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Bahji A, Crockford D, Brasch J, Schutz C, Buckley L, Danilewitz M, Dubreucq S, Mak M, George TP. Training in Substance use Disorders, Part 1: Overview of Clinical Practice Recommendations. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2024; 69:428-456. [PMID: 38613369 PMCID: PMC11107443 DOI: 10.1177/07067437241231128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Affiliation(s)
- Anees Bahji
- Clinical Assistant Professor, Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David Crockford
- Clinical Professor, University of Calgary, Cumming School of Medicine, Department of Psychiatry, Calgary, AB, Canada; Hotchkiss Brain Institute & Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, AB, Canada
| | - Jennifer Brasch
- Associate Professor, Department of Psychiatry & Behavioural Neurosciences, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; Lead, Addiction Psychiatry, St. Joseph's Healthcare, Hamilton, ON, Canada; Past-President, Canadian Society of Addiction Medicine, Calgary, AB, Canada
| | - Christian Schutz
- Professor, Institute of Mental Health, Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; Research Lead Adult Mental Health and Substance Use, Provincial Health Service Authority, Vancouver, BC, Canada
| | - Leslie Buckley
- Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Marlon Danilewitz
- Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Associate Medical Director, General Psychiatry, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada
| | - Simon Dubreucq
- Psychiatrist, Department of Addiction Medicine, CHUM, Montreal, QC, Canada; Assistant Professor, Department of Psychiatry, Université de Montréal, Montréal, QC, Canada
| | - Michael Mak
- Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Adjunct Assistant Professor, Department of Medicine, McMaster University, Hamilton, ON, Canada; Adjunct Research Professor, Department of Psychiatry, Western University, London, ON, Canada
| | - Tony P George
- Professor, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Correll CU, Arango C, Fagerlund B, Galderisi S, Kas MJ, Leucht S. Identification and treatment of individuals with childhood-onset and early-onset schizophrenia. Eur Neuropsychopharmacol 2024; 82:57-71. [PMID: 38492329 DOI: 10.1016/j.euroneuro.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 03/18/2024]
Abstract
Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry, Zucker Hillside Hospital, Northwell Health System, Glen Oaks, NY, USA.
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Birgitte Fagerlund
- Child and Adolescent Mental Health Center, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark; Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Silvana Galderisi
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Martien J Kas
- Groningen Institute for Evolutionary Life Sciences (GELIFES), Neurobiology, University of Groningen, the Netherlands
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Germany; Department of Psychiatry, Department of Psychosis Studies, and Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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Jiménez-Fernández S, Gurpegui M, Correll CU, de Leon J, Schoretsanitis G. A Systematic Review of Clozapine Concentration-Dose Ratio from Therapeutic Drug Monitoring Studies in Children and Adolescents Treated with Clozapine for Mental Disorders. Ther Drug Monit 2024; 46:170-180. [PMID: 38018845 PMCID: PMC10930379 DOI: 10.1097/ftd.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring of clozapine in children and adolescents has received insufficient attention. Calculation of concentration-to-dose (C/D) ratios from trough steady-state concentrations estimate drug clearance. METHODS A systematic electronic literature search was conducted in 3 article databases from inception until January 10, 2023, and articles reporting clozapine concentrations in children and adolescents were retrieved. The pharmacokinetic quality of the studies was assessed, and clozapine C/D ratios were calculated using the sample mean clozapine dose and concentration. RESULTS Of the 37 articles of potential interest, only 7 reported clozapine trough and steady-state concentrations. After excluding case reports and a study confounded by fluvoxamine, 4 studies on psychosis from Europe and the United States were included. The clozapine C/D ratios were similar to published adult values and ranged from 0.82 to 1.24 with a weighted mean of 1.08 ng/mL per mg/d. The weighted means were 334 mg/d for the dose and 380 ng/mL for the concentration. The stratified analysis of the weighted mean clozapine C/D ratios from 2 studies showed lower values in 52 male (1.05 ng/mL per mg/d) than in 46 female (1.46 ng/mL per mg/d) children and adolescents, with values similar to those reported for European adult nonsmokers. Two female adolescents had high clozapine C/D ratios (2.54 ng/mL per mg/d), an Asian American patient with borderline obesity and a patient with intellectual disability with low dosage (mean = 102 mg/d) and concentration (mean = 55 ng/mL). CONCLUSIONS Reports on clozapine therapeutic drug monitoring in children and adolescents are limited in number and quality. Future studies should focus on basic pharmacokinetic issues, such as stratification by sex, smoking, and relevant comedications with inductive or inhibitory properties.
