-metabolic risk factors, the proportion receiving appropriate management was assessed. RESULTS Of 451 registered clozapine clinic attenders, 92.2% completed questionnaires and anthropometric measurements. 58.3% met criteria for metabolic syndrome. 79.6% were overweight or obese. 55.9% had blood pressure meeting metabolic syndrome criteria. 46.6% had elevated fasting blood glucose and 55.2% had elevated blood triglycerides. 43.6% were current smokers. Only 10% achieved recommended weekly physical activity levels. Unhealthy food categories were highly consumed. 32.1% were on additional antipsychotics. In the majority of individuals, cardio-metabolic risk factors were untreated or under-treated. CONCLUSIONS Clozapine use was associated with very high rates of cardiovascular and metabolic risk factors, which were frequently under-treated. Management of both physical and mental health should be prioritized. Polypharmacy should be rationalized. Future research should investigate the effectiveness of smoking cessation and lifestyle interventions in this high-risk population.
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Is the risk of antipsychotic polypharmacy discontinuation dependent on the agents used? Psychiatry Res 2018; 263:238-244. [PMID: 29195836 DOI: 10.1016/j.psychres.2017.09.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/30/2017] [Accepted: 09/21/2017] [Indexed: 11/20/2022]
Abstract
This study assesses the risks and benefits of switching from two to one antipsychotic among participants on two non-clozapine oral antipsychotics, and among those on combinations involving either clozapine or an injectable antipsychotic. Ninety adult participants with schizophrenia or schizoaffective disorder were assigned to stay on polypharmacy or to switch to monotherapy. Half of these participants were receiving combinations of non-clozapine oral antipsychotics and half were receiving combinations involving either clozapine or an injectable antipsychotic. Participants were assessed every 60 days for one year. We examined differences in symptom and side effect trajectories as a function of group assignment and time for both medication groups. Participants who switched from two to one non-clozapine oral antipsychotic experienced significant increases in symptoms relative to stay participants. They also saw significant side effect benefits. Switch participants on combinations involving clozapine or an injectable antipsychotic did not differ over time from stay participants on either symptom or side effect measures. It appears that patients on these combinations can be safely switched to monotherapy. While there may be symptom related risks associated with switching patients on combinations of non-clozapine oral antipsychotics, there are significant health related benefits. Clozapine or injectable antipsychotic monotherapy are recommended options.
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Abstract
SummaryPolypharmacy is usually employed where single drugs are considered insufficiently effective. Some polypharmacy is rational and evidence based, some neither. Antipsychotic polypharmacy remains stubbornly widespread despite condemnation of the practice by numerous bodies. The practice could not be said to be evidence based. Its persistence probably stems from a well-meaning desire to improve response and from confusion about the mechanism of action of antipsychotics. In particular, the concept that more antipsychotic(s) must always be, or might be, ‘better’ is virtually groundless. Nonetheless, some specific antipsychotic polypharmacy regimens have shown particular benefits on adverse effect profiles. Targeted, evidence-based polypharmacy may be the way forward.
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Tungaraza TE, Zahid U, Venkataramaiah B. Polypharmacy and high-dose antipsychotics at the time of discharge from acute psychiatric wards. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/pb.bp.110.033167] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and methodTo determine the extent of prescribed antipsychotic polypharmacy and high-dose antipsychotics at the time of discharge from an acute psychiatric ward. Copies of discharge summaries for patients between the ages of 18 and 65 were examined; only those that had antipsychotic medications at the time of discharge were included. Names and doses of antipsychotics and all other medications concurrently prescribed were recorded.ResultsA total of 651 discharge summaries were included in the study. Nearly a quarter of individuals were discharged on one antipsychotic as the only medication to take home; only 6.8% were discharged on a high-dose antipsychotic and of those on combinations 59.6% were on depot medications. Combining antipsychotics significantly predicted the use of high dose.Clinical implicationsMost patients were discharged on doses of antipsychotics within the British National Formulary limits; however, a small proportion is still sent home on high doses of antipsychotics. Combining antipsychotics remains the strongest predictor of high-dose antipsychotic use; clinicians need to be aware of this.
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Abstract
In the treatment of resistant schizophrenia, a number of meta-analyses attempted to quantify the efficacy and tolerability of antipsychotic (AP) polypharmacy v. monotherapy with contradictory results. Recently, a systematic review and meta-analysis of randomised controlled trials investigated the efficacy and tolerability of AP combination v. monotherapy in schizophrenia. It included 31 studies: 21 double-blind (considered high-quality studies) and 10 open-label (considered low-quality studies). The meta-analysis showed that, overall, the combination of two APs was more effective than monotherapy in terms of symptom reduction (standardised mean difference (SMD) = -0.53, 95% confidence interval (CI) -0.87 to -0.19); however, this result was confirmed only in the subgroup of low-quality studies. Negative symptoms improved when combining a D2 antagonist with a D2 partial agonist (SMD = -0.41, 95% CI -0.79 to -0.03) both in double-blind and open-label studies. In the present commentary, the results of this systematic review are critically discussed in terms of their clinical and research implications.
