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Tanzer T, Pham B, Warren N, Barras M, Kisely S, Siskind D. Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses. Expert Opin Drug Saf 2024:1-21. [PMID: 38814794 DOI: 10.1080/14740338.2024.2362796] [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: 01/25/2024] [Accepted: 05/29/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge. AREAS COVERED This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024. EXPERT OPINION Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.
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Affiliation(s)
- Timothy Tanzer
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- Medicine, University of Queensland, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Betty Pham
- Department of Pharmacy, Metro South Community and Oral Health, Brisbane, Australia
| | - Nicola Warren
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Michael Barras
- Princess Alexandra Hospital, Department of Pharmacy, Brisbane, Australia
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Steve Kisely
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan Siskind
- Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
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Alalawi A, Albalawi E, Aljohani A, Almutairi A, Alrehili A, Albalawi A, Aldhafiri A. Decoding Clozapine-Induced Agranulocytosis: Unraveling Interactions and Mitigation Strategies. PHARMACY 2024; 12:92. [PMID: 38921968 DOI: 10.3390/pharmacy12030092] [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: 03/24/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024] Open
Abstract
Agranulocytosis represents a severe complication associated with the administration of clozapine. Clozapine is an antipsychotic medication that has demonstrated substantial efficacy in remediating refractory schizophrenia and various other psychiatric disorders. Nonetheless, it is crucial to monitor patients for neutropenia regularly during clozapine therapy. Therefore, this article aimed to delve into the prevalence of agranulocytosis during clozapine treatment by scrutinizing the extant literature to discern trends and correlations. This review endeavored to explore factors such as drug interactions, dose-related factors, duration of treatment, and genetic predispositions that could potentially influence the likelihood of patients developing agranulocytosis while undergoing clozapine therapy. Moreover, this review enunciates the ramifications of agranulocytosis on both patients and healthcare providers and meticulously evaluates the strategies to mitigate this risk and ensure optimal patient outcomes.
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Affiliation(s)
- Ali Alalawi
- Drug Information Centre, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Enas Albalawi
- Pharmacy Department, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Abdullah Aljohani
- Medication Safety, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Abdullah Almutairi
- Inpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Abdulraouf Alrehili
- Outpatient Pharmacy, Specialized Psychiatric Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Areej Albalawi
- Laboratory Department, Madina Hospital in King Salman Bin Abdulaziz Medical City, Medina 42319, Saudi Arabia
| | - Ahmed Aldhafiri
- Pharmacology and Toxicology Department, College of Pharmacy, Taibah University, Medina 42353, Saudi Arabia
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Yin Y, Lin C, Wei L, Tong J, Huang J, Tian B, Tan S, Wang Z, Yang F, Tong Y, Chen S, Hong LE, Tan Y. History of suicidal behavior and clozapine prescribing among people with schizophrenia in China: a cohort study. BMC Psychiatry 2024; 24:440. [PMID: 38867174 PMCID: PMC11167794 DOI: 10.1186/s12888-024-05893-y] [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] [Received: 01/08/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Clozapine is an off-label drug used in most countries to prevent suicide in individuals with schizophrenia. However, few studies have reported real-world prescription practices. This study aimed to explore the association between a history of suicidal behavior and clozapine prescribing during eight weeks of hospitalization for individuals with early-stage schizophrenia. METHODS This observational cohort study used routine health data collected from a mental health hospital in Beijing, China. The study included 1057 inpatients who had schizophrenia onset within 3 years. History of suicidal behavior was coded from reviewing medical notes according to the Columbia Suicide Severity Rating Scale. Information on antipsychotic use during hospitalization was extracted from the prescription records. Time to clozapine use was analyzed using Cox regression models adjusted for sociodemographic and clinical covariates. RESULTS The prevalence rates of self-harm, suicidal behavior, and suicide attempt were 12.3%, 7.5%, and 5.4%, respectively. A history of self-harm history was positively associated with clozapine uses upon admission (4.1% vs. 0.8%, exact p = 0.009). Among those who had not used clozapine and had no clozapine contraindication, A history of suicidal behavior increased the possibility of switch to clozapine within 56 days after admission (Hazard Ratio[95% CI], 6.09[2.08-17.83]) or during hospitalization (4.18[1.62-10.78]). CONCLUSION The use of clozapine for early-stage schizophrenia was more frequent among those with suicidal behavior than among those without suicidal behavior in China, although the drug instructions do not label its use for suicide risk.
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Affiliation(s)
- Yi Yin
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
- Beijing Suicide Research and Prevention Center, World Health Organization Collaborating Center for Research and Training in Suicide Prevention, Beijing, People's Republic of China
| | - Chen Lin
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Lijing Wei
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Jinghui Tong
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Junchao Huang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Baopeng Tian
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Shuping Tan
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Zhiren Wang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Fude Yang
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Yongsheng Tong
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
| | - Song Chen
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China.
| | - L Elliot Hong
- Maryland Psychiatric Research Center, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, United States of America
| | - Yunlong Tan
- Peking University HuiLongGuan Clinical Medical School, Beijing HuiLongGuan Hospital, Beijing, People's Republic of China
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4
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De Las Cuevas C, Sanz EJ, Gross JA, Correll CU, Verdoux H, Lally J, de Filippis R, Schulte PFJ, Molden E, Arrojo-Romero M, Bostrom AD, Schoretsanitis G, Fernandez-Egea E, de Leon J. Revealing the reporting disparity: VigiBase highlights underreporting of clozapine in other Western European countries compared to the UK. Schizophr Res 2024; 268:175-188. [PMID: 38065799 DOI: 10.1016/j.schres.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 06/15/2024]
Abstract
BACKGROUND Pharmacovigilance studies indicate clozapine history is marked by adverse drug reactions (ADRs). OBJECTIVE In a 2021 article, the United Kingdom (UK) had >90 % of European clozapine-related fatal outcomes in VigiBase, the World Health Organization's pharmacovigilance database. Two possibly opposing hypotheses could explain this disparity: 1) fewer reported fatal outcomes in other Western European countries mainly reflect underreporting to VigiBase, and 2) the higher number of UK reports reflects higher real relative mortality. METHODS VigiBase reports from clozapine's introduction to December 31, 2022, were studied for ADRs and the top 10 causes of fatal outcomes. The UK was compared with 11 other top reporting Western countries (Germany, Denmark, France, Finland, Ireland, Italy, Netherlands, Norway, Spain, Sweden and Switzerland). Nine countries (except Ireland and Switzerland) were compared after controlling for population and clozapine prescriptions. RESULTS The UK accounted for 29 % of worldwide clozapine-related fatal outcomes, Germany 2 % and <1 % in each of the other countries. The nonspecific label "death" was the top cause in the world (46 %) and in the UK (33 %). "Pneumonia" was second in the world (8 %), the UK (12 %), Ireland (8 %) and Finland (14 %). Assuming that our corrections for population and clozapine use are correct, other countries underreported only 1-10 % of the UK clozapine fatal outcome number. CONCLUSIONS Different Western European countries consistently underreport to VigiBase compared to the UK, but have different reporting/publishing styles for clozapine-related ADRs/fatal outcomes. Three Scandinavian registries suggest lives are saved as clozapine use increases, but this cannot be studied in pharmacovigilance databases.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.
| | - Hélène Verdoux
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France.
| | - John Lally
- Department of Psychiatry, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.; Department of Psychiatry, St Vincent's Hospital Fairview, Dublin, Ireland; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK.
| | - Renato de Filippis
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Peter F J Schulte
- Mental Health Services Noord-Holland-Noord, Alkmaar, the Netherlands; Dutch Clozapine Collaboration Group, Castricum, the Netherlands.
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Oslo, Norway.
| | - Manuel Arrojo-Romero
- Department of Psychiatry, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain.
| | - Adrian D Bostrom
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden.
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, NY, USA; Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
| | - Emilio Fernandez-Egea
- Department of Psychiatry, University of Cambridge, Cambridge, UK,; Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn Hospital, Fulbourn, Cambridge, UK.
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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O'Donoghue B, Piacenza F, Plapp H, Siskind D, Lyne J. Response rates to sequential trials of antipsychotic medications according to algorithms or treatment guidelines in psychotic disorders. A systematic review and meta-analysis. Schizophr Res 2024; 268:193-204. [PMID: 38493023 DOI: 10.1016/j.schres.2024.02.035] [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: 08/25/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND There is a relative lack of research evaluating the outcomes when treatment guidelines or algorithms for psychotic disorders are followed. This systematic review and meta-analysis determined the response rates to antipsychotic medications at different stages of these algorithms and whether these response rates differ in first episode cohorts. METHODS Data sources: A systematic search strategy was conducted across four databases PubMed, EMBASE, PsycINFO (Ovid) and CINAHL. Studies that had sequential trials of different antipsychotic medications were included. A meta-analysis of proportions was performed using random effects models and sub-group analysis in first episode psychosis studies. RESULTS Of the 4078 unique articles screened, fourteen articles, from nine unique studies, were eligible and included 2522 participants. The proportion who experienced a response to any antipsychotic in the first stage of an algorithm was 0.53 (95 % C.I.:0.38,0.68) and this decreased to 0.26 (95 % C.I.:0.15,0.39) in the second stage. When clozapine was used in the third stage, the proportion that achieved a response was 0.43 (95 % C.I. 0.19, 0.69) compared to 0.26 (95 % C.I.:0.05,0.54) if a different antipsychotic was used. Four studies included 907 participants with a first episode of psychosis and the proportions that achieved a response were: 1st stage: 0.63 (95 % C.I.: 0.45, 0.79); 2nd stage: 0.34 (95 % C.I.:0.16,0.55); clozapine 3rd stage: 0.45 (95 % C.I.:0.0,0.97), different antipsychotic 3rd stage: 0.15 (95 % C.I.,0.01,0.37). DISCUSSION These findings support the recommendation to have a trial of clozapine after two other antipsychotic medications have been found to be ineffective.
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Affiliation(s)
- Brian O'Donoghue
- Department of Psychiatry, University College Dublin, Ireland; Department of Psychiatry, St Vincent's University Hospital, Dublin, Ireland; Department of Psychiatry, Royal College of Surgeons, Ireland; Centre for Youth Mental Health, University of Melbourne, Australia.
| | | | - Helena Plapp
- Department of Psychiatry, St Vincent's University Hospital, Dublin, Ireland; Orygen, Melbourne, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia; University of Queensland, School of Clinical Medicine, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - John Lyne
- Department of Psychiatry, Royal College of Surgeons, Ireland; Health Service Executive, Newcastle Hospital, Wicklow, Ireland
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Chen WY, Chen PH, Pan CH, Su SS, Tsai SY, Chen CC, Kuo CJ. Clozapine and its protective effect on all-cause, natural, and suicide mortality in patients with schizophrenia: A nationwide cohort study in Taiwan. Schizophr Res 2024; 268:150-160. [PMID: 37479588 DOI: 10.1016/j.schres.2023.07.014] [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: 04/22/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
AIM Clozapine is indicated as the last-line agent for the treatment of refractory schizophrenia due to its side effects. This study included an Asian schizophrenia population and investigated the effect of clozapine on the risks of all-cause, natural, and suicide mortality. METHODS This study included a large-scale schizophrenia inpatient cohort derived from the National Health Insurance Research Database from January 1, 2001, to December 31, 2019 (n = 43,025). Of them, we selected those who received clozapine (clozapine cohort, n = 5800). From those who never used clozapine, we selected two individuals for each patient in the clozapine cohort by matching by age, sex, and the year of the index date (ratio: 1:2, control cohort, n = 11,583). The clozapine and nonclozapine control cohorts together were defined as the study cohort (n = 17,383). Multivariate Cox proportional-hazards regression with a time-dependent model was performed to investigate the effect of individual antipsychotic agents on mortality. RESULTS All individual first-generation antipsychotics were not associated with mortality risk. However, most individual second-generation antipsychotics exerted protective effects against all-cause and natural mortality. Furthermore, only clozapine and risperidone were significantly associated with a low risk of suicide mortality. Only clozapine exhibited a dose-dependent relationship with all-cause, natural, and suicide mortality. CONCLUSIONS This study provides robust evidence supporting the strong protective effect of clozapine on all-cause, suicide, and natural mortality risks in an Asian population. Under close monitoring, clozapine use can be advantageous in patients with schizophrenia who are at a high risk of suicide.
