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Tamene FB, Mihiretie EA, Mulugeta A, Kassaye A, Gubae K, Wondm SA. Medication non-adherence and associated factors among peoples with schizophrenia: multicenter cross-sectional study in Northwest Ethiopia. BMC Psychiatry 2024; 24:567. [PMID: 39160469 PMCID: PMC11334456 DOI: 10.1186/s12888-024-06004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 08/06/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Schizophrenia is a serious and debilitating psychiatric disorder that is linked to marked social and occupational impairment. Despite the vital relevance of medication, non-adherence with recommended pharmacological treatments has been identified as a worldwide problem and is perhaps the most difficult component of treating schizophrenia. There are limited studies conducted on magnitude and potential factors of medication non-adherence among peoples with schizophrenia in Ethiopia. OBJECTIVES This study aimed to assess medication non-adherence and associated factors among peoples with schizophrenia at comprehensive specialized hospitals in Northwest Ethiopia. METHODS An institutional-based cross-sectional study was conducted among 387 peoples with schizophrenia at selected hospitals in the Northwest of Ethiopia from June to August 2022. Study participants were enrolled using systematic random sampling. Medication non-adherence was measured using Medication Adherence Rating Scale (MARS). Data entry and analysis were done using Epi-data version 4.6.0 and SPSS version 24, respectively. A multivariable logistic regression model was fitted to identify factors associated with medication non-adherence. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant. RESULTS The prevalence of medication non-adherence was 51.2% (95% CI: 46.3, 56.3). Duration of treatment for more than ten years (AOR = 3.76, 95% CI: 1.43, 9.89), substance use (AOR = 1.92, 95% CI: 1.17, 3.13), antipsychotic polypharmacy, (AOR = 2.01, 95% CI: 1.11, 3.63) and extra-pyramidal side effect (AOR = 2.48, 95% CI: 1.24, 4.94) were significantly associated with medication non-adherence. CONCLUSION In this study, half of the participants were found to be medication non-adherent. Respondents with a longer duration of treatment, substance users, those on antipsychotic polypharmacy, and those who develop extra-pyramidal side effect need prompt screening and critical follow-up to improve medication adherence.
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Affiliation(s)
- Fasil Bayafers Tamene
- Department of Pharmacy, Health Science College, Debre Markos University, Debre Markos, Ethiopia.
| | - Endalamaw Aschale Mihiretie
- Clinical Pharmacy Unit, Department of Pharmacy, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Abiy Mulugeta
- Depatment of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Abenet Kassaye
- Department of Psychiatric Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Kale Gubae
- Department of Pharmacy, Health Science College, Debre Markos University, Debre Markos, Ethiopia
| | - Samuel Agegnew Wondm
- Department of Pharmacy, Health Science College, Debre Markos University, Debre Markos, Ethiopia
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Korkmaz ŞA, Koca E, Yilmaz Ö, Özbek T, Güçlü MA, Kizgin S. Real-World Evidence of Antipsychotic Monotherapy Versus Polypharmacy in the Treatment of Schizophrenia Spectrum Disorders. J Clin Psychopharmacol 2024; 44:250-257. [PMID: 38489589 DOI: 10.1097/jcp.0000000000001837] [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: 03/17/2024]
Abstract
PURPOSE/BACKGROUND It is still not well known whether antipsychotic monotherapy versus polypharmacy differs in terms of efficacy in the emergency department (ED) utilization, presentation with agitation/aggression, and rehospitalization in schizophrenia spectrum disorders (SSD) patients. This study aimed to determine the effectiveness of antipsychotic monotherapy and polypharmacy for these outcomes in the real world. METHODS/PROCEDURES The study was conducted with electronic health records of 669 SSD patients admitted to the ED. Patients were evaluated in 4 groups according to antipsychotic use at the first admission to ED: antipsychotic noncompliance for more than 90 days, antipsychotic noncompliance for 15 to 90 days, antipsychotic monotherapy, and polypharmacy. All patients followed up for at least 1 year after index admission. The primary outcomes determined an association between antipsychotic monotherapy versus polypharmacy and all-cause psychiatric hospitalization between the groups after index admission in the SSD. FINDINGS/RESULTS The groups, including patients with antipsychotic noncompliance, had higher ED visits, more hospitalizations, and more admissions with agitation/aggression compared with antipsychotic monotherapy or polypharmacy. However, no differences were found between monotherapy and polypharmacy groups regarding these outcomes. In addition, there was no difference in the risk of hospitalization in monotherapy antipsychotic users compared with polypharmacy users. Patients discharged with monotherapy or polypharmacy also had similar rehospitalization rates at follow-up. IMPLICATIONS/CONCLUSIONS There is no positive evidence that recommending polypharmacy over antipsychotic monotherapy is superior with regard to the resulting frequency of ED visits, ED admissions with agitation/aggression, hospitalization, and rehospitalization. In this context, antipsychotic monotherapy may be preferred over polypharmacy in patients who are not resistant to treatment.