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Koshy B, Gopal Das CM, Rajashekarachar Y, Bharathi DR, Hosur SS. A cross-sectional comparative study on the assessment of quality of life in psychiatric patients under remission treated with monotherapy and polypharmacy. Indian J Psychiatry 2017; 59:333-340. [PMID: 29085093 PMCID: PMC5659084 DOI: 10.4103/psychiatry.indianjpsychiatry_126_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
CONTEXT The concept of quality of life (QoL) is becoming an important measure of the impact of psychiatric disorders. It is natural that once patient achieves remission, QoL would improve, but very few studies are conducted under this phase. This study compares the differences in QoL in remitted patients with monotherapy and polypharmacy. AIMS The aim of this study is to compare the QoL between psychiatric patients in remission treated with monotherapy and polypharmacy. SETTINGS AND DESIGN It is a questionnaire based cross-sectional comparative study. MATERIALS AND METHODS This study included outpatients under remission who come for follow-up in psychiatric department. Semi-structured data collection form was used. Remission was confirmed using suitable scales, and QoL was assessed using the World Health Organization quality of life-Brief (WHOQOL-BREF) scale. Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) were applied to understand the overall improvement and functioning levels. RESULTS Out of the total 100 patients enrolled in the study, fifty patients were on monotherapy and fifty patients on polypharmacy. The cost of medication was comparatively high for polypharmacy (Rs. 3568.92 [±348.54]) than monotherapy (Rs. 1936.56 [±252.07]). The QoL in physical, psychological, and social domains was significantly high in patients on polypharmacy rather than monotherapy when assessed using the WHOQOL-BREF scale. Ninety-six percent of monotherapy patients had CGI scores between 1.5 and 2.4 while 74% of polypharmacy patients had scores between 1.0 and 1.5. Ninety-six percent of monotherapy patients had <80 GAF scores while 92% of polypharmacy patients had >80. CONCLUSIONS Patients treated with polypharmacy had better QoL and also clinical improvement and functioning levels were superior.
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Affiliation(s)
- Benson Koshy
- Departments of Pharmacy Practice, SJMCP, Chitradurga, Karnataka, India
| | - C M Gopal Das
- Department of Psychiatry, BMCH and RC, Chitradurga, Karnataka, India
| | | | - D R Bharathi
- Department of Psychiatry, BMCH and RC, Chitradurga, Karnataka, India
| | - Shashank S Hosur
- Department of Psychiatry, BMCH and RC, Chitradurga, Karnataka, India
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Barber S, Olotu U, Corsi M, Cipriani A. Clozapine combined with different antipsychotic drugs for treatment-resistant schizophrenia. Cochrane Database Syst Rev 2017; 3:CD006324. [PMID: 28333365 PMCID: PMC6464566 DOI: 10.1002/14651858.cd006324.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Between 40% and 70% of people with treatment-resistant schizophrenia do not respond to clozapine, despite adequate blood levels. For these people, a number of treatment strategies have emerged, including the prescription of a second anti-psychotic drug in combination with clozapine. OBJECTIVES To determine the clinical effects of various clozapine combination strategies with antipsychotic drugs in people with treatment-resistant schizophrenia both in terms of efficacy and tolerability. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (to 28 August 2015) and MEDLINE (November 2008). We checked the reference lists of all identified randomised controlled trials (RCT). For the first version of the review, we also contacted pharmaceutical companies to identify further trials. SELECTION CRITERIA We included only RCTs recruiting people of both sexes, aged 18 years or more, with a diagnosis of treatment-resistant schizophrenia (or related disorders) and comparing clozapine plus another antipsychotic drug with clozapine plus a different antipsychotic drug. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data, we calculated risk ratios (RRs) and 95% confidence intervals (CI) on an intention-to-treat basis using a random-effects meta-analysis. For continuous data, we calculated mean differences (MD) and 95% CIs. We used GRADE to create 'Summary of findings' tables and assessed risk of bias for included studies. MAIN RESULTS We identified two further studies with 169 participants that met our inclusion criteria. This review now includes five studies with 309 participants. The quality of evidence was low, and, due to the high degree of heterogeneity between studies, we were unable to undertake a formal meta-analysis to increase the statistical power.For this update, we specified seven main outcomes of interest: clinical response in mental state (clinically significant response, mean score/change in mental state), clinical response in global state (mean score/change in global state), weight gain, leaving the study early (acceptability of treatment), service utilisation outcomes (hospital days or admissions to hospital) and quality of life.We found some significant differences between clozapine combination strategies for global and mental state (clinically significant response and change), and there were data for leaving the study early and weight gain. We found no data for service utilisation and quality of life. Clozapine plus aripiprazole versus clozapine plus haloperidolThere was no long-term significant difference between aripiprazole and haloperidol combination strategies in change of mental state (1 RCT, n = 105, MD 0.90, 95% CI -4.38 to 6.18, low quality evidence). There were no adverse effect data for weight gain but there was a benefit of aripiprazole for adverse effects measured by the LUNSERS at 12 weeks (1 RCT, n = 105, MD -4.90, 95% CI -8.48 to -1.32) and 24 weeks (1 RCT, n = 105, MD -4.90, 95% CI -8.25 to -1.55), but not 52 weeks (1 RCT, n = 105, MD -4.80, 95% CI -9.79 to 0.19). Similar numbers of participants from each group left the study early (1 RCT, n = 106, RR 1.27, 95% CI 0.72 to 2.22, very low quality evidence). Clozapine plus amisulpride versus clozapine plus quetiapine One study showed a significant benefit of amisulpride over quetiapine in the short term, for both change in global state (Clinical Global Impression (CGI): 1 RCT, n = 50, MD -0.90, 95% CI -1.38 to -0.42, very low quality evidence) and mental state (Brief Psychiatric Rating Scale (BPRS): 1 RCT, n = 50, MD -4.00, 95% CI -5.86 to -2.14, low quality evidence). Similar numbers of participants from each group left the study early (1 RCT, n = 56, RR 0.20, 95% CI 0.02 to 1.60, very low quality evidence) Clozapine plus risperidone versus clozapine plus sulpirideThere was no difference between risperidone and sulpiride for clinically significant response, defined by the study as 20% to 50% reduction in Positive and Negative Syndrome Scale (PANSS) (1 RCT, n = 60, RR 0.82, 95% CI 0.40 to 1.68, very low quality evidence). There were similar equivocal results for weight gain (1 RCT, n = 60, RR 0.40, 95% CI 0.08 to 1.90, very low quality evidence) and mental state (PANSS total: 1 RCT, n = 60, MD -2.28, 95% CI -7.41 to 2.85, very low quality evidence). No-one left the study early. Clozapine plus risperidone versus clozapine plus ziprasidoneThere was no difference between risperidone and ziprasidone for clinically significant response (1 RCT, n = 24, RR 0.80, 95% CI 0.28 to 2.27, very low quality evidence), change in global state CGI-II score (1 RCT, n = 22, MD -0.30, 95% CI -0.82 to 0.22, very low quality evidence), change in PANSS total score (1 RCT, n = 16, MD 1.00, 95% CI -7.91 to 9.91, very low quality evidence) or leaving the study early (1 RCT, n = 24, RR 1.60, 95% CI 0.73 to 3.49, very low quality evidence). Clozapine plus ziprasidone versus clozapine plus quetiapineOne study found, in the medium term, a superior effect for ziprasidone combination compared with quetiapine combination for clinically significant response in mental state (> 50% reduction PANSS: 1 RCT, n = 63, RR 0.54, 95% CI 0.35 to 0.81, low quality evidence), global state (CGI - Severity score: 1 RCT, n = 60, MD -0.70, 95% CI -1.18 to -0.22, low quality evidence) and mental state (PANSS total score: 1 RCT, n = 60, MD -12.30, 95% CI -22.43 to -2.17, low quality evidence). There was no effect for leaving the study early (1 RCT, n = 63, RR 0.52, CI 0.05 to 5.41, very low quality evidence). AUTHORS' CONCLUSIONS The reliability of results from this review is limited, evidence is of low or very low quality. Furthermore, due to the limited number of included studies, we were unable to undertake formal meta-analyses. As a consequence, any conclusions drawn from these findings are based on single, small-sized RCTs with high risk of type II error. Properly conducted and adequately powered RCTs are required. Future trialists should seek to measure patient-important outcomes such as quality of life, as well as clinical response and adverse effects.
