Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

Prevalence of depressive symptoms, suicidal ideation and behaviours in young people presenting with a first episode of psychosis

OBJECTIVES

Suicide accounts for a proportion of the early mortality in people affected by psychotic disorders. The early phase of illness can represent a particularly high-risk time for suicide. Therefore, in a cohort of young people presenting with first-episode psychosis, this study aimed to determine: (i) the prevalence of suicidal ideation, intent with plan and self-harm and any associated demographic or clinical factors and (ii) the prevalence of depressive symptoms and any associated demographic or clinical factors.

METHODS

Young people with a first episode of psychosis attending the Early Psychosis Prevention and Intervention Centre in Melbourne were included. Suicidal behaviours were recorded using a structured risk assessment - 'Clinical Risk Assessment and Management in the Community', and depressive symptoms were measured using the PHQ-9.

RESULTS

A total of 355 young people were included in the study. 57.2% were male, 95.4% were single and over one quarter were migrants. At the time of presentation, 34.6% had suicidal ideation, 6.2% had suicidal intent with a plan, and 21.4% had engaged in self-harm before their presentation. Combined, 39.7% (n = 141) presented with suicidal ideation, intent with plan or self-harm. A total of 71.5% (n = 118) had moderately severe or severe depressive symptoms, which was strongly associated with suicidal ideation or behaviours at the time of presentation (OR = 4.21, 95% C.I. 2.10-8.44).

CONCLUSIONS

Depressive symptoms, self-harm and suicidal behaviours are commonly present in the early phases of a psychotic disorder, which has important clinical implications for assessment and management.

Prevalence, correlates, tolerability-related outcomes, and efficacy-related outcomes of antipsychotic polypharmacy: a systematic review and meta-analysis

BACKGROUND

Antipsychotic polypharmacy remains a clinical reality, despite an increased risk of adverse events and little evidence of additional efficacy compared with antipsychotic monotherapy. In this systematic review and meta-analysis, we aimed to provide a comprehensive assessment of antipsychotic polypharmacy prevalence, trends, and correlates across mental disorders.

METHODS

We searched MEDLINE and Embase from Jan 1, 2009 to April 30, 2024, for any original study (observational and interventional) reporting antipsychotic polypharmacy prevalence in populations with mental disorders or use of antipsychotics, regardless of age or diagnosis. Relevant studies before May 1, 2009, were identified from two previous systematic reviews of antipsychotic polypharmacy prevalence. Pooled antipsychotic polypharmacy prevalence was estimated using random-effects meta-analysis. Using subgroup and mixed-effects meta-regression analyses, we sought to identify relevant correlates of antipsychotic polypharmacy. People with lived experience were not involved in the project. This review is registered with PROSPERO (CRD42022329953).

FINDINGS

We analysed 517 studies with 599 individual timepoints reporting on 4 459 149 individuals (mean age 39·5 years [range 6·4-86·3]; data on sex and ethnicity were infrequently reported). Most studies included patients with schizophrenia spectrum disorders (SSDs; k=270, 52%). Overall, 24·8% (95% CI 22·9-26·7) of the populations received antipsychotic polypharmacy, ranging from 33·2% (30·6-36·0) in people with SSDs to 5·2% (4·0-6·8) in people with dementia. Antipsychotic polypharmacy prevalence varied by region from 15·4% (95% CI 12·9-18·2) in North America to 38·6% (27·7-50·6) in Africa. Overall antipsychotic polypharmacy prevalence increased significantly from 1970 to 2023 (β=0·019, 95% CI 0·009-0·029; p=0·0002) and was higher in adults than in children and adolescents (27·4%, 95% CI 25·2-29·8 vs 7·0%, 4·7-10·3; p<0·0001) and among inpatients than among outpatients (31·4%, 27·9-35·2 vs 19·9%, 16·8-23·3; p<0·0001). Compared with antipsychotic monotherapy, antipsychotic polypharmacy was associated with an increased risk of relapse (relative risk [RR] 1·42, 95% CI 1·04-1·93; p=0·028), psychiatric hospitalisation (1·24, 1·12-1·38; p<0·0001), worse global functioning (standardised mean difference [SMD] -0·31, 95% CI -0·44 to -0·19; p<0·0001), and more adverse events, including extrapyramidal symptoms (RR 1·63, 95% CI 1·13-2·36; p=0·0098), dystonia (5·91, 1·20-29·17; p=0·029), anticholinergic use (1·91, 1·55-2·35; p<0·0001), higher side-effect scores (SMD 0·33, 95% CI 0·24-0·42; p<0·0001), longer corrected QT interval (0·24, 0·23-0·26; p<0·0001), and greater all-cause mortality risk (RR 1·19, 95% CI 1·00-1·41; p=0·047).

INTERPRETATION

The prevalence of antipsychotic polypharmacy has increased globally over the past 50 years and is particularly high in patients with SSDs. Prescription of antipsychotic polypharmacy is associated with greater illness severity and poorer outcomes than is antipsychotic monopharmacy but does not resolve these issues. Furthermore, antipsychotic polypharmacy is associated with higher side-effect burden, including all-cause mortality.

FUNDING

None.

Deep brain stimulation of Hippocampus in Treatment-resistant Schizophrenia (DBS-HITS): protocol for a crossover randomized controlled trial

BACKGROUND

Ventral hippocampus (vHipp) in schizophrenia is in a state of hyperactivity and hypermetabolism, where the glutamate/gamma-aminobutyric acid (GABA) imbalance leads to downstream dopamine hyperactivity in the midbrain-limbic system. High-frequency deep brain stimulation (DBS) can disrupt the abnormal synchronization of functional circuits and modulate local brain networks.

METHODS

The DBS-HITS study is a crossover randomized controlled trial. DBS will be applied to bilateral vHipp in six patients. They will be randomly assigned to receive 3-month high-frequency active stimulation and then 3-month sham stimulation, or vice versa. After 6-month crossover trial phase, all participants will undergo personalized active stimulation. Researchers will assess clinical symptoms and neurocognition, collect EEG and PET-CT data during planned follow-ups. Adverse event will be researcher-assessed or participant self-reported throughout the trial.

DISCUSSION

To our knowledge, the DBS-HITS study is the first hippocampal DBS randomized controlled trial for schizophrenia. The goal of the DBS-HITS study is to assess the efficacy and safety of hippocampal DBS in treatment-resistant schizophrenia (TRS) and to investigate its impact on hippocampal activity and glutamate/GABA metabolism. The study is expected to deepen our understanding of the effects and side-effects of neuromodulation in TRS to facilitate individualized DBS treatment.

TRIAL REGISTRATION

NCT05694000 in ClinicalTrial.gov, registered on January 23, 2023.

Clinical patterns of metabolic syndrome in young, clinically stable, olanzapine-exposed patients with schizophrenia

BACKGROUND

Schizophrenia (SCZ) is a chronic, disabling mental illness with a high disease burden and is often comorbid with metabolic syndrome (MetS). The aim of this study was to determine the prevalence of MetS in young, clinically stable, olanzapine-exposed patients with SCZ and to explore predictive factors affecting the development and severity of MetS.

METHODS

A total of 274 patients with SCZ who met the inclusion criteria were enrolled in this study, and their demographic data and general clinical information were collected. Concurrently, patients were assessed for psychopathology, illness severity, and antipsychotic drug-related adverse effects.

RESULTS

The prevalence of MetS in the target population was 35.77%, and the MetS subtype of abdominal obesity + high triglycerides + low level of high-density lipoprotein cholesterol accounted for the majority of patients in the MetS subgroup. Binary logistic regression showed that body mass index (BMI), uric acid (UA), thyroid-stimulating hormone, and QT-c interval could significantly and positively predict the development of MetS. Multiple linear regression showed that olanzapine concentration, BMI, and UA could significantly and positively predict higher MetS scores.

CONCLUSION

This study reports the clinical patterns of MetS in young, clinically stable, olanzapine-exposed patients with SCZ and identifies the correlations influencing the development and severity of MetS. These findings could potentially be applied toward the prevention of and intervention in MetS.

Antipsychotic Use and Risk of Breast Cancer in Women With Severe Mental Illness: Replication of a Nationwide Nested Case-Control Database Study

BACKGROUND AND HYPOTHESIS

Breast cancer is more prevalent in women with severe mental illness than in the general population, and use of prolactin-increasing antipsychotics may be a contributing factor.

STUDY DESIGN

A nested case-control study was conducted using the Swedish nationwide registers (inpatient/outpatient care, sickness absence, disability pension, prescribed drugs, cancers). All women aged 18-85 years with schizophrenia/schizoaffective/other nonaffective psychotic disorder/bipolar disorder and breast cancer (cases) were matched for age, primary psychiatric diagnosis, and disease duration with five women without cancer (controls). The association between cumulative exposure to prolactin-increasing/prolactin-sparing antipsychotics and breast cancer was analyzed using conditional logistic regression, adjusted for comorbidities and co-medications.

