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Habuchi F, Ishida N, Matsushita R, Ishizaki J, Suga Y. Analysis of Atypical Antipsychotics-Induced Adverse Events Related to Diabetes Mellitus in Patients With Dementia Using the Japanese Adverse Drug Event Report Database. Ann Pharmacother 2024; 58:912-920. [PMID: 38124305 DOI: 10.1177/10600280231213507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with dementia are prescribed low-dose atypical antipsychotics (AAPs) to treat psycho-behavioral symptoms. Although AAPs are known to cause diabetes mellitus-related adverse events (DMAEs), information regarding AAPs-induced DMAEs experienced by patients with dementia is lacking. OBJECTIVE To use the Japan Adverse Drug Event Report (JADER) database to assess the onset tendencies and patterns of DMAEs attributable to AAPs prescribed to patients with dementia. METHODS We performed an analysis using dementia cases from the JADER database that were registered from April 2004 to December 2022. Data in the JADER database are completely anonymized; thus, we did not require institutional review board approval for using the JADER database in our study. The reporting odds ratio and proportional reporting ratio (PRR) were used to assess the onset tendencies of DMAEs with AAPs. In addition, Weibull shape parameters were used to assess the patterns of DMAEs that occur with the use of AAPs. RESULTS We identified AAPs associated with DMAEs. In particular, low doses of quetiapine showed the potential to induce DMAEs. An analysis of the onset of DMAEs showed the early failure patterns for AAPs (median onset = 38 days). CONCLUSION AND RELEVANCE The AAPs may cause DMAEs in patients with dementia. Low doses of quetiapine may induce DMAEs. Health care workers should focus on the development of DMAEs during the early administration period of AAPs. These results may assist with the safe management of patients with dementia who use AAPs.
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Affiliation(s)
- Fuga Habuchi
- Division of Pharmacy, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Natsuko Ishida
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Ryo Matsushita
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Junko Ishizaki
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Yukio Suga
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
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Qubad M, Dupont G, Hahn M, Martin SS, Puntmann V, Nagel E, Reif A, Bittner RA. When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis. CNS Drugs 2024; 38:671-696. [PMID: 38951464 PMCID: PMC11316720 DOI: 10.1007/s40263-024-01100-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
| | - Gabriele Dupont
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Martina Hahn
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Mental Health, Varisano Hospital Frankfurt Hoechst, Frankfurt, Germany
| | - Simon S Martin
- Department of Radiology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Valentina Puntmann
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Eike Nagel
- Department of Cardiology, Institute for Experimental and Translational Cardiovascular Imaging, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - Robert A Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, University Hospital, Frankfurt, Germany.
- Ernst Strüngmann Institute for Neuroscience (ESI) in Cooperation with Max Planck Society, Frankfurt, Germany.
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Correll CU, Tusconi M, Carta MG, Dursun SM. What Remains to Be Discovered in Schizophrenia Therapeutics: Contributions by Advancing the Molecular Mechanisms of Drugs for Psychosis and Schizophrenia. Biomolecules 2024; 14:906. [PMID: 39199294 PMCID: PMC11353083 DOI: 10.3390/biom14080906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/14/2024] [Accepted: 07/17/2024] [Indexed: 09/01/2024] Open
Abstract
Schizophrenia is a frequently debilitating and complex mental disorder affecting approximately 1% of the global population, characterized by symptoms such as hallucinations, delusions, disorganized thoughts and behaviors, cognitive dysfunction, and negative symptoms. Traditional treatment has centered on postsynaptic dopamine antagonists, commonly known as antipsychotic drugs, which aim to alleviate symptoms and improve functioning and the quality of life. Despite the availability of these medications, significant challenges remain in schizophrenia therapeutics, including incomplete symptom relief, treatment resistance, and medication side effects. This opinion article explores advancements in schizophrenia treatment, emphasizing molecular mechanisms, novel drug targets, and innovative delivery methods. One promising approach is novel strategies that target neural networks and circuits rather than single neurotransmitters, acknowledging the complexity of brain region interconnections involved in schizophrenia. Another promising approach is the development of biased agonists, which selectively activate specific signaling pathways downstream of receptors, offering potential for more precise pharmacological interventions with fewer side effects. The concept of molecular polypharmacy, where a single drug targets multiple molecular pathways, is exemplified by KarXT, a novel drug combining xanomeline and trospium to address both psychosis and cognitive dysfunction. This approach represents a comprehensive strategy for schizophrenia treatment, potentially improving outcomes for patients. In conclusion, advancing the molecular understanding of schizophrenia and exploring innovative therapeutic strategies hold promise for addressing the unmet needs in schizophrenia treatment, aiming for more effective and tailored interventions. Future research should focus on these novel approaches to achieve better clinical outcomes and improve the functional level and quality of life for individuals with schizophrenia.
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Affiliation(s)
- Christoph U. Correll
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY 10128, USA;
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
- Department of Child and Adolescent Psychiatry, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
| | | | - Mauro Giovanni Carta
- Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy;
| | - Serdar M. Dursun
- Neurochemical Research Unit, Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2G5, Canada;
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Bokhari SA, Lutfi L, Elnoor M, Mujahid B, Osman A. Polypharmacy to Clozapine Monotherapy in Treatment-Resistant Schizophrenia: A Case Report and Review of the Literature. Cureus 2024; 16:e63871. [PMID: 39100027 PMCID: PMC11298013 DOI: 10.7759/cureus.63871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/06/2024] Open
Abstract
This case report discusses a 25-year-old Middle Eastern female with a 14-year history of schizophrenia, managed as an inpatient for nearly eight years. Initially referred to a psychiatrist at age 12, with one-year-long concerns about preoccupation with the idea of having a serious illness, depressed mood, decreased appetite, social withdrawal, and aggression, she underwent multiple admissions, various medication combinations, and electroconvulsive therapy but remained resistant to treatment until clozapine monotherapy was initiated in 2023. After starting clozapine, improvements were noted in speech, communication, and eye contact, though negative symptoms and bouts of aggression persisted. This case highlights the efficacy of clozapine monotherapy in managing treatment-resistant schizophrenia after years of ineffective polypharmacy treatment. The importance of clozapine in treating treatment-resistant schizophrenia cannot be understated. Despite its efficacy, clozapine is often underutilised globally due to concerns about adverse effects and the need for blood monitoring, leading to the overuse of antipsychotic polypharmacy. This polypharmacy is associated with higher adverse event rates, increased costs, and uncertain long-term safety. This case report demonstrates the successful management of treatment-resistant schizophrenia with clozapine monotherapy. The patient's significant improvement supports the need to prioritise clozapine, highlighting its benefits over polypharmacy and advocating for its broader use to enhance patient outcomes.
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Affiliation(s)
- Syed Ali Bokhari
- Psychiatry, Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, ARE
| | - Lubna Lutfi
- Psychiatry and Behavioral Sciences, Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, ARE
| | - Muhanad Elnoor
- Psychiatry, Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, ARE
| | - Beenish Mujahid
- Psychiatry, Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, ARE
| | - Abdelaziz Osman
- Psychiatry, Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, ARE
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Normand SL, Zelevinsky K, Finnerty M, Leckman-Westin E, Chen Q, Jeong J, Abing H, Tsuei J, Horvitz-Lennon M. Racial-Ethnic Disparities in Quality of Care Among Medicaid Beneficiaries With Schizophrenia. Psychiatr Serv 2024:appips20230564. [PMID: 38863327 DOI: 10.1176/appi.ps.20230564] [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] [Indexed: 06/13/2024]
Abstract
OBJECTIVE The authors sought to update and expand the evidence on the quality of health care and disparities in care among Medicaid beneficiaries with schizophrenia. METHODS Adult beneficiaries of New York State Medicaid with schizophrenia receiving care during 2016-2019 were identified. Composite quality scores were derived from item response theory models by using evidence-based indicators of the quality of mental and general medical health care. Risk-adjusted racial-ethnic differences in quality were estimated and summarized as percentiles relative to White beneficiaries' mean quality scores. RESULTS The study included 71,013 beneficiaries; 42.8% were Black, 22.9% Latinx, 27.4% White, and 6.9% other race-ethnicity. Overall, 68.8% had a mental health follow-up within 30 days of discharge, and 90.2% had no preventable hospitalizations for chronic obstructive pulmonary disease or asthma. Among beneficiaries receiving antipsychotic medications, medication adherence was adequate for 43.7%. Fourteen indicators for mental and general medical health care quality yielded three composites: two for mental health care (pharmacological and ambulatory) and one for acute mental and general medical health care. Mean quality of pharmacological mental health care for Black and Latinx beneficiaries was lower than for White beneficiaries (39th and 44th percentile, respectively). For Black beneficiaries, mean quality of ambulatory mental health care was also lower (46th percentile). In New York City, Black beneficiaries received lower-quality care in all domains. The only meaningful group difference in the quality of acute mental and general medical health care indicated higher-quality care for individuals with other race-ethnicity. CONCLUSIONS Disparities in the quality of Medicaid-financed health care persist, particularly for Black beneficiaries. Regional differences merit further attention.
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Affiliation(s)
- Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Katya Zelevinsky
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Molly Finnerty
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Emily Leckman-Westin
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Qingxian Chen
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Junghye Jeong
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Haley Abing
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Jeannette Tsuei
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
| | - Marcela Horvitz-Lennon
- Department of Health Care Policy, Harvard Medical School, Boston (Normand, Zelevinsky, Abing); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston (Normand); Office of Mental Health, New York State Department of Health, Albany (Finnerty, Leckman-Westin, Chen, Jeong); Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York (Leckman-Westin); RAND, Santa Monica, California (Tsuei), and Boston (Horvitz-Lennon); Department of Psychiatry, Cambridge Health Alliance and Harvard Medical School, Cambridge, Massachusetts (Horvitz-Lennon)
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Augustin E, Beaudoin M, Giguère S, Ziady H, Phraxayavong K, Dumais A. The Relationship between Sense of Presence, Emotional Response, and Clinical Outcomes in Virtual Reality-Based Therapy for Treatment-Resistant Schizophrenia: An Exploratory Correlational Study. J Pers Med 2024; 14:614. [PMID: 38929835 PMCID: PMC11204393 DOI: 10.3390/jpm14060614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Avatar therapy (AT) is a novel virtual reality-based psychotherapy that has been developed to treat auditory verbal hallucinations (AVH) in treatment-resistant schizophrenia. Various psychotherapeutic components, such as emotions and sense of presence, could contribute to clinical outcomes. However, the interplay between sense of presence, emotions, and clinical response has seldom been investigated. This study aimed to explore the relations between sense of presence, emotions, and clinical outcomes in AT. To conduct this investigation, data from previous and ongoing AT trials were used. Sense of presence and emotions were assessed using standardized questionnaires. AVH were evaluated using the Psychotic Symptom Rating Scales. While sense of presence was positively associated with positive emotions such as control and serenity, no significant associations were found for negative emotions. Moreover, a higher level of sense of presence was associated with a bigger decrease in AVH. Overall, positive emotions seem to be associated with sense of presence in AT. Sense of presence also seems to be involved in the therapeutic outcome, thereby suggesting that this could be an important component related to clinical response. More studies are needed to confirm these trends, which could be generalized to other virtual reality-based psychotherapies.
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Affiliation(s)
- Elischa Augustin
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Mélissa Beaudoin
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Sabrina Giguère
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- School of Social Work, Faculty of Arts and Sciences, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Hind Ziady
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | | | - Alexandre Dumais
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- Services et Recherches Psychiatriques AD, Montreal, QC H1N 3V2, Canada;
- Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, QC H1C 1H1, Canada
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Kitagawa K, Uekusa S, Hanai Y, Kimura I, Tsukahara M, Kagawa A, Sasaoka K, Sakishiro Y, Miyake A, Watanabe Y, Baba D, Kodama M, Kishi Y, Yamada N, Yoshio T, Matsuo K. Changes in psychopharmacotherapy for patients with schizophrenia in a psychiatric institution in Japan: A 12-year prescription survey pre- and post-introduction of clozapine. Asian J Psychiatr 2024; 96:104047. [PMID: 38640549 DOI: 10.1016/j.ajp.2024.104047] [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: 12/15/2023] [Revised: 04/03/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024]
Abstract
Psychopharmacotherapy for patients with schizophrenia in Japan has a long history of polypharmacy, which is rare worldwide but remains a critical problem. One reason for this is that clozapine was not available in Japan until 2009. We aimed to investigate the changes in psychopharmacotherapy in patients with schizophrenia over 12 years pre- and post-introduction of clozapine to clarify how psychopharmacotherapy for patients with schizophrenia has changed with the introduction of clozapine. We retrospectively collected data from the medical records of inpatients diagnosed with schizophrenia at the Okayama Psychiatric Medical Center. Chlorpromazine equivalent (CP-eq) decreased from 1276.6 mg/day in 2009 to 613.9 mg/day in 2020. The prescribed daily dose/defined daily dose (PDD/DDD) decreased from 3.0 in 2009 to 1.2 in 2020. The monotherapy rate increased from 24.4 % in 2009 to 74.6 % in 2020. Our institution began using clozapine in 2010, and the prescription rate for clozapine increased to 37.3 % in 2020. The prescription rate for more than three antipsychotics decreased from 27.8 % in 2009 to 0.8 % in 2020. The increase in clozapine prescription has contributed to an increased rate of antipsychotic monotherapy and a decreased rate of polypharmacy, promoting the optimization of schizophrenia medication. Clozapine therapy should be further promoted in Japan to reduce treatment-resistant schizophrenia due to polypharmacy as much as possible.