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Affiliation(s)
- Sarah Barber
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUK
| | | | - Martina Corsi
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUK
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUK
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Armstrong KS, Temmingh H. Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country. ACTA ACUST UNITED AC 2017; 39:293-301. [PMID: 28177063 PMCID: PMC7111406 DOI: 10.1590/1516-4446-2016-2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/07/2016] [Indexed: 01/02/2023]
Abstract
Objective: The aim of our study was to examine the prevalence of and factors associated with antipsychotic polypharmacy (APP) among patients with serious mental illness in the current South African health care context. Methods: We collected data on patient, illness, and treatment characteristics of patients discharged on one or more antipsychotic agents from January to June 2014. We analyzed the associations of APP with demographic and clinical variables using hierarchical multivariable logistic regression, and examined prescription patterns. Results: The prevalence of APP in our study population of 577 patients was 28.4%. Demographic and clinical characteristics significantly associated with APP included age > 29, male sex, diagnosis of schizophrenia, comorbid intellectual disability, comorbid substance use, greater number of hospital admissions, and high-dose prescribing. First-generation antipsychotics and long-acting injectable preparations were prominent in APP combinations. Co-prescription of anticholinergic agents and sodium valproate demonstrated a significant association with APP. Conclusion: APP appears common in our population, despite lack of evidence for the practice and possible risk of harm. Our findings suggest a complex interplay among patient, illness, and treatment factors relevant to APP in our setting that could be targeted for intervention.
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Affiliation(s)
- Kerryn S Armstrong
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Observatory, Cape Town, South Africa
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Observatory, Cape Town, South Africa
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Galling B, Roldán A, Hagi K, Rietschel L, Walyzada F, Zheng W, Cao X, Xiang Y, Zink M, Kane JM, Nielsen J, Leucht S, Correll CU. Antipsychotic augmentation vs. monotherapy in schizophrenia: systematic review, meta-analysis and meta-regression analysis. World Psychiatry 2017; 16:77-89. [PMID: 28127934 PMCID: PMC5269492 DOI: 10.1002/wps.20387] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Antipsychotic polypharmacy in schizophrenia is much debated, since it is common and costly with unclear evidence for its efficacy and safety. We conducted a systematic literature search and a random effects meta-analysis of randomized trials comparing augmentation with a second antipsychotic vs. continued antipsychotic monotherapy in schizophrenia. Co-primary outcomes were total symptom reduction and study-defined response. Antipsychotic augmentation was superior to monotherapy regarding total symptom reduction (16 studies, N=694, standardized mean difference, SMD=-0.53, 95% CI: -0.87 to -0.19, p=0.002). However, superiority was only apparent in open-label and low-quality trials (both p<0.001), but not in double-blind and high-quality ones (p=0.120 and 0.226, respectively). Study-defined response was similar between antipsychotic augmentation and monotherapy (14 studies, N=938, risk ratio = 1.19, 95% CI: 0.99 to 1.42, p=0.061), being clearly non-significant in double-blind and high-quality studies (both p=0.990). Findings were replicated in clozapine and non-clozapine augmentation studies. No differences emerged regarding all-cause/specific-cause discontinuation, global clinical impression, as well as positive, general and depressive symptoms. Negative symptoms improved more with augmentation treatment (18 studies, N=931, SMD=-0.38, 95% CI: -0.63 to -0.13, p<0.003), but only in studies augmenting with aripiprazole (8 studies, N=532, SMD=-0.41, 95% CI: -0.79 to -0.03, p=0.036). Few adverse effect differences emerged: D2 antagonist augmentation was associated with less insomnia (p=0.028), but more prolactin elevation (p=0.015), while aripiprazole augmentation was associated with reduced prolactin levels (p<0.001) and body weight (p=0.030). These data suggest that the common practice of antipsychotic augmentation in schizophrenia lacks double-blind/high-quality evidence for efficacy, except for negative symptom reduction with aripiprazole augmentation.
