Compliance with medication regimens for mental and physical disorders

Effective Treatment for Mental and Substance Use Disorders in 21 Countries

Importance

Accurate baseline information about the proportion of people with mental disorders who receive effective treatment is required to assess the success of treatment quality improvement initiatives.

Objective

To examine the proportion of mental and substance use disorders receiving guideline-consistent treatment in multiple countries.

Design, Setting, and Participants

In this cross-sectional study, World Mental Health (WMH) surveys were administered to representative adult (aged 18 years and older) household samples in 21 countries. Data were collected between 2001 and 2019 and analyzed between February and July 2024. Twelve-month prevalence and treatment of 9 DSM-IV anxiety, mood, and substance use disorders were assessed with the Composite International Diagnostic Interview. Effective treatment and its components were estimated with cross-tabulations. Multilevel regression models were used to examine predictors.

Main Outcomes and Measures

The main outcome was proportion of effective treatment received, defined at the disorder level using information about disorder severity and published treatment guidelines regarding adequate medication type, control, and adherence and adequate psychotherapy frequency. Intermediate outcomes included perceived need for treatment, treatment contact separately in the presence and absence of perceived need, and minimally adequate treatment given contact. Individual-level predictors (multivariable disorder profile, sex, age, education, family income, marital status, employment status, and health insurance) and country-level predictors (treatment resources, health care spending, human development indicators, stigma, and discrimination) were traced through intervening outcomes.

Results

Among the 56 927 respondents (69.3% weighted average response rate), 32 829 (57.7%) were female; the median (IQR) age was 43 (31-57) years. The proportion of 12-month person-disorders receiving effective treatment was 6.9% (SE, 0.3). Low perceived need (46.5%; SE, 0.6), low treatment contact given perceived need (34.1%; SE, 1.0), and low effective treatment given minimally adequate treatment (47.0%; SE, 1.7) were the major barriers, but with substantial variation across disorders. Country-level general medical treatment resources were more important than mental health treatment resources. Other than for the multivariable disorder profile, which was associated with all intermediate outcomes, significant predictors were largely mediated by treatment contact.

Conclusions and Relevance

In addition to the gaps in treatment quality, these results highlight the importance of increasing perceived need, the largest barrier to effective treatment; the importance of training primary care treatment clinicians in recognition and treatment of mental disorders; the need to improve the continuum of care, especially from minimally adequate to effective treatment; and the importance of bridging the effective treatment gap for men and people with lower education.

Initiation of Antipsychotics During the First Year After First-Episode Psychosis: A Population-Based Study

BACKGROUND

Antipsychotics are recommended after first-episode psychosis. Knowledge on the current use patterns in real-world settings is thus important to inform clinical practice. We aimed to describe antipsychotic initiation during 1 year after first-episode psychosis and its associated factors.

METHODS

Population-based cohort study using linked nationwide health and population registers from Norway. The study population comprised 8052 persons aged 16-45 years with first-episode psychosis diagnosed in secondary care (ICD-10 F20, F22-F29) in the period 2011-2019. Initiation of antipsychotic use was defined as being dispensed antipsychotics (ATC N05A, excl. lithium) at least once from -90 to +365 days from secondary care diagnosis of first-episode psychosis. Antipsychotic polypharmacy during follow-up was defined as having at least 90 days with overlapping drug use periods modeled using the Prescriptions to Drug Use Periods method. Adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) for the association between socioeconomic and clinical factors and initiation of antipsychotic use were calculated using modified Poisson regression.

RESULTS

In total, 4413 persons (54.8%) initiated antipsychotic use after first-episode psychosis with proportions ranging from 45.5% in 2012 to 62.1% in 2019. Oral formulations of olanzapine (34.9%), quetiapine (21.2%), and aripiprazole (11.6%) were most common at initiation, whereas long-acting injectables (LAIs) and clozapine were rarely used. Among the initiators, 13.8% started a polypharmacy period lasting more than 90 days. Factors associated with antipsychotic initiation were lower age (aRR 1.14, 95% CI 1.08-1.21; 26-35 years vs. 36-45 years), higher education (1.11, 1.05-1.18), being employed (1.04, 1.00-1.09), being hospitalized (1.13, 1.09-1.18), being diagnosed late in the study period (1.16, 1.11-1.22; 2017-2019 vs. 2011-2013), or with previously diagnosed bipolar disorder, depression, or anxiety disorders.

CONCLUSIONS

The antipsychotic use pattern is largely within the current clinical guideline. Primary non-compliance and disease severity may explain the socioeconomic and clinical differences related to initiation of antipsychotic use.

Oral versus long-acting injectable antipsychotics in schizophrenia spectrum disorders: A systematic review of patients' subjective experiences

Schizophrenia spectrum disorders significantly impact daily functioning, with antipsychotic medications regarded as the gold standard treatment. However, their efficacy is often limited by side effects and adherence rates. Understanding patient perspectives and subjective experiences, particularly regarding oral versus long-acting injectable (LAI) antipsychotics, is crucial for improving medication outcomes and patient-tailored treatments. A systematic review of qualitative studies was conducted following the ENTREQ guidelines. Data were extracted from PubMed, Scopus, and PsycInfo, with thematic synthesis used to identify key themes in patient-reported experiences. Thirty-nine studies (1.477 patients) were included and analyzed, revealing three core themes: (1) perception and experience of medication, (2) social dynamics and influence, and (3) trust and communication with healthcare providers. Side effects and lack of information were often mentioned by patients. While LAI antipsychotics were linked to symptom stability and functional improvements, many patients lacked adequate information about their effects, contributing to adherence difficulties. Stigma and negative beliefs were common across both oral and LAI formulations, thus determining significant barriers to medication adherence. This review emphasizes that patients' experiences with antipsychotic medications are shaped by three key factors: the environment, the therapeutic relationship, and the drug itself. Two critical areas warrant particular attention: psychoeducation and stigma. Bridging psychoeducational gaps and addressing stigma could significantly enhance treatment adherence and outcomes. Additionally, greater emphasis on providing comprehensive and accurate information about antipsychotic treatment options is essential to support patient-centred care and informed decision-making.

Clinical pharmacy activities specific to patients treated with lithium

OBJECTIVES

Medication compliance in lithium-treated patients is poor (43-46%) and may be responsible for relapse or toxicity. Improving understanding of treatment principles leads to increased medication adherence. To do this, targeted and personalised pharmaceutical interviews on lithium were developed and implemented by a clinical pharmacy team in adult psychiatric departments of the Lille university hospital center. The primary aim of this work was to assess medication adherence with lithium, patients' understanding of the drug and of potential adverse effects. A secondary objective was to evaluate the feasibility of these pharmaceutical interviews in practice.

METHODS

Implementation of self-assessment questionnaires measuring medication adherence (Medication Adherence Rating Scale) as well as knowledge of lithium and risk of exposure to toxic effects (Lithium Knowledge Test) of patients. Conducting targeted pharmaceutical interviews about lithium, and recording of time spent, satisfaction of medical teams and difficulties encountered.

RESULTS

Twenty patients were included in the 6-month study. Every patient benefited from a personalized pharmaceutical interview by a pharmacy intern focused on lithium during his hospitalization. Lithium adherence, patient knowledge and risk exposure to lithium toxicity was 5.5±0.9 (target ≥8), 8.9±0.9 (target >6) and 4.0±0.5 (target <4). The median time required for these new activities was 95minutes per patient. Medical satisfaction was observed in 70% to 100% of cases depending on the criterion assessed. The lack of pharmaceutical time and communication difficulties were the main obstacles encountered.

CONCLUSION

Medication compliance in patients treated with lithium is poor as described in the literature. To improve this and to optimise drug management, patients have benefited from targeted and personalised pharmaceutical interviews. The satisfaction of patients and the medical team made it possible to sustain these new pharmaceutical activities.

Protective effects of psychiatric medications against COVID-19 mortality before vaccines

The coronavirus disease pandemic caused by the coronavirus SARS-CoV-2, which emerged in the United States in late 2019 to early 2020 and quickly escalated into a national public health crisis. Research has identified psychiatric conditions as possible risk factors associated with COVID-19 infection and symptom severity. This study aims to determine whether specific classes of psychiatric medications could reduce the likelihood of infection and alleviate the severity of the disease. The objective of this study is to investigate the relationship between neuropsychiatric medication usage and COVID-19 outcomes before the widespread utilization of COVID-19 vaccines. This cross-sectional study used Optum's de-identified Clinformatics Data Mart Database to identify patients diagnosed with COVID-19 in 2020 and their psychiatric medication prescriptions in the United States. Ordered logistic regression was used to predict the likelihood of a higher COVID-19 severity level for long-term and new users. Results were adjusted for demographic characteristics and medical and psychiatric comorbidities. Most users were classified into the long-term user analysis group. Long-term users were 9% less likely to have a higher severity score (CI: 0.89-0.93, p-value < 0.001) than non-users. SSRI antidepressant users, both long-term (OR: 1.09; CI: 1.06-1.12) and short-term (OR: 1.17; CI: 1.07-1.27) were significantly more likely to have a lower severity score. However, the results varied across long-term and short-term users for all medication classes. Results of the current study suggest that psychopharmacological agents are associated with reduced COVID-19 severity levels and that antidepressant medications may have a protective role against COVID-19.

