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Patrichi B, Ţăpoi C, Rogojină RŞ, Bedreagă I, Dumitrache A, Itu A, Dragomir R, Buciuc AG. Antipsychotic polypharmacy in adult patients diagnosed with schizophrenia: A retrospective study. Exp Ther Med 2021; 22:1225. [PMID: 34539821 PMCID: PMC8438669 DOI: 10.3892/etm.2021.10659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Antipsychotic polypharmacy (APP) is a common practice in the treatment of schizophrenia. In this study, we aimed to identify the prevalence of APP in our department, as well as the trends associated with co-prescribing antipsychotics. We collected data from the medical records of all 193 inpatients diagnosed with schizophrenia who were admitted to Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital (Bucharest, Romania), Department 9, during January 2019-December 2019. Demographic characteristics of the patients, clinical diagnosis, psychiatric admission type and duration of hospitalization were examined. Data regarding the antipsychotic regimen at discharge and other psychotropic drugs used were collected. A total of 69 (35.75%) patients received more than 2 antipsychotics upon discharge. Patients treated with APP did not differ in regards to sex, age, education level, employment status, marital status, living situation, type of admission from those receiving antipsychotic monotherapy (APM). Prolonged hospitalization was found to be an independent predictor of APP (P=0.014). Most of the combinations used in our unit included clozapine (47.8%), and the most frequently used treatment in the APP group was the combination of paliperidone and clozapine (14.5%). In the APP group, 30 (43.5%) patients included in their regimen was a long-acting intramuscular antipsychotic. There was no significant difference in terms of the use of mood stabilizers, antiparkinsonian drugs or anxiolytics between the APP and the APM group; yet, a higher prevalence of antidepressant use, although not statistically significant (P=0.067), in the APP group compared to the APM group, was observed. The use of APP as a long-term regimen is a common practice in our department, as it is worldwide. There is a great need for randomized-control trials and evidence-based studies in order to define the safest and most effective combinations of antipsychotics and also the characteristics of patients that may benefit from these combinations.
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Affiliation(s)
- Bogdan Patrichi
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania.,Department of General Psychiatry, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Cristiana Ţăpoi
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Radu Ştefan Rogojină
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Irina Bedreagă
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Anca Dumitrache
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Andreea Itu
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Radu Dragomir
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
| | - Adela-Georgiana Buciuc
- Department of General Psychiatry, 'Prof. Dr. Alexandru Obregia' Clinical Psychiatry Hospital, 041914 Bucharest, Romania
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Prescription practices in the treatment of agitation in newly hospitalized Chinese schizophrenia patients: data from a non-interventional naturalistic study. BMC Psychiatry 2019; 19:216. [PMID: 31291931 PMCID: PMC6617899 DOI: 10.1186/s12888-019-2192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/23/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Data on the pharmacological management of acute agitation in schizophrenia are scarce. The aim of this study is to investigate the prescription practices in the treatment of agitation in Chinese patients with schizophrenia. METHODS We conducted a large, multicenter, observational study in 14 psychiatry hospitals in China. Newly hospitalized schizophrenia patients with the PANSS-EC total score ≥ 14 and a value ≥4 on at least one of its five items were included in the study. Their drug treatments of the first 2 weeks in hospital were recorded by the researchers. RESULTS Eight hundred and 53 patients enrolled in and 847 (99.30%) completed the study. All participants were prescribed antipsychotics, 40 (4.72%) were prescribed benzodiazepine in conjunction with antipsychotics and 81 were treated with modified electric convulsive therapy (MECT). Four hundred and 12 (48.64%) patients were prescribed only one antipsychotic, in the order of olanzapine (120 patients, 29.13%), followed by risperidone (101 patients, 24.51%) and clozapine (41 patients, 9.95%). About 435 (51.36%) participants received antipsychotic polypharmacy, mostly haloperidol + risperidone (23.45%), haloperidol+ olanzapine (17.01%), olanzapine+ ziprasidone (5.30%), haloperidol + clozapine (4.37%) and haloperidol + quetiapine (3.90%). Binary logistic regression analysis suggests that a high BARS score (OR 2.091, 95%CI 1.140-3.124), severe agitation (OR 1.846, 95%CL 1.266-2.693), unemployment or retirement (OR 1.614, 95%CL 1.189-2.190) and aggressiveness on baseline (OR 1.469, 95%CL 1.032-2.091) were related to an increased antipsychotic polypharmacy odds. Male sex (OR 0.592, 95%CL 0.436-0.803) and schizophrenia in older persons (age ≥ 55 years, OR 0.466, 95%CL 0.240-0.902) were less likely to be associated with antipsychotic polypharmacy. CONCLUSION The present study demonstrates that monotherapy and polypharmacy display equally common patterns of antipsychotic usage in managing agitation associated with schizophrenia in China. The extent and behavioral activities of agitation and several other factors were associated with polypharmacy.
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Suzuki K, Harada A, Suzuki H, Capuani C, Ugolini A, Corsi M, Kimura H. Combined treatment with a selective PDE10A inhibitor TAK-063 and either haloperidol or olanzapine at subeffective doses produces potent antipsychotic-like effects without affecting plasma prolactin levels and cataleptic responses in rodents. Pharmacol Res Perspect 2018; 6. [PMID: 29417763 PMCID: PMC5817828 DOI: 10.1002/prp2.372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/22/2017] [Indexed: 01/23/2023] Open
Abstract
Activation of indirect pathway medium spiny neurons (MSNs) via promotion of cAMP production is the principal mechanism of action of current antipsychotics with dopamine D2 receptor antagonism. TAK‐063 [1‐[2‐fluoro‐4‐(1H‐pyrazol‐1‐yl)phenyl]‐5‐methoxy‐3‐(1‐phenyl‐1H‐pyrazol‐5‐yl)pyridazin‐4(1H)‐one] is a novel phosphodiesterase 10A inhibitor that activates both direct and indirect pathway MSNs through increasing both cAMP and cGMP levels by inhibition of their degradation. The activation of indirect pathway MSNs through the distinct mechanism of action of these drugs raises the possibility of augmented pharmacological effects by combination therapy. In this study, we evaluated the potential of combination therapy with TAK‐063 and current antipsychotics, such as haloperidol or olanzapine after oral administration. Combined treatment with TAK‐063 and either haloperidol or olanzapine produced a significant increase in phosphorylation of glutamate receptor subunit 1 in the rat striatum. An electrophysiological study using rat corticostriatal slices showed that TAK‐063 enhanced N‐methyl‐D‐aspartic acid receptor‐mediated synaptic responses in both direct and indirect pathway MSNs to a similar extent. Further evaluation using pathway‐specific markers revealed that coadministration of TAK‐063 with haloperidol or olanzapine additively activated the indirect pathway, but not the direct pathway. Combined treatment with TAK‐063 and either haloperidol or olanzapine at subeffective doses produced significant effects on methamphetamine‐ or MK‐801‐induced hyperactivity in rats and MK‐801‐induced deficits in prepulse inhibition in mice. TAK‐063 at 0.1 mg/kg did not affect plasma prolactin levels and cataleptic response from antipsychotics in rats. Thus, TAK‐063 may produce augmented antipsychotic‐like activities in combination with antipsychotics without effects on plasma prolactin levels and cataleptic responses in rodents.