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Affiliation(s)
- Britta Galling
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité-Universitätsmedizin BerlinBerlinGermany,Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA
| | - Alexandra Roldán
- Department of PsychiatryInstitut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Katsuhiko Hagi
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Sumitomo Dainippon Pharma Co.TokyoJapan
| | - Liz Rietschel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBernSwitzerland
| | - Frozan Walyzada
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA
| | - Wei Zheng
- Guangzhou Brain Hospital, Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Xiao‐Lan Cao
- Department of PsychiatryChinese University of Hong KongHong Kong SARChina
| | - Yu‐Tao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of MacaoTaipa, MacaoSARChina
| | - Mathias Zink
- Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg UniversityMannheimGermany
| | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA,Feinstein Institute for Medical ResearchManhassetNYUSA,Albert Einstein College of MedicineBronxNYUSA
| | - Jimmi Nielsen
- Department of PsychiatryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Stefan Leucht
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität MünchenMunichGermany
| | - Christoph U. Correll
- Zucker Hillside Hospital, Psychiatry Research, Northwell HealthGlen OaksNYUSA,Hofstra Northwell School of MedicineHempsteadNYUSA,Feinstein Institute for Medical ResearchManhassetNYUSA,Albert Einstein College of MedicineBronxNYUSA
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James BO, Omoaregba JO, Raji SO, Imishue OE, Okonoda KM, Nyamali YI, Famuyiwa PA, Correll CU. Attitudes towards and rationale for antipsychotic polypharmacy among psychiatrists in Nigeria: Characteristics associated with high reported antipsychotic polypharmacy. Psychiatry Res 2017; 248:134-139. [PMID: 28063386 DOI: 10.1016/j.psychres.2016.12.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/29/2016] [Accepted: 12/24/2016] [Indexed: 11/25/2022]
Abstract
Antipsychotic polypharmacy (APP) is commonplace despite lacking evidence of its effectiveness. We aimed to identify psychiatrists' rationale for and attitudes towards APP and to determine if attitudes influence antipsychotic polypharmacy prescription rates in a survey of a nationally representative sample of Nigerian psychiatrists (of which a majority were senior trainees: 74.2%). Prescriber characteristics, practices and attitudes were compared in 'high' (>30%) vs. 'low' (≤30%) antipsychotic polypharmacy prescribers and results were adjusted for multiple comparisons. Altogether, prescribers reported utilizing antipsychotic polypharmacy in 36.2% of their patients. Compared to 'low' antipsychotic polypharmacy prescribers, 'high' prescribers were significantly more likely using first-generation antipsychotics (FGA) combination, to have attempted a switch to monotherapy in less patients, or been successful in doing so. 'High' and 'low' antipsychotic polypharmacy prescribers were equally moderately concerned about the effects of antipsychotic polypharmacy and also did not differ regarding reasons not justifying antipsychotic polypharmacy. In a multivariable, backward elimination logistic regression model, 'low' antipsychotic polypharmacy was associated with having successfully switched patients to monotherapy, whereas the 'high' antipsychotic polypharmacy was associated with preferring FGA+FGA combinations and aiming for a reduction of non-antipsychotic medications. Antipsychotic polypharmacy is common among psychiatrists in Nigeria, with 'high' and 'low' antipsychotic polypharmacy prescribers sharing similar concerns/attitudes, but differing regarding their primary aim for antipsychotic polypharmacy and in their specific antipsychotic polypharmacy use characteristics.
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Affiliation(s)
- B O James
- Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Benin-City, Nigeria.
| | - J O Omoaregba
- Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Benin-City, Nigeria
| | - S O Raji
- Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Benin-City, Nigeria
| | - O E Imishue
- Department of Clinical Services, Neuro-Psychiatric Hospital, Aro, Abeokuta, Nigeria
| | - K M Okonoda
- Department of Psychiatry, University of Jos, Jos, Plateau State, Nigeria; Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Y I Nyamali
- Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Yaba, Lagos, Nigeria
| | - P A Famuyiwa
- Department of Clinical Services, Federal Neuro-Psychiatric Hospital, Calabar, Cross River, Nigeria
| | - C U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health System, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Manhasset, NY, USA
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Abstract
Although treatment-resistant schizophrenia (TRS) was described 50 years ago and has a gold standard treatment with clozapine based on well-defined criteria, there is still a matter of great interest and controversy. In terms of the underlying mechanisms of the development of TRS, progress has been made for the elucidation of the neurochemical mechanisms. Structural neuroimaging studies have shown that patients with TRS have significant reduction of the prefrontal cortex volume when compared with non- TRS. This article updates and enhances our previous review with new evidence mainly derived from new studies, clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- Helio Elkis
- Instituto de Psiquiatria HC- FMUSP, Rua Ovidio Pires de Campos 785-São Paulo, SP-05403-010, Brazil.
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Galling B, Roldán A, Rietschel L, Hagi K, Walyzada F, Zheng W, Cao XL, Xiang YT, Kane JM, Correll CU. Safety and tolerability of antipsychotic co-treatment in patients with schizophrenia: results from a systematic review and meta-analysis of randomized controlled trials. Expert Opin Drug Saf 2016; 15:591-612. [PMID: 26967126 DOI: 10.1517/14740338.2016.1165668] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Antipsychotic co-treatment is common in schizophrenia, despite lacking evidence for its efficacy and safety. Areas: We conducted a systematic search of PubMed/PsycInfo/CJN/WangFan/CBM without language restrictions from database inception until 05/25/2015 for randomized trials comparing antipsychotic monotherapy with antipsychotic co-treatment in ≥20 adults with schizophrenia reporting meta-analyzable adverse events (AEs) data. Meta-analyzing 67 studies (n=4,861, duration=10.3±5.2 weeks), antipsychotic co-treatment was similar to monotherapy regarding intolerability-related discontinuation (risk ratio (RR)=0.84, 95% confidence interval (CI)=0.53-1.33, p=0.455). While incidence of ≥1 AE was lower with antipsychotic co-treatment (RR=0.77, 95%CI=0.66-0.90, p=0.001), these results were solely driven by open-label and efficacy-focused studies. Adjunctive D2-antagonists lead to less nausea (RR=0.220, 95%CI=0.06-0.87, p=0.030) and insomnia (RR=0.26, 95%CI=0.08-0.86, p=0.028), but higher prolactin (SMD=2.20, 95%CI=0.43-3.96, p=0.015). Conversely, adjunctive partial D2-agonists (aripiprazole=100%) resulted in lower electrocardiogram abnormalities (RR=0.43, 95%CI=0.25-0.73, p=0.002), constipation (RR=0.45, 95%CI=0.25-0.79, p=0.006), drooling/hypersalivation (RR=0.14, 95%CI=0.07-0.29, p<0.001), prolactin (SMD=-1.77, 95%CI=-2.38, -1.15, p<0.001), total and LDL-cholesterol (SMD=-0.33, 95%CI=-0.55, -0.11, p=0.003; SMD=-0.33, 95%CI=-0.54, -0.10, p=0.004). EXPERT OPINION No double-blind evidence for altered AE burden associated with antipsychotic co-treatment was found. However, AEs were insufficiently and incompletely reported and follow-up duration was modest. Adjunctive partial D2-agonists might be beneficial for counteracting several AEs. High-quality, long-term studies that comprehensively assess AEs are needed.