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Affiliation(s)
- Sara Jiménez-Fernández
- Child and Adolescent Mental Health Unit, Virgen de Las Nieves University Hospital, Granada, Spain
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
| | - Manuel Gurpegui
- CTS-549 Research Group (Psychiatry and Neurosciences), Junta de Andalucía, Spain
- Granada Center for Psychiatric Studies, Granada, Spain
| | - Christoph U. Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain; and
| | - Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Zucker School of Medicine at Northwell/Hofstra, Hempstead, New York
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zürich, Switzerland
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Halawa N, Armstrong M, Fancy S, Abidi S. Clozapine-induced myocarditis and subsequent rechallenge: a narrative literature review and case report. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2023; 32:e252-e263. [PMID: 38034406 PMCID: PMC10686227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/03/2023] [Indexed: 12/02/2023]
Abstract
Clozapine is an antipsychotic medication that has been proven effective for the management of treatment-resistant schizophrenia (TRS). For some patients, it is the only medication that can improve disease burden and quality of life. Clozapine comes with various potentially serious adverse effects which may dissuade physicians from prescribing it despite its well-documented efficacy. One of these adverse effects is clozapine-induced myocarditis (CIM). Due to these risks, patients who undergo a clozapine rechallenge after CIM require close monitoring. Myocardial damage can be reversible if CIM is promptly identified, and clozapine is discontinued appropriately. The gold-standard for diagnosing myocarditis is an endomyocardial biopsy but there are no clear recommendations for how to use less invasive screening assessments to monitor for CIM during a clozapine rechallenge. This review article aims to increase awareness of CIM and provide guidance on monitoring and management. The accompanying case report presents a proposed strategy, including biomarkers that were used to identify inflammation and cardiac injury which guided the treatment of an adolescent patient who had a successful clozapine rechallenge. Further research is necessary to validate the proposed monitoring protocol and to further advance guidance for clinicians.
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Affiliation(s)
- Nadine Halawa
- Adjunct Faculty and Lecturer, Department of Pharmacy, Dalhousie University; Clinical Pharmacy Specialist, IWK Child and Adolescent Mental Health and Addictions Program, Halifax, Nova Scotia
| | | | - Sarah Fancy
- Assistant Professor, Department of Psychiatry, Dalhousie University; Staff Psychiatrist, IWK Garron Centre for Child and Adolescent Mental Health, Halifax, Nova Scotia
| | - Sabina Abidi
- Associate Professor, Department of Psychiatry, Dalhousie University; Associate Chief, Division of Child and Adolescent Psychiatry IWK Mental Health and Addictions Program; Head, IWK Youth Psychosis Program, Halifax, Nova Scotia
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Cheng C, Nadin S, Bohonis H, Katt M, Dewa CS. NorthBEAT: exploring the service needs of youth experiencing early psychosis in Northern Ontario. FRONTIERS IN HEALTH SERVICES 2023; 3:1163452. [PMID: 38028941 PMCID: PMC10646171 DOI: 10.3389/frhs.2023.1163452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023]
Abstract
Introduction Early Psychosis Intervention (EPI) is critical for best outcomes. Among 369 diseases, psychosis is among those causing the greatest disability. Evidence-based interventions for youth in early stages of psychosis (EPI programs) have prevented chronic disability. Yet, EPI is frequently inaccessible for youth living in rural communities. Moreover, Indigenous youth often face more precipitous situations given inadequate staffing, and culturally unsafe care. The NorthBEAT (Barriers to Early Assessment and Treatment) project sought to understand the service needs of youth with psychosis in Northern Ontario. The goals were: (1) to describe the mental health of a subset of adolescents receiving EPI care; (2) examine Indigenous youth as a significant and vulnerable population; (3) to understand the barriers and facilitators for Indigenous and non-Indigenous youth receiving EPI. Methods Mixed methods (structured and narrative interviews) included: psychometric scales interviews with youth, and narrative interviews with youth, their family, and service providers Data validation workshops were held with participants. Results Structured interviews with 26 youth (M = 17 years) found the participants functioning moderately well with duration of untreated psychosis ranging from 1 to 96 months (M = 26 months). No significant differences were found in functioning or duration of psychosis between Indigenous and non-Indigenous youth. Narrative interviews were conducted with 18 youth, 11 family members, and 14 service providers. Identified barriers were a lack of knowledge about psychosis among service providers, a disconnected system leading to delays in treatment, help not wanted by youth, expansive geographical context. Service needs were: finding the right point of access, support for families, pre-crisis intervention, reduced stigma for youth and their families, and an EPI approach to care. Discussion Rural and northern youth face similar barriers to accessing EPI as urban youth. However, northern youth face additional unique challenges due to expansive geographical context, limited resources and lack of knowledge about services.