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Affiliation(s)
- Kazunori Suzuki
- CNS Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Akina Harada
- CNS Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Hirobumi Suzuki
- CNS Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Clizia Capuani
- Center for Drug Design & Discovery, Aptuit Inc., Verona, Italy
| | | | - Mauro Corsi
- Center for Drug Design & Discovery, Aptuit Inc., Verona, Italy
| | - Haruhide Kimura
- CNS Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
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Karadag H, Orsel S, Akkoyunlu S, Kahilogulları AK, Guriz O, Turkcapar H, Hatiloglu U. Comparison of Polypharmacy in Schizophrenia and Other Psychotic Disorders in Outpatient and Inpatient Treatment Periods: A Naturalistic One Year Follow-up Study. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20120419124219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Hasan Karadag
- Psychiatry Service of Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara - Turkey
| | - Sibel Orsel
- Psychiatry Service of Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara - Turkey
| | | | | | - Olga Guriz
- Psychiatry Service of Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara - Turkey
| | - Hakan Turkcapar
- Psychiatry Service of Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara - Turkey
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Woo YS, Park JE, Kim DH, Sohn I, Hwang TY, Park YM, Jon DI, Jeong JH, Bahk WM. Blonanserin Augmentation of Atypical Antipsychotics in Patients with Schizophrenia-Who Benefits from Blonanserin Augmentation?: An Open-Label, Prospective, Multicenter Study. Psychiatry Investig 2016; 13:458-67. [PMID: 27482249 PMCID: PMC4965658 DOI: 10.4306/pi.2016.13.4.458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/12/2016] [Accepted: 03/07/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the efficacy and tolerability of atypical antipsychotics (AAPs) with augmentation by blonanserin in schizophrenic patients. METHODS aA total of 100 patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP were recruited in this 12-week, open-label, non-comparative, multicenter study. Blonanserin was added to their existing AAP regimen, which was maintained during the study period. Efficacy was primarily evaluated using the Positive and Negative Syndrome Scale (PANSS) at baseline and at weeks 2, 4, 8, and 12. Predictors for PANSS response (≥20% reduction) were investigated. RESULTS The PANSS total score was significantly decreased at 12 weeks of blonanserin augmentation (-21.0±18.1, F=105.849, p<0.001). Moreover, 51.0% of participants experienced a response at week 12. Premature discontinuation of blonanserin occurred in 17 patients (17.0%); 4 of these patients dropped out due to adverse events. The patients who benefited the most from blonanserin were those with severe symptoms despite a treatment with a higher dose of AAP. CONCLUSION Blonanserin augmentation could be an effective strategy for patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP.
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Affiliation(s)
- Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Eon Park
- Department of Psychiatry, Keyo Hospital, Keyo Medical Foundation, Uiwang, Republic of Korea
| | - Do-Hoon Kim
- Department of Psychiatry, Hallym University Medical Center, Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Inki Sohn
- Department of Psychiatry, Keyo Hospital, Keyo Medical Foundation, Uiwang, Republic of Korea
| | - Tae-Yeon Hwang
- WHO Collaborating Center of Yongin Mental Hospital, Yongin, Republic of Korea
| | - Young-Min Park
- Department of Psychiatry, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Republic of Korea
| | - Duk-In Jon
- Department of Psychiatry, College of Medicine, Hallym University, Anyang, Republic of Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Abstract
This article reviews the results of longitudinal studies on frontal brain volume reduction in patients with schizophrenia spectrum disorders and focuses on the relationship with antipsychotic treatment. Based on a systematic literature search all studies were included in which results on changes of brain volumes over a longer period of time were correlated with antipsychotic treatment dose and disease severity. The findings indicate that there is evidence for grey and white matter volume changes of the frontal brain, which cannot be explained by the severity of the disease alone but are also very likely a manifestation of long-term effects of antipsychotics. Whether second generation antipsychotics have an advantage compared to first generation antipsychotics is currently unclear. Considering the contribution of antipsychotics to the changes in brain structure, which seem to depend on cumulative dosage and can exert adverse effects on neurocognition, negative and positive symptoms and psychosocial functioning, the guidelines for antipsychotic long-term drug treatment should be reconsidered. This is the reason why we and others recommend prescribing the lowest dose necessary to control symptoms. In non-schizophrenic psychiatric disorders, antipsychotics should be used only with great caution after a careful risk-benefit assessment. Moreover, treatment approaches which can help to minimize antipsychotic medication or even administer them only selectively are of increasing importance.
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Gaviria AM, Franco JG, Aguado V, Rico G, Labad J, de Pablo J, Vilella E. A Non-Interventional Naturalistic Study of the Prescription Patterns of Antipsychotics in Patients with Schizophrenia from the Spanish Province of Tarragona. PLoS One 2015; 10:e0139403. [PMID: 26427051 PMCID: PMC4591292 DOI: 10.1371/journal.pone.0139403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 09/10/2015] [Indexed: 12/28/2022] Open
Abstract
Background The analysis of prescribing patterns in entire catchment areas contributes to global mapping of the use of antipsychotics and may improve treatment outcomes. Objective To determine the pattern of long-term antipsychotic prescription in outpatients with schizophrenia in the province of Tarragona (Catalonia-Spain). Methods A naturalistic, observational, retrospective, non-interventional study based on the analysis of registries of computerized medical records from an anonymized database of 1,765 patients with schizophrenia treated between 2011 and 2013. Results The most used antipsychotic was risperidone, identified in 463 (26.3%) patients, followed by olanzapine in 249 (14.1%), paliperidone in 225 (12.7%), zuclopenthixol in 201 (11.4%), quetiapine in 141 (8%), aripiprazole in 100 (5.7%), and clozapine in 100 (5.7%). Almost 8 out of 10 patients (79.3%) were treated with atypical or second-generation antipsychotics. Long-acting injectable (LAI) formulations were used in 44.8% of patients. Antipsychotics were generally prescribed in their recommended doses, with clozapine, ziprasidone, LAI paliperidone, and LAI risperidone being prescribed at the higher end of their therapeutic ranges. Almost 7 out of 10 patients (69.6%) were on antipsychotic polypharmacy, and 81.4% were on psychiatric medications aside from antipsychotics. Being prescribed quetiapine (OR 14.24, 95% CI 4.94–40.97), LAI (OR 9.99, 95% CI 6.45–15.45), psychiatric co-medications (OR 4.25, 95% CI 2.72–6.64), and paliperidone (OR 3.13, 95% CI 1.23–7.92) were all associated with an increased likelihood of polypharmacy. Being prescribed risperidone (OR 0.54, 95% CI 0.35–0.83) and older age (OR 0.98, 95% CI 0.97–0.99) were related to a low polypharmacy probability. Conclusions Polypharmacy is the most common pattern of antipsychotic use in this region of Spain. Use of atypical antipsychotics is extensive. Most patients receive psychiatric co-medications such as anxiolytics or antidepressants. Polypharmacy is associated with the use of quetiapine or paliperidone, use of a LAI, younger age, and psychiatric co-medication.