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Affiliation(s)
- Kohei Kitagawa
- Department of Clinical Research, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Shusuke Uekusa
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Japan.
| | - Yuki Hanai
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Japan
| | - Itsuki Kimura
- Department of Pharmacy, Toho University Omori Medical Center, Ota, Japan
| | - Masaru Tsukahara
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Azusa Kagawa
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Kenji Sasaoka
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Yui Sakishiro
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Ayaka Miyake
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Yuki Watanabe
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Daiki Baba
- Department of Pharmacy, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Masafumi Kodama
- Department of Clinical Research, Okayama Psychiatric Medical Center, Okayama, Japan; Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Yoshiki Kishi
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Takashi Yoshio
- Sumiyoshikaiseikai Sumiyoshi Hospital Yamanashi, Japan; Department of Hospital Pharmaceutics, Faculty of Pharmaceutical Sciences, Showa University, Shinagawa, Japan
| | - Kazuhiro Matsuo
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, Funabashi, Japan
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Faden J, Citrome L. A systematic review of clozapine for aggression and violence in patients with schizophrenia or schizoaffective disorder. Schizophr Res 2024; 268:265-281. [PMID: 38290941 DOI: 10.1016/j.schres.2023.11.008] [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: 10/01/2023] [Revised: 10/26/2023] [Accepted: 11/19/2023] [Indexed: 02/01/2024]
Abstract
Although uncommon, the risk of aggression and violence is greater in people with schizophrenia than in the general population. Clozapine is the "gold standard" pharmacologic treatment for the management of persistent agitation and aggression in people with schizophrenia and is consistently recommended by guidelines and reviews for this purpose. Although clozapine is indicated for treatment-resistant schizophrenia based on its superior efficacy, studies have proposed that clozapine may have specific properties that ameliorate aggression and hostility that are distinct from its antipsychotic effects. A literature review was conducted on June 3, 2023, using the US National Library of Medicine's PubMed resource to identify articles focusing on clozapine for the treatment of aggression, violence, and/or hostility in patients with schizophrenia or schizoaffective disorder. The majority of evidence, including from randomized control trials, supports the utilization of clozapine as maintenance treatment for persistent aggressive behavior in patients with schizophrenia, and supports that its anti-aggressive effects may be independent from its antipsychotic properties (e.g. - treatment of hallucinations and delusions). Future randomized control studies evaluating clozapine and clozapine serum levels with aggression as the primary outcome would be of benefit.
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Affiliation(s)
- Justin Faden
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America.
| | - Leslie Citrome
- New York Medical College, Valhalla, NY, United States of America
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9
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Yang Z, Takeuchi H, Yee JY, See YM, Tang C, Ng BT, Lee J. Once-daily versus divided dosing regimens of clozapine: A cross-sectional study in Singapore. Schizophr Res 2024; 268:66-73. [PMID: 37833207 DOI: 10.1016/j.schres.2023.10.001] [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: 05/30/2023] [Revised: 09/12/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Clozapine is recognized as the gold standard medication for treatment-resistant schizophrenia. Despite the general recommendation of administering in a divided dosing regimen, clozapine is often prescribed once daily at night in clinical practice. This study aims to compare patient characteristics, psychiatric symptoms, side effects, and plasma concentration of clozapine between once-daily dosing and divided dosing regimens. METHODS This cross-sectional study included 159 participants with treatment-resistant schizophrenia or schizoaffective disorder. Participant's demographic information, anthropometric data, and medical history were collected. Their psychiatric symptoms, cognition, functioning, and side effects were evaluated. RESULTS Once-daily dosing regimen was associated with younger age and competitive employment. Lower clinical symptom severity, better functioning and cognitive performance were observed in the once-daily dosing group. Lower daily dose of clozapine, trough plasma concentrations of clozapine and norclozapine were also significantly associated with once-daily dosing regimen. CONCLUSION The study results support once-daily dosing of clozapine as a viable option to selected patients in clinical practice, as no association of severe symptoms or side effects were associated with once-daily dosing regimen. More studies are needed to examine the relationship between clinical outcomes and clozapine dosing regimen.
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Affiliation(s)
- Zixu Yang
- Research Division, Institute of Mental Health, Singapore
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Japan
| | - Jie Yin Yee
- Research Division, Institute of Mental Health, Singapore
| | - Yuen Mei See
- Research Division, Institute of Mental Health, Singapore
| | - Charmaine Tang
- Department of Psychosis, Institute of Mental Health, Singapore
| | - Boon Tat Ng
- Department of Pharmacy, Institute of Mental Health, Singapore
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
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10
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Zhong M, Liu Z, Wang F, Yang J, Chen E, Lee E, Wu G, Yang J. Effects of long-term antipsychotic medication on brain instability in first-episode schizophrenia patients: a resting-state fMRI study. Front Pharmacol 2024; 15:1387123. [PMID: 38846088 PMCID: PMC11153814 DOI: 10.3389/fphar.2024.1387123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/02/2024] [Indexed: 06/09/2024] Open
Abstract
Early initiation of antipsychotic treatment plays a crucial role in the management of first-episode schizophrenia (FES) patients, significantly improving their prognosis. However, limited attention has been given to the long-term effects of antipsychotic drug therapy on FES patients. In this research, we examined the changes in abnormal brain regions among FES patients undergoing long-term treatment using a dynamic perspective. A total of 98 participants were included in the data analysis, comprising 48 FES patients, 50 healthy controls, 22 patients completed a follow-up period of more than 6 months with qualified data. We processed resting-state fMRI data to calculate coefficient of variation of fractional amplitude of low-frequency fluctuations (CVfALFF), which reflects the brain regional activity stability. Data analysis was performed at baseline and after long-term treatment. We observed that compared with HCs, patients at baseline showed an elevated CVfALFF in the supramarginal gyrus (SMG), parahippocampal gyrus (PHG), caudate, orbital part of inferior frontal gyrus (IOG), insula, and inferior frontal gyrus (IFG). After long-term treatment, the instability in SMG, PHG, caudate, IOG, insula and inferior IFG have ameliorated. Additionally, there was a positive correlation between the decrease in dfALFF in the SMG and the reduction in the SANS total score following long-term treatment. In conclusion, FES patients exhibit unstable regional activity in widespread brain regions at baseline, which can be ameliorated with long-term treatment. Moreover, the extent of amelioration in SMG instability is associated with the amelioration of negative symptoms.
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Affiliation(s)
- Maoxing Zhong
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhening Liu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Feiwen Wang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jun Yang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Eric Chen
- Department of Psychiatry, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Edwin Lee
- Department of Psychiatry, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Guowei Wu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jie Yang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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11
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Kotov R, Carpenter WT, Cicero DC, Correll CU, Martin EA, Young JW, Zald DH, Jonas KG. Psychosis superspectrum II: neurobiology, treatment, and implications. Mol Psychiatry 2024; 29:1293-1309. [PMID: 38351173 DOI: 10.1038/s41380-024-02410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 02/16/2024]
Abstract
Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.
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Affiliation(s)
- Roman Kotov
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA.
| | | | - David C Cicero
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Elizabeth A Martin
- Department of Psychological Science, University of California, Irvine, Irvine, CA, USA
| | - Jared W Young
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA
| | - David H Zald
- Rutgers University, The State University of New Jersey, New Brunswick, NJ, USA
| | - Katherine G Jonas
- Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA
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12
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Korkmaz ŞA, Koca E, Yilmaz Ö, Özbek T, Güçlü MA, Kizgin S. Real-World Evidence of Antipsychotic Monotherapy Versus Polypharmacy in the Treatment of Schizophrenia Spectrum Disorders. J Clin Psychopharmacol 2024; 44:250-257. [PMID: 38489589 DOI: 10.1097/jcp.0000000000001837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
PURPOSE/BACKGROUND It is still not well known whether antipsychotic monotherapy versus polypharmacy differs in terms of efficacy in the emergency department (ED) utilization, presentation with agitation/aggression, and rehospitalization in schizophrenia spectrum disorders (SSD) patients. This study aimed to determine the effectiveness of antipsychotic monotherapy and polypharmacy for these outcomes in the real world. METHODS/PROCEDURES The study was conducted with electronic health records of 669 SSD patients admitted to the ED. Patients were evaluated in 4 groups according to antipsychotic use at the first admission to ED: antipsychotic noncompliance for more than 90 days, antipsychotic noncompliance for 15 to 90 days, antipsychotic monotherapy, and polypharmacy. All patients followed up for at least 1 year after index admission. The primary outcomes determined an association between antipsychotic monotherapy versus polypharmacy and all-cause psychiatric hospitalization between the groups after index admission in the SSD. FINDINGS/RESULTS The groups, including patients with antipsychotic noncompliance, had higher ED visits, more hospitalizations, and more admissions with agitation/aggression compared with antipsychotic monotherapy or polypharmacy. However, no differences were found between monotherapy and polypharmacy groups regarding these outcomes. In addition, there was no difference in the risk of hospitalization in monotherapy antipsychotic users compared with polypharmacy users. Patients discharged with monotherapy or polypharmacy also had similar rehospitalization rates at follow-up. IMPLICATIONS/CONCLUSIONS There is no positive evidence that recommending polypharmacy over antipsychotic monotherapy is superior with regard to the resulting frequency of ED visits, ED admissions with agitation/aggression, hospitalization, and rehospitalization. In this context, antipsychotic monotherapy may be preferred over polypharmacy in patients who are not resistant to treatment.
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Affiliation(s)
- Şükrü Alperen Korkmaz
- From the Department of Psychiatry, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Esra Koca
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Özge Yilmaz
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Tayfun Özbek
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | | | - Sadice Kizgin
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
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13
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Bartel RL, Knight JR, Worsham W, Bilder DA. Discordance Between Psychiatric Diagnoses and Medication Use in Children and Adults With Autism Presenting in Crisis. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:150-161. [PMID: 38680982 PMCID: PMC11046722 DOI: 10.1176/appi.focus.20230027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Autistic individuals experience high rates of behavioral crises that present to healthcare providers for medication management. Co-occurring psychiatric conditions and psychotropic medication use are common among this patient population. Particularly for those with limited expressive language, evaluating for the presence of psychiatric and medical conditions that could contribute to distress is a critical component of crisis management. A records review study was completed on 126 autistic individuals for whom medical decision-making support was requested from The Huntsman Mental Health Institute Neurobehavior Consultation Service. Crisis manifestations and historical information were provided by the parent or caregiver through an online questionnaire. Nearly all individuals presented with behavioral (96.8%) and emotional (96.8%) symptoms; 97.6% received at least one co-occurring psychiatric diagnosis. Additionally, 75.4% of parents or caregivers endorsed the presence of a medical condition that they believed could be contributing to the crisis presentation. Most individuals (92.1%) were prescribed at least one psychotropic medication; 69.8% were taking an antipsychotic, suggesting a history of treatment resistance. The alignment between psychotropic medications and psychiatric diagnoses was evaluated in the context of prior studies and reviews on psychiatric management in autistic and neurotypical populations. Several individuals were taking a combination of medications that included both indicated and contraindicated medications for the psychiatric disorder diagnosed, likely contributing to treatment resistance. Identifying discordance between psychotropic medication use and psychiatric conditions present offers an opportunity to pursue better treatment outcomes for autistic individuals, particularly for those experiencing treatment-resistant agitation.