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Affiliation(s)
- Chiachen Cheng
- Addictions and Mental Health, St. Joseph’s Care Group, Thunder Bay, ON, Canada
- Centre for Rural and Northern Health Research, Lakehead University, Thunder Bay, ON, Canada
- Clinical Sciences Division, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
| | - Shevaun Nadin
- Addictions and Mental Health, St. Joseph’s Care Group, Thunder Bay, ON, Canada
- Centre for Rural and Northern Health Research, Lakehead University, Thunder Bay, ON, Canada
| | - Hafsa Bohonis
- Dr. Gilles Arcand Centre for Health Equity, Northern Ontario School of Medicine University, Thunder Bay, ON, Canada
| | - Mae Katt
- Centre for Rural and Northern Health Research, Lakehead University, Thunder Bay, ON, Canada
| | - Carolyn S. Dewa
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Davis, CA, United States
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Tuncturk M, Ermis C, Buyuktaskin D, Turan S, Saglam Y, Alarslan S, Guler D, Sut E, Unutmaz G, Guzel AB, Atay Canbek O, Inal N, Karacetin G, Hazell P. Electroconvulsive therapy or clozapine for adolescents with treatment-resistant schizophrenia: an explorative analysis on symptom dimensions. Int J Psychiatry Clin Pract 2023; 27:257-263. [PMID: 36576216 DOI: 10.1080/13651501.2022.2160764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/16/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This study sought to compare pre-intervention patient characteristics and post-intervention outcomes in a naturalistic sample of adolescent inpatients with treatment-resistant psychotic symptoms who received either electroconvulsive therapy (ECT) or clozapine. METHODS Data of adolescents with schizophrenia/schizoaffective disorder receiving ECT or clozapine were retrospectively collected from two tertiary-care psychiatry-teaching university hospitals. Subscale scores of the Positive and Negative Symptom Scale (PANSS) factors were calculated according to the five-factor solution. Baseline demographics, illness characteristics, and post-intervention outcomes were compared. RESULTS There was no significant difference between patients receiving ECT (n = 13) and clozapine (n = 66) in terms of age, sex, and the duration of hospital stay. The ECT group more commonly had higher overall illness and aggression severity. Smoking was less frequent in the clozapine group. Baseline resistance/excitement symptom severity was significantly higher in the ECT group, while positive, negative, affect, disorganisation, and total symptom scores were not. Both interventions provided a significant reduction in PANSS scores with large effect sizes. CONCLUSION Both ECT and clozapine yielded high effectiveness rates in adolescents with treatment-resistant schizophrenia/schizoaffective disorder. Youth receiving ECT were generally more activated than those who received clozapine.
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Affiliation(s)
- Mustafa Tuncturk
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | | | | | - Serkan Turan
- Department of Child and Adolescent Psychiatry, Uludag University School of Medicine, Bursa, Turkey
| | - Yesim Saglam
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Sezen Alarslan
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Duru Guler
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ekin Sut
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Guldal Unutmaz
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ayse Beste Guzel
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Ozge Atay Canbek
- Department of Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Neslihan Inal
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Gul Karacetin
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Philip Hazell
- Specialty of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Gupta N, Gupta M, Esang M. Lost in Translation: Challenges in the Diagnosis and Treatment of Early-Onset Schizophrenia. Cureus 2023; 15:e39488. [PMID: 37362509 PMCID: PMC10290525 DOI: 10.7759/cureus.39488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.
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Affiliation(s)
- Nihit Gupta
- Psychiatry, Dayton Children's Hospital, Dayton, USA
| | - Mayank Gupta
- Psychiatry and Behavioral Sciences, Southwood Psychiatric Hospital, Pittsburgh, USA
| | - Michael Esang
- Psychiatry and Behavioral Sciences, Clarion Psychiatric Center, Clarion, USA
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Ramos Alves M, Bergamaschi CDC, Barberato-Filho S, de Melo DO, Mayer RCF, de Oliveira JC, Gabriel FC, Sekercioglu N, Abdala CVM, Lopes LC. Critical appraisal and comparison of recommendations of clinical practice guidelines for the treatment of schizophrenia in children and adolescents: a methodological survey. BMJ Open 2023; 13:e070332. [PMID: 36746538 PMCID: PMC9906266 DOI: 10.1136/bmjopen-2022-070332] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/08/2023] Open
Abstract
INTRODUCTION The production of clinical practice guidelines (CPGs) has grown in the past years. Notwithstanding, the quality of these documents and their recommendations for the treatment of schizophrenia in children and adolescents is still unknown. OBJECTIVE To assess the quality of the guidelines and recommendations for the treatment of schizophrenia in this population. METHODS CPGs from 2004 to December 2020 were identified through a systematic search on EMBASE, MEDLINE, PsycINFO, PubMed, Epistemonikos, VHL, Global Index Medicus and specific CPG databases. The CPGs' quality was independently assessed by three reviewers using AGREE II and they were considered of high quality if they scored ≥60% in domains 3 and 6. The evidence classification systems were described, the quality of recommendations was assessed in pairs using AGREE-REX and the recommendations were compared. RESULTS The database search retrieved 3182 results; 2030 were screened and 29 were selected for full-text reading. Four guidelines were selected for extraction. Two CPGs were considered of high quality in the AGREE II assessment. We described the commonly agreed recommendations for each treatment phase. The pharmacological recommendations were described in all treatment phases. Scores of AGREE-REX were lower for psychosocial recommendations. CONCLUSION There are still few clinical studies and CPGs regarding schizophrenia in children and adolescents. The quality of the documents was overall low, and the quality of the recommendations report has much to improve. There is also a lack of transparency about the quality of the evidence and the strength of the recommendations. PROTOCOL REGISTRATION NUMBER CRD42020164899.