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Affiliation(s)
- Ana M. Gaviria
- Hospital Universitari Institut Pere Mata, Universitat Rovira i Virgili, CIBERSAM, IISPV Reus, Spain
| | - José G. Franco
- Hospital Universitari Institut Pere Mata, Universitat Rovira i Virgili, CIBERSAM, IISPV Reus, Spain
- * E-mail:
| | - Víctor Aguado
- Hospital Universitari Institut Pere Mata, Reus, Spain
| | - Guillem Rico
- Hospital Universitari Institut Pere Mata, Reus, Spain
| | - Javier Labad
- Hospital Universitari Institut Pere Mata, Universitat Rovira i Virgili, CIBERSAM, IISPV Reus, Spain
| | - Joan de Pablo
- Hospital Universitari Institut Pere Mata, Universitat Rovira i Virgili, CIBERSAM, IISPV Reus, Spain
| | - Elisabet Vilella
- Hospital Universitari Institut Pere Mata, Universitat Rovira i Virgili, CIBERSAM, IISPV Reus, Spain
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Bergendal A, Schiöler H, Wettermark B, Björkstén KS. Concomitant use of two or more antipsychotic drugs is common in Sweden. Ther Adv Psychopharmacol 2015; 5:224-31. [PMID: 26301078 PMCID: PMC4535048 DOI: 10.1177/2045125315588647] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To assess the prevalence of concomitant use of two or more antipsychotic drugs and other psychotropic drugs in the Swedish population. METHODS Data for this observational cohort study were collected from the Swedish Prescribed Drug Register including all dispensed drugs to the entire Swedish population (9.4 million inhabitants). We identified all individuals with at least one dispensed prescription of antipsychotic drug during January to June 2008. After 12 months, a second exposure period was chosen. Individuals who were dispensed two or more antipsychotic drugs in both periods were considered long-time users of antipsychotic polypharmacy. RESULTS In 2008, 1.5% of the Swedish population was dispensed antipsychotic drugs, the majority (75%) using only one antipsychotic drug. Out of individuals who were dispensed 2 or more antipsychotic drugs during the first period, 62% also was also dispensed at least 2 antipsychotic drugs during the second period. A total of 665 different unique combinations were used in 2008. Individuals prescribed two or more antipsychotic drugs during both periods were more often dispensed anxiolytics and sedatives than those who were dispensed only one antipsychotic drug. Elderly were dispensed antipsychotic drugs much more often than younger persons. CONCLUSIONS In Sweden, 25% of patients dispensed antipsychotic drugs receive a combination of two or more antipsychotic drugs. Individuals who are dispensed antipsychotic polypharmacy are more often dispensed anxiolytics and sedatives than those prescribed only one antipsychotic drug. Long-term observational studies are needed to assess the efficacy and safety of such combinations.
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Affiliation(s)
- Annica Bergendal
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital, Huddinge, C1:68, SE-141 86 Stockholm, Sweden
| | - Helena Schiöler
- National Board of Health and Welfare, SE-106 30 Stockholm, Sweden
| | - Björn Wettermark
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, C1:68, SE-141 86 Stockholm Sweden and Stockholm County Council, Box 6909, SE-102 39 Stockholm, Sweden
| | - Karin Sparring Björkstén
- Department of Neurobiology, Care sciences and Society, Karolinska Institutet, SLSO, Psykiatri Södra Stockholm, Box 5040, SE-121 05 Johanneshov, Sweden
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Prevalence and correlates of antipsychotic polypharmacy in children and adolescents receiving antipsychotic treatment. Int J Neuropsychopharmacol 2014; 17:1095-105. [PMID: 23673334 PMCID: PMC4010557 DOI: 10.1017/s1461145712001320] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Antipsychotic polypharmacy (APP), which is common in adults with psychotic disorders, is of unproven efficacy and raises safety concerns. Although youth are increasingly prescribed antipsychotics, little is known about APP in this population. We performed a systematic PubMed search (last update 26 January 2013) of studies reporting the prevalence of APP in antipsychotic-treated youth. Summary statistics and statistical tests were calculated at the study level and not weighted by sample size. Fifteen studies (n = 58 041, range 68-23 183) reported on APP in youth [mean age = 13.4 ± 1.7 yr, 67.1 ± 10.2% male, 77.9 ± 27.4% treated with second-generation antipsychotics (SGAs)]. Data collected in these studies covered 1993-2008. The most common diagnoses were attention-deficit hyperactivity disorder (ADHD; 39.9 ± 23.5%) and conduct disorder/oppositional defiant disorder (CD/ODD; 33.6 ± 24.8). In studies including predominantly children (mean age = <13 yr, N = 5), the most common diagnosis were ADHD (50.6 ± 25.4%) and CD/ODD (39.5 ± 27.5%); while in studies with predominantly adolescents (mean age = ⩾13 yr, N = 7) the most common diagnoses were schizophrenia-spectrum disorders (28.6 ± 23.8%), anxiety disorders (26.9 ± 14.9%) and bipolar-spectrum disorders (26.6 ± 7.0%), followed closely by CD/ODD (25.8 ± 17.7). The prevalence of APP among antipsychotic-treated youth was 9.6 ± 7.2% (5.9 ± 4.5% in child studies, 12.0 ± 7.9% in adolescent studies, p = 0.15). Higher prevalence of APP was correlated with a bipolar disorder or schizophrenia diagnosis (p = 0.019) and APP involving SGA+SGA combinations (p = 0.0027). No correlation was found with APP definition [⩾1 d (N = 10) vs. >30-⩾90 d (N = 5), p = 0.88]. Despite lacking safety and efficacy data, APP in youth is not uncommon, even in samples predominantly consisting of non-psychotic patients. The duration, clinical motivations and effectiveness of this practice require further study.
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History, background, concepts and current use of comedication and polypharmacy in psychiatry. Int J Neuropsychopharmacol 2014; 17:983-96. [PMID: 24044761 DOI: 10.1017/s1461145713000837] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Based on a careful literature search a review is presented of the history, background, concepts and current use of comedication and polypharmacy in psychiatry. The pros and cons of comedication and polypharmacy are presented, as well as their apparent increase in recent times. Possible reasons for the increase of comedication/polypharmacy are described. Both the potential advantages as well as the potential risks are discussed. The one sided view that all comedication/polypharmacy is nothing but problematic is questioned. Comedication/polypharmacy seems to be, among others, the current answer to the well-known limited efficacy and effectiveness of current monotherapy treatment strategies.
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Grau-López L, Roncero C, Daigre C, Miquel L, Barral C, Gonzalvo B, Collazos F, Casas M. Observational Study on Medications Prescribed to Dual-Diagnosis Outpatients. J Addict Med 2014; 8:84-9. [DOI: 10.1097/adm.0000000000000024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sarkar P, Chakraborty K, Misra A, Shukla R, Swain SP. Pattern of psychotropic prescription in a tertiary care center: a critical analysis. Indian J Pharmacol 2014; 45:270-3. [PMID: 23833371 PMCID: PMC3696299 DOI: 10.4103/0253-7613.111947] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 09/09/2012] [Accepted: 03/01/2013] [Indexed: 11/21/2022] Open
Abstract
Objectives: To study the prescription pattern of psychotropic drugs in a Tertiary Care Hospital in Eastern India with special reference to polypharmacy. Materials and Methods: A total of 411 patients were included in the study through systematic sampling. Patients were diagnosed by a Consultant Psychiatrist before inclusion in the study using a semi-structured interview schedule based on the International Classification of Disease (ICD), classification of mental and behavioral disorders, 10th version). The most recently prescribed psychopharmacological medication of those patients was studied. A checklist to assess the pattern of prescription and evaluate reasons of polypharmacy was filled up by the prescribing consultant. Results: About 76.6% of the patients received polypharmacy in the index study. Males were more exposed to polypharmacy compared to women (80.93% vs. 70.85%). Gender and diagnosis had a predictive value with regard to the polypharmacy. Polypharmacy was more common in organic mental disorders (F0), psychoactive substance abuse disorders (F1), psychotic disorders (F2), mood disorders (F3) and in childhood, and adolescent mental disorders (F9). Most frequently, antipsychotic drugs were prescribed followed by tranquilizers/hypnotics and anticholinergics. Antidepressants (35.13%) were more commonly prescribed as monotherapy. Anticholinergics (100%) and tranquilizers/hypnotics (96.7%) were the drugs more commonly used in combination with other psychotropics. The three most common reasons for prescribing polypharmacy were augmentation (43.8%) of primary drug followed by its use to prevent adverse effects of primary drug (39.6%) and to treat comorbidity (34.9%). Conclusions: Polypharmacy is a common practice despite the research based guidelines suggest otherwise. More vigorous research is needed to address this sensitive issue.