Motivational Interviewing in Patients with Acute Psychosis: A Feasibility Study

Background and Hypothesis

Psychotic disorders are among the top causes of disability worldwide. Guidelines emphasize the need for psychotherapeutic approaches in the acute phase of this illness. Motivational interviewing (MI) is highly suitable for establishing a therapeutic alliance wherein the patient's intrinsic motivation can be strengthened to adhere to therapy. This pilot study investigated the feasibility and impact of MI for patients with acute psychosis.

Study Design

A feasibility study was conducted, comparing MI and supportive counseling. The sample included 20 inpatients, who all received 4 therapy sessions. In line with CONSORT guidelines for pilot and feasibility studies, we measured various feasibility outcomes. Clinical outcomes were assessed using linear regression models, with baseline values used as covariates.

Study Results

The recruitment target (N = 24) was achieved at 83% in a reasonable timeframe (8 months), with a retention rate of 83% and a completion rate of 71%. The eligibility rate (82 %) was high, the consent rate (48%) was moderate, and both the dropout rate 17% and the missing data rate (0.3%) were low. Regarding the clinical outcomes, a group difference was found for the severity of psychotic symptoms, with an advantage for MI (b = -12.0, 95% CI: [-18.7, -5.2], P < 0.01), although the small sample size must be kept in mind.

Conclusions

The study demonstrated the feasibility and acceptability of a clinical trial with MI for patients with psychosis in an inpatient setting. MI could offer benefits, particularly in terms of reducing psychotic symptoms.

Healthcare costs associated with receipt of effective mental healthcare coverage in individuals with moderate or severe symptoms of anxiety and depression

BACKGROUND

Effective mental healthcare coverage (EMHC) is an important health system performance indicator of a population's mental healthcare needs. This study aims to assess the factors and healthcare costs associated with the receipt of EMHC for anxiety and depression.

METHODS

This study draws on data from participants from Alberta's Tomorrow Project with moderate or severe symptoms of anxiety and depression during the first wave of the COVID-19 pandemic (2020) with available medico-administrative and complete data [n = 720]. EMHC was assessed during the eighteen months as of March 1, 2020, and defined as adequate pharmacotherapy (i.e., antidepressant dispensed, with ≥ 80% proportion of days covered and 4 follow-up medical visits) and/or adequate psychotherapy (≥ 8 physician consultations for psychotherapy) depending on the severity of symptoms. Logistic regression analysis was used to study EMHC as a function of study variables. Regressions with augmented inverse probability weighting were used to estimate the total healthcare costs attributable to receipt of EMHC during the first 18-month period of the pandemic, controlling for confounders. Mean adjusted differences with 95% bias-corrected bootstrap confidence intervals (CIs) are presented.

RESULTS

The proportion receiving EMHC was 26.7%. Individuals with worse self-rated mental health after the pandemic than before were less likely to receive EMHC. Those with a lifetime diagnosis of depression and anxiety were more likely to receive EMHC. The overall mean adjusted total healthcare costs attributable to receipt of EMHC during the pandemic was $2601 [ - $247, $5694]. The mean adjusted outpatient costs attributable to EMHC was significantly higher and reached $1613 [$873, $2577].

CONCLUSION

The study's findings highlight the existence of health inequalities and potential unmet mental health needs in individuals with worsening mental health during the pandemic. The receipt of EMHC during the pandemic was not significantly associated with increased total healthcare costs. These findings underscore the need for mental health policies that are aimed at improving timely access to EMHC to address population unmet mental health service needs.

Bilateral hypothalamotomy plus dominant amygdalotomy with Gamma Knife radiosurgery. A non-invasive alternative when everything has failed in the management of aggressive behavior disorder

Background

Impulsive aggression is the core symptom of intermittent explosive disorder, which can be a feature of several psychiatric disorders. There is a subset of individuals who do not respond adequately to medical treatment; they are treatment refractory. The objective of this report is to describe a case of a patient with a background of schizophrenia and concomitant refractory aggressiveness disorder, treated with two-stage bilateral hypothalamotomy and unilateral amygdalotomy with Gamma Knife radiosurgery (GKR).

Case Description

A 36-year-old male presented with a background of paranoid schizophrenia. Episodes of self- and hetero-aggressiveness were present at the initial diagnosis. High dosages of psychotropic medication were taken, and 70 sessions of electroconvulsive therapy were performed; however, no adequate response was obtained. Bilateral hypothalamotomy plus left amygdalotomy through GKR was performed. After 25 months of follow-up, a marked decrease in the frequency, degree, severity of aggressiveness and the requirement for psychotropic medications was observed.

Conclusion

Hypothalamotomy plus amygdalotomy with Gamma Knife may be an effective ablative technique for the management of refractory aggressive disorder in patients with mental illness.

Acceptability, User Satisfaction, and Feasibility of an App-Based Support Service During the COVID-19 Pandemic in a Psychiatric Outpatient Setting: Prospective Longitudinal Observational Study

BACKGROUND

Patients with mental disorders often have difficulties maintaining a daily routine, which can lead to exacerbated symptoms. It is known that apps can help manage mental health in a low-threshold way and can be used in therapeutic settings to complement existing therapies.

OBJECTIVE

The aim of this study was to evaluate the acceptability, usability, and feasibility of an app-based support service specifically developed for outpatients with severe mental disorders in addition to regular face-to-face therapy during the COVID-19 pandemic.

METHODS

Patients in a psychiatric outpatient department at a German university hospital were invited to use an app-based support service designed transdiagnostically for mental disorders for 4 weeks. The app included 7 relaxation modules, consisting of video, audio, and psychoeducational text; ecological momentary assessment-like questionnaires on daily mood answered via a visual smiley-face scale; and an activity button to record and encourage daily activities. Standardized questionnaires at baseline (T0; preintervention time point) and after 4 weeks (T2; postintervention time point) were analyzed. Feedback via the smiley-face scale was provided after using the app components (T1; during the intervention). Measures included depressive symptoms, quality of life, treatment credibility and expectancy, and satisfaction. Furthermore, participation rates, use of app modules and the activity button, and daily mood and the provided feedback were analyzed (T2).

RESULTS

In total, 57 patients participated in the study, and the data of 38 (67%) were analyzed; 17 (30%) dropped out. Satisfaction with the app was high, with 53% (30/57) of the participants stating being rather satisfied or satisfied. Furthermore, 79% (30/38) of completers stated they would be more likely or were definitely likely to use an app-based support service again and recommend it. Feasibility and acceptability were high, with nearly half (18/38, 47%) of the completers trying relaxation modules and 71% (27/38) regularly responding to the ecological momentary assessment-like questionnaire between 15 and 28 times (mean 19.91, SD 7.57 times). The activity button was used on average 12 (SD 15.72) times per completer, and 58% (22/38) felt "definitely" or "rather" encouraged to perform the corresponding activities. Depressive symptomatology improved significantly at the postintervention time point (P=.02). Quality of life showed a nonsignificant increase in the physical, psychological, and social domains (P=.59, P=.06, and P=.42, respectively) and a significant improvement in the environment domain (P=.004). Treatment credibility and expectancy scores were moderate and significantly decreased at T2 (P=.02 and P<.001, respectively). Posttreatment expectancy scores were negatively associated with posttreatment depressive symptomatology (r=-0.36; P=.03).

CONCLUSIONS

App-based programs seem to be an accessible tool for stabilizing patients with severe mental disorders, supporting them in maintaining a daily routine, complementing existing face-to-face treatments, and overall helping respond to challenging situations such as the COVID-19 pandemic.

Cariprazine Orodispersible Tablet: A New Formulation for Cariprazine

INTRODUCTION

Cariprazine is an atypical dopamine receptor partial agonist antipsychotic available in the form of capsules. Although capsules are one of the most desirable routes of administration, there are certain situations (e. g., in an acute psychiatric setting, or when swallowing difficulties, or liquid shortages are present) when they cannot be administered. Therefore, alternative solutions like orodispersible tablets are needed. This study aimed to investigate the bioequivalence of a newly developed orodispersible tablet to the commercially available hard gelatine capsule of cariprazine 1.5 mg.