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Affiliation(s)
- Maíra Ramos Alves
- Graduate Course in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
| | | | | | | | | | - Jardel Corrêa de Oliveira
- Graduate Course in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
- Family Physician, Florianópolis Family Medicine Residency Program, Florianópolis, Brazil
| | | | - Nigar Sekercioglu
- Health Research Methodology, McMaster University, Mississauga, Ontario, Canada
| | | | - Luciane Cruz Lopes
- Graduate Course in Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
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Cortese S, Besag FM, Clark B, Hollis C, Kilgariff J, Moreno C, Nicholls D, Wilkinson P, Woodbury-Smith M, Sharma A. Common practical questions - and answers - at the British Association for Psychopharmacology child and adolescent psychopharmacology course. J Psychopharmacol 2023; 37:119-134. [PMID: 36476096 PMCID: PMC9912307 DOI: 10.1177/02698811221140005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The British Association for Psychopharmacology course on child and adolescent psychopharmacology has been run for more than 20 years and is currently a very popular course, attracting around 140 delegates/year from across the United Kingdom and abroad. As Faculty of recent sessions of the course, we have selected the most common questions we have been asked in recent years and provided evidence-based and/or expert-informed answers. We have included 27 questions and answers related to attention-deficit/hyperactivity disorder, anxiety and depressive disorders, autism spectrum disorder, bipolar disorder, eating disorders, epilepsy (in differential diagnosis or comorbid with mental health conditions), obsessive-compulsive disorder, personality disorders, psychotic spectrum disorders, and tics/Tourette syndrome in children and young people. We hope that this article will be helpful for prescribers in their daily clinical practice and we look forward to further, high-level evidence informing the answers to these and other questions in child and adolescent psychopharmacology.
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Affiliation(s)
- Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Solent NHS Trust, Southampton, UK.,Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York City, NY, USA.,Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Frank Mc Besag
- UCL School of Pharmacy, London, UK.,East London Foundation NHS Trust, Bedfordshire, UK.,Institute of Psychiatry, Psychology and Neuroscience, KCL, London, UK
| | - Bruce Clark
- National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, UK
| | - Chris Hollis
- Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Queen's Medical Centre, Nottingham, UK.,National Institute of Mental Health (NIHR) MindTech Medtech Co-operative, Institute of Mental Health, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Mental Health & Technology Theme, Institute of Mental Health, Nottingham, UK
| | - Joseph Kilgariff
- Department of Child and Adolescent Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Queen's Medical Centre, Nottingham, UK
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Dasha Nicholls
- Division of Psychiatry, Imperial College London, London, UK.,NIHR ARC Northwest, London, UK
| | - Paul Wilkinson
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK.,Cambridgeshire and Peterborough NHS Foundation Trust, Cambridgeshire, UK
| | | | - Aditya Sharma
- Academic Psychiatry, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Specialist Adolescent Mood Disorders Service (SAMS), Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
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Correll CU, Agid O, Crespo-Facorro B, de Bartolomeis A, Fagiolini A, Seppälä N, Howes OD. A Guideline and Checklist for Initiating and Managing Clozapine Treatment in Patients with Treatment-Resistant Schizophrenia. CNS Drugs 2022; 36:659-679. [PMID: 35759211 PMCID: PMC9243911 DOI: 10.1007/s40263-022-00932-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
Treatment-resistant schizophrenia (TRS) will affect about one in three patients with schizophrenia. Clozapine is the only treatment approved for TRS, and patients should be treated as soon as possible to improve their chances of achieving remission. Despite its effectiveness, concern over side effects, monitoring requirements, and inexperience with prescribing often result in long delays that can expose patients to unnecessary risks and compromise their chances of achieving favorable long-term outcomes. We critically reviewed the literature on clozapine use in TRS, focusing on guidelines, systematic reviews, and algorithms to identify strategies for improving clozapine safety and tolerability. Based on this, we have provided an overview of strategies to support early initiation of clozapine in patients with TRS based on the latest evidence and our clinical experience, and have summarized the key elements in a practical, evidence-based checklist for identifying and managing patients with TRS, with the aim of increasing confidence in prescribing and monitoring clozapine therapy.