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Affiliation(s)
- Wen-Yin Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Pao-Huan Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Hung Pan
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Sheng-Siang Su
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Shang-Ying Tsai
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chiao-Chicy Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Medical College, Taipei, Taiwan
| | - Chian-Jue Kuo
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
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Niitsu T, Yasui-Furukori N, Inada K, Kanazawa T, Iyo M, Ueno T, Hashimoto R. Current practice for clozapine-induced leukopenia in Japanese psychiatric hospitals: A nationwide survey. Schizophr Res 2024; 268:82-87. [PMID: 38038428 DOI: 10.1016/j.schres.2023.10.011] [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: 05/31/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023]
Abstract
Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. In Japan, its use requires management by a blood monitoring system called the Clozaril Patient Monitoring Service (CPMS) for the early detection of serious side effects such as agranulocytosis, which is extremely rare. Monitoring services vary among the clozapine suppliers in different countries. Additionally, Japanese patients can be started on clozapine treatment exclusively through an 18-week inpatient admission at a psychiatric hospital capable of coordinating with a hematologist. One reported reason for the lack of widespread clozapine use in Japan is the difficulty in establishing collaboration with hematologists when agranulocytosis/leukopenia occurs. Hence, we conducted a nationwide web-based survey of CPMS-registered psychiatric facilities in Japan to determine the status of collaboration with hematology departments. Valid responses were received from the psychiatrists responsible for prescribing clozapine at 203 of the 547 facilities (response rate: 37.1 %). The largest number of psychiatric facilities (61 %) collaborated with hematologists at another facility with a psychiatry department, while psychiatrists in 32 % of the facilities worked with hematologists at their own facilities. Most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist. The actual workload of hematologists was limited, and the patients might experience the burden of repeated blood sampling. This study suggests that disseminating information regarding the status of collaborations with hematologists may promote the widespread use of clozapine in Japan. SHORT COMMENT FOR TWITTER: This study suggests that most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist.
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Affiliation(s)
- Tomihisa Niitsu
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tetsufumi Kanazawa
- Department of Neuropsychiatry, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Masaomi Iyo
- Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takefumi Ueno
- National Hospital Organization, Hizen Psychiatric Medical Center, Saga, 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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8
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De Las Cuevas C, Sanz EJ, de Leon J. Adverse drug reactions and their fatal outcomes in clozapine patients in VigiBase: Comparing the top four reporting countries (US, UK, Canada and Australia). Schizophr Res 2024; 268:165-174. [PMID: 37301669 DOI: 10.1016/j.schres.2023.05.004] [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: 03/29/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Pharmacovigilance findings and box warnings in the clozapine package inserts have marked the history of clozapine. OBJECTIVE This is the largest review of clozapine adverse drug reactions (ADRs) and their associated fatal outcomes. Reports to the World Health Organization's global pharmacovigilance database, VigiBase™, were analyzed, extending from clozapine's introduction to December 31, 2022. METHODS The analysis focused on the top four reporting countries: United States (US), United Kingdom (UK), Canada and Australia (83 % of fatal outcomes worldwide). Attempts were made to control for population and clozapine prescription in each country. RESULTS Clozapine ADRs worldwide accounted for 191,557 reports, with the highest number (53,505) in "blood and lymphatic system disorder". Of the 22,596 fatal outcomes reported in clozapine patients, 9587 were from the US, 6567 from the UK, 3623 from Canada and 1484 from Australia. The top category worldwide in fatal outcomes was nonspecifically labeled "death" with 46 % (range 22-62 %). "Pneumonia" was second with 30 % (range 17-45 %). Agranulocytosis was numerically only the 35th top clozapine ADR associated with fatal outcomes. On average, 2.3 clozapine ADRs were reported per fatal outcome. Infections were associated with 24.2 % of the UK fatal outcomes (9.4 %-11.9 % in the 3 other countries). CONCLUSIONS The four countries appeared to report clozapine ADRs in different ways, making comparisons difficult. We estimated higher fatal outcomes in the UK and Canada after controlling for cross-sectional estimations of population and published clozapine use. This last hypothesis is limited by the lack of precise estimation of accumulated clozapine use in each country.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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9
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Kane JM, Schoretsanitis G, Rubio JM, Correll CU. Clozapine in treatment-resistant schizophrenia: Reflections from the Hallmark US clinical trial and beyond. Schizophr Res 2024; 268:9-13. [PMID: 38290942 DOI: 10.1016/j.schres.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/01/2024]
Affiliation(s)
- John M Kane
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA; Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
| | - Jose M Rubio
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA
| | - Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA; The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany; German Center for Mental Health (DZPG), partner site Berlin, Germany
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10
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Sagud M, Breznoscakova D, Celofiga A, Chihai J, Chkonia E, Ristic Ignjatovic D, Injac Stevovic L, Kopecek M, Kurvits K, Kuzo N, Lazáry J, Mazaliauskienė R, Mladina Perisa D, Novotni A, Panov G, Pikirenia U, Rădulescu FȘ, Sukiasyan SG, Taube M, Tomori S, Wilkowska A, De Las Cuevas C, Sanz EJ, de Leon J. An expert review of clozapine in Eastern European countries: Use, regulations and pharmacovigilance. Schizophr Res 2024; 268:53-59. [PMID: 37783650 DOI: 10.1016/j.schres.2023.09.002] [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: 06/01/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVES To compare the prevalence, regulations, and pharmacovigilance practices of clozapine use in Eastern European countries (except Russia). METHODS Questionnaires and data from administrative databases (2016 and 2021), package inserts and national guidelines were collected from 21 co-authors from 21 countries. Reports of clozapine adverse drug reactions (ADRs) sent to the global pharmacovigilance database (VigiBase™) were analyzed from introduction to December 31, 2022. RESULTS Clozapine prescription among antipsychotics in 2021 varied six-fold across countries, from 2.8 % in the Czech Republic to 15.8 % in Montenegro. The utilization of antipsychotics in both 2016 and 2021 was highest in Croatia, and lowest in Serbia in 2016, and Montenegro in 2021, which had half the defined daily dose (DDD)/1000/day compared to the Croatian data. From 2016 to 2021, the prevalence of antipsychotic use increased in almost all countries; the proportion of clozapine use mainly remained unchanged. Differences were detected in hematological monitoring requirements and clozapine approved indications. Only a few national schizophrenia guidelines mention clozapine-induced myocarditis or individual titration schemes. The VigiBase search indicated major underreporting regarding clozapine and its fatal outcomes. By comparison, the United Kingdom had less than half the population of these Eastern European countries but reported to VigiBase more clozapine ADRs by 89-fold and clozapine fatal outcomes by almost 300-fold. CONCLUSION Clozapine is under-utilized in Eastern European countries. Introducing individualized clozapine treatment schedules may help to maximize clozapine benefits and safety. Major improvement is needed in reporting clozapine ADRs and fatal outcomes in Eastern European countries.
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Affiliation(s)
- Marina Sagud
- School of Medicine, University of Zagreb, Zagreb, Croatia; University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Dagmar Breznoscakova
- Department of Social and Behavioural Medicine, Faculty of Medicine, Pavol Jozef Safarik University, Kosice, Slovakia.
| | - Andreja Celofiga
- Department of Psychiatry, University Medical Centre, Maribor, Maribor, Slovenia.
| | - Jana Chihai
- State University of Medicine and Pharmacy Nicolae Testemitanu, Chişinău, Republic of Moldova.
| | - Eka Chkonia
- Tbilisi State Medical University, Department of Psychiatry, Tbilisi, Georgia.
| | - Dragana Ristic Ignjatovic
- University of Kragujevac, Faculty of Medical Sciences, Department of Psychiatry, Kragujevac, Serbia.
| | - Lidija Injac Stevovic
- Medical Faculty, University of Montenegro, Psychiatric Clinic, Clinical Centre of Montenegro, Podgorica, Montenegro.
| | - Miloslav Kopecek
- National Institute of Mental Health, Klecany, Czech Republic; Department of Psychiatry, Charles University, Third Faculty of Medicine, Prague, Czech Republic.
| | - Katrin Kurvits
- Bureau of Pharmacovigilance, Department of Post-authorisation Safety, State Agency of Medicines, Estonia.
| | - Nazar Kuzo
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland.
| | - Judit Lazáry
- National Institute of Mental Health, Neurology and Neurosurgery, Budapest, Hungary.
| | - Ramunė Mazaliauskienė
- Psychiatric Clinic, Lithuanian Health Sciences University Kaunas Hospital, Lithuanian Health Sciences University, Kaunas, Lithuania.
| | - Djurdjica Mladina Perisa
- County Hospital "Dr. Fra Mihovil Sučić" Livno, Svetog Ive 2, Livno 80101, Bosnia and Herzegovina.
| | - Antoni Novotni
- University Clinic of Psychiatry Medical Faculty, University Ss. Cyril and Methodius-Skopje, North Macedonia.
| | - Georgi Panov
- Psychiatric Clinic, University Hospital "Prof Dr Stoyan Kirkovich" Trakia University, Stara Zagora, Bulgaria.
| | - Uladzimir Pikirenia
- Department of Psychiatry and Medical Psychology, Belarusian State Medical University, Minsk, Belarus.
| | - Flavian Ștefan Rădulescu
- Center for Drug Sciences, Faculty of Pharmacy, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.
| | - Samvel Grant Sukiasyan
- Psychiatric Services of Center of Psychosocial Recovery, Yerevan, Armenia; Department of Applied Psychology of the Armenian State Pedagogical University named after Kh. Abovyan, Yerevan, Armenia.
| | - Māris Taube
- Department of Psychiatry and Narcology, Riga Stradinš University, Riga, Latvia; Department for Depression and Crisis, Riga Center of Psychiatry and Narcology, Riga, Latvia.
| | - Sonila Tomori
- University Hospital Center "Mother Teresa", Tirana, Albania.
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland.
| | - Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, School of Medicine, University of La Laguna, Canary Islands, Spain; Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain.
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Canary Islands, Spain; Hospital Universitario de Canarias, Tenerife, Spain.
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, United States of America; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain.
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11
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Cheng A, Buten S, Large M. Time for a change to clozapine haematological monitoring. Australas Psychiatry 2024:10398562241258764. [PMID: 38820548 DOI: 10.1177/10398562241258764] [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: 06/02/2024]
Abstract
OBJECTIVES This paper critiques the haematological monitoring guidelines for clozapine. It describes the history of clozapine, as well as the pathophysiology and epidemiology of clozapine-induced neutropenia (CIN) and agranulocytosis (CIA). The paper appraises the extant literature on mandatory clozapine haematological monitoring. CONCLUSION Contemporary Australian protocols for clozapine haematological monitoring are not consistent with the current evidence base. CIN and CIA are rare occurrences, and the associated risk of death is low. Potential modifications to existing guidelines include changing neutrophil thresholds for patients with benign ethnic neutropenia and reducing the frequency or removing haematological monitoring after two years of clozapine treatment.