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Affiliation(s)
- Şükrü Alperen Korkmaz
- From the Department of Psychiatry, Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
| | - Esra Koca
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Özge Yilmaz
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Tayfun Özbek
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
| | | | - Sadice Kizgin
- Department of Psychiatry, Ankara Bilkent City Hospital, Ankara, Turkey
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Lagreula J, Dagenais-Beaulé V, de Timary P, Elens L, Dalleur O. Prescribing and deprescribing trends in schizophrenia: An overview of inpatients in Belgium and in the Canadian province of Québec. Basic Clin Pharmacol Toxicol 2023; 133:691-702. [PMID: 36988426 DOI: 10.1111/bcpt.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
Although switching to antipsychotic monotherapy improves patient outcomes in schizophrenia, antipsychotic deprescribing is rarely performed, and its use varies between countries, as do psychotropic prescribing patterns. This study aimed to determine factors associated with antipsychotic deprescribing at discharge after a psychiatric hospitalization and to compare psychotropic prescribing patterns between Belgium and Québec, Canada. Data on adult inpatients with schizophrenia were collected retrospectively in seven hospitals. At discharge, the number of antipsychotics had decreased in 22.2% of the 63 Canadian patients and 9.9% of the 516 Belgian patients. A number of factors increased the likelihood of antipsychotic deprescribing: a hospitalization in the Canadian hospital (aOR = 4.13, 95% CI 1.48-11.5), living in a residential facility (aOR = 2.51, 95% CI 1.05-4.39), ≥2 previous antipsychotic trials (aOR = 15.38, 95% CI 3.62-65.36), having an antipsychotic side effect (aOR = 1.86, 95% CI 1.01-3.44) and being in a general hospital (aOR = 2.28, 95% CI 1.09-4.75). Patients on a long-acting injectable antipsychotic (aOR = 0.51, 95% CI 0.26-0.98), with prior clozapine use (aOR = 0.36, 95% CI 0.13-0.95), greater antipsychotic exposure (aOR = 0.35, 95% CI 0.2-0.61) and more hypno-sedatives (aOR = 0.65, 95% CI 0.43-0.98), were less likely to be deprescribed. Specific deprescribing interventions could target patients who are less likely to be deprescribed.
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Affiliation(s)
- Juliette Lagreula
- Clinical Pharmacy Research Group (CLIP)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Fonds de la Recherche Scientifique - FNRS, Brussels, Belgium
| | - Vincent Dagenais-Beaulé
- Pharmacy Department & Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Québec, Canada
| | - Philippe de Timary
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
- Adult Psychiatry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Louvain Center for Toxicology and Applied Pharmacology (LTAP)-Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Olivia Dalleur
- Clinical Pharmacy Research Group (CLIP)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Pharmacy Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Tamene FB, Sema FD, Mihiretie EA, Siyum TS, Sendekie AK. Health-related quality of life and associated factors among patients with schizophrenia at comprehensive specialised hospitals in the Northwest Ethiopia: a multicentre cross-sectional study. BMJ Open 2023; 13:e074112. [PMID: 37967996 PMCID: PMC10660835 DOI: 10.1136/bmjopen-2023-074112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVES The aim of this study was to assess the health-related quality of life (HRQoL) and associated factors among patients with schizophrenia at comprehensive specialised hospitals in Northwest Ethiopia. DESIGN AND SETTING A cross-sectional study was conducted among 422 patients with schizophrenia who were followed at comprehensive specialised hospitals in Northwest Ethiopia from 1 June to 30 August 2022. PARTICIPANTS All adult patients with schizophrenia who had regular follow-up in the outpatient departments of the selected hospitals were study participants. MAIN OUTCOME MEASURES The main outcome of this study was HRQoL which was measured using the WHO Quality of Life Scale-Bref Version. Data entry and analysis were done using Epi-data version 4.6.1 and SPSS version 24, respectively. Linear regression was used to assess the association between quality of life and independent variables. Variables with a p value <0.05 at a 95% CI were considered statistically significant. RESULTS The mean score of the overall Quality of Life Scale-Brief Version was 22.42±3.60. No formal education (ß=-1.53; 95% CI: -2.80 to -0.27), duration of treatment (ß = -3.08; 95% CI: -4.71 to -1.45), comorbidity (ß=-1.14; 95% CI: -1.99 to -0.29), substance use (ß=-0.89; 95% CI: -1.56 to -0.23), extrapyramidal side effects (ß=-2.02; 95% CI: -2.90 to -1.14), non-adherence (ß=-0.83; 95% CI: -1.44 to -0.23), and antipsychotic polypharmacy (ß=-1.77; CI: -2.57 to -0.96) were negatively associated with quality of life. CONCLUSION AND RECOMMENDATION In this study, the social domain was recorded as having the lowest mean score, which may indicate that patients with schizophrenia could need better psychosocial support. Patients with a longer duration of treatment, who had comorbid illnesses, were substance users, developed EPS, were non-adherent to medications and were on antipsychotic polypharmacy, needs critical follow-up to improve HRQoL.