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Affiliation(s)
- Pinaki Sarkar
- Department of Psychiatry, College of Medicine and J.N.M. Hospital, West Bengal University of Health Sciences, Kalyani, West Bengal, India
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Roh D, Chang JG, Kim CH, Cho HS, An SK, Jung YC. Antipsychotic polypharmacy and high-dose prescription in schizophrenia: a 5-year comparison. Aust N Z J Psychiatry 2014; 48:52-60. [PMID: 23671214 DOI: 10.1177/0004867413488221] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The co-prescription of multiple antipsychotic drugs continues to increase despite a lack of evidence supporting this practice. The purpose of this study was to quantify and describe recent trends of antipsychotic polypharmacy in Korean schizophrenic inpatients by comparing prescribed medications between the years of 2005 and 2010. METHODS We reviewed comprehensive medication profiles of schizophrenic patients discharged from a university psychiatric hospital in 2005 (n=194) or 2010 (n=201). Antipsychotic polypharmacy was defined as the concurrent receipt of two or more chemically distinct antipsychotics for at least 14 days. High antipsychotic dose was defined as a prescribed daily dose to defined daily dose ratio of greater than 1.5. RESULTS Antipsychotic polypharmacy increased between 2005 (37.1%) and 2010 (48.3%, p=0.025). The most frequently used drug within combinations of antipsychotics was haloperidol in 2005 (51.4%) and quetiapine in 2010 (48.5%). Overall, no changes were observed between 2005 and 2010 in the rate of prescribing high-dose antipsychotics. High-dose antipsychotic monotherapy decreased across years (from 30.4 to 18.4%), but high-dose antipsychotic polypharmacy increased (from 34.0 to 45.3%). Regression analysis revealed that antipsychotic polypharmacy was strongly associated with high doses of prescribed antipsychotics (odds ratio=18.60, p<0.001). CONCLUSIONS The practice of prescribing multiple antipsychotics to patients with schizophrenia is increasing, and high-dose antipsychotic drugs are more likely to be prescribed in combination than in isolation. The reasons for this pattern of prescription and its impact warrants further study.
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Affiliation(s)
- Daeyoung Roh
- 1Severence Mental Health Hospital, Yonsei University College of Medicine, Gyeonggi-do, Korea
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Description of long-term polypharmacy among schizophrenia outpatients. Soc Psychiatry Psychiatr Epidemiol 2013; 48:631-8. [PMID: 23007295 DOI: 10.1007/s00127-012-0586-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This large nationwide study describes the prevalence and predictors of long-term antipsychotic polypharmacy among patients with schizophrenia. METHODS A register-based longitudinal study of all people in Finland, who had at least one hospitalization due to schizophrenia during the years 2000-2007 and who were alive on March 1, 2007. Entry to the cohort was defined from the first hospitalization for schizophrenia during the years 2000-2007, and the date of assessment of antipsychotic polypharmacy was March 1, 2007. We studied separately chronic (N = 8,037) and recent onset (N = 8,046) schizophrenia patients. Antipsychotic polypharmacy was defined as overlapping of two or more filled prescriptions of antipsychotics for over 60 days. RESULTS In a total 16,083 patients with schizophrenia the prevalence of antipsychotic polypharmacy was 46.2 % (N = 7,436, mean age 47.5 years, male 55 %). The longer the duration of schizophrenia, the more common the antipsychotic polypharmacy. Long index hospitalization and being male significantly associated with antipsychotic polypharmacy among all schizophrenia patients. Especially, in chronic schizophrenia patients, the previous use of benzodiazepine like agents was associated with antipsychotic polypharmacy, but the use of antidepressants associated with less frequent antipsychotic polypharmacy. CONCLUSIONS Antipsychotic polypharmacy was widely prevalent among patients with schizophrenia and it was associated with long hospitalizations and long duration of illness. Benzodiazepine use was associated with increased risk and antidepressant use with decreased risk of antipsychotic polypharmacy when the effect of other clinical and socioeconomic factors was adjusted. Research is needed of risks and benefits of antipsychotic polypharmacy and augmentation of antipsychotic with other psychoactive drugs.
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Correll CU, Gallego JA. Antipsychotic polypharmacy: a comprehensive evaluation of relevant correlates of a long-standing clinical practice. Psychiatr Clin North Am 2012; 35:661-81. [PMID: 22929872 PMCID: PMC3717367 DOI: 10.1016/j.psc.2012.06.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Antipsychotic polypharmacy (APP) is common in the treatment of schizophrenia spectrum disorders. The literature indicates that APP is related to patient, illness, and treatment variables that are proxy measures for greater illness acuity, severity, complexity, and chronicity. The largely unknown relative risks and benefits of APP need to be weighed against the known risks and benefits of clozapine for treatment-resistant patients. To inform evidence-based clinical practice, controlled, high-quality antipsychotic combination and discontinuation trials are necessary to determine the effectiveness, safety, and role of APP in the management of severely ill patients with insufficient response to antipsychotic monotherapy.
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Affiliation(s)
- Christoph U. Correll
- The Zucker Hillside Hospital, Division of Psychiatry Research, North Shore-LIJ Health System, 75-59, 263rd Street, Glen Oaks, NY 11004, USA,Hofstra North Shore-LIJ School of Medicine, Hempstead, NY 11549, USA,Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA,The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA,Corresponding author.
| | - Juan A. Gallego
- The Zucker Hillside Hospital, Division of Psychiatry Research, North Shore-LIJ Health System, 75-59, 263rd Street, Glen Oaks, NY 11004, USA,The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
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Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry 2012; 13:318-78. [PMID: 22834451 DOI: 10.3109/15622975.2012.696143] [Citation(s) in RCA: 382] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry Guidelines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This first part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia.
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Affiliation(s)
- Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany.
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Baandrup L, Sørensen J, Lublin H, Nordentoft M, Glenthoj B. Association of antipsychotic polypharmacy with health service cost: a register-based cost analysis. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2012; 13:355-363. [PMID: 21452062 DOI: 10.1007/s10198-011-0308-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 02/24/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To investigate the association of antipsychotic polypharmacy in schizophrenia with cost of primary and secondary health service use. METHOD Comparative analysis of health service cost for patients prescribed antipsychotic polypharmacy versus antipsychotic monotherapy. Resource utilisation and costs were described using central Danish registers for a 2 year period (2007-2008). We included patients attached to one of two Danish psychiatric referral centres in 1 January 2008 and/or 1 January 2009. Their prescribed treatment with either antipsychotic polypharmacy or monotherapy at the two cross-sectional dates was recorded and used as proxy of polypharmacy exposure during the preceding year. A multivariate generalised linear model was fitted with total costs of primary and secondary health service use as dependent variable, and antipsychotic polypharmacy, diagnosis, age, gender, disease duration, psychiatric inpatient admissions, and treatment site as covariates. RESULTS The sample consisted of 736 outpatients with a diagnosis in the schizophrenia spectrum. Antipsychotic polypharmacy was associated with significantly higher total health service costs compared with monotherapy (2007: 25% higher costs; 2008: 17% higher costs) when adjusting for potential confounders and risk factors. A subgroup analysis suggested that the excessive costs associated with antipsychotic polypharmacy were partly accounted for by the functional level of the patients. CONCLUSION The results demonstrate that antipsychotic co-prescribing is associated with increased use of health care services, even though no causal relations can be inferred from an observational study.
