Does long term use of psychiatric drugs cause more harm than good?

What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness?

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.

Is Target-Based Drug Discovery Efficient? Discovery and "Off-Target" Mechanisms of All Drugs

Target-based drug discovery is the dominant paradigm of drug discovery; however, a comprehensive evaluation of its real-world efficiency is lacking. Here, a manual systematic review of about 32000 articles and patents dating back to 150 years ago demonstrates its apparent inefficiency. Analyzing the origins of all approved drugs reveals that, despite several decades of dominance, only 9.4% of small-molecule drugs have been discovered through "target-based" assays. Moreover, the therapeutic effects of even this minimal share cannot be solely attributed and reduced to their purported targets, as they depend on numerous off-target mechanisms unconsciously incorporated by phenotypic observations. The data suggest that reductionist target-based drug discovery may be a cause of the productivity crisis in drug discovery. An evidence-based approach to enhance efficiency seems to be prioritizing, in selecting and optimizing molecules, higher-level phenotypic observations that are closer to the sought-after therapeutic effects using tools like artificial intelligence and machine learning.

Communalistic use of psychoactive plants as a bridge between traditional healing practices and Western medicine: A new path for the Global Mental Health movement

The Global Mental Health (GMH) movement aims to provide urgently needed treatment to those with mental illness, especially in low- and middle-income countries. Due to the complexity of providing mental health services to people from various cultures, there is much debate among GMH advocates regarding the best way to proceed. While biomedical interventions offer some degree of help, complementary approaches should focus on the social/community aspects. Many cultures conduct traditional rituals involving the communal use of psychoactive plants. We propose that these practices should be respected, protected, and promoted as valuable tools with regard to mental health care at the community level. The traditional use of psychoactive plants promotes community engagement and participation, and they are relatively affordable. Furthermore, the worldviews and meaning-making systems of local population are respected. The medical systems surrounding the use of psychoactive plants can be explained in biomedical terms, and many recently published clinical trials have demonstrated their therapeutic potential. Psychoactive plants and associated rituals offer potential benefits as complementary aspects of mental health services. They should be considered as such by international practitioners and advocates of the GMH movement.

Pharmaceutical Advertising and the Subtle Subversion of Patient Autonomy

Direct-to-consumer pharmaceutical advertising (DTCPA) is pervasive in the United States. Beyond its effect on consumer behavior, DTCPA changes the relationship between individuals and physicians. The author provides a brief history of pharmaceutical advertising in the United States. The author then analyzes the current commonly used marketing techniques of pharmaceutical companies and argues that pharmaceutical companies are "irrational authorities" in Erich Fromm's sense of the term since they seek to exploit persons. Using concepts from various philosophers from the Continental tradition, with a particular emphasis on the work of Michel Foucault, the author analyzes the power relations involved in DTCPA and ultimately argues that DTCPA subtly undermines the contemporary paradigm of patient autonomy while simultaneously depending upon it by treating health consumers as "dividuals," that is, as porous entities to be manipulated.

Areas of Interest and Social Consideration of Antidepressants on English Tweets: A Natural Language Processing Classification Study

Background: Antidepressants are the foundation of the treatment of major depressive disorders. Despite the scientific evidence, there is still a sustained debate and concern about the efficacy of antidepressants, with widely differing opinions among the population about their positive and negative effects, which may condition people’s attitudes towards such treatments. Our aim is to investigate Twitter posts about antidepressants in order to have a better understanding of the social consideration of antidepressants. Methods: We gathered public tweets mentioning antidepressants written in English, published throughout a 22-month period, between 1 January 2019 and 31 October 2020. We analysed the content of each tweet, determining in the first place whether they included medical aspects or not. Those with medical content were classified into four categories: general aspects, such as quality of life or mood, sleep-related conditions, appetite/weight issues and aspects around somatic alterations. In non-medical tweets, we distinguished three categories: commercial nature (including all economic activity, drug promotion, education or outreach), help request/offer, and drug trivialization. In addition, users were arranged into three categories according to their nature: patients and relatives, caregivers, and interactions between Twitter users. Finally, we identified the most mentioned antidepressants, including the number of retweets and likes, which allowed us to measure the impact among Twitter users. Results: The activity in Twitter concerning antidepressants is mainly focused on the effects these drugs may have on certain health-related areas, specifically sleep (20.87%) and appetite/weight (8.95%). Patients and relatives are the type of user that most frequently posts tweets with medical content (65.2%, specifically 80% when referencing sleep and 78.6% in the case of appetite/weight), whereas they are responsible for only 2.9% of tweets with non-medical content. Among tweets classified as non-medical in this study, the most common subject was drug trivialization (66.86%). Caregivers barely have any presence in conversations in Twitter about antidepressants (3.5%). However, their tweets rose more interest among other users, with a ratio 11.93 times higher than those posted by patients and their friends and family. Mirtazapine is the most mentioned antidepressant in Twitter (45.43%), with a significant difference with the rest, agomelatine (11.11%). Conclusions: This study shows that Twitter users that take antidepressants, or their friends and family, use social media to share medical information about antidepressants. However, other users that do not talk about antidepressants from a personal or close experience, frequently do so in a stigmatizing manner, by trivializing them. Our study also brings to light the scarce presence of caregivers in Twitter.

Neurodualism: People Assume that the Brain Affects the Mind more than the Mind Affects the Brain

People commonly think of the mind and the brain as distinct entities that interact, a view known as dualism. At the same time, the public widely acknowledges that science attributes all mental phenomena to the workings of a material brain, a view at odds with dualism. How do people reconcile these conflicting perspectives? We propose that people distort claims about the brain from the wider culture to fit their dualist belief that minds and brains are distinct, interacting entities: Exposure to cultural discourse about the brain as the physical basis for the mind prompts people to posit that mind-brain interactions are asymmetric, such that the brain is able to affect the mind more than vice versa. We term this hybrid intuitive theory neurodualism. Five studies involving both thought experiments and naturalistic scenarios provided evidence of neurodualism among laypeople and, to some extent, even practicing psychotherapists. For example, lay participants reported that "a change in a person's brain" is accompanied by "a change in the person's mind" more often than vice versa. Similarly, when asked to imagine that "future scientists were able to alter exactly 25% of a person's brain," participants reported larger corresponding changes in the person's mind than in the opposite direction. Participants also showed a similarly asymmetric pattern favoring the brain over the mind in naturalistic scenarios. By uncovering people's intuitive theories of the mind-brain relation, the results provide insights into societal phenomena such as the allure of neuroscience and common misperceptions of mental health treatments.