STUDY RESULTS

Among 132 061 women, 1642 (1.24%) developed breast cancer between 2010 and 2021, at a mean age of 63.3 ± 11.8 years. Compared with 8173 matched controls, the odds of breast cancer increased in women with prior exposure to prolactin-increasing antipsychotics for 1-4 years (adjusted odds ratio [aOR] = 1.20, 95% confidence interval [CI] = 1.03-1.41), and for ≥ 5 years (aOR = 1.47, 95%CI = 1.26-1.71). There were no increased or decreased odds of breast cancer with exposure to prolactin-sparing antipsychotics of either 1-4 years (aOR = 1.17, 95%CI = 0.98-1.40) or ≥5 years (aOR = 0.99, 95%CI = 0.78-1.26). The results were consistent across all sensitivity analyses (ie, according to different age groups, cancer types, and primary psychiatric diagnosis).

CONCLUSIONS

Although causality remains uncertain, exposure to prolactin-elevating antipsychotics for ≥ 1 year was associated with increased odds of breast cancer in women with severe mental illness. When prescribing antipsychotics, a shared decision-making process should consider individual risk factors for breast cancer.

The association between benzodiazepine prescriptions and the risk of laxative use in schizophrenia treatment

AIM

Constipation is one of the most common adverse effects in schizophrenia treatment, and it can sometimes cause severe gastrointestinal disease. However, the results of association studies between constipation and psychotropic medications in patients with schizophrenia are inconsistent. Therefore, we investigated the characteristics of psychotropic and laxative prescriptions at discharge in patients with schizophrenia to clarify the association between psychotropics and constipation.

METHODS

We analyzed the data of 139 patients with schizophrenia with or without laxative prescriptions at discharge from eight institutions in 2020.

RESULTS

Sixty-two patients were prescribed laxatives at discharge. The prescription of benzodiazepines in the laxative use group (66.1%) was significantly higher than that in the non-laxative use group (39.0%) (p = 1.4 × 10-3), and the mean number of benzodiazepines in the laxative use group (1.2 ± 1.1/day) was significantly higher than that in the non-laxative use group (0.7 ± 0.9/day) (p = 2.6 × 10-3). Multivariate logistic regression analyses revealed that benzodiazepine prescriptions were significantly associated with laxative usage (odds ratio, 3.059; 95% confidence interval, 1.523-6.144; p = 2.0 × 10-3).

CONCLUSION

Benzodiazepines may be associated with constipation in patients with schizophrenia. Therefore, clinicians should be cautious when prescribing benzodiazepines for the treatment of schizophrenia.

Twenty-Three Years of Declining Lithium Use: Analysis of a Pharmacoepidemiological Dataset from German-Speaking Countries

INTRODUCTION

Pharmacoepidemiological data suggest that lithium prescriptions for bipolar disorder are gradually decreasing, with less attention having been paid to other indications.

METHODS

We examined lithium prescriptions between 1994 and 2017 in data provided by the Drug Safety in Psychiatry Program AMSP, including psychiatric hospitals in Germany, Austria and Switzerland. We compared lithium use for different diagnoses before and after 2001 and in three periods (T1: 1994-2001, T2: 2002-2009, and T3: 2010-2017).

RESULTS

In a total of 158,384 adult inpatients (54% female, mean age 47.4±17.0 years), we observed a statistically significant decrease in lithium prescriptions between 1994-2000 and 2001-2017 in patients with schizophrenia spectrum disorder from 7.7% to 5.1% and in patients with affective disorders from 16.8% to 9.6%. Decreases in use were also observed for diagnostic subgroups: schizoaffective disorder (ICD-10 F25: 27.8% to 17.4%), bipolar disorder (F31: 41.3% to 31%), depressive episode (F32: 8.1% to 3.4%), recurrent depression (F33: 17.9% to 7.5%, all: p<0.001) and emotionally unstable (borderline) personality disorder (6.3% to 3.9%, p=0.01). The results in T1 vs. T2 vs. T3 were for F25: 26.7% vs. 18.2% vs. 16.2%, F32: 7.7% vs. 4.2% vs. 2.7%, F33: 17.2% vs. 8.6% vs. 6.6% and for F31: 40.8% vs. 31.7% vs 30.0%, i. e. there was no further decrease for lithium use in bipolar disorder after 2002. Lithium's main psychotropic co-medications were quetiapine (21.1%), lorazepam (20.6%), and olanzapine (15.2%).

DISCUSSION

In inpatients, the use of lithium has decreased in patients with bipolar disorder and also with various other psychiatric diagnoses.

Clinical High-Risk for Psychosis (CHR-P) circa 2024: Synoptic analysis and synthesis of contemporary treatment guidelines

The construct of Clinical-High Risk for Psychosis (CHR-P) identifies young help-seeking subjects in putative prodromal stages of psychosis and is a central component of the Early Intervention (EI) paradigm in Mental Health, aimed at facilitating rapid entry into appropriate care pathways to prevent the onset of psychosis or mitigate is biopsychosocial consequences. This approach, which promotes an innovative culture of care for early, at risk situations, is inspired by a clinical staging concept as a guide to optimal treatment. The objective of this article is to map the existing guidelines in the field of CHR-P treatment recommendations, examine overlaps and differences, and critically evaluate blind spots to be addressed in future guideline updated. The search identified 9 guidelines focused on CHR-P or schizophrenia and other psychotic conditions but containing a specific section on CHR-P or prodromal psychosis. All guidelines acknowledge that psychosis is preceded by more or less pronounced prodromal stages, and most detail CHR-P criteria. Among guidelines, 8 out of 9 indicate cognitive-behavioural therapy as the best psychotherapeutic option and 7 out of 9 suggest that antipsychotics can be prescribed as second option in case psychosocial and/or other pharmacological interventions prove insufficient or inadequate in reducing clinical severity and subjective suffering. Antidepressants, mood stabilizers, and benzodiazepines were considered for the treatment of comorbid disorders. Only the European Psychiatric Association Guidance paper distinguished treatment recommendations for adults and minors. Agreements in treatment guidelines were discussed in light of recent meta-analytical evidences on pharmacological and non-pharmacological treatments for CHR-P, suggesting the need to provide an updated, age-sensitive consensus on how to manage CHR-P individuals.

Verification of successful maintenance by serum drug level during a guided antipsychotic reduction to reach minimum effective dose (GARMED) trial

BACKGROUND

Inconsistent results regarding the risk of relapse and better subjective outcomes of previous antipsychotic dose reduction trials in patients with remitted psychosis have not been verified using therapeutic drug monitoring (TDM). This study examined plasma drug concentrations of a dose-tapering trial which exhibited the potential of successful maintenance under lower antipsychotic dosages.

METHODS

A 2-year open-label randomized prospective trial recruited remitted patients to undergo guided antipsychotic tapering. Blood samples were collected at baseline, annually, and after each dose reduction. Plasma aripiprazole/dehydroaripiprazole concentrations were determined using LC-MS/MS. The relationship between the dose and serum drug levels was examined using Spearman's correlation. Divided at 120 ng/mL, relapse rate, global function, quality of life, and psychopathology were compared between high- and low- drug level groups.

RESULTS

A total of 126 blood samples were collected, after excluding13 samples due of non-adherence. The correlation coefficients between dosage and drug level were 0.853 (aripiprazole) and 0.864 (dehydroaripiprazole), and the dose and concentration plots were parallel along the tapering trajectories, except patients with non-adherence. The concentration-to-dose ratio of aripiprazole in this cohort, 17.79 ± 7.23 ng/mL/mg, was higher than that in Caucasian populations. No significant differences were observed in the clinical outcomes between the high- and low-level groups. Remarkably, 12 of 15 patients maintained remission at plasma aripiprazole concentrations of <120 ng/mL.

CONCLUSIONS

The lower-than-expected doses reached in our antipsychotic tapering trial were substantiated to provide adequate prophylactic effects by TDM results in a subset of patients treated with aripiprazole, even considering the differences in pharmacogenomics between ethnicities.

Pharmacological Treatments of Negative Symptoms in Schizophrenia-An Update

Schizophrenia is a chronic psychotic disorder comprising positive symptoms, negative symptoms, and cognitive deficits. Negative symptoms are associated with stigma, worse functional outcomes, and a significant deterioration in quality of life. Clinical diagnosis is challenging despite its significance, and current treatments offer little improvement in the burden of negative symptoms. This article reviews current pharmacological strategies for treating negative symptoms. Dopaminergic, glutamatergic, serotonergic, noradrenergic, cholinergic, anti-inflammatory compounds, hormones, and psychostimulants are explored. Finally, we review pharmacological global treatment guidelines for negative symptoms. In general, switching to a second-generation antipsychotic seems to be most often recommended for patients with schizophrenia on first-generation antipsychotics, and an add-on antidepressant is considered when depression is also present. However, the treatment of negative symptoms remains an unmet need. Future, larger clinical studies and meta-analyses are needed to establish effective pharmacological agents for the effective treatment of negative symptoms.

