The Pitfalls of Psychotropic Polypharmacy

Sales and regulatory status of fixed dose combination psychotropic drugs in India: a retrospective longitudinal study

Background

There is limited evidence to support use of fixed dose combination (FDC) drugs in the treatment of psychiatric disorders. This study aimed to examine the sales and regulatory status of psychotropic FDCs in India, in the context of two government regulatory initiatives.

Methods

Official documents were searched to establish an account of the initiatives and measures targeting psychotropic FDCs. This was integrated with private market data (2008 to 2020). Descriptive statistics were used to examine changes in FDC numbers/formulations and sales volumes in standard units (SU) over time.

Results

Psychotropic FDC sales volumes (percentage market share) increased from 0.8 billion SU (18.4%) in 2008 to 1.4 billion SU (20.1%) in 2020. The numbers (formulations) of FDCs also increased, from 28 (101) in 2008 to 33 (143) in 2020. Unapproved FDCs accounted for 69.3% of psychotropic FDC sales in 2008, decreasing slightly to 60.3% in 2020. Of 21 psychotropic FDCs considered under the regulatory initiatives, three went on to be banned, and two of these remained on the market in 2020.

Conclusions

Unapproved FDCs continue to account for most psychotropic FDC sales, potentially putting the public at risk because their safety and efficacy have not been evaluated.

Factors associated with risk of falling among younger inpatients in a mental health setting-A systematic review

AIM

To synthesise evidence related to risk factors of falls among younger mental health inpatients age ≤65 years old.

BACKGROUND

Hospitalised patients with mental illness are at increased risk of falling. Specific risk factors for falls for younger inpatients are poorly understood.

DESIGN

Systematic review.

METHODS

Medline, CINAHL, APA PsycINFO, Scopus and Web of Science were searched for studies published in English till December 2022. The review followed the 2020 PRISMA checklist. Odds ratios and P values of significant risk fall factors and the frequency of factors related to circumstances of falls were extracted.

RESULTS

Nine studies were included and 95 risk factors, across seven categories were extracted. These categories included socio-demographic, fall-related factors, functional status, health and mental status, psychiatric diagnosis and assessment, medication, and staff related factors. Factors related to medication, health and mental status are most reported. Majority of the patients sustained minor or no injury from the fall and circumstances of fall vary across studies.

CONCLUSION

Factors strongly associated with risk of falls were dizziness, use of psychotropics and antihypertensive drugs. A meta-analysis of risk factors was not possible due to different dependent variables studied, controlled confounding variables and control groups used.

RELEVANCE TO CLINICAL PRACTICE

Fall prevention is relevant to all patients in mental health settings. Approaches to fall risk assessment and management need to be better tailored to younger mental health patients in the psychiatric setting.

PATIENT AND PUBLIC CONTRIBUTION

Patient or public contribution was not possible because of the study design.

Fatigue in Alzheimer's disease: biological basis and clinical management-a narrative review

BACKGROUND

Fatigue is a common symptom in neurodegenerative diseases and is associated with decreased cognitive performances. A full knowledge of the causes and physiopathological pathways leading to fatigue in Alzheimer's disease could help treating this symptom and obtain positive effects on cognitive functions.

OBJECTIVES

To provide an overview of the clinical conditions and the biological mechanisms leading to fatigue in Alzheimer's disease patients. To review the recent advances on fatigue management and describe the landscape of future possibilities.

METHODS

We performed a narrative review including all type of studies (e.g. cross-sectional and longitudinal analysis, reviews, clinical trials).

RESULTS

We found very few studies considering the symptom fatigue in Alzheimer's disease patients. Populations, designs, and objectives varied across studies rendering comparability across studies difficult to perform. Results from cross-sectional and longitudinal analysis suggest that the amyloid cascade may be involved in the pathogenesis of fatigue and that fatigue may be a prodromal manifestation of Alzheimer's disease. Fatigue and neurodegeneration of Alzheimer's disease could share common brain signatures (i.e. hippocampal atrophy and periventricular leukoaraiosis). Some mechanisms of aging (i.e. inflammation, mitochondrial dysfunction, telomere shortening) may be proposed to play a common underlying role in Alzheimer's disease neurodegeneration and muscle fatigability. Considering treatments, donepezil has been found to reduce cognitive fatigue in a 6-week randomized controlled study. Fatigue is frequently reported as an adverse event in patients treated by anti-amyloid agents in clinical trials.

CONCLUSION

The literature is actually inconclusive about the main causes of fatigue in Alzheimer's disease individuals and its potential treatments. Further research is needed to disentangle the role of several components such as comorbidities, depressive symptoms, iatrogenic factors, physical decline and neurodegeneration itself. Given the clinical relevance of this symptom, it seems to be important to systematically assess fatigue by validated tools in Alzheimer's disease clinical trials.

Real-world characteristics of European patients receiving SNRIs as first-line treatment for major depressive disorder

BACKGROUND

Serotonin-norepinephrine reuptake inhibitors (SNRIs) are among the most frequently prescribed antidepressants (ADs) for major depressive disorder (MDD), with an increasing trend in the last decade. Given the relative dearth of information regarding rationales for their preferred use as first-line ADs in the broad clinical routine, the present study systematically investigated real-world characteristics of MDD patients prescribed either SNRIs or other AD substances across different countries and treatment settings.

METHODS

In the present secondary analyses based on a large European, multi-site, naturalistic and cross-sectional investigation with a retrospective assessment of treatment outcome, we firstly defined the proportion of MDD patients receiving SNRIs as first-line AD psychopharmacotherapy and secondly compared their sociodemographic and clinical characteristics to those patients prescribed alternative first-line ADs during their current major depressive episode (MDE).

RESULTS

Within the total sample of 1410 MDD patients, 336 (23.8 %) received first-line SNRIs. Compared to other ADs, SNRIs were significantly associated with inpatient care, suicidality and treatment resistance during the current MDE, and a longer lifetime duration of psychiatric hospitalizations. Moreover, greater severity of depressive symptoms at study entry, higher daily doses of the administered ADs, as well as more frequent prescriptions of psychopharmacotherapeutic add-on strategies in general and antipsychotic augmentation in particular, were significantly related to first-line SNRIs.

CONCLUSIONS

Considering the limitations of a cross-sectional and retrospective study design, our data point towards a preferred use of first-line SNRIs in a generally more severely ill MDD patients, although they did not lead to superior treatment outcomes compared to alternative ADs.