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Affiliation(s)
- Lone Baandrup
- Centre for Neuropsychiatric Schizophrenia Research, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Glostrup, Nordre Ringvej 29-67, 2600 Glostrup, Denmark.
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Gallego JA, Bonetti J, Zhang J, Kane JM, Correll CU. Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009. Schizophr Res 2012; 138:18-28. [PMID: 22534420 PMCID: PMC3382997 DOI: 10.1016/j.schres.2012.03.018] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/05/2012] [Accepted: 03/07/2012] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions. METHODS Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses. RESULTS Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR=42-100%]), the median APP rate was 19.6% (IQR=12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs)+second-generation antipsychotics (SGAs) (42.4%, IQR=0.0-71.4%) followed by FGAs+FGAs (19.6%, IQR=0.0-100%) and SGAs+SGAs (1.8%, IQR=0.0-28%). APP rates were not different between decades (1970-1979:28.8%, IQR=7.5-44%; 1980-1989:17.6%, IQR=10.8-38.2; 1990-1999:22.0%, IQR=11-40; 2000-2009:19.2% IQR=14.4-29.9, p=0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p<0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p=0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p=0.03), with non-significant changes in Europe. APP was associated with inpatient status (p<0.001), use of FGAs (p<0.0001) and anticholinergics (<0.001), schizophrenia (p=0.01), less antidepressant use (p=0.02), greater LAIs use (p=0.04), shorter follow-up (p=0.001) and cross-sectional vs. longitudinal study design (p=0.03). In a meta-regression, inpatient status (p<0.0001), FGA use (0.046), and schizophrenia diagnosis (p=0.004) independently predicted APP (N=66, R(2)=0.44, p<0.0001). CONCLUSIONS APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.
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Affiliation(s)
- Juan A. Gallego
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA,The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | - Jianping Zhang
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - John M. Kane
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA,Albert Einstein College of Medicine, Bronx, New York, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Christoph U. Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA,Albert Einstein College of Medicine, Bronx, New York, USA,Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA,The Feinstein Institute for Medical Research, Manhasset, New York, USA
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Bernardo M, Coma A, Ibáñez C, Zara C, Bari JM, Serrano-Blanco A. Antipsychotic polypharmacy in a regional health service: a population-based study. BMC Psychiatry 2012; 12:42. [PMID: 22587453 PMCID: PMC3511232 DOI: 10.1186/1471-244x-12-42] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 02/17/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND To analyse the extent and profile of outpatient regular dispensation of antipsychotics, both in combination and monotherapy, in the Barcelona Health Region (Spain), focusing on the use of clozapine and long-acting injections (LAI). METHODS Antipsychotic drugs dispensed for people older than 18 and processed by the Catalan Health Service during 2007 were retrospectively reviewed. First and second generation antipsychotic drugs (FGA and SGA) from the Anatomical Therapeutic Chemical classification (ATC) code N05A (except lithium) were included. A patient selection algorithm was designed to identify prescriptions regularly dispensed. Variables included were age, gender, antipsychotic type, route of administration and number of packages dispensed. RESULTS A total of 117,811 patients were given any antipsychotic, of whom 71,004 regularly received such drugs. Among the latter, 9,855 (13.9%) corresponded to an antipsychotic combination, 47,386 (66.7%) to monotherapy and 13,763 (19.4%) to unspecified combinations. Of the patients given antipsychotics in association, 58% were men. Olanzapine (37.1%) and oral risperidone (36.4%) were the most common dispensations. Analysis of the patients dispensed two antipsychotics (57.8%) revealed 198 different combinations, the most frequent being the association of FGA and SGA (62.0%). Clozapine was dispensed to 2.3% of patients. Of those who were receiving antipsychotics in combination, 6.6% were given clozapine, being clozapine plus amisulpride the most frequent association (22.8%). A total of 3.800 patients (5.4%) were given LAI antipsychotics, and 2.662 of these (70.1%) were in combination. Risperidone was the most widely used LAI. CONCLUSIONS The scant evidence available regarding the efficacy of combining different antipsychotics contrasts with the high number and variety of combinations prescribed to outpatients, as well as with the limited use of clozapine.
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Affiliation(s)
- Miguel Bernardo
- Schizophrenia Clinic Program, Department of Psychiatry, Neuroscience Institute, Hospital Clinic de Barcelona, Barcelona, Spain.
| | - Anna Coma
- Pharmacy Direction. Catalan Health Service, Barcelona, Spain
| | - Cristina Ibáñez
- Pharmacy Direction. Catalan Health Service, Barcelona, Spain
| | - Corinne Zara
- Pharmacy Direction. Catalan Health Service, Barcelona, Spain
| | - Josep Maria Bari
- Schizophrenia Clinic Program, Department of Psychiatry, Neuroscience Institute, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Antoni Serrano-Blanco
- Parc Sanitari Sant Joan de Déu, Servicios de Salud Mental y Fundación Sant Joan de Déu, Red de Investigación en Actividades Preventivas y Promoción de la Salud (RedIAPP), Barcelona, Spain
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20
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Längle G, Steinert T, Weiser P, Schepp W, Jaeger S, Pfiffner C, Frasch K, Eschweiler GW, Messer T, Croissant D, Becker T, Kilian R. Effects of polypharmacy on outcome in patients with schizophrenia in routine psychiatric treatment. Acta Psychiatr Scand 2012; 125:372-81. [PMID: 22321029 DOI: 10.1111/j.1600-0447.2012.01835.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Evaluating the effects of different types of psychotropic polypharmacy on clinical outcomes and quality of life (QOL) in 374 patients with schizophrenia and schizoaffective disorder in routine care. METHOD Psychotropic regimen, clinical outcomes, and QOL were assessed before discharge and after 6, 12, 18, and 24 months. Data were analyzed by mixed-effects regression models for longitudinal data controlling for selection bias by means of propensity scores. RESULTS At baseline 22% of participants received antipsychotic monotherapy (APM) (quetiapine, olanzapine, or risperidone), 20% more than one antipsychotic drug, 16% received antipsychotics combined with antidepressants, 16% antipsychotics plus benzodiazepines, 11.5% had antipsychotics and mood stabilizers, and 16% psychotropic drugs from three or more subclasses. Patients receiving APM had better clinical characteristics and QOL at baseline. Patients receiving i) antipsychotics plus benzodiazepines or ii) antipsychotics plus drugs from at least two additional psychotropic drug categories improved less than patients with APM. CONCLUSION Combinations of antipsychotics with other psychotropic drugs seem to be effective in special indications. Nevertheless, combinations with benzodiazepines and with compounds from multiple drug classes should be critically reviewed. It is unclear whether poorer outcomes in patients with such treatment are its result or its cause.
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Affiliation(s)
- G Längle
- Department of Psychiatry and Psychotherapy, Zentrum für Psychiatrie Südwürttemberg, Bad Schussenried, Germany.