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Affiliation(s)
- C U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Ofer Agid
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | | | - Andrea de Bartolomeis
- Section on Clinical Psychiatry and Psychology, Laboratory of Molecular and Translational Psychiatry and Unit of Treatment Resistant Psychosis, University of Naples Federico II, Naples, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Niko Seppälä
- Department of Psychiatry Satasairaala, Harjavalta, Finland
| | - Oliver D Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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11
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Lopez-Morinigo JD, Leucht S, Arango C. Pharmacological Treatment of Early-Onset Schizophrenia: A Critical Review, Evidence-Based Clinical Guidance and Unmet Needs. PHARMACOPSYCHIATRY 2022; 55:233-245. [PMID: 35777418 PMCID: PMC9458343 DOI: 10.1055/a-1854-0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Early-onset schizophrenia (EOS) – onset before age 18 – is linked
with great disease burden and disability. Decision-making for EOS
pharmacological treatment may be challenging due to conflicting information from
evidence and guidelines and unidentified care needs may remain unmet. We searched for systematic reviews, meta-analyses and umbrella reviews of EOS
pharmacological treatment published in PubMed over the past 10 years and
selected five clinical guidelines from Europe, North-America and Australia.
Based on predefined outcomes, we critically compared the evidence supporting
EOS-approved drugs in Europe and/or North-America with guidelines
recommendations. We also evaluated the coverage of these outcomes to identify
unmet needs. One systematic review, nine meta-analyses and two umbrella reviews (k=203
trials, N=81,289 participants, including duplicated samples across
selected articles) were retrieved. Evidence supported the efficacy of
aripiprazole, clozapine, haloperidol, lurasidone, molindone, olanzapine,
quetiapine, risperidone and paliperidone in EOS, all of which obtained approval
for EOS either in Europe and/or in North-America. Cognition, functioning
and quality of life, suicidal behaviour and mortality and services utilisation
and cost-effectiveness were poorly covered/uncovered. Among the antipsychotics approved for EOS, aripiprazole, lurasidone, molindone,
risperidone, paliperidone and quetiapine emerged as efficacious and comparably
safe options. Olanzapine is known for a high risk of weight gain and haloperidol
for extrapyramidal side-effects. Treatment-resistant patients should be offered
clozapine. Future long-term trials looking at cognition, functioning, quality of
life, suicidal behaviour, mortality, services utilisation and cost-effectiveness
are warranted. Closer multi-agency collaboration may bridge the gap between
evidence, guidelines and approved drugs.
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Affiliation(s)
- Javier-David Lopez-Morinigo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaninger Straße 22, Munich, Germany
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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12
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Hui CLM, Chen EYH, Swapna V, Tagata H, Mizuno M, Liu C, Takeuchi H, Kim SW, Chung YC. Guidelines for Discontinuation of Antipsychotics in Patients Who Recover From First-Episode Schizophrenia Spectrum Disorders: Derived From the Aggregated Opinions of Asian Network of Early Psychosis Experts and Literature Review. Int J Neuropsychopharmacol 2022; 25:737-758. [PMID: 35451023 PMCID: PMC9515132 DOI: 10.1093/ijnp/pyac002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 04/20/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Antipsychotic discontinuation has been a long-standing clinical and medicolegal issue. The Asian Network of Early Psychosis developed guidelines for antipsychotic discontinuation in patients who recover from first-episode non-affective psychosis. We reviewed the existing studies and guidelines on antipsychotic discontinuation to develop guidelines for antipsychotic discontinuation in such patients. METHODS We reviewed the relevant studies, reviews, guidelines, and ongoing trials related to antipsychotic discontinuation in patients with first-episode psychosis or schizophrenia. The quality of randomized controlled trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Most studies had low to very low quality, and 2 had moderate quality. All studies, except 1, advised against antipsychotic discontinuation because of higher relapse rates in the antipsychotic discontinuation group (19%-82% at 1-year follow-up) than the treatment maintenance group compared with the maintenance group. Based on expert opinion and Grading of Recommendations Assessment, Development, and Evaluation evidence of trials, guidelines have been recommended for future discontinuation studies on patients with first-episode schizophrenia spectrum disorders. CONCLUSIONS Currently, there are no recommendations for antipsychotic discontinuation in patients with first-episode schizophrenia spectrum disorders. However, there is a pressing need to conduct more rigorous research in remitted patients using more stringent criteria of full recovery, which can form the basis of guidelines on when and how antipsychotics should be tapered and discontinued. Studies that evaluate the patient characteristics and biomarkers that predict successful antipsychotic discontinuation are also needed.
