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Lee J, Oh S, Moon SY, Loh SK, Kim M, Lee TY, Kwon JS. Impact of long-acting injectable aripiprazole on the concomitant medication and antipsychotic polypharmacy: a retrospective, observational study of 127 patients with psychosis. Int Clin Psychopharmacol 2024; 39:250-256. [PMID: 37982292 DOI: 10.1097/yic.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Antipsychotic polypharmacy (APP) has become prevalent over the years, but several concerns have been raised over APP. Accumulating evidence suggests that aripiprazole long-acting injectable (LAI) may reduce the rate of APP, but the association remains speculative. This retrospective observational study included 127 patients with psychosis and observed them for 1.8 ± 1.3 years, up to 4 years. Prescription data of antipsychotics (APs), mood stabilisers, benzodiazepines, and anti-extrapyramidal side effect medications were obtained at baseline and the last observation. Daily chlorpromazine equivalent (CPZ) dose of APs decreased from 124.40 ± 235.35 mg to 77.95 ± 210.36 mg ( P = 0.027). The daily dose of anticholinergics and beta-blockers also significantly decreased after introducing aripiprazole LAI. Among the patients having APP, the number of concurrent APs along with daily CPZ dose of APs decreased after initiation of aripiprazole LAI from 1.28 ± 0.62 to 0.85 ± 0.73 ( P < 0.001) and 298.33 ± 308.70 mg to 155.43 ± 280.53 mg ( P = 0.004), respectively. Treatment with aripiprazole LAI for up to 4 years in patients with psychosis was associated with a reduced number of prescribed APs in patients having an APP and a reduced dose of APs and concurrent psychotropic medications.
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Affiliation(s)
- Junhee Lee
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul
- Department of Psychiatry, Uijeongbu Eulji Medical Center, Uijeongbu
| | - Sanghoon Oh
- Department of Psychiatry, Uijeongbu Eulji Medical Center, Uijeongbu
| | - Sun-Young Moon
- Department of Psychiatry, Hallym University Kangnam Sacred Heart Hospital
| | - Silvia Kyungjin Loh
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
| | - Minah Kim
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
| | - Tae Young Lee
- Department of Neuropsychiatry, Pusan National University Yangsan Hospital, Yangsan
| | - Jun Soo Kwon
- Institute of Human Behavioral Medicine, Seoul National University Medical Research Center, Seoul
- Department of Psychiatry, Seoul National University College of Medicine, Seoul
- Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea
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Ying J, Chew QH, Wang Y, Sim K. Global Neuropsychopharmacological Prescription Trends in Adults with Schizophrenia, Clinical Correlates and Implications for Practice: A Scoping Review. Brain Sci 2023; 14:6. [PMID: 38275511 PMCID: PMC10813099 DOI: 10.3390/brainsci14010006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
It is important to examine the psychotropic prescription practices in schizophrenia, as it can inform regarding changing treatment choices and related patient profiles. No recent reviews have evaluated the global neuropsychopharmacological prescription patterns in adults with schizophrenia. A systematic search of the literature published from 2002 to 2023 found 88 empirical papers pertinent to the utilization of psychotropic agents. Globally, there were wide inter-country and inter-regional variations in the prescription of psychotropic agents. Overall, over time there was an absolute increase in the prescription rate of second-generation antipsychotics (up to 50%), mood stabilizers (up to 15%), and antidepressants (up to 17%), with an observed absolute decrease in the rate of antipsychotic polypharmacy (up to 15%), use of high dose antipsychotic (up to 12% in Asia), clozapine (up to 9%) and antipsychotic long-acting injectables (up to 10%). Prescription patterns were mainly associated with specific socio-demographic (such as age), illness (such as illness duration), and treatment factors (such as adherence). Further work, including more evidence in adjunctive neuropsychopharmacological treatments, pharmaco-economic considerations, and examination of cohorts in prospective studies, can proffer insights into changing prescription trends relevant to different treatment settings and predictors of such trends for enhancement of clinical management in schizophrenia.
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Affiliation(s)
- Jiangbo Ying
- East Region, Institute of Mental Health, Singapore 539747, Singapore
| | - Qian Hui Chew
- Research Division, Institute of Mental Health, Singapore 539747, Singapore
| | - Yuxi Wang
- East Region, Institute of Mental Health, Singapore 539747, Singapore
| | - Kang Sim
- West Region, Institute of Mental Health, Singapore 539747, Singapore
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Alsabhan JF, Almalag HM, Aljafali L, Alnughamish H, Almutlaq G. Prescribing pattern of antipsychotics for patients with schizophrenia using the total daily dose online tool. Saudi Pharm J 2023; 31:101837. [PMID: 38033746 PMCID: PMC10682108 DOI: 10.1016/j.jsps.2023.101837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/18/2023] [Indexed: 12/02/2023] Open
Abstract
This study aimed to investigate the prescribing pattern of antipsychotic medications for schizophrenia using the British National Formulary total daily dose (TDD) online tool. We analysed data from the electronic medical records at King Khalid University Hospital (KKUH) of 272 patients diagnosed with schizophrenia who were prescribed both typical and atypical antipsychotic medications. The results showed that aripiprazole was the most commonly prescribed antipsychotic drug, followed by haloperidol then risperidone. The TDD online tool was used to calculate the TDD of each prescribed antipsychotic medication. Most patients were prescribed doses within the recommended range for each medication, although some were prescribed doses above or below the recommended range. Moreover, a high recommended TDD was associated with the combined use of antipsychotics rather than monotherapy. Additionally, high TDD levels were associated with the following antipsychotics: haloperidol, olanzapine, paliperidone, and quetiapine. Our findings highlight the importance of using evidence-based tools such as the TDD online tool to guide prescribing practices and ensure optimal dosing of antipsychotic medications for patients with schizophrenia.
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Affiliation(s)
- Jawza F Alsabhan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Haya M Almalag
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Lubna Aljafali
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hessa Alnughamish
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Gaida Almutlaq
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Lin CH, Huang CJ, Lin TC, Chan HY, Chen JJ. Schizophrenia patients discharged on antipsychotic polypharmacy from a public psychiatric hospital in Taiwan, 2006-2021. Psychiatry Res 2023; 330:115575. [PMID: 37913621 DOI: 10.1016/j.psychres.2023.115575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/22/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
The aim of this study was to identify the factors associated with antipsychotic polypharmacy (APP), investigate whether APP could affect the risk of rehospitalization, and explore temporal trends in APP use. Schizophrenia patients discharged from the study hospital between 2006 and 2021 (n = 16,722) were included in the analysis. The logistic regression model was employed to determine the predictors significantly associated with APP use. Survival analysis was used to compare time to rehospitalization between APP and antipsychotic monotherapy (AMT). The temporal trend of APP use was analyzed using the Cochran-Armitage Trend test. In comparison with the patients (n = 10,909) who were discharged on AMT, those (n = 5,813) on APP were significantly more likely to be male gender, to receive LAIs, to take clozapine, to take anticholinergic agents, to have a greater number of previous hospitalizations, and to have a higher CPZ equivalent dose of antipsychotic prescription. The prescription rate of APP significantly increased from 18.4 % in 2006 to 44.9 % in 2021. Compared with AMT, APP was associated with more clozapine use, more LAI use, higher doses of antipsychotics, and an increased risk of rehospitalization. In addition, the prescription of APP continued to increase during the study period.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chun-Jen Huang
- Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ta-Chun Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan, Taiwan; Department of Psychiatry, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Jiahn-Jyh Chen
- Department of General Psychiatry, Taoyuan Psychiatric Center, Taoyuan, Taiwan
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Lassen S, Heintz T, Pedersen T, Jentz C, Nathanielsen N, Heilmann P, Sørensen LU. Nationwide study on antipsychotic polypharmacy among forensic psychiatric patients. Int J Circumpolar Health 2023; 82:2218654. [PMID: 37300837 DOI: 10.1080/22423982.2023.2218654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
This nationwide retrospective cross-sectional study examines the prevalence of antipsychotic polypharmacy (APP) and demographic, forensic, and clinical factors associated with its practice among Greenlandic forensic psychiatric patients. We collected data from electronic patient files, court documents, and forensic psychiatric assessments. We defined APP as two or more concurrent prescriptions of antipsychotic medication. The study population of 74 patients had a mean age of 41.4 years, and 61 were men. All included patients had either schizophrenia or another ICD-10 F2-diagnosis. We used unpaired t-tests and Chi2 or Fisher's exact test. The prevalence of APP was 35% (n = 26), and there was a significant association between APP and a prescription of clozapine (Chi2, p = 0.010), olanzapine (Fisher's test, p = 0.003), and aripiprazole (Fisher's test, p = 0.013). Furthermore, we found a significant association between APP and prescription of a first-generation antipsychotic (FGA) (Chi2, p = 0.011). Despite recommendations in guidelines, the use of APP is common practice. The majority of forensic psychiatric patients suffer from severe psychiatric disorders, often with other comorbidities, including substance use disorder. The severity and complexity in mental health render forensic psychiatric patients at high risk of APP treatment. Further knowledge on APP use is crucial to secure and further improve the psychopharmacological treatment for this group of patients.