METHODS

This was a phase I, open-label, randomized, single-dose bioequivalence study. It had a 2-period, 2-sequence, cross-over design, where each subject received one test and one reference product in a randomized sequence, separated by a wash-out period of 55 days. Blood sampling was performed over 72 h after dosing. Cariprazine concentrations were analyzed by a validated HPLC-MS/MS method. Standard bioequivalence statistics was applied to PK parameters calculated by non-compartmental analysis. Safety measures were analyzed descriptively.

RESULT

Pharmacokinetic data of 43 healthy volunteers and safety data of 54 subjects was analyzed. Cariprazine AUC0-72h and Cmax geometric mean ratios were 117.76% and 100.88%, respectively. The 90% confidence intervals were within the pre-defined bioequivalence acceptance limits of 80.00% - 125.00%. Safety data was in line with the Summary of Product Characteristics of Cariprazine.

DISCUSSION

The result of this clinical trial proved the bioequivalence of the new orodispersible tablet formulation when compared to hard gelatine capsules, enabling an alternative option for treatment of those suffering from schizophrenia.

Interventions to improve medication adherence in adults with mental-physical multimorbidity in primary care: a systematic review

BACKGROUND

Medication non-adherence is a notable contributor to healthcare inefficiency, resulting in poor medication management, impaired patient outcomes, and ineffective symptom control.

AIM

To summarise interventions targeting medication adherence for adults with mental-physical multimorbidity in primary healthcare settings.

DESIGN AND SETTING

A systematic review of the literature - published in any language and with any country of origin - was conducted.

METHOD

MEDLINE, EMBASE, PsycInfo, Web of Science, Cochrane Library, and the Cumulated Index to Nursing and Allied Health Literature - more commonly known as CINAHL - were searched for relevant studies. Data were extracted and synthesised using narrative synthesis. The Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify intervention types. Risk of bias was assessed using the National Heart, Lung, and Blood Institute's quality assessment tool for controlled intervention studies.

RESULTS

Eleven studies, representing 2279 patients, were included. All interventions examined were classified into one EPOC domain, namely 'delivery arrangements'. All included studies examined patients who had a physical condition and depression. Seven studies examining interventions focused on coordination of care and management of care processes reported statistically significant improvements in medication adherence that were attributed to the intervention. Four studies considering the use of information and communication technology observed no changes in medication adherence.

CONCLUSION

Interventions that coordinate and manage healthcare processes may help improve patients' adherence to medication regimes in those with mental-physical multimorbidity. However, it is still necessary to better understand how digital health technology can support patients in following their medication regimes. As the growing challenges of treating multimorbidity are faced, everyone involved in health services - from providers to policymakers - must be receptive to a more integrated approach to healthcare delivery.

Association of schizophrenia with fracture-related femoral neck displacement: A cross-sectional retrospective study

Aim

Fracture-related femoral neck displacement is more likely in patients with schizophrenia because of delayed diagnosis, as these patients frequently have less severe fracture-associated subjective symptoms. This study aimed to investigate the association of schizophrenia with the risk of fracture-related femoral neck displacement in hospitalized patients.

Methods

We retrospectively analyzed the medical records of patients with femoral neck fractures treated between April 2013 and March 2018 at a single institution. Multivariate logistic regression was used to explore the relationship between schizophrenia and fracture-related femoral neck displacement after adjusting for risk factors.

Results

We compared 30 and 194 patients with and without schizophrenia, respectively. The prevalence of fracture-related displacement was 80.0% in patients with schizophrenia and 62.4% in the controls (p = 0.06). After adjusting for confounding variables, schizophrenia significantly correlated with fracture-related femoral neck displacement (odds ratio: 4.74, 95% confidence interval: 1.09-20.60, p = 0.0378).

Conclusions

Schizophrenia is associated with a higher risk of severe femoral neck fracture. To improve outcomes and alleviate the societal burden of femoral neck fractures, early radiographic assessment and surgical intervention for femoral fractures are essential for patients with schizophrenia, even in those without pain symptoms.

Treatment adherence rates across different psychiatric disorders and settings: findings from a large patient cohort

Approximately 50% of patients with psychiatric disorders do not fully adhere to the prescribed psychopharmacological therapy, significantly impacting the progression of the disorder and the patient's quality of life. The present study aimed to assess potential differences in terms of rates and clinical features of treatment adherence in a large cohort of psychiatric patients with different diagnoses attending various psychiatric services. The study included 307 psychiatric patients diagnosed with a primary major depressive disorder, bipolar disorder, anxiety disorder, schizophrenic spectrum disorder, or personality disorder. Patient's adherence to treatment was evaluated using the Clinician Rating Scale, with a cutoff of at least five defining adherence subgroups. One-third of the sample reported poor medication adherence. A lower rate of adherence emerged among patients with schizophrenic spectrum disorder and bipolar disorder. Subjects with poor adherence were more frequently inpatients and showed higher current substance use, a greater number of previous hospitalizations, and more severe scores at psychopathological assessment compared with patients with positive adherence. Poor adherence was associated with symptom severity and increased rates of relapses and rehospitalizations. In addition, substance use appears to be an unfavorable transdiagnostic factor for treatment adherence.

Coping strategies and adherence in people with mood disorder: a cross-sectional study

Introduction

Non-adherence to treatment recommendations is a significant problem, as it contributes to the progression of the disease and to the exacerbation of distressing symptoms. Failure to cope with the disease and elevated levels of stress, in turn, influence the choice of strategy for coping with a difficult situation, and thus adherence to recommendations.

Objectives

The purpose of our study was to evaluate the impact of the subjects' stress coping styles on therapeutic adherence, life satisfaction, disease acceptance and quality of life (QoL) in people with mood disorders.

Methods

This survey-based study included 102 respondents diagnosed with mood disorders, living in the West Pomeranian Voivodeship. It was performed using the sociodemographic questionnaire and standardized tools: The Coping Inventory for Stressful Situations (CISS), The Satisfaction with Life Scale (SWLS), The Short Form-36 (SF-36) Health Survey, The Adherence to Refills and Medication Scale (ARMS), and The Acceptance of Illness Scale (AIS).

Results

Some 47.06% of the respondents suffered from depressive disorders, while 34.31% had depression or mixed anxiety disorder. Patients who made greater use of an emotion-focused style were found to have significantly lower life satisfaction than other patients. Moreover, this style was related to such SF-36 domains as general health, social functioning, role emotional, vitality, and mental health, as well as to physical component summary (PCS) and mental component summary (MCS).

Conclusion

Treatment non-adherence is a serious challenge in the treatment of patients with mood disorders. Individuals who do not adequately follow treatment recommendations often resort to alternative activities as a mechanism for coping with difficult situations. Patients who predominantly adopt an emotion-oriented coping style tend to experience lower life satisfaction and greater difficulty accepting their condition compared to their peers. Conversely, patients who adopt a task-oriented coping style report better quality of life than those who rely on emotion-oriented coping or alternative activities.

The Effect of Pharmacy-Led Medication Reconciliation on Odds of Psychiatric Relapse at a Community Hospital

Purpose: Individuals with psychiatric disorders are at increased risk for treatment non-adherence and related complications, especially during transitions of care. Medication reconciliation is now a standard process during hospital admissions that is uniformly recommended by international organizations to aid in safe and effective care transitions. Pharmacy-led medication reconciliation (PMR) practices are poised to represent a standardized method of reconciliation attempt within this underserved population with complex medication histories. Methods: A retrospective cross-sectional study using medical chart review was conducted for all adults admitted to the inpatient psychiatric service at a community hospital in Buffalo, NY, during 2 months in 2018. Outcomes were 30- and 180-day psychiatric readmission rates, 30- and 180-day visit rates to the outpatient comprehensive psychiatric emergency program (CPEP), and composite 30- and 180-day relapse. Receipt of pharmacy-led medication reconciliation was identified from pharmacy documentation in the electronic medical record. Results: 78% of patient's medication lists on admission were reconciled, with 49% of reconciliations made by the inpatient pharmacy. Presence of a PMR did not alter the odds of inpatient readmission alone, however patients without a PMR were found to have 2.13 times higher odds of visiting the hospital's outpatient CPEP within 30-days (P = .012) and 1.9 times higher odds of any composite psychiatric relapse within 30-days (P = .024). Conclusions: Implementation of hospital-wide pharmacy-led medication reconciliation on admission may help reduce psychiatric relapse across multiple care settings.