Benefits and harms of Risperidone and Paliperidone for treatment of patients with schizophrenia or bipolar disorder: a meta-analysis involving individual participant data and clinical study reports

BACKGROUND

Schizophrenia and bipolar disorder are severe mental illnesses which are highly prevalent worldwide. Risperidone and Paliperidone are treatments for either illnesses, but their efficacy compared to other antipsychotics and growing reports of hormonal imbalances continue to raise concerns. As existing evidence on both antipsychotics are solely based on aggregate data, we aimed to assess the benefits and harms of Risperidone and Paliperidone in the treatment of patients with schizophrenia or bipolar disorder, using individual participant data (IPD), clinical study reports (CSRs) and publicly available sources (journal publications and trial registries).

METHODS

We searched MEDLINE, Central, EMBASE and PsycINFO until December 2020 for randomised placebo-controlled trials of Risperidone, Paliperidone or Paliperidone palmitate in patients with schizophrenia or bipolar disorder. We obtained IPD and CSRs from the Yale University Open Data Access project. The primary outcome Positive and Negative Syndrome Scale (PANSS) score was analysed using one-stage IPD meta-analysis. Random-effect meta-analysis of harm outcomes involved methods for coping with rare events. Effect-sizes were compared across all available data sources using the ratio of means or relative risk. We registered our review on PROSPERO, CRD42019140556.

RESULTS

Of the 35 studies, IPD meta-analysis involving 22 (63%) studies showed a significant clinical reduction in the PANSS in patients receiving Risperidone (mean difference - 5.83, 95% CI - 10.79 to - 0.87, I2 = 8.5%, n = 4 studies, 1131 participants), Paliperidone (- 6.01, 95% CI - 8.7 to - 3.32, I2 = 4.3%, n = 13, 3821) and Paliperidone palmitate (- 7.89, 95% CI - 12.1 to - 3.69, I2 = 2.9%, n = 5, 2209). CSRs reported nearly two times more adverse events (4434 vs. 2296 publication, relative difference (RD) = 1.93, 95% CI 1.86 to 2.00) and almost 8 times more serious adverse events (650 vs. 82; RD = 7.93, 95% CI 6.32 to 9.95) than the journal publications. Meta-analyses of individual harms from CSRs revealed a significant increased risk among several outcomes including extrapyramidal disorder, tardive dyskinesia and increased weight. But the ratio of relative risk between the different data sources was not significant. Three treatment-related gynecomastia events occurred, and these were considered mild to moderate in severity.

CONCLUSION

IPD meta-analysis conclude that Risperidone and Paliperidone antipsychotics had a small beneficial effect on reducing PANSS score over 9 weeks, which is more conservative than estimates from reviews based on journal publications. CSRs also contained significantly more data on harms that were unavailable in journal publications or trial registries. Sharing of IPD and CSRs are necessary when performing meta-analysis on the efficacy and safety of antipsychotics.

How Efficacious Are Antipsychotic Drugs for Schizophrenia? An Interpretation Based on 13 Effect Size Indices

BACKGROUND

The magnitude of the superiority of antipsychotics over placebo is debated. One reason is that the effect-size index which is usually used in meta-analyses is in standard deviation units. Many other indices, some of which are more intuitive, exist.

METHODS

We explain the formulae, advantages, and limitations of 13 effect-size indices: Mean Difference (MD), Standardized-Mean-Difference (SMD), Correlation Coefficient, Ratio-of-Means (RoM, endpoint and change data), Improvement Fraction (IF), Drug-Response Fraction (DRF), Minimally-Clinically-Important-Difference-Units (MCIDU), Number-Needed-to-Treat-derived from SMD (NNT), Odds Ratio (OR), Relative Risk (RR), and Risk Difference (RD) derived from SMD, Drug-response and Placebo-response in percent. We applied these indices to meta-analyses comparing antipsychotic drugs with placebo for acute schizophrenia.

RESULTS

The difference of all antipsychotics pooled vs placebo (105 trials with 22741 participants) was: MD 9.4 (95% CI 8.4,10.2) PANSS points, SMD 0.47 (0.42,0.51), Correlation coefficient 0.23 (0.21,0.25), RoM endpoint 0.83 (0.81,0.85), RoM change 1.94 (1.84,2.02), IF (%) 49 (46,51), DRF (%) 94 (84,102), MCIDU 0.63 (0.56,0.68), NNT 5 (5,6), OR 2.34 (2.14, 2.52), RR 1.67 (1.59,1.73), RD 20% (18-22), and 50% (48, 52) improved on drug compared to 30% on placebo. Results of individual drugs compared to placebo are presented, as well.

CONCLUSIONS

Taken together these indices show a substantial, but not a large superiority of antipsychotics compared to placebo. The general chronicity of the patients in the trials must be considered. Future meta-analyses should report other effect size indices in addition to the Standardized-Mean-Difference, in particular percentage responders in the drug and placebo groups. They can be easily derived and would enhance the interpretation of research findings.

Lithium as a Neuroprotective Agent for Bipolar Disorder: An Overview

Lithium (Li⁺) is a first option treatment for adult acute episodes of Bipolar Disorder (BD) and for the prophylaxis of new depressed or manic episodes. It is also the preferred choice as maintenance treatment. Numerous studies have shown morphological abnormalities in the brains of BD patients, suggesting that this highly heritable disorder may exhibit progressive and deleterious changes in brain structure. Since treatment with Li⁺ ameliorates these abnormalities, it has been postulated that Li⁺ is a neuroprotective agent in the same way atypical antipsychotics are neuroprotective in patients diagnosed with schizophrenia spectrum disorders. Li⁺'s neuroprotective properties are related to its modulation of nerve growth factors, inflammation, mitochondrial function, oxidative stress, and programmed cell death mechanisms such as autophagy and apoptosis. Notwithstanding, it is not known whether Li⁺-induced neuroprotection is related to the inhibition of its putative molecular targets in a BD episode: the enzymes inositol-monophosphatase, (IMPase), glycogen-synthase-kinase 3β (GSK3), and Protein kinase C (PKC). Furthermore, it is uncertain whether these neuroprotective mechanisms are correlated with Li⁺'s clinical efficacy in maintaining mood stability. It is expected that in a nearby future, precision medicine approaches will improve diagnosis and expand treatment options. This will certainly contribute to ameliorating the medical and economic burden created by this devastating mood disorder.

Factors Associated With Use of Medications for Anxiety and Depression in Pharmacy Students in Brazil

Objective. To map undergraduate pharmacy students' use of medications for anxiety and depression and associated factors at one university in Brazil.Methods. A cross-sectional study was conducted from May to July 2019 among undergraduate pharmacy students at one university. Data regarding sociodemographic issues and the use of psychotropics were collected using an online questionnaire. Exploratory descriptive analysis of data, the chi-square test, and multivariate binary logistic regression were performed to identify factors associated with the use of medications for anxiety and depression.Results. Of 900 students enrolled, usable survey responses were received from 198. Most respondents were female with a mean age of 22.3 years. Among these, 17.7% of pharmacy students used medications to treat anxiety and 13.1% used medications for depression. The most common psychotropics were escitalopram and fluoxetine. There were two peak usage times: the initial and final year of pharmacy school. Dissatisfaction with the pharmacy program and psychological care were significantly associated with the use of medications for anxiety. In contrast, monthly income from three to 15 times the minimum wage, religiosity/spirituality, and psychological care were associated with students' use of medications for depression.Conclusion. There was a high prevalence of medication use to treat anxiety and depression among undergraduate pharmacy students, and this use was associated with psychological care, monthly income, and religiosity/spirituality.