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Affiliation(s)
| | - Christy L M Hui
- Department of Psychiatry Unive, University of Hong Kong , Hong Kong, SAR , China
| | - Eric Y H Chen
- Department of Psychiatry Unive, University of Hong Kong , Hong Kong, SAR , China
- State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong , Hong Kong, SAR , China
| | - Verma Swapna
- Institute of Mental Health , Singapore
- Duke-NUS Medical School , Singapore
| | - Hiromi Tagata
- Department of Neuropsychiatry, Toho University School of Medicine , Tokyo , Japan
| | - Masafumi Mizuno
- Department of Neuropsychiatry, Toho University School of Medicine , Tokyo , Japan
- Tokyo Metropolitan Matsuzawa Hospital , Tokyo , Japan
| | - Chen‑Chung Liu
- Department of Psychiatry, National Taiwan University Hospital , Taipei , Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University , Taipei , Taiwan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine , Tokyo , Japan
- Schizophrenia Program, Centre for Addiction and Mental Health , Toronto, ON , Canada
| | - Sung-Wan Kim
- Mindlink, Gwangju Bukgu Mental Health Center , Gwangju , Korea
- Department of Psychiatry, Chonnam National University Medical School , Gwangju , Korea
| | - Young-Chul Chung
- Department of Psychiatry, Jeonbuk National University Medical School , Jeonju , Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital , Jeonju , Korea
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13
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Comparative Efficacy and Tolerability of Antipsychotics for Juvenile Psychotic Disorders: A Systematic Review and Network Meta-Analysis. J Clin Psychopharmacol 2022; 42:198-208. [PMID: 35020712 DOI: 10.1097/jcp.0000000000001506] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Psychotic disorders produce important morbidity and disability in children and adolescents. There have been few relevant treatment trials, encouraging assessment of research aimed at testing efficacy and safety of antipsychotics for juveniles. We aimed to compare the short- and long-term efficacy and safety of antipsychotics to treat psychotic disorders among children and adolescents. METHODS Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and EMBASE) were searched for clinical trials of antipsychotics in children or adolescents, from database inception to May 2021. We searched for clinical trials comparing antipsychotics with control conditions for juvenile psychosis based on blinded review by 2 independent investigators (C.S.Y. and M.L.). We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses and applied the Cochrane risk-of-bias tool to appraise study quality. One reviewer (A.B.) performed data abstraction which was confirmed by 2 independent, blinded reviewers (C.S.Y. and M.L.). Primary outcomes were scores rating psychosis symptoms and dichotomized retention in treatment protocols versus dropouts because of adverse events. Effect sizes were pooled using frequentist random-effects network meta-analysis modeling to generate summary rate ratios (RRs) and Cohen d standardized mean differences. RESULTS Systematic searching generated 1330 unique records. Of these, short-term (n = 15, for 6 [3-12] weeks) and long-term (n = 10, for 12 [6-60] months) treatment trials involved 2208 (39.2% females; median age, 15.3 years), and 1366 subjects (35.0% females; median age, 15.6 years), respectively. Short-term reduction of psychosis scores ranked clozapine (d = -1.35; 95% confidence interval [CI], -1.97 to -0.73]), molindone (-1.22; 95% CI, -1.68 to -0.75), olanzapine (-1.12; 95% CI, -1.44 to -0.81), and risperidone (-0.93; 95% CI, -1.22 to -0.63) as the most effective agents. In longer-term treatment, only lurasidone was effective. Clozapine (RR, 12.8) and haloperidol (RR, 5.15) led to more all-cause and adverse event-related dropouts. There were few trials/drug (1 each for aripiprazole, asenapine, lurasidone, molindone, paliperidone, and ziprasidone, short term; aripiprazole, clozapine, haloperidol, lurasidone, and molindone, long-term). Heterogeneity and inconsistency were high, especially in long-term trials, without evidence of publication bias. CONCLUSIONS Some antipsychotics were effective and tolerated short term, but longer-term evidence was very limited. The overall paucity of trials and of adequate controls indicates that more well-designed randomized controlled trials are required for adequate assessment of antipsychotic drug treatment for juveniles. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021232937.
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14
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Saito T, Sugimoto S, Sakaguchi R, Nakamura H, Ishigooka J. Efficacy and Safety of Blonanserin Oral Tablet in Adolescents with Schizophrenia: A 6-Week, Randomized Placebo-Controlled Study. J Child Adolesc Psychopharmacol 2022; 32:12-23. [PMID: 35133884 PMCID: PMC8884167 DOI: 10.1089/cap.2021.0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives: To evaluate the short-term efficacy and safety of blonanserin in adolescents with schizophrenia. Methods: This 6-week multicenter, double-blind, randomized, placebo-controlled study investigated fixed-dose blonanserin (8 or 16 mg/day) in patients 12-18 years of age diagnosed with schizophrenia, as indicated by a Positive and Negative Syndrome Scale (PANSS) total score of 60-120 and a Clinical Global Impressions-Severity score of ≥3. The primary endpoint was change from baseline to week 6 in the PANSS total score, using a mixed model for repeated measures analysis. Safety was assessed by the incidence and severity of adverse events (AEs). Results: Among 151 randomized patients, 150 were included in the primary analysis population. Demographic and clinical characteristics were similar across groups at baseline. The rate of study discontinuation was 14.9%, 23.5%, and 28.3% in patients administered with placebo, blonanserin 8 mg/day, and blonanserin 16 mg/day, respectively. The least-squares mean change (95% confidence interval [CI]) from baseline to week 6 in PANSS total score was -10.6 (-16.10 to -5.10), -15.3 (-20.80 to -9.86), and -20.5 (-25.89 to -15.16) in patients administered placebo, 8 mg/day blonanserin, and 16 mg/day blonanserin, respectively. The 16-mg/day blonanserin group showed significantly greater reduction in the PANSS total score than the placebo group (least-squares mean difference [95% CI]: -9.9 [-17.61 to -2.25], p = 0.012, effect size: 0.538), although the 8-mg/day group showed no significant difference. The incidence of AEs such as akathisia, somnolence, and hyperprolactinemia was higher in the blonanserin groups than in the placebo group. AEs associated with blonanserin were generally mild and were consistent with its known profile in adults with schizophrenia. Conclusions: Blonanserin achieved a sufficient efficacy in adolescent patients, and the safety profile was similar to that in adults, which suggests that blonanserin may be a safe treatment option for adolescents with schizophrenia. Study registration number: Japic CTI-111724.