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Affiliation(s)
- Britta Galling
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA
| | - Alexandra Roldán
- b Department of Psychiatry, Institut d'Investigació Biomédica-Sant Pau (IIB-SANT PAU) , Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB) , Barcelona , Spain
| | - Liz Rietschel
- c University Hospital of Child and Adolescent Psychiatry and Psychotherapy , University of Bern , Bern , Switzerland
| | - Katsuhiko Hagi
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,d Sumitomo Dainippon Pharma Co., Ltd., Medical Affairs , Tokyo , Japan
| | - Frozan Walyzada
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA
| | - Wei Zheng
- e Department of Psychiatry, Guangzhou Brain Hospital (Guangzhou Huiai Hospital), Affilated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Xiao-Lan Cao
- f Department of Psychiatry , Chinese University of Hong Kong , Hong Kong , China
| | - Yu-Tao Xiang
- g Unit of Psychiatry, Faculty of Health Sciences , University of Macau , Macao , China
| | - John M Kane
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,h Hofstra North Shore LIJ School of Medicine , Hempstead , NY , USA.,i The Feinstein Institute for Medical Research , Manhasset , NY , USA.,j Albert Einstein College of Medicine , Bronx , NY , USA
| | - Christoph U Correll
- a The Zucker Hillside Hospital , Psychiatry Research, Northwell Health , Glen Oaks , NY , USA.,h Hofstra North Shore LIJ School of Medicine , Hempstead , NY , USA.,i The Feinstein Institute for Medical Research , Manhasset , NY , USA.,j Albert Einstein College of Medicine , Bronx , NY , USA
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Trends in the access to and the use of antipsychotic medications and psychotropic co-treatments in Asian patients with schizophrenia. Epidemiol Psychiatr Sci 2016; 25:9-17. [PMID: 26289066 PMCID: PMC6998674 DOI: 10.1017/s2045796015000694] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
To date, antipsychotics remain the mainstay of treatment for schizophrenia and related disorders although other psychotropic medications and non-pharmaceutical interventions have been used adjunctively in some patients and settings. Regular surveys on access to and prescription patterns of psychotropic medications in clinical practice are an important and efficient way of examining the use and time trends of treatments in a given population and region. Unlike developed Western countries, Asian countries have not fully undergone deinstitutionalisation of the severely and chronically mentally ill, and community-based mental health services are still under-developed. As a result, a large number of psychiatric patients still receive treatments in psychiatric hospitals. Moreover, there have been very limited studies examining access to and prescription patterns of psychotropic medications for schizophrenia patients in Asian countries. In this paper, we focus on the only international project on the use of psychotropic medications in schizophrenia patients in selected East and Southeast Asian countries/territories summarising its major findings. Most of the first- and second-generation antipsychotics (FGAs and SGAs) are available in Asian countries, but the access to psychotropic medications is largely affected by socio-cultural and historical contexts, health insurance schemes, health care policy, medication cost and consumers' preference across different countries/territories. Overall, the proportional use of FGAs, high dose antipsychotic treatment and antipsychotic polypharmacy have decreased, while the use of SGAs and antidepressants have increased and the utilisation of benzodiazepines and mood stabilisers has remained relatively stable over time. However, within these general trends, there is great inter-country variation regarding the psychotropic prescribing patterns and trends in Asian schizophrenia patients that also seems to differ from data in many Western countries.
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Razzouk D, Kayo M, Sousa A, Gregorio G, Cogo-Moreira H, Cardoso AA, Mari JDJ. The impact of antipsychotic polytherapy costs in the public health care in Sao Paulo, Brazil. PLoS One 2015; 10:e0124791. [PMID: 25853709 PMCID: PMC4390144 DOI: 10.1371/journal.pone.0124791] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/10/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Guidelines for the treatment of psychoses recommend antipsychotic monotherapy. However, the rate of antipsychotic polytherapy has increased over the last decade, reaching up to 60% in some settings. Studies evaluating the costs and impact of antipsychotic polytherapy in the health system are scarce. OBJECTIVE To estimate the costs of antipsychotic polytherapy and its impact on public health costs in a sample of subjects with psychotic disorders living in residential facilities in the city of Sao Paulo, Brazil. METHOD A cross-sectional study that used a bottom-up approach for collecting costs data in a public health provider's perspective. Subjects with psychosis living in 20 fully-staffed residential facilities in the city of Sao Paulo were assessed for clinical and psychosocial profile, severity of symptoms, quality of life, use of health services and pharmacological treatment. The impact of polytherapy on total direct costs was evaluated. RESULTS 147 subjects were included, 134 used antipsychotics regularly and 38% were in use of antipsychotic polytherapy. There were no significant differences in clinical and psychosocial characteristics between polytherapy and monotherapy groups. Four variables explained 30% of direct costs: the number of antipsychotics, location of the residential facility, time living in the facility and use of olanzapine. The costs of antipsychotics corresponded to 94.4% of the total psychotropic costs and to 49.5% of all health services use when excluding accommodation costs. Olanzapine costs corresponded to 51% of all psychotropic costs. CONCLUSION Antipsychotic polytherapy is a huge economic burden to public health service, despite the lack of evidence supporting this practice. Great variations on antipsychotic costs explicit the need of establishing protocols for rational antipsychotic prescriptions and consequently optimising resource allocation. Cost-effectiveness studies are necessary to estimate the best value for money among antipsychotics, especially in low and middle income countries.