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Affiliation(s)
- Roxanne L Bartel
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Jacob R Knight
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Whitney Worsham
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
| | - Deborah A Bilder
- Department of Psychiatry, Huntsman Mental Health Institute (Bartel, Bilder); and School of Medicine (Knight), University of Utah, Salt Lake City; Department of Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire (Worsham)
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14
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NISHIMURA YUKO, YOTSUMOTO KAYANO, HASHIMOTO TAKESHI. Impacts of a Self-directed Social Resources Study Program on Negative Symptoms and Quality of Life in Schizophrenia Outpatients: A Randomized Controlled Trial. THE KOBE JOURNAL OF MEDICAL SCIENCES 2024; 70:E15-E21. [PMID: 38644296 PMCID: PMC11086633 DOI: 10.24546/0100488377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/09/2024] [Indexed: 04/23/2024]
Abstract
To clarify whether a self-directed study program on social resources improves negative symptoms, quality of life (QOL), and social participation among outpatients with schizophrenia. Eighty-six participants were randomly divided into intervention and control groups. In addition to the usual day programs, the intervention group participated in a self-directed study program on social resources once a week for eight weeks. The control group participated only in the usual day programs. Negative symptoms and QOL were assessed at baseline and post-intervention using the Positive and Negative Syndrome Scale (PANSS) and the WHO Quality of Life-BREF (WHOQOL-BREF), respectively. Social participation was also assessed. After the intervention, there were no significant differences in the PANSS negative symptoms and WHOQOL-BREF total scores between the two groups. Within-group, PANSS negative symptom scores significantly improved in the intervention group (p < 0.05), but not in the control group. The WHOQOL-BREF physical health subscale scores improved significantly only in the intervention group (p < 0.05). Social participation remained unchanged between the intervention and control groups. The results suggest that a self-directed study program on social resources may be useful for improving negative symptoms and physical QOL in outpatients with schizophrenia. The findings highlight the potential of such interventions to bridge the existing gap in psychosocial rehabilitation strategies for this population.
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Affiliation(s)
- YUKO NISHIMURA
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
- Department of Psychiatry and Neurology, Kobe University Hospital, Kobe, Japan
| | - KAYANO YOTSUMOTO
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - TAKESHI HASHIMOTO
- Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Kobe, Japan
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15
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Kawamata Y, Sugawara N, Sasaki T, Yokoyama S, Okayasu H, Shinozaki M, Takeuchi Y, Sato A, Ishikawa T, Komahashi‐Sasaki H, Miyazaki K, Fukasawa T, Furukori H, Yasui‐Furukori N. Factors associated with the initiation of laxative use in the same patients with schizophrenia over a 20-year period: Retrospective cohort study. Neuropsychopharmacol Rep 2024; 44:60-66. [PMID: 37698084 PMCID: PMC10932797 DOI: 10.1002/npr2.12378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Constipation is a common adverse effect of antipsychotics, but little investigation has been conducted. We aimed to address the factors associated with the initiation of laxative use in the same patients with schizophrenia over a 20-year period. METHODS We enrolled patients with schizophrenia attending each hospital (n = 14) from April 1, 2021, and retrospectively examined all prescriptions as of April 1, 2016, 2011, 2006, and 2001, every 5 years starting in 2021, for this population. 716 participants with complete data were included in the analysis. The Cochran Q test followed by Bonferroni correction and the Cochran-Armitage trend test were used to determine the differences and trends of the frequency of each laxative. Multivariate logistic regression analysis was performed to assess the factors on the initiation of laxative use over a 20-year period. RESULTS Of the patients, 25.1% were treated with laxatives in 2001, and 34.1% were treated in 2021. The numbers of patients treated with any laxatives significantly differed over the 20-year period, with a significant increasing trend. In all laxatives, the numbers of patients treated with magnesium oxide, lubiprostone and elobixibat differed with a significant increasing trend. Female sex, age, the total DZP equivalent dose, and the doses of levomepromazine maleate, olanzapine, quetiapine, zotepine, lithium, and carbamazepine in 2021 were significant factors associated with the initiation of laxative use over the 20-year period. CONCLUSIONS Careful monitoring is needed for patients treated with levomepromazine maleate, olanzapine, quetiapine and zotepine. Optimizing prescriptions according to treatment guidelines could reduce antipsychotic-induced constipation.
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Affiliation(s)
- Yasushi Kawamata
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryKikuchi HospitalTochigiJapan
| | - Norio Sugawara
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryTMC ShimotsugaTochigiJapan
| | - Taro Sasaki
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryAsahi HospitalTochigiJapan
| | - Saaya Yokoyama
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryAoki HospitalTochigiJapan
| | - Hiroaki Okayasu
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryFudogaoka HospitalSaitamaJapan
| | - Masataka Shinozaki
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryTakizawa HospitalTochigiJapan
| | - Yoshitaka Takeuchi
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryOkamotodai HospitalTochigiJapan
| | - Aoi Sato
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryMuroi HospitalTochigiJapan
| | - Takaaki Ishikawa
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatrySaitama‐Konan HospitalSaitamaJapan
| | - Hazuki Komahashi‐Sasaki
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryKanuma HospitalTochigiJapan
| | - Kensuke Miyazaki
- Department of NeuropsychiatryHirosaki‐Aiseikai HospitalAomoriJapan
| | | | - Hanako Furukori
- Department of NeuropsychiatryKuroichi‐Akebono HospitalAomoriJapan
| | - Norio Yasui‐Furukori
- Department of Psychiatry, School of MedicineDokkyo Medical UniversityTochigiJapan
- Department of PsychiatryTMC ShimotsugaTochigiJapan
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Kang N, Yoon HS, Kim SH, Jeong JH, Kim M, Kwon JS. Comparative Study of the Efficacy and Side Effects of Brand-Name and Generic Clozapine for Long-Term Maintenance Treatment Among Korean Patients With Schizophrenia: A Retrospective Naturalistic Mirror-Image Study. Psychiatry Investig 2024; 21:311-320. [PMID: 38569589 PMCID: PMC10990625 DOI: 10.30773/pi.2023.0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/01/2024] [Accepted: 01/17/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Clozapine is considered the most reliable drug for treatment-resistant schizophrenia. In 2014, a generic formulation of clozapine (Clzapine) was introduced in Korea. This study was performed to provide clinical information regarding the use of clozapine and to compare efficacy and tolerability when converting from the brand-name formulation (Clozaril) to the generic formulation during longterm maintenance treatment among Korean patients with schizophrenia. METHODS This mirror-image study retrospectively investigated the electronic medical records of patients who had switched from Clozaril to Clzapine with a ≥1-year duration for each formulation. Clinical data were collected, including information regarding clozapine use, psychiatric hospitalization, co-medications, and blood test findings. Data before and after the switch were compared using paired t-tests. RESULTS Among 332 patients, the mean 1-year dosages were 233.32±149.35 mg/day for Clozaril and 217.36±136.66 mg/day for Clzapine. The mean clozapine concentration-to-dose ratios were similar before and after the switch (Clozaril, 1.33±0.68; Clzapine, 1.26±0.80). Switching from Clozaril to Clzapine resulted in no significant differences in the hospitalization rate, hospitalization duration, or laboratory findings (liver function parameters, serum cholesterol level, and serum glucose level). Equivalent doses of co-prescribed antidepressants were decreased, but concomitant medications otherwise showed no significant differences. CONCLUSION Clinical efficacy and tolerability appear comparable when switching to Clzapine during clozapine maintenance treatment. This study offers descriptive real-world clinical insights into clozapine maintenance treatment in Korea, thereby providing patients with more treatment options and contributing to the development of maintenance guidelines tailored to the Korean population.
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Affiliation(s)
- Nuree Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Yoon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Hoon Jeong
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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17
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Smessaert S, Detraux J, Desplenter F, De Hert M. Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review. CNS Drugs 2024; 38:105-123. [PMID: 38236524 DOI: 10.1007/s40263-023-01054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects. METHODS A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality. RESULTS Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%). CONCLUSIONS Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines. REGISTRATION PROSPERO registration number, CRD42023402480.
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Affiliation(s)
- Sarah Smessaert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium.
| | - Johan Detraux
- Department of Biomedical Sciences, Research Group Psychiatry, University Psychiatric Center KU Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
| | - Franciska Desplenter
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Marc De Hert
- University Psychiatric Center Katholieke Universiteit Leuven, Leuvensesteenweg 517, 3070, Kortenberg, Belgium
- Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
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18
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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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19
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Mohammad-Gholizad F, Karimzadeh I, Moghimi-Sarani E, Arshadi M, Mortazavi N. Evaluation and Comparison of the Effectiveness of Atropine Eye Drops, Ipratropium Bromide Nasal Spray, and Amitriptyline Tablet in the Management of Clozapine-Associated Sialorrhea in Patients With Refractory Schizophrenia: A Randomized Clinical Trial. J Clin Psychopharmacol 2024; 44:9-15. [PMID: 38100776 DOI: 10.1097/jcp.0000000000001786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
PURPOSE Clozapine, a second-generation antipsychotic medication, is mainly indicated for managing treatment-resistant schizophrenia. Among all the nonthreatening adverse effects of clozapine, sialorrhea is a stigmatizing complication occurring in approximately 31.0% to 97.4% of patients. In this study, 2 topical agents (atropine eye drop and ipratropium nasal spray) and a systemic medication (amitriptyline) were compared simultaneously for the management of clozapine-associated sialorrhea. METHODS We conducted a randomized, single-blinded, non-placebo-controlled clinical trial from June 2022 to January 2023. Eligible patients were randomly allocated into 3 mentioned groups. Patients were monitored for sialorrhea weekly based on scales, including the Toronto Nocturnal Hypersalivation Scale, Clinical Global Impression-Improvement, and Clinical Global Impression-Severity for 1 month. Possible adverse drug reactions and adherence were also recorded. RESULTS Twenty-four patients, including 6, 10, and 8 individuals in ipratropium bromide nasal spray, atropine eye drop, and amitriptyline groups, completed the study, respectively. The cohort's demographic, baseline clinical, and sociocultural characteristics were comparable among the 3 groups. Within-group comparisons, between times baseline and week 4, demonstrated that significant differences were in groups atropine and amitriptyline based on Toronto Nocturnal Hypersalivation Scale, in 3 groups based on Clinical Global Impression-Improvement, and also in only-atropine group based on Clinical Global Impression-Severity. Likewise, between-group comparisons showed that atropine was significantly more effective in clozapine-associated sialorrhea management than amitriptyline and ipratropium, in the first 2 weeks and second 2 weeks of study, respectively. Regarding safety, the interventions were tolerated relatively well. CONCLUSIONS Conclusively, atropine is more efficacious than amitriptyline, within the first 2 weeks of study and also relative to ipratropium, overall. As time effect was significant between atropine and amitriptyline, according to analysis of covariance test, further investigation with longer follow-up duration would be prudent. In addition, expanding patient population with larger sample size should be conducted for more precision.
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Affiliation(s)
| | - Iman Karimzadeh
- From the Department of Clinical Pharmacy, School of Pharmacy
| | - Ebrahim Moghimi-Sarani
- Department of Psychiatry, Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Arshadi
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Negar Mortazavi
- From the Department of Clinical Pharmacy, School of Pharmacy
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Opler MGA, Claxton A, McGrory J, Gasper S, Wang M, Yagoda S. Functioning and Cognition in Patients with Schizophrenia After Initiating Treatment with Aripiprazole Lauroxil: Secondary Outcomes and Post Hoc Analysis. INNOVATIONS IN CLINICAL NEUROSCIENCE 2024; 21:43-51. [PMID: 38495608 PMCID: PMC10941858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background Clinical practice guidelines support efforts to improve functioning in patients with schizophrenia. Discrepancies in the perception of cognitive status between clinicians, patients with schizophrenia, and their caregivers have been associated with impaired functional abilities in patients; medication side effects might worsen both cognition and daily functioning. We assessed daily/social functioning and cognition in stable patients with schizophrenia who switched to the long-acting injectable (LAI) antipsychotic aripiprazole lauroxil (AL). Methods Clinically stable adults with residual symptoms of schizophrenia or intolerance following three or more doses of paliperidone palmitate or risperidone LAI were switched to flexibly dosed open-label AL treatment (441mg, 662mg, or 882mg every 4 weeks or 882mg every 6 weeks) for six months (ClinicalTrials.gov identifier: NCT02634320). Daily/social functioning was assessed using the Personal and Social Performance Scale (PSP); total and subscale scores were summarized using descriptive statistics. The cognitive status of patients was assessed using the New York Assessment of Adverse Cognitive Effects of Neuropsychiatric Treatment (NY-AACENT) at baseline and Month 6 or early termination, providing patient, caregiver, and clinician perspectives. A post hoc analysis assessed level of agreement in ratings of cognitive status among respondents, evaluated at baseline and last assessment, using weighted kappa coefficients (0.01-0.20, slight agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, substantial agreement.). Results All 51 enrolled patients received one or more AL doses; 35 completed the study, and 45 contributed data at last assessment. Mean age was 40.6 years; 72.5 percent of patients were male. Based on PSP total score, functioning was maintained from baseline (mean [standard deviation (SD)]: 55.1 [10.5]) through six months of AL treatment (mean [SD]: 57.7 [13.2]). Proportions of patients rating personal and social functioning issues as "not present" or "mild" remained stable between baseline and Month 6 for each PSP subscale. At baseline (n=50), cognitive difficulties were most commonly rated "not present" or "mild" in all NY-AACENT domains by patients (58-86% across domains), clinicians (62-94%), and caregivers (50-92%), and these rates were maintained or increased at last assessment for all reporters. Weighted kappa coefficients indicated fair-to-substantial agreement between patients and clinicians across domains at last assessment (0.32-0.64; baseline: 0.14-0.55); patient-caregiver agreement ranged from 0.07 to 0.50 at last assessment (baseline: 0.25-0.60). Conclusion In clinically stable patients with schizophrenia who initiated AL, self-reported functioning was maintained over six months of treatment. Clinician-, caregiver-, and patient-reported cognitive function was stable at baseline and maintained in all NY-AACENT domains; patient-clinician agreement on level of cognitive impairment increased over six months of treatment with AL.