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Affiliation(s)
- Stine Lassen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Thale Heintz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Tilde Pedersen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Christian Jentz
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Naaja Nathanielsen
- The Directorate of Correctional Services, Prison and Probation Service, Nuuk, Greenland
| | | | - Lisbeth Uhrskov Sørensen
- Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
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Lin TC, Lin CH. Schizophrenia Patients Discharged on Clozapine Plus Long-Acting Injectable Antipsychotics From a Public Psychiatric Hospital in Taiwan, 2006-2021. Int J Neuropsychopharmacol 2023; 26:808-816. [PMID: 37616565 PMCID: PMC10674076 DOI: 10.1093/ijnp/pyad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Some schizophrenia patients treated with clozapine experience an inadequate response and adherence problems. The purpose of this study was to compare time to rehospitalization within 6 months in schizophrenia patients discharged on 3 clozapine regimens. Additionally, the temporal trend of prescription rate in each group was also explored. METHODS Schizophrenia patients discharged from the study hospital from January 1, 2006, to December 31, 2021, (n = 3271) were included in the analysis. The type of clozapine prescribed at discharge was divided into 3 groups: clozapine plus long-acting injectable antipsychotics (clozapine + LAIs), clozapine plus other oral antipsychotics (clozapine + OAPs), and clozapine monotherapy. Survival analysis was used to compare time to rehospitalization within 6 months after discharge among the 3 groups. The temporal trend in the prescription rate of each group was analyzed using the Cochran-Armitage Trend test. RESULTS Patients discharged on clozapine + LAIs had a significantly longer time to rehospitalization than those on clozapine + OAPs or clozapine monotherapy. The prescription rates of clozapine + LAIs and clozapine + OAPs significantly increased over time, whereas the prescription rates of clozapine monotherapy significantly decreased. CONCLUSIONS Compared with the clozapine + OAPs group, the clozapine + LAIs group had a lower risk of rehospitalization and a lower dose of clozapine prescribed. Therefore, if a second antipsychotic is required for patients who are taking clozapine alone, LAIs should be considered earlier.
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Affiliation(s)
- Ta-Chun Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
- Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
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Luthra S, Duggan L, Agrawal A, Kaur G, Luthra N. Prevalence of High-dose Antipsychotic Prescribing in Schizophrenia: A Clinical Audit in a Regional Queensland Mental Health Service. Int J Appl Basic Med Res 2023; 13:70-76. [PMID: 37614838 PMCID: PMC10443448 DOI: 10.4103/ijabmr.ijabmr_504_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/19/2023] [Accepted: 04/19/2023] [Indexed: 08/25/2023] Open
Abstract
Background Antipsychotic medication is widely recognized as a critical intervention in both acute and ongoing treatments of schizophrenia. Guidelines endorse the routine practice of monotherapy with antipsychotic medication at the minimum effective dose. Despite the recommendations, high-dose antipsychotic prescribing and polytherapy appear to be common practice. Objective The objective of this study was to determine the prevalence of high-dose antipsychotic prescribing in adult patients with schizophrenia in a regional Queensland hospital and to know if the prescribing practices are in keeping with the international guidelines and with the local policy introduced in December 2017. Methods This was a cross-sectional survey/clinical audit of 358 adult patients with schizophrenia open to the service in both community and inpatient settings. The individual prescribing practices of psychiatrists were also examined. Results A minority (15%) were prescribed high doses (high-dose single agent and high dose by polytherapy) and 20% were prescribed polytherapy (including high dose and within normal dose range). Conclusion Eighty-five percent of the patients with the diagnosis of schizophrenia open to the service were prescribed antipsychotic within the dose range. In this respect, prescribing was aligned with current evidence-based guidelines.
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Affiliation(s)
- Shalini Luthra
- Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Lorna Duggan
- Mental Health Alcohol and Other Drugs Services, Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Aanchal Agrawal
- Central Queensland Hospital and Health Service, Rockhampton, Australia
| | - Gurpreeti Kaur
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Neeru Luthra
- Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Soliman G, LaCaze A. Psychotropic medicines are frequently dosed outside recommended ranges: a clinical audit in an Australian mental health hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ghadir Soliman
- Department of Pharmacy St John of God Richmond Hospital North Richmond Australia
| | - Adam LaCaze
- School of Pharmacy and Pharmacology The University of Queensland Brisbane Australia
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Hu J, McMillan SS, Theodoros T, Collins JC, El-Den S, O’Reilly CL, Wheeler AJ. Psychotropic medication use in people living with severe and persistent mental illness in the Australian community: a cross-sectional study. BMC Psychiatry 2022; 22:705. [PMID: 36380352 PMCID: PMC9667665 DOI: 10.1186/s12888-022-04324-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Psychotropic polypharmacy and high-dose prescribing may play a role in therapy, however, with associated risks. The aim of this study was to describe current prescribing practices and use of four psychotropic medication groups (antipsychotics, antidepressants, mood stabilisers and benzodiazepines), focusing on polypharmacy (across and within groups) and high-dose prescribing in adults experiencing severe and persistent mental illness (SPMI) in the Australian community. METHODS 318 people taking psychotropic medication for SPMI had a medication review undertaken by a community pharmacist. Participants were recruited as part of an RCT from three Australian states/territories between September 2020-July 2021. All psychotropic medication and daily doses were recorded and reviewed for alignment with current clinical guidelines. Univariate and multiple logistic regression models investigated factors associated with antipsychotic, antidepressant, and mood stabiliser polypharmacy, and antipsychotic and antidepressant high-dose therapy. Variables included age, gender, geographic location, self- reported mental illness(es), hospital admission(s) in previous 6-months and prescriber type. RESULTS 806 psychotropic medications were prescribed for the 318 participants. Mood stabiliser polypharmacy was recorded in 19.0% of participants prescribed mood stabilisers; antipsychotic polypharmacy in 18.4% of participants prescribed antipsychotics; antidepressant polypharmacy in 11.3% of those prescribed antidepressants; and three participants (5.1%) were prescribed two benzodiazepines concurrently. Almost 18.6% of the cohort was receiving high-dose treatment; 18 participants were prescribed high-dose antipsychotics and 39 high-dose antidepressants, with two participants prescribed both. Adjusted logistic regression for polypharmacy found male gender, psychiatrist as sole prescriber, or multiple prescribers, were associated with antipsychotic polypharmacy. The adjusted model for high-dose therapy found psychiatrist as sole prescriber was significantly associated with antipsychotic and antidepressant high-dose prescribing. CONCLUSION Psychotropic polypharmacy was common in this community cohort experiencing SPMI. Whilst polypharmacy is not always inappropriate, it is a complex construct with potential benefits alongside potential risks. Benefits and harms need to be balanced however this practice is not supported by clear guidance to assist health practitioners. This study highlights the important need for regular medication reviews and strengthened communication between consumers and all healthcare professionals involved in community mental health care, to support safe and effective use of psychotropic medications.
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Affiliation(s)
- Jie Hu
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Sara S McMillan
- grid.1022.10000 0004 0437 5432Menzies Health Institute Queensland, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432School of Pharmacy and Medical Sciences, Griffith University, Brisbane, Australia ,grid.1022.10000 0004 0437 5432Centre for Mental Health, Griffith University, Nathan campus, 4111 Brisbane, Australia
| | - Theo Theodoros
- grid.1003.20000 0000 9320 7537University of Queensland Faculty of Medicine, Brisbane, Australia ,Metro South Mental Health Services, Brisbane, Australia
| | - Jack C Collins
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Sarira El-Den
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Claire L O’Reilly
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney School of Pharmacy, University of Sydney, Sydney, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia. .,Centre for Mental Health, Griffith University, Nathan campus, 4111, Brisbane, Australia. .,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Marchi M, Galli G, Fiore G, Mackinnon A, Mattei G, Starace F, Galeazzi GM. Machine-Learning for Prescription Patterns: Random Forest in the Prediction of Dose and Number of Antipsychotics Prescribed to People with Schizophrenia. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:450-461. [PMID: 35879029 PMCID: PMC9329108 DOI: 10.9758/cpn.2022.20.3.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 11/18/2022]
Abstract
Objective We aimed to predict antipsychotic prescription patterns for people with schizophrenia using machine learning (ML) algorithms. Methods In a cross-sectional design, a sample of community mental health service users (SUs; n = 368) with a primary diagnosis of schizophrenia was randomly selected. Socio-demographic and clinical features, including the number, total dose, and route of administration of the antipsychotic treatment were recorded. Information about the number and the length of psychiatric hospitalization was retrieved. Ordinary Least Square (OLS) regression and ML algorithms (i.e., random forest [RF], supported vector machine, K-nearest neighborhood, and Naïve Bayes) were used to estimate the predictors of total antipsychotic dosage and prescription of antipsychotic polytherapy (APP). Results The strongest predictor of the total dose was APP. The number of Community Mental Health Centers (CMHC) contacts was the most important predictor of APP and, with APP omitted, of dosage. Treatment with anticholinergics predicted APP, emphasizing the strong correlation between APP and higher antipsychotic dose. RF performed better than OLS regression and the other ML algorithms in predicting both antipsychotic dose (root square mean error = 0.70, R2 = 0.31) and APP (area under the receiving operator curve = 0.66, true positive rate = 0.41, and true negative rate = 0.78). Conclusion APP is associated with the prescription of higher total doses of antipsychotics. Frequent attenders at CMHCs, and SUs recently hospitalized are often treated with APP and higher doses of antipsychotics. Future prospective studies incorporating standardized clinical assessments for both psychopathological severity and treatment efficacy are needed to confirm these findings.