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Affiliation(s)
- Denise Razzouk
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Monica Kayo
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Aglaé Sousa
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Gregorio
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Andrea Alves Cardoso
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Jair de Jesus Mari
- Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
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Seppälä N, Leinonen E, Viikki M, Solismaa A, Nuolivirta T, Kampman O. Factors associated with subjective side-effects during clozapine treatment. Nord J Psychiatry 2015; 69:161-6. [PMID: 25225739 DOI: 10.3109/08039488.2014.947321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Clozapine is associated with subjectively unpleasant or clinically serious side-effects, which may affect treatment adherence. The aims of the study were to explore the association of clozapine+ norclozapine serum concentration and other factors with subjective side-effects in schizophrenia patients. METHODS In this cross-sectional study, 237 patients with a diagnosis of schizophrenia, schizo-affective or other non-organic psychoses completed the Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS), a self-report scale measuring side-effects of antipsychotics and a clinical questionnaire. Clozapine+ norclozapine serum concentration of 190 patients was measured. Of the patients 80 (33.7%) were on antipsychotic combination therapy. RESULTS Higher clozapine+ norclozapine concentrations were associated with the depression-anxiety factor of LUNSERS and antipsychotic combination treatments were associated with sympatichotonia-tension factor. Younger patients reported sedation more often than older patients. CONCLUSION According to the present results, high clozapine concentrations were associated with depression-anxiety symptoms, but the causality remains unknown.
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Affiliation(s)
- Niko Seppälä
- Niko Seppälä, Department of Psychiatry, Satakunta Hospital District, University of Tampere , FI-29200 Harjavalta , and Medical School, Faculty of Medicine, University of Tampere , FI-33140 Tampere , Finland
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Wu YH, Lai CY, Chang YS. Antipsychotic polypharmacy among elderly patients with schizophrenia and dementia during hospitalization at a Taiwanese psychiatric hospital. Psychogeriatrics 2015; 15:7-13. [PMID: 25515355 DOI: 10.1111/psyg.12067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/29/2014] [Accepted: 08/17/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study was to investigate the prescribing patterns for antipsychotic drugs in elderly hospitalized patients with a diagnosis of schizophrenia or dementia at a psychiatric hospital in Taiwan from 2007 to 2012. This study also explored the predictors of antipsychotic polypharmacy (APP). METHODS We collected patients' demographic data, including year of admission, age, gender, and length of hospital stay, and drug-related information. RESULTS Second-generation antipsychotic (SGA) monotherapy was the most common type of therapy in both those with dementia and with schizophrenia, and quetiapine and risperidone were the most commonly prescribed drugs for these conditions, respectively. In late-life schizophrenia, 33.8% of the patients used first-generation antipsychotics (FGA) alone. Regarding APP, a combination of FGA and SGA and combinations of SGA were most commonly noted in schizophrenia patients and dementia patients, respectively. Overall, APP increased from 2007 to 2012. It was significantly more common in patients with dementia (odds ratio: 3.49, 95% confidence interval: 1.29-9.39, P = 0.014), less concurrent use of hypnotics and sedatives (odds ratio: 0.41, 95% confidence interval: 0.17-0.99, P = 0.046), and a higher-than-recommended dose of antipsychotic drugs (odds ratio: 4.98, 95% confidence interval: 2.75-9.02, P < 0.001). CONCLUSIONS FGA are still commonly used for the late-life schizophrenia at our hospital. Given their potentially hazardous side effects, FGA must be employed with caution. The use of APP involving SGA increased over the 6 years of the study period, especially among patients with dementia. However, the use of SGA in dementia began to decline after the US Food and Drug Administration's 2005 warning about SGA being associated with increased mortality in dementia patients, which contrasts with the trends examined in this study. Further controlled trials exploring the efficacy, safety, and tolerability of APP in this population are warranted to gain an additional insight into this practice.
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Affiliation(s)
- Yu-Hsuan Wu
- Department of Neuropsychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
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Li Q, Xiang YT, Su YA, Shu L, Yu X, Chiu HF, Correll CU, Ungvari GS, Lai KY, Ma C, Wang GH, Bai PS, Li T, Sun LZ, Shi JG, Chen XS, Mei QY, Li KQ, Si TM. Antipsychotic polypharmacy in schizophrenia patients in China and its association with treatment satisfaction and quality of life: findings of the third national survey on use of psychotropic medications in China. Aust N Z J Psychiatry 2015; 49:129-36. [PMID: 24923760 DOI: 10.1177/0004867414536931] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study examined the use, demographic and clinical correlates of antipsychotic polypharmacy (APP) and its associations with treatment satisfaction and quality of life (QOL) in schizophrenia patients in China. METHOD A total of 4239 patients in 45 nationwide Chinese psychiatric hospitals/centers were interviewed in 2012 in the third cross-sectional study, with the first two having been conducted in 2002 and 2006. Patients' socio-demographic and clinical characteristics, including psychopathology, side effects, satisfaction with treatment and QOL, were recorded using a standardized protocol and data collection procedure. RESULTS The proportion of APP prescriptions in 2012 was 34.2%, which was significantly higher than the frequency of APP in 2002 (26.1%) and 2006 (26.4%) (p<0.001). Of patients on APP, 91.1% received two antipsychotics, 8.6% received three and 0.3% received four or more antipsychotics. Multiple logistic regression analyses revealed that compared to those on antipsychotic monotherapy, patients on APP and their families had lower satisfaction with treatment, had higher QOL in the mental domain, younger age of onset, more side effects, higher doses of antipsychotics and were more likely to receive first-generation antipsychotics and less likely to receive benzodiazepines (total R (2)=0.31, p<0.001). CONCLUSIONS APP was found in about one in three schizophrenia patients. The prevalence of APP seems to have been increasing since 2002. Considering the increased frequency of drug-induced side effects and the patients' and their relatives' dissatisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of APP and its alternatives is warranted.
