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Uguz F, Sharma V, Boyce P, Clark CT, Galbally M, Koukopoulos A, Marsh W, Stevens A, Viguera A. Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors. J Clin Psychopharmacol 2023; 43:434-452. [PMID: 37683233 DOI: 10.1097/jcp.0000000000001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
ABSTRACT Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.
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Affiliation(s)
- Faruk Uguz
- From the Department of Psychiatry, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Verinder Sharma
- Schulich School of Medicine and Dentistry, The University of Western Ontario; Lawson Health Research Institute; Parkwood Institute Mental Health, Perinatal Mental Health Clinic, London Health Sciences Center, London, Ontario, Canada
| | - Philip Boyce
- Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Crystal T Clark
- Department of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Megan Galbally
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Alexia Koukopoulos
- University Hospital Policlinico Umberto I, La Sapienza University of Rome; Centro Lucio Bini, Rome, Italy
| | - Wendy Marsh
- Department of Psychiatry, University of Massachusetts Medical School/UMass Memorial Medical Center, Worcester, MA.
| | - Anja Stevens
- Centre for Bipolar Disorders, Dimence Group, Deventer, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Psychiatry, the Netherlands
| | - Adele Viguera
- Cleveland Clinic, Cleveland Clinic Neurological Institute, Cleveland, OH
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Kulkarni J, Gurvich C, Gilbert H, Worsley R, Li Q, Karimi L. The use of first and second-generation antipsychotic drugs and the potential to develop gestational diabetes mellitus among perinatal patients with psychosis. Schizophr Res 2023; 254:22-26. [PMID: 36758325 DOI: 10.1016/j.schres.2023.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
There is limited knowledge about the effects of antipsychotic exposure on the development of gestational diabetes mellitus (GDM) in women with mental illness. Studies have demonstrated an association between antipsychotic medications and metabolic problems such as weight gain and diabetes mellitus in non-pregnant patients with psychiatric disorders. GDM increases the risk of adverse maternal outcomes, including pregnancy-induced hypertension, antepartum and postpartum haemorrhage, and caesarean delivery. The National Register of Antipsychotic Medication in Pregnancy (NRAMP) is a prospective Australian cohort study that observed women who took antipsychotics during pregnancy. Data from 205 women were extracted for the final analysis and included women who took first or second-generation antipsychotics (FGA,SGA) during the first trimester of pregnancy (at minimum) and had a diagnosis of a psychotic disorder (n = 180). The comparison (non-exposed) group (n = 25) were women with psychosis who chose not to take any antipsychotic during the first trimester (at minimum). The comparison groups were not matched, although groups were homogenous in terms of sex, age range, diagnosis and perinatal status. The results of logistic regression analysis revealed that women who were exposed to FGAs, SGAs were seven and five times, respectively, more likely to develop GDM compared to non-exposed groups. When adjusted for confounding variables such as BMI and family history of diabetes, the potential of developing GDM decreased for women taking SGAs. In conclusion, the risk of developing GDM is lower in women taking SGAs compared with women taking FDAs. In addition, family history of diabetes and BMI adds to the risk.
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Affiliation(s)
- Jayashri Kulkarni
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia.
| | - Caroline Gurvich
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia
| | - Heather Gilbert
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia
| | - Roisin Worsley
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia
| | - Qi Li
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia.