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Affiliation(s)
- Fasil Bayafers Tamene
- Department of Pharmacy, Debre Markos University College of Health Science, Debre Markos, Ethiopia
| | - Feser Dula Sema
- Department of Clinical Pharmacy, University of Gondar, Gondar, Ethiopia
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Tamene FB, Sema FD, Sendekie AK. Antipsychotic polypharmacy and associated factors among patients with schizophrenia: Multicenter cross-sectional study in Northwest Ethiopia. PLoS One 2023; 18:e0290037. [PMID: 37578965 PMCID: PMC10424862 DOI: 10.1371/journal.pone.0290037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) remains common despite guideline recommendations to minimize combinations, except after repeated antipsychotic monotherapy trials. This study aimed to assess APP and its associated factors among schizophrenia patients at comprehensive specialized hospitals in Northwest Ethiopia. METHODS An institutional-based cross-sectional study was conducted among 422 schizophrenia patients at selected hospitals in Ethiopia from June to August 2022. The data were collected using a semi-structured questionnaire. Study participants were enrolled using systematic random sampling. Data entry and analysis were done with Epi-data version 4.6.1 and SPSS version 24, respectively. APP was determined by reviewing the number of medications based on relevant evidence. A multivariable logistic regression model was fitted to identify APP factors. Variables with a p-value of < 0.05 at a 95% confidence interval were considered statistically significant. RESULTS From a total of 430 approached samples, 422 (98.1% response rate) eligible patients were included in the study. An overall APP prevalence was 22.7% (95% CI: 19-27). Duration of illness (AOR = 2.88; 95% CI: 1.49, 5.59); duration of treatment (AOR = 3.79; 95% CI: 1.05, 13.62); number of admissions (AOR = 4.93; 95% CI: 2.52, 9.64); and substance use (AOR = 2.58; 95% CI: 1.49, 4.47) were significantly associated with APP. CONCLUSION AND RECOMMENDATION In this study, APP was recorded in a considerable number of patients. Patients with a longer duration of illness and treatment, frequent admissions, and substance users need critical follow-up to minimize antipsychotic medication use.
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Affiliation(s)
- Fasil Bayafers Tamene
- Clinical Pharmacy Unit, Pharmacy Department, Health Science College, Debre Markos University, Debre Markos, Ethiopia
| | - Faisel Dula Sema
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ashenafi Kibret Sendekie
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Yang JC, Thygesen JH, Werbeloff N, Hayes JF, Osborn DPJ. Antipsychotic polypharmacy and adverse drug reactions among adults in a London mental health service, 2008-2018. Psychol Med 2023; 53:4220-4227. [PMID: 35485715 PMCID: PMC10317812 DOI: 10.1017/s0033291722000952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) occurs commonly but it is unclear whether it is associated with an increased risk of adverse drug reactions (ADRs). Electronic health records (EHRs) offer an opportunity to examine APP using real-world data. In this study, we use EHR data to identify periods when patients were prescribed 2 + antipsychotics and compare these with periods of antipsychotic monotherapy. To determine the relationship between APP and subsequent instances of ADRs: QT interval prolongation, hyperprolactinaemia, and increased body weight [body mass index (BMI) ⩾ 25]. METHODS We extracted anonymised EHR data. Patients aged 16 + receiving antipsychotic medication at Camden & Islington NHS Foundation Trust between 1 January 2008 and 31 December 2018 were included. Multilevel mixed-effects logistic regression models were used to elucidate the relationship between APP and the subsequent presence of QT interval prolongation, hyperprolactinaemia, and/or increased BMI following a period of APP within 7, 30, or 180 days respectively. RESULTS We identified 35 409 observations of antipsychotic prescribing among 13 391 patients. Compared with antipsychotic monotherapy, APP was associated with a subsequent increased risk of hyperprolactinaemia (adjusted odds ratio 2.46; 95% CI 1.87-3.24) and of registering a BMI > 25 (adjusted odds ratio 1.75; 95% CI 1.33-2.31) in the period following the APP prescribing. CONCLUSIONS Our observations suggest that APP should be carefully managed with attention to hyperprolactinaemia and obesity.
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Affiliation(s)
- Justin C. Yang
- Division of Psychiatry, University College London, London, UK
- Camden & Islington NHS Foundation Trust, London, UK
| | - Johan H. Thygesen
- Division of Psychiatry, University College London, London, UK
- Camden & Islington NHS Foundation Trust, London, UK
- Institute of Health Informatics, University College London, London, UK
| | - Nomi Werbeloff
- Division of Psychiatry, University College London, London, UK
- Camden & Islington NHS Foundation Trust, London, UK
- The Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Ramat Gan, Israel
| | - Joseph F. Hayes
- Division of Psychiatry, University College London, London, UK
- Camden & Islington NHS Foundation Trust, London, UK
| | - David P. J. Osborn
- Division of Psychiatry, University College London, London, UK
- Camden & Islington NHS Foundation Trust, London, UK
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Schulz RN, Jannace KC, Hisle-Gorman EJ, Pasquina PF. Retrospective Examination of Service Dog Training Program Participation and Mental Healthcare Utilization. Arch Phys Med Rehabil 2023; 104:237-244. [PMID: 35917950 DOI: 10.1016/j.apmr.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the association between Service Dog Training Program (SDTP) participation and mental health care utilization. DESIGN Retrospective cohort study. SETTING Outpatient rehabilitation clinic at a large military treatment facility. PARTICIPANTS Military Health System beneficiaries who attended at least 1 SDTP session at a large military treatment facility (N=597). SDTP program enrollment records identified participants. INTERVENTION The SDTP, a unique application of animal-assisted therapy, is intended to improve the mental and cognitive health for individuals with war-related trauma. MAIN OUTCOME MEASURES Negative binomial regression calculated the associations between the SDTP participation rate and 2 mental health care utilization outcomes: mental health encounter days and psychotropic medication months' supply. RESULTS Most of the 597 participants were male, enlisted service members, and aged 25-34 years. Approximately 46% had a posttraumatic stress disorder diagnosis, 21% had a traumatic brain injury diagnosis, 47% had an opioid prescription, and 58% had a sleep aid prescription pre-SDTP participation. Participation was categorized into low (≤1 sessions), medium (>1 and ≤2 sessions), and high (>2 sessions) monthly participation. In adjusted analysis, high monthly SDTP participation was associated with 18% fewer post-SDTP mental health encounter days (rate ratio [RR], 0.82; 95% confidence interval [CI], 0.68-0.96) than low monthly SDTP participation. High monthly SDTP participation was also associated with a 22% fewer post-SDTP psychotropic prescription months' supply (RR, 0.78; 95% CI, 0.64-0.95) than low monthly SDTP participation in adjusted analysis. CONCLUSIONS Results suggest that participants who attend more than 2 SDTP sessions monthly encounter mental health care differently post SDTP than participants who attended 1 or fewer monthly sessions. Adjunct therapies, such as the SDTP, may offer patients a nonstigmatizing way to engage in mental health care.