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Affiliation(s)
- Mattia Marchi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giacomo Galli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianluca Fiore
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrew Mackinnon
- Black Dog Institute, University of New South Wales, Sydney, NSW, Australia
| | - Giorgio Mattei
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Starace
- Department of Mental Health and Drug Abuse, Azienda Unità Sanitaria Locale (AUSL) Modena, Modena, Italy
| | - Gian M. Galeazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Department of Mental Health and Drug Abuse, Azienda Unità Sanitaria Locale (AUSL) Modena, Modena, Italy
- Dipartimento di Salute Mentale e Dipendenze Patologiche, AUSL-IRCSS di Reggio Emilia, Reggio Emilia, Italy
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Mandarelli G, Carabellese F, Di Sciascio G, Catanesi R. Antipsychotic Polypharmacy and High-Dose Antipsychotic Regimens in the Residential Italian Forensic Psychiatric Population (REMS). Front Psychol 2022; 13:722985. [PMID: 35222172 PMCID: PMC8866699 DOI: 10.3389/fpsyg.2022.722985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Few data exist regarding treatment with antipsychotics in forensic psychiatric patient populations with high social dangerousness. We performed a secondary analysis of 681 patients treated with at least one antipsychotic, extracted from a 1-year observational retrospective study, conducted on 730 patients treated in the Italian Residencies for Execution of Security Measures (REMS) (96.4% of the REMS population). We aimed at investigating antipsychotic polypharmacy (prescription of two or more concomitant antipsychotics) and high dose/very high-dose antipsychotics, as well as the possible factors associated with such therapeutic regimens. High dose/very high-dose antipsychotics were defined as a prescribed daily dose to WHO-defined daily dose ratio greater than 1.5 or 3.0, respectively. Binary logistic regression analysis was used in three models to test possible predictors of antipsychotic polypharmacy, high-dose antipsychotics, and very high-dose antipsychotic prescription. Antipsychotic polypharmacy resulted in n = 308 (45.2%) of the patients, n = 346 (50.8%) received high-dose antipsychotics, and n = 96 (14.1%) very high-dose antipsychotics. The multivariate analysis disclosed an association between antipsychotic polypharmacy and male gender (odds ratio (OR): 2.75 and 95% CI: 1.34–5.65), long-acting injectable (LAI) antipsychotic prescription (OR: 2.62 and 95% CI: 1.84–3.74), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.13–2.36). High-dose antipsychotics were also associated with male gender (OR: 2.01 and 95% CI: 1.02–3.95), LAI antipsychotic prescription (OR: 2.78 and 95% CI: 1.95–3.97), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.12–2.36). The use of antipsychotic polypharmacy and high-dose antipsychotics is frequent in the REMS population. These results might depend on regulatory and organizational aspects of the REMS system, including variability in structures, lack of a common model of care, and lack of stratified therapeutic security.
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Affiliation(s)
- Gabriele Mandarelli
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
- *Correspondence: Gabriele Mandarelli,
| | - Felice Carabellese
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
| | | | - Roberto Catanesi
- Interdisciplinary Department of Medicine, Section of Criminology and Forensic Psychiatry, University of Bari “Aldo Moro”, Bari, Italy
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Kim JJ, Pae CU, Han C, Bahk WM, Lee SJ, Patkar AA, Masand PS. Exploring Hidden Issues in the Use of Antipsychotic Polypharmacy in the Treatment of Schizophrenia. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:600-609. [PMID: 34690115 PMCID: PMC8553537 DOI: 10.9758/cpn.2021.19.4.600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 12/23/2022]
Abstract
The mainstay of schizophrenia treatment is pharmacological therapy using various antipsychotics including first- and second-generation antipsychotics which have different pharmacokinetic and pharmacodynamic property leading to differential presentation of adverse events (AEs) and treatment effects such as negative symptoms, cognitive symptoms and cormorbid symptoms. Major treatment guidelines suggest the use of antipsychotic monotherapy (APM) as a gold standard in the treatment of schizophrenia. However, the effects of APM is inadequate and less potent to achieve symptom remission as well as functional recovery in real practice which has been consistently reported in numerous controlled clinical trials, large practical trials, independent small studies and systematic reviews till today. Therefore anti-psychotic polypharmacy (APP) regardless of the class of antipsychotics has been also commonly utilized for many reasons in real world practice. However, APP has also crucial pitfalls including increase of total psychotics including antipsychotics, high-doses of antipsychotics used, poor compliance, drug-drug interaction and risks for developing AEs, all of which are paradoxically related to poor clinical outcomes, whereas APP has also substantial advantages in reduction of re-hospitalization, severe psychopathology and targeted control of concurrent symptoms. Given currently limited therapeutic options, it is also important to properly utilize APP in order to maximize its clinical utility and minimize its risk for better treatment outcomes for patients with schizophrenia, based on risk/benefit with full understanding of pharmacological and clinical issues on APP. The present paper intends to address intriguing and important issues in the use of APP in real world practice.
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Affiliation(s)
- Jung-Jin Kim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Jung Lee
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
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Japanese Society of Neuropsychopharmacology: "Guideline for Pharmacological Therapy of Schizophrenia". Neuropsychopharmacol Rep 2021; 41:266-324. [PMID: 34390232 PMCID: PMC8411321 DOI: 10.1002/npr2.12193] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022] Open
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Pae CU, Han C, Bahk WM, Lee SJ, Patkar AA, Masand PS. Consideration of Long-Acting Injectable Antipsychotics for Polypharmacy Regimen in the Treatment of Schizophrenia: Put It on the Table or Not? CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:434-448. [PMID: 34294613 PMCID: PMC8316655 DOI: 10.9758/cpn.2021.19.3.434] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Antipsychotic monotherapy (APM) is considered best-acceptable treatment option regardless of antipsychotic class and formulation types for treating schizophrenia. However, antipsychotic polypharmacy (APP) has been also widely utilized in routine clinical practice. Despite APP has some clinical benefits it has also numerous pitfalls in relation with increased total number and doses of APs leading to adverse events as well as decrease of treatment adherence and persistence resulting in poor clinical outcomes. Recent introduction of long-acting injectable antipsychotics (LAIs) to the market has offered a chance for better medication adherence/persistence and also provided a simplification of treatment regime leading to more stabilized treatment for schizophrenia patients. When we cannot stay away from APP in the treatment of schizophrenia, clinicians need to find more proper APP regimens and thereby utilization of APP in efficient way should be a practical strategy to benefit schizophrenia patient in a real world treatment setting. With this regard, LAIs can be one of available APP regimen for treatment of schizophrenia in routine practice since their clinical utility and pharmacokinetic stability over oral APs have been well-elaborated today. However, when we have to commence LAIs as a part of APP with oral APs or other LAIs, every effort should be made before doing so whether or not validated and available treatment options or other clinical factors were not done or evaluated yet. Any treatment guidelines do not support APP regardless of the formulation of APP regimen or address two or more LAIs for treatment of schizophrenia till today.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Changsu Han
- Department of Psychiatry, Korea University College of Medicine, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Jung Lee
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ashwin A Patkar
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
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Patterns of antipsychotic prescriptions in patients with schizophrenia in China: A national survey. Asian J Psychiatr 2021; 62:102742. [PMID: 34243064 DOI: 10.1016/j.ajp.2021.102742] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/16/2021] [Accepted: 06/25/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION To investigate the patterns and correlates of antipsychotic prescriptions among recently discharged inpatients with schizophrenia in China. METHODS The study included discharged patients from 41 tertiary psychiatric hospitals in 29 provinces between March 19-30, 2019. A total of 1032 inpatients with schizophrenia were included. Socio-demographic and clinical data were retrieved from medical records upon discharge. RESULTS Patients received a total of 13 unique antipsychotic medications, which included 9 s-generation antipsychotics (SGAs) and 4 first-generation antipsychotics (FGAs). The utilization rates of SGAs and FGAs were 98.8 % and 6.1 % respectively. The three most commonly antipsychotic medications were risperidone (35.1 %), olanzapine (31.3 %), and clozapine (24.6 %). The mean chlorpromazine equivalent dose was 452.12 ± 230.74 mg/day. The utilization rate of mood stabilizers was 18.9 %, 8.8 % for antidepressants, 20.3 % for sleep improvers, and 9.9 % for anticholinergics. More than two fifths patients (43.1 %) received two or more antipsychotic medications. Predictors of antipsychotic polypharmacy included younger age, residing in Central or West China, a longer duration of illness, a history of prior hospitalizations, and having agitated behavior during the hospitalization. CONCLUSION Antipsychotic polypharmacy in China is common on inpatients settings. The proportion of antipsychotic polypharmacy in China is higher than in many other countries, despite limited data to support the efficacy of many combinations. Clozapine remains one of most commonly prescribed antipsychotics in China, either as a monotherapy or combination therapy.
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Factors predicting high-dose and combined antipsychotic prescribing in New Zealand: High-dose antipsychotic prescribing. Psychiatry Res 2021; 302:113996. [PMID: 34126462 DOI: 10.1016/j.psychres.2021.113996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 05/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Guidelines recommend using antipsychotic monotherapy at the lowest effective dose, however high-dose and antipsychotic polypharmacy prescribing (APP) remain commonplace. The aim of this study was to determine the prevalence and patterns of high-dose antipsychotic prescribing and APP among mental health service users in New Zealand (NZ). METHODS A retrospective audit of service users discharged from inpatient (n=657), or registered with community (n=1560), mental health services at Auckland District Health Board was undertaken. Case notes were reviewed and data on demographics, antipsychotic routes and doses were collected. Outcomes measures included: frequency of total high-dose prescribing, high-dose monotherapy, APP, high-dose APP, and factors associated with these prescribing practices. Logistic regression models were used to examine the relationships between explanatory and outcome variables. RESULTS Of the service users prescribed an antipsychotic (n = 2217), 14% were prescribed a high-dose antipsychotic. The frequency of high-dose monotherapy, APP, and high-dose APP was 3%, 26% and 11%, respectively. Being male, Māori, on compulsory treatment, having a schizophrenia diagnosis, or being prescribed polypharmacy were associated with high-dose antipsychotics. Olanzapine was most frequently prescribed in both high dosing (55%) and APP (40%). CONCLUSIONS There is a high prevalence of high-dose prescribing and APP in this NZ setting.
