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Fonseca de Freitas D, Kadra-Scalzo G, Agbedjro D, Francis E, Ridler I, Pritchard M, Shetty H, Segev A, Casetta C, Smart SE, Downs J, Christensen SR, Bak N, Kinon BJ, Stahl D, MacCabe JH, Hayes RD. Using a statistical learning approach to identify sociodemographic and clinical predictors of response to clozapine. J Psychopharmacol 2022; 36:498-506. [PMID: 35212240 PMCID: PMC9066692 DOI: 10.1177/02698811221078746] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND A proportion of people with treatment-resistant schizophrenia fail to show improvement on clozapine treatment. Knowledge of the sociodemographic and clinical factors predicting clozapine response may be useful in developing personalised approaches to treatment. METHODS This retrospective cohort study used data from the electronic health records of the South London and Maudsley (SLaM) hospital between 2007 and 2011. Using the Least Absolute Shrinkage and Selection Operator (LASSO) regression statistical learning approach, we examined 35 sociodemographic and clinical factors' predictive ability of response to clozapine at 3 months of treatment. Response was assessed by the level of change in the severity of the symptoms using the Clinical Global Impression (CGI) scale. RESULTS We identified 242 service-users with a treatment-resistant psychotic disorder who had their first trial of clozapine and continued the treatment for at least 3 months. The LASSO regression identified three predictors of response to clozapine: higher severity of illness at baseline, female gender and having a comorbid mood disorder. These factors are estimated to explain 18% of the variance in clozapine response. The model's optimism-corrected calibration slope was 1.37, suggesting that the model will underfit when applied to new data. CONCLUSIONS These findings suggest that women, people with a comorbid mood disorder and those who are most ill at baseline respond better to clozapine. However, the accuracy of the internally validated and recalibrated model was low. Therefore, future research should indicate whether a prediction model developed by including routinely collected data, in combination with biological information, presents adequate predictive ability to be applied in clinical settings.
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Affiliation(s)
| | | | - Deborah Agbedjro
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Emma Francis
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Isobel Ridler
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Hitesh Shetty
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Aviv Segev
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Shalvata Mental Health Center, Hod Hasharon, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cecilia Casetta
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Sophie E Smart
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- MRC Centre for Neuropsychiatric Genetics & Genomics, Cardiff University, Cardiff, UK
| | - Johnny Downs
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | | | | | | | - Daniel Stahl
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - James H MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Richard D Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Combination Therapy of Long-Acting Injectable Second-Generation Antipsychotics and Oral Antipsychotics: A Retrospective Chart Review and Prescribers' Attitude Survey. J Clin Psychopharmacol 2022; 42:81-86. [PMID: 34668878 DOI: 10.1097/jcp.0000000000001487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although long-acting injectable antipsychotics (LAI-APs) have been considered as a monotherapeutic option in the maintenance treatment of schizophrenia, it has been recently reported that the combination therapy of LAI-APs and oral antipsychotics (OAPs) is common. METHODS We conducted a retrospective chart review to examine the situation of the combination therapy of LAI second-generation antipsychotics (LAI-SGAs) and OAPs, and a questionnaire survey to investigate prescribers' attitudes toward the combination therapy. We included patients who received any LAI-SGAs for 1 month or longer and classified them into monotherapy and combination therapy groups. We collected information on age, sex, primary psychiatric diagnosis, and concomitant psychotropic medications. RESULTS Of the 132 patients, 39 (29.5%) received the combination therapy of LAI-SGAs and OAPs. Long-acting injectable risperidone was significantly associated with receiving the combination therapy compared with LAI aripiprazole. Olanzapine was the most common OAP in combination with LAI-SGAs. Only 8 patients (20.5%) concurrently received the same type of OAPs as LAI-SGAs. More than 60% of the patients received OAP polypharmacy before the initiation of LAI-SGAs. The psychiatrists in charge prescribed LAI-SGAs mainly because of a concern about adherence, and OAPs mainly because of insufficient dose of LAI-SGAs, to patients in the combination therapy group. They estimated that adherence to OAPs in two thirds of the patients in the combination therapy group was 80% or higher. CONCLUSIONS The present study showed that the combination therapy of LAI-SGAs and OAPs is often conducted in real-world clinical practice. Considering the reason for the introduction of LAI-APs, clinicians should carefully monitor patients' adherence to OAPs concurrently used with LAI-APs.