Trauma-focused therapy in early psychosis: results of a feasibility randomized controlled trial of EMDR for psychosis (EMDRp) in early intervention settings

BACKGROUND

Trauma is prevalent amongst early psychosis patients and associated with adverse outcomes. Past trials of trauma-focused therapy have focused on chronic patients with psychosis/schizophrenia and comorbid Post-Traumatic Stress Disorder (PTSD). We aimed to determine the feasibility of a large-scale randomized controlled trial (RCT) of an Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) intervention for early psychosis service users.

METHODS

A single-blind RCT comparing 16 sessions of EMDRp + TAU v. TAU only was conducted. Participants completed baseline, 6-month and 12-month post-randomization assessments. EMDRp and trial assessments were delivered both in-person and remotely due to COVID-19 restrictions. Feasibility outcomes were recruitment and retention, therapy attendance/engagement, adherence to EMDRp treatment protocol, and the 'promise of efficacy' of EMDRp on relevant clinical outcomes.

RESULTS

Sixty participants (100% of the recruitment target) received TAU or EMDR + TAU. 83% completed at least one follow-up assessment, with 74% at 6-month and 70% at 12-month. 74% of EMDRp + TAU participants received at least eight therapy sessions and 97% rated therapy sessions demonstrated good treatment fidelity. At 6-month, there were signals of promise of efficacy of EMDRp + TAU v. TAU for total psychotic symptoms (PANSS), subjective recovery from psychosis, PTSD symptoms, depression, anxiety, and general health status. Signals of efficacy at 12-month were less pronounced but remained robust for PTSD symptoms and general health status.

CONCLUSIONS

The trial feasibility criteria were fully met, and EMDRp was associated with promising signals of efficacy on a range of valuable clinical outcomes. A larger-scale, multi-center trial of EMDRp is feasible and warranted.

Impact of long-acting injectable antipsychotics vs. oral medication on relapses of patients with psychosis and bipolar disorder

Relapse associated with multiple hospital readmissions of patients with chronic and severe mental disorders, such as psychosis and bipolar disorder, is frequently associated with non-adherence to treatment. The primary aim of the study was to compare the effectiveness of long-acting injectable (LAI) treatment, vs. oral medication in reducing readmissions of patients with psychotic or bipolar disorder in a community sample of 164 patients with psychosis and 29 patients with bipolar disorder (n = 193), with poor adherence to oral medication. The mean follow up period was 5.6 years and the number of readmissions were compared for an equal-length period of oral treatment preceding the onset of LAI administration. We observed a significant decrease of 45.2 % in total hospital readmissions after receiving LAIs treatment. The effect was significant both for patients with a pre-LAI treatment history of predominantly voluntary hospitalizations and with predominantly involuntary admissions. In addition, we observed equal effectiveness of first- vs. second-generation LAIs in reducing total hospital readmissions regardless of type of pre-treatment admission history (voluntary vs. involuntary). LAIs appear to be effective in reducing both voluntary and involuntary hospital readmissions in patients with psychosis and bipolar disorder with a history of poor adherence to treatment.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

Patient's Perspective on Psychiatric Drugs: A Multicenter Survey-Based Study

OBJECTIVE

We aimed to identify the expectations and preferences for medication and medical decision-making in patients with major psychiatric disorders.

METHODS

A survey was conducted among patients with major psychiatric disorders who visited psychiatric outpatient clinics at 15 hospitals between 2016 and 2018 in Korea. The survey consisted of 12 questions about demographic variables and opinions on their expectations for medication, important medical decision-makers, and preferred drug type. The most preferred value in each category in the total population was identified, and differences in the preference ratio of each item among the disease groups were compared.

RESULTS

A total of 707 participants were surveyed. In the total population, patients reported high efficacy (44.01%±21.44%) as the main wish for medication, themselves (37.39%±22.57%) and a doctor (35.27%±22.88%) as the main decision makers, and tablet/capsule (36.16%±30.69%) as the preferred type of drug. In the depressive disorders group, the preference ratio of high efficacy was significantly lower, and the preference ratio of a small amount was significantly higher than that of the psychotic disorder and bipolar disorder groups. The preference ratio of a doctor as an important decision maker in the bipolar disorder group was higher compared to the other groups.

CONCLUSION

This study revealed the preference for medications and showed differences among patients with psychiatric disorders. Providing personalized medicine that considers a patient's preference for the drug may contribute to the improvement of drug compliance and outcomes.

Adherence of patients with schizophrenia to hypothyroidism treatment

Adherence to prescription medications is critical for both remission from schizophrenia and control of physical comorbidities. While schizophrenia with comorbid hypothyroidism is common, there is little research on adherence to hypothyroidism treatment in this population. The current study used a retrospective, matched case-control design. The cohort included 1,252 patients diagnosed with schizophrenia according to ICD-10 and 3,756 controls matched for gender, age, socioeconomic status and ethnicity without diagnosis of schizophrenia. All data were retrieved from the electronic medical database of a large health maintenance organization. Retrieved data included demographics, thyroid functionality test results and prescribed medications. Measures of adherence to therapy were used for analyses as were data from follow-ups of patients with hypothyroidism. A diagnosis of hypothyroidism was found in 299 patients, 115 of whom were also diagnosed with schizophrenia. The 184 without schizophrenia constituted the control group. No statistically significant differences were found between the two groups regarding prescriptions for L-thyroxin and TSH levels and number of TSH tests. Adherence of patients with schizophrenia to hypothyroidism treatment was found to be as good as that of individuals without a schizophrenia diagnosis.

How can we improve the care of patients with schizophrenia in the real-world? A population-based cohort study of 456,003 patients

An important step to improve outcomes for patients with schizophrenia is to understand treatment patterns in routine practice. The aim of the current study was to describe the long-term management of patients with schizophrenia treated with antipsychotics (APs) in real-world practice. This population-based study included adults with schizophrenia and who had received ≥3 deliveries of an AP from 2012-2017, identified using a National Health Data System. Primary endpoints were real-life prescription patterns, patient characteristics, healthcare utilization, comorbidities and mortality. Of the 456,003 patients included, 96% received oral APs, 17.5% first-generation long-acting injectable APs (LAIs), and 16.1% second generation LAIs. Persistence rates at 24 months after treatment initiation were 23.9% (oral APs), 11.5% (first-generation LAIs) and 20.8% (second-generation LAIs). Median persistence of oral APs, first-generation LAIs and second-generation LAIs was 5.0, 3.3, and 6.1 months, respectively. Overall, 62.1% of patients were administered anxiolytics, 45.7% antidepressants and 28.5% anticonvulsants, these treatments being more frequently prescribed in women and patients aged ≥50 years. Dyslipidemia was the most frequent metabolic comorbidity (16.2%) but lipid monitoring was insufficient (median of one occasion). Metabolic comorbidities were more frequent in women. Standardized patient mortality remained consistently high between 2013 and 2015 (3.3-3.7 times higher than the general French population) with a loss of life expectancy of 17 years for men and 8 years for women. Cancer (20.2%) and cardiovascular diseases (17.2%) were the main causes of mortality, and suicide was responsible for 25.4% of deaths among 18-34-year-olds. These results highlight future priorities for care of schizophrenia patients. The global persistence of APs used in this population was low, whereas rates of psychiatric hospitalization remain high. More focus on specific populations is needed, such as patients aged >50 years to prevent metabolic disturbances and 18-34-year-olds to reduce suicide rates.

Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic

Background

The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool.

Objective

The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany.

Methods

The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants' home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers.

Results

In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants' sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05).

Conclusion

A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients.

Clinical trial registration

https://clinicaltrials.gov/, DRKS00027911.

Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital

Introduction

Urinary tract infections (UTIs) are one of the most common indications for antibiotic use; patients with psychiatric disorders have a greater risk for UTI compared with patients without these disorders. However, there is little guidance on how best to manage antibiotic therapy in psychiatric hospitals. This study assessed the impact of a Board Certified Psychiatric Pharmacist (BCPP)-driven guideline on managing UTI treatment in an acute psychiatric hospital.

Methods

The guideline was developed by the psychiatric pharmacy team and distributed to internists, psychiatrists, and pharmacists. Preintervention data were assessed for patients admitted between November 30, 2019, and February 23, 2020; postintervention data were assessed from February 25, 2020, to April 24, 2020. All patients ages 13 years and older who were admitted and had orders for an antibiotic to treat a UTI were included in this study. Appropriate UTI management was defined as an appropriate agent, dose, route, and frequency per the treatment guideline. Additionally, the following criteria were to be ordered and assessed to be deemed appropriate: urinalysis, urine culture, complete blood count, basic or complete metabolic panel, temperature, and subjective symptoms.

Results

Before intervention, 19.0% of antibiotic orders were appropriate; after intervention, 46.7% of antibiotic orders were appropriate (P = .048).

