Cardiovascular effects of novel antipsychotic medications

Developing a System of Health Support for Young People Experiencing First-Episode Psychosis: Protocol for a Co-design Process

BACKGROUND

People living with psychosis face a substantially increased risk of poor psychological well-being and physical health and premature mortality. Encouraging positive health behaviors from an early stage is crucial to the health and well-being of this population but is often overshadowed by symptom management within early intervention services.

OBJECTIVE

Experience-based co-design is a participant-centered approach that aims to combine service user narratives with service design methods to design systems of support for health and well-being. This study aims to use experience-based co-design principles to co-design a system that supports the health and well-being of young people experiencing first-episode psychosis (FEP), which considers the lived experience of these people within the context of early intervention services. We also aim to develop a set of principles to guide future systems to support the health and well-being of young people experiencing FEP.

METHODS

Up to 15 young people living with FEP aged 16 to 24 years who are service users of early intervention services in psychosis, their immediate support networks (family or friends), and health professionals involved with early intervention services in psychosis will be invited to participate in a series of co-design workshops. Data will be collected in various forms, including expressive forms (eg, art and spoken word) and traditional methods (interview transcription and surveys), with phenomenographic and thematic analyses being used to understand these data. Furthermore, the co-design process will draw upon indigenous (Māori) knowledge and the lived experience of mental health services from the perspectives of the members of the research team. The co-design process will be evaluated in terms of acceptability from the perspective of service users via rating scales and interviews. The study will be conducted within the Lower North Island in Aotearoa New Zealand.

RESULTS

Data collection will be performed between August 2022 and February 2023. Drawing from extended consultations with service users and service providers, we have developed a robust co-design process with which we intend to collect rich qualitative and quantitative data. The results of this process will be used to create a system of support that can be immediately applied and as preliminary evidence for funding and resource applications to deliver and evaluate a "full" version of the co-designed system of support.

CONCLUSIONS

The co-designed system of support and accompanying set of principles will offer a potentially impactful health and well-being intervention for young people experiencing FEP in Aotearoa New Zealand. Furthermore, making the co-design process transparent will further the field in terms of providing a blueprint for this form of participant-focused research.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622001323718; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384775&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44980.

Regulation of monoamine levels by typical and atypical antipsychotics in Caenorhabditis elegans mutant for nuclear distribution element genes

Mammalian nuclear distribution genes encode proteins with essential roles in neuronal migration and brain formation during embryogenesis. The implication of human nuclear distribution genes, namely nudC and NDE1 (Nuclear Distribution Element 1)/NDEL1 (Nuclear Distribution Element-Like 1), in psychiatric disorders including schizophrenia and bipolar disorder, has been recently described. The partial loss of NDEL1 expression results in neuronal migration defects, while ndel1 null knockout (KO) leads to early embryonic lethality in mice. On the other hand, loss-of-function of the orthologs of nuclear distribution element genes (nud) in Caenorhabditis elegans renders viable worms and influences behavioral endophenotypes associated with dopaminergic and serotoninergic pathways. In the present work, we evaluated the role of nud genes in monoamine levels at baseline and after the treatment with typical or atypical antipsychotics. Dopamine, serotonin and octopamine levels were significantly lower in homozygous loss-of-function mutant worms KO for nud genes compared with wild-type (WT) C. elegans at baseline. While treatment with antipsychotics determined significant differences in monoamine levels in WT, the nud KO mutant worms appear to respond differently to the treatment. According to the best of our knowledge, we are the first to report the influence of nud genes in the monoamine levels changes in response to antipsychotic drugs, ultimately placing the nuclear distribution genes family at the cornerstone of pathways involved in the modulation of monoamines in response to different classes of antipsychotic drugs.

Neuropeptides and oligopeptidases in schizophrenia

Schizophrenia (SCZ) is a complex psychiatric disorder with severe impact on patient's livelihood. In the last years, the importance of neuropeptides in SCZ and other CNS disorders has been recognized, mainly due to their ability to modulate the signaling of classical monoaminergic neurotransmitters as dopamine. In addition, a class of enzymes coined as oligopeptidases are able to cleave several of these neuropeptides, and their potential implication in SCZ was also demonstrated. Interestingly, these enzymes are able to play roles as modulators of neuropeptidergic systems, and they were also implicated in neurogenesis, neurite outgrowth, neuron migration, and therefore, in neurodevelopment and brain formation. Altered activity of oligopeptidases in SCZ was described only more recently, suggesting their possible utility as biomarkers for mental disorders diagnosis or treatment response. We provide here an updated and comprehensive review on neuropeptides and oligopeptidases involved in mental disorders, aiming to attract the attention of physicians to the potential of targeting this system for improving the therapy and for understanding the neurobiology underlying mental disorders as SCZ.