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Affiliation(s)
- Rebecca N Schulz
- Uniformed Services University of Health Sciences, Bethesda, Maryland; Walter Reed National Military Medical Center, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland.
| | - Kalyn C Jannace
- Uniformed Services University of Health Sciences, Bethesda, Maryland; Walter Reed National Military Medical Center, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | | | - Paul F Pasquina
- Uniformed Services University of Health Sciences, Bethesda, Maryland; Walter Reed National Military Medical Center, Bethesda, Maryland
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Jia N, Li Z, Li X, Jin M, Liu Y, Cui X, Hu G, Liu Y, He Y, Yu Q. Long-term effects of antipsychotics on mortality in patients with schizophrenia: a systematic review and meta-analysis. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2022; 44:664-673. [PMID: 36709510 PMCID: PMC9851750 DOI: 10.47626/1516-4446-2021-2306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To gather current evidence on the impact of antipsychotics on long-term mortality in patients with schizophrenia. METHODS We systematically searched for articles in Embase, PubMed, and PsycINFO reporting the long-term mortality (follow-up > 1 year) of patients with schizophrenia who were using any antipsychotics. We then conducted multiple meta-analyses to determine differences in long-term mortality between different types of antipsychotics. RESULTS We identified 45 articles that provided unadjusted long-term mortality rates, including 46,171 deaths during 2,394,911 person-years. The pooled mortality rate was 9.9 (95%CI = 7.4-12.7) per 1,000 person-years. The unadjusted crude mortality rate of antipsychotic drug users was lower than that of non-users (risk ratio [RR] = 0.546, 95%CI = 0.480-0.621), first-generation antipsychotics caused higher all-cause mortality than second-generation antipsychotics (RR = 1.485, 95%CI = 1.361-1.620), and polypharmacy had better effects than monotherapy on long-term mortality (RR = 0.796, 95%CI = 0.689-0.921). As for the causes of death, heart disease and cardiovascular disease ranked highest among cause-specific mortality (5.6 per 1,000 person-years). CONCLUSION Since antipsychotics had a beneficial effect on long-term mortality in schizophrenia, greater precaution should be taken with patients who do not take them. However, since disease severity, comorbidities, and other confounding factors cannot be fully controlled, further research and verification are needed.
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Affiliation(s)
- Ningning Jia
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Zhijun Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Xinwei Li
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Mengdi Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yane Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Xingyao Cui
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Guoyan Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yang Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yang He
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Qiong Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China,Correspondence: Qiong Yu, Jilin University, School of Public Health, Department of Epidemiology and Biostatistics, Changchun 130021, China. E-mail:
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Hu J, McMillan SS, Theodoros T, Collins JC, El-Den S, O’Reilly CL, Wheeler AJ. Psychotropic medication use in people living with severe and persistent mental illness in the Australian community: a cross-sectional study. BMC Psychiatry 2022; 22:705. [PMID: 36380352 PMCID: PMC9667665 DOI: 10.1186/s12888-022-04324-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Psychotropic polypharmacy and high-dose prescribing may play a role in therapy, however, with associated risks. The aim of this study was to describe current prescribing practices and use of four psychotropic medication groups (antipsychotics, antidepressants, mood stabilisers and benzodiazepines), focusing on polypharmacy (across and within groups) and high-dose prescribing in adults experiencing severe and persistent mental illness (SPMI) in the Australian community. METHODS 318 people taking psychotropic medication for SPMI had a medication review undertaken by a community pharmacist. Participants were recruited as part of an RCT from three Australian states/territories between September 2020-July 2021. All psychotropic medication and daily doses were recorded and reviewed for alignment with current clinical guidelines. Univariate and multiple logistic regression models investigated factors associated with antipsychotic, antidepressant, and mood stabiliser polypharmacy, and antipsychotic and antidepressant high-dose therapy. Variables included age, gender, geographic location, self- reported mental illness(es), hospital admission(s) in previous 6-months and prescriber type. RESULTS 806 psychotropic medications were prescribed for the 318 participants. Mood stabiliser polypharmacy was recorded in 19.0% of participants prescribed mood stabilisers; antipsychotic polypharmacy in 18.4% of participants prescribed antipsychotics; antidepressant polypharmacy in 11.3% of those prescribed antidepressants; and three participants (5.1%) were prescribed two benzodiazepines concurrently. Almost 18.6% of the cohort was receiving high-dose treatment; 18 participants were prescribed high-dose antipsychotics and 39 high-dose antidepressants, with two participants prescribed both. Adjusted logistic regression for polypharmacy found male gender, psychiatrist as sole prescriber, or multiple prescribers, were associated with antipsychotic polypharmacy. The adjusted model for high-dose therapy found psychiatrist as sole prescriber was significantly associated with antipsychotic and antidepressant high-dose prescribing. CONCLUSION Psychotropic polypharmacy was common in this community cohort experiencing SPMI. Whilst polypharmacy is not always inappropriate, it is a complex construct with potential benefits alongside potential risks. Benefits and harms need to be balanced however this practice is not supported by clear guidance to assist health practitioners. This study highlights the important need for regular medication reviews and strengthened communication between consumers and all healthcare professionals involved in community mental health care, to support safe and effective use of psychotropic medications.