| | - Leila Karimi
- The Monash Alfred Psychiatry research centre, The Alfred and Monash University Central Clinical School, Monash University, Melbourne, Australia
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Momen NC, Robakis T, Liu X, Reichenberg A, Bergink V, Munk-Olsen T. In utero exposure to antipsychotic medication and psychiatric outcomes in the offspring. Neuropsychopharmacology 2022; 47:759-766. [PMID: 34750566 PMCID: PMC8782838 DOI: 10.1038/s41386-021-01223-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
Information on neurodevelopmental effects of antenatal exposure to antipsychotics is limited to 10 studies, all examining children up to 5 years of age or less. The paper aimed to investigate the association between in utero exposure to antipsychotics and psychiatric outcomes in children using Danish nationwide registers. In total, 9011 liveborn singletons born 1998-2015 in Denmark whose mothers took antipsychotic medication before pregnancy were identified. Children whose mothers continued to take antipsychotics during pregnancy were compared with children of mothers who discontinued antipsychotics before pregnancy. As a negative control, paternal antipsychotic use in the same window was investigated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression for the primary outcome of psychiatric disorders, as well for subcategories of psychiatric disorders. In total, 9.9% of children in the discontinuation group and 11.0% of children in the continuation group received a psychiatric disorder diagnosis during follow-up. The adjusted HR for psychiatric disorders among offspring in the continuation group compared to the discontinuation group was 1.10 (95% CI 0.93-1.30). For antipsychotic use in the fathers, the HR was 1.05 (95% CI 0.89-1.24). The study does not provide evidence of increased risk of psychiatric disorders among children of women who continue antipsychotic treatment during pregnancy. This was observed after accounting for the underlying risk conferred by maternal psychiatric disorders. This suggests women who need to continue antipsychotic medications during pregnancy can do so without adverse psychiatric outcomes for offspring.
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Affiliation(s)
- Natalie C. Momen
- grid.7048.b0000 0001 1956 2722National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Thalia Robakis
- grid.59734.3c0000 0001 0670 2351Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Xiaoqin Liu
- grid.7048.b0000 0001 1956 2722National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Abraham Reichenberg
- grid.59734.3c0000 0001 0670 2351Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY USA ,grid.59734.3c0000 0001 0670 2351Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY USA ,grid.59734.3c0000 0001 0670 2351The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA ,grid.59734.3c0000 0001 0670 2351Seaver Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Veerle Bergink
- grid.59734.3c0000 0001 0670 2351Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY USA ,grid.5645.2000000040459992XDepartment of Psychiatry, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Trine Munk-Olsen
- grid.7048.b0000 0001 1956 2722National Centre for Register-based Research, Aarhus University, Aarhus, Denmark ,grid.452548.a0000 0000 9817 5300iPSYCH-Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark ,grid.7048.b0000 0001 1956 2722CIRRAU-Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
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Heinonen E, Forsberg L, Nörby U, Wide K, Källén K. Antipsychotic Use During Pregnancy and Risk for Gestational Diabetes: A National Register-Based Cohort Study in Sweden. CNS Drugs 2022; 36:529-539. [PMID: 35220525 PMCID: PMC9095513 DOI: 10.1007/s40263-022-00908-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to study whether antipsychotic use during pregnancy is associated with gestational diabetes. METHODS This was a Swedish national register-based cohort study on the Medical Birth Register and the Prescribed Drug Register including all 1,307,487 singleton births between July 2006 and December 2017. Antipsychotics were divided into first-generation antipsychotics (n = 728), high-risk metabolic second-generation antipsychotics including olanzapine, clozapine and quetiapine (n = 1710), and other second-generation antipsychotics (n = 541). The risks for gestational diabetes, foetal growth disturbances, pre-eclampsia, caesarean section and preterm labour were assessed. Women treated during pregnancy were compared to women not treated during pregnancy and to women who used antipsychotics before/after but not during pregnancy. RESULTS The crude risk ratio for gestational diabetes for women treated with high-risk metabolic second-generation antipsychotics during pregnancy was 2.2 (95% confidence interval [CI] 1.6-2.9) compared to untreated pregnant women (n = 1,296,539) and 1.8 (95% CI 1.4-2.5) compared to women treated before/after pregnancy (n = 34,492). After adjustment for maternal factors including body mass index, the risk ratios were 1.8 (95% CI 1.3-2.4) and 1.6 (95% CI 1.2-2.1). Exposed infants had an increased risk of being large for gestational age: adjusted risk ratios 1.6 (95% CI 1.3-1.9) and 1.3 (95% CI 1.1-1.6) compared to no maternal antipsychotic use during pregnancy and maternal use before/after the pregnancy. Other antipsychotics were not associated with metabolic risks. CONCLUSIONS Olanzapine, clozapine and quetiapine used during pregnancy were associated with increased risks for gestational diabetes and the infant being large for gestational age. Enhanced metabolic monitoring should be considered for pregnant women using these drugs.