Pharmacological Treatment for Long-Term Patients with Schizophrenia and Its Effects on Sleep in Daily Clinical Practice: A Pilot Study

Background: Pharmacological treatment is still the key intervention in the disease management of long-term patients with schizophrenia; however, how it affects sleep and whether gender differences exist remains unclear. Methods: Forty-six long-term outpatients with schizophrenia entered the study. The numbers of antipsychotics, sleep medications, antidepressants, and anxiolytics were analyzed. Moreover, all patients were tested using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Correlation analyses were conducted between the medication used and the scores on the two subjective sleep inventories. Results: A large variability, ranging from 0 to 8, in the total number of psychiatric drugs per person was found between the patients. Despite ongoing pharmacological treatment, the patients scored high on the PSQI, but not on the ESS; this indicates that they report problems with sleep, but not with daytime sleepiness. A significant positive correlation between the use of antipsychotics and the ESS score, but not the PSQI score, was found; moreover, no gender differences were found. Conclusions: A large variability exists in the pharmacological treatment of long-term patients with schizophrenia. To date, patients’ sleep problems have been insufficiently treated, and gender differences have not been adequately accounted for in the pharmacological treatment of schizophrenia. More and larger international clinical studies are warranted to verify the findings of the present preliminary pilot study before any firm conclusions can be drawn and before any changes to the drug treatment of male and female patients with schizophrenia can be recommended.

Cardiovascular Risk in Early Psychosis: Relationship with Inflammation and Clinical Features 6 Months after Diagnosis

BACKGROUND

We aimed to investigate the state of cardiovascular risk/protection factors in early psychosis patients.

METHODS

A total 119 subjects were recruited during the first year after their first episode of psychosis. Eighty-five of these subjects were followed during the next 6 months. Cardiovascular risk/protection factors were measured in plasma and co-variated by sociodemographic/clinical characteristics. Multiple linear regression models detected the change of each biological marker from baseline to follow-up in relation to clinical scales, antipsychotic medication, and pro-/antiinflammatory mediators.

RESULTS

Glycosylated hemoglobin is a state biomarker in first episode of psychosis follow-up patients and inversely correlated to the Global Assessment of Functioning scale. We found opposite alterations in the levels of VCAM-1 and E-selectin in first episode of psychosis baseline conditions compared with control that were absent in the first episode of psychosis follow-up group. Adiponectin levels decreased in a continuum in both pathological time points studied. E-Selectin plasma levels were inversely related to total antipsychotic equivalents and adiponectin levels inversely co-related to the Global Assessment of Functioning scale. Finally, adiponectin levels were directly related to antiinflammatory nuclear receptor PPARγ expression in first episode of psychosis baseline conditions and to proinflammatory nuclear factor nuclear factor κB activity in follow-up conditions, respectively.

CONCLUSIONS

Our results support the need for integrating cardiovascular healthcare very early after the first episode of psychosis.

Myocardial infarction risk and antipsychotics use revisited: a meta-analysis of 10 observational studies

OBJECTIVE

Associations between antipsychotic agent (AP) use and myocardial infarction (MI) risk have been inconsistent and remain controversial. We therefore conducted a meta-analysis of observational studies to address this knowledge gap.

METHOD

Detailed electronic database searches were performed to identify reports of observational studies that evaluated the association between AP use and the risk of MI. Pooled odds ratios (ORs) were calculated using random or fixed-effects models.

RESULTS

In total, four case-control studies, two case-crossover studies, one case-case time control study, three cohort studies, and one self-controlled case series were included. The pooled OR (95% confidence interval (CI)) between any AP use and MI risk was 1.55 (1.33-1.79) compared with non-use: 1.39 (1.06-1.82) for atypical AP use and 1.57 (1.29-1.91) for typical AP use. Subgroup analyses indicated that male gender, schizophrenia diagnosis, and AP exposure periods ≤60 days were associated with higher risk of MI.

CONCLUSION

Current evidence, based on 10 observational studies, suggested that AP use might be a potential risk factor of MI. However, we cannot conclude at this time due to significant heterogeneity among studies. We suggest that, instead of not using APs in fear of MI risk, careful cardiovascular monitoring before and during AP treatment in high-risk patients is needed. Additional high-quality prospective studies are required to evaluate the association between APs and the risk of MI.