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Affiliation(s)
- Jie Hu
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Sara S McMillan
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432School of Pharmacy and Medical Sciences, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432Centre for Mental Health, Griffith University, Nathan campus, 4111 Brisbane, Australia
| | - Theo Theodoros
- grid.1003.20000 0000 9320 7537University of Queensland Faculty of Medicine, Brisbane, Australia ,Metro South Mental Health Services, Brisbane, Australia
| | - Jack C Collins
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Sarira El-Den
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Claire L O’Reilly
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia. .,Centre for Mental Health, Griffith University, Nathan campus, 4111, Brisbane, Australia. .,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Edinoff AN, Ellis ED, Nussdorf LM, Hill TW, Cornett EM, Kaye AM, Kaye AD. Antipsychotic Polypharmacy-Related Cardiovascular Morbidity and Mortality: A Comprehensive Review. Neurol Int 2022; 14:294-309. [PMID: 35324580 PMCID: PMC8954521 DOI: 10.3390/neurolint14010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Schizophrenia is a psychotic disorder that exists at the more extreme end of a spectrum of diseases, and significantly affects daily functioning. Cardiovascular adverse effects of antipsychotic medications are well known, and include changes in blood pressure and arrhythmias. Sudden cardiac death is the leading cause of death worldwide, and antipsychotic medications are associated with numerous cardiac side effects. A possible link exists between antipsychotic medications and sudden cardiac death. Common prescribing patterns that may influence cardiovascular events include the use of multiple antipsychotics and/or additional drugs commonly prescribed to patients on antipsychotics. The results of this review reflect an association between antipsychotic drugs and increased risk of ventricular arrhythmias and sudden cardiac death by iatrogenic prolongation of the QTc interval. QTc prolongation and sudden cardiac death exist in patients taking antipsychotic monotherapy. The risk increases for the concomitant use of specific drugs that prolong the QTc interval, such as opioids, antibiotics, and illicit drugs. However, evidence suggests that QTc intervals may not adequately predict sudden cardiac death. In considering the findings of this narrative review, we conclude that it is unclear whether there is a precise association between antipsychotic polypharmacy and sudden cardiac death with QTc interval changes. The present narrative review warrants further research on this important potential association.
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Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Science Center Shreveport, 1501 Kings Hwy, Shreveport, LA 71103, USA
- Correspondence: ; Tel.: +1-(318)-675-8969
| | - Emily D. Ellis
- School of Medicine, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (E.D.E.); (L.M.N.); (T.W.H.)
| | - Laura M. Nussdorf
- School of Medicine, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (E.D.E.); (L.M.N.); (T.W.H.)
| | - Taylor W. Hill
- School of Medicine, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (E.D.E.); (L.M.N.); (T.W.H.)
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (E.M.C.); (A.D.K.)
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA;
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (E.M.C.); (A.D.K.)
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11
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Lagreula J, de Timary P, Elens L, Dalleur O. Antipsychotic polypharmacy and clozapine prescribing patterns: evolution and correlates before and after a psychiatric hospitalisation. Ther Adv Psychopharmacol 2022; 12:20451253221112587. [PMID: 36051501 PMCID: PMC9425880 DOI: 10.1177/20451253221112587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Antipsychotic polypharmacy (APP) prescribing and clozapine underuse are considered inappropriate prescribing in schizophrenia. Psychiatric hospitalisations may be suitable occasions to re-evaluate patient pharmacotherapy and to switch to monotherapy. OBJECTIVES To explore the evolution of APP and other psychotropic prescribing patterns during psychiatric hospitalisations, to detect characteristics associated with APP on admission and at discharge, and to examine clozapine prescribing patterns. DESIGN We performed a retrospective observational study based on electronic health records. METHODS Data on adult inpatients diagnosed with schizophrenia spectrum disorders were collected retrospectively from 6 Belgian hospitals in 2020-2021. RESULTS Of the 516 patients included, APP prescribing increased significantly from 47.9% on hospital admission to 59.1% at discharge. On admission and at discharge, APP was associated with prior clozapine use (ORadmission = 2.53, CI = 1.1-5.84, ORdischarge = 11.01, CI = 4.45-27.28), treatment with a first-generation antipsychotic (ORadmission = 26.79, CI = 13.08-54.86, ORdischarge = 25.2, CI = 12.2-52.04), increased antipsychotic exposure (ORadmission = 8.93, CI = 5.13-15.56, ORdischarge = 19.89, CI = 10-39.54), and a greater number of hypno-sedatives (ORadmission = 1.88, CI = 1.23-2.88, ORdischarge = 4.18, CI = 2.53-6.91). APP was negatively associated with involuntary admission (ORadmission = 0.31, CI = 0.14-0.7, ORdischarge = 0.3, CI = 0.13-0.68). When using an alternative definition of monotherapy (i.e. including patients with an add-on low-dose antipsychotic for sleep disorders), alcohol use disorder (ORadmission = 0.26, CI = 0.13-0.54) and higher age (ORdischarge = 0.53, CI = 0.29-0.95) were negatively associated with APP, and living in a residential facility (ORdischarge = 2.39 CI = 1.21-4.71) and a higher daily dosage of benzodiazepines during the stay (ORdischarge = 1.32 CI = 1.03-1.69) increased the odds of being discharged on APP. On admission, 9.3% of patients were being treated with clozapine. Although 28.1% of patients were eligible for clozapine treatment, only 11% of patients were discharged with a clozapine prescription. For 7 of the 10 patients with a new clozapine prescription, it was directly prescribed in combination with another antipsychotic, without a prior trial of clozapine monotherapy. CONCLUSION Suboptimal prescriptions of antipsychotics in patients with schizophrenia persist after psychiatric hospitalisations and are associated with identifiable characteristics.