Conclusion

The implementation of a BCPP-driven treatment algorithm was associated with a significant increase in appropriate antibiotic regimens for the treatment of UTIs in patients admitted to a psychiatric hospital.

Long-Acting Injectable Antipsychotic Treatment for Schizophrenia in Asian Population: A Scoping Review

Evidence of comparative benefits of long-acting injectable (LAI) antipsychotics in Asian patients with schizophrenia has been inconsistent. This scoping review aimed to synthesize the current evidence in the past ten years and provide an overview of efficacy, safety, treatment adherence, patient attitudes, and healthcare resource utilization of LAI in this population. A systematic search was conducted with a pre-defined search strategy in six electronic databases including Chinese National Knowledge Infrastructure (CNKI), Wanfang, PubMed, Embase, CINAHL, and PsycArticles. A total of 46 studies were included, including 15 cohort studies, 13 single-arm trials, 10 randomized controlled trials, four mirror-image studies, three cross-sectional studies, and one controlled clinical trial. Paliperidone palmitate once-monthly injection (27/46) and risperidone LAI (14/46) were the most frequently investigated LAIs. Compared with oral antipsychotic medications (OAMs), LAIs demonstrated a lower rate of relapse/hospitalization and comparable improvement in efficacy. Adverse events (AEs) were similar between LAIs and OAMs, although types and incidence varied. Significant reduction in the length of hospitalization and number of outpatient visits/inpatient admission was observed after initiation of LAIs. These findings suggest that LAI demonstrated comparable efficacy and safety among Asian populations with schizophrenia in comparison to OAMs. Better adherence and lower relapse were observed in patients receiving LAIs from published evidence. Future research is warranted to better understand the comprehensive performance of LAI in specific population or context.

Psychotropic Medication Adherence and Its Associated Factors Among Schizophrenia Patients: Exploring the Consistency of Adherence Scales

Background and objective Non-adherence to psychotropic medication can aggravate an individual's illness, diminish treatment efficacy, or make patients less responsive to future therapeutic interventions. There are several scales available to measure non-adherence to medications. In this study, we aimed to measure psychotropic medication adherence and its associated factors among schizophrenic outpatients in Saudi Arabia. Methodology A cross-sectional study was conducted with a view to measuring psychotropic medication adherence and its associated factors. The Medication Adherence Rating Scale (MARS) and the Drug Attitude Inventory-10 (DAI-10) were translated into Arabic, and their internal consistency was measured. The adjusted odds ratios (AOR) were calculated using logistic regression in the IBM SPSS Statistics software version 23 (IBM Corp., Armonk, NY). Results Spearman's rho correlation indicated a negative association between DAI-10 and MARS scores (r = -0.579; p<0.05). The Arabic version of MARS was more reliable than DAI-10, as evidenced by Cronbach's alpha value. Of note, 60.20% (n = 59) of the sample demonstrated high adherence levels. The adherence level based on MARS scoring remained unaffected (p>0.05) in terms of gender, age, employment, marital status, educational level, income level, and duration of sickness. These results were obtained by using the multivariate logistic regression model; 89% of respondents reported not using psychiatric drugs given by someone else, despite the adherence rate not affecting this number. Conclusion The rate of non-adherence to psychotropic treatment was found to be high in our cohort. Hence, it is imperative to develop comprehensive intervention methods targeting the causes of non-adherence to psychiatric medication.

Which Severe Mental Illnesses Most Increase the Risk of Developing Dementia? Comparing the Risk of Dementia in Patients with Schizophrenia, Major Depressive Disorder and Bipolar Disorder

Objective

Previous studies have shown that certain severe mental illnesses (SMIs) increase the risk of dementia, but those that increase the risk to a greater degree in comparison with other SMIs are unknown. Furthermore, physical illnesses may alter the risk of developing dementia, but these cannot be well-controlled.

Methods

Using the Taiwan National Health Insurance Research Database, patients with schizophrenia, bipolar disorder and major depressive disorder (MDD) were recruited. We also recruited normal healthy subjects as the control group. All subjects were aged over 60 years, and the duration of follow-up was from 2008 to 2015. Multiple confounders were adjusted, including physical illnesses and other variables. Use of medications, especially benzodiazepines, was analyzed in a sensitivity analysis.

Results

36,029 subjects (MDD: 23,371, bipolar disorder: 4,883, schizophrenia: 7,775) and 108,084 control subjects were recruited after matching according to age and sex. The results showed that bipolar disorder had the highest hazard ratio (HR) (HR: 2.14, 95% confidence interval [CI]: 1.99-2.30), followed by schizophrenia (HR: 2.06, 95% CI: 1.93-2.19) and MDD (HR: 1.60, 95% CI: 1.51-1.69). The results remained robust after adjusting for covariates, and sensitivity analysis showed similar results. Anxiolytics use did not increase the risk of dementia in any of the three groups of SMI patients.

Conclusion

SMIs increase the risk of dementia, and among them, bipolar disorder confers the greatest risk of developing dementia. Anxiolytics may not increase the risk of developing dementia in patients with an SMI, but still need to be used with caution in clinical practices.

Insights into the Mechanism of Action of Antipsychotic Drugs Derived from Animal Models: Standard of Care versus Novel Targets

Therapeutic intervention for schizophrenia relies on blockade of dopamine D2 receptors in the associative striatum; however, there is little evidence for baseline overdrive of the dopamine system. Instead, the dopamine system is in a hyper-responsive state due to excessive drive by the hippocampus. This causes more dopamine neurons to be in a spontaneously active, hyper-responsive state. Antipsychotic drugs alleviate this by causing depolarization block, or excessive depolarization-induced dopamine neuron inactivation. Indeed, both first- and second-generation antipsychotic drugs cause depolarization block in the ventral tegmentum to relieve positive symptoms, whereas first-generation drugs also cause depolarization in the nigrostriatal dopamine system to lead to extrapyramidal side effects. However, by blocking dopamine receptors, these drugs are activating multiple synapses downstream from the proposed site of pathology: the loss of inhibitory influence over the hippocampus. An overactive hippocampus not only drives the dopamine-dependent positive symptoms, but via its projections to the amygdala and the neocortex can also drive negative and cognitive symptoms, respectively. On this basis, a novel class of drugs that can reverse schizophrenia at the site of pathology, i.e., the hippocampal overdrive, could be effective in alleviating all three classes of symptoms of schizophrenia while also being better tolerated.

Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis

Introduction

Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment.

Methods

A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest.

Results

87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation.

Discussion

Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.

Real-World Evidence of Aripiprazole Tablets with Sensor: Treatment Patterns and Impacts on Psychiatric Healthcare Resource Utilization

Purpose

Maintaining adherence to antipsychotic (AP) medication is often challenging. Aripiprazole tablets with sensor (AS) contain an ingestible event marker and communicate with wearable patches and a smartphone app to provide objective medication ingestion data. This study evaluated real-world treatment patterns of AS usage and its impact on psychiatric healthcare resource utilization (HCRU).

Patients and Methods

This retrospective, observational cohort study identified individuals who initiated AS between 1/1/2019 and 6/30/2020 with 3 months baseline and 6 months of follow-up data using a commercial medical and pharmacy claims database (Clarivate). Controls were propensity score-matched (4:1) to AS initiators based on age (±2 years), sex, diagnosis (major depressive disorder [MDD], schizophrenia, bipolar I disorder [BP-I], other), insurance, and baseline oral AP use (yes/no). Days of AP supply were evaluated using a general regression model. The frequency of psychiatric HCRU during follow-up was compared between groups using a zero-inflated regression model.

Results

Most AS initiators were diagnosed with MDD (61.2%) and were women (61.2%); mean age was 37.7 years (standard deviation: 14.1). Most AS initiators (53.1%) continued treatment for >60 days (mean days of supply = 77). After adjusting for covariates, AS initiators had 41% more days of AP supply during follow-up compared with controls (P <0.0001) and significantly lower adjusted odds ratios (ORs) for psychiatric outpatient visits (adjusted OR = 0.80; P <0.05), emergency department visits (adjusted OR = 0.11; P <0.05), inpatient visits (adjusted OR = 0.42; P <0.05), and other medical services (adjusted OR = 0.25; P <0.05).

Conclusion

Participants who implemented AS had significantly more days of AP supply and fewer psychiatric care visits. These preliminary results suggest AS usage can help build regular medication-taking habits and holds promise for reducing psychiatric HCRU. Additional studies with larger sample sizes are warranted to inform clinical practice and coverage decisions.