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Affiliation(s)
| | - Amy Claxton
- Drs. Claxton, McGrory, Wang, and Yagoda and Ms. Gasper are with Alkermes, Inc. in Waltham, Massachusetts
- Drs. Claxton and Wang and Ms. Gasper were employees of Alkermes, Inc. at the time of the study
| | - James McGrory
- Drs. Claxton, McGrory, Wang, and Yagoda and Ms. Gasper are with Alkermes, Inc. in Waltham, Massachusetts
| | - Sabina Gasper
- Drs. Claxton, McGrory, Wang, and Yagoda and Ms. Gasper are with Alkermes, Inc. in Waltham, Massachusetts
- Drs. Claxton and Wang and Ms. Gasper were employees of Alkermes, Inc. at the time of the study
| | - Meihua Wang
- Drs. Claxton, McGrory, Wang, and Yagoda and Ms. Gasper are with Alkermes, Inc. in Waltham, Massachusetts
- Drs. Claxton and Wang and Ms. Gasper were employees of Alkermes, Inc. at the time of the study
| | - Sergey Yagoda
- Drs. Claxton, McGrory, Wang, and Yagoda and Ms. Gasper are with Alkermes, Inc. in Waltham, Massachusetts
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21
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Amerio A, Magnani L, Arduino G, Fesce F, de Filippis R, Parise A, Costanza A, Nguyen KD, Saverino D, De Berardis D, Aguglia A, Escelsior A, Serafini G, De Fazio P, Amore M. Immunomodulatory Effects of Clozapine: More Than Just a Side Effect in Schizophrenia. Curr Neuropharmacol 2024; 22:1233-1247. [PMID: 38031778 PMCID: PMC10964093 DOI: 10.2174/1570159x22666231128101725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 12/01/2023] Open
Abstract
Recent evidence suggests a possible relationship between the immune system and schizophrenia spectrum disorders (SSDs), as neuroinflammation appears to play a role in major psychiatric conditions. Neuroinflammation is as a broad concept representing a physiological protective response to infection or injury, but in some cases, especially if chronic, it may represent an expression of maladaptive processes, potentially driving to clinical dysfunction and neurodegeneration. Several studies are concurrently highlighting the importance of microglia, the resident immune cells of the central nervous system, in a huge number of neurodegenerative diseases, including multiple sclerosis, Alzheimer's and Parkinson's diseases, as well as SSDs. A more fundamental phenomenon of maladaptive coupling of microglia may contribute to the genesis of dysfunctional brain inflammation involved in SSDs, from the onset of their neurophenomenological evolution. Clozapine and other antipsychotic drugs seem to express a provable immunomodulant effect and a more specific action on microglia, while neuroactive steroids and nonsteroidal anti-inflammatory drugs may reduce some SSDs symptoms in add-on therapy. Given these theoretical premises, this article aims to summarize and interpret the available scientific evidence about psychotropic and anti-inflammatory drugs that could express an immunomodulant activity on microglia.
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Affiliation(s)
- Andrea Amerio
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Magnani
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Gabriele Arduino
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Fabio Fesce
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Alberto Parise
- Department of Geriatric-Rehabilitation,, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland
- Department of Psychiatry, Faculty of Biomedical Sciences, University of Italian Switzerland (USI) Lugano, Switzerland
| | - Khoa D. Nguyen
- Department of Microbiology and Immunology, Stanford University, Palo Alto, CA, USA
- Tranquis Therapeutics, Palo Alto, CA, USA
| | - Daniele Saverino
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DiMeS), Section of Human Anatomy, University of Genoa, Genoa, Italy
| | - Domenico De Berardis
- NHS, Department of Mental Health, Psychiatric Service for Diagnosis and Treatment, Hospital “G. Mazzini”, Teramo, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Escelsior
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluca Serafini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Mario Amore
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI),
Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Kolli P, Kelley G, Rosales M, Faden J, Serdenes R. Olanzapine Pharmacokinetics: A Clinical Review of Current Insights and Remaining Questions. Pharmgenomics Pers Med 2023; 16:1097-1108. [PMID: 38146514 PMCID: PMC10749543 DOI: 10.2147/pgpm.s391401] [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: 08/01/2023] [Accepted: 11/30/2023] [Indexed: 12/27/2023] Open
Abstract
Olanzapine is one of the most widely used antipsychotics since its initial approval by the US Food and Drug Administration in 1996 and has undergone extensive pharmacokinetic study. Despite being utilized in clinical psychiatry for decades, there remain questions regarding the variety of available formulations, the utility of therapeutic drug monitoring, altered kinetic properties in special populations/medical illnesses, the use of high-dose olanzapine, and drug interactions, among many others. We performed a narrative literature review of olanzapine pharmacokinetics in June 2023 using the US National Library of Medicine's PubMed.gov resource (https://www.ncbi.nlm.nih.gov/pubmed) and Google Scholar. Herein, we review clinically relevant aspects of olanzapine pharmacokinetic data while highlighting knowledge gaps and potential areas of future study.
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Affiliation(s)
- Priyanka Kolli
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Grace Kelley
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Marianela Rosales
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Justin Faden
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Ryan Serdenes
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
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23
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Ying J, Chew QH, Wang Y, Sim K. Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review. Brain Sci 2023; 14:6. [PMID: 38275511 PMCID: PMC10813099 DOI: 10.3390/brainsci14010006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.
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Affiliation(s)
- Jiangbo Ying
- East Region, Institute of Mental Health, Singapore 539747, Singapore
| | - Qian Hui Chew
- Research Division, Institute of Mental Health, Singapore 539747, Singapore
| | - Yuxi Wang
- East Region, Institute of Mental Health, Singapore 539747, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore 539747, Singapore
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24
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Falkai P, Rossner MJ, Raabe FJ, Wagner E, Keeser D, Maurus I, Roell L, Chang E, Seitz-Holland J, Schulze TG, Schmitt A. Disturbed Oligodendroglial Maturation Causes Cognitive Dysfunction in Schizophrenia: A New Hypothesis. Schizophr Bull 2023; 49:1614-1624. [PMID: 37163675 PMCID: PMC10686333 DOI: 10.1093/schbul/sbad065] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND AND HYPOTHESIS Cognitive impairment is a hallmark of schizophrenia, but no effective treatment is available to date. The underlying pathophysiology includes disconnectivity between hippocampal and prefrontal brain regions. Supporting evidence comes from diffusion-weighted imaging studies that suggest abnormal organization of frontotemporal white matter pathways in schizophrenia. STUDY DESIGN Here, we hypothesize that in schizophrenia, deficient maturation of oligodendrocyte precursor cells (OPCs) into mature oligodendrocytes substantially contributes to abnormal frontotemporal macro- and micro-connectivity and subsequent cognitive deficits. STUDY RESULTS Our postmortem studies indicate a reduced oligodendrocyte number in the cornu ammonis 4 (CA4) subregion of the hippocampus, and others have reported the same histopathological finding in the dorsolateral prefrontal cortex. Our series of studies on aerobic exercise training showed a volume increase in the hippocampus, specifically in the CA4 region, and improved cognition in individuals with schizophrenia. The cognitive effects were subsequently confirmed by meta-analyses. Cell-specific schizophrenia polygenic risk scores showed that exercise-induced CA4 volume increase significantly correlates with OPCs. From animal models, it is evident that early life stress and oligodendrocyte-related gene variants lead to schizophrenia-related behavior, cognitive deficits, impaired oligodendrocyte maturation, and reduced myelin thickness. CONCLUSIONS Based on these findings, we propose that pro-myelinating drugs (e.g., the histamine blocker clemastine) combined with aerobic exercise training may foster the regeneration of myelin plasticity as a basis for restoring frontotemporal connectivity and cognition in schizophrenia.
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Affiliation(s)
- Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
- Max-Planck-Institute of Psychiatry, Munich, Germany
| | - Moritz J Rossner
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Florian J Raabe
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Daniel Keeser
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
- NeuroImaging Core Unit Munich (NICUM), University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Isabel Maurus
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Lukas Roell
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
- NeuroImaging Core Unit Munich (NICUM), University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Emily Chang
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Johanna Seitz-Holland
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas G Schulze
- Institute for Psychiatric Phenomic and Genomic (IPPG), Munich, Germany
| | - Andrea Schmitt
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilian University, Munich, Germany
- Laboratory of Neuroscience (LIM27), Institute of Psychiatry, University of São Paulo (USP), São Paulo-SP, Brazil
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25
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Miley KM, Hooker SA, Crain AL, O'Connor PJ, Haapala JL, Bond DJ, Rossom RC. 30-year Cardiovascular Disease Risk for Young Adults with Serious Mental Illness. Gen Hosp Psychiatry 2023; 85:139-147. [PMID: 38487652 PMCID: PMC10936711 DOI: 10.1016/j.genhosppsych.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
Objective To estimate 30-year CVD risk and modifiable risk factors in young adults with serious mental illness (SMI) versus those without, and assess variations in CVD risk by race, ethnicity, and sex. Method In this cross-sectional study, we estimated and compared the Framingham 30-year CVD risk score and individual modifiable CVD risk factors in young adult (20-39 years) primary care patients with and without SMI at two US healthcare systems (January 2016-Septemeber 2018). Interaction terms assessed whether the SMI-risk association differed across demographic groups. Results Covariate-adjusted 30-year CVD risk was significantly higher for those with (n=4228) versus those without (n=155,363) SMI (RR 1.28, 95% CI [1.26, 1.30]). Patients with SMI had higher rates of hypertension (OR 2.02 [1.7, 2.39]), diabetes (OR 3.14 [2.59, 3.82]), obesity (OR 1.93 [1.8, 2.07]), and smoking (OR 4.94 [4.6, 5.36]). The increased 30-year CVD risk associated with SMI varied significantly by race and sex: there was an 8% higher risk in Black compared to White patients (RR 1.08, [1.04, 1.12]) and a 9% lower risk in men compared to women (RR 0.91 [0.88, 0.94]). Conclusions Young adults with SMI are at increased 30-year risk of CVD, and further disparities exist for Black individuals and women.
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Affiliation(s)
- Kathleen M Miley
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
- University of Minnesota Medical School. 420 Delaware St SE, Minneapolis, Minnesota, 55455, USA
| | - Stephanie A Hooker
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
- University of Minnesota Medical School. 420 Delaware St SE, Minneapolis, Minnesota, 55455, USA
| | - A Lauren Crain
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
| | - Patrick J O'Connor
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
- University of Minnesota Medical School. 420 Delaware St SE, Minneapolis, Minnesota, 55455, USA
| | - Jacob L Haapala
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
| | - David J Bond
- Johns Hopkins University, Department of Psychiatry and Behavioral Sciences. 600 N Wolfe St., Baltimore, Maryland 21205, USA
| | - Rebecca C Rossom
- HealthPartners Institute. 8170 33 Ave S., Minneapolis, Minnesota 55425, USA
- University of Minnesota Medical School. 420 Delaware St SE, Minneapolis, Minnesota, 55455, USA
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26
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Wang T, Codling D, Bhugra D, Msosa Y, Broadbent M, Patel R, Roberts A, McGuire P, Stewart R, Dobson R, Harland R. Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records. Schizophr Res 2023; 260:168-179. [PMID: 37669576 PMCID: PMC10881407 DOI: 10.1016/j.schres.2023.08.024] [Citation(s) in RCA: 1] [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] [Received: 04/01/2022] [Revised: 07/11/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors. METHODS This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription). RESULTS The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group. CONCLUSIONS Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.