Understanding Side Effects of Antidepressants: Large-scale Longitudinal Study on Social Media Data

BACKGROUND

Antidepressants are known to show heterogeneous effects across individuals and conditions, posing challenges to understanding their efficacy in mental health treatment. Social media platforms enable individuals to share their day-to-day concerns with others and thereby can function as unobtrusive, large-scale, and naturalistic data sources to study the longitudinal behavior of individuals taking antidepressants.

OBJECTIVE

We aim to understand the side effects of antidepressants from naturalistic expressions of individuals on social media.

METHODS

On a large-scale Twitter data set of individuals who self-reported using antidepressants, a quasi-experimental study using unsupervised language analysis was conducted to extract keywords that distinguish individuals who improved and who did not improve following the use of antidepressants. The net data set consists of over 8 million Twitter posts made by over 300,000 users in a 4-year period between January 1, 2014, and February 15, 2018.

RESULTS

Five major side effects of antidepressants were studied: sleep, weight, eating, pain, and sexual issues. Social media language revealed keywords related to these side effects. In particular, antidepressants were found to show a spectrum of effects from decrease to increase in each of these side effects.

CONCLUSIONS

This work enhances the understanding of the side effects of antidepressants by identifying distinct linguistic markers in the longitudinal social media data of individuals showing the most and least improvement following the self-reported intake of antidepressants. One implication of this work concerns the potential of social media data as an effective means to support digital pharmacovigilance and digital therapeutics. These results can inform clinicians in tailoring their discussion and assessment of side effects and inform patients about what to potentially expect and what may or may not be within the realm of normal aftereffects of antidepressants.

A cross-sectional study of psychotropic drug use in the elderly: Consuming patterns, risk factors and potentially inappropriate use

OBJECTIVES

The aims of the present study were: (1) to describe psychotropic drug consumption patterns in an outpatient population aged 65 years and older; (2) to determine the impact of a number of demographic and clinical factors on psychotropic consumption; and (3) to determine the ratio of potentially inappropriate psychotropic agents prescribed to the above population.

METHODS

Cross-sectional, observational study of outpatients aged 65 years and older. Data on sociodemographic and clinical variables were collected. Psychotropic drugs were classified into three categories: anxiolytics-hypnotics, antidepressants, and antipsychotics. To determine the risk factors for psychotropic drug use among these patients, a multivariate logistic regression model was developed and subsequently validated using bootstrap resampling techniques. To identify the psychotropic drugs to be avoided, a review of treatments received by the patients was performed based on the 2015 version of the Beers criteria.

RESULTS

The study included 225 outpatients of whom 30.7% were on psychotropic drugs for chronic treatment. The highest likelihood of psychotropic utilisation corresponded to the following profile: female, living in a nursing home, having two or more prescribing physicians, and having received six or more different diagnoses. According to Beers criteria, 51 patients (22.7% of the sample and 73.9% of patients on psychotropic drugs) had been prescribed at least one potentially inappropriate psychotropic drug.

CONCLUSION

Elderly patients commonly use psychotropic medications and are the most vulnerable to the adverse effects of these drugs. It is necessary to re-evaluate the pertinence and accuracy of these medical prescriptions.

Rationale and neurobiological effects of treatment with antipsychotics in patients with chronic schizophrenia considering dopamine supersensitivity

The long-term treatment of patients with schizophrenia often involves the management of relapses for most patients and the development of treatment resistance in some patients. To stabilize the clinical course and allow as many patients as possible to recover, clinicians need to recognize dopamine supersensitivity, which can be provoked by administration of high dosages of antipsychotics, and deal with it properly. However, no treatment guidelines have addressed this issue. The present review summarized the characteristics of long-acting injectable antipsychotics, dopamine partial agonists, and clozapine in relation to dopamine supersensitivity from the viewpoints of receptor profiles and pharmacokinetics. The potential merits and limitations of these medicines are discussed, as well as the risks of treating patients with established dopamine supersensitivity with these classes of drugs. Finally, the review discussed the biological influence of antipsychotic treatment on the human brain based on findings regarding the relationship between the hippocampus and antipsychotics.

The report of the joint WPA/CINP workgroup on the use and usefulness of antipsychotic medication in the treatment of schizophrenia

This is a report of a joint World Psychiatric Association/International College of Neuropsychopharmacology (WPA/CINP) workgroup concerning the risk/benefit ratio of antipsychotics in the treatment of schizophrenia. It utilized a selective but, within topic, comprehensive review of the literature, taking into consideration all the recently discussed arguments on the matter and avoiding taking sides when the results in the literature were equivocal. The workgroup's conclusions suggested that antipsychotics are efficacious both during the acute and the maintenance phase, and that the current data do not support the existence of a supersensitivity rebound psychosis. Long-term treated patients have better overall outcome and lower mortality than those not taking antipsychotics. Longer duration of untreated psychosis and relapses are modestly related to worse outcome. Loss of brain volume is evident already at first episode and concerns loss of neuropil volume rather than cell loss. Progression of volume loss probably happens in a subgroup of patients with worse prognosis. In humans, antipsychotic treatment neither causes nor worsens volume loss, while there are some data in favor for a protective effect. Schizophrenia manifests 2 to 3 times higher mortality vs the general population, and treatment with antipsychotics includes a number of dangers, including tardive dyskinesia and metabolic syndrome; however, antipsychotic treatment is related to lower mortality, including cardiovascular mortality. In conclusion, the literature strongly supports the use of antipsychotics both during the acute and the maintenance phase without suggesting that it is wise to discontinue antipsychotics after a certain period of time. Antipsychotic treatment improves long-term outcomes and lowers overall and specific-cause mortality.

The evidence base for psychotropic drugs approved by the European Medicines Agency: a meta-assessment of all European Public Assessment Reports

AIMS

To systematically assess the level of evidence for psychotropic drugs approved by the European Medicines Agency (EMA).