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Affiliation(s)
- Juliette Lagreula
- Clinical Pharmacy Research Group (CLIP), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain, Avenue Mounier 72, 1200 Brussels, Belgium.,Fonds de la Recherche Scientifique (FNRS), Brussels, Belgium
| | - Philippe de Timary
- Institute of Neuroscience, UCLouvain, Brussels, Belgium.,Psychiatry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK), Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Olivia Dalleur
- Clinical Pharmacy Research Group (CLIP), Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium.,Pharmacy Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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12
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Review: Influence of the CYP450 Genetic Variation on the Treatment of Psychotic Disorders. J Clin Med 2021; 10:jcm10184275. [PMID: 34575384 PMCID: PMC8464829 DOI: 10.3390/jcm10184275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/11/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022] Open
Abstract
Second-generation antipsychotic metabolism is mainly carried out by the CYP450 superfamily, which is highly polymorphic. Therefore, knowing the influence of the different known CYP450 polymorphisms on antipsychotic plasmatic levels and, consequently, the biological effect could contribute to a deeper knowledge of interindividual antipsychotic treatment variability, prompting possible solutions. Considering this, this state of the art review aimed to summarize the current knowledge about the influence of the diverse characterized phenotypes on the metabolism of the most used second-generation antipsychotics. Forty studies describing different single nucleotide polymorphisms (SNPs) associated with the genes CYP1A2, CYP2D6, CYP3A4, CYP3A5, and ABCB1 and their influence on pharmacokinetics of olanzapine, clozapine, aripiprazole, risperidone, and quetiapine. Most of the authors concluded that although significant differences in the pharmacokinetic parameters between the different phenotypes could be observed, more thorough studies describing pharmacokinetic interactions and environmental conditions, among other variables, are needed to fully comprehend these pharmacogenetic interactions.
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13
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Lähteenvuo M, Tiihonen J. Antipsychotic Polypharmacy for the Management of Schizophrenia: Evidence and Recommendations. Drugs 2021; 81:1273-1284. [PMID: 34196945 PMCID: PMC8318953 DOI: 10.1007/s40265-021-01556-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 12/13/2022]
Abstract
Schizophrenia is a debilitating illness with a lifetime prevalence estimate of 0.6% and consists of symptoms from the positive, negative, and cognitive domains. Social support, therapy, psychoeducation, and overall case management are very important aspects of the treatment of schizophrenia. However, as abnormalities in neurotransmission are one of the key findings of schizophrenia pathology, pharmacotherapies are cornerstones of the management of schizophrenia. Antipsychotics have been used as the primary pharmacological treatment of schizophrenia. These agents often have a good effect on reducing positive symptoms, but may not markedly improve negative symptoms or cognitive defects. However, at least 20% of individuals with schizophrenia do not experience a substantial response from monotherapy with antipsychotics. Further, despite evolving treatment protocols and advances in early recognition of the disorder, 70% of patients with schizophrenia require long-term, even lifetime, medication to control their symptoms and do not achieve complete recovery. To address these shortcomings, clinicians and research scientists have explored different combinations of treatments, polypharmacy, to improve the treatment of patients. Antipsychotic polypharmacy has been shown to cause more side effects than monotherapy, which is the main reason why most treatment guidelines caution against it. Antipsychotic monotherapy should be strived for and clozapine should be tried at the latest if two monotherapy trials with other antipsychotics have failed and no absolute contraindications exist. If residual symptoms exist despite trials of adequate dose and duration, other reasons that may reduce treatment effect should be ruled out. Long-acting injectables or blood concentration measurements should be considered to affirm compliance and proper serum levels. Antipsychotic polypharmacy should be considered and discussed with patients from whom the aforementioned procedures do not produce a satisfactory treatment result. In some cases, antipsychotic polypharmacy may produce better results than other forms of treatment augmentation, such as benzodiazepines. In particular, combining aripiprazole with clozapine may be effective in reducing treatment side effects or residual symptoms, and this is likely to hold true for combining other partial dopamine D2 agonists with clozapine as well, although currently scant data exist. More research is needed, both in controlled but also real-world settings, to define optimal antipsychotic polypharmacy and/or other psychotropic treatment augmentation strategies for specific patient groups and situations.
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Affiliation(s)
- Markku Lähteenvuo
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland.