Treatment of Cognitive Impairment Associated with Schizophrenia Spectrum Disorders: New Evidence, Challenges, and Future Perspectives

Cognitive impairment associated with schizophrenia (CIAS) represents one of the core features of the disorder and has a significant impact on functional and rehabilitation outcomes of people living with schizophrenia spectrum disorders (SSD). The aim of this critical review is to highlight the most recent evidence on effective treatments available for CIAS, to discuss the current challenges in this field, and to present future perspectives that may help to overcome them. Concerning psychopharmacological approaches, among the most indicated strategies for the management and prevention of CIAS is to favor second-generation antipsychotic medications and avoid long-term and high-dose treatments with anticholinergic medications and benzodiazepines. Moreover, non-pharmacological approaches such as cognitive remediation and physical exercise-based programs represent evidence-based interventions in the treatment of CIAS that have shown reliable evidence of effectiveness on both cognitive and functional outcomes. These treatments, however, are still delivered to people accessing mental health services with a diagnosis of CIAS in an uneven manner, even in high-income countries. Academic and clinical partnership and collaboration, as well as advocacy from service users, families, carers, and stakeholders' organizations could help to reduce the bench to bedside gap in the treatment of CIAS. Future perspectives include the development of novel pharmacological agents that could be effective in the treatment of CIAS, the implementation of novel technologies such as telemedicine and virtual reality in the delivery of evidence-based interventions to improve accessibility and engagement, and further research in the field of non-invasive brain stimulation.

Long-acting antipsychotic treatments: focus on women with schizophrenia

Effective management of schizophrenia (SZ) requires long-term treatment with antipsychotics (APs) to prevent clinical relapse, attain remission and improve patients' personal and social functioning, and quality of life. Although APs remain the cornerstone treatment for patients with SZ, despite their potential benefits, long-acting injectable APs (LAI-APs) remain underused, most notably in women with SZ. The efficacy and tolerability of APs differ significantly between men and women, and some of these differences are more noticeable depending on the patient's age and the stage of the disorder. Although sex differences may influence treatment outcomes in SZ, their pertinence has been insufficiently addressed, especially regarding the use of LAI-APs. Some biological and social experiences, such as pregnancy, lactation, contraception and menopause, are specific to women, but these remain under-researched issues. Implications of this disorder in parenting are also of special pertinence regarding women; therefore, taking sex differences into account when treating SZ patients is now recommended, and improving personalized approaches has been proposed as a priority in the management of psychosis. In this narrative, critical review, we address some aspects specific to sex and their implications for the clinical management of women with SZ, with a special focus on the potential role of LAI-AP treatments.

Sex Differences Between Female and Male Individuals in Antipsychotic Efficacy and Adverse Effects in the Treatment of Schizophrenia

BACKGROUND AND OBJECTIVE

Antipsychotics are core treatments for people living with psychotic disorders. Understanding individualised factors that influence both efficacy and adverse responses will improve outcomes. The objective of this study was to examine sex differences in antipsychotic-related efficacy and tolerability.

METHODS

This was a secondary analysis of data from phase 1 and 1a of Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE); participants with schizophrenia were randomly assigned to double-blinded treatment with oral olanzapine, quetiapine, risperidone, ziprasidone or perphenazine. Measures included Positive and Negative Syndrome Scale (PANSS), Clinical Global Impressions (CGI) scale and Calgary Depression Rating Scale, as well as self-reported side effects, medication compliance, dosage, weight measurements and various blood parameters.

RESULTS

There were 1460 participants including 380 female and 1080 male individuals. Very few differences existed between male and female participants in response, adverse reactions, compliance or antipsychotic dosage. However, significantly more female participants than male participants reported constipation (28% vs 16%), dry mouth (50% vs 38%), gynecomastia/galactorrhea (11% vs 3%), incontinence/nocturia (16% vs 8%) and self reported weight gain (37% vs 24%) [all p < 0.001]. Within the risperidone treatment group, there was a significantly greater increase in prolactin levels (p < 0.001) among female participants (n = 61) than male participants (n = 159). No overall differences in clinician-rated measures, weight gain or other laboratory indicators were found.

CONCLUSIONS

While overall sex differences were limited across efficacy and tolerability for antipsychotic treatment, there were some specific findings with risperidone. Further examination of sex differences within antipsychotic trials will be important to improve efficacy and reduce adverse responses across as well as individualising care for people with schizophrenia.

Cariprazine Orodispersible Tablet: A New Formulation for Cariprazine

INTRODUCTION

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

METHODS

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

RESULT

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

DISCUSSION

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

Impact of long-acting injectable aripiprazole on the concomitant medication and antipsychotic polypharmacy: a retrospective, observational study of 127 patients with psychosis

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.

Polypharmacy to Clozapine Monotherapy in Treatment-Resistant Schizophrenia: A Case Report and Review of the Literature

This case report discusses a 25-year-old Middle Eastern female with a 14-year history of schizophrenia, managed as an inpatient for nearly eight years. Initially referred to a psychiatrist at age 12, with one-year-long concerns about preoccupation with the idea of having a serious illness, depressed mood, decreased appetite, social withdrawal, and aggression, she underwent multiple admissions, various medication combinations, and electroconvulsive therapy but remained resistant to treatment until clozapine monotherapy was initiated in 2023. After starting clozapine, improvements were noted in speech, communication, and eye contact, though negative symptoms and bouts of aggression persisted. This case highlights the efficacy of clozapine monotherapy in managing treatment-resistant schizophrenia after years of ineffective polypharmacy treatment. The importance of clozapine in treating treatment-resistant schizophrenia cannot be understated. Despite its efficacy, clozapine is often underutilised globally due to concerns about adverse effects and the need for blood monitoring, leading to the overuse of antipsychotic polypharmacy. This polypharmacy is associated with higher adverse event rates, increased costs, and uncertain long-term safety. This case report demonstrates the successful management of treatment-resistant schizophrenia with clozapine monotherapy. The patient's significant improvement supports the need to prioritise clozapine, highlighting its benefits over polypharmacy and advocating for its broader use to enhance patient outcomes.

Cariprazine maintenance treatment during pregnancy - a case report

Data on reproductive safety of recently approved newer antipsychotics are limited. Here, we report a case vignette of a patient with schizophrenia treated with cariprazine during pregnancy. The patient became pregnant unexpectedly while taking medication. As a result of shared decision-making, the patient and her psychiatrist decided to continue the treatment, which proved to be protective against relapse and had no adverse effect either on the course of pregnancy or on the health of the newborn. Cariprazine maintenance treatment during pregnancy was found to be safe in our case.

In-Hospital Use of Long-Acting Injectable Antipsychotics and Readmission Risk in Patients With First-Admission Schizophrenia in Taiwan

Importance

Long-acting injectable antipsychotics (LAIs) can help decrease the rate of nonadherence to medications in patients with schizophrenia, but these drugs are underutilized in clinical practice, especially in Asian countries. One strategy for the early prescription of LAIs is to administer the drugs during patients' first admission, when they have more time to absorb medication-related knowledge.

Objective

To estimate the prevalence of and risk factors for in-hospital use of LAIs among first-admission patients with schizophrenia in Taiwan and to examine the association of early discontinuation with readmission risk among patients receiving LAIs.

Design, Setting, and Participants

This cohort study included data from a claims database for patients with a first admission for schizophrenia at psychiatric wards in Taiwan from 2004 to 2017. Eligible patients were diagnosed with schizophrenia or schizoaffective disorder at discharge and aged between 15 and 64 years. Data analysis was performed from April to September 2022.

Exposure

In-hospital use of LAIs with or without early discontinuation.

Main Outcome and Measures

Readmission for any psychotic disorder following discharge from first admission, with risk estimated via multivariable survival regression analysis, including the Cox proportional hazards (CPH) model and accelerated failure time (AFT) model.

Results

Of the 56 211 patients with a first admission for schizophrenia (mean [SD] age, 38.1 [12.1] years; 29 387 men [52.3%]), 46 875 (83.4%) did not receive any LAIs during admission, 5665 (10.1%) received LAIs with early discontinuation, and 3671 (6.5%) received LAIs without early discontinuation. The prevalence of receiving LAIs increased by 4%, from 15.3% (3863 of 25 251 patients) to 19.3% (3013 of 15 608 patients) between 2004-2008 and 2013-2017. After controlling for sex, year, prior antipsychotic use, age at first admission, and length of stay, the CPH regression analysis revealed that the readmission risk increased among patients receiving LAIs with early discontinuation (adjusted hazard ratio [aHR], 1.25; 95% CI, 1.21-1.30) but decreased among patients receiving LAIs without early discontinuation (aHR, 0.88; 95% CI, 0.84-0.92) compared with patients not receiving LAIs. Results remained similar for the AFT model.

Conclusions and Relevance

The incidence of in-hospital use of LAIs among patients with a first admission for schizophrenia has remained low. In this study, early discontinuation of LAIs was associated with readmission risk-specifically, early discontinuation with a higher risk while the lack of early discontinuation with a lower risk compared with treatment with oral antipsychotics alone-which suggests our results have implications for improving the efficacy of LAI administration among patients with a first admission for schizophrenia.