Towards measuring effective coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder in São Paulo metropolitan area, Brazil

BACKGROUND

Major depressive disorder (MDD) contributes to a significant proportion of disease burden, disability, economic losses, and impact on need of treatment and health care in Brazil, but systematic information about its treatment coverage is scarce. This paper aims to estimate the gap in treatment coverage for MDD and identify key bottlenecks in obtaining adequate treatment among adult residents in the São Paulo Metropolitan area, Brazil.

METHODS

A representative face-to-face household survey was conducted among 2942 respondents aged 18+ years to assess 12-month MDD, characteristics of 12-month treatment received, and bottlenecks to deliver care through the World Mental Health Composite International Diagnostic Interview.

RESULTS

Among those with MDD (n = 491), 164 (33.3% [SE, 1.9]) were seen in health services, with an overall 66.7% treatment gap, and only 25.2% [SE, 4.2] received effective treatment coverage, which represents 8.5% of those in need, with a 91.5% gap in adequate care (66.4% due to lack of utilization and 25.1% due to inadequate quality and adherence). Critical service bottlenecks identified were: use of psychotropic medication (12.2 percentage points drop), use of antidepressants (6.5), adequate medication control (6.8), receiving psychotherapy (19.8).

CONCLUSIONS

This is the first study demonstrating the huge treatment gaps for MDD in Brazil, considering not only overall coverage, but also identifying specific quality- and user-adjusted bottlenecks in delivering pharmacological and psychotherapeutic care. These results call for urgent combined actions focused in reducing effective treatment gaps within services utilization, as well as in reducing gaps in availability and accessibility of services, and acceptability of care for those in need.

Acceptability of cognitive remediation for schizophrenia: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acceptability is an important factor for predicting intervention use and potential treatment outcomes in psychosocial interventions. Cognitive remediation (CR) improves cognition and functioning in people with a diagnosis of schizophrenia, but its acceptability, and the impact of participants and treatment characteristics, remain to be investigated. Few studies provide a direct measure of acceptability, but treatment drop-out rates are often available and represent a valid surrogate.

METHOD

The systematic search conducted for the most comprehensive CR outcomes database for schizophrenia was updated in December 2020. Eligible studies were randomized clinical trials comparing CR with any other control condition in patients diagnosed with schizophrenia spectrum disorders and that also reported drop-out in treatment and control arms separately. Acceptability was measured as odd-ratios (OR) of drop-out.

RESULTS

Of 2119 identified reports, 151 studies, reporting 169 comparisons between CR and control interventions with 10 477 participants were included in the analyses. The overall rate of drop-out was 16.58% for CR programs and 15.21% for control conditions. In the meta-analysis, no difference emerged between CR interventions and controls [OR 1.10, 95% confidence interval (CI) 0.96-1.25, p = 0.177]. Factors improving acceptability were: inpatient only recruitment, participants with fewer years of education and lower premorbid IQ, the presence of all CR core elements, and the presence of techniques to transfer cognitive gains into real-world functioning.

CONCLUSIONS

CR for people diagnosed with schizophrenia is effective and has a good acceptability profile, similar to that of other evidence-based psychosocial interventions.

Semaglutide for the treatment of antipsychotic-associated weight gain in patients not responding to metformin - a case series

Metformin is the currently accepted first-line treatment for antipsychotic-associated weight gain (AAWG). However, not all patients benefit from metformin. Glucagon-like peptide-1 receptor agonists (GLP1-RA) have shown promise in the management of obesity in the general population, with preliminary evidence supporting efficacy in AAWG. Semaglutide is a weekly injectable GLP-1RA which received recent approval for obesity management and noted superiority over other GLP-1RAs. This study explored the efficacy and tolerability of semaglutide in AAWG among individuals with severe mental illness. A retrospective chart review of patients treated with semaglutide in the Metabolic Clinic at the Center for Addiction and Mental Health (CAMH) between 2019 and 2021 was conducted. Patients failing a trial of metformin (<5% weight loss or continuing to meet criteria for metabolic syndrome) after 3 months at the maximum tolerated dose (1500-2000 mg/day) were initiated on semaglutide up to 2 mg/week. The primary outcome measure was a change in weight at 3, 6, and 12 months. Twelve patients on weekly semaglutide injections of 0.71 ± 0.47 mg/week were included in the analysis. About 50% were female; the average age was 36.09 ± 13.32 years. At baseline, mean weight was 111.4 ± 31.7 kg, BMI was 36.7 ± 8.2 kg/m2, with a mean waist circumference of 118.1 ± 19.3 cm. A weight loss of 4.56 ± 3.15 kg (p < 0.001), 5.16 ± 6.27 kg (p = 0.04) and 8.67 ± 9 kg (p = 0.04) was seen at 3, 6, and 12 months, respectively, after initiation of semaglutide with relatively well-tolerated side-effects. Initial evidence from our real-world clinical setting suggests that semaglutide may be effective in reducing AAWG in patients not responding to metformin. Randomized control trials investigating semaglutide for AAWG are needed to corroborate these findings.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs).

METHODS

Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage.

RESULTS

12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage.

CONCLUSION

There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.

Effects of a probiotic add-on treatment on fronto-limbic brain structure, function, and perfusion in depression: Secondary neuroimaging findings of a randomized controlled trial

BACKGROUND

Probiotics are suggested to improve depressive symptoms via the microbiota-gut-brain axis. We have recently shown a beneficial clinical effect of probiotic supplementation in patients with depression. Their underlying neural mechanisms remain unknown.

METHODS

A multimodal neuroimaging approach including diffusion tensor imaging, resting-state functional MRI, and arterial spin labeling was used to investigate the effects of a four-weeks probiotic supplementation on fronto-limbic brain structure, function, and perfusion and whether these effects were related to symptom changes.

RESULTS

Thirty-two patients completed both imaging assessments (18 placebo and 14 probiotics group). Probiotics maintained mean diffusivity in the left uncinate fasciculus, stabilized it in the right uncinate fasciculus, and altered resting-state functional connectivity (rsFC) between limbic structures and the temporal pole to a cluster in the precuneus. Moreover, a cluster in the left superior parietal lobule showed altered rsFC to the subcallosal cortex, the left orbitofrontal cortex, and limbic structures after probiotics. In the probiotics group, structural and functional changes were partly related to decreases in depressive symptoms.

LIMITATIONS

This study has a rather small sample size. An additional follow-up MRI session would be interesting for seeing clearer changes in the relevant brain regions as clinical effects were strongest in the follow-up.

CONCLUSION

Probiotic supplementation is suggested to prevent neuronal degeneration along the uncinate fasciculus and alter fronto-limbic rsFC, effects that are partly related to the improvement of depressive symptoms. Elucidating the neural mechanisms underlying probiotics' clinical effects on depression provide potential targets for the development of more precise probiotic treatments.

Identifying risk factors to predict violent behaviour in community patients with severe mental disorders: A retrospective study of 5277 patients in China

BACKGROUND

Patients with Severe Mental Disorders (SMD) have a higher risk of violent behaviour than the general population. The study aimed to investigate the predictive factors for the occurrence of violent behaviour in community SMD patients.

METHODS

The cases and follow-up data were collected from SMD patient Information Management system in Jiangning District, Jiangsu Province. The incidence of violent behaviours was described and analyzed. Logistic regression model was used to examine the influencing factors for violent behaviours in those patients.

RESULTS

Among 5277 community patients with SMD in Jiangning District, 42.4% (2236/5277) had violent behaviours. The stepwise logistic regression analysis revealed that the disease-related factors (including disease type, disease course, times of hospitalization, medication adherence, past violent behaviours), the demographic factors (age, male sex, educational level, economic and social living status), and the policy-related factors (like free treatment, annual physical check, disability certificate, family physician services, and community interviews) were significantly related to the violent behaviours in community SMD patients. After gender stratification, we found that male patients with unmarried status and with a longer course of disease were more likely to violent. However, we found that female patients with lower economic status and educational experience were more likely to violent.

CONCLUSION

Our results suggest that community SMD patients had a high incidence of violent behaviour. The findings may provide valuable information for policymakers and mental health professionals worldwide taking a number of measures to reduce the incidence of violence in community SMD patients and to better maintain social security.

Psychiatric healthcare resource utilization following initiation of aripiprazole once-monthly: a retrospective real-world study

OBJECTIVES

This observational retrospective real-world study examined changes in healthcare resource utilization (HCRU) pre- and post-initiation of aripiprazole once-monthly (AOM 400) in patients with schizophrenia or bipolar I disorder.

METHODS

Electronic health record-derived, de-identified data from the NeuroBlu Database (2013-2020) were used to identify patients ≥18 years with schizophrenia (n = 222) or bipolar I disorder (n = 129) who were prescribed AOM 400, and had visit data within 3, 6, 9, or 12 months pre- and post-initial AOM 400 prescription. Rates of inpatient hospitalization, emergency department visits, inpatient readmissions, and average length of stay were examined and compared over 3, 6, 9, and 12 months pre-/post-AOM 400 using a McNemar test.