METHODS

Cross-sectional analysis of all European Public Assessment Reports (EPARs) and meta-analyses of the many studies reported in these EPARs. Eligible EPARs were identified from the EMA's website and individual study reports were requested from the Agency when necessary. All marketing authorisation applications (defined by the drug, the route of administration and given indications) for psychotropic medications for adults (including drugs used in psychiatry and addictology) were considered. EPARs solely based on bioequivalence studies were excluded. Our primary outcome measure was the presence of robust evidence of comparative effectiveness, defined as at least two 'positive' superiority studies against an active comparator. Various other features of the approvals were assessed, such as evidence of non-inferiority v. active comparator and superiority v. placebo. For studies with available data, effect sizes were computed and pooled using a random effect meta-analysis for each dose of each drug in each indication.

RESULTS

Twenty-seven marketing authorisations were identified. For one, comparative effectiveness was explicitly considered as not needed in the EPAR. Of those remaining, 21/26 (81%) did not provide any evidence of superiority against an active comparator, 2/26 (8%) were based on at least two trials showing superiority against active comparator and three (11%) were based on one positive trial; 1/26 provided evidence for two positive non-inferiority analyses v. active comparator and seven (26%) provided evidence for one. In total, 20/27 (74%) evaluations reported evidence of superiority v. placebo with two or more trials. Among the meta-analyses of initiation studies against active comparator (57 available comparisons), the median effect size was 0.051 (range -0.503; 0.318). Twenty approved evaluations (74%) reported evidence of superiority v. placebo on the basis of two or more initiation trials and seven based on a single trial. Among meta-analyses of initiation studies against placebo (125 available comparisons), the median effect size was -0.283 (range -0.820; 0.091). Importantly, among the 89 study reports requested on the EMA website, only 19 were made available 1 year after our requests.

CONCLUSIONS

The evidence for psychiatric drug approved by the EMA was in general poor. Small to modest effects v. placebo were considered sufficient in indications where an earlier drug exists. Data retrieval was incomplete after 1 year despite EMA's commitment to transparency. Improvements are needed.

Multiple Causes of Dementia as Engineered Senescence

All traumas—cranial, cardiovascular, hormone, viral, bacterial, fungi, parasites, misfolded protein, genetic, behavior, environmental and medication—affect the brain. This paper itemizes studies showing the many different causes of dementia including Alzheimer’s disease. Causes interact with each other, act sequentially by preparing the optimal conditions for its successor, initiate other diseases, allow for other traumas to accumulate and degrade protective features of the brain. Since such age-related cognitive impairment is not exclusively a human attribute there might be support for an evolutionary theory of dementia. Relying on theories of antagonistic pleiotropy and polymorphism, the brain has been designed to sequester trauma. Because of increased longevity, the short-term tactic of sequestering trauma becomes a long-term liability. We are engineered to sequester these insults until a tipping point is reached. Dementia is an evolutionary trade-off for longevity. We cannot cure dementia without understanding the overall biology of aging.

Recent Stressful Life Events in Euthymic Major Depressive Disorder Patients: Sociodemographic and Clinical Characteristics

BACKGROUND

Stressful life events (SLE) may influence the illness course and outcome. This study aimed to characterize socio-demographic and clinical features of euthymic major depressive disorder (MDD) outpatients with SLE compared with those without.

METHODS

The present sample included 628 (mean age=55.1 ± 16.1) currently euthymic MDD outpatients of whom 250 (39.8%) reported SLE and 378 (60.2%) did not.

RESULTS

After univariate analyses, outpatients with SLE were most frequently widowed and lived predominantly with friends/others. Moreover, relative to outpatients without SLE, those with SLE were more likely to have a family history of suicidal behavior, manifested melancholic features, report a higher Coping Orientation to the Problems Experienced (COPE) positive reinterpretation/growth and less likely to have a comorbid panic disorder, residual interepisodic symptoms, use previous psychiatric medications, and currently use of antidepressants. Having a family history of suicide (OR=9.697; p=≤.05), history of psychotropic medications use (OR=2.888; p=≤.05), and reduced use of antidepressants (OR=.321; p=.001) were significantly associated with SLE after regression analyses. Mediation analyses showed that the association between current use of antidepressants and SLE was mediated by previous psychiatric medications.

CONCLUSION

Having a family history of suicide, history of psychotropic medications use, and reduced use of antidepressants is linked to a specific "at risk" profile characterized by the enhanced vulnerability to experience SLE.

Efficacy and tolerability of pharmacological and non-pharmacological interventions in older patients with major depressive disorder: A systematic review, pairwise and network meta-analysis

As there is currently no comprehensive evaluation about the efficacy and safety of interventions in elderly patients with major depressive disorder, we did a systematic review and network meta-analysis about all interventions in this population. We searched the specialised register of the Cochrane common mental disorders group, MEDLINE, EMBASE, PsycINFO, CochraneLibrary, ClinicalTrials.gov and the WHO registry until Dec 12, 2017 to identify all randomized controlled trials about the treatment of major depressive disorder in patients over an age of 65. The primary outcome was response defined as reduction of at least 50% on the Hamilton Depression Scale or any other validated depression scale. Secondary outcomes were remission, depressive symptoms, dropouts total, dropouts owing to inefficacy and dropouts due to adverse events, quality of life and social functioning. Additionally, we analysed 116 adverse events. We identified 129 references from 53 RCTs with 9274 participants published from 1990 to 2017. The mean participant age was 73.7 years. In terms of the primary outcome response to treatment the network-meta-analysis showed significant superiority compared to placebo for quetiapine and duloxetine; in addition, agomelatine, imipramine and vortioxetine outperformed placebo in pairwise meta-analyses, and there were also significant superiorities of several antidepressants compared to placebo in secondary efficacy outcomes. Very limited evidence suggests that competitive memory training, geriatric home treatment group and detached mindfulness condition reduce depressive symptoms. Several antidepressants and quetiapine have been shown to be efficacious in elderly patients with major depressive disorder, but due to the comparably few available data, the results are not robust. Differences in the multiple side-effects analysed should also be considered in drug choice. Although there were significant effects for some non-pharmacological treatments, the overall evidence for non-pharmacological treatments in major depressive disorder is insufficient, because it is based on a few trials with usually small sample sizes.

The effect of baseline antipsychotic status on the 12-month outcome in initially stabilized patients with schizophrenia

INTRODUCTION

Recently, the usefulness of antipsychotics has been challenged. The aim of the study was to measure the real-life effect of antipsychotic treatment on remission and recovery rates in already stabilized patients with schizophrenia after 1 year.

MATERIAL AND METHODS

The study included 133 stabilized patients with schizophrenia (77 males and 56 females; aged 33.55 ± 11.22 years). The assessment included testing at baseline and after 1 year with the Positive and Negative Syndrome Scale, Calgary Depression Scale, State-Trait Anxiety Inventory, UKU, Extrapyramidal Symptom Rating Scale, and General Assessment of Functioning.

RESULTS

More patients were on antipsychotics after 1 year (increase by 16.45%). There was an increase in the remission by 75% and in the recovery rate by 66%. It was not possible to predict the outcome on the basis of baseline variables.