Minimizing cardiovascular adverse effects of atypical antipsychotic drugs in patients with schizophrenia

The use of atypical antipsychotic agents has rapidly increased in the United States and worldwide in the last decade. Nonetheless, many health care practitioners do not appreciate the significance of the cardiovascular side effects that may be associated with their use and the means to minimize them. Thus, atypical antipsychotic medications can cause cardiovascular side effects such as arrhythmias and deviations in blood pressure. In rare cases, they may also cause congestive heart failure, myocarditis, and sudden death. Patients with schizophrenia have a higher risk of cardiovascular mortality than healthy individuals, possibly because of excessive smoking, the underlying disorder itself, or a combination of both factors. Increased awareness of these potential complications can allow pharmacists and physicians to better manage and monitor high risk patients. Accurate assessments are very important to avoid medications from being given to patients inappropriately. Additionally, monitoring patients regularly via blood draws and checking blood pressure, heart rate, and electrocardiogram can help catch any clinical problems and prevent further complications. Finally, patient and family-member education, which pharmacists in particular can play key roles in, is central for the management and prevention of side effects, which is known to reflect positively on morbidity and mortality in these patients.

Effects on prolongation of Bazett's corrected QT interval of seven second-generation antipsychotics in the treatment of schizophrenia: a meta-analysis

The use of second-generation antipsychotics (SGAs) for the treatment of schizophrenia has surged worldwide. Amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, sertindole and ziprasidone have now been commonly prescribed. Their effects on QT interval differ but evidence remains sparse and mostly inconclusive. Since prolongation of heart-rate corrected QT interval has been implicated as an useful surrogate marker to predict drug-related cardiac mortality and pro-arrhythmic potentials, it is timely and necessary to compare the effects of Bazett's corrected QT interval (QT(Bc)) prolongation for the commonly prescribed SGAs. A meta-analysis was conducted according to suggestions by the Quality of Reporting of Meta-analysis group with literature identified using various databases and augmented with hand-searching to assess the magnitude and risk on QT(Bc) prolongation by these seven SGAs for treatments in adult subjects with schizophrenia. Because of incomplete QT(Bc) data reporting, quetiapine could not be assessed by the meta-analytical approach in this study. Aripiprazole was the only SGA associated with both statistically significant lower risk and mean change in QT(Bc), with sertindole giving a statistically significant worsening effect on mean QT(Bc). Other analyses did not demonstrate any statistically significant pooled effects for the studied SGAs, neither on the magnitude over mean or mean change, nor the risk on QT(Bc) prolongation.

The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments

OBJECTIVES

Safety monitoring is an important aspect of bipolar disorder treatment, as mood-stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost-effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.

METHODS

These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus-based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.

RESULTS

General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.

CONCLUSIONS

These guidelines are derived from evolving and often indirect data, with minimal empirical cost-effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.

Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery

This randomised, double-blinded, placebo-controlled study was primarily aimed to evaluate the potential of risperidone to prevent postoperative delirium following cardiac surgery with cardiopulmonary bypass and the secondary objective was to explore clinical factors associated with postoperative delirium. One-hundred-and-twenty-six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomly assigned to receive either 1 mg of risperidone or placebo sublingually when they regained consciousness. Delirium and other outcomes were assessed. The confusion assessment method for intensive care unit was used to assess postoperative delirium. The incidence of postoperative delirium in the risperidone group was lower than the placebo group (11.1% vs. 31.7% respectively, P=0.009, relative risk = 0.35, 95% confidence interval [CI] = 0.16-0.77). Other postoperative outcomes were not statistically different between the groups. In exploring the factors associated with delirium, univariate analysis showed many factors were associated with postoperative delirium. However multiple logistic regression analysis showed a lapse of 70 minutes from the time of opening eyes to following commands and postoperative respiratory failure were independent risk factors (P=0.003, odds ratio [OR] = 4.57, 95% CI = 1.66-12.59 and P=0.038, OR = 13.78, 95% CI = 1.15-165.18 respectively). A single dose of risperidone administered soon after cardiac surgery with cardiopulmonary bypass reduces the incidence of postoperative delirium. Multiple factors tended to be associated with postoperative delirium, but only the time from opening eyes to following commands and postoperative respiratory failure were independent risk factors in this study.