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Affiliation(s)
- Tao Wang
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom.
| | - David Codling
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Dinesh Bhugra
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom
| | - Yamiko Msosa
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom
| | - Matthew Broadbent
- South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Rashmi Patel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Angus Roberts
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Philip McGuire
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Oxford Health, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Richard Dobson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom; Institute of Health Informatics, University College London, Euston Road, London NW1 2DA, United Kingdom; Health Data Research UK London, University College London, Euston Road, London NW1 2DA, United Kingdom
| | - Robert Harland
- South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
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27
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Jawad MY, Meshkat S, Tabassum A, Mckenzie A, Di Vincenzo JD, Guo Z, Musavi NB, Phan L, Ceban F, Kwan AT, Ramachandra R, Le GH, Mansur RB, Rosenblat JD, Ho R, Rhee TG, McIntyre RS. The bidirectional association of nonalcoholic fatty liver disease with depression, bipolar disorder, and schizophrenia. CNS Spectr 2023; 28:541-560. [PMID: 36268655 DOI: 10.1017/s1092852922001043] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a complex metabolic-inflammatory disease associated with poor outcomes and decreased quality of life. NAFLD is overrepresented in patients with psychiatric disorders like depression, bipolar disorder, and schizophrenia; however, a comprehensive review on NAFLD and psychiatric disorders remains to be delineated. This review endeavors to investigate the association of NAFLD with psychiatric disorders, including shared pathogenesis and future clinical derivatives. Extant literature suggests that patients with psychiatric disorders (in particular, mood disorders) are more susceptible to the development of NAFLD due to multiple reasons, including but not limited to hypothalamic-pituitary-adrenal axis dysregulation, metabolic syndrome, and chronic perceived stress. Moreover, the clinical manifestations of mood disorders (e.g., anhedonia, psychomotor retardation, lifestyle modification, etc.), and potentially long-term treatment with weight-gaining agents, differentially affect these patients, making them more prone to NAFLD. Considering the increased morbidity associated with both mood disorders and NAFLD, our review recommends regular screenings for NAFLD in select patients with mood disorders exhibiting signs of increased risk (i.e., obesity, metabolic syndrome, diabetes, or family history of NAFLD) for better diagnosis and holistic care of both potentially interrelated conditions.
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Affiliation(s)
- Muhammad Youshay Jawad
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Aniqa Tabassum
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Andrea Mckenzie
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Ziji Guo
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | | | - Lee Phan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Angela Th Kwan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ranuk Ramachandra
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Gia Han Le
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore, Singapore
| | - Taeho Greg Rhee
- Department of Psychiatry, School of Medicine, Yale University, New Haven, CT, USA
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT, USA
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
- Brain and Cognition Discovery Foundation, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
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Wagner E, Strube W, Görlitz T, Aksar A, Bauer I, Campana M, Moussiopoulou J, Hapfelmeier A, Wagner P, Egert-Schwender S, Bittner R, Eckstein K, Nenadić I, Kircher T, Langguth B, Meisenzahl E, Lambert M, Neff S, Malchow B, Falkai P, Hirjak D, Böttcher KT, Meyer-Lindenberg A, Blankenstein C, Leucht S, Hasan A. Effects of Early Clozapine Treatment on Remission Rates in Acute Schizophrenia (The EARLY Trial): Protocol of a Randomized-Controlled Multicentric Trial. PHARMACOPSYCHIATRY 2023; 56:169-181. [PMID: 37506738 PMCID: PMC10484642 DOI: 10.1055/a-2110-4259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 05/15/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Quick symptomatic remission after the onset of psychotic symptoms is critical in schizophrenia treatment, determining the subsequent disease course and recovery. In this context, only every second patient with acute schizophrenia achieves symptomatic remission within three months of initiating antipsychotic treatment. The potential indication extension of clozapine-the most effective antipsychotic-to be introduced at an earlier stage (before treatment-resistance) is supported by several lines of evidence, but respective clinical trials are lacking. METHODS Two hundred-twenty patients with acute non-treatment-resistant schizophrenia will be randomized in this double-blind, 8-week parallel-group multicentric trial to either clozapine or olanzapine. The primary endpoint is the number of patients in symptomatic remission at the end of week 8 according to international consensus criteria ('Andreasen criteria'). Secondary endpoints and other assessments comprise a comprehensive safety assessment (i. e., myocarditis screening), changes in psychopathology, global functioning, cognition, affective symptoms and quality of life, and patients' and relatives' views on treatment. DISCUSSION This multicentre trial aims to examine whether clozapine is more effective than a highly effective second-generation antipsychotics (SGAs), olanzapine, in acute schizophrenia patients who do not meet the criteria for treatment-naïve or treatment-resistant schizophrenia. Increasing the likelihood to achieve symptomatic remission in acute schizophrenia can improve the overall outcome, reduce disease-associated burden and potentially prevent mid- and long-term disease chronicity.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Wolfgang Strube
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Thomas Görlitz
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Aslihan Aksar
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Ingrid Bauer
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
| | - Mattia Campana
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Joanna Moussiopoulou
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of AI and Informatics in Medicine, School of Medicine,
Technical University of Munich, Munich, Germany
- Institute of General Practice and Health Services Research, School of
Medicine, Technical University of Munich, Munich, Germany
| | - Petra Wagner
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Silvia Egert-Schwender
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Robert Bittner
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy,
University Hospital Frankfurt, Frankfurt, Germany
| | - Kathrin Eckstein
- Clinic for Psychiatry and Psychotherapy, University of
Tübingen, Tübingen, Germany
| | - Igor Nenadić
- Department of Psychiatry and Psychotherapy, Philipps-University
Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, Philipps-University
Marburg, Marburg, Germany
| | - Berthold Langguth
- Department of Psychiatry and Psychotherapy, University of Regensburg,
Regensburg, Germany
| | - Eva Meisenzahl
- Department of Psychiatry and Psychotherapy, LVR-Klinikum
Düsseldorf, Kliniken der Heinrich-Heine-Universität
Düsseldorf, Düsseldorf, Germany
| | - Martin Lambert
- Department of Psychiatry and Psychotherapy, Centre for Psychosocial
Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg,
Germany
| | - Sigrid Neff
- Department of Psychiatry and Psychotherapy 1 und 2,
Rheinhessen-Fachklinik Alzey, Academic Hospital of the University of Mainz,
Alzey, Germany
| | - Berend Malchow
- Department of Psychiatry and Psychotherapy, University Medical Center
Göttingen, Göttingen, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, LMU University Hospital,
LMU Munich, Munich, Germany
| | - Dusan Hirjak
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Kent-Tjorben Böttcher
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental
Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim,
Germany
| | - Christiane Blankenstein
- Münchner Studienzentrum, Technical University of Munich, School
of Medicine, Munich, Germany
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of
Munich, School of Medicine, Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical
Faculty, University of Augsburg, Augsburg, Germany
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Wagner E, Siskind D, Falkai P, Howes O, Correll C, Lee J, Honer WG, Kane JM, Fernandez-Egea E, Barnes TRE, Hasan A. Clozapine Optimization: A Delphi Consensus Guideline From the Treatment Response and Resistance in Psychosis Working Group. Schizophr Bull 2023; 49:962-972. [PMID: 36943247 PMCID: PMC10318876 DOI: 10.1093/schbul/sbad030] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND HYPOTHESIS There is limited evidence to guide the approaches to clozapine treatment. Accordingly, an international initiative was undertaken with the aim of developing consensus recommendations for the optimization of clozapine monotherapy. STUDY DESIGN We conducted an online Delphi survey among members of the Treatment Response and Resistance in Psychosis (TRRIP) working group comprising experts from twenty-nine countries. The threshold criterion for a consensus recommendation was ≥ 75% agreement ("agree" and "strongly agree" responses) on a question. Agreement of ≥ 50% but < 75% in a second or third Delphi round was deemed to provide guidance. STUDY RESULTS Forty-nine (first round), 32 (second round), and 48 (third round) of the 91 current TRRIP members participated. Expert recommendations at ≥ 75% comprised second-line treatment with clozapine in cases of persistent positive symptoms with co-occurring extrapyramidal symptoms, tardive dyskinesia, or suicidality/aggression. There was considerable disagreement on myocarditis screening parameters. The management of somatic and neuropsychiatric adverse drug reactions warrants further research for more evidence-based recommendations. Rechallenge with clozapine was recommended for eosinophilia, sinus tachycardia and fever and guidance (agreement ≥ 50%) was reached for pneumonia and thrombocytopenia. CONCLUSIONS Given the limited evidence available, this consensus-based series of recommendations and guidance statements supports clinical decision-making to optimize clozapine monotherapy and provides guidance for future research in treatment-resistant schizophrenia.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Dan Siskind
- Department of Psychiatry, School of Medicine, University of Queensland, Brisbane, Australia
- Mobile Intensive Rehabilitation Team, Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Christoph Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin, Berlin, Germany
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore
- Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - William G Honer
- Department of Psychiatry, Institute of Mental Health, The University of British Columbia, Vancouver, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, Canada
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Institute for Behavioral Science, Feinstein Institute for Medical Research, Manhasset, NY, USA
- Departments of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emilio Fernandez-Egea
- Cambridge Psychosis Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, BKH Augsburg, Augsburg, Germany
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Hashimoto N, Yasui-Furukori N, Hasegawa N, Ishikawa S, Hori H, Iida H, Ichihashi K, Miura K, Matsumoto J, Numata S, Kodaka F, Furihata R, Ohi K, Ogasawara K, Iga JI, Muraoka H, Komatsu H, Takeshima M, Atake K, Kido M, Nakamura T, Kishimoto T, Hishimoto A, Onitsuka T, Okada T, Ochi S, Nagasawa T, Makinodan M, Yamada H, Tsuboi T, Yamada H, Inada K, Watanabe K, Hashimoto R. Change of prescription for patients with schizophrenia or major depressive disorder during admission: real-world prescribing surveys from the effectiveness of guidelines for dissemination and education psychiatric treatment project. BMC Psychiatry 2023; 23:473. [PMID: 37380997 DOI: 10.1186/s12888-023-04908-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/27/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Polypharmacy of additional psychotropics alongside the main treatment drug (antipsychotics in schizophrenia and antidepressants in major depressive disorder) is common in Japan. Our goal is to align psychotropic prescription in Japan with international standards, while reducing the differences between facilities. To achieve this goal, we aimed to compare prescriptions at the time of hospital admission and discharge. METHODS Data on prescriptions at admission and discharge from 2016 to 2020 were collected. We divided the patients into four groups: (1) mono_mono group, monotherapy of the main drug at admission and discharge; (2) mono_poly group, monotherapy at admission and polypharmacy at discharge; (3) poly_poly group, polypharmacy at admission and discharge; and (4) poly_mono group, polypharmacy at admission and monotherapy at discharge. We compared the changes in dosage and number of psychotropics among the four groups. RESULTS For both schizophrenia and major depressive disorder, the patients who received monotherapy with the main drug at admission were likely to receive main drug monotherapy at discharge and vice versa. For schizophrenia, the polypharmacy was prescribed more often in the mono_poly group than that in the mono_mono group. The prescription was not changed at all for more than 10% of the patients. CONCLUSIONS It is critical to avoid a polypharmacy regimen to ensure that guideline-compliant treatment is provided. We expect higher rates of monotherapy with the main drug after the EGUIDE lectures. TRIAL REGISTRATION The study protocol was registered in the University Hospital Medical Information Network Registry (UMIN000022645).
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Affiliation(s)
- Naoki Hashimoto
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, 321-0293, Shimotsuga, Tochigi, Japan.
| | - Naomi Hasegawa
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Shuhei Ishikawa
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Hikaru Hori
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hitoshi Iida
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kayo Ichihashi
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Kenichiro Miura
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Junya Matsumoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Shusuke Numata
- Department of Psychiatry, Graduate School of Biomedical Science, Tokushima University, Tokushima, Japan
| | - Fumitoshi Kodaka
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryuji Furihata
- Agency for Student Support and Disability Resources, Kyoto University, Kyoto, Japan
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuyoshi Ogasawara
- Center for Postgraduate Clinical Training and Career Development, Nagoya University Hospital, Nagoya, Japan
| | - Jun-Ichi Iga
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroyuki Muraoka
- Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Sendai, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Kiyokazu Atake
- Health Administration Center (Kyusyu region), Nippon Telegraph and Telephone West Corporation, Fukuoka, Japan
| | | | - Toshinori Nakamura
- Department of Psychiatry, Shinshu University School of Medicine, Matsumoto, Japan
| | - Taishiro Kishimoto
- Hills Joint Research Laboratory for Future Preventive Medicine and Wellness, Keio University School of Medicine, Tokyo, Japan
| | - Akitoyo Hishimoto
- Department of Psychiatry, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Tsuyoshi Okada
- Department of Psychiatry, Jichi Medical University, Shimotsuke, Japan
| | - Shinichiro Ochi
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tatsuya Nagasawa
- Department of NeuroPsychiatry, Kanazawa Medical University, Ishikawa, Japan
| | | | - Hiroki Yamada
- Department of Psychiatry, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Takashi Tsuboi
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Hisashi Yamada
- Department of Neuropsychiatry, Hyogo Medical University, Hyogo, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Ryota Hashimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
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Puranen A, Koponen M, Lähteenvuo M, Tanskanen A, Tiihonen J, Taipale H. Real-world effectiveness of antidepressant use in persons with schizophrenia: within-individual study of 61,889 subjects. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:34. [PMID: 37236980 DOI: 10.1038/s41537-023-00364-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
The aim of this study was to investigate the real-world effectiveness of antidepressant use in persons with schizophrenia. The register-based study cohort included all 61,889 persons treated in inpatient care due to schizophrenia during 1972-2014 in Finland. The main outcome was hospitalization due to psychosis and secondary outcomes included non-psychiatric hospitalization and all-cause mortality. We used within-individual design to compare the risk of hospitalization-based outcomes during the time periods of antidepressant use to antidepressant non-use periods within the same person, and traditional between-individual Cox models for mortality. The risk of psychosis hospitalization was lower during antidepressant use as compared to non-use (adjusted Hazard Ratio, aHR, 0.93, 95% CI 0.92-0.95). Antidepressants were associated with a decreased risk of mortality (aHR 0.80, 95% CI 0.76-0.85) and a slightly increased risk of non-psychiatric hospitalization (aHR 1.03, 95% CI 1.01-1.06). In conclusion, these results indicate that antidepressants might be useful and relatively safe to use in this population.