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Affiliation(s)
- Adrian Cheng
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia; and School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Sara Buten
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Matthew Large
- Department of Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia; and School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
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12
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O'Donoghue B, Mora L, Bismark M, Thompson A, McGorry P. Identifying and managing treatment resistance early with the integration of a clozapine clinic within an early intervention for psychosis service. Early Interv Psychiatry 2024. [PMID: 38783545 DOI: 10.1111/eip.13578] [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: 11/30/2023] [Revised: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Despite being the most effective antipsychotic medication for treatment-resistant psychosis, clozapine is often under-utilized with long delays to initiation. AIMS This study aimed to determine whether the integration of a clozapine clinic within an early intervention for psychosis service resulted in a change in the rate and time to initiation of clozapine, the number of trials of different antipsychotic medications prior to clozapine, community initiation and discontinuation rates. METHODS A clozapine clinic was established in the Early Psychosis Prevention and Intervention Centre in Melbourne. This was a pre- and post-evaluation study design. The 'clozapine clinic' cohort included those who commenced on clozapine from 01 January 2016 to 30 June 2018. RESULTS Prior to the clozapine clinic, 24 young people commenced clozapine over the 30-month period compared to 36 in the clozapine clinic cohort (RR = 1.30, 95% CI: 0.75-2.28, p = .32). In the pre-clozapine clinic cohort, 4.6% of all those with a first episode of psychosis were commenced on clozapine compared to 6% in the clozapine clinic cohort. Prior to the clozapine clinic, the median time to the commencement of clozapine was 72 weeks (IQR: 38, 87), compared to 53.5 weeks (IQR: 38, 81.5) in the clozapine clinic (Z = -0.86, p = .393). The mean number of different antipsychotic medications prior to commencing clozapine remained stable at 3.2 (SD ± 1.1) in both cohorts (t = -0.20, p = .841). There was a lower rate of discontinuation in the clozapine clinic (43.5% vs. 14.7%, HR = 0.30, 95% CI: 0.09-0.98, p = .046). CONCLUSIONS While this study was underpowered and there are limitations to the naturalistic study design, the findings lend support to the integration of a clozapine clinic within early intervention for psychosis services.
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Affiliation(s)
- Brian O'Donoghue
- Department of Psychiatry, University College Dublin, Dublin, Ireland
- Department of Psychiatry, St Vincents University Hospital, Dublin, Ireland
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
| | - Linda Mora
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Te Whatu Ora, Kapiti Coast, New Zealand
| | - Andrew Thompson
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
| | - Patrick McGorry
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Parkville, Victoria, Australia
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13
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Lind PA, Parker RK, Northwood K, Siskind DJ, Medland SE. Clozapine Efficacy and Adverse Drug Reactions Among a Nationwide Study of 1021 Australians Prescribed Clozapine: The ClozaGene Study. Schizophr Bull 2024:sbae065. [PMID: 38713070 DOI: 10.1093/schbul/sbae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND AND HYPOTHESIS The ClozaGene Study is a nationwide cohort of adults who have been treated with clozapine. While clozapine is indicated in the management of treatment-resistant schizophrenia, it is associated with a considerable adverse drug reaction (ADR) burden, and not all patients achieve adequate symptomatic response. The current study focuses on self-reported experiences of clozapine use and response, clozapine-associated ADRs, and mental health comorbidity. STUDY DESIGN A total of 1021 participants (41.0% female; aged 46.2 ± 10.6 years [range 18-66]) were recruited via a mail-out based on prescriptions for clozapine. Participants completed a self-report questionnaire. STUDY RESULTS Most participants (90.1%, n = 912) were living with schizophrenia while 41.5% reported a lifetime diagnosis of depression, 15.6% bipolar disorder, and 8.1% schizoaffective disorder. Clozapine was currently prescribed to 944 (92.5%) participants and 37.8% of these participants self-reported currently taking additional antipsychotic medication. Nearly 3 quarters of participants living with schizophrenia reported that clozapine helped control their schizophrenia symptoms moderately to very well. The most commonly reported ADRs were sialorrhea (80.3%), weight gain (71.0%), constipation (56.9%), and sedation (52.8%). The prevalence of clozapine cessation due to clozapine-induced myocarditis and neutropenia was 1% and 0.4%, respectively. CONCLUSIONS Our findings highlight the high rate of psychotic and metabolic symptoms and ADRs among adults prescribed clozapine in the general Australian population. Future genomic analyses will focus on identifying genetic variants influencing clozapine treatment response and side effects.
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Affiliation(s)
- Penelope A Lind
- Psychiatric Genetics, Mental Health and Neuroscience Research Program, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, Australia
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Richard K Parker
- Psychiatric Genetics, Mental Health and Neuroscience Research Program, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Korinne Northwood
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Dan J Siskind
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Metro South Addiction and Mental Health Service, Brisbane, Australia
| | - Sarah E Medland
- Psychiatric Genetics, Mental Health and Neuroscience Research Program, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
- School of Psychology, University of Queensland, Brisbane, Australia
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14
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Sarpal DK, Cole ES, Gannon JM, Li J, Adair DK, Chengappa KNR, Donohue JM. Variation of Clozapine Use for Treatment of Schizophrenia: Evidence from Pennsylvania Medicaid and Dually Eligible Enrollees. Community Ment Health J 2024; 60:743-753. [PMID: 38294579 DOI: 10.1007/s10597-023-01226-7] [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] [Received: 09/20/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024]
Abstract
While clozapine is the most effective antipsychotic treatment for treatment-resistant schizophrenia, it remains underutilized across the United States, warranting a more comprehensive understanding of variation in use at the county level, as well as characterization of existing prescribing patterns. Here, we examined both Medicaid and Medicare databases to (1) characterize temporal and geographic variation in clozapine prescribing and, (2) identify patient-level characteristics associated with clozapine use. We included Medicaid and Fee for Service Medicare data in the state of Pennsylvania from January 1, 2013, through December 31, 2019. We focused on individuals with continuous enrollment, schizophrenia diagnosis, and multiple antipsychotic trials. Geographic variation was examined across counties of Pennsylvania. Regression models were constructed to determine demographic and clinical characteristics associated with clozapine use. Out of 8,255 individuals who may benefit from clozapine, 642 received treatment. We observed high medication burden, overall, including multiple antipsychotic trials. We also identified variation in clozapine use across regions in Pennsylvania with a disproportionate number of prescribers in urban areas and several counties with no identified clozapine prescribers. Finally, demographic, and clinical determinants of clozapine use were observed including less use in people identified as non-Hispanic Black, Hispanic, or with a substance use disorder. In addition, greater medical comorbidity was associated with increased clozapine use. Our work leveraged both Medicaid and Medicare data to characterize and surveil clozapine prescribing. Our findings support efforts monitor disparities and opportunities for the optimization of clozapine within municipalities to enhance clinical outcomes.
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Affiliation(s)
- Deepak K Sarpal
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Evan S Cole
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica M Gannon
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jie Li
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dale K Adair
- Office of Mental Health and Substance Abuse Services, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - K N Roy Chengappa
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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15
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Wang T, Wang L, Yao Y, Liu N, Peng A, Ling M, Ye F, Sun J. Building and Validation of an Acute Event Prediction Model for Severe Mental Disorders. Neuropsychiatr Dis Treat 2024; 20:885-896. [PMID: 38645710 PMCID: PMC11032721 DOI: 10.2147/ndt.s453838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/09/2024] [Indexed: 04/23/2024] Open
Abstract
Background The global incidence of acute events in psychiatric patients is intensifying, and models to successfully predict acute events have attracted much attention. Objective To explore the influence factors of acute incident severe mental disorders (SMDs) and the application of Rstudio statistical software, and build and verify a nomogram prediction model. Methods SMDs were taken as research objects. The questionnaire survey method was adopted to collect data. Patients with acute event independent factors were screened. R software multivariable Logistic regression model was constructed and a nomogram was drawn. Results A total of 342 patients with SMDs were hospitalized, and the number of patients who encountered acute events was 64, which accounted for 18.70% of all patients. Statistical significances were found in many aspects (all P ˂ 0.05). Such aspects included Medication adherence, disease diagnosis, marital status, caregivers, social support and the hospitalization environment (odds ratio (OR) = 4.08, 11.62, 12.06, 10.52, 0.04 and 0.61, respectively) were independent risk factors for the acute events of patients with SMDs. The prediction model was modeled, and the AUC was 0.77 and 0.80. The calibration curve shows that the model has good calibration. The clinical decision curve shows that the model has a good clinical effect. Conclusion The constructed risk prediction model shows good prediction effectiveness in the acute events of patients with SMDs, which is helpful for the early detection of clinical mental health staff at high risk of acute events.
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Affiliation(s)
- Ting Wang
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
- School of Medicine & Nursing, Huzhou University, Huzhou, Zhejiang, People’s Republic of China
| | - Lin Wang
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
| | - Yunliang Yao
- School of Medicine & Nursing, Huzhou University, Huzhou, Zhejiang, People’s Republic of China
| | - Nan Liu
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
| | - Aiqin Peng
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
| | - Min Ling
- School of Medicine & Nursing, Huzhou University, Huzhou, Zhejiang, People’s Republic of China
| | - Fei Ye
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
| | - JiaoJiao Sun
- Affliated WuTaiShan Hospital of Medical College of Yangzhou University, Yangzhou Mental Health Center, Yangzhou, Jiangsu, People’s Republic of China
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16
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Castle D, Copolov D, Singh B, Bastiampillai T. Seven decades of antipsychotic drugs: Why is the life of Australians with schizophrenia still so suboptimal? Aust N Z J Psychiatry 2024; 58:201-206. [PMID: 38130026 DOI: 10.1177/00048674231209840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
The advent of dopamine (D2) receptor-blocking medications over 70 years ago, ushered in a new era of biological treatment for schizophrenia. However, we argue that little subsequent progress has been made in translating this into fulfilled and fulfilling lives for people with schizophrenia. This Viewpoint asks why this is the case, and suggests ways forward for capitalising on extant and emerging new treatments for psychotic disorders, to the betterment of the lives of people living with schizophrenia.
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Affiliation(s)
- David Castle
- Department of Psychiatry, University of Tasmania, Hobart, TAS, Australia
| | - David Copolov
- Department of Psychiatry, Monash University, Clayton, VIC, Australia
| | - Bruce Singh
- Department of Psychiatry, The Melbourne Clinic, The University of Melbourne, Richmond, VIC, Australia
| | - Tarun Bastiampillai
- Department of Psychiatry, Monash University, Clayton, VIC, Australia
- Department of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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17
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Northwood K, Myles N, Clark SR, Every-Palmer S, Myles H, Kisely S, Warren N, Siskind D. Evaluating the epidemiology of clozapine-associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study. Lancet Psychiatry 2024; 11:27-35. [PMID: 38040009 DOI: 10.1016/s2215-0366(23)00343-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Clozapine is associated with the risk of serious neutropenia. However, this risk might decrease over time, meaning that indefinite absolute neutrophil count (ANC) monitoring could be unnecessary. We aimed to determine the epidemiology and timing of clozapine-associated neutropenia outcomes, to investigate variables that might contribute to the odds of neutropenia, and to determine risk of competing neutropenic events during clozapine treatment. METHODS We performed a retrospective analysis of the Australian and New Zealand Viatris Pharmacovigilance system (one of two monitoring databases for these two countries) between June 6, 1990, and Oct 25, 2022. Patients were excluded from analysis if they commenced clozapine before 1990, did not have a haematology test within 2 weeks of commencement date, or had no follow-up. We measured minor neutropenia (ANC 1·0-1·5 × 109 per L) and serious neutropenia (ANC <1·0 × 109 per L) leading to cessation of clozapine within 6 weeks of the neutropenic event. We determined the rates of minor and serious neutropenia and calculated odds ratios (ORs) for the likelihood of neutropenia leading to cessation. For serious neutropenia leading to cessation, we used time-to-event to calculate rolling weekly averages and to perform competing risk analysis of outcomes using Cox proportional hazards models and a Fine-Gray subdistribution hazards regression model. For the subset of data where information on previous clozapine use was available, we did an analysis for participants who did and did not have previous clozapine exposure. FINDINGS We included 26 630 people, with 2·6 million ANC values. Within the total cohort, 17 585 people (66%) were male, 9025 (33·9%) female, and 20 (0·1%) other gender, and the mean age was 36·1 years (SD 13·7). We did not have data on race or ethnicity. Of the 26 630 people taking clozapine, 1146 (4·3%) had minor neutropenia, 313 (1·2%) had serious neutropenia leading to cessation, and 223 (0·8%) had serious neutropenia unrelated to clozapine without cessation. In people with no previous exposure to clozapine (n=15 973), the cumulative incidence of serious neutropenia leading to cessation was 0·9% at 18 weeks and 1·4% at 2 years; the weekly incidence rate for serious neutropenia leading to cessation peaked at 9 weeks (0·128%) and fell to a rolling average weekly incidence of 0·001% by 2 years. For minor neutropenia, the cumulative incidence was 1·7% at 18 weeks and 3·5% at 2 years; the weekly incidence rate peaked at 9 weeks (0·218%) and fell to a stable rolling average of 0·01%. The median time to a serious neutropenic event leading to cessation was 17 weeks (IQR 9·96-102). Previous clozapine exposure reduced the risk of serious neutropenia leading to cessation (OR 0·19, 95% CI 0·12-0·31; p <0·0001). INTERPRETATION Most serious neutropenia leading to clozapine cessation occurs within 18 weeks of treatment and becomes negligible after 2 years. Weekly haematological monitoring after the first 18 weeks could be safely reduced to once every 4 weeks and ceased after 2 years unless clinically indicated. Clozapine retrial after interruption with 2 cumulative years of unremarkable testing might not require further haematological monitoring. A serious neutropenia ANC threshold of ≤1·0 × 109 per L could be used in more jurisdictions. FUNDING None.