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Affiliation(s)
- Essi Heinonen
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 14157, Stockholm, Sweden. .,Department of Paediatrics, Unit of Neonatology at Karolinska University Hospital, Stockholm, Sweden.
| | - Lisa Forsberg
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 14157 Stockholm, Sweden
| | - Ulrika Nörby
- Department of Clinical Sciences, Centre of Reproduction, Epidemiology, Tornblad Institute, Lund University, Lund, Sweden ,Health and Medical Care Administration, Region Stockholm, Stockholm, Sweden
| | - Katarina Wide
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 14157 Stockholm, Sweden ,Department of Pediatrics, Unit of Emergency Pediatrics at Karolinska University Hospital, Stockholm, Sweden
| | - Karin Källén
- Department of Clinical Sciences, Centre of Reproduction, Epidemiology, Tornblad Institute, Lund University, Lund, Sweden
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Germack HD, Combellick J, Cooper M, Koller K, McMichael B. Antidepressants Are the Most Commonly Discontinued Psychotherapeutic Medications in Pregnancy. Womens Health Issues 2021; 32:241-250. [PMID: 34840082 DOI: 10.1016/j.whi.2021.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Psychiatric illnesses are common during the perinatal period. The use of antipsychotic medication during pregnancy has increased over the past two decades. In many instances, clinicians agree that untreated psychiatric illness during the perinatal period is more dangerous than the risks imposed by continuing psychotherapeutic medication. We describe patterns of psychotherapeutic medication continuation and discontinuation during pregnancy in a large U.S. cohort. METHODS We assessed the relationship between the demographic and clinical characteristics of women who continued or discontinued psychotherapeutic medications-antidepressants, anxiolytics/sedatives, anticonvulsants, antipsychotics, mood stabilizers, and stimulants-during pregnancy. This study used data from 2008 to 2015 from the Medical Expenditure Panel Survey. We used t tests and Medical Expenditure Panel Survey Household Component longitudinal sampling weights in the analysis of this data. RESULTS There were few significant differences noted in clinical and demographic characteristics between women who continued and discontinued medications during pregnancy. Those who continued were less likely to be employed (46.95% of continuers were employed vs. 80.55% of discontinuers; p = .0053). Women taking antipsychotics were more likely to continue medications during pregnancy (64.60% continually used antipsychotics vs. 35.40% discontinued antipsychotics; p = .008), whereas women taking antidepressants were more likely to discontinue their use (19.62% continually used antidepressants vs. 80.38% discontinued antidepressants; p = .032). For each medication category, women resumed medication after pregnancy. CONCLUSIONS Antidepressants are the most commonly discontinued psychotherapeutic medication during pregnancy. We recommend further research examining factors that may influence this observed difference.
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Affiliation(s)
- Hayley D Germack
- Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania.
| | | | - Mandy Cooper
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Krista Koller
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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Seeman MV, González-Rodríguez A. Stratification by Sex and Hormone Level When Contrasting Men and Women in Schizophrenia Trials Will Improve Personalized Treatment. J Pers Med 2021; 11:929. [PMID: 34575706 PMCID: PMC8471344 DOI: 10.3390/jpm11090929] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sex and gender differences have been reported in the prevalence, expression, treatment response, and outcome of schizophrenia, but most reports are based on relatively small samples that have not been stratified for the impact of sex hormone levels. This literature review aims to show how women's hormone levels can impact the results of male/female comparisons. METHODS This is a narrative review of data from publications of the last decade. RESULTS Epidemiologic evidence, reports of the impact of hormones on cognition, results of sexually dimorphic responses to treatment, and male/female trajectories of illness over time all suggest that female hormone fluctuations exert major effects on male/female differences in schizophrenia. CONCLUSIONS Information on hormonal status in women participants is rarely available in clinical studies in schizophrenia, which makes male/female comparisons largely uninterpretable. These are the current challenges. Opportunities for individualized treatment are growing, however, and will undoubtedly result in improved outcomes for both women and men in the future.