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Affiliation(s)
- Takuya Saito
- Department of Child and Adolescent Psychiatry, Hokkaido University Hospital, Sapporo, Japan
| | - Saori Sugimoto
- Sumitomo Dainippon Pharma Co., Ltd., Chuo-ku, Tokyo, Japan
| | | | - Hiroshi Nakamura
- Sumitomo Dainippon Pharma Co., Ltd., Chuo-ku, Tokyo, Japan.,Address correspondence to: Hiroshi Nakamura, MS, Sumitomo Dainippon Pharma Co., Ltd., 1-13-1 Kyobashi, Chuo-Ku, Tokyo 104-8356, Japan
| | - Jun Ishigooka
- Institute of CNS Pharmacology, Shibuya-ku, Tokyo, Japan
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15
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Saito T, Hyodo Y, Sakaguchi R, Nakamura H, Ishigooka J. Long-Term Safety and Efficacy of Blonanserin Oral Tablet in Adolescents with Schizophrenia: A 52-Week, Multicenter, Open-Label Extension Study. J Child Adolesc Psychopharmacol 2022; 32:24-35. [PMID: 34612724 PMCID: PMC8884169 DOI: 10.1089/cap.2021.0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives: To evaluate the long-term efficacy and safety/tolerability of oral blonanserin in adolescents with schizophrenia (Study registration number: JapicCTI-111725). Methods: This 52-week, multicenter, open-label extension study enrolled adolescent patients with schizophrenia who opted to enter in this study after the completion of the preceding placebo-controlled study. Blonanserin tablet was orally administered twice daily, after morning and evening meals, for 52 weeks using dose-titration method within a range between 4 and 24 mg/day. The primary end point was the change from baseline to the end of the study in the Positive and Negative Syndrome Scale (PANSS) total score. Safety/tolerability was assessed by the incidence and severity of adverse events. Results: Of 117 patients who completed the preceding placebo-controlled study, 109 entered this extension study and 43 (39.4%) of them discontinued the study treatment. The safety analysis set comprised 106 patients who received the study drug at least once, including 36 and 70 patients treated with placebo (DB-placebo group) and blonanserin tablet (DB-blonanserin group), respectively, in the placebo-controlled study. At the last assessment, the mean change in PANSS total score overall [mean (standard deviation)] was -24.9 (20.76) from the baseline of the placebo-controlled study, which was similar in the DB-placebo and DB-blonanserin groups. The overall incidence of adverse events was 90.6%, and most of them were mild or moderate in severity, with similar incidence of extrapyramidal symptoms (38.7%) to that in adults receiving long-term blonanserin oral tablet treatment and minimal change in weight and metabolic parameters. Conclusions: This long-term extension study showed that 52 weeks of oral blonanserin treatment improved or stabilized psychiatric symptoms in patients with adolescent schizophrenia. There were no major issues with the safety or tolerability of blonanserin administration in this study. Considering relatively less adverse effects on weight increase and metabolic parameters, blonanserin is expected to be a safe/tolerable treatment option for adolescent schizophrenia that can be used seamlessly from adolescence to adulthood.