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Nikolić N, Hill K, Campbell E, Wickramasinghe V, Whale R. Early access to clozapine in Early Intervention in Psychosis: Hope vs reality. A mixed method service analysis. Early Interv Psychiatry 2021; 15:193-200. [PMID: 32281741 DOI: 10.1111/eip.12962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/17/2020] [Accepted: 03/15/2020] [Indexed: 11/29/2022]
Abstract
AIM Improving access to clozapine is a recognized priority nationally across Early Intervention in Psychosis Services (EIPS) in the UK. Treatment resistance (TR) may be identifiable from early episode psychosis and appears to be characterized by negative symptoms and younger age of onset. This mixed method cross-sectional snapshot analysis of antipsychotic (AP) prescribing in an EIPS, explored clozapine eligibility (CE) and prioritization of AP prescribing based on choice, selectivity and appropriateness. METHOD We screened 150 service users and 79% (n = 119) were retained after inclusion criteria were applied. We explored CE in all service users who were indicated clozapine based on the product licence (n = 78), and whether there was association between CE and number of hospital admissions, AP trials, age at first episode and duration of untreated psychosis. RESULTS Following multidisciplinary clinical discussions, we found that 23 service users were CE; 8 were offered and declined clozapine. When compared to non-CE service users, significant factors associated with CE were history of two or more hospital admissions (Mann-Whitney U = 269, P = .008), more than two trials of two different APs (Mann-Whitney U = 517, P ≤ .01), and younger age first episode (independent-samples t-test, P = .047). A total of 47.5% of all service users had been started on olanzapine as their first AP, despite high risk of cardiometabolic syndrome. CONCLUSION We propose that EIP services adopt a proactive approach in screening for TR, taking into account negative symptoms and young age at onset, prioritizing service users with two or more hospital admissions and AP trials.
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Affiliation(s)
- Nikola Nikolić
- Early Intervention in Psychosis Service, Sussex Partnership NHS Foundation Trust, Worthing, UK.,Early Intervention in Psychosis Programme, NHS South East England, Horley, UK
| | - Katherine Hill
- Early Intervention in Psychosis Service, Sussex Partnership NHS Foundation Trust, Worthing, UK.,Department of Medical Education, Brighton and Sussex Medical School, Brighton, UK
| | - Emogen Campbell
- Department of Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | - Vijitha Wickramasinghe
- Early Intervention in Psychosis Service, Sussex Partnership NHS Foundation Trust, Hailsham, UK
| | - Richard Whale
- Early Intervention in Psychosis Service, Sussex Partnership NHS Foundation Trust, Worthing, UK.,Department of Medical Education, Brighton and Sussex Medical School, Brighton, UK
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Stokes I, Griffiths SL, Jones R, Everard L, Jones PB, Fowler D, Hodgekins J, Amos T, Freemantle N, Sharma V, Marshall M, Singh SP, Birchwood M, Upthegrove R. Prevalence of treatment resistance and clozapine use in early intervention services. BJPsych Open 2020; 6:e107. [PMID: 32938513 PMCID: PMC7576650 DOI: 10.1192/bjo.2020.89] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics. AIMS This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services. METHOD Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points. RESULTS A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine. CONCLUSIONS Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.