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Affiliation(s)
- Mary V. Seeman
- Department of Psychiatry, University of Toronto, #605 260 Heath St. W., Toronto, ON M5P 3L6, Canada
| | - Alexandre González-Rodríguez
- Department of Mental Health, Mutua Terrassa University Hospital, University of Barcelona, 08221 Terrassa, Barcelona, Spain;
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Orsolini L, Sceusa F, Pompili S, Mauro A, Salvi V, Volpe U. Severe and persistent mental illness (SPMI) in pregnancy and breastfeeding: focus on second-generation long acting injectable antipsychotics. Expert Opin Drug Saf 2021; 20:1207-1224. [PMID: 33966552 DOI: 10.1080/14740338.2021.1928634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Pregnant women and fetuses are more likely than ever to be exposed to antipsychotic drugs (APs) during pregnancy and postpartum period. Second-generation APs (SGA) are increasingly used among women in reproductive age. Key outcomes (i.e., congenital malformations, pregnancy and maternal outcomes, neonatal/infant risks, and developmental/long-term outcomes) following the exposure to APs remain limited in number and size and yield of inconsistent findings overall, particularly regarding long-acting injectable AP (LAI-APs) formulations.Areas covered: The review aims at providing a summary of current knowledge on potential risks and safety profile of LAI-APs during pregnancy and breastfeeding, specifically focusing on SGA.Expert opinion: The management of safety and tolerability of long-acting injectable AP (LAI-APs) is far from having solid scientific evidence. In fact, due to ethical reasons, there is a lack of randomized clinical trials that limits the reliability and generalizability of the available data on LAI-APs safety profile during the perinatal period, being limited in the scientific literature only to isolated case reports. Therefore, it seems to be important for the future pathways to perinatal mental health care, providing a network of specialized clinicians and systematically collecting data of pregnant/puerperal women on oral and/or LAI APs-therapy about mother and infant outcomes.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Francesca Sceusa
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Simone Pompili
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Antonella Mauro
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Virginio Salvi
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, School of Medicine, Polytechnic University of Marche, Ancona, Italy
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Wang Z, Wong ICK, Man KKC, Alfageh BH, Mongkhon P, Brauer R. The use of antipsychotic agents during pregnancy and the risk of gestational diabetes mellitus: a systematic review and meta-analysis. Psychol Med 2021; 51:1028-1037. [PMID: 31969198 DOI: 10.1017/s003329171900401x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Previous studies have found contradicting results with regard to the use of antipsychotics during pregnancy and the risk of gestational diabetes mellitus (GDM). We aimed to evaluate the association between antipsychotic use in pregnancy and GDM. METHODS A systematic literature search was conducted in PubMed, EMBASE, PsycINFO and Cochrane Library databases up to March 2019, for data from observational studies assessing the association between gestational antipsychotic use and GDM. Non-English studies, animal studies, case reports, conference abstracts, book chapters, reviews and summaries were excluded. The primary outcome was GDM. Estimates were pooled using a random effect model, with the I2 statistic used to estimate heterogeneity of results. Our study protocol was registered with PROSPERO number: CRD42018095014. RESULTS In total 10 cohort studies met the inclusion criteria in our systematic review with 6642 exposed and 1 860 290 unexposed pregnancies. Six studies were included in the meta-analysis with a pooled adjusted relative risk of 1.24 overall [95% confidence interval (CI) 1.09-1.42]. The I2 result suggested low heterogeneity between studies (I2 = 6.7%, p = 0.373). CONCLUSION We found that the use of antipsychotic medications during pregnancy is associated with an increased risk of GDM in mothers. However, the evidence is still insufficient, especially for specific drug classes. We recommend more studies to investigate this association for specific drug classes, dosages and comorbidities to help clinicians to manage the risk of GDM if initiation or continuation of antipsychotic prescriptions during pregnancy is needed.