A systematic review of clozapine for aggression and violence in patients with schizophrenia or schizoaffective disorder

Although uncommon, the risk of aggression and violence is greater in people with schizophrenia than in the general population. Clozapine is the "gold standard" pharmacologic treatment for the management of persistent agitation and aggression in people with schizophrenia and is consistently recommended by guidelines and reviews for this purpose. Although clozapine is indicated for treatment-resistant schizophrenia based on its superior efficacy, studies have proposed that clozapine may have specific properties that ameliorate aggression and hostility that are distinct from its antipsychotic effects. A literature review was conducted on June 3, 2023, using the US National Library of Medicine's PubMed resource to identify articles focusing on clozapine for the treatment of aggression, violence, and/or hostility in patients with schizophrenia or schizoaffective disorder. The majority of evidence, including from randomized control trials, supports the utilization of clozapine as maintenance treatment for persistent aggressive behavior in patients with schizophrenia, and supports that its anti-aggressive effects may be independent from its antipsychotic properties (e.g. - treatment of hallucinations and delusions). Future randomized control studies evaluating clozapine and clozapine serum levels with aggression as the primary outcome would be of benefit.

A network meta-analysis of efficacy, acceptability, and tolerability of antipsychotics in treatment-resistant schizophrenia

OBJECTIVE

Clozapine is considered as the standard treatment for this subgroup, but the evidence is not unequivocal. There are several potential alternatives being used because of the possible adverse effects of clozapine. We aimed to examine the efficacy and adverse events of different antipsychotics in treatment-resistant schizophrenia by performing a network meta-analysis.

METHODS

We searched the Cochrane Schizophrenia Group register for randomized-controlled trials (up to March 06, 2022) and MEDLINE (up to January 20, 2023). We included blinded and open studies and participants with a broad definition of treatment resistance. The primary outcome was overall symptoms of schizophrenia; secondary outcomes were response to treatment, positive and negative symptoms of schizophrenia, discontinuation, side effects, quality of life, and functioning. The study was registered in Open Science Framework ( https://osf.io/9nf2y/ ).

RESULTS

We included 60 studies involving 6838 participants in the network meta-analysis. In the primary outcome, clozapine and olanzapine were more efficacious than risperidone, haloperidol, fluphenazine, sertindole, chlorpromazine, and quetiapine (range of mean SMDs, - 0.11 to - 0.48). The difference between clozapine and olanzapine was trivial and uncertain (SMD - 0.05, 95% CI, - 0.21 to 0.11). The result of other efficacy outcomes as well as subgroup and sensitivity analyses were consistent with the primary analysis. Clozapine and olanzapine were associated with more weight gain, and clozapine was associated with more sedation events compared to many other antipsychotics.

CONCLUSIONS

Clozapine remains the gold standard for patients with treatment-resistant schizophrenia. Olanzapine seems to be second-best and could be tried before switching to clozapine.

A review on side effect management of second-generation antipsychotics to treat schizophrenia: a drug safety perspective

INTRODUCTION

Effective side effects management present a challenge in antipsychotic treatment with second-generation antipsychotics (SGAs). In recent years, most of the commonly used SGAs, except for clozapine, have been shown to differ only slightly in their effectiveness, but considerably regarding perceived side effects, safety profiles, and compatibility to preexisting medical conditions.

AREAS COVERED

The current state of available evidence on side-effect management in SGA treatment of patients with schizophrenia spectrum disorders (SSD) is reviewed. In addition, current guideline recommendations are summarized, highlighting evidence gaps.

EXPERT OPINION

SGA safety and side effects needs to be considered in treatment planning. Shared decision-making assistants (SDMA) can support patients, practitioners and relatives to orient their decisions toward avoiding side effects relevant to patients' adherence. Alongside general measures like psychosocial and psychotherapeutic care, switching to better tolerated SGAs can be considered a relatively safe strategy. By contrast, novel meta-analytical evidence emphasizes that dose reduction of SGAs can statistically increase the risk of relapse and other unfavorable outcomes. Further, depending on the type and severity of SGA-related side effects, specific treatments can be used to alleviate induced side effects (e.g. add-on metformin to reduce weight-gain). Finally, discontinuation should be reserved for acute emergencies.

Relationship between stable smoking behavior and cognitive function in male schizophrenia patients

OBJECTIVE

To explore the relationship between stable smoking behavior and cognitive function in male schizophrenia patients.

METHODS

A simple random sampling method is applied to select 120 patients with schizophrenia admitted to a hospital from August 2020 to December 2022 as the subjects. They are divided into two groups based on whether they smoked or not. Their cognitive function is evaluated using the Stroop test (SWCT), continuous task test (CPT), and Chinese version of the Schizophrenic Cognitive Function Battery Test (MCCB). The Spearman correlation analysis is applied to verify the correlation between smoking behavior and SWCT, CPT, and MCCB in patients. Additionally, the Fagerstrom Nicotine Dependence Scale (FTND) is used to evaluate the nicotine dependence degree in smoking group patients. Pearson correlation analysis verifies the correlation between nicotine dependence and SWCT, CPT, MCCB in smoking group patients.

RESULTS

Among 120 patients include in this study, 3 have symptoms during the trial period, and 1 patient has an error in filling out the questionnaire, all of which are excluded. Finally, 116 valid documents are collected, with an effective recovery rate of 96.67%. According to the SWCT test results, the number of single word errors, single word time, double word errors, and double word time in the smoking group exceed the non-smoking group (P < 0.05). According to the CPT test results, the number of correct reactions in the smoking group is below the non-smoking group. The correct average reaction time, error rate of interference items, and error rate of ineffective items exceed the non-smoking group (P < 0.05). According to the MCCB test results, the scores of connectivity, visual spatial memory, and continuous operation test in the smoking group are below the non-smoking group (P < 0.05). The Spearman correlation analysis results show that stable smoking behavior in male schizophrenia patients is positively correlated with the number of single word errors, double word errors, double word time, correct mean reaction time, interference item error rate, and invalid item error rate (r = 0.216-0.524, P < 0.05). It is also positively correlated with the number of correct reactions, immediate memory, language function, delayed memory, MCCB connectivity, visual spatial memory, and continuous operation (r = -0.212-0.356, P < 0.05). The Pearson correlation analysis results show that the nicotine dependence degree in stable male schizophrenia patients is negatively correlated with monochromatic error count, immediate memory, visual span, attention, and MCCB scores (r = -0.321-0.930, P < 0.05).

CONCLUSION

Smoking in male schizophrenic patients may have impacts on their cognitive function. This impact worsens as the patient's nicotine dependence increases, especially on their memory function. Effective measures should be taken in clinical practice to correct patients' smoking behavior, reduce their nicotine dependence, and improve their cognitive function.

Real-World Evidence of Antipsychotic Monotherapy Versus Polypharmacy in the Treatment of Schizophrenia Spectrum Disorders

PURPOSE/BACKGROUND

It is still not well known whether antipsychotic monotherapy versus polypharmacy differs in terms of efficacy in the emergency department (ED) utilization, presentation with agitation/aggression, and rehospitalization in schizophrenia spectrum disorders (SSD) patients. This study aimed to determine the effectiveness of antipsychotic monotherapy and polypharmacy for these outcomes in the real world.

METHODS/PROCEDURES

The study was conducted with electronic health records of 669 SSD patients admitted to the ED. Patients were evaluated in 4 groups according to antipsychotic use at the first admission to ED: antipsychotic noncompliance for more than 90 days, antipsychotic noncompliance for 15 to 90 days, antipsychotic monotherapy, and polypharmacy. All patients followed up for at least 1 year after index admission. The primary outcomes determined an association between antipsychotic monotherapy versus polypharmacy and all-cause psychiatric hospitalization between the groups after index admission in the SSD.

FINDINGS/RESULTS

The groups, including patients with antipsychotic noncompliance, had higher ED visits, more hospitalizations, and more admissions with agitation/aggression compared with antipsychotic monotherapy or polypharmacy. However, no differences were found between monotherapy and polypharmacy groups regarding these outcomes. In addition, there was no difference in the risk of hospitalization in monotherapy antipsychotic users compared with polypharmacy users. Patients discharged with monotherapy or polypharmacy also had similar rehospitalization rates at follow-up.

IMPLICATIONS/CONCLUSIONS

There is no positive evidence that recommending polypharmacy over antipsychotic monotherapy is superior with regard to the resulting frequency of ED visits, ED admissions with agitation/aggression, hospitalization, and rehospitalization. In this context, antipsychotic monotherapy may be preferred over polypharmacy in patients who are not resistant to treatment.

Does Slow and Steady Win the Race? Rates of Antipsychotic Discontinuation, Antipsychotic Dose, and Risk of Psychotic Relapse

BACKGROUND

Antipsychotics are recommended for prevention of relapse in schizophrenia. It is unclear whether increased risk of relapse following antipsychotic discontinuation is predominantly associated with an absolute magnitude of dose reduction or rate of antipsychotic reduction. Establishing the responsible mechanism is important because prolonged withdrawal schedules have been suggested to reduce risk of relapse.