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Liu X, Sun H, Zhang Y, Sun Y, Wang W, Xu L, Liu W. Clozapine affects the pharmacokinetics of risperidone and inhibits its metabolism and P-glycoprotein-mediated transport in vivo and in vitro: A safety attention to antipsychotic polypharmacy with clozapine and risperidone. Toxicol Appl Pharmacol 2021; 422:115560. [PMID: 33957192 DOI: 10.1016/j.taap.2021.115560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 02/08/2023]
Abstract
Antipsychotic polypharmacy (APP), as one maintenance treatment strategy in patients with schizophrenia, has gained popularity in real-world clinical settings. Risperidone (RIS) and clozapine (CLZ) are the most commonly prescribed second-generation antipsychotics, and they are often used in combination as APP. In this study, the pharmacokinetics of RIS and CLZ in rats were examined after co-administration to explore the reliability and rationality of co-medication with RIS and CLZ. In addition, the effects of CLZ on RIS metabolism and transport in vitro were investigated. The results illustrated that in the 7-day continuous administration test in rats, when co-administered with CLZ, the area under curve and peak concentrations of RIS were increased by 2.2- and 3.1-fold at the first dose, respectively, increased by 3.4- and 6.2-fold at the last dose, respectively. The metabolite-to-parent ratio of RIS was approximately 22% and 33% lower than those of RIS alone group at the first and last doses, respectively. Moreover, CLZ significantly increased RIS concentrations in the brain (3.0-4.8 folds) and cerebrospinal fluid (2.1-3.5 folds) in rats, which was slightly lower than the impact of verapamil on RIS after co-medication. Experiments in vitro indicated that CLZ competitively inhibited the conversion of RIS to 9-hydroxy-RIS with the inhibition constants of 1.36 and 3.0 μM in rat and human liver microsomes, respectively. Furthermore, the efflux ratio of RIS in Caco-2 monolayers was significantly reduced by CLZ at 1 μM. Hence, CLZ may affect the exposure of RIS by inhibiting its metabolism and P-glycoprotein-mediated transport. These findings highlighted that APP with RIS and CLZ might increase the plasma concentrations of RIS and 9-hydroxy-RIS beyond the safety ranges and cause toxic side effects.
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Affiliation(s)
- Xinghua Liu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
| | - Heyuan Sun
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
| | - Yumu Zhang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
| | - Yufei Sun
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
| | - Wenyan Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China.
| | - Lixiao Xu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
| | - Wanhui Liu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai 264005, PR China
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Risk of seizures associated with antipsychotic treatment in pediatrics with psychiatric disorders: a nested case-control study in Korea. Eur Child Adolesc Psychiatry 2021; 30:391-399. [PMID: 32266577 DOI: 10.1007/s00787-020-01525-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/31/2020] [Indexed: 01/29/2023]
Abstract
Antipsychotic drugs raise seizure risk in adults, and antipsychotic drug use is increasing among pediatric psychiatric disorder patients. However, few studies have examined seizure risk in this younger patient population. To evaluate seizure risk in pediatric patients on antipsychotics, we conducted a nested case-control study using a nationwide database. Patient information was retrieved from the Korean Health Insurance Review and Assessment (HIRA) database from 2008-2018. Antipsychotic use among newly diagnosed psychiatric patients was gathered starting 1 year before the index date and categorized as recent, past, consistent, or none. Seizure cases among these patients were defined based on (1) prescription of antiepileptic drugs or (2) an electroencephalography (EEG) examination among patients with seizure diagnostic code. A conditional logistic regression model was constructed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for seizure risk due to antipsychotic use. In total, 1523 seizure cases and 6092 seizure-free controls aged 8-19 years with newly diagnosed psychiatric disorders were included for analysis. Logistic regression revealed a significant association between antipsychotic use and seizure development (recent users OR = 4.03, 95% CI 3.4-4.79; consistent users: OR = 2.84, 95% CI 2.44-3.3). Seizure risk enhanced further with an increase in the number of antipsychotic drugs used. Risperidone, aripiprazole, quetiapine, olanzapine, paliperidone, and blonanserin were independently associated with greater seizure risk. Pediatric patients receiving antipsychotics, especially new or multiple antipsychotic users, should be carefully monitored for seizure development.
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Jeon SM, Park S, Kwon S, Kwon JW. Association Between Antipsychotic Treatment and Neurological Adverse Events in Pediatric Patients: A Population-Based Cohort Study in Korea. Front Psychiatry 2021; 12:668704. [PMID: 34122182 PMCID: PMC8187563 DOI: 10.3389/fpsyt.2021.668704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Potential adverse effects might be caused by increasing the number of antipsychotic prescriptions. However, the empirical evidence regarding pediatric psychiatric patients is insufficient. Therefore, we explored the antipsychotic-induced adverse effects focusing on the neurological system. Method: Using the medical information of pediatric patients retrieved from the claims data of Health Insurance Review and Assessment in Korea, we identified those psychiatric patients who were started on antipsychotic treatment at age 2-18 years between 2010 and 2018 (n = 10,969). In this study, movement disorders and seizures were considered as major neurological adverse events. The extended Cox model with time-varying covariates was applied to explore the association between antipsychotic medication and adverse events. Findings: Total 1,894 and 1,267 cases of movement disorders and seizures occurred in 32,046 and 33,280 person-years, respectively. The hazard risks of neurological adverse events were 3-8 times higher in the exposed to antipsychotics period than in the non-exposure period. Among the exposure periods, the most dangerous period was within 30 days of cumulative exposure. High doses or polypharmacy of antipsychotics was associated with increased risks of neurological adverse events. Among individual antipsychotics, haloperidol showed the highest risk of developing movement disorders among the examined agents. Quetiapine showed a lower risk of developing movement disorders but a higher risk of developing seizures than risperidone. Conclusion: These findings suggest that antipsychotics should be used with caution in pediatric patients, especially regarding initial exposure, high dose, and polypharmacy.
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Affiliation(s)
- Soo Min Jeon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
| | - Susan Park
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
| | - Soonhak Kwon
- Department of Pediatric Neurology, Kyung-pook National University Children's Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Jin-Won Kwon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, South Korea
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Pae CU. Antipsychotic Polypharmacy in Treatment of Schizophrenia; Should or Should Not? Chonnam Med J 2020; 56:157-165. [PMID: 33014754 PMCID: PMC7520369 DOI: 10.4068/cmj.2020.56.3.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022] Open
Abstract
Antipsychotics have been utilized as the standard treatment for schizophrenia regardless of illness phase where antipsychotic monotherapy (APM) is routinely recommended as the gold standard rather than antipsychotic polypharmacy (APP). However, approximately 20 to 40% of patients with schizophrenia do not respond to APM based on randomized controlled clinical trials and large practical clinical trials indicating that the subgroup of patients with schizophrenia would need differential treatment approaches beyond traditional treatment strategies such as APM. Numerous studies have supported the use of APP in particular for patients with certain clinical situations including: failure to show efficacy or tolerability from treatment with APM, need for different treatment for targeting specific symptom domains, severe illness, failure to treatment with clozapine, skepticism about following treatment guidelines, or cross titration periods. Furthermore, recent large cohort studies and practical clinical trials have proposed more benefits of APP rather than APM in terms of rehospitalization, mortality, and specific symptoms. APP has recently become more widely utilized and recognized as one of the next treatment strategies to clinicians for patients with schizophrenia. Some experts have already proposed the revision of treatment guidelines incorporating APP as evidence-based treatment option for certain patients with schizophrenia. Taken together, APP now deserves an evidence-based and acceptable treatment strategy, not an empirical or preferential treatment approach for treatment of schizophrenia in contemporary clinical practice.
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Affiliation(s)
- Chi-Un Pae
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Cell Death Disease Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Buhagiar K, Templeton G, Blyth H, Dey M, Giacco D. Mortality risk from long-term treatment with antipsychotic polypharmacy vs monotherapy among adults with serious mental illness: A systematic review and meta-analysis of observational studies. Schizophr Res 2020; 223:18-28. [PMID: 32948381 DOI: 10.1016/j.schres.2020.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/21/2020] [Accepted: 08/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term use of more than one concurrent antipsychotic [antipsychotic polypharmacy (APP)] is widely believed to contribute to excess mortality in people with serious mental illness (SMI) compared to those taking only one antipsychotic (monotherapy). However, no conclusive evidence is available. METHODS We conducted a systematic search in 6 major electronic databases from inception until December 2019, identifying observational studies examining the association between mortality and exposure to long-term APP vs monotherapy. Studies were eligible if they adopted a follow-up design and antipsychotic exposure was >3 months among adults with SMI. We determined the pooled mortality risk using random-effects meta-analyses. The review was registered in PROSPERO (CRD42019148044). RESULTS A total of 12 studies fulfilled all eligibility criteria reporting quantitative data for 834, 534 person years. No difference was found in the association between all-cause mortality and APP vs monotherapy use, in both crude (rate ratio = 0.94, 95% CI 0.81-1.10, p = 0.446; I2 = 83.2%, p < 0.001; 10 studies) and adjusted models (adjusted HR = 0.98, 95% CI 0.80-1.19, p = 0.802; I2 = 58.3%, p < 0.05; 5 studies). Meta-regression did not identify any moderators influencing all-cause mortality risk. For natural causes of death, risk estimates followed the same pattern: (i) crude rate ratio = 0.88, 95% CI 0.67-1.14, p = 0.324; I2 = 77.7%, p = 0.01 (5 studies); (ii) adjusted HR = 1.04, 95% CI 0.90-1.99, p = 0.590; I2 = 0.0%, p = 0.744 (5 studies). CONCLUSION Mortality risk of APP use in people with SMI appears to be comparable to that of monotherapy use, although work to date remains heterogeneous, precluding firm conclusions from made. Complex real-world clinical scenarios may be contributing to this lack of variation between these two types of antipsychotic use.