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Niuvankuja 65, 70240, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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14
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Application of a Pharmacogenetics-Based Precision Medicine Model (5SPM) to Psychotic Patients That Presented Poor Response to Neuroleptic Therapy. J Pers Med 2020; 10:jpm10040289. [PMID: 33352925 PMCID: PMC7767089 DOI: 10.3390/jpm10040289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/08/2023] Open
Abstract
Antipsychotics are the keystone of the treatment of severe and prolonged mental disorders. However, there are many risks associated with these drugs and not all patients undergo full therapeutic profit from them. The application of the 5 Step Precision Medicine model(5SPM), based on the analysis of the pharmacogenetic profile of each patient, could be a helpful tool to solve many of the problematics traditionally associated with the neuroleptic treatment. In order to solve this question, a cohort of psychotic patients that showed poor clinical evolution was analyzed. After evaluating the relationship between the prescribed treatment and pharmacogenetic profile of each patient, a great number of pharmacological interactions and pharmacogenetical conflicts were found. After reconsidering the treatment of the conflictive cases, patients showed a substantial reduction on mean daily doses and polytherapy cases, which may cause less risk of adverse effects, greater adherence, and a reduction on economic costs.
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15
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Faden J, Kiryankova-Dalseth N, Barghini R, Citrome L. Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia? Expert Opin Pharmacother 2020; 22:635-646. [PMID: 33251870 DOI: 10.1080/14656566.2020.1847274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION : Despite treatment with antipsychotic medication, approximately 1/3 of individuals with schizophrenia will fail to have an adequate response. To treat these patients, a commonly utilized approach is antipsychotic combination therapy. Antipsychotic combination therapy is controversial with mixed efficacy and tolerability results. It is also unclear if antipsychotic combination therapy reduces or increases the risk of psychiatric hospitalization. AREAS COVERED : The authors review the prevalence, efficacy and tolerability concerns, and rationale behind antipsychotic combination therapy. Evidence comparing antipsychotic monotherapy vs polypharmacy using hospitalization as an outcome measure is summarized. EXPERT OPINION : Psychiatric rehospitalization is a useful measure of treatment effectiveness, incorporating aspects of treatment efficacy and tolerability. The evidence comparing the impact of antipsychotic monotherapy vs combination therapy on rehospitalization is mixed. Evidence is primarily retrospective in nature, and there is high heterogeneity between studies, which could partially explain the mixed results. There is likely a subset of patients for whom antipsychotic combination therapy reduces the risk of hospitalization greater than antipsychotic monotherapy. Patients should be treated individually taking into account their specific pattern of response.
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Affiliation(s)
- Justin Faden
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Ruby Barghini
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Leslie Citrome
- Department of Psychiatry & Behavioral Sciences, New York Medical College, Valhalla, NY, USA
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16
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Azorin JM, Simon N. Antipsychotic polypharmacy in schizophrenia: evolving evidence and rationale. Expert Opin Drug Metab Toxicol 2020; 16:1175-1186. [DOI: 10.1080/17425255.2020.1821646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | - Nicolas Simon
- Department of Clinical Pharmacology, Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
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17
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Buhagiar K, Templeton G, Blyth H, Dey M, Giacco D. Mortality risk from long-term treatment with antipsychotic polypharmacy vs monotherapy among adults with serious mental illness: A systematic review and meta-analysis of observational studies. Schizophr Res 2020; 223:18-28. [PMID: 32948381 DOI: 10.1016/j.schres.2020.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/21/2020] [Accepted: 08/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term use of more than one concurrent antipsychotic [antipsychotic polypharmacy (APP)] is widely believed to contribute to excess mortality in people with serious mental illness (SMI) compared to those taking only one antipsychotic (monotherapy). However, no conclusive evidence is available. METHODS We conducted a systematic search in 6 major electronic databases from inception until December 2019, identifying observational studies examining the association between mortality and exposure to long-term APP vs monotherapy. Studies were eligible if they adopted a follow-up design and antipsychotic exposure was >3 months among adults with SMI. We determined the pooled mortality risk using random-effects meta-analyses. The review was registered in PROSPERO (CRD42019148044). RESULTS A total of 12 studies fulfilled all eligibility criteria reporting quantitative data for 834, 534 person years. No difference was found in the association between all-cause mortality and APP vs monotherapy use, in both crude (rate ratio = 0.94, 95% CI 0.81-1.10, p = 0.446; I2 = 83.2%, p < 0.001; 10 studies) and adjusted models (adjusted HR = 0.98, 95% CI 0.80-1.19, p = 0.802; I2 = 58.3%, p < 0.05; 5 studies). Meta-regression did not identify any moderators influencing all-cause mortality risk. For natural causes of death, risk estimates followed the same pattern: (i) crude rate ratio = 0.88, 95% CI 0.67-1.14, p = 0.324; I2 = 77.7%, p = 0.01 (5 studies); (ii) adjusted HR = 1.04, 95% CI 0.90-1.99, p = 0.590; I2 = 0.0%, p = 0.744 (5 studies). CONCLUSION Mortality risk of APP use in people with SMI appears to be comparable to that of monotherapy use, although work to date remains heterogeneous, precluding firm conclusions from made. Complex real-world clinical scenarios may be contributing to this lack of variation between these two types of antipsychotic use.
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Affiliation(s)
- Kurt Buhagiar
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Georgia Templeton
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Henrietta Blyth
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Domenico Giacco
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Warwick Medical School, University of Warwick, Coventry, UK.