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Affiliation(s)
- Arto Puranen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | - Marjaana Koponen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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Tao Y, Wan R, Wang J, Liu Q, Tian M, Wang L, Yang Y, Zou Y, Luo Y, Ke F, Zhou Q, Wang D, Gao D. Carbonized human hair derived carbon dots for detection of clozapine. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 298:122803. [PMID: 37148662 DOI: 10.1016/j.saa.2023.122803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/27/2023] [Accepted: 04/26/2023] [Indexed: 05/08/2023]
Abstract
Clozapine (CLZ) is known as the most effective antipsychotic medication for schizophrenia. However, low dosage or over dosage of CLZ is adverse to the treatment of Schizophrenia. Thus, it is necessary to develop effective detection method for CLZ. Recently, due to the advantages such as excellent optical properties, good photobleachability and sensitivity, carbon dots (CDs)-based fluorescent sensors for the detection of target analytes have drawn a great deal of attention. In this work, blue fluorescent CDs (Named as B-CDs) with quantum yield (QY) as high as 38% were obtained by using carbonized human hair as source material through one-step dialysis method for the first time. B-CDs showed obvious graphite-like structure with an average of 1.76 nm, containing abundant functional groups such as -C=O, amino N and C-N on the surface of carbon cores. Optical analysis showed that the B-CDs exhibited excitation-dependent emission property with maximum emission wavelength of 450 nm. Moreover, B-CDs were further applied as a fluorescence sensor to the detection of CLZ. The B-CDs based sensor exhibited a good quenching response by CLZ through the inner filter effect and static quenching mechanism with a limit of detection of 67 ng/mL, which was much lower than the minimal effective concentration in blood (0.35 μg/mL). Finally, to test the practical application value of the developed fluorescence method, the determination of the content of CLZ in tablets and the concentration in blood was carried out. Compared with the results of high-performance liquid chromatography (HPLC) method, it can be found that the constructed fluorescence detection method showed high accuracy and had great application potential in the detection of CLZ. Additionally, the results of cytotoxicity experiment showed that B-CDs had low cytotoxicity, which laid the foundation for the subsequent application of B-CDs in biological systems.
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Affiliation(s)
- Yongqing Tao
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Runlan Wan
- School of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Junji Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Qiuyi Liu
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Meng Tian
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Luchun Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yulian Yang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yuemeng Zou
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yuanning Luo
- School of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Famin Ke
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Quan Zhou
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Dandan Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Die Gao
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan 646000, China.
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Abstract
PURPOSE OF REVIEW Insomnia is common in schizophrenia. Insomnia has been associated with suicidal ideation and behavior, as well as greater severity of psychopathology, in schizophrenia. This review performs a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia. RECENT FINDINGS We searched major electronic databases from inception until November 2022 for studies of insomnia, suicide, and psychopathology in patients with schizophrenia. Random effects meta-analysis calculating odds ratios (ORs, for suicide) and effect sizes (ESs, for psychopathology) and 95% confidence intervals (CIs) were performed. Ten studies met the inclusion criteria, comprising 3428 patients with schizophrenia. Insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28-2.65, P < 0.01) and suicide attempt or death (OR = 5.83, 95% CI 1.61-2.96, P < 0.01). Insomnia was also associated with total (ES = 0.16, 95% CI 0.09-0.23, P < 0.01), positive (ES = 0.14, 95% CI 0.08-0.20, P = 0.02), and general (ES = 0.17, 95% CI 0.08-0.27, P < 0.01) psychopathology. In meta-regression analyses, BMI was negatively associated with suicidal ideation. Otherwise, age, sex, and study year were all unrelated to the associations. SUMMARY Insomnia is associated with suicide and psychopathology in schizophrenia. Formal assessment and treatment of insomnia appears relevant to the clinical care of schizophrenia.
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Affiliation(s)
| | - William V McCall
- Medical College of Georgia, Augusta University
- Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia, USA
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White SA, Stone E, Murphy KA, Daumit GL, McGinty EE. Smoking Cessation Medication Prescribing for Smokers With and Without Mental Illness. Psychiatr Serv 2023; 74:332-340. [PMID: 36349496 PMCID: PMC10066821 DOI: 10.1176/appi.ps.202100690] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study examined trends in receipt of smoking cessation medications among smokers with and without mental illness, including serious mental illness, from 2005 to 2019 and characterized physician attitudes and practices related to tobacco screening and cessation treatment. METHODS Medical Expenditure Panel Survey (MEPS) data (2005-2019) were examined for receipt of cessation medication prescriptions for bupropion, varenicline, and nicotine replacement therapy (NRT) among 55,662 smokers-18,353 with any mental illness and 7,421 with serious mental illness. Qualitative interviews with 40 general internists and psychiatrists between October and November 2017 used a semistructured guide. MEPS data were analyzed with descriptive statistics, and interviews were analyzed with hybrid inductive-deductive coding. RESULTS From 2005 to 2019, at least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion. Over 14 years, the proportion of smokers receiving varenicline peaked at 2.1% among those with no mental illness, 2.9% among those with any mental illness, and 2.4% among those with serious mental illness. The respective peak proportions for NRT were 0.4%, 1.1%, and 1.6%; for bupropion, they were 1.2%, 8.4%, and 16.7%. Qualitative themes were consistent across general internists and psychiatrists; providers viewed cessation treatment as challenging because of the perception of smoking as a coping mechanism and agreed on barriers to treatment, including lack of insurance coverage and contraindications for people with mental illness. CONCLUSIONS System- and provider-level strategies to support evidence-based smoking cessation treatment for people with and without mental illness are needed.
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Affiliation(s)
- Sarah A White
- Department of Health Policy and Management (White, Stone, McGinty), Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins School of Medicine (Murphy, Daumit), Baltimore
| | - Elizabeth Stone
- Department of Health Policy and Management (White, Stone, McGinty), Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins School of Medicine (Murphy, Daumit), Baltimore
| | - Karly A Murphy
- Department of Health Policy and Management (White, Stone, McGinty), Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins School of Medicine (Murphy, Daumit), Baltimore
| | - Gail L Daumit
- Department of Health Policy and Management (White, Stone, McGinty), Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins School of Medicine (Murphy, Daumit), Baltimore
| | - Emma E McGinty
- Department of Health Policy and Management (White, Stone, McGinty), Johns Hopkins Bloomberg School of Public Health, and Division of General Internal Medicine, Johns Hopkins School of Medicine (Murphy, Daumit), Baltimore
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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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Tsukahara M, So R, Nakajima S, Kitagawa K, Kodama M, Takeuchi H. Longitudinal changes in clozapine dose in patients with treatment-resistant schizophrenia: a 5-year retrospective cohort study. Int Clin Psychopharmacol 2023; 38:96-101. [PMID: 36165515 DOI: 10.1097/yic.0000000000000429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This retrospective cohort study aimed to investigate the longitudinal changes in clozapine dose over a 5-year period in patients with treatment-resistant schizophrenia (TRS). Patients with TRS who were administered clozapine at a hospital between April 2012 and December 2016 and continued treatment with clozapine for at least 1 year were included. Clozapine doses were compared at the dose-fixation point, defined as when the same regimen of clozapine had been continued for 8 weeks or longer, and the post-dose-fixation phase, at 12, 36 and 60 months after clozapine initiation. We included 103 patients and found no significant differences in clozapine dose between the dose-fixation point and post-dose-fixation phase. Approximately half of the patients were categorized into an unchanged group at 12 months after clozapine initiation, whereas approximately 40% of patients were categorized into either the decreased or increased group at 60 months. Multivariable regression analysis revealed that the change in clozapine dose between the dose-fixation point and 60 months after clozapine initiation was negatively associated with clozapine dose at the dose-fixation point. On average, the clozapine dose was unchanged during long-term treatment in patients with TRS, although the dose was decreased or increased in approximately 40% of the patients.
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Affiliation(s)
- Masaru Tsukahara
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama
| | - Ryuhei So
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Kitagawa
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama
| | - Masafumi Kodama
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Chatterjee I, Chatterjee S. Investigating the symptomatic and morphological changes in the brain based on pre and post-treatment: A critical review from clinical to neuroimaging studies on schizophrenia. IBRO Neurosci Rep 2023. [DOI: 10.1016/j.ibneur.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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Lunghi C, Rochette L, Massamba V, Tardif I, Ouali A, Sirois C. Psychiatric and non-psychiatric polypharmacy among older adults with schizophrenia: Trends from a population-based study between 2000 and 2016. Front Pharmacol 2023; 14:1080073. [PMID: 36825148 PMCID: PMC9941679 DOI: 10.3389/fphar.2023.1080073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Abstract
Background: Schizophrenia is a severe psychiatric disorder associated with multiple psychiatric and non-psychiatric comorbidities. As adults with schizophrenia age, they may use many medications, i.e., have polypharmacy. While psychiatric polypharmacy is well documented, little is known about trends and patterns of global polypharmacy. This study aimed to draw a portrait of polypharmacy among older adults with schizophrenia from 2000 to 2016. Methods: This population-based cohort study was conducted using the data of the Quebec Integrated Chronic Disease Surveillance System of the National Institute of Public Health of Quebec to characterize recent trends and patterns of medication use according to age and sex. We identified all Quebec residents over 65 years with an ICD-9 or ICD-10 diagnosis of schizophrenia between 2000 and 2016. We calculated the total number of medications used by every individual each year and the age-standardized proportion of individuals with polypharmacy, as defined by the usage of 5+, 10+, 15+, and 20+ different medications yearly. We identified the clinical and socio-demographic factors associated with polypharmacy using robust Poisson regression models considering the correlation of the responses between subjects and analyzed trends in the prevalence of different degrees of polypharmacy. Results: From 2000 to 2016, the median number of medications consumed yearly rose from 8 in 2000 to 11 in 2016. The age-standardized proportion of people exposed to different degrees of polypharmacy also increased from 2000 to 2016: 5+ drugs: 76.6%-89.3%; 10+ drugs: 36.9%-62.2%; 15+: 13.3%-34.4%; 20+: 3.9%-14.4%. Non-antipsychotic drugs essentially drove the rise in polypharmacy since the number of antipsychotics remained stable (mean number of antipsychotics consumed: 1.51 in 2000 vs. 1.67 in 2016). In the multivariate regression, one of the main clinically significant factor associated with polypharmacy was the number of comorbidities (e.g., Polypharmacy-10+: RR[2 VS. 0-1] = 1.4; 99% IC:1.3-1.4, RR[3-4] = 1.7 (1.7-1.8); RR[5+] = 2.1 (2.1-2.2); Polypharmacy-15+: RR[2 VS 0-1] = 1.6; 99% IC:1.5-1.7, RR[3-4] = 2.5 (2.3-2.7); RR[5+] = 4.1 (3.8-4.5). Conclusion: There was a noticeable increase in polypharmacy exposure among older adults with schizophrenia in recent years, mainly driven by non-antipsychotic medications. This raises concerns about the growing risks for adverse effects and drug-drug interactions in this vulnerable population.