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Affiliation(s)
- Z Wang
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - I C K Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - K K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - B H Alfageh
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - P Mongkhon
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - R Brauer
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
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Methodological Evaluation of Antipsychotic Use During Pregnancy and Gestational Diabetes Mellitus. J Clin Psychopharmacol 2021; 40:319-320. [PMID: 32332476 DOI: 10.1097/jcp.0000000000001211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dragoi AM, Radulescu I, Năsui BA, Pop AL, Varlas VN, Trifu S. Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety-Particularities in the Context of COVID-19. Brain Sci 2020; 10:E840. [PMID: 33187329 PMCID: PMC7697202 DOI: 10.3390/brainsci10110840] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND clozapine (CLZ) use is precarious due to its neurological, cardiovascular, and hematological side effects; however, it is the gold standard in therapy-resistant schizophrenia (TRS) in adults and is underused. OBJECTIVE to examine the most recent CLZ data on (a) side effects concerning (b) recent pharmacological mechanisms, (c) therapy benefits, and (d) the particularities of the COVID-19 pandemic. DATA SOURCES a search was performed in two databases (PubMed and Web of Science) using the specific keywords "clozapine" and "schizophrenia", "side effects", "agranulocytosis", "TRS", or "bipolar affective disorder (BAF)" for the last ten years. STUDY ELIGIBILITY CRITERIA clinical trials on adults with acute symptoms of schizophrenia or related disorders. RESULTS we selected 37 studies, randomized controlled trials (RCTs), and clinical case series (CCS), centered on six main topics in the search area: (a) CLZ in schizophrenia, (b) CLZ in bipolar disorder, (c) side effects during the clozapine therapy, (d) CLZ in pregnancy, (e) CLZ in early-onset schizophrenia, and (f) CLZ therapy and COVID-19 infection. LIMITATIONS we considered RCTs and CCS from two databases, limited to the search topics. Conclusions and implications of key findings: (a) clozapine doses should be personalized for each patient based on pharmacogenetics testing when available; the genetic vulnerability postulates predictors of adverse reactions' severity; patients with a lower genetic risk could have less frequent hematological monitoring; (b) a CLZ-associated risk of pulmonary embolism imposes prophylactic measures for venous thromboembolism; (c) convulsive episodes are not an indication for stopping treatment; the plasma concentration of clozapine is a better side effect predictor than the dosage; (d) COVID-19 infection may enhance clozapine toxicity, generating an increased risk of pneumonia. Therapy must be continued with the proper monitoring of the white blood count, and the clozapine dose decreased by half until three days after the fever breaks; psychiatrists and healthcare providers must act together.
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Affiliation(s)
- Ana Miruna Dragoi
- Department of Psychiatry, “Alexandru Obregia” Clinical Hospital for Psychiatry, 10 Berceni St., 041914 Bucharest, Romania;
| | - Ioana Radulescu
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Bogdana Adriana Năsui
- Department of Community Health, “Iuliu Hațieganu” University of Medicine and Pharmacy, 6 Louis Pasteur St., 400349 Cluj-Napoca, Romania; or
| | - Anca Lucia Pop
- Department of Clinical Laboratory, Food Safety, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia St., 020945 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of General Medicine, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania; (I.R.); (V.N.V.)
| | - Simona Trifu
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania;
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Abstract
OBJECTIVE In this paper, we aimed at reviewing evidence-based treatment options for bipolar mania and proposed tentative evidence-based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication. METHOD A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices. RESULTS To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long-term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence. DISCUSSION Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long-term.