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Ascher-Svanum H, Brnabic AJ, Lawson AH, Kinon BJ, Stauffer VL, Feldman PD, Kelin K. Comparison of patients undergoing switching versus augmentation of antipsychotic medications during treatment for schizophrenia. Neuropsychiatr Dis Treat 2012; 8:113-8. [PMID: 22536066 PMCID: PMC3333785 DOI: 10.2147/ndt.s30268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
It is often difficult to determine whether a patient may best benefit by augmenting their current medication or switching them to another. This post-hoc analysis compares patients' clinical and functional profiles at the time their antipsychotic medications were either switched or augmented. Adult outpatients receiving oral antipsychotic treatment for schizophrenia were assessed during a 12-month international observational study. Clinical and functional measures were assessed at the time of first treatment switch/augmentation (0-14 days prior) and compared between Switched and Augmented patient groups. Due to low numbers of patients providing such data, interpretations are based on effect sizes. Data at the time of change were available for 87 patients: 53 Switched and 34 Augmented. Inadequate response was the primary reason for treatment change in both groups, whereas lack of adherence was more prevalent in the Switched group (26.4% vs 8.8%). Changes in clinical severity from study initiation to medication change were similar, as indicated by Clinical Global Impressions-Severity scores. However, physical and mental component scores of the 12-item Short-Form Health Survey improved in the Augmented group, but worsened in the Switched group. These findings suggest that the patient's worsening or lack of meaningful improvement prompts clinicians to switch antipsychotic medications, whereas when patients show some improvement, clinicians may be more likely to try bolstering the improvements through augmentation. Current findings are consistent with physicians' stated reasons for switching versus augmenting antipsychotics in the treatment of schizophrenia. Confirmation of these findings requires further research.
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Affiliation(s)
- Haya Ascher-Svanum
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
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Hazra M, Uchida H, Sproule B, Remington G, Suzuki T, Mamo DC. Impact of feedback from pharmacists in reducing antipsychotic polypharmacy in schizophrenia. Psychiatry Clin Neurosci 2011; 65:676-8. [PMID: 22176287 DOI: 10.1111/j.1440-1819.2011.02280.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective was to examine effects of active interventions on physician's prescribing of antipsychotic polypharmacy. Prescriptions for patients with schizophrenia at the Centre for Addiction and Mental Health, Canada were collected in 2006 (n = 648) and 2008 (n = 778). During the intervening period, a pharmacist monitored prescriptions with antipsychotic polypharmacy and contacted corresponding prescribers to provide education on risks of polypharmacy. Moreover, educational sessions on polypharmacy were presented to inpatient and outpatient teams. A three-fold decrease in the prevalence of antipsychotic polypharmacy was observed between 2006 (18.3%) and 2008 (6.6%). Thus, active monitoring of prescriptions with educational interventions could reduce antipsychotic polypharmacy.
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Affiliation(s)
- Monica Hazra
- Centre for Addiction and Mental Health, University of Toronto, Ontario, Canada
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Abstract
BACKGROUND Based on the glutamatergic NMDA receptor hypofunction theory of schizophrenia, NMDA receptor modulators (NMDARMs) may have therapeutic potential in the treatment of schizophrenia. OBJECTIVE This meta-analysis aimed to evaluate the potential of modulators of the NMDA receptor as adjunctive therapy for schizophrenia, using the results from published trials. DATA SOURCES A primary electronic search for controlled clinical trials using NMDARMs in schizophrenia was conducted on the PubMed, Cochrane Library, EMBASE, CINAHL® and PsycINFO databases. A secondary manual search of references from primary publications was also performed. STUDY SELECTION Inclusion criteria were the application of an established method of diagnosis, randomized case assignment, comparison of NMDARM add-on therapy with placebo, and double-blind assessment of symptoms in chronic schizophrenia using standardized rating scales. Results were based on a total sample size of 1253 cases from 29 trials that fulfilled the specified criteria. DATA EXTRACTION Scores on rating scales or on their relevant subscales were obtained for all selected studies from published results for the minimum dataset to compute the difference between post- and pre-trial scores and their pooled standard deviation for NMDARM add-on therapy and placebo groups for negative, positive and total symptoms. RESULTS A negative standardized mean difference (SMD) indicates therapeutic benefit in favour of NMDARM add-on therapy and all SMD results mentioned here are statistically significant. The overall effect size for NMDARMs as a group was small for negative (SMD -0.27) and medium for total (SMD -0.40) symptoms of chronic schizophrenia. Subgroup analysis revealed medium effect sizes for D-serine and N-acetyl-cysteine (NAC) for negative (SMD -0.53 and -0.45, respectively) and total (SMD -0.40 and -0.64, respectively) symptoms, and for glycine (SMD -0.66) and sarcosine (SMD -0.41) for total symptoms. As adjuvants to non-clozapine antipsychotics, additional therapeutic benefits were observed for NMDARM as a group (SMD -0.14) and glycine (SMD -0.54) for positive symptoms; D-serine (SMD -0.54), NAC (SMD -0.45) and sarcosine (SMD -0.39) for negative symptoms; and NMDARM as a group (SMD -0.38), D-serine (SMD -0.40), glycine (SMD -1.12), NAC (SMD -0.64) and sarcosine (SMD -0.53) for total symptoms. When added to clozapine, none of the drugs demonstrated therapeutic potential, while addition of glycine (SMD +0.56) worsened positive symptoms. CONCLUSIONS Taking into consideration the number of trials and sample size in subgroup analyses, D-serine, NAC and sarcosine as adjuncts to non-clozapine antipsychotics have therapeutic benefit in the treatment of negative and total symptoms of chronic schizophrenia. While glycine improves positive and total symptoms as an adjuvant to non-clozapine antipsychotics, it worsens them when added to clozapine.
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Affiliation(s)
- Surendra P Singh
- General Adult Psychiatry, Mental Health Directorate, Wolverhampton City Primary Care Trust, Wolverhampton, West Midlands, UK
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Correll CU, Shaikh L, Gallego JA, Nachbar J, Olshanskiy V, Kishimoto T, Kane JM. Antipsychotic polypharmacy: a survey study of prescriber attitudes, knowledge and behavior. Schizophr Res 2011; 131:58-62. [PMID: 21419603 PMCID: PMC3159758 DOI: 10.1016/j.schres.2011.02.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 02/08/2011] [Accepted: 02/15/2011] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Although common in psychiatric practice, reasons for antipsychotic polypharmacy (APP) have remained unclear. METHODS Single-site, semi-structured interview study of prescribers at a psychiatric teaching hospital inquiring about APP attitudes and behaviors, including frequency, preferred combinations, rationale and concerns. RESULTS Forty-four prescribers reported using APP in 17.0 ± 10.0% of antipsychotic-treated patients. Although clinicians themselves initiated APP in only 23.3 ± 27.0% of cases, they did not attempt conversion to antipsychotic monotherapy in 40.9 ± 37.7%, despite reported successful conversion in 28.0 ± 30.8% of cases. The following reasons justified most APP (0-10): cross-titration (9.2 ± 1.4), failed clozapine trial (8.2 ± 2.2), randomized controlled evidence (8.0 ± 2.0), and clozapine intolerance (7.7 ± 2.6). Prescribers felt "moderately" (5.0 ± 1.9) concerned about APP (0-10), mostly due to chronic side effects (7.6 ± 2.0), lack of evidence (7.1 ± 2.2), non-adherence risk (6.7 ± 2.3) and mortality risk (6.7 ± 3.2), while increased cost (4.9 ± 2.5) and higher total antipsychotic dose (4.2 ± 2.9) ranked lowest. Comparing high with low APP prescribers (>10% vs. ≤ 10% of patients; mean: 36.1 ± 19.8 vs. 3.4 ± 3.4, p<0.0001), no differences emerged on 25/26 ratings regarding APP justification and 9/9 ratings regarding concerns. In a multivariate analyses, only attending status (OR=10.3, p=0.0043) and endorsing a specific APP preference (OR=21.4, p=0.011) predicted APP use >10% (r(2):0.35, p<0.0001), yet no uniformly preferred APP strategy emerged. CONCLUSIONS High APP prescribers had more clinical experience, less concerns about APP and more likely a preferred APP choice, although no overall preferred strategy emerged. Otherwise, high and low APP prescribers shared attitudes toward APP. Both had inherited most of their APP cases and were reluctant to convert patients to antipsychotic monotherapy.