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Affiliation(s)
- Carlotta Lunghi
- Department of Health Sciences, Université du Québec à Rimouski, Lévis, QC, Canada,Population Health and Optimal Health Practices, CHU de Québec - Université Laval Research Center, Québec, QC, Canada,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy,Institut national de Santé Publique du Québec, Québec, QC, Canada,*Correspondence: Carlotta Lunghi, ,
| | - Louis Rochette
- Institut national de Santé Publique du Québec, Québec, QC, Canada
| | | | | | - Amina Ouali
- Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Caroline Sirois
- Population Health and Optimal Health Practices, CHU de Québec - Université Laval Research Center, Québec, QC, Canada,Institut national de Santé Publique du Québec, Québec, QC, Canada,Faculty of Pharmacy, Université Laval, Québec, QC, Canada,Quebec Excellence Centre on Aging, VITAM Research Centre on Sustainable Health, Québec, QC, Canada
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Predictors of full recovery in patients with early stage schizophrenia spectrum disorders. Psychiatry Res 2023; 320:115035. [PMID: 36584504 DOI: 10.1016/j.psychres.2022.115035] [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: 05/03/2022] [Revised: 12/20/2022] [Accepted: 12/25/2022] [Indexed: 12/28/2022]
Abstract
To promote recovery in psychosis, targeting modifiable factors related to recovery is critical. Using more strict definition of full recovery, we examined predictors for recovery in patients with early stage schizophrenia spectrum disorders (SSD) followed up to 6.5 years. The target subjects were 375 patients with early stage SSD who had been over at least 1-year after registration and evaluated. The criteria for full recovery were having the score of the Positive and Negative Syndrome Scale (PANSS) 8-item ≤ 2 and adequate functional recovery for at least 1-year. We performed univariate Cox and stepwise Cox regression in both total and acute patients. In stepwise Cox regression, several independent predictors for recovery, i.e., negative symptoms of the PANSS, duration of untreated psychosis (DUP) and non-professional job were identified in patients with early stage SSD. In acute patients, other factors such as professional job and subjective well-being under neuroleptics were more important. The present study identified independent predictors for recovery modifiable by various psychosocial intervention and early intervention services. Moreover, it highlights the need of providing different treatment strategies depending on clinical status.
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Lang X, Zang X, Yu F, Xiu M. Effects of low-dose combined olanzapine and sertraline on negative and depressive symptoms in treatment-resistant outpatients with acute exacerbated schizophrenia. Front Pharmacol 2023; 14:1166507. [PMID: 37153770 PMCID: PMC10160398 DOI: 10.3389/fphar.2023.1166507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Background: Treatment-resistant schizophrenia (TRS) is a major clinical challenge. Current antipsychotic medications do not adequately address negative and depressive symptoms in patients with TRS, and novel treatments are thus needed. This study examines the efficacy of low-dose combined olanzapine (OLA) and sertraline on depressive and negative symptoms in patients with TRS. Methods: A total of 34 TRS outpatients with acutely exacerbated schizophrenia were randomly assigned to OLA monotherapy (12.5-20 mg/day) (control group) or low-dose combined OLA (7.5-10 mg/day) and sertraline (50-100 mg/day) (OS group). Clinical symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of treatment in weeks 4, 8, 12, and 24. Depressive symptoms and social functioning were also assessed. Results: Compared to the control group, the OS group showed significant improvements in depressive and negative symptoms over time. In addition, the low-dose combination of OLA and sertraline significantly improved social functioning compared with OLA monotherapy. There were no significant between-group differences in psychotic symptom improvement. However, the reduction in Hamilton Depression Rating Scale total score and PANSS negative subscore were not associated with improvements in social functioning, suggesting that these effects of combined treatment are independent. Conclusion: Low-dose combined OLA and sertraline may be effective in the treatment of negative and depressive symptoms compared with standard OLA monotherapy in patients with TRS who are experiencing an acute exacerbation of schizophrenia. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT04076371].
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Affiliation(s)
- Xiaoe Lang
- Department of Psychiatry, First Hospital of Shanxi Medical University, Taiyuan, China
| | | | - Feng Yu
- Qingdao Mental Health Center, Qingdao, China
| | - Meihong Xiu
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, China
- *Correspondence: Meihong Xiu,
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Yasui-Furukori N, Kawamata Y, Sasaki T, Yokoyama S, Okayasu H, Shinozaki M, Takeuchi Y, Sato A, Ishikawa T, Komahashi-Sasaki H, Miyazaki K, Fukasawa T, Furukori H, Sugawara N, Shimoda K. Prescribing Trends for the Same Patients with Schizophrenia Over 20 Years. Neuropsychiatr Dis Treat 2023; 19:921-928. [PMID: 37089914 PMCID: PMC10120815 DOI: 10.2147/ndt.s390482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 04/07/2023] [Indexed: 04/25/2023] Open
Abstract
Background Recent pharmacoepidemiology data show an increase in the proportion of patients receiving second-generation antipsychotic (SGA) monotherapy, but no studies have analyzed the same patients over a long period of time. Therefore, in this study, we retrospectively evaluated schizophrenia patients with available data for 20 years to determine whether the drug treatments in the same patients have changed in the past 20 years. Methods The study began in April 2021 and was conducted in 15 psychiatric hospitals in Japan. Schizophrenia patients treated in the same hospital for 20 years were retrospectively examined for all prescriptions in 2016, 2011, 2006, and 2001 (ie, every 5 years). Results The mean age of the 716 patients surveyed in 2021 was 61.7 years, with 49.0% being female. The rate of antipsychotic monotherapy use showed a slight increasing trend over the past 20 years; the rate of SGA use showed a marked increasing trend from 28.9% to 70.3% over the past 20 years, while the rate of SGA monotherapy use showed a gradual increasing trend over the past 20 years. The rates of concomitant use of anticholinergics, antidepressants, anxiolytics/sleep medications, and mood stabilizers showed decreasing, flat, flat, and flat trends over the past 20 years, respectively. Conclusion The results of this study showed a slow but steady substitution of SGAs for first-generation antipsychotics (FGAs) over time, even in the same patients.
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Affiliation(s)
- Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, TMC Shimotsuga, Tochigi, Japan
- Correspondence: Norio Yasui-Furukori, Department of Psychiatry, Dokkyo Medical University, School of Medicine, Mibu, Shimotsuga, Tochigi, 321-0293, Japan, Tel +81-282-86-1111, Fax +81-282-86-5187, Email
| | - Yasushi Kawamata
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Kikuchi Hospital, Tochigi, Japan
| | - Taro Sasaki
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Asahi Hospital, Tochigi, Japan
| | - Saaya Yokoyama
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Aoki Hospital, Tochigi, Japan
| | - Hiroaki Okayasu
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Fudogaoka Hospital, Saitama, Japan
| | - Masataka Shinozaki
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Takizawa Hospital, Tochigi, Japan
| | - Yoshitaka Takeuchi
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Okamotodai Hospital, Tochigi, Japan
| | - Aoi Sato
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Muroi Hospital, Tochigi, Japan
| | - Takaaki Ishikawa
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Saitama-Konan Hospital, Saitama, Japan
| | - Hazuki Komahashi-Sasaki
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, Kanuma Hospital, Tochigi, Japan
| | - Kensuke Miyazaki
- Department of Neuropsychiatry, Hirosaki-Aiseikai Hospital, Aomori, Japan
| | | | - Hanako Furukori
- Department of Neuropsychiatry, Kuroichi-Akebono Hospital, Aomori, Japan
| | - Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
- Department of Psychiatry, TMC Shimotsuga, Tochigi, Japan
| | - Kazutaka Shimoda
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
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Li P, Benson C, Geng Z, Seo S, Patel C, Doshi JA. Antipsychotic utilization, healthcare resource use and costs, and quality of care among fee-for-service Medicare beneficiaries with schizophrenia in the United States. J Med Econ 2023; 26:525-536. [PMID: 36961119 DOI: 10.1080/13696998.2023.2189859] [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: 01/11/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND No research to date has examined antipsychotic (AP) use, healthcare resource use (HRU), costs, and quality of care among those with schizophrenia in the Medicare program despite it serving as the primary payer for half of individuals with schizophrenia in the US. OBJECTIVES To provide national estimates and assess regional variation in AP treatment utilization, HRU, costs, and quality measures among Medicare beneficiaries with schizophrenia. METHODS Cross-sectional descriptive analysis of 100% Medicare claims data from 2019. The sample included all adult Medicare beneficiaries with continuous fee-for-service coverage and ≥1 inpatient and/or ≥2 outpatient claims with a diagnosis for schizophrenia in 2019. Summary statistics on AP use; HRU and cost; and quality measures were reported at the national, state, and county levels. Regional variation was measured using the coefficient of variation (CoV). RESULTS We identified 314,888 beneficiaries with schizophrenia. About 91% used any AP; 20% used any long-acting injectable antipsychotic (LAI); and 14% used atypical LAIs. About 28% of beneficiaries had ≥1 hospitalization and 47% had ≥1 emergency room (ER) visits, the vast majority of which were related to mental health (MH). Total annual all-cause, MH, and schizophrenia-related costs were $23,662, $15,000 and $12,109, respectively. Among those with hospitalizations, 18.4% and 27.3% had readmission within 7 and 30 days and 56% and 67% had a physician visit and AP fill within 30 days post-discharge, respectively. Overall, 81% of beneficiaries were deemed adherent to their AP medications. Larger interstate variations were observed in LAI use than AP use (CoV: 0.21 vs 0.02). County-level variations were larger than state-level variations for all measures. CONCLUSIONS In this first study examining a national sample of Medicare beneficiaries with schizophrenia, we found low utilization rates of LAIs and high levels of hospital admissions/readmissions and ER visits. State and county-level variations were also found in these measures.
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Affiliation(s)
- Pengxiang Li
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Zhi Geng
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sanghyuk Seo
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Charmi Patel
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | - Jalpa A Doshi
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Qubad M, Bittner RA. Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Ther Adv Psychopharmacol 2023; 13:20451253231158152. [PMID: 36994117 PMCID: PMC10041648 DOI: 10.1177/20451253231158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/31/2023] Open
Abstract
Despite its enduring relevance as the single most effective and important evidence-based treatment for schizophrenia, underutilization of clozapine remains considerable. To a substantial degree, this is attributable to a reluctance of psychiatrists to offer clozapine due to its relatively large side-effect burden and the complexity of its use. This underscores the necessity for continued education regarding both the vital nature and the intricacies of clozapine treatment. This narrative review summarizes all clinically relevant areas of evidence, which support clozapine's wide-ranging superior efficacy - for treatment-resistant schizophrenia (TRS) and beyond - and make its safe use eminently feasible. Converging evidence indicates that TRS constitutes a distinct albeit heterogeneous subgroup of schizophrenias primarily responsive to clozapine. Most importantly, the predominantly early onset of treatment resistance and the considerable decline in response rates associated with its delayed initiation make clozapine an essential treatment option throughout the course of illness, beginning with the first psychotic episode. To maximize patients' benefits, systematic early recognition efforts based on stringent use of TRS criteria, a timely offer of clozapine, thorough side-effect screening and management as well as consistent use of therapeutic drug monitoring and established augmentation strategies for suboptimal responders are crucial. To minimize permanent all-cause discontinuation, re-challenges after neutropenia or myocarditis should be considered. Owing to clozapine's unique efficacy, comorbid conditions including substance use and most somatic disorders should not dissuade but rather encourage clinicians to consider clozapine. Moreover, treatment decisions need to be informed by the late onset of clozapine's full effects, which for reduced suicidality and mortality rates may not even be readily apparent. Overall, the singular extent of its efficacy combined with the high level of patient satisfaction continues to distinguish clozapine from all other available antipsychotics.
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Affiliation(s)
- Mishal Qubad
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Horan WP, Depp CA, Hurst S, Linthicum J, Vargas G, Klein H, Keefe RSE, Harvey PD. Qualitative Analysis of the Content Validity of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) in Schizophrenia: A Multi-Stakeholder Perspective. SCHIZOPHRENIA BULLETIN OPEN 2023; 4:sgad012. [PMID: 38026054 PMCID: PMC10664622 DOI: 10.1093/schizbullopen/sgad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
The US Food and Drug Agency (FDA) requires clinical trials targeting cognitive impairment associated with schizophrenia (CIAS) to demonstrate the functional relevance of cognitive improvements by employing a functional co-primary measure. Although quantitative evidence supports the suitability of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) for this purpose, FDA guidelines for qualification of clinical outcome assessments require evidence of content validity, defined as qualitative evidence that key stakeholders view the measure as relevant and important. To collect this important qualitative data, semi-structured interviews were conducted with outpatients with schizophrenia (n = 24), caregivers (n = 12), and professional peer support specialists (n = 12) to elicit their views about the definition and importance of functional independence, the importance of the functional domains assessed by the VRFCAT (meal planning, using transportation, handling money, shopping), and the relevance of the VRFCAT tasks to these domains. Qualitative thematic analyses revealed consistent themes across groups in defining functional independence, including performing instrumental self-care, financial, and social tasks; making decisions autonomously; and not depending on others to carry out daily activities. There were, however, notable differences in their views regarding the importance of and barriers to functional independence. All groups viewed the VRFCAT as assessing skill domains that are central to independent functioning and, with some minor differences, the VRFCAT tasks were viewed as relevant and meaningful examples of the domains. These qualitative results provide converging evidence that key stakeholders view the VRFCAT as a content-valid measure.