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Affiliation(s)
- Kurt Buhagiar
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Georgia Templeton
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Henrietta Blyth
- Department of Research, Innovation and Medical Education, East London NHS Foundation Trust, London, UK.
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Domenico Giacco
- Unit for Social & Community Psychiatry, Queen Mary University of London, London, UK; Warwick Medical School, University of Warwick, Coventry, UK.
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Northwood K, Theodoros T, Wang N, Siskind D. High-dose antipsychotic therapy and reflective prescribing: development of an online tool for rapid, easy calculation of antipsychotic total daily dose. Australas Psychiatry 2020; 28:410-413. [PMID: 32391726 DOI: 10.1177/1039856220917080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Safe and effective antipsychotic prescribing is a fundamental skill in psychiatric practice; however, antipsychotic medications are not without risk. These risks are increased when antipsychotics are prescribed in high doses, with or without polypharmacy. Decision-making regarding antipsychotic prescribing can be hampered by a lack of readily available or easily approachable tools for calculating and interpreting total daily doses, especially when antipsychotic polypharmacy is involved. Our objective was to create an accessible method for calculating antipsychotic total daily dosing. METHODS We have developed an online calculator for determining antipsychotic total daily dose using information on recommended maximum total daily dosing based on the British National Formulary. RESULTS This calculator is free, easy to implement and allows for users to input a large variety of possible antipsychotic dosing regimens. CONCLUSIONS It is hoped that this tool will allow clinicians to readily review their prescribing practice, inform decision-making and improve patient safety outcomes. Further research may be appropriate to determine the impact of this tool on these intended goals.
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Affiliation(s)
| | - Theo Theodoros
- Metro South Addiction and Mental Health Services, Australia
| | - Nancy Wang
- Metro South Addiction and Mental Health Services, Australia
| | - Dan Siskind
- Metro South Addiction and Mental Health Services, Australia.,University of Queensland, School of Clinical Medicine, Australia
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Takahashi T, Otsubo T, Kunisawa S, Sasaki N, Imanaka Y. Factors associated with high-dose antipsychotic prescriptions in outpatients with schizophrenia: An analysis of claims data from a Japanese prefecture. Neuropsychopharmacol Rep 2020; 40:224-231. [PMID: 32452649 PMCID: PMC7722669 DOI: 10.1002/npr2.12109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 02/17/2020] [Accepted: 02/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background Antipsychotics are commonly prescribed in high doses in combination with multiple psychotropic drugs. This study focused on the high‐dose antipsychotic prescriptions in patients with schizophrenia, while aiming to identify their associations with patients’ characteristics and concurrent psychotropic prescriptions. Methods This cross‐sectional study used claims data from a prefecture in Japan, between October 2014 and March 2015, to investigate antipsychotic prescriptions in adult outpatients with schizophrenia. The objective variable was the presence/absence of a high‐dose prescription. The explanatory variables included sex, age (category), presence of comorbid conditions, and the use of psychiatrist's therapy. Results After exclusion, a total of 13 471 patients with schizophrenia were analyzed. The frequency of high‐dose prescriptions was higher in men, with chlorpromazine‐equivalent values highest in the age ranges of 45‐54 and 35‐44 years for men and women, respectively. Patients aged below 65 years with cerebrovascular diseases showed a decrease in high‐dose prescriptions. There was a high frequency of polypharmacy psychotropic drug use in combination with a high‐dose antipsychotic prescription in patients aged below 65 years. Conclusion High‐dose antipsychotics are often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care. This study aimed to identify the association between concurrent psychotropic prescriptions and high‐dose antipsychotic prescriptions in patients with schizophrenia in Japan. In this study, high‐dose antipsychotics were often used in combination with several psychotropic agents in patients with schizophrenia. Our findings emphasize the need to evaluate the prescribing behavior of physicians to avoid high‐dose antipsychotic prescriptions for improved patient care.
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Affiliation(s)
- Tatsuichiro Takahashi
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsuya Otsubo
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, Kyoto, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Noriko Sasaki
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Meftah AM, Deckler E, Citrome L, Kantrowitz JT. New discoveries for an old drug: a review of recent olanzapine research. Postgrad Med 2020; 132:80-90. [DOI: 10.1080/00325481.2019.1701823] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Amir M Meftah
- Department of Psychiatry, Columbia University, New York, NY, USA
- Schizophrenia Research, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Elizabeth Deckler
- Department of Psychiatry, Columbia University, New York, NY, USA
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Leslie Citrome
- Department of Psychiatry, New York Medical College, Valhalla, NY, USA
| | - Joshua T Kantrowitz
- Department of Psychiatry, Columbia University, New York, NY, USA
- Schizophrenia Research, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY, USA
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Nguyen ML, Sunderland B, Lim S, Hattingh L, Chalmers L. The hidden magnitude of polypharmacy: using defined daily doses and maximum licensed daily doses to measure antipsychotic load. Int J Clin Pharm 2019; 41:1642-1651. [DOI: 10.1007/s11096-019-00930-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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Kadra G, Spiros A, Shetty H, Iqbal E, Hayes RD, Stewart R, Geerts H. Predicting parkinsonism side-effects of antipsychotic polypharmacy prescribed in secondary mental healthcare. J Psychopharmacol 2018; 32:1191-1196. [PMID: 30232932 PMCID: PMC6238161 DOI: 10.1177/0269881118796809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Computer-modelling approaches have the potential to predict the interactions between different antipsychotics and provide guidance for polypharmacy. AIMS To evaluate the accuracy of the quantitative systems pharmacology platform to predict parkinsonism side-effects in patients prescribed antipsychotic polypharmacy. METHODS Using anonymized data from South London and Maudsley NHS Foundation Trust electronic health records we applied quantitative systems pharmacology, a neurophysiology-based computer model of humanized neuronal circuits, to predict the risk for parkinsonism symptoms in patients with schizophrenia prescribed two concomitant antipsychotics. The performance of the quantitative systems pharmacology model was compared with the performance of simple parameters such as: combination of affinity constants (1/Ksum); sum of D2R occupancies (D2R) and chlorpromazine equivalent dose. RESULTS We identified 832 patients with schizophrenia who were receiving two antipsychotics for six or more months, between 1 January 2007 and 31 December 2014. The area under the receiver operating characteristic (AUROC) curve for the quantitative systems pharmacology model was 0.66 ( p = 0.01), while AUROCs for D2R, 1/Ksum and chlorpromazine equivalent dose were 0.52 ( p = 0.350), 0.53 ( p = 0.347) and 0.52 ( p = 0.330) respectively. CONCLUSION Our results indicate that quantitative systems pharmacology has the potential to predict the risk of parkinsonism associated with antipsychotic polypharmacy from minimal source information, and thus might have potential decision-support applicability in clinical settings.
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Affiliation(s)
- Giouliana Kadra
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK,Giouliana Kadra, BRC Neucleus, Mapother House, De Crespigny Park, IOPPN, King’s College London, London, SE5 8AF, UK.
| | | | - Hitesh Shetty
- South London and Maudsley NHS Trust, BRC Nucleus, London, UK
| | - Ehtesham Iqbal
- King’s College London, SGDP, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Richard D Hayes
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Robert Stewart
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK,South London and Maudsley NHS Trust, BRC Nucleus, London, UK
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Kadra G, Stewart R, Shetty H, MacCabe JH, Chang C, Taylor D, Hayes RD. Long-term antipsychotic polypharmacy prescribing in secondary mental health care and the risk of mortality. Acta Psychiatr Scand 2018; 138:123-132. [PMID: 29845597 PMCID: PMC6099447 DOI: 10.1111/acps.12906] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate the association between long-term antipsychotic polypharmacy use and mortality; and determine whether this risk varies by cause of death and antipsychotic dose. METHODS Using data from a large anonymised mental healthcare database, we identified all adult patients with serious mental illness (SMI) who had been prescribed a single antipsychotic or polypharmacy, for six or more months between 2007 and 2014. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical factors and smoking, to examine the association between APP use and the risk of death. RESULTS We identified 10 945 adults with SMI who had been prescribed long-term antipsychotic monotherapy (76.9%) or APP (23.1%). Patients on long-term APP had a small elevated risk of mortality, which was significant in some but not all models. The adjusted hazard ratios for death from natural and unnatural causes associated with APP were 1.2 (0.9-1.4, P = 0.111) and 1.1 (0.7-1.9, P = 0.619) respectively. The strengths of the associations between APP and mortality outcomes were similar after further adjusting for % BNF antipsychotic dose (P = 0.031) or olanzapine equivalence (P = 0.088). CONCLUSION The findings suggest that the effect of long-term APP on mortality is not clear-cut, with limited evidence to indicate an association, even after controlling for the effect of dose.