DISCUSSION

There is an accumulating beneficial effect of antipsychotic treatment over a 12-month period; early lack of remission is not prognostic of a poor outcome. There might be different neurobiological mechanisms underlying acute and sustained response. Both remission and recovery are difficult to achieve for patients with schizophrenia and characterize only a minority of patients. Only a very small minority of patients (4.5%) that is impossible to identify a priori would do well without off antipsychotics.

Withdrawal Confounding in Randomized Controlled Trials of Antipsychotic, Antidepressant, and Stimulant Drugs, 2000-2017

BACKGROUND

Results of relapse prevention randomized controlled trials (RCTs) which discontinue psychotropic drug treatment from some participants may be confounded by drug withdrawal symptoms. We test for the confound by calculating whether ≥50% of the difference in relapse risk between drug-discontinued and drug-maintained groups is present at discontinuation time points (DCTs) with "short" and "long" assumptions regarding onset and duration of withdrawal symptoms.

METHODS

In eligible RCTs of antidepressants, antipsychotics, and stimulants from 2000 to 2017 (n = 30) selected from a systematic review, differences in relapse risk were examined by arithmetic and graphical comparison of mean behavioral scores or survival plots.

RESULTS

Only 14 studies (46.6%) with 15 analyses of relapse risk provided sufficient data. Under short and long DCTs, 9 of 13 (69.2%) and 7 of 9 (77.8%) interpretable analyses, respectively, suggested a withdrawal confound. The proportion of endpoint placebo-maintenance group difference present by the DCT averaged 69.1% (range, 58.7-148.0%, n = 13) for short DCT assumptions, and 79.0% (range, 51.5-183.3%, n = 9) under long DCTs. One study (3.33%) controlled for withdraw al effects, and 1 yielded inconclusive results.

CONCLUSIONS

These results support suggestions that withdrawal symptoms confound the results of relapse prevention RCTs. Accounting for such symptoms in RCTs is an ethical, scientific, and clinical imperative. Justifications for relapse prevention RCTs employing a discontinuation procedure require more scrutiny.

The debate regarding maintenance treatment with antipsychotic drugs in schizophrenia

Several large meta-analyses of maintenance trials have confirmed that patients who suffer from chronic schizophrenia, randomized to placebo, are likely to experience earlier symptomatic worsening than patients randomized to a dopamine (DA)-blocking drug. These findings led expert groups to issue treatment guidelines, which recommend treatment with DA-blocking drugs for periods ranging from several years to indefinitely. The recommendations were accepted by the majority of, but not all, the experts, some of whom proposed a targeted or intermittent therapy approach by which DA-blocking drugs are discontinued upon symptomatic remission, to be renewed in case of symptom re-emergence. The debate between continued and targeted treatment approaches arises from disagreements regarding scientific and ethical questions. Scientifically, the discussion focuses on the quality and interpretation of the supporting or detracting evidence regarding each treatment option. For example, what is the percentage of individuals who can maintain stability off drugs? What is the rate of individuals who exacerbate despite maintenance treatment? What is the percentage of individuals who experience drug-related adverse effects? How can we interpret results of open-label, nonrandomized targeted trials? Regarding ethical questions, the debating sides disagree on how to weigh the impact of the decreased risk for exacerbation versus the certainty of adverse effects on the patients quality of life, and how to reach a patient-therapist shared decision within the constraints of mental illness.

Does Gender Influence Outcome in Schizophrenia?

Good outcome of schizophrenia has several meanings and most of these meanings carry both positive and negative undertones depending on perspective. Currently, a person's subjective sense that illness has been partly overcome and that life is meaningful has come to be viewed as the most valid signpost of a good outcome. A review of the literature shows that women have certain advantages over men in that their illness starts at a later age and that their symptoms respond more quickly and more completely to available treatments. These advantages serve women well at the outset of illness but benefits appear to dissipate over time. Gender differences in outcome thus vary depending on the age of the patient. They also vary with the social and cultural background of the study population. Neither sex, therefore, has a monopoly on good outcome. The hope is that studying gender differences will uncover critical elements of good outcome that lead to interventions that will benefit both women and men.

What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis

OBJECTIVES

Antidepressant prescribing almost doubled in the Netherlands between 1996 and 2012, which could be accounted for by longer continuation after the first prescription. This might be problematic given a growing concern of large-scale antidepressant dependence. We aimed to assess the extent and determinants of chronic antidepressant prescribing among patient aged 18 years and older. We hypothesise a relatively large prevalence of chronic (>2 years) prescription.

DESIGN

A longitudinal observational study based on routinely registered prescription data from general practice.

SETTING

189 general practices in the Netherlands.

PARTICIPANTS

326 025 patients with valid prescription data for all 5 years of the study.

OUTCOME MEASURES

Primary outcome measure: the number of patients (N) receiving at least four antidepressant prescriptions in 2011, as well as during each of the four subsequent years. Secondary outcome measure: the above, but specified for selective serotonin reuptake inhibitors and for tricyclic antidepressants.

RESULTS

Antidepressants were prescribed to almost 7% of our 326 025 participants each year. They were prescribed for depression (38%), anxiety (17%), other psychological disorders (20%) and non-psychological indications (25%). Antidepressants were prescribed in all 5 years to the 42% of the population who had at least four prescriptions dispensed in 2011. Chronic prescribing was higher among women than men, for those aged 45-64 years than for those aged >65 years and for those treated for depression or anxiety than for non-psychological indications (eg, neuropathic pain). Chronic prescribing also varied markedly among general practices.

CONCLUSION

Chronic antidepressant use is common for depression and for anxiety and non-psychological diagnoses. Once antidepressants have been prescribed, general practitioners and other prescribers should be aware of the risks associated with long-term use and should provide annual monitoring of the continued need for therapy.

Dominant Cultural and Personal Stigma Beliefs and the Utilization of Mental Health Services: A Cross-National Comparison

Purpose: The detrimental impact of stigma on the utilization of mental health services is a well-established finding. Nevertheless, most studies consider only the personal or interactional dimensions of stigma. This contribution makes a distinction between the dominant beliefs about stigma within a culture and the personal beliefs of individuals with regard to stigma. We hypothesize that both have an impact on professional-care seeking within the field of mental health. Methods: A multi-level research design is used to estimate the effects of both types of stigma beliefs on the likelihood of consulting general and specialized health professionals about mental health problems in 28 European countries (N of individuals = 24,881, Eurobarometer 248, 2005-2006). Results: In countries where stigmatizing beliefs are dominant, the likelihood of seeking help from specialized mental health professionals is constrained, and individuals refrain from contacting general practitioners when in need of formal support, regardless of their own personal stigma beliefs. Conclusion: The present study signals the importance of stigma beliefs as shared cultural phenomena, and of personal stigma beliefs to the likelihood of seeking professional care for mental health problems. We therefore propose that most studies on stigma and formal-care seeking underestimate the pervasive effects of stigma beliefs, due to methodological individualism.