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Affiliation(s)
- William P Horan
- WCG Clinical Endpoint Solutions, Cary, NC
- Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, CA
| | - Colin A Depp
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California, San Diego, CA
| | - Samantha Hurst
- Herbert Wertheim School of Public Health & Human Longevity Science, University of California, San Diego, CA
| | | | - Gabriela Vargas
- Department of Psychiatry & Behavioral Sciences, University of Miami Miller School of Medicine, Research Service Bruce W. Carter VA Medical Center, Miami, FL
| | - Hans Klein
- WCG Clinical Endpoint Solutions, Cary, NC
| | | | - Philip D Harvey
- Department of Psychiatry & Behavioral Sciences, University of Miami Miller School of Medicine, Research Service Bruce W. Carter VA Medical Center, Miami, FL
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Morgan K, Rickert L. Comparison of antipsychotic prescribing practices following failure of antipsychotic monotherapy in the acute care setting. Ment Health Clin 2022; 12:329-335. [PMID: 36644588 PMCID: PMC9819140 DOI: 10.9740/mhc.2022.12.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Numerous strategies exist following antipsychotic monotherapy failure including transition to another antipsychotic, dosing above FDA recommendations, or dual antipsychotic therapy. This study described antipsychotic prescribing practices on an acute psychiatry unit following antipsychotic monotherapy failure and compared outcomes to determine if any strategy resulted in superior short-term outcomes. Methods This retrospective chart review assessed postintervention time to discharge for patients with schizophrenia or schizoaffective disorder requiring therapy change following treatment failure. Secondary outcomes included 30-day readmission rate, length of stay, and discharge chlorpromazine equivalents. Results There were no differences in number of past antipsychotic trials between groups (4.8 vs 4.5; P = .73). Of all the patients, 73% (n = 30) discharged on alternative antipsychotic monotherapy while 27% (n = 11) discharged on dual antipsychotic therapy. No patients had doses increased above FDA recommendations. The alternative antipsychotic group had shorter mean postintervention time to discharge (8.8 vs 20.6 days; P = .003) and shorter mean length of stay (16.7 vs 32.1 days; P = .03). Median time to discharge was not statistically significant (6.4 vs 14.0 days; P = .17). The dual antipsychotic group had higher mean chlorpromazine equivalents (723 mg vs 356 mg; P = .002). There was no difference in 30-day readmission rates (16.7% vs 27.3%; χ2 = 0.5765; P = .45). Discussion This study found that following failure of antipsychotic monotherapy, transition to an alternative antipsychotic was associated with decreased mean time to discharge as compared to dual antipsychotic therapy. Further studies are needed to assess long-term clinical implications of these findings.
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Affiliation(s)
- Kaitlyn Morgan
- Clinical Pharmacy Practitioner in Behavioral Health, Doris Miller Department of Veterans Affairs Medical Center, Waco, Texas,
| | - Leah Rickert
- Psychiatric Clinical Pharmacy Specialist, Doris Miller Department of Veterans Affairs Medical Center, Waco, Texas
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Kamei H. Polypharmacy Management of Antipsychotics in Patients with Schizophrenia. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1584. [PMID: 36363541 PMCID: PMC9692600 DOI: 10.3390/medicina58111584] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2023]
Abstract
Schizophrenia is a chronic psychiatric disease that is characterized by psychotic symptoms, including positive, negative, affective, and aggressive symptoms, as well as cognitive dysfunction, and is primarily treated using drug therapy, the continuation of which is essential to prevent recurrence/recrudescence. Various second-generation antipsychotics with pharmacological properties or adverse events that differ from those of conventional antipsychotics have recently been introduced, and pharmaceutical management is required for drug efficacy assessments and adverse event monitoring/management of these drugs. Antipsychotic monotherapy (APM) is the gold standard treatment for schizophrenia and is recommended in various guidelines. However, a subgroup of patients with schizophrenia do not or only partially respond to APM. Therefore, antipsychotic polypharmacy (APP), in which ≥2 antipsychotics are combined, has been routinely utilized to compensate for insufficient responses to APM in clinical practice. APP has recently been proposed as an evidence-based treatment option, but does not consider clinicians' experience. However, the risk of APP-related adverse events is high. The application of APP needs to be carefully reviewed, whilst taking into consideration patient backgrounds. Furthermore, the risk of APP-related adverse events is higher in elderly patients than in the general population; therefore, caution is needed. This review discusses the merits of APP, matters that need to be considered, and a switch from APP to APM, and also focuses on the application of APP in clinical practice.
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Affiliation(s)
- Hiroyuki Kamei
- Office of Clinical Pharmacy Practice and Health Care Management, Faculty of Pharmacy, Meijo University, Nagoya 468-8503, Japan
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Mayeli A, Clancy KJ, Sonnenschein S, Sarpal DK, Ferrarelli F. A narrative review of treatment interventions to improve cognitive performance in schizophrenia, with an emphasis on at-risk and early course stages. Psychiatry Res 2022; 317:114926. [PMID: 36932470 PMCID: PMC10729941 DOI: 10.1016/j.psychres.2022.114926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 10/31/2022]
Abstract
Cognitive dysfunction is a core feature of schizophrenia (SCZ), which unfavorably affects SCZ patients' daily functioning and overall clinical outcome. An increasing body of evidence has shown that cognitive deficits are present not only at the beginning of the illness but also several years before the onset of psychosis. Nonetheless, the majority of treatment interventions targeting cognitive dysfunction in SCZ, using both pharmacological and nonpharmacological approaches, have focused on chronic patients rather than individuals at high risk or in the early stages of the disease. In this article, we provide a narrative review of cognitive interventions in SCZ patients, with a particular focus on pre-emptive interventions in at-risk/early course individuals when available. Furthermore, we discuss current challenges for these pre-emptive treatment interventions and provide some suggestions on how future work may ameliorate cognitive dysfunction in these individuals.
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Affiliation(s)
- Ahmad Mayeli
- Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave, Suite 456, Pittsburgh, PA 15213, USA
| | - Kevin J Clancy
- Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave, Suite 456, Pittsburgh, PA 15213, USA
| | - Susan Sonnenschein
- Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave, Suite 456, Pittsburgh, PA 15213, USA
| | - Deepak K Sarpal
- Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave, Suite 456, Pittsburgh, PA 15213, USA
| | - Fabio Ferrarelli
- Department of Psychiatry, University of Pittsburgh, 3501 Forbes Ave, Suite 456, Pittsburgh, PA 15213, USA.
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Shnayder NA, Khasanova AK, Strelnik AI, Al-Zamil M, Otmakhov AP, Neznanov NG, Shipulin GA, Petrova MM, Garganeeva NP, Nasyrova RF. Cytokine Imbalance as a Biomarker of Treatment-Resistant Schizophrenia. Int J Mol Sci 2022; 23:ijms231911324. [PMID: 36232626 PMCID: PMC9570417 DOI: 10.3390/ijms231911324] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
Treatment-resistant schizophrenia (TRS) is an important and unresolved problem in biological and clinical psychiatry. Approximately 30% of cases of schizophrenia (Sch) are TRS, which may be due to the fact that some patients with TRS may suffer from pathogenetically “non-dopamine” Sch, in the development of which neuroinflammation is supposed to play an important role. The purpose of this narrative review is an attempt to summarize the data characterizing the patterns of production of pro-inflammatory and anti-inflammatory cytokines during the development of therapeutic resistance to APs and their pathogenetic and prognostic significance of cytokine imbalance as TRS biomarkers. This narrative review demonstrates that the problem of evaluating the contribution of pro-inflammatory and anti-inflammatory cytokines to maintaining or changing the cytokine balance can become a new key in unlocking the mystery of “non-dopamine” Sch and developing new therapeutic strategies for the treatment of TRS and psychosis in the setting of acute and chronic neuroinflammation. In addition, the inconsistency of the results of previous studies on the role of pro-inflammatory and anti-inflammatory cytokines indicates that the TRS biomarker, most likely, is not the serum level of one or more cytokines, but the cytokine balance. We have confirmed the hypothesis that cytokine imbalance is one of the most important TRS biomarkers. This hypothesis is partially supported by the variable response to immunomodulators in patients with TRS, which were prescribed without taking into account the cytokine balance of the relation between serum levels of the most important pro-inflammatory and anti-inflammatory cytokines for TRS.
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Affiliation(s)
- Natalia A. Shnayder
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-620-02-20-78-13 (N.A.S. & R.F.N.)
| | - Aiperi K. Khasanova
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | - Anna I. Strelnik
- International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, 443016 Samara, Russia
- Department of Psychiatry, Narcology and Psychotherapy, Samara State Medical University, 443016 Samara, Russia
| | - Mustafa Al-Zamil
- Department of Physiotherapy, Faculty of Continuing Medical Education, Peoples’ Friendship University of Russia, 117198 Moscow, Russia
| | - Andrey P. Otmakhov
- Basic Department of Psychological and Social Support, St. Petersburg State Institute of Psychology and Social Work, 199178 Saint Petersburg, Russia
- St. Nikolay Psychiatric Hospital, 190121 Saint Petersburg, Russia
| | - Nikolay G. Neznanov
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | - German A. Shipulin
- Centre for Strategic Planning and Management of Biomedical Health Risks Management, 119121 Moscow, Russia
| | - Marina M. Petrova
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Natalia P. Garganeeva
- Department of General Medical Practice and Outpatient Therapy, Siberian State Medical University, 634050 Tomsk, Russia
| | - Regina F. Nasyrova
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, 443016 Samara, Russia
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-620-02-20-78-13 (N.A.S. & R.F.N.)
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50
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Seitz-Holland J, Wojcik JD, Cetin-Karayumak S, Lyall AE, Pasternak O, Rathi Y, Vangel M, Pearlson G, Tamminga C, Sweeney JA, Clementz BA, Schretlen DA, Viher PV, Stegmayer K, Walther S, Lee J, Crow T, James A, Voineskos A, Buchanan RW, Szeszko PR, Malhotra AK, Kelly S, Shenton ME, Keshavan MS, Mesholam-Gately RI, Kubicki M. Cognitive deficits, clinical variables, and white matter microstructure in schizophrenia: a multisite harmonization study. Mol Psychiatry 2022; 27:3719-3730. [PMID: 35982257 PMCID: PMC10538303 DOI: 10.1038/s41380-022-01731-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 02/08/2023]
Abstract
Cognitive deficits are among the best predictors of real-world functioning in schizophrenia. However, our understanding of how cognitive deficits relate to neuropathology and clinical presentation over the disease lifespan is limited. Here, we combine multi-site, harmonized cognitive, imaging, demographic, and clinical data from over 900 individuals to characterize a) cognitive deficits across the schizophrenia lifespan and b) the association between cognitive deficits, clinical presentation, and white matter (WM) microstructure. Multimodal harmonization was accomplished using T-scores for cognitive data, previously reported standardization methods for demographic and clinical data, and an established harmonization method for imaging data. We applied t-tests and correlation analysis to describe cognitive deficits in individuals with schizophrenia. We then calculated whole-brain WM fractional anisotropy (FA) and utilized regression-mediation analyses to model the association between diagnosis, FA, and cognitive deficits. We observed pronounced cognitive deficits in individuals with schizophrenia (p < 0.006), associated with more positive symptoms and medication dosage. Regression-mediation analyses showed that WM microstructure mediated the association between schizophrenia and language/processing speed/working memory/non-verbal memory. In addition, processing speed mediated the influence of diagnosis and WM microstructure on the other cognitive domains. Our study highlights the critical role of cognitive deficits in schizophrenia. We further show that WM is crucial when trying to understand the role of cognitive deficits, given that it explains the association between schizophrenia and cognitive deficits (directly and via processing speed).
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Affiliation(s)
- Johanna Seitz-Holland
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Joanne D Wojcik
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, USA
| | - Suheyla Cetin-Karayumak
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda E Lyall
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ofer Pasternak
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yogesh Rathi
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Vangel
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Carol Tamminga
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA
| | - John A Sweeney
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH, USA
| | - Brett A Clementz
- Department of Psychology and Neuroscience, Bio-Imaging Research Center, University of Georgia, Athens, GA, USA
| | - David A Schretlen
- Department of Psychiatry and Behavioral Sciences, Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Petra Verena Viher
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Katharina Stegmayer
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Sebastian Walther
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Jungsun Lee
- Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tim Crow
- Department of Psychiatry, SANE POWIC, Warneford Hospital, University of Oxford, Oxford, UK
| | - Anthony James
- Department of Psychiatry, SANE POWIC, Warneford Hospital, University of Oxford, Oxford, UK
| | - Aristotle Voineskos
- Center for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Robert W Buchanan
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Philip R Szeszko
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mental Illness Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, NY, USA
| | - Anil K Malhotra
- The Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sinead Kelly
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, USA
| | - Martha E Shenton
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, USA
| | - Raquelle I Mesholam-Gately
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, USA
| | - Marek Kubicki
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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