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Affiliation(s)
- G. Kadra
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - R. Stewart
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
- South London and Maudsley NHS Foundation TrustLondonUK
| | - H. Shetty
- South London and Maudsley NHS Foundation TrustLondonUK
| | - J. H. MacCabe
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - C.‐K. Chang
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - D. Taylor
- South London and Maudsley NHS Foundation TrustLondonUK
| | - R. D. Hayes
- Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
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Risk of weight gain for specific antipsychotic drugs: a meta-analysis. NPJ SCHIZOPHRENIA 2018; 4:12. [PMID: 29950586 PMCID: PMC6021430 DOI: 10.1038/s41537-018-0053-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 12/04/2022]
Abstract
People with schizophrenia are at considerably higher risk of cardiometabolic morbidity than the general population. Second-generation antipsychotic drugs contribute to that risk partly through their weight gain effects, exacerbating an already high burden of disease. While standard ‘as-randomized’ analyses of clinical trials provide valuable information, they ignore adherence patterns across treatment arms, confounding estimates of realized treatment exposure on outcome. We assess the effect of specific second-generation antipsychotics on weight gain, defined as at least a 7% increase in weight from randomization, using a Bayesian hierarchical model network meta-analysis with individual patient level data. Our data consisted of 14 randomized clinical trials contributing 5923 subjects (mean age = 39 [SD = 12]) assessing various combinations of olanzapine (n = 533), paliperidone (n = 3482), risperidone (n = 540), and placebo (n = 1368). The median time from randomization to dropout or trial completion was 6 weeks (range: 0–60 weeks). The unadjusted probability of weight gain in the placebo group was 4.8% across trials. For each 10 g chlorpromazine equivalent dose increase in olanzapine, the odds of weight gain increased by 5 (95% credible interval: 1.4, 5.3); the effect of risperidone (odds ratio = 1.6 [0.25, 9.1]) was estimated with considerable uncertainty but no different from paliperidone (odds ratio = 1.3 [1.2, 1.5]). People taking a commonly prescribed antipsychotic to treat schizophrenia have an increased risk of weight gain. Sharon-Lise Normand of Harvard Medical School in the US and colleagues analysed data from 14 randomized control trials representing almost 6000 people taking one of three antipsychotic drugs for schizophrenia, or a placebo. Using a unique statistical approach, they found that people taking the drug olanzapine had the highest risk of weight gain. People taking paliperidone had only a small risk, while there was uncertainty regarding the drug riperidone. Antipsychotic drugs can often be taken for decades, so understanding their cummulative effects on patient health is crucial to improving quality of life and preventing premature mortality. The method used in this study is unique and could be used to analyse other aspects of drug use.
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Lin CH, Wang FC, Lin SC, Huang YH, Chen CC. A randomized, double-blind, comparison of the efficacy and safety of low-dose olanzapine plus low-dose trifluoperazine versus full-dose olanzapine in the acute treatment of schizophrenia. Schizophr Res 2017; 185:80-87. [PMID: 28109665 DOI: 10.1016/j.schres.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 11/26/2016] [Accepted: 01/03/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Antipsychotic polypharmacy is common in clinical practice, but not recommended in guidelines for treating schizophrenia patients. This study aimed to compare the efficacy and safety of low-dose olanzapine plus low-dose trifluoperazine (a first-generation antipsychotic [FGA]) to full-dose olanzapine (a second-generation antipsychotic [SGA]) in the treatment of acute schizophrenia. METHOD In this 6-week, double-blind, fixed-dose study, patients were randomized to receive 5mg/day of olanzapine plus 5mg/day of trifluoperazine or 10mg/day of olanzapine for 6weeks. Efficacy measures, including the Positive and Negative Syndrome Scale (PANSS) and other scales, safety measures, side effect measures, and quality of life were assessed regularly. Response was defined as at least a 30% reduction in the PANSS total score. RESULTS Both groups were similar in: 1) baseline characteristics, 2) score changes in all efficacy measures, safety measures, side effect measures, and quality of life, and 3) response rates at each visit. The polypharmacy group with low-dose olanzapine did not have less weight gain and lower lipid levels than the monotherapy group with full-dose olanzapine. CONCLUSION Polypharmacy is as efficacious and safe as, but cheaper than, monotherapy in the acute treatment of schizophrenia. Whether our findings can be generalized to other combinations of an appropriate ratio of one FGA to another SGA dosage, which can achieve favorable clinical responses and side effect profiles, needs further investigation.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fu-Chiang Wang
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Shih-Chi Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Yu-Hui Huang
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Cheng-Chung Chen
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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McMillan SS, Jacobs S, Wilson L, Theodoros T, Robinson G, Anderson C, Mihala G, Wheeler AJ. Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points. BMC Psychiatry 2017; 17:139. [PMID: 28407747 PMCID: PMC5390470 DOI: 10.1186/s12888-017-1295-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/31/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Antipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatment-resistant schizophrenia, clozapine use is endorsed before combining antipsychotics. This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and high-dose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored. METHODS A retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed using multivariable logistic regression. RESULTS Most patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge. CONCLUSIONS In a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.
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Affiliation(s)
- Sara S McMillan
- Menzies Health Insitute, Griffith University, Brisbane, Australia.
| | - Sara Jacobs
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Louise Wilson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Theo Theodoros
- grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Royal Australia and New Zealand College of Psychiatrists Trainee, Melbourne, Victoria Australia ,Metro South Addiction and Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Gail Robinson
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Metro North Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Claire Anderson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Gabor Mihala
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia
| | - Amanda J Wheeler
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.9654.eFaculty of Medical and Health Sciences, Auckland University, Auckland, New Zealand
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Armstrong KS, Temmingh H. Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country. ACTA ACUST UNITED AC 2017; 39:293-301. [PMID: 28177063 PMCID: PMC7111406 DOI: 10.1590/1516-4446-2016-2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/07/2016] [Indexed: 01/02/2023]
Abstract
Objective: The aim of our study was to examine the prevalence of and factors associated with antipsychotic polypharmacy (APP) among patients with serious mental illness in the current South African health care context. Methods: We collected data on patient, illness, and treatment characteristics of patients discharged on one or more antipsychotic agents from January to June 2014. We analyzed the associations of APP with demographic and clinical variables using hierarchical multivariable logistic regression, and examined prescription patterns. Results: The prevalence of APP in our study population of 577 patients was 28.4%. Demographic and clinical characteristics significantly associated with APP included age > 29, male sex, diagnosis of schizophrenia, comorbid intellectual disability, comorbid substance use, greater number of hospital admissions, and high-dose prescribing. First-generation antipsychotics and long-acting injectable preparations were prominent in APP combinations. Co-prescription of anticholinergic agents and sodium valproate demonstrated a significant association with APP. Conclusion: APP appears common in our population, despite lack of evidence for the practice and possible risk of harm. Our findings suggest a complex interplay among patient, illness, and treatment factors relevant to APP in our setting that could be targeted for intervention.
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Affiliation(s)
- Kerryn S Armstrong
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Observatory, Cape Town, South Africa
| | - Henk Temmingh
- Department of Psychiatry and Mental Health, University of Cape Town, Valkenberg Hospital, Observatory, Cape Town, South Africa
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Sengul MCB, Karadag F, Sengul C, Karakulah K, Kalkanci O, Herken H. Risk of Psychotropic Drug Interactions in Real World Settings: a Pilot Study in Patients with Schizophrenia and Schizoaffective Disorder. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140311041445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Filiz Karadag
- Gazi University School of Medicine, Department of Psychiatry, Ankara - Turkey
| | - Cem Sengul
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Kamuran Karakulah
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Ozgur Kalkanci
- Servergazi State Hospital, Psychiatry Clinic, Denizli - Turkey
| | - Hasan Herken
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
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Berrouiguet S, Barrigón ML, Brandt SA, Ovejero-García S, Álvarez-García R, Carballo JJ, Lenca P, Courtet P, Baca-García E. Development of a Web-Based Clinical Decision Support System for Drug Prescription: Non-Interventional Naturalistic Description of the Antipsychotic Prescription Patterns in 4345 Outpatients and Future Applications. PLoS One 2016; 11:e0163796. [PMID: 27764107 PMCID: PMC5072715 DOI: 10.1371/journal.pone.0163796] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 09/14/2016] [Indexed: 12/03/2022] Open
Abstract
PURPOSE The emergence of electronic prescribing devices with clinical decision support systems (CDSS) is able to significantly improve management pharmacological treatments. We developed a web application available on smartphones in order to help clinicians monitor prescription and further propose CDSS. METHOD A web application (www.MEmind.net) was developed to assess patients and collect data regarding gender, age, diagnosis and treatment. We analyzed antipsychotic prescriptions in 4345 patients attended in five Psychiatric Community Mental Health Centers from June 2014 to October 2014. The web-application reported average daily dose prescribed for antipsychotics, prescribed daily dose (PDD), and the PDD to defined daily dose (DDD) ratio. RESULTS The MEmind web-application reported that antipsychotics were used in 1116 patients out of the total sample, mostly in 486 (44%) patients with schizophrenia related disorders but also in other diagnoses. Second generation antipsychotics (quetiapine, aripiprazole and long-acting paliperidone) were preferably employed. Low doses were more frequently used than high doses. Long acting paliperidone and ziprasidone however, were the only two antipsychotics used at excessive dosing. Antipsychotic polypharmacy was used in 287 (26%) patients with classic depot drugs, clotiapine, amisulpride and clozapine. CONCLUSIONS In this study we describe the first step of the development of a web application that is able to make polypharmacy, high dose usage and off label usage of antipsychotics visible to clinicians. Current development of the MEmind web application may help to improve prescription security via momentary feedback of prescription and clinical decision support system.