Long-Term Antipsychotic Effectiveness in First Episode of Psychosis: A 3-Year Follow-Up Randomized Clinical Trial Comparing Aripiprazole, Quetiapine, and Ziprasidone

Background

Different effectiveness profiles among second-generation antipsychotics may be a key point to optimize treatment in patients suffering a first episode of psychosis to affect long-term outcome. The aim of this study was to compare the clinical effectiveness of aripiprazole, ziprasidone, and quetiapine in the treatment of first episode of psychosis at 3-year follow-up.

Method

From October 2005 to January 2011, a prospective, randomized, open-label study was undertaken. Two hundred-two first-episode, drug-naïve patients were randomly assigned to aripiprazole (n=78), ziprasidone (n =62), or quetiapine (n=62) and followed-up for 3 years. The primary effectiveness measure was all cause of treatment discontinuation. In addition, an analysis based on the intention-to-treat principle was conducted in the analysis for clinical efficacy.

Results

The overall dropout rate at 3 years reached 19.3%. Treatment discontinuation rates were significantly different among treatment groups (aripiprazole=73.08%, ziprasidone=79.03%, and quetiapine=95.16%) (χ2=11.680; P=.001). Statistically significant differences in terms of nonefficacy, nonadherence, and side effects were observed among treatment groups along the 3-year follow-up determining significant differences in time to all-cause discontinuation (log-rank=32.260; P=.001). Significant differences between treatments were found in the categories of sleepiness/sedation (χ2=9.617; P=.008) and increased sleep duration (χ2=6.192; P=.004). No significant differences were found in the profile of extrapyramidal symptoms. Patients on aripiprazole were more likely to be prescribed benzodiazepines.

Conclusions

First-episode psychosis patients on quetiapine were more likely to discontinue treatment due to nonefficacy. Identifying different discontinuation patterns may contribute to optimize treatment selection after first episode of psychosis.

Relationship Between Mindfulness and Posttraumatic Stress in Women Who Experienced Stillbirth

OBJECTIVE

To explore the potential factors that mediate the relationship between mindfulness and symptoms of posttraumatic stress (PTS) in women who experienced stillbirth.

DESIGN

A cross-sectional analysis of baseline data before women's participation in an online mindfulness intervention (i.e., online yoga).

SETTING

This was a national study, and women participated in their own homes.

PARTICIPANTS

Women who experienced stillbirth (N = 74) within the past 2 years and resided in the United States.

METHODS

Women were recruited nationally, primarily through social media. Participants (N = 74) completed baseline assessments (self-report mental and physical health surveys) via a Web-based survey tool. We conducted an exploratory factor analysis of the COPE Inventory subscales to reduce the number of variables before entry into a mediation model. We then tested the mediation effects of sleep quality, self-esteem, resilience, and maladaptive coping on the relationship between mindfulness and PTS symptoms.

RESULTS

Through the exploratory factor analysis we identified a two-factor solution. The first factor included nine subscales that represented adaptive coping strategies, and the second factor included five subscales that represented maladaptive coping strategies. Results from multiple mediation analysis suggested that mindfulness had a significant inverse relationship to PTS symptoms mediated by sleep quality.

CONCLUSION

Mindfulness practices may have potential benefits for grieving women after stillbirth. Evidence-based approaches to improve sleep quality also may be important to reduce PTS symptoms in women after stillbirth.

The Mortality and Myocardial Effects of Antidepressants Are Moderated by Preexisting Cardiovascular Disease: A Meta-Analysis

BACKGROUND

Antidepressants (ADs) are commonly prescribed medications, but their long-term health effects are debated. ADs disrupt multiple adaptive processes regulated by evolutionarily ancient biochemicals, potentially increasing mortality. However, many ADs also have anticlotting properties that can be efficacious in treating cardiovascular disease. We conducted a meta-analysis assessing the effects of ADs on all-cause mortality and cardiovascular events in general-population and cardiovascular-patient samples.

METHODS

Two reviewers independently assessed articles from PubMed, EMBASE, and Google Scholar for AD-related mortality controlling for depression and other comorbidities. From these articles, we extracted information about cardiovascular events, cardiovascular risk status, and AD class. We conducted mixed-effect meta-analyses testing sample type and AD class as moderators of all-cause mortality and new cardiovascular events.

RESULTS

Seventeen studies met our search criteria. Sample type consistently moderated health risks. In general-population samples, AD use increased the risks of mortality (HR = 1.33, 95% CI: 1.14-1.55) and new cardiovascular events (HR = 1.14, 95% CI: 1.08-1.21). In cardiovascular patients, AD use did not significantly affect risks. AD class also moderated mortality, but the serotonin reuptake inhibitors were not significantly different from tricyclic ADs (TCAs) (HR = 1.10, 95% CI: 0.93-1.31, p = 0.27). Only "other ADs" were differentiable from TCAs (HR = 1.35, 95% CI: 1.08-1.69). Mortality risk estimates increased when we analyzed the subset of studies controlling for premedication depression, suggesting the absence of confounding by indication.

CONCLUSIONS

The results support the hypothesis that ADs are harmful in the general population but less harmful in cardiovascular patients.

What is the risk-benefit ratio of long-term antipsychotic treatment in people with schizophrenia?

The long-term benefit-to-risk ratio of sustained antipsychotic treatment for schizophrenia has recently been questioned. In this paper, we critically examine the literature on the long-term efficacy and effectiveness of this treatment. We also review the evidence on the undesired effects, the impact on physical morbidity and mortality, as well as the neurobiological correlates of chronic exposure to antipsychotics. Finally, we summarize factors that affect the risk-benefit ratio. There is consistent evidence supporting the efficacy of antipsychotics in the short term and mid term following stabilization of acute psychotic symptoms. There is insufficient evidence supporting the notion that this effect changes in the long term. Most, but not all, of the long-term cohort studies find a decrease in efficacy during chronic treatment with antipsychotics. However, these results are inconclusive, given the extensive risk of bias, including increasing non-adherence. On the other hand, long-term studies based on national registries, which have lower risk of bias, find an advantage in terms of effectiveness during sustained antipsychotic treatment. Sustained antipsychotic treatment has been also consistently associated with lower mortality in people with schizophrenia compared to no antipsychotic treatment. Nevertheless, chronic antipsychotic use is associated with metabolic disturbance and tardive dyskinesia. The latter is the clearest undesired clinical consequence of brain functioning as a potential result of chronic antipsychotic exposure, likely from dopaminergic hypersensitivity, without otherwise clear evidence of other irreversible neurobiological changes. Adjunctive psychosocial interventions seem critical for achieving recovery. However, overall, the current literature does not support the safe reduction of antipsychotic dosages by 50% or more in stabilized individuals receiving adjunctive psychosocial interventions. In conclusion, the critical appraisal of the literature indicates that, although chronic antipsychotic use can be associated with undesirable neurologic and metabolic side effects, the evidence supporting its long-term efficacy and effectiveness, including impact on life expectancy, outweighs the evidence against this practice, overall indicating a favorable benefit-to-risk ratio. However, the finding that a minority of individuals diagnosed initially with schizophrenia appear to be relapse free for long periods, despite absence of sustained antipsychotic treatment, calls for further research on patient-level predictors of positive outcomes in people with an initial psychotic presentation.