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Affiliation(s)
- Qian Li
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Yu-Tao Xiang
- Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Yun-Ai Su
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Liang Shu
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Xin Yu
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Helen Fk Chiu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY, USA
| | - Gabor S Ungvari
- The University of Notre Dame Australia/Marian Centre, Perth, Australia
| | - Kelly Yc Lai
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Cui Ma
- Psychiatric Hospital, Guangzhou, China
| | - Gao-Hua Wang
- Department of Psychiatry, Renmin Hospital, Wuhan University, Wuhan, China
| | - Pei-Shen Bai
- The First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Tao Li
- West China Hospital, Sichuan University, China
| | | | | | | | - Qi-Yi Mei
- Suzhou Guangji Hospital, Suzhou, China
| | - Ke-Qing Li
- Hebei Mental Health Center, Hebei, China
| | - Tian-Mei Si
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
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Abstract
Clinical experience with aripiprazole has confirmed the effectiveness and the safety of this novel antipsychotic drug in patients with schizophrenia as well as for the treatment of mania in type I bipolar disorder. However the generalization of the results from clinical trials requires further effort in order to address some issues and to overcome incorrect and partial interpretation of the clinical evidence. This article provides some straightforward guidance that may help clinical psychiatrists to translate the mechanism of action of aripiprazole into clinical setting, thus improving the appropriate use of the drug through rational application of its pharmacological profile. Examples of paradigmatic clinical situations are presented and discussed, suggesting possible intervention strategies, which may contribute to achieving the most appropriate use of the pharmacological properties of aripiprazole in real life settings.
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Affiliation(s)
- Guido Di Sciascio
- Department of Psychiatry, University Hospital "Policlinico", Bari, Italy
| | - Marco Andrea Riva
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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Verdoux H, Pambrun E. Clozapine use pattern in persons with and without treatment for Parkinson's disease in real-world conditions: a naturalistic study in a community-based sample. Acta Psychiatr Scand 2014; 130:487-97. [PMID: 25302631 DOI: 10.1111/acps.12344] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To explore the pattern of clozapine use in persons with severe mental illness and in persons with Parkinson's disease and the characteristics associated with early discontinuation in naturalistic conditions. METHOD A historical fixed cohort study of persons newly treated with clozapine was performed on a representative community-based sample of persons affiliated to the French health insurance system (n = 611,393). Treatment for Parkinson's disease was used as a proxy for this condition and lack of such treatment as a proxy for severe mental illness (SMI). RESULTS The prevalences of antipsychotic and clozapine use were 4.4% and <0.1% respectively. Of the 237 persons with a new outpatient prescription of clozapine, 25% were prescribed an antiparkinsonian treatment. In persons with SMI, the median duration of the index episode of clozapine treatment was 4.9 months (Interquartile range 1.0-20.5). Longer duration was independently associated with coprescription of anxiolytics or antidepressant. Few new additions of antipsychotics were observed during the clozapine episode. CONCLUSION Efforts have to be made to optimize clozapine treatment in real-world conditions. Considering the high frequency of persons with Parkinson's disease among clozapine users, further studies have to be performed in this population.
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Affiliation(s)
- H Verdoux
- University of Bordeaux, U657, Bordeaux, France; INSERM, U657, Bordeaux, France; Centre Hospitalier Charles Perrens, Bordeaux, France
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Miyamoto S, Jarskog LF, Fleischhacker WW. New therapeutic approaches for treatment-resistant schizophrenia: a look to the future. J Psychiatr Res 2014; 58:1-6. [PMID: 25070124 DOI: 10.1016/j.jpsychires.2014.07.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/18/2014] [Accepted: 07/01/2014] [Indexed: 01/29/2023]
Abstract
Schizophrenia for many patients is a lifelong mental disorder with significant consequences on most functional domains. One fifth to one third of patients with schizophrenia experience persistent psychotic symptoms despite adequate trials of antipsychotic treatment, and are considered to have treatment-resistant schizophrenia (TRS). Clozapine is the only medication to demonstrate efficacy for psychotic symptoms in such patients. However, clozapine is not effective in 40%-70% of patients with TRS and it has significant limitations in terms of potentially life-threatening side effects and the associated monitoring. Accordingly, a number of pharmacological and non-pharmacological biological approaches for clozapine-resistant TRS have emerged. This article provides a brief updated critical review of recent therapeutic strategies for TRS, particularly for clozapine-resistant TRS, which include pharmacotherapy, electroconvulsive therapy, repetitive transcranial magnetic stimulation, and transcranial direct current stimulation.
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Affiliation(s)
- Seiya Miyamoto
- Department of Neuropsychiatry, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - L Fredrik Jarskog
- North Carolina Psychiatric Research Center, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Gardner DM. Competent psychopharmacology. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:406-11. [PMID: 25161064 PMCID: PMC4143296 DOI: 10.1177/070674371405900802] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022]
Abstract
There is little doubt that undergraduate and post-graduate training of physicians, pharmacists, and nurses is insufficient to prepare them to use psychotropics safely and effectively, especially in the context of their expanded off-label uses. Therefore, the development of competencies in psychotropic prescribing needs to be approached as a long-term, practice-based learning commitment. Proposed are the abilities and knowledge components necessary for safe and effective use of psychotropics. Typical challenges in prescribing for chronic and recurrent illnesses include highly variable responses and tolerability, drug interactions, and adverse effects that can be serious, irreversible, and even fatal. Prescribing psychotropics is further complicated by negative public and professional reports and growing patient concerns about the quality of care, and questions about the efficacy, safety, and addictive risks of psychotropics. Increased efforts are needed to enhance clinical training and knowledge in psychopharmacology among trainees and practising clinicians, with more comprehensive and sustained attention to the assessment of individual patients, and greater reliance on patient education and collaboration. Improved competence in psychotropic prescribing should lead to more informed, thoughtful, and better-targeted applications as one component of more comprehensive clinical care.