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Affiliation(s)
- Korinne Northwood
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicholas Myles
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Scott R Clark
- Discipline of Psychiatry, Adelaide University, Adelaide, SA, Australia
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Hannah Myles
- Northern Adelaide Health Network, Adelaide, SA, Australia
| | - Steve Kisely
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Metro South Health, Brisbane, QLD, Australia; Physical and Mental Health Stream, Queensland Centre for Mental Health Research, Brisbane, QLD, Australia.
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Kotake K, Mitsuboshi S, Hosokawa T, Kitamura N, Kawakami Y. Effect of cytochrome P450 1A2 inhibitors on rhabdomyolysis in patients on clozapine: Analysis using the US Food and Drug Administration's Adverse Event Reporting System. Schizophr Res 2023; 262:102-103. [PMID: 37944342 DOI: 10.1016/j.schres.2023.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 10/03/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, Okayama, Japan.
| | | | - Tomonari Hosokawa
- Department of Psychiatry, Zikei Hospital/Zikei Institute of Psychiatry, Okayama, Japan
| | - Naoya Kitamura
- Department of Neuropsychiatry, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Yasuhiro Kawakami
- Department of Pharmacy, Okayama Saiseikai General Hospital, Okayama, Japan
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Lim K, Yee JY, See YM, Ng BT, Zheng S, Tang C, Lencz T, Lee J, Lam M. Deconstructing the genetic architecture of treatment-resistant schizophrenia in East Asian ancestry. Asian J Psychiatr 2023; 90:103826. [PMID: 37944474 DOI: 10.1016/j.ajp.2023.103826] [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: 08/04/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) affects a substantial proportion of patients who do not respond adequately to antipsychotic medications, yet the underlying biological mechanism remains poorly understood. This study investigates the link between the genetic predisposition to schizophrenia and TRS. METHODS 857 individuals diagnosed with schizophrenia were divided into TRS (n = 142) and non-TRS (n = 715) based on well-defined TRS criteria. Polygenic risk scores (PRS) were calculated using schizophrenia genome-wide association summary statistics from East-Asian and European ancestry populations. PRS was estimated using both P-value thresholding and Bayesian framework methods. Logistic regression analyses were performed to differentiate between TRS and non-TRS individuals. RESULTS The schizophrenia PRS derived from the East-Asian training dataset effectively distinguished between TRS and non-TRS individuals (R2 = 0.029, p = 4.86 ×10-5, pT = 0.1, OR = 1.52, 95% CI = 1.242-1.861), with higher PRS values observed in the TRS group. Similar PRS analysis was conducted based on the European ancestry GWAS summary statistics, but we found superior prediction based on the East-Asian ancestry discovery data. CONCLUSION This study reveals an association between common risk variants for schizophrenia and TRS status, suggesting that the genetic burden of schizophrenia may partly contribute to treatment resistance in individuals with schizophrenia. These findings propose the potential use of genetic risk factors for early TRS identification and timely access to clozapine. However, the ancestral background of the discovery sample is crucial for successfully implementing PRS in clinical settings.
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Affiliation(s)
- Keane Lim
- Research Division, Institute of Mental Health, Singapore
| | - Jie Yin Yee
- Research Division, Institute of Mental Health, Singapore
| | - Yuen Mei See
- Research Division, Institute of Mental Health, Singapore
| | - Boon Tat Ng
- Department of Pharmacy, Institute of Mental Health, Singapore
| | - Shushan Zheng
- Department of Psychosis, Institute of Mental Health, Singapore
| | - Charmaine Tang
- Department of Psychosis, Institute of Mental Health, Singapore
| | - Todd Lencz
- Feinstein Institutes for Medical Research, NY, USA
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore; Population and Global Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| | - Max Lam
- Research Division, Institute of Mental Health, Singapore; Feinstein Institutes for Medical Research, NY, USA; Population and Global Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
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Muñoz-Manchado LI, Villagrán-Moreno JM, Palacios-Garrán R, Pérez-Revuelta JI. Looking to the future after reintroduction of clozapine. SPANISH JOURNAL OF PSYCHIATRY AND MENTAL HEALTH 2023; 16:266-267. [PMID: 38591738 DOI: 10.1016/j.sjpmh.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/31/2023] [Indexed: 04/10/2024]
Affiliation(s)
- Leticia I Muñoz-Manchado
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain.
| | - Jose María Villagrán-Moreno
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain; Department of Psychiatry, University of Cádiz, Cádiz, Spain
| | - Roberto Palacios-Garrán
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain
| | - Jose Ildefonso Pérez-Revuelta
- UGC North of Cadiz, Mental Health Inpatient Unit, General Hospital, Jerez de la Frontera, Spain; Serious Mental Disorder Research Group, Cadiz Biomedical Research and Innovation Institute, Spain; Department of Psychiatry, University of Cádiz, Cádiz, Spain
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21
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Starzer MSK, Hansen HG, Hjorthøj C, Speyer H, Albert N, Nordentoft M. Predictors of Mortality Following a Schizophrenia Spectrum Diagnosis: Evidence From the 20-Year Follow-up of the OPUS Randomized Controlled Trial. Schizophr Bull 2023; 49:1256-1268. [PMID: 37527479 PMCID: PMC10483333 DOI: 10.1093/schbul/sbad111] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND AND HYPOTHESIS The life expectancy of patients diagnosed with schizophrenia is 10-12 years lower than in the general population and the mortality gap seems to be worsening. Many of these deaths might be avoidable. We aimed to determine mortality rates and causes of death after a first-episode psychosis, and to examine if clinical characteristics at baseline or during illness could predict mortality. STUDY DESIGN The OPUS study was a randomized controlled trial of 578 patients first diagnosed with schizophrenia spectrum disorders. Patients were clinically assessed after 2, 5, 10, and 20 years. Information about time and cause of death was obtained from the Danish Cause of Death Register. Hazard ratios were used to assess predictors of death. STUDY RESULTS In total, 82 (14.4%) participants died during 20 years of follow-up. The most common cause of death was suicide (27%). At baseline employment (HR 0.47 P = .049), psychotic disorder other than schizophrenia (HR 0.36, P = .017), and longer duration of untreated psychosis (HR 0.57 P = .042) predicted lower mortality while substance use predicted higher mortality (HR 2.56, P < .001). During follow-up, symptom remission without antipsychotic medication and recovery predicted lower mortality (HR 0.08 P = .013 and HR 0.21, P = .028) while substance use (HR 3.64 P < .001), and all chronic illnesses predicted increased risk. CONCLUSIONS There is an increased risk of early mortality in schizophrenia compared to the background population, and there is an urgent need for new efforts to improve the disparities in health that lead to this increased mortality.
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Affiliation(s)
- Marie Stefanie Kejser Starzer
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Helene Gjervig Hansen
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Helene Speyer
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nikolai Albert
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Mental Health Centre Amager, University Hospital of Copenhagen, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health – CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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22
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Liu T, Gao P, Xie C, Zhang H, Shi Z, Chen R. Study on the daily dose and serum concentration of clozapine in psychiatric patients and possible influencing factors of serum concentration. BMC Psychiatry 2023; 23:596. [PMID: 37582705 PMCID: PMC10428656 DOI: 10.1186/s12888-023-05078-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/02/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Clozapine is the most effective drug for treatment-resistant schizophrenia, and the dosage and concentration of clozapine in the treatment of mental illness vary greatly in different populations and are affected by many factors. METHODS The serum clozapine concentration of 3734 psychiatric patients was detected, and data on daily dose, sex, age and other medical records were collected for statistical analysis. RESULTS The mean daily dose, mean serum concentration and mean C/D (concentration/dose) ratio of clozapine were 191.02 ± 113.47 mg/day, 326.15 ± 235.66 ng/mL and 1.94 ± 1.25 ng/mL per mg/day, respectively. There was difference in daily dose between sexes, and females had higher daily dose (p <0.01), higher serum clozapine concentrations (p < 0.01) and higher C/D ratios (p < 0.01). There were significant differences in daily dose (p < 0.001), serum drug concentration (p < 0.001) and C/D ratio (p < 0.001) among different age groups. The daily dose decreased with age (p for trend < 0.001), and the C/D ratio increased with age (p for trend < 0.001). Inpatients and outpatients had no difference in daily dose, but inpatients had higher serum concentration (p < 0.001) and C/D ratio (p < 0.001). There was no difference in daily dose among different occupations, but there were significant differences in serum concentration (p < 0.001) and C/D ratio (p < 0.001), and unemployed patients may have higher serum concentration and C/D ratio. Duration of disease, comorbidity, marital status, and psychotic type may influence the daily dose and serum concentration. CONCLUSIONS The effective daily dose and serum concentration of clozapine in the study area may be lower than recommended levels, and women have higher serum concentrations and slower metabolic rates. With increasing age, the daily dose decreases, and the metabolic rate slows. Inpatient status and occupation of patients may influence the serum concentration and metabolic rate of clozapine.
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Affiliation(s)
- Taixiu Liu
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Peng Gao
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China.
| | - Chuange Xie
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Heng Zhang
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Zheng Shi
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
| | - Ruirui Chen
- Department of Clinical Laboratory, Shandong Daizhuang Hospital, Jining, 272051, China
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23
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Uka F, Konjufca J, Ramadani F, Arënliu A, Bërxulli D, Jovanović N, Russo M. The relations between socio-demographic information and negative symptoms, mental health, and quality of life: a latent profile analysis with psychotic patients in Kosovo. Front Psychiatry 2023; 14:1135385. [PMID: 37564239 PMCID: PMC10410071 DOI: 10.3389/fpsyt.2023.1135385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/27/2023] [Indexed: 08/12/2023] Open
Abstract
The current study aims to identify meaningful psychotic patients' profiles by examining certain combinations of patient's demographic and socio-economic variables (sex, age, marital status, number of children, cohabitant and level of education). Moreover, we aim to assess whether there is any significant effect of class membership (profile) on negative symptoms, health state, and quality of life among psychotic patients. A convenience sample of 103 patients (age: M = 22, SD = 1.75), was drawn from the clinical populations of Kosovo. Demographic and socio-economic data was obtained through individual interviews, meanwhile a battery of questionnaires was used to assess negative symptoms, mental health, and quality of life of patients. The 4-class solution was selected as the best fitting model and used in subsequent analyses. Results indicated a significant effect of class membership on health state, quality of life and negative symptoms. Practical implications are discussed.