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18
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Luykx JJ, Stam N, Tanskanen A, Tiihonen J, Taipale H. In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine. Br J Psychiatry 2020; 217:498-505. [PMID: 31910911 PMCID: PMC7511905 DOI: 10.1192/bjp.2019.267] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided. AIMS To compare the real-world effectiveness of antipsychotics after clozapine cessation. METHOD From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences. RESULTS Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001). CONCLUSIONS Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.
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Affiliation(s)
- Jurjen J. Luykx
- Assistant Professor, Departmentsof Psychiatry and Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University; and Department of Outpatient Psychiatry, GGNet Mental Health, The Netherlands,Correspondence: Jurjen J. Luykx.
| | - Noraly Stam
- Researcher, Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Antti Tanskanen
- Researcher, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Public Health Solutions, National Institute for Health and Welfare, Finland
| | - Jari Tiihonen
- Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Finland; and Center for Psychiatric Research, Stockholm City Council, Sweden
| | - Heidi Taipale
- Assistant Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Academy Research Fellow, Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Associate Professor, School of Pharmacy, University of Eastern Finland, Finland
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19
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Jacobs R, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Gutacker N, Kasteridis P, Kendrick T, Mason A, Rice N, Ride J, Siddiqi N, Williams R. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.
Objectives
We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).
Main outcome measures
Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.
Results
Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Lauren Aylott
- Expert by experience
- Hull York Medical School, York, UK
| | | | | | - Simon Gilbody
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Tony Kendrick
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
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20
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Baandrup L. Polypharmacy in schizophrenia. Basic Clin Pharmacol Toxicol 2020; 126:183-192. [PMID: 31908124 DOI: 10.1111/bcpt.13384] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022]
Abstract
Schizophrenia is a severe mental disorder characterized by a heterogeneous symptom profile which comprises a clinical platform for widespread use of polypharmacy even though antipsychotic monotherapy is the recommended treatment regimen. This narrative review provides a summary of the current gap between evidence and practice for use of antipsychotic combination therapy in patients with schizophrenia. Antipsychotic polypharmacy is frequently prescribed instead of following international consensus of clozapine monotherapy in treatment-resistant patients. Antipsychotic-benzodiazepine combination therapy clearly has a role in the treatment of acute agitation whereas there is no evidence to support an effect on core schizophrenia symptoms when chronically prescribed. Antidepressants are typically added to antipsychotic treatment in case of persistent negative symptoms. Available evidence suggests that antidepressants may improve negative symptom control in schizophrenia. Combining an antipsychotic with an antiepileptic is not supported by any firm evidence, but individual mood stabilizers have come out positively in single trials. Generally, the evidence base for polypharmacy in schizophrenia maintenance treatment is sparse but may be warranted in certain clinical situations. Therapeutic benefits and side effects should be carefully monitored and considered to ensure a beneficial risk-benefit ratio if prescribing polypharmacy for specific clinical indications.
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Affiliation(s)
- Lone Baandrup
- Centre for Neuropsychiatric Schizophrenia Research (CNSR), Mental Health Centre Glostrup, Glostrup, Denmark.,Mental Health Centre Copenhagen, Hellerup, Denmark
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21
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Lin SK. Antipsychotic Polypharmacy: A Dirty Little Secret or a Fashion? Int J Neuropsychopharmacol 2019; 23:125-131. [PMID: 31867671 PMCID: PMC7093996 DOI: 10.1093/ijnp/pyz068] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/18/2019] [Indexed: 11/23/2022] Open
Abstract
The term polypharmacy was originally coined to refer to problems related to multiple drug consumption and excessive drug use during the treatment of a disease or disorder. In the treatment of schizophrenia, polypharmacy usually refers to the simultaneous use of 2 or more antipsychotic medications or combined (adjunct) medications such as mood stabilizers, antidepressants, anxiolytics, or hypnotics in addition to single or multiple antipsychotics. Two decades ago, antipsychotic polypharmacy was criticized as being more expensive, having unproven efficacy, and causing more side effects. However, in recent years, antipsychotic polypharmacy has become more or less acceptable in the views of clinical practitioners and academic researchers. Results from recent reviews have suggested that the common practice of antipsychotic polypharmacy lacks double-blind or high-quality evidence of efficacy, except for negative symptom reduction with aripiprazole augmentation. We reviewed some representative studies that enrolled large numbers of patients and compared antipsychotic polypharmacy and monotherapy during the past decade. The results revealed that a certain proportion of select patients can benefit from antipsychotic polypharmacy without further negative consequences. Because most of the current treatment guidelines from different countries and organizations prefer monotherapy and discourage all antipsychotic polypharmacy, guidelines regarding the use of antipsychotic polypharmacy in clinical practice should be revised. On the basis of the findings of 2 large-scale studies from Asia and Europe, we also suggest ideal rates of various maintenance treatments of schizophrenia, which are as follows: antipsychotic polypharmacy, 30%; combined mood stabilizer, 15%; combined antidepressant, 10%; combined anxiolytics, 30%; and combined hypnotic, 10%.
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Affiliation(s)
- Shih-Ku Lin
- Department of Psychiatry, School of Medicine, Taipei Medical University and Department of Psychiatry, Taipei City Hospital and Psychiatry Center, Taipei, Taiwan,Correspondence: Dr Shih-Ku Lin, Taipei City Hospital and Psychiatric Center, 309 Songde Road, Xinyi District, Taipei 110, Taiwan ()
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