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Affiliation(s)
- Imogen Stokes
- Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, UK
| | | | - Rowena Jones
- School of Psychology, Institute for Mental Health, University of Birmingham; and Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK
| | - Linda Everard
- Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK
| | | | - David Fowler
- Department of Psychology, University of Sussex, UK
| | | | | | - Nick Freemantle
- Institute of Clinical Trials & Methodology, University College London, UK
| | - Vimal Sharma
- Faculty of Health and Social Care, University of Chester, UK
| | | | - Swaran P Singh
- Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK
| | | | - Rachel Upthegrove
- Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham; School of Psychology, Institute for Mental Health, University of Birmingham; Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK
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5
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Casetta C, Gaughran F, Oloyede E, Onwumere J, Pritchard M, Shergill SS, Whiskey E, MacCabe JH. Real-world effectiveness of admissions to a tertiary treatment-resistant psychosis service: 2-year mirror-image study. BJPsych Open 2020; 6:e82. [PMID: 32744200 PMCID: PMC7453801 DOI: 10.1192/bjo.2020.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/31/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Treatment-resistant schizophrenia is a major disabling illness which often proves challenging to manage in a secondary care setting. The National Psychosis Unit (NPU) is a specialised tertiary in-patient facility that provides evidence-based, personalised, multidisciplinary interventions for complex treatment-resistant psychosis, in order to reduce the risk of readmission and long-term care costs. AIMS This study aimed to assess the long-term effectiveness of treatment at the NPU by considering naturalistic outcome measures. METHOD Using a mirror image design, we compared the numbers of psychiatric and general hospital admissions, in-patient days, acuity of placement, number of psychotropic medications and dose of antipsychotic medication prescribed before and following NPU admission. Data were obtained from the Clinical Records Interactive Search system, an anonymised database sourced from the South London and Maudsley NHS Trust electronic records, and by means of anonymous linkage to the Hospital Episode Statistics system. RESULTS Compared with the 2 years before NPU admission, patients had fewer mental health admissions (1.65 ± 1.44 v. 0.87 ± 0.99, z = 5.594, P < 0.0001) and less mental health bed usage (335.31 ± 272.67 v. 199.42 ± 261.96, z = 5.195 P < 0.0001) after NPU admission. Total in-patient days in physical health hospitals and total number of in-patient days were also significantly reduced (16.51 ± 85.77 v. 2.83 ± 17.38, z = 2.046, P = 0.0408; 351.82 ± 269.09 v. 202.25 ± 261.05, z = 5.621, P < 0.0001). The reduction in level of support required after treatment at the NPU was statistically significant (z = -8.099, P < 0.0001). CONCLUSIONS This study demonstrates the long-term effectiveness of a tertiary service specialising in treatment-resistant psychosis.
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Affiliation(s)
- Cecilia Casetta
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | - Ebenezer Oloyede
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | - Juliana Onwumere
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Sukhi S. Shergill
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | - Eromona Whiskey
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
| | - James Hunter MacCabe
- King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, South London and Maudsley NHS Foundation Trust, London, UK
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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7
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Proinflammatory and anti-inflammatory biomarkers in schizophrenia and influence of simvastatin on the interleukin-6. Int Clin Psychopharmacol 2019; 34:84-88. [PMID: 30461427 DOI: 10.1097/yic.0000000000000241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study sought to assess biomarkers of inflammation in stable patients with schizophrenia (SZ) on clozapine therapy. We recruited 60 outpatients with SZ and 60 healthy controls, matched for sex and age. Compared with controls, patients had significantly increased concentrations of interleukin-6 and tumor necrosis factor-α. Interestingly, patients on simvastatin had lower interleukin-6 levels compared with patients not on simvastatin and controls. This study corroborated previous evidence for increased inflammatory biomarkers in SZ and detected a potential anti-inflammatory action of simvastatin in patients with a clinical diagnosis of SZ on clozapine therapy.
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Cho J, Hayes RD, Jewell A, Kadra G, Shetty H, MacCabe JH, Downs J. Clozapine and all-cause mortality in treatment-resistant schizophrenia: a historical cohort study. Acta Psychiatr Scand 2019; 139:237-247. [PMID: 30478891 PMCID: PMC6492259 DOI: 10.1111/acps.12989] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Large-scale epidemiological studies have demonstrated a protective effect of clozapine on mortality in people with schizophrenia. Clozapine is reserved for use in patients with treatment-resistant schizophrenia (TRS), but evidence of clozapine's effect on mortality exclusively within TRS samples is inconclusive. Hence, we aimed to investigate the effect of clozapine use on all-cause mortality in TRS patients. METHODS A historical patient cohort sample of 2837 patients, who met criteria for TRS between 1 Jan 2008 and 1 Jan 2016, were selected from the South London and Maudsley NHS Foundation Trust (SLAM) electronic health records (EHR). The national Zaponex Treatment Access System (ZTAS) mandatory monitoring system linked to the SLAM EHR was used to distinguish which patients were initiated on clozapine (n = 1025). Cox proportional hazard models were used, adjusting for sociodemographics, clinical monitoring, mental and physical illness severity and functional status. RESULTS After controlling for potential confounders, the protective effect of clozapine on all-cause mortality was significant (adjusted hazard ratio 0.61; 95% confidence interval 0.38-0.97; P = 0.04). CONCLUSIONS Clozapine reduces the risk of mortality in patients who meet criteria for TRS. We provide further evidence that improving access to clozapine in TRS is likely to reduce the mortality gap in schizophrenia.