RESULTS

Statistically significant differences were seen in both schizophrenia and bipolar I disorder patient cohorts pre- and post-AOM 400 in inpatient hospitalization rates (p < .001 all time points, both cohorts) and 30-day readmission per patient rates (p < .001 all time points, both cohorts). Statistically significant improvement in mean length of stay was observed in both cohorts at all time points, except for at six months in patients with schizophrenia. Emergency department visit rates were significantly lower after AOM 400 initiation for both cohorts at all time points (p < .001).

CONCLUSIONS

A reduction in the rate of hospitalizations, emergency department visits, 30-day readmissions, and average length-of-stay was observed for patients diagnosed with either schizophrenia or bipolar I disorder, which suggests a positive effect of AOM 400 treatment on HCRU outcomes and is supportive of earlier analyses from different data sources.

Telemedicine as a Tool to Improve Medicine Adherence in Patients with Affective Disorders - A Systematic Literature Review

Affective disorders are a common psychological impairment. A major problem with respect to treatment is medication non-adherence. eHealth interventions are already widely used in the treatment of patients living with affective disorders. The aim of this systematic literature review is to obtain the current scientific evidence to eHealth as a tool to improve medication adherence in patients with affective disorders. A systematic search was performed across PubMed, Cochrane Library, Web of Science and PsycInfo. Studies in English and German published between 2007 and 2020 were included. The review followed the PRISMA guidelines and were performed with the CADIMA online tool. A total of 17 articles were included in this review. Eleven studies were randomized controlled trials, two were controlled clinical trials, and four had a pre-/post-design. Three different types of interventions could be identified: internet-based self-management programs (n=4), multi-faceted interventions addressing different dimensions of medication adherence (n=4), and single-faceted interventions (n=9) comprising four mobile interventions and five telehealth interventions. Eleven interventions addressed patients with (comorbid) depressions and six addressed patients with bipolar disorders. Six interventions showed a statistically significant positive effect on medication adherence. None of the studies showed a statistically significant negative effect. All interventions which had a statistically significant positive effect on medication adherence involved personal contacts between therapists and patients. All included eHealth interventions are at least as effective as control conditions and seems to be effective for patients with depression as well as with bipolar disorders. Personal contacts seem to improve the effectiveness of eHealth interventions. eHealth interventions are an effective way to improve medication adherence in patients with affective disorders. In rural or underserved regions, eHealth can supplement usual care interventions on medication adherence by expanding access. More analyses are needed in order to understand determinants for the effectiveness of eHealth interventions on medication adherence enhancement.

Use of an Ingestible, Sensor-Based Digital Adherence System to Strengthen the Therapeutic Relationship in Serious Mental Illness

Serious mental illness is a chronic condition that requires long-term pharmacological treatment. Adherence to oral antipsychotic medication has specific nuances that affects patients and physicians alike. For patients with serious mental illness, nonadherence increases their risk of hospitalization and relapse. Nonadherence is a formidable barrier for physicians in accurately assessing medication efficacy and helping patients achieve their fullest potential. A digital adherence system approved by the Food and Drug Administration can provide near-real time aripiprazole ingestion information. The system records ingestions through an embedded ingestible sensor in oral aripiprazole, which sends a transient local signal to a patch worn on the patient's torso that is then stored on a paired smartphone app. With patient permission, these data can be viewed remotely by their physician, along with a patient's mood, activity, and time spent resting. Such data are able to do the following: reveal broad patterns of medication adherence behavior to the patient as well as their physician; help physicians and patients understand and create more realistic expectations for adherence; promote discussion of treatment options; and minimize therapeutic appointment time devoted to determining actual adherence, thereby maximizing the time available to address each patient's distinctive reasons for their adherence pattern. Crucially, extra time created during appointments can be used to strengthen the therapeutic relationship, which may translate into both improvements in adherence and patient attitude toward their medication. Future investigations are needed to examine how this technology impacts the development of training and best practice guidelines for its use. Otherwise, the potential benefits of this technology may be lost, or worse, inadequate and inappropriate use may harm the therapeutic relationship.

Antipsychotics and Medical Comorbidity: A Retrospective Study in an Urban Outpatient Psychiatry Clinic

Patients with psychotic disorders have increased rates of medical comorbidities. In this cross-sectional study, we investigated the relationship between antipsychotics and medical comorbidities among patients with psychotic disorders in an urban psychiatry clinic in Atlanta, Georgia (n = 860). Each antipsychotic group was compared to a group of patients from the same sample who were not on any antipsychotic, and logistic regression models were constructed for each comorbidity. Ziprasidone was associated with diabetes (aOR 2.56, 95% CI 1.03-6.38) and obesity (aOR 3.19, 95% CI 1.37-7.41). Aripiprazole was associated with obesity (aOR 2.39, 95% CI 1.27-4.51). Clozapine was associated with GERD (aOR 3.59, 95% CI 1.11-11.61), movement disorders (aOR 4.44, 95% CI 1.02-19.32), and arrythmias (4.89, 95% CI 1.44-16.64). Two antipsychotics that are considered weight neutral, ziprasidone and aripiprazole, were associated with cardiometabolic comorbidities. This study suggests that research is warranted to study the association between antipsychotics, medical comorbidity, and psychotic symptom burden.

A Pilot Remote Drama Therapy Program Using the Co-active Therapeutic Theater Model in People with Serious Mental Illness

The impact of drama therapy on mental health recovery remains poorly understood. We examined the effects of a pilot remote drama therapy program for community members living with serious mental illness. The entire intervention was delivered remotely. Participants with serious mental illness completed a 12-week drama therapy program which included an online performance open to the public. Four quantitative scales were administered pre- and post-program. A focus group was conducted 1 week after the performance. Six participants completed the program and crafted a public performance themed around hope. No significant differences were identified in the quantitative measures. Five themes were identified in the post-performance focus group. Drama therapy presents an opportunity for individuals with serious mental illness to process and share their journeys with their diagnoses and re-create a healthy sense of self with increased community awareness.

A Digital Intervention Using Daily Financial Incentives to Increase Medication Adherence in Severe Mental Illness: Single-Arm Longitudinal Pilot Study

BACKGROUND

Medication nonadherence is prevalent in severe mental illness and is associated with multiple negative outcomes. Mobile technology and financial incentives show promise to improve medication adherence; however, studies in mental health, especially with oral medications, are lacking.

OBJECTIVE

The aim of this paper is to assess the feasibility and effectiveness of offering financial incentives through a mobile app based on behavioral economics principles to improve medication adherence in severe mental illness.

METHODS

A 10-week, single-arm longitudinal pilot study was conducted. Patients earned rewards in the context of app-based adherence incentives. The reward was split into biweekly payments made in increments of US $15, minus any US $2 per day penalties for missed check-ins. Time-varying effect modeling was used to summarize the patients' response during the study.

RESULTS

A total of 25 patients were enrolled in this pilot study, of which 72% (n=18) were female, and 48% (n=12) were of a White racial background. Median age was 24 (Q1-Q3: 20.5-30) years. Participants were more frequently diagnosed with schizophrenia and related disorders (n=9, 36%), followed by major depressive disorder (n=8, 32%). App engagement and medication adherence in the first 2 weeks were higher than in the last 8 weeks of the study. At study endpoint, app engagement remained high (n=24, Z=-3.17; P<.001), but medication adherence was not different from baseline (n=24, Z=-0.59; P=.28).

CONCLUSIONS

Financial incentives were effectively delivered using an app and led to high engagement throughout the study and a significantly increased medication adherence for 2 weeks. Leveraging behavioral economics and mobile health technology can increase medication adherence in the short term.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04191876; https://clinicaltrials.gov/ct2/show/NCT04191876.

Passive Mobile Self-tracking of Mental Health by Veterans With Serious Mental Illness: Protocol for a User-Centered Design and Prospective Cohort Study

BACKGROUND

Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms.

OBJECTIVE

The aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms.

METHODS

A mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms.

RESULTS

The study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021.

CONCLUSIONS

Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39010.

Determinants of effective treatment coverage for major depressive disorder in the WHO World Mental Health Surveys

Background

Most individuals with major depressive disorder (MDD) receive either no care or inadequate care. The aims of this study is to investigate potential determinants of effective treatment coverage.

Methods

In order to examine obstacles to providing or receiving care, the type of care received, and the quality and use of that care in a representative sample of individuals with MDD, we analyzed data from 17 WHO World Mental Health Surveys conducted in 15 countries (9 high-income and 6 low/middle-income). Of 35,012 respondents, 3341 had 12-month MDD. We explored the association of socio-economic and demographic characteristics, insurance, and severity with effective treatment coverage and its components, including type of treatment, adequacy of treatment, dose, and adherence.