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Affiliation(s)
- Fitim Uka
- Department of Psychology, University of Pristina “Hasan Prishtina”, Prishtina, Kosovo
| | - Jon Konjufca
- Department of Psychology, University of Pristina “Hasan Prishtina”, Prishtina, Kosovo
| | - Fjolla Ramadani
- Department of Psychology, University of Pristina “Hasan Prishtina”, Prishtina, Kosovo
| | - Aliriza Arënliu
- Department of Psychology, University of Pristina “Hasan Prishtina”, Prishtina, Kosovo
| | - Dashamir Bërxulli
- Department of Psychology, University of Pristina “Hasan Prishtina”, Prishtina, Kosovo
| | - Nikolina Jovanović
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, United Kingdom
| | - Manuela Russo
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, United Kingdom
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24
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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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25
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Lashin HI, Sharif AF. Evaluation of various scoring systems as predictors of the need for intensive care unit admission and other adverse outcomes among patients with acute clozapine poisoning. Toxicol Res (Camb) 2023; 12:468-479. [PMID: 37397925 PMCID: PMC10311143 DOI: 10.1093/toxres/tfad029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/25/2023] [Accepted: 04/06/2023] [Indexed: 07/04/2023] Open
Abstract
Acute clozapine poisoning (ACP) is frequently reported worldwide. We evaluated the efficacy of the Poison Severity Score (PSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS) as predictors for intensive care unit (ICU) admission, mechanical ventilation (MV), mortality, and length of hospital stay in patients with ACP. A retrospective cohort study was conducted using records of patients diagnosed with ACP from January 2017 to June 2022 and admitted to an Egyptian poison control center. Analyzing 156 records showed that all assessed scores were significant predictors of the studied outcomes. The PSS and APACHE II score showed the highest area under the curve (AUC) as ICU admission predictors with insignificant variations. The APACHE II score showed the best discriminatory power in predicting MV and mortality. Nevertheless, MEWS exhibited the highest odds ratio (OR) as an ICU predictor (OR = 2.39, and 95% confidence interval = 1.86-3.27) and as a mortality predictor (OR = 1.98, and 95% confidence interval = 1.16-4.41). REMS and MEWS were better predictors of length of hospital stay compared with the APACHE II score. The simpler, lab-independent nature and the comparable discrimination but higher odds ratio of MEWS compared with APACHE II score justify MEWS' superior utility as an outcome predictor in ACP. We recommend using either the APACHE II score or MEWS, depending on the availability of laboratory investigations, resources, and the case's urgency. Otherwise, the MEWS is a substantially feasible, economical, and bedside alternative outcome predictor in ACP.
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Affiliation(s)
- Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asmaa F Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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26
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Lee MA, Cola P, Jayathilake K, Meltzer HY. Long-Term Outcome of Clozapine in Treatment-Resistant Schizophrenia. J Clin Psychopharmacol 2023; 43:211-219. [PMID: 36975722 DOI: 10.1097/jcp.0000000000001671] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
PURPOSE/BACKGROUND The favorable effect of clozapine on psychotic symptoms in patients with treatment-resistant (TR) schizophrenia (SCZ) in short-term studies is well established. However, prospective studies of the long-term outcome of clozapine treatment on psychopathology, cognition, quality of life, and functional outcome in TR-SCZ are limited. METHODS/PROCEDURES Here, we have examined the long-term (mean duration of follow-up 14 years) effects of clozapine on those outcomes in a prospective, open label study in 54 TR-SCZ patients. Assessments were performed at baseline, 6 weeks, 6 months, and at the last follow-up. FINDINGS/RESULTS Brief Psychiatric Rating Scale (BPRS) total, positive symptoms, and anxiety/depression at the last follow-up improved significantly from baseline, as well as from the 6-month evaluation ( P < 0.0001), with a 70.5% responder rate (≥20% improvement at the last follow-up from baseline). Quality of Life Scale (QLS) total improved by 72% at the last follow-up, with 24% of patients rated as having "good" functioning compared with 0% at baseline. Suicidal thoughts/behavior was significantly reduced at the last follow-up from the baseline. No significant change in negative symptoms was found at the last follow-up in the total sample. Short-term memory function declined at the last follow-up from baseline, but there was no significant change in processing speed. The QLS total showed a significant negative correlation with BPRS positive symptoms but not with cognitive measures, or negative symptoms, at the last follow-up. IMPLICATIONS/CONCLUSIONS For patients with TR-SCZ, improving psychotic symptoms with clozapine seems to have a more significant impact than negative symptoms or cognition on improving psychosocial function.
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Affiliation(s)
- Myung A Lee
- From the Department of Psychiatry, Vanderbilt University, School of Medicine, Nashville, TN
| | - Philip Cola
- Weatherhead School of Management and School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Karu Jayathilake
- Department of Psychiatry and Behavioral Sciences, Pharmacology and Neuroscience, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Herbert Y Meltzer
- Department of Psychiatry and Behavioral Sciences, Pharmacology and Neuroscience, Northwestern Feinberg School of Medicine, Chicago, IL
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27
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John AP, Stanley S, Haywood D. Rates and Reasons for Clozapine Treatment Interruptions: Impact of the Frequency of Hematologic Monitoring and Cardiac Adverse Events. J Clin Psychopharmacol 2023; 43:233-238. [PMID: 37126829 DOI: 10.1097/jcp.0000000000001673] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Differing rates and reasons for interruptions of clozapine treatment have been reported globally. This article evaluated the rates and reasons for clozapine therapy interruptions in Australia and explored the impact of the frequency of hematological monitoring on these parameters. METHODS Data of the patients who were newly commenced on clozapine at three metropolitan public mental health services in Western Australia over 11 years were retrospectively collated. The rate and reasons for clozapine therapy interruptions and their association with the frequency of hematological monitoring, age, sex, and treatment site were analyzed using parametric, nonparametric, and correlational analyses. RESULTS Of the 457 patients whose data were collected, 69.6% had an interruption of treatment with 41.2% of those occurring during the period of mandatory weekly hematological monitoring in the first 18 weeks. Nonadherence (57.4%) and adverse effects (28.8%) were the 2 main reasons for the treatment interruptions. Cardiac issues accounted for the majority of the interruptions (61.8%) due to specified adverse effects, and these occurred significantly more commonly within the first 18 weeks. Location, age, and sex did not predict the possibility of treatment interruptions. CONCLUSIONS The high rates of clozapine treatment interruption observed during the period of weekly monitoring point toward the need to address the burden of frequent hematological monitoring for patients. Disproportionately higher rates of interruption due to cardiac adverse effects observed in this study compared with research from non-Australian settings raise the possibility of geographical differences in the adverse effects leading to treatment discontinuation.
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28
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Nobile B, Godin O, Gard S, Samalin L, Brousse G, Loftus J, Aubin V, Belzeaux R, Dubertret C, Le Strat Y, Mazer N, de Prémorel A, Roux P, Polosan M, Schwintzer T, Llorca PM, Biseul I, Etain B, Moirand R, Olié E, Haffen E, Leboyer M, Courtet P, Guillaume S, Icick R. Physical and mental health status of former smokers and non-smokers patients with bipolar disorder. Acta Psychiatr Scand 2023; 147:373-388. [PMID: 36751870 DOI: 10.1111/acps.13535] [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: 09/22/2022] [Revised: 12/29/2022] [Accepted: 01/21/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Up to 70% individuals with bipolar disorder (BD) are lifetime tobacco smokers, a major modifiable risk factor for morbidity. However, quitting smoking is rarely proposed to individuals with BD, mainly because of fear of unfavorable metabolic or psychiatric changes. Evaluating the physical and mental impact of tobacco cessation is primordial. The aim of this study was to characterize the psychiatric and nonpsychiatric correlates of tobacco smoking status (never- vs. current vs. former smokers) in individuals with BD. METHODS 3860 individuals with ascertained BD recruited in the network of Fondamental expert centers for BD between 2009 and 2020 were categorized into current, former, and never tobacco smokers. We compared the sociodemographic and clinical characteristics assessed by standard instruments (e.g., BD type, current symptoms load, and non-psychiatric morbidity-including anthropometric and biological data) of the three groups using multinomial regression logistic models. Corrections for multiple testing were applied. RESULTS Current smokers had higher depression, anxiety, and impulsivity levels than former and never-smokers, and also higher risk of comorbid substance use disorders with a gradient from never to former to current smokers-suggesting shared liability. Current smokers were at higher risk to have a metabolic syndrome than never-smokers, although this was only evidenced in cases, who were not using antipsychotics. CONCLUSIONS Tobacco smoking was associated with high morbidity level. Strikingly, as in the general population, quitting smoking seemed associated with their return to the never-smokers' levels. Our findings strongly highlight the need to spread strategies to treat tobacco addiction in the BD population.
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Affiliation(s)
- Bénédicte Nobile
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- FondaMental Foundation, Créteil, France
| | - Ophélia Godin
- FondaMental Foundation, Créteil, France
- INSERM U955, Département Hospitalo-Universitaire de Psychiatrie et d'Addictologie des Hôpitaux Universitaires H Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Sébastien Gard
- FondaMental Foundation, Créteil, France
- Center Hospitalier Charles Perrens, France NutriNeuro, INRAE UMR 1286, University of Bordeaux, Pôle de Psychiatrie Générale et Universitaire, Bordeaux, France
| | - Ludovic Samalin
- FondaMental Foundation, Créteil, France
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, Clermont-Ferrand, France
| | - Georges Brousse
- FondaMental Foundation, Créteil, France
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, Clermont-Ferrand, France
| | - Joséphine Loftus
- FondaMental Foundation, Créteil, France
- Center Hospitalier Princesse Grace, Pôle de Psychiatrie, Monaco, Monaco
| | - Valérie Aubin
- FondaMental Foundation, Créteil, France
- Center Hospitalier Princesse Grace, Pôle de Psychiatrie, Monaco, Monaco
| | - Raoul Belzeaux
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
- FondaMental Foundation, Créteil, France
- Pôle de Psychiatrie, Assistance Publique Hôpitaux de Marseille, INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - Caroline Dubertret
- FondaMental Foundation, Créteil, France
- INSERM UMR1266, AP-HP, Groupe Hospitalo-Universitaire AP-HP Nord, service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Université de Paris, Colombes, France
| | - Yann Le Strat
- FondaMental Foundation, Créteil, France
- INSERM UMR1266, AP-HP, Groupe Hospitalo-Universitaire AP-HP Nord, service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Université de Paris, Colombes, France
| | - Nicolas Mazer
- FondaMental Foundation, Créteil, France
- INSERM UMR1266, AP-HP, Groupe Hospitalo-Universitaire AP-HP Nord, service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Université de Paris, Colombes, France
| | - Alix de Prémorel
- FondaMental Foundation, Créteil, France
- INSERM UMR1266, AP-HP, Groupe Hospitalo-Universitaire AP-HP Nord, service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Université de Paris, Colombes, France
| | - Paul Roux
- FondaMental Foundation, Créteil, France
- UVSQ, CESP UMR1018, DevPsy-DisAP, Centre Hospitalier de Versailles, Pôle de Psychiatrie et Santé Mentale, Université Paris-Saclay, Le Chesnay, France
| | - Mircea Polosan
- FondaMental Foundation, Créteil, France
- CHU de Grenoble et des Alpes, Grenoble Institut des Neurosciences (GIN) Inserm, Université Grenoble Alpes, Grenoble, France
| | - Thomas Schwintzer
- FondaMental Foundation, Créteil, France
- Centre Psychothérapique de Nancy, Pôle Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie du Grand Nancy, Laxou, France
- INSERM U1254, IADI, Université de Lorraine, Nancy, France
- Faculté de Médecine, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Pierre-Michel Llorca
- FondaMental Foundation, Créteil, France
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, CNRS, Clermont Auvergne INP, Institut Pascal, Clermont-Ferrand, France
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- FondaMental Foundation, Créteil, France
| | - Isabelle Biseul
- FondaMental Foundation, Créteil, France
- Département de Psychiatrie et de Médecine Addictologique, AP-HP.Nord, Groupe Hospitalo-universitaire Lariboisière-Fernand Widal, DMU Neurosciences, Paris, France
| | - Bruno Etain
- FondaMental Foundation, Créteil, France
- Département de Psychiatrie et de Médecine Addictologique, AP-HP.Nord, Groupe Hospitalo-universitaire Lariboisière-Fernand Widal, DMU Neurosciences, Paris, France
- INSERM UMRS 1144, Université de Paris Cité, Paris, France
| | - Remi Moirand
- FondaMental Foundation, Créteil, France
- Service de Psychiatrie de l'Adulte, CIC-1431 INSERM, CHU de Besançon, Laboratoire de Neurosciences, UFC, UBFC, Besançon, France
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- FondaMental Foundation, Créteil, France
| | - Emmanuel Haffen
- FondaMental Foundation, Créteil, France
- Service de Psychiatrie de l'Adulte, CIC-1431 INSERM, CHU de Besançon, Laboratoire de Neurosciences, UFC, UBFC, Besançon, France
| | - Marion Leboyer
- FondaMental Foundation, Créteil, France
- AP-HP, Hôpitaux Universitaires Henri Mondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Université Paris Est Créteil, INSERM U955, Paris, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- FondaMental Foundation, Créteil, France
| | - Sébastien Guillaume
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, Montpellier, France
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- FondaMental Foundation, Créteil, France
| | - Romain Icick
- FondaMental Foundation, Créteil, France
- Centre Psychothérapique de Nancy, Pôle Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie du Grand Nancy, Laxou, France
- INSERM U1254, IADI, Université de Lorraine, Nancy, France
- Département de Psychiatrie et de Médecine Addictologique, AP-HP.Nord, Groupe Hospitalo-universitaire Lariboisière-Fernand Widal, DMU Neurosciences, Paris, France
- INSERM UMRS 1144, Université de Paris Cité, Paris, France
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Two-year cohort-up study of clozapine prescription in Chinese patients with schizophrenia treated in rural primary care. Asian J Psychiatr 2023; 81:103434. [PMID: 36603401 DOI: 10.1016/j.ajp.2022.103434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Few studies have examined the clozapine in cohort studies of Chinese patients with schizophrenia in rural primary care. The objective of this two-year cohort study was to describe the usage of clozapine and investigate and identify the demographic, clinical correlations and risk variables which affect the use of clozapine in patients with schizophrenia. A random cluster sampling technique was used, and participants were collected from China National Psychiatric Management System (CNPMS). The variables for clozapine use in individuals with schizophrenia who had undergone a two-year follow-up were determined using the generalized estimating equation (GEE). In this study, 742 patients with schizophrenia were invited, and 491 completed the two-year follow-up study. Being married, more years of education, more waist circumference, using mood stabilizer, using anticholinergic, higher ITAQ (Insight and Treatment Attitude Questionnaire) scores were more significantly related to the use of clozapine. Older age of onset, using second-generation antipsychotics (SGAs) except clozapine predicted a lower prevalence of using clozapine. The usage of clozapine was very common in patients with schizophrenia treated by primary care physicians, and was influenced by a variety of factors, including price of drugs, clinical factors, health regulations, and the characteristics of treatment environment. Further examination of the rationale and appropriateness of clozapine in primary care in China is necessary.