STUDY DESIGN

Individual patient data from antipsychotic discontinuation studies were obtained. We estimated the occupancy of receptors over time using half-lives and median effective dose ED50 values obtained from pharmacokinetic and receptor occupancy studies. Hazard ratios for relapse events were calculated using Cox proportional hazards models to assess the influence of formulation (oral, 1-monthly, and 3-monthly injections). The change in hazard ratio over time was estimated, and the effect of time-varying covariates was calculated, including rate of occupancy reduction and absolute receptor occupancy.

STUDY RESULTS

Five studies including 1388 participants with schizophrenia were identified (k = 2: oral, k = 2: 1-monthly injection, k = 1: 3-monthly injection). Withdrawal of long-acting injectable medication did not lead to a lower hazard ratio compared with withdrawal of oral medication, and this included the period immediately following randomization. Hazard ratios were not associated with the rate of decline of receptor occupancy; however, they were associated with reduced absolute occupancy in trials of long-acting injections (P = .038).

CONCLUSIONS

Antipsychotic discontinuation is associated with an increased risk of psychotic relapse, related to receptor occupancy. Although relapse does not appear to be related to the rate of discontinuation, gradual discontinuation strategies may allow for easier antipsychotic reinstatement in case of symptomatic worsening.

Areas of interest and sentiment analysis towards second generation antipsychotics, lithium and mood stabilizing anticonvulsants: Unsupervised analysis using Twitter

BACKGROUND

Severe mental disorders like Schizophrenia and related psychotic disorders (SRD) or Bipolar Disorder (BD) require pharmacological treatment for relapse prevention and quality of life improvement. Yet, treatment adherence is a challenge, partly due to patients' attitudes and beliefs towards their medication. Social media listening offers insights into patient experiences and preferences, particularly in severe mental disorders.

METHODS

All tweets posted between 2008 and 2022 mentioning the names of the main drugs used in SRD and BD were analyzed using advanced artificial intelligence techniques such as machine learning, and deep learning, along with natural language processing.

RESULTS

In this 15-year study analyzing 893,289 tweets, second generation antipsychotics received more mentions in English tweets, whereas mood stabilizers received more tweets in Spanish. English tweets about economic and legal aspects displayed negative emotions, while Spanish tweets seeking advice showed surprise. Moreover, a recurring theme in Spanish tweets was the shortage of medications, evoking feelings of anger among users.

LIMITATIONS

This study's analysis of Twitter data, while insightful, may not fully capture the nuances of discussions due to the platform's brevity. Additionally, the wide therapeutic use of the studied drugs, complicates the isolation of disorder-specific discourse. Only English and Spanish tweets were examined, limiting the cultural breadth of the findings.

CONCLUSION

This study emphasizes the importance of social media research in understanding user perceptions of SRD and BD treatments. The results provide valuable insights for clinicians when considering how patients and the general public view and communicate about these treatments in the digital environment.

Proportion of Antipsychotics with CYP2D6 Pharmacogenetic (PGx) Associations Prescribed in an Early Intervention in Psychosis (EIP) Cohort: A Cross-Sectional Study

BACKGROUND

Prescribing drugs for psychosis (antipsychotics) is challenging due to high rates of poor treatment outcomes, which are in part explained by an individual's genetics. Pharmacogenomic (PGx) testing can help clinicians tailor the choice or dose of psychosis drugs to an individual's genetics, particularly psychosis drugs with known variable response due to CYP2D6 gene variants ('CYP2D6-PGx antipsychotics').

AIMS

This study aims to investigate differences between demographic groups prescribed 'CYP2D6-PGx antipsychotics' and estimate the proportion of patients eligible for PGx testing based on current pharmacogenomics guidance.

METHODS

A cross-sectional study took place extracting data from 243 patients' medical records to explore psychosis drug prescribing, including drug transitions. Demographic data such as age, sex, ethnicity, and clinical sub-team were collected and summarised. Descriptive statistics explored the proportion of 'CYP2D6-PGx antipsychotic' prescribing and the nature of transitions. We used logistic regression analysis to investigate associations between demographic variables and prescription of 'CYP2D6-PGx antipsychotic' versus 'non-CYP2D6-PGx antipsychotic'.

RESULTS

Two-thirds (164) of patients had been prescribed a 'CYP2D6-PGx antipsychotic' (aripiprazole, risperidone, haloperidol or zuclopenthixol). Over a fifth (23%) of patients would have met the suggested criteria for PGx testing, following two psychosis drug trials. There were no statistically significant differences between age, sex, or ethnicity in the likelihood of being prescribed a 'CYP2D6-PGx antipsychotic'.

CONCLUSIONS

This study demonstrated high rates of prescribing 'CYP2D6-PGx-antipsychotics' in an EIP cohort, providing a rationale for further exploration of how PGx testing can be implemented in EIP services to personalise the prescribing of drugs for psychosis.

Tolerability and safety outcomes of first-line oral second-generation antipsychotics in patients with schizophrenia

INTRODUCTION

Antipsychotics are the foundation of pharmacologic treatment for schizophrenia. There are many oral antipsychotics available and given that these medications are generally considered comparably efficacious when titrated to an adequate dose, their varied tolerability, and safety profiles become critically important for medication selection.

AREAS COVERED

This paper reviews tolerability and safety considerations for first-line second-generation oral antipsychotics currently approved for the treatment of schizophrenia in the USA. Excluded from consideration are clozapine and non-oral formulations.

EXPERT OPINION

Among antipsychotics, there are many differences in adverse reactions observed in clinical trials, such as variable likelihood to cause sedation vs insomnia, weight gain and abnormalities in glucose/lipid metabolism, hyperprolactinemia, potential for impact on the QT interval, and motoric adverse effects. Additional safety data that can help with medication selection include safety in pregnancy and lactation, and potential for drug-drug interactions. Ultimately, working with patients to personalize treatment by focusing on safety and individual tolerability considerations for various adverse effects can help in building a therapeutic alliance and improving patients' outcomes.

Borderline personality disorder vs. schizophrenia spectrum disorders in young people recruited within an "Early Intervention in Psychosis" service: clinical and outcome comparisons

Borderline Personality Disorder (BPD) is under-recognized in First-Episode Psychosis (FEP) and its psychotic manifestations are difficult to differentiate from Schizophrenia Spectrum Disorders (SSD). The aim of this investigation was to compare clinical, sociodemographic, and outcome characteristics between FEP patients with BPD vs. FEP subjects with SSD both at baseline and across a 2-year follow-up period. Participants completed the Health of the Nation Outcome Scale (HoNOS), the Positive And Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF) scale both at entry and every 12 months during the follow-up. A mixed-design ANOVA model was conducted to investigate the temporal stability of clinical scores within and between the two subgroups. Among 356 FEP participants, 49 had a BPD diagnosis. Compared to FEP/SSD (n = 307), FEP/BPD patients showed higher prevalence of employment, current substance use, and past attempted suicide. They had a lower equivalent dose of antipsychotic medication at entry and lower levels of negative symptoms. Finally, they had a higher 2-year drop-out rate and a significant improvement in psychopathological scores limited to the first year of treatment. BPD as categorical entity represents a FEP subgroup with specific clinical challenges. Appropriate treatment guidelines for this FEP subgroup are thus needed.

Antipsychotic Medication and Risk of Metabolic Disorders in People With Schizophrenia: A Longitudinal Study Using the UK Clinical Practice Research Datalink

BACKGROUND AND HYPOTHESIS

Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics.

STUDY DESIGN

A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose.

STUDY RESULTS

Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found.

CONCLUSIONS

Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study.

Association between olanzapine plasma concentrations and treatment response: A systematic review, meta-analysis and individual participant data meta-analysis

AIMS

By meta-analysing pooled studies and available individual participant data, we aim to provide new insight on olanzapine therapeutic drug monitoring in schizophrenia.

METHOD

We conducted a computerized search of bibliographic databases (Pubmed, Cochrane library, Web of Science and PsycINFO) to identify studies that assessed the relationship between olanzapine plasma concentration and the change in patients' clinical scores. We investigated this relationship with olanzapine plasma level 12h00 post-intake using a random-effects model.

RESULTS

7 studies were included in the pooled data analysis (781 patients). We found no difference in oral dose between responders and non-responders but a significantly higher concentration of 4.50 µg/L in responders (p < 0.01). Olanzapine concentration above the thresholds identified in each study was associated with response (odd ratio = 3.50, p = 0.0007). We identified that non-responder patients showed greater inter-individual variability than responders. In the individual data analysis (159 patients), we found no relationship between dose and clinical response but an association between plasma level and response in the shape of a parabolic curve. The Receiver Operating Characteristic curve found a threshold of 22.07 µg/L to identify responders (96% sensitivity, 86% specificity) and a threshold of 56.47 µg/L to identify a decreased probability of response.

CONCLUSION

In contrast to oral dose, our work confirmed that plasma olanzapine levels are associated with clinical response and should therefore be used to optimise treatment. We determined a treatment response threshold of 22.07 µg/L and suggest that a concentration above the therapeutic window may result in a decreased response.