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Affiliation(s)
- Christoph U. Correll
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA, Albert Einstein College of Medicine, Bronx, New York, USA, The Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Ladan Shaikh
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - Juan A. Gallego
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - Jeffrey Nachbar
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - Vladimir Olshanskiy
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - Taishiro Kishimoto
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA
| | - John M. Kane
- The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, New York, USA, Albert Einstein College of Medicine, Bronx, New York, USA, The Feinstein Institute for Medical Research, Manhasset, New York, USA
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Abstract
OBJECTIVES This study describes the prevalence of antipsychotic polypharmacy in patients admitted to a geriatric psychiatry unit, compares polypharmacy by psychiatric diagnosis, explores predictors of polypharmacy, and examines changes in antipsychotic polypharmacy from baseline to discharge. METHODS A retrospective examination was made of patients admitted to an inpatient geriatric psychiatry ward between 2006 and 2010. All patients with a diagnosis of schizophrenia, bipolar disorder, or dementia prescribed a regularly scheduled antipsychotic for at least 1 month prior to admission were included. RESULTS Of the 416 patients meeting selection criteria, nearly 13% were prescribed antipsychotic polypharmacy at the time of admission. Quetiapine was the antipsychotic most commonly involved in polypharmacy. By discharge, the rate of antipsychotic polypharmacy had decreased to 8% (X=4.74, df=1, p=0.03). Patients with a history of a severe mental illness were significantly more likely to have been prescribed antipsychotic polypharmacy compared with those with only a diagnosis of dementia (X=14.67, df=1, p=<0.001). Living situation and psychiatric diagnosis were significant predictors of antipsychotic polypharmacy. CONCLUSION Older adults admitted to a geriatric psychiatry ward on a scheduled antipsychotic were commonly prescribed more than one antipsychotic. This was most likely in patients living in a facility (e.g., assisted living, skilled nursing, long-term care) and in those patients with a severe mental illness. A better understanding of the efficacy and safety of antipsychotic polypharmacy in older adults, especially those with dementia, is necessary in order to use these medications rationally.
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Tsutsumi C, Uchida H, Suzuki T, Watanabe K, Takeuchi H, Nakajima S, Kimura Y, Tsutsumi Y, Ishii K, Imasaka Y, Kapur S. The evolution of antipsychotic switch and polypharmacy in natural practice--a longitudinal perspective. Schizophr Res 2011; 130:40-6. [PMID: 21624824 DOI: 10.1016/j.schres.2011.05.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 05/09/2011] [Accepted: 05/16/2011] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Most patients with schizophrenia first start with a single antipsychotic, and yet most finally end up 'switching' or using 'polypharmacy'. The objective of this study was to examine the evolution of antipsychotic switch and polypharmacy in the real-world from a longitudinal perspective. METHODS A systematic review of longitudinal antipsychotic prescriptions in 300 patients with schizophrenia (ICD-10) for up to 2 years after their first visit to one of the 4 participating psychiatric clinics in Tokyo, Japan between January, 2007 and June, 2008, was conducted. Reasons for prescription change were also examined. The evolution of switching and polypharmacy was studied, and prescribed doses were compared to suggested dose ranges by the Texas Medication Algorithm Project (TMAP). RESULTS 208 patients started their antipsychotic treatment with monotherapy. 34.1% of the patients gave up monotherapy with an initial antipsychotic to move to antipsychotic switch (27.4%) and/or polypharmacy (17.8%) within 2 years. The main reason for antipsychotic switch was 'ineffectiveness'; interestingly, this happened despite the fact that the monotherapy dose was below the recommended range in 47.4% of the antipsychotic switch. In a subgroup of 100 patients who started as antipsychotic-free, 2-year prevalence rates of switching and antipsychotic polypharmacy were 27.0% and 18.0%, respectively, and polypharmacy was resorted to after a median of 1 antipsychotic had been tried for 84 days (median). CONCLUSIONS These findings raise a concern that physicians may perform an antipsychotic switch without exploring the entire dose range and resort to antipsychotic polypharmacy without trying an adequate number of antipsychotics.
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Affiliation(s)
- Chisa Tsutsumi
- Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Visceglia E, Lewis S. Yoga Therapy as an Adjunctive Treatment for Schizophrenia: A Randomized, Controlled Pilot Study. J Altern Complement Med 2011; 17:601-7. [DOI: 10.1089/acm.2010.0075] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abstract
Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.
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Affiliation(s)
- Thomas R E Barnes
- Division of Experimental Medicine,Centre for Mental Health, Imperial College London, Charing Cross Campus, London, UK.
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Barnes TRE. Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2011; 25:567-620. [PMID: 21292923 DOI: 10.1177/0269881110391123] [Citation(s) in RCA: 239] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.
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Affiliation(s)
- Thomas R E Barnes
- Centre for Mental Health, Imperial College, Charing Cross Campus, London, UK.
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Santone G, Bellantuono C, Rucci P, Picardi A, Preti A, de Girolamo G. Patient characteristics and process factors associated with antipsychotic polypharmacy in a nationwide sample of psychiatric inpatients in Italy. Pharmacoepidemiol Drug Saf 2010; 20:441-9. [DOI: 10.1002/pds.2083] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 11/02/2010] [Accepted: 11/05/2010] [Indexed: 11/12/2022]
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Centorrino F, Ventriglio A, Vincenti A, Talamo A, Baldessarini RJ. Changes in medication practices for hospitalized psychiatric patients: 2009 versus 2004. Hum Psychopharmacol 2010; 25:179-86. [PMID: 20196186 DOI: 10.1002/hup.1095] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We tested the hypothesis that combinations and total daily doses of psychotropics for hospitalized patients diagnosed with major psychiatric disorders are rising. METHODS We evaluated McLean Hospital records of 481 consecutive inpatients with DSM-IV schizophrenia, schizoaffective, or bipolar disorders in 2004 (n = 278) or 2009 (n = 203) to compare characteristics and treatments. RESULTS In 2009, Clinical Global Impression (CGI)-severity scores were 6% lower at intake and improved 1.7 times more than in 2004, as hospitalization-length decreased by 12%. Polytherapy (> or = 2 psychotropics) increased in 2009 (affective or schizoaffective disorders > schizophrenia). Total psychotropics/patient (3.1-3.2) remained stable but mood-stabilizers/patient increased markedly and antipsychotics/patient decreased somewhat in 2009. Antipsychotic-choice (2009) ranked: quetiapine, aripiprazole, risperidone, and others; mood-stabilizers ranked: lamotrigine, valproate, lithium, and others (1/4 off-label). In 2009, final total antipsychotic doses (mg/day) increased by 97%, and mood-stabilizers by 75%. Adverse-effect rates fell by half. Factors differing independently for 2009 versus 2004 ranked: (a) more CGI improvement, (b) more mood-stabilizers/patient, (c) lower admission CGI scores, and (c) higher total antipsychotic dose. COMMENT Combinations and doses of antipsychotic and mood-stabilizing drugs for inpatients increased markedly (2004 vs. 2009) without consistent correspondence of agents/person and doses, without apparent increase in major adverse effects, and with possibly superior clinical improvement.