Results

High level of education (OR = 1.63; 1.19, 2.24), private insurance (OR = 1.62; 1.06, 2.48), and age (30–59yrs; OR = 1.58; 1.21, 2.07) predicted effective treatment coverage for depression in a multivariable logistic regression model. Exploratory bivariate models further indicate that education may follow a dose—response relation; that people with severe depression are more likely to receive any services, but less likely to receive adequate services; and that in low and middle-income countries, private insurance (the only significant predictor) increased the likelihood of receiving effective treatment coverage four times.

Conclusions

In the regression models, specific social determinants predicted effective coverage for major depression. Knowing the factors that determine who does and does not receive treatment contributes to improve our understanding of unmet needs and our ability to develop targeted interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00539-6.

Clinical, gut microbial and neural effects of a probiotic add-on therapy in depressed patients: a randomized controlled trial

A promising new treatment approach for major depressive disorder (MDD) targets the microbiota-gut-brain (MGB) axis, which is linked to physiological and behavioral functions affected in MDD. This is the first randomized controlled trial to determine whether short-term, high-dose probiotic supplementation reduces depressive symptoms along with gut microbial and neural changes in depressed patients. Patients with current depressive episodes took either a multi-strain probiotic supplement or placebo over 31 days additionally to treatment-as-usual. Assessments took place before, immediately after and again four weeks after the intervention. The Hamilton Depression Rating Sale (HAM-D) was assessed as primary outcome. Quantitative microbiome profiling and neuroimaging was used to detect changes along the MGB axis. In the sample that completed the intervention (probiotics N = 21, placebo N = 26), HAM-D scores decreased over time and interactions between time and group indicated a stronger decrease in the probiotics relative to the placebo group. Probiotics maintained microbial diversity and increased the abundance of the genus Lactobacillus, indicating the effectivity of the probiotics to increase specific taxa. The increase of the Lactobacillus was associated with decreased depressive symptoms in the probiotics group. Finally, putamen activation in response to neutral faces was significantly decreased after the probiotic intervention. Our data imply that an add-on probiotic treatment ameliorates depressive symptoms (HAM-D) along with changes in the gut microbiota and brain, which highlights the role of the MGB axis in MDD and emphasizes the potential of microbiota-related treatment approaches as accessible, pragmatic, and non-stigmatizing therapies in MDD. Trial Registration: www.clinicaltrials.gov , identifier: NCT02957591.

The association between birth weight, ponderal index, psychotropic medication, and type 2 diabetes in individuals with severe mental illness

BACKGROUND

Impaired fetal growth may increase vulnerability towards metabolic disturbances associated with some medications. We examined whether birth weight and ponderal index modify the association between psychotropic medication and type 2 diabetes among young adults with severe psychiatric diagnosis.

METHODS

A total of 36,957 individuals born in Denmark between 1973 and 1983 with a diagnosis of schizophrenia, bipolar disorder, or depression were followed from first diagnosis until 2018. Cox proportional hazard models were applied to analyse risk of type 2 diabetes with use of psychotropic medications and interactions between psychotropic medication and birth weight and ponderal index, respectively.

RESULTS

During follow-up, 1575 (4.2%) individuals received a diagnosis of type 2 diabetes. Use of antipsychotic, mood stabilizing and antidepressant medications were associated with higher hazard ratios (HRs) of type 2 diabetes (HR_{antipsychotics} 1.68 [95%CI 1.49-1.90]; HR_{mood stabilizing medication} 1.41 [95%CI 1.25-1.59]; HR_{antidepressants} 2.00 [95%CI 1.68-2.37]), as were a birth weight below 2500 g (HR 1.13 [95%CI 1.01-1.28]), and high ponderal index (HR 1.26 [95%CI 1.11-1.43]). The highest rates of type 2 diabetes for each psychotropic medication category were found in medication users with low birth weight or high ponderal index. However, neither birth weight nor ponderal index significantly modified the association between psychotropic medication and diabetes risk.

CONCLUSION

Psychotropic medication use, birth weight, and ponderal index were risk factors for type 2 diabetes in patients with severe mental illness, but neither birth weight nor ponderal index modified the association between psychotropic medication and type 2 diabetes.

Primary Nonadherence to Antipsychotic Treatment Among Persons with Schizophrenia

It has remained unclear what factors relate to primary nonadherence to antipsychotic treatment and whether specific agents and routes of administration differ in how patients adhere to them. We collected electronic prescriptions and their dispensings from the Finnish electronic prescription database for 29 956 patients with schizophrenia prescribed antipsychotics via electronic prescription during 2015-2016. We defined primary nonadherence as being prescribed an antipsychotic, which was not dispensed from the pharmacy within one year from prescription. Using logistic regression, we analyzed whether several sociodemographic and clinical factors related to nonadherence. We found that 31.7% (N = 9506) of the patients demonstrated primary nonadherence to any of their prescribed antipsychotics. We found that young age (OR = 1.77, 95%CI = 1.59-1.96), concomitant benzodiazepines (OR = 1.47, 95%CI = 1.40-1.55) and mood stabilizers (OR = 1.29, 95%CI = 1.21-1.36), substance abuse (OR = 1.26 95%CI = 1.19-1.35), previous suicide attempt (OR = 1.21, 95%CI = 1.11-1.31), diabetes (OR = 1.15, 95%CI = 1.06-1.25), asthma/COPD (OR = 1.14, 95%CI = 1.04-1.25), and cardiovascular disease (OR = 1.12, 95%CI = 1.05-1.19), were related to primary nonadherence to antipsychotic treatment. Patients using clozapine showed the lowest nonadherence (4.77%, 95%CI = 4.66-4.89), and patients using long-acting injectables were more adherent to treatment (7.27%, 95%CI = 6.85-7.71) when compared to respective oral agents (10.26%, 95%CI = 10.02-10.49). These results suggest that selection between different pharmacological agents and routes of administration while taking into account patients' concomitant medications (benzodiazepines in particular) and comorbidities play a key role in primary nonadherence to antipsychotic treatment.

Profiling the Skeletal Muscle Proteome in Patients on Atypical Antipsychotics and Mood Stabilizers

Atypical antipsychotics (AAP) are used in the treatment of severe mental illness. They are associated with several metabolic side effects including insulin resistance. The skeletal muscle is the primary tissue responsible for insulin-stimulated glucose uptake. Dysfunction of protein regulation within the skeletal muscle following treatment with AAPs may play a role in the associated metabolic side effects. The objective of this study was to measure protein abundance in the skeletal muscle of patients on long-term AAP or mood stabilizer treatment. Cross-sectional muscle biopsies were obtained from patients with bipolar disorder and global protein abundance was measured using stable isotope labeling by amino acid (SILAC) combined with high-performance liquid chromatography-electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS). Sixteen patients completed muscle biopsies and were included in the proteomic analyses. A total of 40 proteins were significantly different between the AAP group and the mood stabilizer group. In-silico pathway analysis identified significant enrichment in several pathways including glucose metabolism, cell cycle, apoptosis, and folate metabolism. Proteome abundance changes also differed based on protein biological processes and function. In summary, significant differences in proteomic profiles were identified in the skeletal muscle between patients on AAPs and mood stabilizers. Future work is needed to validate these findings in prospectively sampled populations.

Schizophrenia and Hospital Admissions for Cardiovascular Events in a Large Population: The APNA Study

(1) Background: Patients with schizophrenia have higher mortality, with cardiovascular diseases being the first cause of mortality. This study aims to estimate the excess risk of hospital admission for cardiovascular events in schizophrenic patients, adjusting for comorbidity and risk factors. (2) Methods: The APNA study is a dynamic prospective cohort of all residents in Navarra, Spain. A total of 505,889 people over 18 years old were followed for five years. The endpoint was hospital admissions for a cardiovascular event. Direct Acyclic Graphs (DAG) and Cox regression were used. (3) Results: Schizophrenic patients had a Hazard Ratio (HR) of 1.414 (95% CI 1.031–1.938) of hospital admission for a cardiovascular event after adjusting for age, sex, hypertension, type 2 diabetes, dyslipidemia, smoking, low income, obesity, antecedents of cardiovascular disease, and smoking. In non-adherent to antipsychotic treatment schizophrenia patients, the HR was 2.232 (95% CI 1.267–3.933). (4) Conclusions: Patients with schizophrenia have a higher risk of hospital admission for cardiovascular events than persons with the same risk factors without schizophrenia. Primary care nursing interventions should monitor these patients and reduce cardiovascular risk factors.