Effects of yoga on clinical symptoms, quality of life and social functioning in patients with schizophrenia: A systematic review and meta-analysis

BACKGROUND

Yoga is gradually being explored as a potential complementary intervention in addition to psychiatric drugs for schizophrenia. However, there are conflicts on the efficacy of yoga for schizophrenia. This meta-analysis was aimed to evaluate the association of yoga intervention with reductions on clinical symptoms and improvements in quality of life (QoL) as well as social functioning among schizophrenia.

METHOD

Systematic literature search was undertaken to identify all RCTs that compared yoga with active or passive controls for patients with schizophrenia from inception to July 2023. The outcomes were measurements of positive symptoms, negative symptoms, QoL and social functioning. Random-effects models were performed to calculate the effect sizes in the standardized mean differences reporting as Hedges' s g statistic.

RESULTS

19 studies enrolling 1274 participants with schizophrenia were included. Yoga had a medium effect on positive symptoms in the short term (Hedges's g = 0.31) and small effect in the long term (Hedges's g = 0.18). Medium significant effects were also found on negative symptoms in both the short term (Hedges's g = 0.44) and the long term (Hedges's g = 0.35). Yoga had a significant impact on improving both total QoL (Hedges's g = 0.34) and social functioning (Hedges's g = 0.45) with medium effect sizes.

CONCLUSIONS

Yoga was associated with significant reductions on negative and positive symptoms, and significant improvements in QoL as well as social functioning in patients with schizophrenia. Future research should explore the long-term efficacy of yoga for schizophrenia, encompassing more diverse populations.

Network Meta-Analysis Indicates Superior Effects of Omega-3 Polyunsaturated Fatty Acids in Preventing the Transition to Psychosis in Individuals at Clinical High-Risk

BACKGROUND

The efficacy of pharmacological and nutritional interventions in individuals at clinical high risk for psychosis (CHR-P) remains elusive. This study aims to investigate the efficacy of pharmacological and nutritional interventions in CHR-P and whether these interventions can enhance the efficacy of psychological treatments.

METHODS

We systematically reviewed data from 5 databases until July 24, 2021: PubMed, Web of Science, EMBASE, China National Knowledge Infrastructure, and WanFang Data. The primary outcome was the transition to psychosis. Network meta-analyses were conducted at 3 time points (6, 12, and ≥24 months) considering both pharmacological/nutritional interventions alone and its combination with psychotherapy.

RESULTS

Out of 11 417 identified references, 21 studies were included, comprising 1983 participants. CHR-P participants receiving omega-3 polyunsaturated fatty acids treatment were associated with a lower probability of transition compared with placebo/control at 6 months (odds ratio [OR] = 0.07, 95% confidence interval [CI] = .01 to .054), 12 months (OR = 0.14, 95% CI = .03 to .66), and ≥24 months (OR = 0.16, 95% CI = .05 to .54). Moreover, risperidone plus psychotherapy was associated with a lower likelihood of transition at 6 months compared with placebo/control plus psychotherapy, but this result was not sustained over longer durations.

CONCLUSION

Omega-3 polyunsaturated fatty acids helped in preventing transitions to psychosis compared with controls.

PROSPERO REGISTRATION NUMBER

CRD42021256209.

Evaluating Monitoring Guidelines of Clozapine-Induced Adverse Effects: a Systematic Review

BACKGROUND AND OBJECTIVES

Despite the evidence that no other antipsychotic is effective as clozapine for the treatment of resistant schizophrenia, it is associated with various metabolic, neuroendocrine, cardiovascular, and gastrointestinal adverse effects. Guidelines aiming to address the monitoring of clozapine's (serious) adverse effects can be helpful to prevent and treat these effects. However, many of these guidelines seem to lack one or more important monitoring recommendations. We aimed to systematically review the content and quality of existing monitoring guidelines/recommendations for clozapine-induced adverse effects.

METHODS

A comprehensive and systematic literature search, using the MEDLINE, Embase, Web of Science, and Cochrane databases, was conducted for guidelines/recommendations on the monitoring of clozapine-induced adverse events, published between January 2004 and April 2023 (last search 16 April 2023). Only peer-reviewed published guidelines reporting on the comprehensive monitoring of all major clozapine-induced adverse effects and including evidence-based recommendations, developed after the year 2004, were included. Studies reporting on the monitoring of adverse effects of clozapine without being a formal guideline, guidelines reporting on the monitoring of one or a limited number of adverse effects of clozapine, guidelines that were not peer reviewed or published, expert opinion papers without formal consensus guideline development, or guidelines developed before the year 2004, were excluded. The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool was used to evaluate the guidelines/recommendations' quality.

RESULTS

Only one guideline met the inclusion criteria. This consensus statement made recommendations for hematological monitoring, and the monitoring of metabolic, cardiac, and three other adverse effects. Highest scores for the qualitative assessment were found for the domains "scope and purpose" (66.7%), "clarity of presentation" (44.4%), and "editorial independence" (66.7%). Lowest scores were found for "rigor of development" (14.6%) and "applicability" (0%).

CONCLUSIONS

Future guidelines should develop more comprehensive recommendations about specific clozapine-induced adverse effects, including constipation, myocarditis, tachycardia, and seizures, as well as include a rechallenge policy. There is an urgent need for well-developed, methodologically stringent, guidelines.

REGISTRATION

PROSPERO registration number, CRD42023402480.

Catatonia-related adverse outcomes after long-acting injectable antipsychotics: Case series

Due to a lack of controlled, prospective trials examining the pathophysiology and treatment of catatonia, current guidelines vary regarding how and when to best use antipsychotics in the presence of catatonia and what factors to consider in a thorough risk-benefit analysis. The literature is especially limited in describing the risks and benefits of using long-acting injectable antipsychotics in the presence of catatonia. We describe four cases where patients with preexisting catatonia received long-acting injectable first generation antipsychotics and experienced severe adverse effects (three experienced worsening of catatonia and one experienced neuroleptic malignant syndrome). The evidence base for managing comorbid catatonia and psychosis remains underdeveloped and inconsistent, but there are numerous known risk factors for adverse antipsychotic reactions, which we describe in relation to these cases. Finally, we present best practices to consider when managing comorbid psychosis and catatonia, especially when considering the use of long-acting injectable antipsychotics.

Prevalence and Cost of Antipsychotic Prescribing, within the Context of Psycholeptic Prescribing, in the Irish Setting

Psycholeptic and specifically antipsychotic prescribing is increasing worldwide each year. This study aims to investigate the prevalence and cost of antipsychotic prescribing, within the wider frame of psycholeptic prescribing, in the Irish context. Quantitative analysis of a dataset from the Primary Care Reimbursement Service relating to cost and prescribing frequency of ATC Class N05 psycholeptic drugs from January 2020-August 2022 inclusive was conducted using Microsoft® Excel® for Microsoft 365 MSO (Version 2311) and STATA 18. Descriptive statistics and time-trend regression analysis were used to investigate the prescribing prevalence of psycholeptics and antipsychotics licensed for use in the Republic of Ireland, and the total cost per funding scheme. The prevalence of psycholeptic prescribing increased yearly from 2020-2022, peaking at 328,572 prescriptions in December 2020 with a total cost of psycholeptic drugs to the State in 2021 of €57,886,250, which was 0.5% of an increase on 2020. Over the 32-month time period, the average monthly cost of psycholeptic drugs was €4,436,469 on the General Medical Services (GMS) scheme and €369,154 on the Drug Payment Scheme (DPS). In 2021, quetiapine, olanzapine, and risperidone were the most prescribed antipsychotics, accounting for 66.58% of antipsychotics prescribed on the GMS scheme. This study identified the large expenditure on psycholeptics and antipsychotics in Ireland, with a higher proportion of the Irish healthcare budget spent on antipsychotics than that of the UK and the USA. The development of Irish antipsychotic prescribing guidelines may allow for structured, cost-effective prescribing.

Characteristics of patients with schizophrenia switching from oral antipsychotics to once-monthly paliperidone palmitate (PP1M): a systematic review

BACKGROUND

The utilization of once-monthly paliperidone palmitate (PP1M) in schizophrenia treatment has increased due to its enhanced adherence and convenience. However, there is limited evidence on patient characteristics that may influence treatment outcomes when switching from oral antipsychotics (OAPs) to PP1M therapy. This systematic review aims to identify such patient characteristics and explore potential beneficial factors to aid healthcare professionals in clinical practice.

METHODS

A systematic literature search was conducted in the PubMed, Embase, and Cochrane Library databases up to July 19, 2022. Studies related to patients with schizophrenia who had been previously treated with OAPs and switched to PP1M were identified and included. Outcomes included the Positive and Negative Syndrome Scale (PANSS) total score, the clinical Global Impressions - Severity (CGI-S) score, the Personal and Social Performance (PSP) total score, and hospitalisation rate. Data were independently extracted and analysed. The results were presented through a narrative synthesis.