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Affiliation(s)
- Franca Centorrino
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW Although most guidelines recommend monotherapy in schizophrenia, the combined application of multiple psychotropic agents is very common, especially in treatment-refractory cases. We review the empirical basis supporting these attempts and their relevance for clinical practice. RECENT FINDINGS Polypharmacy intends to address different aspects of treatment resistance, most importantly insufficient response of psychotic positive and negative symptoms, but also cognitive disturbances, affective comorbidity, obsessive-compulsive syndromes and side-effects of antipsychotic drugs. This review summarizes the current state of evidence of combined antipsychotic treatment strategies and the augmentation of antipsychotics with mood stabilizers, antidepressants and experimental substances. SUMMARY In general, rigorous data on combination therapy in schizophrenia are rare and further randomized controlled trials, naturalistic trials and head-to-head-trials are necessary. Some evidence supports a combination of antipsychotics and antidepressants for negative symptoms and comorbid major depressive episodes. The add-on of lithium and mood stabilizers lacks compelling evidence, but might be beneficial for specific subgroups. For treatment-resistant cognitive symptoms, antipsychotic medication should be combined with cognitive remediation, as no pharmacological add-on strategy has gained convincing evidence so far. Treatment-emergent positive and/or negative symptoms under clozapine monotherapy might benefit from adding a second atypical substance.
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Review and meta-analysis of usage of ginkgo as an adjunct therapy in chronic schizophrenia. Int J Neuropsychopharmacol 2010; 13:257-71. [PMID: 19775502 DOI: 10.1017/s1461145709990654] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This study aimed to review the roles of antioxidants in the pathophysiology of schizophrenia, whether the properties of ginkgo can ameliorate symptoms of this illness, and evaluate available literature to test this assumption. This review is based upon published works on antioxidants and ginkgo. A primary electronic search for meta-analysis on the usage of ginkgo or its derived products in schizophrenia was conducted using Pubmed, Cochrane Library, EMBASE, CINAHL, PsycINFO and AMED. Inclusion criteria were: criteria-based diagnosis of schizophrenia, randomized case assignment, use of ginkgo as an add-on therapy, and assessment using standardized rating scales to measure the state of psychopathology for negative and total symptoms of schizophrenia. Additionally, a detailed review was undertaken to investigate if antioxidants are involved in development of psychotic symptoms in schizophrenia. The six studies that fulfilled the selection criteria were constituted of 466 cases on ginkgo and 362 cases on placebo. They all used the Scale for the Assessment of Negative Symptoms (SANS) to measure negative symptoms, and the Scale for the Assessment of Positive Symptoms (SAPS) or the Brief Psychiatric Rating Scale (BPRS) to measure total symptoms. Difference between ginkgo and control groups from their pre- and post-trial scores and its pooled standard deviation were used to compute standardized mean difference (SMD). Ginkgo as an add-on therapy to antipsychotic medication produced statistically significant moderate improvement (SMD=-0.50) in total and negative symptoms of chronic schizophrenia. Ginkgo as add-on therapy ameliorates the symptoms of chronic schizophrenia. The role of antioxidants in pathogenesis of schizophrenia has also been explored.
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Weinmann S, Aderhold V. Antipsychotic medication, mortality and neurodegeneration: The need for more selective use and lower doses. PSYCHOSIS-PSYCHOLOGICAL SOCIAL AND INTEGRATIVE APPROACHES 2010. [DOI: 10.1080/17522430903501999] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Brunoni AR, Fraguas R, Fregni F. Pharmacological and combined interventions for the acute depressive episode: focus on efficacy and tolerability. Ther Clin Risk Manag 2009; 5:897-910. [PMID: 19956554 PMCID: PMC2781064 DOI: 10.2147/tcrm.s5751] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Use of antidepressants is the gold standard therapy for major depression. However, despite the large number of commercially available antidepressant drugs there are several differences among them in efficacy, tolerability, and cost-effectiveness. In addition the optimal augmentation strategy is still not clear when dealing with treatment-resistant depression, a condition that affects 15% to 40% of depressed patients. METHODS We therefore reviewed the main characteristics of these drugs regarding their efficacy, tolerability, side effects and cost-effectiveness, by accessing all meta-analyses and systematic reviews published from 2004 to 2009. In addition, we reviewed the augmentation strategy of associated antidepressants with neurostimulation therapies (such as transcranial magnetic stimulation [TMS] and transcranial direct current stimulation [tDCS]). A search was undertaken in MEDLINE, Web of Science, Cochrane, and Scielo databases. We included: 21 meta-analyses of antidepressant trials, 15 neurostimulation clinical trials and 8 studies of pharmacoeconomics. We then performed a comprehensive review on these articles. RESULTS AND CONCLUSION Although recent meta-analyses suggest sertraline and escitalopram might have increased efficacy/tolerability, other studies and large pragmatic trials have not found these to be superior to other antidepressant drugs. Also, we did not identify any superior drug in terms of cost-effectiveness due to the different designs observed among pharmacoecomics studies. Side effects such as sexual dysfunction, gastrointestinal problems and weight gain were common causes of discontinuation. Tolerability was an important issue for novel neurostimulation interventions, such as TMS and tDCS. These therapies might be interesting augmentation strategies, considering their benign profile of side effects, if proper safety parameters are adopted.
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Affiliation(s)
- Andre R Brunoni
- Department and Institute of Psychiatry, University of Sao Paulo, Brazil
| | - Renerio Fraguas
- Department and Institute of Psychiatry, University of Sao Paulo, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation, Spaulding Rehabilitation Center, Harvard Medical School and Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
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Nielsen RE, Nielsen J. Antipsychotic Drug Treatment for Patients with Schizophrenia: Theoretical Background, Clinical Considerations and Patient Preferences. ACTA ACUST UNITED AC 2009. [DOI: 10.4137/cmt.s2175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The cornerstone in treatment of psychosis is antipsychotic drugs. Treatment options have increased over the years; newer antipsychotic drugs with a proposed increased efficacy regarding negative and cognitive symptoms, but also a shift in side-effects from neurological side-effects to metabolic side-effects have arisen as the new challenge. The basis of successful pharmacological treatment is a fundamental understanding of the mechanisms of action, the desired effects and side-effects of antipsychotic drugs, a good relationship with the patient and a thorough monitoring of the patient before and during treatment. The clinically relevant aspects of antipsychotic drug treatment are reviewed; mechanism of antipsychotic drug action, clinical considerations in treatment, switching antipsychotic drugs, polypharmacy, safety and patient preference.
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Affiliation(s)
- René Ernst Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark
| | - Jimmi Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Aalborg, Denmark
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Abstract
Clozapine is the first choice antipsychotic medication for treatment-refractory schizophrenia; however, there are some disadvantages in using clozapine. A few reports have appeared concerning switching from clozapine to other antipsychotics for treatment-refractory schizophrenia. This report describes the case of a 58-year-old female patient with treatment-refractory schizophrenia who was successfully switched from clozapine 300 mg/day to aripiprazole 20 mg/day because of changes in consciousness. After the switch to aripiprazole, the patient's psychotic condition improved. As expected, we identified few successful cases of switches from clozapine in our search of the literature. Although controlled clinical trial data support use of clozapine in treatment-refractory schizophrenia, some patients cannot tolerate this agent or it may increase the risk of physical problems for some patients. In such situations, clinicians may want to consider prescribing a different antipsychotic or adding another antipsychotic and decreasing the dosage of clozapine.
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