Cardiovascular risks of atypical antipsychotic drug treatment

Atypical antipsychotics are the treatment of choice for patients with schizophrenia. They are generally better tolerated than conventional antipsychotics since most do not cause debilitating extrapyramidal symptoms. They are associated though with an array of cardiovascular adverse events that may affect morbid-mortality of schizophrenic patients. Orthostatic hypotension, electrocardiographic changes and metabolic syndrome (MS) are the main cardiovascular effects of atypical antipsychotics. They contribute to the overall disease burden associated with schizophrenia even though the benefit risk of such treatments still is highly favourable. We aim to review the main cardiovascular side effects of new atypical oral antipsychotics, the pharmacological mechanisms involved, and to which drugs they are particularly attributed.

Mortality in schizophrenia

PURPOSE

The purpose of this article is to describe the current status of knowledge on excess mortality in schizophrenia and its causative factors, and to expand upon previous work evaluating approaches that may reduce mortality rates.

METHODS

Literature available since 1995 was identified in a computerized search of the bibliographical databases Medline and Embase, using the topics 'mortality' and 'schizophrenia', and in a cross-reference search for articles that were particularly relevant.

RESULTS

Schizophrenia is associated with mortality rates that are two to three times higher than those expected or observed in the general population. This excess of mortality is accounted for by a combination of an increased risk of suicide, in particular in young male patients soon after diagnosis, and more importantly, a higher number of natural deaths. In order to diminish the level of suicide among people with schizophrenia, the majority of research has focused on the identification of risk factors that predispose patients to attempt or commit suicide, while unhealthy styles, polypharmacy and inadequate healthcare have been shown to contribute to the high natural mortality. The link between the use of antipychotics and mortality has not been yet clarified.

CONCLUSION

Dramatically increased mortality of schizophrenia patients is well established. It is time to move beyond this topic, and work towards interventions that aim at reducing the mortality risk in such patients.

Assessing cardiovascular risks of olanzapine treatment: a 6-month study versus haloperidol in schizophrenia patients

The introduction of second generation antipsychotics (SGA) represents a major advance in the treatment of schizophrenia. Concerns about the metabolic and cardiovascular adverse effects of the SGA have been widely disseminated. The benefits and risks of these drugs have been studied with a focus on particular organ systems. A basic principle of prevention is that the intensity of risk-reduction therapy should be adjusted to a individual's absolute risk. Hence, the first step is to assess an individual's risk status. The present study was designed to evaluate whether there is an added cardiovascular disease (CVD) risk in switching schizophrenia patients from typical antipsychotics to the SGA olanzapine. Risk status was determined by a 10-year risk assessment as recommended by the USA National Heart, Lung, and Blood Institute. This was carried out with Framingham scoring to identify individuals whose short-term (10-year) risk warrants consideration of intensive treatment. This risk was calculated for schizophrenia patients who were treated by haloperidol for a minimum period of 6 months and again following 6 months of exposure to olanzapine. Forty-three patients fulfilled inclusion criteria. There were 25 male and 18 female patients (mean age 40.7+/-2.4 years). The mean 10-year percentage risk of CVD for the group while on haloperidol treatment was 4.58+/-0.9 and, after 6 months of exposure to olanzapine, this was reduced to 4.12+/-0.9. Changes in the total risk and each evaluated risk variable were not statistically significant, except for a decrease in resting systolic blood pressure. Switching schizophrenia patients from typical antipsychotic treatment to olanzapine is safe and does not increase the long-term risk of cardiovascular disease.

Adverse cardiac effects associated with clozapine

OBJECTIVE

To review the published literature on serious adverse cardiac events associated with the atypical antipsychotic agent, clozapine, and to make recommendations for cardiac assessment of candidates for clozapine treatment and for monitoring of cardiac status after treatment is initiated.

DATA SOURCES

We searched the PubMed and MEDLINE databases for articles published from 1970 to 2004 that contain the keywords "clozapine and myocarditis," "clozapine and cardiomyopathy," "clozapine and cardiotoxicity," "clozapine and sudden death" or "clozapine and mortality." We also manually searched the bibliographies of these articles for related sources.

STUDY SELECTION

We reviewed the 30 case reports, case series, laboratory and clinical trials, data mining studies, and previous reviews identified by this search.

DATA SYNTHESIS

Recent evidence suggests that clozapine is associated with a low (0.015% to 0.188%) risk of potentially fatal myocarditis or cardiomyopathy. The drug is not known to be independently associated with pathologic prolongation of the QTc interval, but it may contribute to pathologic QTc prolongation in patients with other risk factors for this condition.

CONCLUSIONS

The low risk of a serious adverse cardiac event should be outweighed by a reduction in suicide risk for most patients taking clozapine. We provide recommendations for assessing and monitoring cardiac status in patients prior to and after initiation of treatment with clozapine.