RESULTS

Eleven studies with a total of 4150 patients were included, identifying nine potential characteristics. The most commonly reported characteristics was patient's prior treatment with OAPs, followed by the stage of disease, duration of illness (DI), ethnicity, reason for switching to PP1M, history of hospitalisation, time of start injection of PP1M, the PANSS and PSP total score at baseline. Patients in the acute stage, with a shorter DI, a less than 1-week time interval to PP1M injection, and a lower PANSS total score at baseline may have a trend on providing better improvements on PANSS total score. Acute stage and shorter DI also showed potential trends in reducing CGI-S score. Early initiation of PP1M, switching for reasons other than lack of efficacy, and a higher PSP score at baseline exhibited potential trends towards better PSP total score improvements.

CONCLUSION

Our findings may suggest that patients in acute stage, with a shorter duration of illness, with early initiation of PP1M injection, and lower PANSS or PSP scores may trend towards better clinical results when transitioning to PP1M from OAPs. Further research is necessary to validate these potential associations and identify any unexplored characteristics. Such investigations are crucial for providing comprehensive clinical recommendations and informing treatment strategies in this context.

Prescribing and deprescribing trends in schizophrenia: An overview of inpatients in Belgium and in the Canadian province of Québec

Although switching to antipsychotic monotherapy improves patient outcomes in schizophrenia, antipsychotic deprescribing is rarely performed, and its use varies between countries, as do psychotropic prescribing patterns. This study aimed to determine factors associated with antipsychotic deprescribing at discharge after a psychiatric hospitalization and to compare psychotropic prescribing patterns between Belgium and Québec, Canada. Data on adult inpatients with schizophrenia were collected retrospectively in seven hospitals. At discharge, the number of antipsychotics had decreased in 22.2% of the 63 Canadian patients and 9.9% of the 516 Belgian patients. A number of factors increased the likelihood of antipsychotic deprescribing: a hospitalization in the Canadian hospital (aOR = 4.13, 95% CI 1.48-11.5), living in a residential facility (aOR = 2.51, 95% CI 1.05-4.39), ≥2 previous antipsychotic trials (aOR = 15.38, 95% CI 3.62-65.36), having an antipsychotic side effect (aOR = 1.86, 95% CI 1.01-3.44) and being in a general hospital (aOR = 2.28, 95% CI 1.09-4.75). Patients on a long-acting injectable antipsychotic (aOR = 0.51, 95% CI 0.26-0.98), with prior clozapine use (aOR = 0.36, 95% CI 0.13-0.95), greater antipsychotic exposure (aOR = 0.35, 95% CI 0.2-0.61) and more hypno-sedatives (aOR = 0.65, 95% CI 0.43-0.98), were less likely to be deprescribed. Specific deprescribing interventions could target patients who are less likely to be deprescribed.

Switching antipsychotics to partial dopamine D2-agonists in individuals affected by schizophrenia: a narrative review

OBJECTIVE

The aim of this review is to analyse the literature regarding studies centred on the clinical outcome of individuals affected by schizophrenia and treated with various antipsychotics, and then switched to orally administered partial D2-dopamine agonists (PD2A): Aripiprazole (ARI), brexpiprazole (BREX) or cariprazine (CARI).

METHOD

A PubMed literature search was performed on 16 February 2021, and updated on Jan 26, 2022 for literature on antipsychotic switching in individuals affected by schizophrenia. Literature was included from 2002 onward. Six strategies were defined: Abrupt, gradual and cross-taper switch, and 3 hybrid strategies. The primary outcome was all-cause discontinuation rate per switch strategy per goal medication.

RESULTS

In 10 reports on switching to ARI, 21 studies with different strategies were described, but there were only 4 reports and 5 strategies on switching to BREX. Only one study about CARI was included, but it was not designed as a switch study. The studies are difficult to compare due to differences in methodology, previous antipsychotic medication, doses of the introduced P2DA and study duration.

CONCLUSION

This analysis did not reveal evidence for a preferable switching strategy. A protocol should be developed which defines optimal duration, instruments to be used, and the timing of the exams.KEY MESSAGESMost switch studies on partial D2-agonists focus on ARI, with only a few on BREX, while little is known about the clinical outcome of switching individuals to CARIThere is a wide variation of possible switch methods: Abrupt switch - gradual switch - cross-tapering switch - hybrid strategies including plateau switchThe protocols used differ considerably between the studies. A strict comparison between the studies is difficult, for which reason the present evidence does not support an unambiguous preference for a particular switch strategy.From a methodological point of view, a standardised clinical protocol should be developed to allow comparisons between studies regarding the clinical outcome of individuals switched from one antipsychotic drug to another.

Multigenetic Pharmacogenomics-Guided Treatment vs Treatment As Usual Among Hospitalized Men With Schizophrenia: A Randomized Clinical Trial

Importance

Limited evidence supports multigenetic pharmacogenomics-guided treatment (MPGT) in schizophrenia.

Objective

To evaluate the clinical effectiveness of MPGT in schizophrenia in a randomized clinical trial (RCT).

Design, Setting, and Participants

This RCT was conducted from March 2020 to March 2022. Male Chinese Han inpatients aged 18 to 60 years diagnosed with schizophrenia with a Positive and Negative Symptom Scale (PANSS) score of 60 or more from 2 selected study hospitals were included. Patients and raters were masked to MPGT or treatment as usual (TAU) randomization.

Interventions

Participants were randomly assigned in a 1:1 ratio to receive either MPGT or TAU for 12 weeks.

Main Outcomes and Measures

The primary efficacy outcome was the percentage change in PANSS total scores (range, 30 to 210) from baseline to week 6 analyzed by a modified intention-to-treat mixed model for repeated measures. The secondary outcome included response and symptomatic remission rates.

Results

A total of 210 participants (mean [SD] age, 29.2 [8.8] years) were enrolled and analyzed, with 113 assigned to MPGT and 97 to TAU. Compared with those randomized to TAU, participants randomized to MPGT demonstrated a significantly higher percentage change in PANSS score (74.2% vs 64.9%; adjusted mean difference, 9.2 percentage points; 95% CI, 4.4-14.1 percentage points; P < .001) and a higher response rate (93 of 113 [82.3%] vs 63 of 97 [64.9%]; adjusted odds ratio, 2.48; 95% CI, 1.28-4.80; P = .01) at the end of week 6.

Conclusions and Relevance

In this RCT of MPGT, MPGT was more effective than TAU in treating patients with schizophrenia. These findings suggest that multigenetic pharmacogenomic testing could serve as an effective tool to guide the treatment of schizophrenia.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2000029671.

Data-Driven Taxonomy for Antipsychotic Medication: A New Classification System

BACKGROUND

Globally, there are more than 25 licensed antipsychotic medications. Antipsychotics are commonly described as either typical or atypical, but this dichotomous classification does not reflect the diversity of their pharmacological and clinical profiles. There is a need for a data-driven antipsychotic classification scheme suitable for clinicians and researchers that maps onto both pharmacological and clinical effects. Receptor affinity provides one starting point for such a scheme.

METHODS

We analyzed affinities of 27 antipsychotics for 42 receptors from 3325 in vitro receptor binding studies. We used a clustering algorithm to group antipsychotics based on receptor affinity. Using a machine learning model, we examined the ability of this grouping to predict antipsychotic-induced clinical effects quantified according to an umbrella review of clinical trial and treatment guideline data.

RESULTS

Clustering resulted in 4 groups of antipsychotics. The predominant receptor affinity and clinical effect "fingerprints" of these 4 groups were defined as follows: group 1, muscarinic (M2-M5) receptor antagonism (cholinergic and metabolic side effects); group 2, dopamine (D2) partial agonism and adrenergic antagonism (overall low side-effect burden); group 3, serotonergic and dopaminergic antagonism (overall moderate side-effect burden); and group 4, dopaminergic antagonism (extrapyramidal side effects and hyperprolactinemia). Groups 1 and 4 were more efficacious than groups 2 and 3. The classification was shown to predict out-of-sample clinical effects of individual drugs.

CONCLUSIONS

A receptor affinity-based grouping not only reflects compound pharmacology but also detects meaningful clinical differences. This approach has the potential to benefit both patients and researchers by guiding treatment and informing drug development.

The role of pharmacists in supporting service users to optimise antipsychotic medication

Pharmacists have a contribution to make in improving optimising medication use for people on antipsychotic medication. The rates of prescribing antipsychotics have increased in England with an 18% rise from 2015 to 2020. People on antipsychotic medication are not treated as equal partners in conversations about their medications. This can leave people to make decisions about their antipsychotic medications without input from their prescribers which can have significant consequences for individuals. Involving people in the decision-making process, as experts on their own condition, has the potential to improve treatment outcomes. The evidence suggests that involving pharmacists in supporting people with serious mental illnesses will lead to improved clinical outcomes. Key areas for pharmacist involvement are providing information, education and counselling on antipsychotic medication and the side effects and reducing polypharmacy especially when antipsychotics are prescribed off license.

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

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

Development of a Guideline for Antipsychotic-induced Hyperprolactinemia in Korea Using the ADAPTE Process

Objective

To develop an evidence-based guideline for the diagnosis and treatment of antipsychotic-induced hyperprolactinemia by adapting existing high-quality clinical guidelines with a view to improve the clinical symptoms and long-term quality of life of patients by providing appropriate management.