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Affiliation(s)
- Sofian Berrouiguet
- Department of Psychiatry and Emergency, Brest Medical University Hospital, Brest, France
- Logics in Uses, Social Science and Information Science department, Telecom Bretagne, Plouzané, France
| | | | - Sara A. Brandt
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, United States of America
| | | | - Raquel Álvarez-García
- Department of Psychiatry, University Hospital Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Juan Jose Carballo
- Department of Psychiatry at Fundación Jimenez Diaz Hospital, Madrid, Spain
| | - Philippe Lenca
- Logics in Uses, Social Science and Information Science department, Telecom Bretagne, Plouzané, France
| | - Philippe Courtet
- INSERM U888, Department of Psychiatry, Montpellier University Hospital, Montpellier, France
| | | | - Enrique Baca-García
- Department of Psychiatry, IIS-Jimenez Diaz Foundation, Madrid, Spain
- Department of Psychiatry, University Hospital Infanta Elena, Valdemoro, Spain
- Department of Psychiatry, University Hospital Rey Juan Carlos, Móstoles, Spain
- Department of Psychiatry, General Hospital of Villalba, Autonoma University, Madrid, Spain
- CIBERSAM, Madrid, Spain
- Columbia University, New York, NY, United States of America
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Thompson JV, Clark JM, Legge SE, Kadra G, Downs J, Walters JT, Hamshere ML, Hayes RD, Taylor D, MacCabe JH. Antipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders. J Psychopharmacol 2016; 30:436-43. [PMID: 26905920 DOI: 10.1177/0269881116632376] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
RATIONALE Antipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality. OBJECTIVES We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting. METHODS Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP. RESULTS The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13). CONCLUSIONS APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.
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Affiliation(s)
| | - Joanne M Clark
- GKT School of Medical Education, King's College London, London, UK
| | - Sophie E Legge
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Giouliana Kadra
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Johnny Downs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Tr Walters
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Marian L Hamshere
- Institute of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK
| | - Richard D Hayes
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Opsommer E, Dubois J, Bangerter G, Panchaud R, Martin D, Skuza K. Therapeutic Body Wraps in Swiss public adult acute inpatient wards. A retrospective descriptive cohort study. J Psychiatr Ment Health Nurs 2016; 23:207-16. [PMID: 27126065 DOI: 10.1111/jpm.12304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Various expert opinions reported relational benefits and tranquilizing effects of therapeutic body wraps (TBW) in adults experiencing high anxiety in the context of psychosis. Yet, this tranquilizing effect was never investigated in larger samples and in the context of modern psychopharmacology. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study to establish descriptive statistics of this mind-body therapy in French-speaking Switzerland where TBWs are routinely used in two public psychiatric hospitals. It brings knowledge on patients nowadays treated with TBW. Moreover, it opens a new area of investigation on the potential of this nursing technique, which may contribute to reduce anxiolytic medication in severely ill patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study sheds light on a clinical practice in mental health nursing and upon nurses' specific contribution to psychiatric clinic. It investigates a potential for TBWs to reduce the use of anxiolytic medications by patients who agreed to have TBW as part of their treatment. It may help to inform the mental health nursing practice. ABSTRACT Introduction Many patients suffering from serious mental illness experience severe anxiety and those with psychosis often report the feeling of their bodies falling apart. While it is believed that these patients benefit from therapeutic body wraps (TBWs), the use of this adjunct therapy has rarely been studied in adult patients. Aims The aim of this study was to obtain descriptive statistics on the clinical, social-demographic and institutional reality of TBW therapy in Swiss public adult inpatient wards. Methods Retrospective data related to a cohort of 172 adult inpatients were retrieved from records of two public hospitals. Correlations between TBW and the prescriptions of lorazepam were explored. Results TBWs were primarily used for patients diagnosed with either schizophrenia, schizotypal, delusional and other non-mood psychotic disorders or mood disorders. Patients had, on average, four psychiatric hospitalizations, and in 30% of the cases, TBWs were offered during the first hospitalization. Moreover, TBWs were mostly practiced by nurses. Body wraps were potentially associated with a reduction in both anxiolytic and neuroleptic drugs. Discussion/Implication for practice Based on our results, TBW might contribute to the clinical management of anxiety by nurses. The efficacy of TWB regarding anxiety has yet to be investigated in a randomized controlled trial.
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Affiliation(s)
- E Opsommer
- School of Health Sciences, University of Applied Arts and Sciences of Western Switzerland, Lausanne, Switzerland
| | - J Dubois
- Foundation of Nant Psychiatric Hospital, Corsier-sur-Vevey, Switzerland
| | - G Bangerter
- School of Health Sciences, University of Applied Arts and Sciences of Western Switzerland, Lausanne, Switzerland
| | - R Panchaud
- Foundation of Nant Psychiatric Hospital, Corsier-sur-Vevey, Switzerland
| | - D Martin
- School of Health Sciences, University of Applied Arts and Sciences of Western Switzerland, Lausanne, Switzerland
| | - K Skuza
- School of Health Sciences, University of Applied Arts and Sciences of Western Switzerland, Lausanne, Switzerland
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Dold M, Tardy M, Samara MT, Li C, Kasper S, Leucht S. Are all first-generation antipsychotics equally effective in treating schizophrenia? A meta-analysis of randomised, haloperidol-controlled trials. World J Biol Psychiatry 2016; 17:210-20. [PMID: 26919194 DOI: 10.3109/15622975.2015.1083616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Narrative, unsystematic reviews revealed no differences in efficacy between the various first-generation antipsychotics (FGAs) resulting in the psychopharmacological assumption of comparable efficacy between the different FGAs. We sought to determine if the assumption of comparable efficacy of all FGAs can be regarded as evidence-based using meta-analytic statistics. METHODS A systematic literature survey (Cochrane Schizophrenia Group trial register) was applied to identify all RCTs that compared oral haloperidol with another oral FGA in schizophrenia. Primary outcome was dichotomous treatment response. Secondary outcomes were symptom severity measured by rating scales, discontinuation rates, and specific adverse effects. RESULTS Altogether, 79 RCTs with 4343 participants published between 1962 and 1999 were included. We found a significant between-group difference only between haloperidol and nemonapride, but not for the remaining 19 investigated FGAs. There were no significant differences for discontinuation rates. CONCLUSIONS As most of the single meta-analytic comparisons can be regarded as underpowered, the evidence for the assumption of comparable efficacy of all FGAs is inconclusive. We therefore cannot confirm or reject the statements of previous narrative, unsystematic reviews in this regard. Our findings were limited by the small sample size in the individual comparisons and the low methodological quality in many included studies.
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Affiliation(s)
- Markus Dold
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria.,b Department of Psychiatry and Psychotherapy , Technische Universität München , München , Germany
| | - Magdolna Tardy
- b Department of Psychiatry and Psychotherapy , Technische Universität München , München , Germany
| | - Myrto T Samara
- b Department of Psychiatry and Psychotherapy , Technische Universität München , München , Germany
| | - Chunbo Li
- c Shanghai Key Laboratory of Psychotic Disorders , Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Siegfried Kasper
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Stefan Leucht
- b Department of Psychiatry and Psychotherapy , Technische Universität München , München , Germany
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Multitarget drug discovery projects in CNS diseases: quantitative systems pharmacology as a possible path forward. Future Med Chem 2015; 6:1757-69. [PMID: 25574530 DOI: 10.4155/fmc.14.97] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Clinical development in brain diseases has one of the lowest success rates in the pharmaceutical industry, and many promising rationally designed single-target R&D projects fail in expensive Phase III trials. By contrast, successful older CNS drugs do have a rich pharmacology. This article will provide arguments suggesting that highly selective single-target drugs are not sufficiently powerful to restore complex neuronal circuit homeostasis. A rationally designed multitarget project can be derisked by dialing in an additional symptomatic treatment effect on top of a disease modification target. Alternatively, we expand upon a hypothetical workflow example using a humanized computer-based quantitative systems pharmacology platform. The hope is that incorporating rationally multipharmacology drug discovery could potentially lead to more impactful polypharmacy drugs.
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Ersan EE, Yildiz M. Antipsychotic Use Pattern in People with Psychotic Disorder Living in Board and Care Facilities. Noro Psikiyatr Ars 2015; 52:145-150. [PMID: 28360695 DOI: 10.5152/npa.2015.7419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 01/07/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this survey is to determine the pattern of antipsychotic drug use in patients with psychotic disorders, living in board and care facilities and to investigate the related factors. METHODS We evaluated the antipsychotic drug use pattern in outpatients with psychotic disorders according to DSM-IV, living in board and care facilities. Patients using polypharmacy at least one month were compared with patients using monotherapy in terms of clinical and demographic characteristics. RESULTS Antipsychotic polypharmacy (with two: 34%, with more than two: 28%) was identified in 62% of the patients. The most frequently prescribed combination was olanzapine+quetiapine (13%), the rate of first and second generation combination was 50%, the rate of second generation antipsychotic combination was 44%, and the rate of first generation anytipsychotic combination was 4% in the two antipsychotic drug combination group. The rate of clozapine use was 3%. Use of polypharmacy was associated with the diagnosis of schizophrenia and schizoaffective disorder, young age, suicidal behavior, multiple hospitalizations, clinical severity, and the need of anticholinergic drug. CONCLUSION The ratio of using more than two antipsychotic drug combination is high (28%) in psychotic patients living in board and care, and rate of clozapine use is low, which shows that clinical practice is inconsistent with the treatment guidelines recommendations. It appears that further education to rationale antipsychotic drug use in psychiatric practices is required.