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Affiliation(s)
- Martin Harrow
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Thomas H Jobe
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Liping Tong
- Advocate Aurora Health, Downers Grove, IL, USA
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Jakobsen MI, Schaug JP, Nielsen J, Simonsen E. Antipsychotic prescribing practices for outpatients with schizophrenia and reasons for non-clozapine treatment - Data from a Danish quality assessment audit. Nord J Psychiatry 2023:1-10. [PMID: 36651766 DOI: 10.1080/08039488.2022.2160878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Clozapine is the gold standard for treating treatment-resistant schizophrenia (TRS) although widely underutilised. Both organisational, patient- and clinician related reasons for the underutilisation have been reported, however, the clinical impact of either in real-world settings is not fully elucidated. AIM This audit aimed to evaluate the local antipsychotic (AP) prescribing practices for outpatients with schizophrenia and to assess the spectrum and prevalence of journalised reasons for non-clozapine treatment amongst eligible outpatients. METHODS Data on demographics, current and former AP treatments, as well as documented reasons for non-clozapine treatment, was extracted through chart audit. RESULTS Of the 668 affiliated outpatients with schizophrenia, 43% were treated with AP polytherapy (APP) and 19.6% with clozapine. The most prevalent reason for clozapine discontinuation was related to side effects whereas the most prevalent reason for refusal or omission of clozapine treatment was related to the associated monitoring regimen. CONCLUSIONS This audit showed that APP prescribing is a highly prevalent practice in our services when treating outpatients with schizophrenia and that clozapine is underutilised in a 'last resort' manner. The blood-monitoring regimen associated with clozapine treatment was found to be an important factor in the underutilisation. It seemed, however, that the monitoring constituted a barrier for different reasons, requiring different approaches to remedy. Future studies, directly involving both patients and clinicians in the identification and management of the most clinically relevant barriers and their corresponding facilitators, are warranted.
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Affiliation(s)
- Michelle I Jakobsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie P Schaug
- Psychiatric Research Unit, Centre for Evidence-Based Psychiatry, Region Zealand Psychiatry, Slagelse, Denmark
| | - Jimmi Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Psychiatric Centre Glostrup, The Mental Health Services in the Capital Region of Denmark, Glostrup, Denmark
| | - Erik Simonsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Masdrakis VG, Baldwin DS. Prevention of suicide by clozapine in mental disorders: systematic review. Eur Neuropsychopharmacol 2023; 69:4-23. [PMID: 36640481 DOI: 10.1016/j.euroneuro.2022.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Previous research has investigated the efficacy of clozapine in reducing suicidality in patients with schizophrenia and schizoaffective disorder. We aimed to systematically review published evidence, including studies concerning clozapine administration to treat: (a) refractory suicidality in other mental disorders, including bipolar disorder and borderline and other personality disorders; and (b) refractory cases of non-suicidal self-injury. METHOD We performed a PUBMED-search (last day: July 17, 2022) of English-language studies, combining the keywords "clozapine", "suicidality", and "suicide" with various psychopathological terms (e.g. "schizophrenia"). All duplications were eliminated. RESULTS Fifty-one studies were eligible for inclusion in the review. Most studies suggest a superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder, compared to other antipsychotics, or no antipsychotic therapy, which is not due to the close monitoring of patients for blood dyscrasias. No consensus exists as to whether other antipsychotic drugs share this effect. Discontinuation of clozapine is associated with increases in suicidality. Reductions in refractory suicidality/NSSI are observed in clozapine-treated patients with bipolar disorder or borderline personality disorder, but the evidence is limited. Potential biological underpinnings of the anti-suicide effect of clozapine include its unique profile of modulation of brain neurotransmitters; its non-selectivity for neurotransmitter receptors; specific genetic and hormonal factors; effects on neuroinflammation; and ability to elicit epileptiform activity. CONCLUSION The superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder patients is well established. It may have a role in severe and refractory cases of suicidality and non-suicidal self-injury in patients with bipolar disorder or borderline personality disorder, but the level and quality of supporting evidence is limited.
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Affiliation(s)
- Vasilios G Masdrakis
- National and Kapodistrian University of Athens, School of Medicine, First Department of Psychiatry, Eginition Hospital, 74 Vas. Sofias Avenue, 11528 Athens, Greece
| | - David S Baldwin
- University Department of Psychiatry, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom; University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
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Sharif AF, Aouissi HA, Kasemy ZA, Byeon H, Lashin HI. Development and validation of a risk prediction nomogram for disposition of acute clozapine intoxicated patients to intensive care unit. Hum Exp Toxicol 2023; 42:9603271231186154. [PMID: 37379491 DOI: 10.1177/09603271231186154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Clozapine is an atypical antipsychotic drug used for the treatment of refractory schizophrenia. It is reported as the most toxic in its class. Using serum clozapine level as a severity indicator is doubtful and unfeasible, particularly in low resourced countries. METHODS This is an extended two-phase retrospective study that utilized medical records of patients diagnosed with acute clozapine intoxication and admitted to Tanta University Poison Control Center, Egypt during the past 6 years. Two hundred and eight medical records were used to establish and validate a nomogram for predicting the need for intensive care unit (ICU) admission in acute clozapine intoxicated patients. RESULTS A reliable simple bedside nomogram was developed and proved its significant ability to predict the need for ICU admission, with an area under the curve (AUC) of 83.9% and 80.8% accuracy. It encompassed the age of admitted patients (AUC = 64.8%, p = .003), respiratory rate (AUC = 74.7%, p < .001), O2 saturation (AUC = 71.7%, p < .001), and random blood glucose level upon admission (AUC = 70.5%, p < .001). External validation of the proposed nomogram showed a high AUC (99.2%) with an overall accuracy of 96.2%. CONCLUSION There is a need to develop a reliable objective tool predicting the severity and need for ICU admission in acute clozapine intoxication. The proposed nomogram is a substantially valuable tool to estimate ICU admission probabilities among patients with acute clozapine intoxication and will help clinical toxicologists make rapid decisions for ICU admission, especially in countries with low resources.
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Affiliation(s)
- Asmaa F Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Department of Clinical Medical Sciences, College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - H A Aouissi
- Scientific and Technical Research Center on Arid Regions (CRSTRA), Biskra, Algeria
- Laboratoire de Recherche et d'Etude en Aménagement et Urbanisme (LREAU), Université des Sciences et de la Technologie (USTHB), Algiers, Algeria
- Environmental Research Center (CRE), Badji-Mokhtar Annaba University, Annaba, Algeria
| | - Zeinab A Kasemy
- Public Health and Community Medicine Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt
| | - H Byeon
- Department of Digital Anti-Aging Healthcare (BK21), Inje University, Gimhae, Republic of Korea
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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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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Abstract
AIMS Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates. METHOD We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons. RESULTS One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita. CONCLUSIONS Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.
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Jia N, Li Z, Li X, Jin M, Liu Y, Cui X, Hu G, Liu Y, He Y, Yu Q. Long-term effects of antipsychotics on mortality in patients with schizophrenia: a systematic review and meta-analysis. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44:664-673. [PMID: 36709510 PMCID: PMC9851750 DOI: 10.47626/1516-4446-2021-2306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To gather current evidence on the impact of antipsychotics on long-term mortality in patients with schizophrenia. METHODS We systematically searched for articles in Embase, PubMed, and PsycINFO reporting the long-term mortality (follow-up > 1 year) of patients with schizophrenia who were using any antipsychotics. We then conducted multiple meta-analyses to determine differences in long-term mortality between different types of antipsychotics. RESULTS We identified 45 articles that provided unadjusted long-term mortality rates, including 46,171 deaths during 2,394,911 person-years. The pooled mortality rate was 9.9 (95%CI = 7.4-12.7) per 1,000 person-years. The unadjusted crude mortality rate of antipsychotic drug users was lower than that of non-users (risk ratio [RR] = 0.546, 95%CI = 0.480-0.621), first-generation antipsychotics caused higher all-cause mortality than second-generation antipsychotics (RR = 1.485, 95%CI = 1.361-1.620), and polypharmacy had better effects than monotherapy on long-term mortality (RR = 0.796, 95%CI = 0.689-0.921). As for the causes of death, heart disease and cardiovascular disease ranked highest among cause-specific mortality (5.6 per 1,000 person-years). CONCLUSION Since antipsychotics had a beneficial effect on long-term mortality in schizophrenia, greater precaution should be taken with patients who do not take them. However, since disease severity, comorbidities, and other confounding factors cannot be fully controlled, further research and verification are needed.
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Affiliation(s)
- Ningning Jia
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Zhijun Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Xinwei Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Mengdi Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yane Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Xingyao Cui
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Guoyan Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yang Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yang He
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Qiong Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China,Correspondence: Qiong Yu, Jilin University, School of Public Health, Department of Epidemiology and Biostatistics, Changchun 130021, China. E-mail:
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Chammas F, Januel D, Bouaziz N. Inpatient suicide in psychiatric settings: Evaluation of current prevention measures. Front Psychiatry 2022; 13:997974. [PMID: 36386981 PMCID: PMC9650354 DOI: 10.3389/fpsyt.2022.997974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/05/2022] [Indexed: 12/01/2022] Open
Abstract
The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.