Methods

This guideline was developed according to the ADAPTE methodology. The adaptation process included determining key health questions, systematically searching and screening guidelines, evaluating the quality and contents of these guidelines, deriving recommendations for key questions, and performing a peer review. The selection criteria for the guideline search were (1) evidence-based guidelines, (2) published within the last 5 years, and (3) written in English or Korean.

Results

After evaluating the quality and content, we finally selected three guidelines for adaptation. The final output of the development process was 25 recommendations for 10 key questions. We adopted the Agency for Health Research Quality methodology and presented the level of evidence from levels I to IV. In addition, we defined the recommendation grades from grade A (strongly recommended) to D (no recommendation) based on the level of evidence and clinical significance of the recommendation.

Conclusion

The development and dissemination of the adapted guideline is expected to increase the certainty of medical decision making and improve the quality of medical care. Further studies on the effectiveness and applicability of the developed guideline are necessary.

Immunoinflammatory and oxidative alterations in subjects with schizophrenia under clozapine: A meta-analysis

Clozapine presents immunoregulatory properties not well understood. To address this issue, we performed this systematic review to evaluate the immune alterations induced by clozapine and its relationship with the drug's clinical response and compare it with other antipsychotics. Our systematic review has selected nineteen studies meeting the inclusion criteria, from which eleven were included in the meta-analysis, totalizing 689 subjects distributed over three different comparisons. The results revealed that clozapine treatment activates the compensatory immune-regulatory system (CIRS) (Hedges's g = +1.049; CI +0.62 - +1.47, p < 0.001) but has no effects on the immune-Inflammatory Response System (IRS) (Hedges's g= -0.27; CI -1.76 - +1.22, p = 0.71), M1 macrophage (Hedges's g= -0.32; CI -1.78 - +1.14, p = 0.65) and Th1 (Hedge's g = 0.86; CI -0.93 - +1.814, p = 0.07) profiles. Comparing clozapine-treated patients with other anti-psychotics-treated, plasma levels of interleukin (IL)-6 were greater in the clozapine group (Hedge's g = 0.75; CI 0.35 - 1.15, p<0.001). In addition, higher IL-6 plasma levels after four weeks of clozapine treatment were related to the development of clozapine-induced fever; however, IL-6 levels recovered to baseline in 6-10 weeks due to an unexplained compensatory mechanism. In conclusion, our results show that clozapine treatment causes a time-dependent mixed immune profile characterized by increased IL-6 levels and CIRS activation, which may contribute to this drug mechanism of action and adverse effects. Future studies must be designed to investigate the relationship between clozapine-induced immune alterations and symptom remission, treatment resistance, and adverse effects, given the importance of this drug for treating resistant schizophrenia.

Early non-response as a predictor of later non-response to antipsychotics in schizophrenia: a randomized trial

BACKGROUND

It remains a challenge to predict the long-term response to antipsychotics in patients with schizophrenia who do not respond at an early stage. This study aimed to investigate the optimal predictive cut-off value for early non-response that would better predict later non-response to antipsychotics in patients with schizophrenia.

METHODS

This multicenter, 8-week, open-label, randomized trial was conducted at 19 psychiatric centers throughout China. All enrolled participants were assigned to olanzapine, risperidone, amisulpride, or aripiprazole monotherapy for 8 weeks. The positive and negative syndrome scale (PANSS) was evaluated at baseline, week 2, week 4, and week 8. The main outcome was the prediction of nonresponse. Nonresponse is defined as a < 20% reduction in the total scores of PANSS from baseline to endpoint. Severity ratings of mild, moderate, and severe illness corresponded to baseline PANSS total scores of 58, 75, and 95, respectively.

RESULTS

At week 2, a reduction of < 5% in the PANSS total score showed the highest total accuracy in the severe and mild schizophrenia patients (total accuracy, 75.0% and 80.8%, respectively), and patients who were treated with the risperidone and amisulpride groups (total accuracy, 82.4%, and 78.2%, respectively). A 10% decrease exhibited the best overall accuracy in the moderate schizophrenia patients (total accuracy, 84.0%), olanzapine (total accuracy, 79.2%), and aripiprazole group (total accuracy, 77.4%). At week 4, the best predictive cut-off value was < 20%, regardless of the antipsychotic or severity of illness (total accuracy ranging from 89.8 to 92.1%).

CONCLUSIONS

Symptom reduction at week 2 has acceptable discrimination in predicting later non-response to antipsychotics in schizophrenia, and a more accurate predictive cut-off value should be determined according to the medication regimen and baseline illness severity. The response to treatment during the next 2 weeks after week 2 could be further assessed to determine whether there is a need to change antipsychotic medication during the first four weeks.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov (NCT03451734).

Analysis of clozapine-induced seizures using the Japanese Adverse Drug Event Report database

Among antipsychotics, clozapine is associated with a high risk of seizures. This study aimed to generate novel hypotheses regarding trends in the onset of clozapine-induced seizures using the JADER (Japanese Adverse Drug Event Report) database. Seizures were defined according to the Standardized MedDRA Queries (SMQ) for convulsions (SMQ20000079). Trends in the onset of clozapine-induced seizures were assessed using multivariate logistic regression analysis with covariates of sex, age, clozapine dose, antipsychotic polypharmacy, concomitant medications, and history of convulsive disorder. In addition, we assessed the time-to-onset of clozapine-induced seizures using the median time, interquartile range, and Weibull shape parameter. The JADER database registered 2,745 cases of adverse events with clozapine, and 1,784 cases were included in the analysis after excluding cases for which clinical information was not available. Medium (200-400 mg) and high (> 400 mg) doses of clozapine had a significantly higher reporting rate of seizures than low doses (< 200 mg) (adjusted reporting odds ratio [aROR] = 3.05, 95% confidence interval [CI]: 1.86-4.99 and aROR = 9.81, 95% CI: 6.06-15.89, respectively). Younger age, antipsychotic polypharmacy, and concomitant use of lithium were also significantly associated with reports of seizures. The time-to-onset analysis of 222 cases of clozapine-induced seizures showed that the median time was 134 (interquartile range, 72-295) days. The 95% CI of the WSP β-value for clozapine-induced seizures included 1 and was classified as a random failure type. In conclusion, the results suggest that clozapine-induced seizures are dose-dependent adverse events that should be monitored with consideration of the effects of age and concomitant medications. Further epidemiological research is needed to strengthen and validate our hypotheses.

Loxapine in the Treatment of Manic and Psychotic Symptoms in an Individual Intolerant to Multiple Mood-Stabilizing and Antipsychotic Medications

First-line treatments for schizophrenia and schizoaffective disorder include antipsychotics and mood stabilizers, but their use may at times be limited due to severe adverse events. This case describes a 41-year-old male with a history of schizoaffective disorder and polysubstance use who was admitted to an inpatient psychiatry unit for acute manic and psychotic symptoms in the setting of absconding from his residential home and noncompliance with prescribed psychiatric medications. During his inpatient psychiatric hospitalization, he experienced DRESS (drug reaction with eosinophilia and systemic symptoms) with valproate, nephrogenic diabetes insipidus with lithium, potential neuroleptic malignant syndrome with risperidone, and orthostasis/tachycardia with clozapine. He ultimately achieved stabilization of manic and psychotic symptoms with loxapine without experiencing adverse events. This report highlights the potential utility of loxapine in individuals with schizoaffective disorder intolerant to standard mood-stabilizing and antipsychotic medications.

Meta-analysis of insomnia, suicide, and psychopathology in schizophrenia

PURPOSE OF REVIEW

Insomnia is common in schizophrenia. Insomnia has been associated with suicidal ideation and behavior, as well as greater severity of psychopathology, in schizophrenia. This review performs a meta-analysis of associations between insomnia, suicide, and psychopathology in patients with schizophrenia.

RECENT FINDINGS

We searched major electronic databases from inception until November 2022 for studies of insomnia, suicide, and psychopathology in patients with schizophrenia. Random effects meta-analysis calculating odds ratios (ORs, for suicide) and effect sizes (ESs, for psychopathology) and 95% confidence intervals (CIs) were performed. Ten studies met the inclusion criteria, comprising 3428 patients with schizophrenia. Insomnia was associated with a significant increased odds of suicidal ideation (OR = 1.84, 95% CI 1.28-2.65, P  < 0.01) and suicide attempt or death (OR = 5.83, 95% CI 1.61-2.96, P  < 0.01). Insomnia was also associated with total (ES = 0.16, 95% CI 0.09-0.23, P  < 0.01), positive (ES = 0.14, 95% CI 0.08-0.20, P  = 0.02), and general (ES = 0.17, 95% CI 0.08-0.27, P  < 0.01) psychopathology. In meta-regression analyses, BMI was negatively associated with suicidal ideation. Otherwise, age, sex, and study year were all unrelated to the associations.

SUMMARY

Insomnia is associated with suicide and psychopathology in schizophrenia. Formal assessment and treatment of insomnia appears relevant to the clinical care of schizophrenia.