Psychiatric Medication Withdrawal: Survivor Perspectives and Clinical Practice

As patient/survivor movements continue to challenge reductionist biological views of mental health and psychosis, there is rising skepticism toward psychiatric medications and growing interest in withdrawal and alternatives. This new perspective also calls for a rethinking of reductionist assumptions about psychiatric medications themselves. General medical patient experience with collaborative decision making for other conditions has broad implications for psychiatric drug withdrawal, and by recognizing psychiatric medications as psychoactive substances, addiction science also suggests a central role for social context and therapeutic common factors in medication withdrawal response. New understandings of madness and medications support an emerging reconsideration of what constitutes the very definition of “health,” where measuring the absence of disease symptoms gives way to a systems-based focus on self-management, social relationships, and adaptability.

The need for new approaches in CNS drug discovery: Why drugs have failed, and what can be done to improve outcomes

An important goal of biomedical research is to translate basic research findings into useful medical advances. In the field of neuropharmacology this requires understanding disease mechanisms as well as the effects of drugs and other compounds on neuronal function. Our hope is that this information will result in new or improved treatment for CNS disease. Despite great progress in our understanding of the structure and functions of the CNS, the discovery of new drugs and their clinical development for many CNS disorders has been problematic. As a result, CNS drug discovery and development programs have been subjected to significant cutbacks and eliminations over the last decade. While there has been recent resurgence of interest in CNS targets, these past changes in priority of the pharmaceutical and biotech industries reflect several well-documented realities. CNS drugs in general have higher failure rates than non-CNS drugs, both preclinically and clinically, and in some areas, such as the major neurodegenerative diseases, the clinical failure rate for disease-modifying treatments has been 100%. The development times for CNS drugs are significantly longer for those drugs that are approved, and post-development regulatory review is longer. In this introduction we review some of the reasons for failure, delineating both scientific and technical realities, some unique to the CNS, that have contributed to this. We will focus on major neurodegenerative disorders, which affect millions, attract most of the headlines, and yet have witnessed the fewest successes. We will suggest some changes that, when coupled with the approaches discussed in the rest of this special volume, may improve outcomes in future CNS-targeted drug discovery and development efforts. This article is part of the Special Issue entitled "Beyond small molecules for neurological disorders".

Treatment profiles in a Danish psychiatric university hospital department

BACKGROUND

Despite concerns about rising treatment of psychiatric patients with psychotropic medications and declining treatment with psychotherapy, actual treatment profiles of psychiatric patients are largely unknown.

AIMS

To describe patterns in the treatment of patients in a large psychiatric university hospital department.

METHODS

A descriptive mapping of treatment of in- and outpatients in a psychiatric department at Aarhus University Hospital Risskov, Denmark. Information was collected by healthcare staff using a 25-item survey form. The p-value was calculated with a chi-squared test and p < 0.05 was considered significant. The study was preceded by a pilot study on 41 patients.

RESULTS

Over a 1 month period, a total of 343 consecutive patients were assessed and hereof 200 were included in the age range 18-90 years (mean 53.76); 86 men and 114 women. One-hundred and eighty-eight patients (94%) used psychotropic medication, 37 (19%) as monotherapy, and 148 (74%) in combination with non-pharmacological therapy. Ninety-seven (49%) had psychotherapy and 104 (52%) social support. Among inpatients, 21 (64%) had physical therapy, and 10 (30%) electroconvulsive therapy. In total, 163 (82%) had non-pharmacological therapy. Fifty-two (26%) patients had monotherapy, and 148 (74%) polytherapy. Mean number of treatment modalities used per patient was 2.07 for all patients and 3.23 for inpatients.

CONCLUSIONS

In this department, polytherapy including non-pharmacological modalities is applied widely across all settings and patient categories. However, psychotropic medication clearly dominates as the most frequently applied treatment.

Survey of antipsychotic medication curriculum content in Australian university nursing programmes

Antipsychotic medication has long been one of the first-line interventions for people with serious mental illness, with outcomes including reductions in symptoms and relapse rates. More recently, however, questions have been raised about the efficacy of antipsychotic medications, especially in light of their side-effect profile. Such questions have implications for the nurses administering antipsychotic medications, particularly in relation to their knowledge of the antipsychotic medication, its efficacy, and side-effect profile. Also important is the education of nursing students about antipsychotic medications, their use, and management. The present study reports findings of research that explored current curriculum content concerning psychopharmacological treatment in Australian undergraduate and postgraduate nursing programmes. Using a survey design, the research examined the content and modes of delivery of this content to gauge how well students are prepared for administering antipsychotic medication to people with serious mental illness. Findings of the research suggested the need for improvement in preparing nursing students to administer antipsychotic medication, including indications, contraindications, as well as recognition and management of side-effects.

Manic switches induced by antidepressants: an umbrella review comparing randomized controlled trials and observational studies

OBJECTIVE

We aimed to explore whether the prevalence of manic switch was underestimated in randomized controlled trials (RCTs) compared to observational studies (OSs).

METHOD

Meta-analyses and simple and systematic reviews were identified by two reviewers in a blinded, standardized manner. All relevant references were extracted to include RCTs and OSs that provided data about manic switch prevalence after antidepressant treatment for a major depressive episode. The primary outcome was manic switch prevalence in the different arms of each study. A meta-regression was conducted to quantify the impact of certain variables on manic switch prevalence.

RESULTS

A total of 57 papers (35 RCTs and 22 OSs) were included in the main analysis. RCTs underestimated the rate of manic switch [0.53 (0.32-0.87)]. Overestimated prevalence was related to imipraminics [1.85 (1.22-2.79)]; to serotonin-norepinephrine reuptake inhibitors [1.74 (1.06-2.86)]; and to other classes of drugs [1.58 (1.08-2.31)], compared to placebo treatment. The prevalence of manic switch was lower among adults than among children [0.2 (0.07-0.59)]; and higher [20.58 (8.41-50.31)] in case of bipolar disorder.

CONCLUSION

Our results highlight an underestimation of the rates of manic switch under antidepressants in RCTs compared to the rates observed in observational studies.