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Affiliation(s)
- Francesca Chammas
- Centre de Recherche Clinique, EPS Ville-Evrard, Neuilly-sur-Marne, France
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Massuda R, Gama CS, Belmonte-de-Abreu P, Elkis H, de Lucena DF, Bressan R, Noto C, Gadelha A. Clozapine prescription trends in Brazil in the last decade. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44:635-638. [PMID: 36327429 PMCID: PMC9851753 DOI: 10.47626/1516-4446-2022-2572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clozapine is a second-generation antipsychotic indicated for treatment-resistant schizophrenia. Studies in several countries have shown a low rate of clozapine use despite the fact that approximately 30% of schizophrenia cases are treatment-resistant. In Brazil, few studies have addressed the frequency and variety of antipsychotic use in individuals diagnosed with schizophrenia (ICD F20). The objective of this study was to measure the rates of clozapine use in this population in the last decade using Brazilian Ministry of Health data. METHODS Prescriptions made between 2010 and 2020 in all 26 states and the Federal District registered at the Outpatient Information System Database from the Brazilian Health System (SIASUS) were evaluated. RESULTS A total of 25,143,524 prescriptions were recorded in this period, with clozapine representing 8.86% of all antipsychotics. The most frequently prescribed antipsychotic for patients with schizophrenia was olanzapine (35.8%), followed by quetiapine (27.5%). From 2010 to 2020, the rate of clozapine prescriptions in Brazil increased from 7.2% to 10.9%. CONCLUSIONS Despite a slight increase in prescriptions in the last decade, clozapine is still underutilized in Brazil.
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Affiliation(s)
- Raffael Massuda
- Departamento de Psiquiatria, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil,Correspondence: Raffael Massuda, Departamento de Psiquiatria, Universidade Federal do Paraná (UFPR), Rua Padre Camargo, 280, CEP 80060-240, Curitiba, PR, Brazil. E-mail:
| | - Clarissa S. Gama
- Laboratório de Psiquiatria Molecular, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil,Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria e Medicina Legal, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Paulo Belmonte-de-Abreu
- Programa de Pós-Graduação em Psiquiatria e Ciências do Comportamento, Departamento de Psiquiatria e Medicina Legal, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Helio Elkis
- Departamento de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - David Freitas de Lucena
- Departamento de Farmacologia Clínica, Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil
| | - Rodrigo Bressan
- Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Cristiano Noto
- Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Ary Gadelha
- Departamento de Psiquiatria, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Sharma A, Buckhalter S, Siskind DJ, Castle D. Clozapine shared care: mental health services and
GPs
working together for better outcomes for people with schizophrenia. Med J Aust 2022; 217 Suppl 7:S36-S38. [DOI: 10.5694/mja2.51702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/05/2022] [Accepted: 06/29/2022] [Indexed: 11/05/2022]
Affiliation(s)
| | - Shoshana Buckhalter
- Centre for Complex Interventions, Centre for Addiction and Mental Health Toronto Canada
| | - Dan J Siskind
- Addiction and Mental Health Services, Metro South Health Brisbane QLD
- University of Queensland Brisbane QLD
| | - David Castle
- Centre for Complex Interventions, Centre for Addiction and Mental Health Toronto Canada
- University of Toronto Toronto Canada
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A systematic review of clozapine's effectiveness for primary psychotic and bipolar disorders in older adults. Int Psychogeriatr 2022; 34:875-887. [PMID: 33612141 DOI: 10.1017/s1041610220004172] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The primary aim was to systematically review the literature regarding the effectiveness of clozapine in reducing symptoms of primary psychotic and bipolar disorders in older adults. The secondary aim was to describe other reported patient and caregiver outcomes of clozapine treatment in older adults. DESIGN MEDLINE, Embase, PsychINFO, ProQuest, and PubMed databases were searched according to PRISMA guidelines for original empirical research examining the effectiveness of clozapine in adults aged 65 years or more with primary psychotic and bipolar disorders. Identified studies were assessed for methodological quality using the QualSyst tool. RESULTS 1121 records were screened, of which 7 studies met the inclusion criteria. In total, 128 subjects participated in the included studies (111 of whom were from a single study), with an age range of 65-86 years, and diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, and delusional disorder. Indications for clozapine use included treatment resistance and inability to tolerate other treatments. While six out of seven studies reported some improvement on the primary measure of psychopathology after treatment with clozapine, the group effects were modest and based on low-level evidence. Additional reported outcomes included discharge destination, death, and relapse. Most of the included studies were only of adequate methodological quality, with significant risks of bias identified. CONCLUSIONS Clozapine may have positive effects for primary psychotic and bipolar illnesses in some older adults, but the group effects reported were modest and based on low-level evidence studies with methodological limitations. Based on these findings, clinical decision-making about whether or not to trial clozapine should involve an individualized analysis of potential benefits and risks in collaboration with patients and their families and caregivers.
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41
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Kitchen D, Till A, Xavier P. Routine clozapine assay monitoring to improve the management of treatment-resistant schizophrenia. BJPsych Bull 2022; 46:267-270. [PMID: 33910673 PMCID: PMC9768514 DOI: 10.1192/bjb.2021.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
AIMS AND METHOD Routine therapeutic drug monitoring in clozapine therapy has previously not been considered justifiable. Using observational data, the clinical utility of annual clozapine assay monitoring is explored within a large mental health trust. RESULTS After the introduction of routine monitoring, the rate of clozapine assays rose to 2.3 per patient per year, with a consistent reduction in high-risk clozapine assays (<0.1 mg/L or >1.0 mg/L or any result more than 24 months old). High-risk assays are associated with a mortality rate of 31.6 deaths per 1000 patients, more than twice that of those within the target range (0.35-0.60 mg/L and conducted within the past 12 months) (P = 0.048). CLINICAL IMPLICATIONS Routine clozapine assay monitoring has significant clinical utility. Our simple but targeted approach can be readily implemented to reduce the number of patients with high-risk clozapine assay levels, potentially reduce all-cause mortality and provide optimal treatment for those with treatment-resistant schizophrenia.
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Affiliation(s)
- David Kitchen
- Mersey Care NHS Foundation Trust, Liverpool, UK.,Mersey Internal Audit Agency, Liverpool, UK
| | - Alex Till
- Health Education England (North West), Liverpool, UK
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Ventura AMB, Hayes RD, Fonseca de Freitas D. Ethnic disparities in clozapine prescription for service-users with schizophrenia-spectrum disorders: a systematic review. Psychol Med 2022; 52:2212-2223. [PMID: 35787301 PMCID: PMC9527670 DOI: 10.1017/s0033291722001878] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/28/2022] [Accepted: 06/01/2022] [Indexed: 11/05/2022]
Abstract
Clozapine is the only licenced medication for treating treatment-resistant schizophrenia. Previous studies have suggested unequal rates of clozapine treatment by ethnicity among individuals with schizophrenia-spectrum disorders. One previous review has investigated this topic but was restricted to studies from the USA. This current review aims to synthesise the international literature regarding ethnic disparities in clozapine prescription amongst individuals with schizophrenia-spectrum disorders. We searched CINAHL, PubMed, Medline, Embase, APA PsycINFO and Open Grey and reviewed studies reporting on the proportion of service-users prescribed clozapine separately for different ethnic groups, in individuals with a primary diagnosis of schizophrenia or any schizophrenia-spectrum disorders. A narrative synthesis was conducted to integrate information from included studies. The review was registered in PROSPERO (Number: CRD42020221731). From 24 studies, there is strong, consistent evidence that Black and Hispanic service-users in the UK and the USA are significantly less likely to receive clozapine than White/Caucasian service-users after controlling for multiple demographic and clinical potential confounders. In New Zealand, Māori service-users were reported to be more likely to receive clozapine than those of White/European ethnicity. There is mixed evidence regarding Asian service-users in the UK. The mentioned disparities were observed in studies with TRS and non-TRS cohorts. The results imply that access to clozapine treatment varies among ethnic groups. These findings raise an ethical concern as they suggest a compromise of the standards of care in schizophrenia treatment practices. Interventions are needed to reduce clozapine prescribing disparities among ethnic communities.
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Affiliation(s)
- Anita Margarette Bayya Ventura
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Richard D. Hayes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Daniela Fonseca de Freitas
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Kim G, Rim SJ, Jo M, Lee MG, Park SJ, Park S. The Cumulative Effect of Antipsychotic Usage on Mortality in Schizophrenia: A Nationwide Population-based Cohort Study in Korea. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:573-577. [PMID: 35879042 PMCID: PMC9329102 DOI: 10.9758/cpn.2022.20.3.573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/21/2022] [Accepted: 04/10/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Gyurin Kim
- Department of Research Planning, Seoul, Korea
| | | | - Minkyung Jo
- Department of Research Planning, Seoul, Korea
| | - Min Geu Lee
- Department of Research Planning, Seoul, Korea
| | - Se Jin Park
- Department of Research Planning, Seoul, Korea
| | - Subin Park
- Mental Health Research Institute, National Center for Mental Health, Seoul, Korea
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Katz IR, Szymanski BR, Marder SR, Shotwell A, Hein TC, McCarthy JF, Bowersox NW. Comparative risks of all-cause mortality for Veterans with schizophrenia with ongoing receipt of clozapine and other antipsychotic medications. Psychiatry Res 2022; 313:114590. [PMID: 35567853 DOI: 10.1016/j.psychres.2022.114590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/15/2022] [Accepted: 04/30/2022] [Indexed: 11/18/2022]
Abstract
To guide care for patients with schizophrenia, the Veterans Health Administration (VHA) evaluated the associations between current or recent use of clozapine and all-cause mortality and explored associations for other antipsychotic medications. Using a case-control design, patients with schizophrenia who died in fiscal years 2014-2018 were matched on age, sex, race, and VHA facility to up to 10 controls who were alive on the case's date of death (index date). Medication coverage during the 91 days before the index date was classified as none, partial (1-44 days), and consistent (45-91 days). Medication coverage patterns during the index period were compared to coverage patterns during the period of 92-182 days prior to index date with each medication coverage classified as no change, no coverage, increased, or decreased. Conditional logistic regression analyses controlling for patient characteristics identified no associations of consistent or increasing clozapine coverage with mortality; partial and decreasing coverage were associated with greater mortality and these effects did not differ from those of other the medications considered. Exploratory analyses considering non-clozapine antipsychotic agents suggest that consistent coverage by olanzapine may be associated with increased mortality, that mortality associated with olanzapine may be greater than aripiprazole, and that this effect can be attributed primarily to patients with diabetes. Further study of this topic is needed.
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Affiliation(s)
- Ira R Katz
- Department of Veterans Affairs, VA Office of Mental Health and Suicide Prevention, Washington, DC, USA
| | - Benjamin R Szymanski
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, North Campus Research Complex, 2800 Plymouth Rd, Building 16, Room 016-233W, Ann Arbor, MI 48109, USA
| | - Stephen R Marder
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, CA, USA; Veterans Affairs Desert Pacific Mental Illness Research, Education, and Clinical Center, Los Angeles, USA
| | - Abigail Shotwell
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, North Campus Research Complex, 2800 Plymouth Rd, Building 16, Room 016-233W, Ann Arbor, MI 48109, USA
| | - Tyler C Hein
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, North Campus Research Complex, 2800 Plymouth Rd, Building 16, Room 016-233W, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John F McCarthy
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, North Campus Research Complex, 2800 Plymouth Rd, Building 16, Room 016-233W, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, North Campus Research Complex, 2800 Plymouth Rd, Building 16, Room 016-233W, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
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45
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Correll CU, Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Seppälä N, Howes OD. A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia. CNS Drugs 2022; 36:659-679. [PMID: 35759211 PMCID: PMC9243911 DOI: 10.1007/s40263-022-00932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.
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Affiliation(s)
- C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea de Bartolomeis
- Section on Clinical Psychiatry and Psychology, Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, University of Naples Federico II, Naples, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Niko Seppälä
- Department of Psychiatry Satasairaala, Harjavalta, Finland
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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46
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de Freitas DF, Patel I, Kadra-Scalzo G, Pritchard M, Shetty H, Broadbent M, Patel R, Downs J, Segev A, Khondoker M, MacCabe JH, Bhui K, Hayes RD. Ethnic inequalities in clozapine use among people with treatment-resistant schizophrenia: a retrospective cohort study using data from electronic clinical records. Soc Psychiatry Psychiatr Epidemiol 2022; 57:1341-1355. [PMID: 35246709 PMCID: PMC9246775 DOI: 10.1007/s00127-022-02257-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/18/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE Clozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder. METHODS A retrospective cohort study, using information from 11 years of clinical records (2007-2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use. RESULTS Among 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine. CONCLUSION Black service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.