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Affiliation(s)
- David M Gardner
- Professor, Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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Clelland JD, Read LL, Drouet V, Kaon A, Kelly A, Duff KE, Nadrich RH, Rajparia A, Clelland CL. Vitamin D insufficiency and schizophrenia risk: evaluation of hyperprolinemia as a mediator of association. Schizophr Res 2014; 156:15-22. [PMID: 24787057 PMCID: PMC4044915 DOI: 10.1016/j.schres.2014.03.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 12/25/2022]
Abstract
25-Hydroxyvitamin D (25(OH)D) deficits have been associated with schizophrenia susceptibility and supplementation has been recommended for those at-risk. Although the mechanism by which a deficit confers risk is unknown, vitamin D is a potent transcriptional modulator and can regulate proline dehydrogenase (PRODH) expression. PRODH maps to chromosome 22q11, a region conferring the highest known genetic risk of schizophrenia, and encodes proline oxidase, which catalyzes proline catabolism. l-Proline is a neuromodulator at glutamatergic synapses, and peripheral hyperprolinemia has been associated with decreased IQ, cognitive impairment, schizoaffective disorder, and schizophrenia. We investigated the relationship between 25(OH)D and schizophrenia, comparing fasting plasma 25(OH)D in 64 patients and 90 matched controls. We then tested for a mediating effect of hyperprolinemia on the association between 25(OH)D and schizophrenia. 25(OH)D levels were significantly lower in patients, and 25(OH)D insufficiency associated with schizophrenia (OR 2.1, adjusted p=0.044, 95% CI: 1.02-4.46). Moreover, 25(OH)D insufficient subjects had three times greater odds of hyperprolinemia than those with optimal levels (p=0.035, 95% CI: 1.08-8.91), and formal testing established that hyperprolinemia is a significantly mediating phenotype that may explain over a third of the effect of 25(OH)D insufficiency on schizophrenia risk. This study presents a mechanism by which 25(OH)D insufficiency confers risk of schizophrenia; via proline elevation due to reduced PRODH expression, and a concomitant dysregulation of neurotransmission. Although definitive causality cannot be confirmed, these findings strongly support vitamin D supplementation in patients, particularly for those with elevated proline, who may represent a large subgroup of the schizophrenia population.
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Affiliation(s)
- James D. Clelland
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY,Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY
| | - Laura L. Read
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY,Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY
| | - Valérie Drouet
- Department of Pathology and Cell Biology, and Taub Institute for Research on Alzheimer's Disease and the Aging Brain. Columbia University Medical Center. 630 West 168th Street. New York
| | - Angela Kaon
- Movement Disorders and Molecular Psychiatry. The Nathan Kline Institute for Psychiatric Research. 140 Old Orangeburg Road. Orangeburg. NY
| | - Alexandra Kelly
- Department of Pathology and Cell Biology, and Taub Institute for Research on Alzheimer's Disease and the Aging Brain. Columbia University Medical Center. 630 West 168th Street. New York
| | - Karen E. Duff
- Department of Pathology and Cell Biology, and Taub Institute for Research on Alzheimer's Disease and the Aging Brain. Columbia University Medical Center. 630 West 168th Street. New York,New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY
| | - Robert H Nadrich
- Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY,Bellevue Hospital Center, 462 First Avenue, New York, NY
| | - Amit Rajparia
- Department of Psychiatry, New York University Langone Medical Center, 550 First Avenue. New York, NY,Bellevue Hospital Center, 462 First Avenue, New York, NY
| | - Catherine L. Clelland
- Department of Pathology and Cell Biology, and Taub Institute for Research on Alzheimer's Disease and the Aging Brain. Columbia University Medical Center. 630 West 168th Street. New York
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Dold M, Leucht S. Pharmacotherapy of treatment-resistant schizophrenia: a clinical perspective. EVIDENCE-BASED MENTAL HEALTH 2014; 17:33-7. [PMID: 24713315 DOI: 10.1136/eb-2014-101813] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A significant number of patients with schizophrenia do not respond adequately to an initial antipsychotic trial. As first step within a treatment algorithm for therapy-refractory schizophrenia 'pseudoresistance' should be ruled out (eg, re-evaluation of the diagnosis, comorbidities, compliance and adherence in terms of medication intake, adequate dose and treatment duration, and achievement of sufficient plasma levels). In case of treatment resistance, two strategies that are often used in clinical routine care contain dose increase of the current administered antipsychotic drug (dose escalation, high-dose treatment) and switch to another, new antipsychotic. Although the response rates for both options are generally rather low, we see from the evidence-based perspective a slight advantage of the switching strategy (preferably to an antipsychotic with a different receptor-binding profile) compared to a high-dose treatment. After treatment failures with at least two different antipsychotic drugs, a monotherapy with clozapine is considered to be the treatment option of first choice. At present, pharmacological combination and augmentation strategies cannot be regarded as a generally recommendable evidence-based treatment method. Antipsychotic monotherapy should be preferably sought. In case of combination treatment, it appears more appropriate to combine preferentially two antipsychotics with different receptor-binding profiles. Augmentation of antipsychotics with other agents should be used primarily to treat specific target symptoms.
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Affiliation(s)
- Markus Dold
- Department of Psychiatry and Psychotherapy, Technical University Munich, Klinikum rechts der Isar, , Munich, Germany
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