Association of anticholinergic burden with adverse effects in older people with intellectual disabilities: an observational cross-sectional study

BACKGROUND

No studies to date have investigated cumulative anticholinergic exposure and its effects in adults with intellectual disabilities.

AIMS

To determine the cumulative exposure to anticholinergics and the factors associated with high exposure.

METHOD

A modified Anticholinergic Cognitive Burden (ACB) scale score was calculated for a representative cohort of 736 people over 40 years old with intellectual disabilities, and associations with demographic and clinical factors assessed.

RESULTS

Age over 65 years was associated with higher exposure (ACB 1-4 odds ratio (OR) = 3.28, 95% CI 1.49-7.28, ACB 5+ OR = 3.08, 95% CI 1.20-7.63), as was a mental health condition (ACB 1-4 OR = 9.79, 95% CI 5.63-17.02, ACB 5+ OR = 23.74, 95% CI 12.29-45.83). Daytime drowsiness was associated with higher ACB (P<0.001) and chronic constipation reported more frequently (26.6% ACB 5+ v. 7.5% ACB 0, P<0.001).

CONCLUSIONS

Older people with intellectual disabilities and with mental health conditions were exposed to high anticholinergic burden. This was associated with daytime dozing and constipation.

Psychiatric disease as a risk factor in fast-track hip and knee replacement

Recent studies suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Whether this is due to their psychiatric condition, pharmacological treatment, a combination of the two, or something else has not been thoroughly analyzed-and there are no internationally accepted guidelines for perioperative management of psychiatric patients. This overview summarizes our current knowledge on perioperative risks in patients with preoperative psychiatric disorders and the possible role of psychotropic drugs in the perioperative course. This will be useful when planning future strategies for improvement of surgical outcome following hip and knee arthroplasty.

Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports

OBJECTIVE

To study serious harms associated with selective serotonin and serotonin-norepinephrine reuptake inhibitors.Design Systematic review and meta-analysis.

MAIN OUTCOME MEASURES

Mortality and suicidality. Secondary outcomes were aggressive behaviour and akathisia.

DATA SOURCES

Clinical study reports for duloxetine, fluoxetine, paroxetine, sertraline, and venlafaxine obtained from the European and UK drug regulators, and summary trial reports for duloxetine and fluoxetine from Eli Lilly's website.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Double blind placebo controlled trials that contained any patient narratives or individual patient listings of harms.

DATA EXTRACTION AND ANALYSIS

Two researchers extracted data independently; the outcomes were meta-analysed by Peto's exact method (fixed effect model).

RESULTS

We included 70 trials (64,381 pages of clinical study reports) with 18,526 patients. These trials had limitations in the study design and discrepancies in reporting, which may have led to serious under-reporting of harms. For example, some outcomes appeared only in individual patient listings in appendices, which we had for only 32 trials, and we did not have case report forms for any of the trials. Differences in mortality (all deaths were in adults, odds ratio 1.28, 95% confidence interval 0.40 to 4.06), suicidality (1.21, 0.84 to 1.74), and akathisia (2.04, 0.93 to 4.48) were not significant, whereas patients taking antidepressants displayed more aggressive behaviour (1.93, 1.26 to 2.95). For adults, the odds ratios were 0.81 (0.51 to 1.28) for suicidality, 1.09 (0.55 to 2.14) for aggression, and 2.00 (0.79 to 5.04) for akathisia. The corresponding values for children and adolescents were 2.39 (1.31 to 4.33), 2.79 (1.62 to 4.81), and 2.15 (0.48 to 9.65). In the summary trial reports on Eli Lilly's website, almost all deaths were noted, but all suicidal ideation events were missing, and the information on the remaining outcomes was incomplete.

CONCLUSIONS

Because of the shortcomings identified and having only partial access to appendices with no access to case report forms, the harms could not be estimated accurately. In adults there was no significant increase in all four outcomes, but in children and adolescents the risk of suicidality and aggression doubled. To elucidate the harms reliably, access to anonymised individual patient data is needed.

Adverse events and treatment failure leading to discontinuation of recently approved antipsychotic drugs in schizophrenia: A network meta-analysis

Objective:We aimed to gather evidence of the discontinuation rates owing to adverse events or treatment failure for four recently approved antipsychotics (asenapine, blonanserin, iloperidone, and lurasidone).Methods: A systematic review followed by pairwise meta-analysis and mixed treatment comparison meta analysis(MTC) was performed, including randomized controlled trials (RCTs) that compared the use of the above-mentioned drugs versus placebo in patients with schizophrenia. An electronic search was conducted in PubMed, Scopus, Science Direct, Scielo, the Cochrane Library, and International Pharmaceutical Abstracts(January 2015). The included trials were at least single blinded. The main outcome measures extracted were discontinuation owing to adverse events and discontinuation owing to treatment failure.Results: Fifteen RCTs were identified (n = 5400 participants) and 13 of them were amenable for use in our meta-analyses. No significant differences were observed between any of the four drugs and placebo as regards discontinuation owing to adverse events, whether in pairwise meta-analysis or in MTC. All drugs presented a better profile than placebo on discontinuation owing to treatment failure, both in pairwise meta-analysis and MTC. Asenapine was found to be the best therapy in terms of tolerability owing to failure,while lurasidone was the worst treatment in terms of adverse events. The evidence around blonanserin is weak.Conclusion: MTCs allowed the creation of two different rank orders of these four antipsychotic drugs in two outcome measures. This evidence-generating method allows direct and indirect comparisons, supporting approval and pricing decisions when lacking sufficient, direct, head-to-head trials.

Should antidepressant medication be used in the elderly?

Late-life depression is a serious illness accompanied by medical morbidity, cognitive decline and risk of suicide. Antidepressant medications are a cornerstone of treatment for depressed elders. Although they are optimally provided in conjunction with psychotherapy, in many cases they are used alone. Recently, concern has developed over modern antidepressant medication, including concerns about their ultimate efficacy and particular risks that may be seen in older adult populations. Ultimately, antidepressant medications are effective for many individuals and continue to play an important role in treating depressed elders, although the potential risks must be weighed with the patient and their families. Current data do not support restriction of their use and untreated depression has serious negative health consequences. Patients need treatments with better efficacy and safety, including new pharmacological options and better access to and dissemination of nonpharmacological treatment.

Do Psychiatric Medications Cause More Harm Than Good?

A head-to-head debate published in The BMJ was centered on the question "Does long-term use of psychiatric drugs cause more harm than good?" One of the debaters stated that virtually all psychotropic drug use could be stopped without deleterious effects, claiming that these drugs have minimal benefits, are immensely harmful, and cause more than 500,000 deaths each year. In the current article, this conclusion is disputed by the discussion of the history of psychiatric therapeutics, limitations of research investigations, inherent morbidity and mortality associated with mental disorders, and importance of direct care experience with psychiatric patients and their families.