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Affiliation(s)
- Daniela Fonseca de Freitas
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK.
- Department of Psychiatry, University of Oxford, Oxford, UK.
| | - India Patel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - Giouliana Kadra-Scalzo
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
| | - Megan Pritchard
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Hitesh Shetty
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Rashmi Patel
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Johnny Downs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Aviv Segev
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
- Department of Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Shalvata Mental Health Center, Hod Hasharon, Israel
| | | | - James H MacCabe
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Kamaldeep Bhui
- Department of Psychiatry, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard D Hayes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, 16 De Crespigny Park, Denmark Hill, London, SE5 8AF, UK
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47
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Tiihonen J, Tanskanen A, Bell JS, Dawson JL, Kataja V, Taipale H. Clozapine and the risk of haematological malignancies - Authors' reply. Lancet Psychiatry 2022; 9:539-540. [PMID: 35717958 DOI: 10.1016/s2215-0366(22)00204-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm 11364, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden; Neuroscience Center, University of Helsinki, Helsinki, Finland.
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm 11364, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - J Simon Bell
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jessica L Dawson
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; SA Pharmacy, Flinders Medical Centre, Bedford Park, Adelaide, SA, Australia
| | | | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm 11364, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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48
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Ochi S, Tagata H, Hasegawa N, Yasui-Furukori N, Iga JI, Kashiwagi H, Kodaka F, Komatsu H, Tsuboi T, Tokutani A, Numata S, Ichihashi K, Onitsuka T, Muraoka H, Iida H, Ohi K, Atake K, Kishimoto T, Hori H, Takaesu Y, Takeshima M, Usami M, Makinodan M, Hashimoto N, Fujimoto M, Furihata R, Nagasawa T, Yamada H, Matsumoto J, Miura K, Kido M, Hishimoto A, Ueno SI, Watanabe K, Inada K, Hashimoto R. Clozapine Treatment Is Associated With Higher Prescription Rate of Antipsychotic Monotherapy and Lower Prescription Rate of Other Concomitant Psychotropics: A Real-World Nationwide Study. Int J Neuropsychopharmacol 2022; 25:818-826. [PMID: 35723038 PMCID: PMC9593218 DOI: 10.1093/ijnp/pyac036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/18/2022] [Accepted: 06/15/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although clozapine is effective for treatment-resistant schizophrenia (TRS), the rate of clozapine prescription is still low. Whereas antipsychotic monotherapy is recommended in clinical practice guidelines, the rate of antipsychotic polypharmacy is still high. There is little evidence on whether a clozapine prescription influences changes in the rate of monotherapy and polypharmacy, including antipsychotics and other psychotropics. We therefore hypothesized that the rate of antipsychotic monotherapy in patients with TRS who were prescribed clozapine would be higher than that in patients with schizophrenia who were not prescribed clozapine. METHODS We assessed 8306 patients with schizophrenia nationwide from 178 institutions in Japan from 2016 to 2019. We analyzed the psychotropic prescription data at discharge in patients diagnosed with TRS and with no description of TRS (ND-TRS) based on the diagnosis listed in the discharge summary. RESULTS The rate of antipsychotic monotherapy in the TRS with clozapine group (91.3%) was significantly higher than that in the TRS without clozapine group (45.9%; P < 2.0 × 10-16) and the ND-TRS without clozapine group (54.7%; P < 2.0 × 10-16). The rate of antipsychotic monotherapy without any other concomitant psychotropics in the TRS with clozapine group (26.5%) was significantly higher than that in the TRS without clozapine group (12.6%; P = 1.1 × 10-6) and the ND-TRS without clozapine group (17.0%; P = 5.9 × 10-6). CONCLUSIONS Clozapine prescription could be associated with a high rate of antipsychotic monotherapy. Patients will benefit from the correct diagnosis of TRS and thus from proper clozapine prescription.
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Affiliation(s)
- Shinichiro Ochi
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiromi Tagata
- Department of Neuropsychiatry, Toho University School of Medicine, Tokyo, Japan
| | - Naomi Hasegawa
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Norio Yasui-Furukori
- Correspondence: Norio Yasui-Furukori, MD, PhD, Department of Psychiatry, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Shimotsuga, Mibu, Tochigi, 321-0293, Japan ()
| | - Jun-ichi Iga
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroko Kashiwagi
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Forensic Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Fumitoshi Kodaka
- Department of Psychiatry, The Jikei University School of Medicine, Tokyo, Japsan
| | - Hiroshi Komatsu
- Department of Psychiatry, Tohoku University Hospital, Miyagi, Japan
| | - Takashi Tsuboi
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Akira Tokutani
- Department of Pharmacy, The Hospital of Hyogo College of Medicine, Hyogo, Japan
| | - Shusuke Numata
- Department of Psychiatry, Graduate School of Biomedical Science, Tokushima University, Tokushima, Japan
| | - Kayo Ichihashi
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Toshiaki Onitsuka
- Department of Neuroimaging Psychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Muraoka
- Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hitoshi Iida
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kiyokazu Atake
- Nippon Telegraph and Telephone West Corporation Kyushu Health Administration Center, Fukuoka, Japan
| | - Taishiro Kishimoto
- Hills Joint Research Laboratory for Future Preventive Medicine and Wellness, Keio University School of Medicine, Tokyo, Japan
| | - Hikaru Hori
- Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshikazu Takaesu
- Department of Neuropsychiatry, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita, Japan
| | - Masahide Usami
- Department of Child and Adolescent Psychiatry, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
| | - Manabu Makinodan
- Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan
| | - Naoki Hashimoto
- Department of Psychiatry, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Michiko Fujimoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Tatsuya Nagasawa
- Department of NeuroPsychiatry Kanazawa Medical University, Ishikawa, Japan
| | - Hisashi Yamada
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan,Department of Neuropsychiatry, Hyogo College of Medicine, Hyogo, Japan
| | - Junya Matsumoto
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kenichiro Miura
- Department of Pathology of Mental Diseases, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mikio Kido
- Toyama City Hospital, Toyama, Japan,Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Akitoyo Hishimoto
- Department of Psychiatry, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Shu-ichi Ueno
- Department of Neuropsychiatry, Molecules and Function, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, Kitasato University, School of Medicine, Kanagawa, 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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Grasing KW, Burnell K, De A. Biphasic reward effects are characteristic of both lorcaserin and drugs of abuse: implications for treatment of substance use disorders. Behav Pharmacol 2022; 33:238-248. [PMID: 35324488 PMCID: PMC9149059 DOI: 10.1097/fbp.0000000000000672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Lorcaserin is a modestly selective agonist for 2C serotonin receptors (5-HT2CR). Despite early promising data, it recently failed to facilitate cocaine abstinence in patients and has been compared with dopamine antagonist medications (antipsychotics). Here, we review the effects of both classes on drug reinforcement. In addition to not being effective treatments for cocaine use disorder, both dopamine antagonists and lorcaserin can have biphasic effects on dopamine and reward behavior. Lower doses can cause enhanced drug taking with higher doses causing reductions. This biphasic pattern is shared with certain stimulants, opioids, and sedative-hypnotics, as well as compounds without abuse potential that include agonists for muscarinic and melatonin receptors. Additional factors associated with decreased drug taking include intermittent dosing for dopamine antagonists and use of progressive-ratio schedules for lorcaserin. Clinically relevant doses of lorcaserin were much lower than those that inhibited cocaine-reinforced behavior and can also augment this same behavior in different species. Diminished drug-reinforced behavior only occurred in animals after higher doses that are not suitable for use in patients. In conclusion, drugs of abuse and related compounds often act as biphasic modifiers of reward behavior, especially when evaluated over a broad range of doses. This property may reflect the underlying physiology of the reward system, allowing homeostatic influences on behavior.
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Affiliation(s)
- Ken W Grasing
- Substance Use Research Laboratory, Research Service, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
- Division of Clinical Pharmacology, Department of Medicine, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kim Burnell
- Substance Use Research Laboratory, Research Service, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
| | - Alok De
- Substance Use Research Laboratory, Research Service, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
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Correll CU, Solmi M, Croatto G, Schneider LK, Rohani-Montez SC, Fairley L, Smith N, Bitter I, Gorwood P, Taipale H, Tiihonen J. Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors. World Psychiatry 2022; 21:248-271. [PMID: 35524619 PMCID: PMC9077617 DOI: 10.1002/wps.20994] [Citation(s) in RCA: 171] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
People with schizophrenia die 15-20 years prematurely. Understanding mortality risk and aggravating/attenuating factors is essential to reduce this gap. We conducted a systematic review and random-effects meta-analysis of prospective and retrospective, nationwide and targeted cohort studies assessing mortality risk in people with schizophrenia versus the general population or groups matched for physical comorbidities or groups with different psychiatric disorders, also assessing moderators. Primary outcome was all-cause mortality risk ratio (RR); key secondary outcomes were mortality due to suicide and natural causes. Other secondary outcomes included any other specific-cause mortality. Publication bias, subgroup and meta-regression analyses, and quality assessment (Newcastle-Ottawa Scale) were conducted. Across 135 studies spanning from 1957 to 2021 (schizophrenia: N=4,536,447; general population controls: N=1,115,600,059; other psychiatric illness controls: N=3,827,955), all-cause mortality was increased in people with schizophrenia versus any non-schizophrenia control group (RR=2.52, 95% CI: 2.38-2.68, n=79), with the largest risk in first-episode (RR=7.43, 95% CI: 4.02-13.75, n=2) and incident (i.e., earlier-phase) schizophrenia (RR=3.52, 95% CI: 3.09-4.00, n=7) versus the general population. Specific-cause mortality was highest for suicide or injury-poisoning or undetermined non-natural cause (RR=9.76-8.42), followed by pneumonia among natural causes (RR=7.00, 95% CI: 6.79-7.23), decreasing through infectious or endocrine or respiratory or urogenital or diabetes causes (RR=3 to 4), to alcohol or gastrointestinal or renal or nervous system or cardio-cerebrovascular or all natural causes (RR=2 to 3), and liver or cerebrovascular, or breast or colon or pancreas or any cancer causes (RR=1.33 to 1.96). All-cause mortality increased slightly but significantly with median study year (beta=0.0009, 95% CI: 0.001-0.02, p=0.02). Individuals with schizophrenia <40 years of age had increased all-cause and suicide-related mortality compared to those ≥40 years old, and a higher percentage of females increased suicide-related mortality risk in incident schizophrenia samples. All-cause mortality was higher in incident than prevalent schizophrenia (RR=3.52 vs. 2.86, p=0.009). Comorbid substance use disorder increased all-cause mortality (RR=1.62, 95% CI: 1.47-1.80, n=3). Antipsychotics were protective against all-cause mortality versus no antipsychotic use (RR=0.71, 95% CI: 0.59-0.84, n=11), with largest effects for second-generation long-acting injectable anti-psychotics (SGA-LAIs) (RR=0.39, 95% CI: 0.27-0.56, n=3), clozapine (RR=0.43, 95% CI: 0.34-0.55, n=3), any LAI (RR=0.47, 95% CI: 0.39-0.58, n=2), and any SGA (RR=0.53, 95% CI: 0.44-0.63, n=4). Antipsychotics were also protective against natural cause-related mortality, yet first-generation antipsychotics (FGAs) were associated with increased mortality due to suicide and natural cause in incident schizophrenia. Higher study quality and number of variables used to adjust the analyses moderated larger natural-cause mortality risk, and more recent study year moderated larger protective effects of antipsychotics. These results indicate that the excess mortality in schizophrenia is associated with several modifiable factors. Targeting comorbid substance abuse, long-term maintenance antipsychotic treatment and appropriate/earlier use of SGA-LAIs and clozapine could reduce this mortality gap.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
- Department of Mental Health, Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Giovanni Croatto
- Mental Health Department, AULSS 3 Serenissima, Mestre, Venice, Italy
| | | | | | | | | | - István Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Philip Gorwood
- INSERM U1266, Institute of Psychiatry and Neurosciences of Paris (IPNP), Paris, France
- GHU Paris Psychiatrie et Neurosciences (CMME, Sainte-Anne Hospital), Université de Paris, Paris, France
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
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