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Affiliation(s)
- I Pacchiarotti
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, 170 Villarroel st, 12-0, Barcelona, Catalonia, 08036, Spain
| | - G Anmella
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, 170 Villarroel st, 12-0, Barcelona, Catalonia, 08036, Spain
| | - L Colomer
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, 170 Villarroel st, 12-0, Barcelona, Catalonia, 08036, Spain
| | - E Vieta
- Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, University of Barcelona, 170 Villarroel st, 12-0, Barcelona, Catalonia, 08036, Spain
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Association Between Gestational Diabetes and Mental Illness. Can J Diabetes 2020; 44:566-571.e3. [PMID: 32792108 DOI: 10.1016/j.jcjd.2020.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
The rates of both gestational diabetes mellitus (GDM) and mental illness in pregnancy are rising. There is an association between type 2 diabetes and major depressive disorder, anxiety and schizophrenia, thus there is a need for greater understanding of the relationship between GDM and mental illness. This review suggests that there is a bidirectional and complex relationship between antenatal depression, gestational diabetes and postpartum depression. The combined effect of both a history of depression and gestational diabetes significantly increases the risk of postpartum depression. There is an association between severe mental illness and GDM; however, it is strongly mediated by antipsychotic medications and psychosocial factors, in addition to the disease itself. Medication has a major role in treating mental illness during pregnancy and is not directly linked with GDM in either depression or psychosis. Health-care providers should be mindful of the association between GDM and mental illness to appropriately screen and treat both disorders.
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Abstract
PURPOSE OF REVIEW The prevalence of diabetes is 2-3-fold higher in people with severe mental illness than the general population. There are concerns that antipsychotics increase the risk of diabetes. This review will examine the latest epidemiological studies linking antipsychotics and diabetes, as well as the mechanisms underlying the association and the clinical implications to minimise the impact of antipsychotics on metabolic health. RECENT FINDINGS Although there is an increased risk of diabetes in people with first-episode psychosis, the prevalence increases rapidly after antipsychotics are started. Antipsychotics likely increase the risk of diabetes through weight gain and directly by adversely affecting insulin sensitivity and secretion. It is important to implement measures to prevent diabetes, to screen for diabetes to ensure prompt diagnosis and to provide effective diabetes care. Further research is needed to understand how antipsychotics cause diabetes and to improve the clinical management of diabetes in people with severe mental illness.
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Affiliation(s)
- Richard I G Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.
- University Hospital Southampton NHS Trust, The IDS Building (MP887), Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
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Albertini E, Ernst CL, Tamaroff RS. Psychopharmacological Decision Making in Bipolar Disorder During Pregnancy and Lactation: A Case-by-Case Approach to Using Current Evidence. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2019; 17:249-258. [PMID: 32047370 DOI: 10.1176/appi.focus.20190007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The safety of pharmacotherapy for bipolar disorder during pregnancy and lactation remains a subject of debate and uncertainty. Clinicians must balance concerns about anatomical and behavioral teratogenicity, maternal mental health, exposure to multiple drugs, and heightened risks for peripartum mood episodes. Risk-benefit analyses must consider factors such as illness severity, past pregnancy treatment outcomes, known drug responsivity, psychosocial supports, and key windows during fetal development. Pharmacological decision making usually changes over the course of pregnancy, given developments in maternal physiology and critical relapse risk periods. Among mood stabilizers, given current research, many experts eschew divalproex and carbamazepine, consider lamotrigine relatively benign, and voice strong opinions for or against lithium. Most second-generation antipsychotics are considered relatively safe, apart from possible extrapyramidal and other motor signs of withdrawal after delivery. In this review, the authors analyze the practical questions, current controversies, and available evidence regarding psychotropic drug therapy during pregnancy and lactation in bipolar disorder.
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Affiliation(s)
| | - Carrie L Ernst
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York
| | - Rachel S Tamaroff
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York
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Current Resources for Evidence-Based Practice, July 2019. J Obstet Gynecol Neonatal Nurs 2019; 48:478-491. [PMID: 31194933 DOI: 10.1016/j.jogn.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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