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Affiliation(s)
| | - Mustafa Yildiz
- Department of Psychiatry, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Razzouk D, Kayo M, Sousa A, Gregorio G, Cogo-Moreira H, Cardoso AA, Mari JDJ. The impact of antipsychotic polytherapy costs in the public health care in Sao Paulo, Brazil. PLoS One 2015; 10:e0124791. [PMID: 25853709 PMCID: PMC4390144 DOI: 10.1371/journal.pone.0124791] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/10/2015] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Guidelines for the treatment of psychoses recommend antipsychotic monotherapy. However, the rate of antipsychotic polytherapy has increased over the last decade, reaching up to 60% in some settings. Studies evaluating the costs and impact of antipsychotic polytherapy in the health system are scarce. OBJECTIVE To estimate the costs of antipsychotic polytherapy and its impact on public health costs in a sample of subjects with psychotic disorders living in residential facilities in the city of Sao Paulo, Brazil. METHOD A cross-sectional study that used a bottom-up approach for collecting costs data in a public health provider's perspective. Subjects with psychosis living in 20 fully-staffed residential facilities in the city of Sao Paulo were assessed for clinical and psychosocial profile, severity of symptoms, quality of life, use of health services and pharmacological treatment. The impact of polytherapy on total direct costs was evaluated. RESULTS 147 subjects were included, 134 used antipsychotics regularly and 38% were in use of antipsychotic polytherapy. There were no significant differences in clinical and psychosocial characteristics between polytherapy and monotherapy groups. Four variables explained 30% of direct costs: the number of antipsychotics, location of the residential facility, time living in the facility and use of olanzapine. The costs of antipsychotics corresponded to 94.4% of the total psychotropic costs and to 49.5% of all health services use when excluding accommodation costs. Olanzapine costs corresponded to 51% of all psychotropic costs. CONCLUSION Antipsychotic polytherapy is a huge economic burden to public health service, despite the lack of evidence supporting this practice. Great variations on antipsychotic costs explicit the need of establishing protocols for rational antipsychotic prescriptions and consequently optimising resource allocation. Cost-effectiveness studies are necessary to estimate the best value for money among antipsychotics, especially in low and middle income countries.
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Affiliation(s)
- Denise Razzouk
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Monica Kayo
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Aglaé Sousa
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Gregorio
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Hugo Cogo-Moreira
- Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Andrea Alves Cardoso
- Centro de Economia em Saúde Mental (CESM), Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Jair de Jesus Mari
- Department of Psychiatry, Universidade Federal de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
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Li Q, Xiang YT, Su YA, Shu L, Yu X, Chiu HF, Correll CU, Ungvari GS, Lai KY, Ma C, Wang GH, Bai PS, Li T, Sun LZ, Shi JG, Chen XS, Mei QY, Li KQ, Si TM. Antipsychotic polypharmacy in schizophrenia patients in China and its association with treatment satisfaction and quality of life: findings of the third national survey on use of psychotropic medications in China. Aust N Z J Psychiatry 2015; 49:129-36. [PMID: 24923760 DOI: 10.1177/0004867414536931] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study examined the use, demographic and clinical correlates of antipsychotic polypharmacy (APP) and its associations with treatment satisfaction and quality of life (QOL) in schizophrenia patients in China. METHOD A total of 4239 patients in 45 nationwide Chinese psychiatric hospitals/centers were interviewed in 2012 in the third cross-sectional study, with the first two having been conducted in 2002 and 2006. Patients' socio-demographic and clinical characteristics, including psychopathology, side effects, satisfaction with treatment and QOL, were recorded using a standardized protocol and data collection procedure. RESULTS The proportion of APP prescriptions in 2012 was 34.2%, which was significantly higher than the frequency of APP in 2002 (26.1%) and 2006 (26.4%) (p<0.001). Of patients on APP, 91.1% received two antipsychotics, 8.6% received three and 0.3% received four or more antipsychotics. Multiple logistic regression analyses revealed that compared to those on antipsychotic monotherapy, patients on APP and their families had lower satisfaction with treatment, had higher QOL in the mental domain, younger age of onset, more side effects, higher doses of antipsychotics and were more likely to receive first-generation antipsychotics and less likely to receive benzodiazepines (total R (2)=0.31, p<0.001). CONCLUSIONS APP was found in about one in three schizophrenia patients. The prevalence of APP seems to have been increasing since 2002. Considering the increased frequency of drug-induced side effects and the patients' and their relatives' dissatisfaction with antipsychotic treatment, further examination of the rationale and appropriateness of APP and its alternatives is warranted.
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Affiliation(s)
- Qian Li
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Yu-Tao Xiang
- Faculty of Health Sciences, University of Macau, Macao SAR, China
| | - Yun-Ai Su
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Liang Shu
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Xin Yu
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
| | - Helen Fk Chiu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY, USA
| | - Gabor S Ungvari
- The University of Notre Dame Australia/Marian Centre, Perth, Australia
| | - Kelly Yc Lai
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Cui Ma
- Psychiatric Hospital, Guangzhou, China
| | - Gao-Hua Wang
- Department of Psychiatry, Renmin Hospital, Wuhan University, Wuhan, China
| | - Pei-Shen Bai
- The First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Tao Li
- West China Hospital, Sichuan University, China
| | | | | | | | - Qi-Yi Mei
- Suzhou Guangji Hospital, Suzhou, China
| | - Ke-Qing Li
- Hebei Mental Health Center, Hebei, China
| | - Tian-Mei Si
- The Key Laboratory of Mental Health, Ministry of Health & Peking University Institute of Mental Health, Beijing, China
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Treating the violent patient with psychosis or impulsivity utilizing antipsychotic polypharmacy and high-dose monotherapy. CNS Spectr 2014; 19:439-48. [PMID: 25119976 DOI: 10.1017/s1092852914000388] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Insufficient treatment of psychosis often manifests as violent and aggressive behaviors that are dangerous to the patient and others, and that warrant treatment strategies which are not considered first-line, evidence-based practices. Such treatment strategies include both antipsychotic polypharmacy (simultaneous use of 2 antipsychotics) and high-dose antipsychotic monotherapy. Here we discuss the hypothesized neurobiological substrates of various types of violence and aggression, as well as providing arguments for the use of antipsychotic polypharmacy and high-dose monotherapy to target dysfunctional neurocircuitry in the subpopulation of patients that is treatment-resistant, violent, and aggressive. In this review, we focus primarily on the data supporting the use of second-generation, atypical antipsychotics both at high doses and in combination with other antipsychotics.
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Deconstructing violence as a medical syndrome: mapping psychotic, impulsive, and predatory subtypes to malfunctioning brain circuits. CNS Spectr 2014; 19:357-65. [PMID: 25296964 DOI: 10.1017/s1092852914000522] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Violence is a major management issue for forensic mental health systems. Violence can be approached as a medical syndrome and deconstructed into psychotic, impulsive, and predatory subtypes, which are hypothetically mapped onto corresponding malfunctioning brain circuits. Rational management of violence balances treatment with security, while targeting each subtype of violence with approaches unique to the psychotic, impulsive, and predatory forms of violence.
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Schreiner A, Hargarter L, Hitschfield K, Lee JI, Lenskaya I, Sulaiman AH, Diels J. Clinical effectiveness and resource utilization of paliperidone ER for schizophrenia: Pharmacoepidemiologic International Longitudinal Antipsychotic Registry (PILAR). Curr Med Res Opin 2014; 30:1279-89. [PMID: 24597755 DOI: 10.1185/03007995.2014.898630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To document prescribing patterns in clinical practice and assess long-term outcomes related to initiation of paliperidone ER and other oral antipsychotics among patients with schizophrenia in a naturalistic setting. RESEARCH DESIGN AND METHODS An international, non-interventional, naturalistic study of adult patients (≥18 years) with schizophrenia. Patients were assigned to the relevant treatment group (paliperidone ER or 'all other oral antipsychotics') after switching to, or initiating, oral antipsychotic treatment. Retrospective 12 month data collection was followed by 12 month prospective data collection, with 3-monthly assessments. The primary endpoint was time to all-cause discontinuation of new medication. Secondary endpoints included Clinical Global Impression-Severity (CGI-S) score, Clinical Global Impression-Schizophrenia (CGI-SCH) score, Personal and Social Performance (PSP) score, health-related quality of life (HR-QoL) and quality of sleep, evaluation of healthcare resource utilization and patient's treatment satisfaction. RESULTS A total of 4051 patients were included in the intent-to-treat (ITT) analysis set. All-cause study discontinuation rates were comparable between the paliperidone ER group (16.8%) and the 'all other oral antipsychotics' group (15.5%). There was no difference in the time to discontinuation of newly initiated antipsychotic treatments between paliperidone ER and 'all other oral antipsychotics' groups. Paliperidone ER was associated with greater improvements from baseline to endpoint in both the PSP scale score (+14.2 vs +13.1, p = 0.041) and the physical component of quality of life (SF-12 Physical scores; +3.9 vs +2.9, p = 0.003) compared to 'all other oral antipsychotics'. Improvements in mean CGI-S score, CGI-SCH score, HR-QoL, quality of sleep and daytime drowsiness, as well as patients' treatment satisfaction were comparable between treatment groups. The incidence of adverse events was comparable between groups. CONCLUSIONS This study provides valuable data on the prescribing habits and treatment outcomes associated with use of paliperidone ER in everyday clinical practice, and supports previous findings of the favorable functional improvement and treatment satisfaction associated with paliperidone ER. CLINICAL TRIAL REGISTRATION NCT00696813; R076477SCH4015 (Register of German Association of Research-based Pharmaceutical Companies [VFA] http://www.vfa.de/de/arzneimittel-forschung/datenbanken-zu-arzneimitteln/nisdb).
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