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Affiliation(s)
- J. Cho
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK
| | - R. D. Hayes
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK
| | - A. Jewell
- South London and Maudsley NHS Foundation TrustLondonUK
| | - G. Kadra
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK
| | - H. Shetty
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - J. H. MacCabe
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - J. Downs
- Institute of Psychiatry Psychology and NeuroscienceKing's College LondonLondonUK,NIHR Maudsley Biomedical Research CentreLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
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9
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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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10
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Lange-Asschenfeldt C. [Psychiatric pharmacotherapy of older individuals with severe mental illness]. Z Gerontol Geriatr 2018; 51:770-778. [PMID: 30302537 DOI: 10.1007/s00391-018-1455-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronic schizophrenia, depression, and bipolar disorders, among other chronic psychiatric disorders with onset at youth or early adulthood are often referred to as severe mental illness (SMI). Aging with SMI is associated with various psychosocial, physiological, and medical problems with potential impact on psychiatric pharmacotherapy. OBJECTIVES Determination and discussion of problems and special features of the psychopharmacological treatment of older persons with SMI and presentation of treatment recommendations for the distinct diagnoses. MATERIALS AND METHODS International literature and guidelines were searched. In addition, the basic literature and expert opinions are discussed. RESULTS General problems that influence the psychiatric pharmacotherapy of older persons with SMI include nonadherence, nonresponse, polypharmacy, and distinct pharmacokinetic changes with aging and somatic comorbidity. Psychotropic drugs may exhibit cardiovascular, metabolic, and neuropsychiatric risks, among others. The literature regarding effectiveness of psychotropic drugs, drug groups, or combination of drugs in older patients with SMI is scarce to nonexistent. CONCLUSIONS Drug treatment of older persons with SMI should be part of an overall treatment plan that also has to include social and psychotherapeutic components that address the specific problems of this population. Most importantly, psychiatric pharmacotherapy should consider these risks and the treatment should be tailored to a patient's individual risk profile. Due to a general lack of evidence in this special population, treatment strategies of standard guidelines should be adjusted with special consideration to physiological changes of age.
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Affiliation(s)
- Christian Lange-Asschenfeldt
- Abteilung Gerontopsychiatrie, Klinik und Poliklinik für Psychiatrie und Psychotherapie, LVR-Klinikum, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Bergische Landstr. 2, 40629, Düsseldorf, Deutschland.
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Lee LHN, Procyshyn RM, White RF, Woodward TS, Honer WG, Barr AM. Antipsychotic prescribing patterns on admission to and at discharge from a tertiary care program for treatment-resistant psychosis. PLoS One 2018; 13:e0199758. [PMID: 30096136 PMCID: PMC6086406 DOI: 10.1371/journal.pone.0199758] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 06/13/2018] [Indexed: 11/18/2022] Open
Abstract
Retrospective data were collected from 330 individuals who were treated at a tertiary care program for treatment-resistant psychosis between 1994 and 2010. The main objectives were to compare the use of antipsychotic monotherapy to polypharmacy and to characterize within-individual changes in treatment and symptomatology between admission and discharge. At admission, individuals who were prescribed only one antipsychotic were comparable to those who were prescribed at least two antipsychotics with regard to demographics and symptom severity. The use of psychotropic medications other than antipsychotics was also similar between the two groups. However, the magnitude of antipsychotic utilization was greater in individuals who were receiving antipsychotic polypharmacy. In addition, a greater proportion received excessive doses at admission. Similar findings were observed when the two antipsychotic prescribing practices were compared at discharge. Three important patterns were identified when investigating within-individual changes. First, fewer individuals were prescribed more than one antipsychotic at discharge. This was accompanied by a general decrease in the magnitude of antipsychotic utilization. Second, the number of individuals who were prescribed clozapine had increased by discharge. Most who were already prescribed clozapine at admission had their doses increased. Third, improvements in symptomatology were observed across all of the subscales included in the Positive and Negative Symptom Scale (PANSS); 57.9% of individuals experienced a relative reduction in total PANSS scores exceeding 20%. Based on these findings, it is possible to alleviate symptom severity while reducing antipsychotic utilization when patients are treated at a tertiary care program for treatment-resistant psychosis.
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Affiliation(s)
- Lik Hang N. Lee
- Department of Pharmacology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ric M. Procyshyn
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Randall F. White
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Todd S. Woodward
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - William G. Honer
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alasdair M. Barr
- Department of Pharmacology, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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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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