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Affiliation(s)
- Takuya Saito
- Department of Child and Adolescent Psychiatry, Hokkaido University Hospital, Sapporo, Japan
| | - Yohei Hyodo
- Sumitomo Dainippon Pharma Co., Ltd., Chuo-Ku, Tokyo, Japan
| | | | - Hiroshi Nakamura
- Sumitomo Dainippon Pharma Co., Ltd., Chuo-Ku, Tokyo, Japan.,Address correspondence to: Hiroshi Nakamura, MS, Sumitomo Dainippon Pharma Co., Ltd., 1-13-1 Kyobashi, Chuo-Ku, Tokyo 104-8356, Japan
| | - Jun Ishigooka
- Institute of CNS Pharmacology, Shibuya-ku, Tokyo, Japan
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16
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English T, Castle D. Treating schizophrenia: Should we emphasise 'first do no harm'? Aust N Z J Psychiatry 2022; 56:8-10. [PMID: 34144645 DOI: 10.1177/00048674211025696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tom English
- St Vincent's Mental Health Service, Melbourne, Fitzroy, VIC, Australia
| | - David Castle
- Centre for Complex Interventions, Centre for Addictions and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Vaitheswaran S, Currie G, Dhandapani VR, Mohan G, Rangaswamy T, Preet Singh S. Implementation of first episode psychosis intervention in India - A case study in a low-and middle-income country. SSM - MENTAL HEALTH 2021; 1:None. [PMID: 34957426 PMCID: PMC8654684 DOI: 10.1016/j.ssmmh.2021.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/11/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022] Open
Abstract
First Episode Psychosis (FEP) is a serious mental illness affecting adolescents and young persons. While many effective interventions are available, there has not been much research to understand the implementation of such interventions in India and other low- and middle-income countries (LMIC). We studied the implementation of an FEP intervention program in a specialist mental health facility in Chennai, India, using a well-established framework for doing so, the Consolidated Framework for Implementation Research (CFIR). We conducted 27 in-depth interviews with the service users (15 persons with FEP and 12 family caregivers of persons with FEP). We also conducted a focus group discussion with 8 service providers and in-depth interviews with 7 other service providers including those in the service management. A thematic analysis approach was used to identify emerging themes. First, we found CFIR effectively accommodated implementation challenges evident in LMICs; that is, it is transferable to LMIC settings. Second, we highlight barriers to implementation that include cost, limited human resources, cultural and professional hierarchy, divergence from evidence-based guidelines, and lack of awareness and stigma in the wider community. Third, we highlight facilitators for implementation such as, leadership engagement, the need for change that was recognized within the service, cosmopolitan perspectives derived from clinicians’ local and international collaborative experiences and expertise, compatibility of the intervention with the existing systems within the organization, accommodating the needs of the service users, and rapport developed by the service with the service users. Fourth, we propose a model of service delivery incorporating a task-sharing approach for first episode psychosis in resource restricted settings based on the feedback from the stakeholders. Implementation of interventions for First Episode Psychosis in India is explored systematically. Resource constraints, cultural factors, lack of awareness, and stigma are the main barriers to the implementation. Buy-in from the service providers, accommodating the needs and developing rapport with the service users are the facilitators.
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Affiliation(s)
- Sridhar Vaitheswaran
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, UK
| | - Vijaya Raghavan Dhandapani
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Greeshma Mohan
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Thara Rangaswamy
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Swaran Preet Singh
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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18
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Stutzman DL. Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. Ment Health Clin 2021; 11:320-333. [PMID: 34824957 PMCID: PMC8582767 DOI: 10.9740/mhc.2021.11.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.
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Clinical practice guideline for end-of-life care in patients with cancer: a modified ADAPTE process. Support Care Cancer 2021; 30:2497-2505. [PMID: 34786639 DOI: 10.1007/s00520-021-06558-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study seeks to adapt a guideline for end-of-life care in patients with cancer to be used by healthcare teams. METHODS This methodological study was conducted by modifying the ADAPTE process and adding to it a qualitative study and consensus ratings by a multidisciplinary panel of experts. A qualitative study was thus performed to identify the end-of-life needs of patients with cancer. Then, the source guidelines and the results of the qualitative study were used to draft the initial version of the guideline, with 85 adaptation recommendations. A multidisciplinary panel of healthcare experts performed the external review of the recommendations based on the four criteria of relatedness, comprehensibility, usefulness, and feasibility and scored them on a scale of 1-9. The mean score of each recommendation was calculated, and the recommendations were classified into three categories: appropriate (mean score of 7-9), uncertain (mean score of 4-6.99), and inappropriate (mean score of 1-3.99). RESULTS All the recommendations were approved, as they all had a mean score of 7 or higher, and were then categorized into 11 dimensions: communication management; participatory and evidence-based decision-making management; pain management; dyspnea management; nausea and vomiting management; anorexia and cachexia management; constipation management; death rattle management; management of delirium, anxiety, and restlessness; hydration management; and pharmacological considerations. CONCLUSION The adaptation of the guideline for end-of-life care in patients with cancer in Iran was performed by modifying the ADAPTE process with the participation of multidisciplinary stakeholders and based on the local needs.
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Kirli U, Alptekın K. Pharmacotherapy of Schizophrenia in Acute and Maintenance Phase. ACTA ACUST UNITED AC 2021; 58:S17-S23. [PMID: 34658631 PMCID: PMC8498812 DOI: 10.29399/npa.27441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 08/26/2021] [Indexed: 11/25/2022]
Abstract
Schizophrenia is one of the leading disorders causing impairment in society. Therefore, it is crucial to review evidence-based treatment approaches which are both effective and causing minimum side effects. In this paper, treatment recommendations for first episode schizophrenia, patients in acute phase with a history of multiple episodes, and patients in the maintenance phase will be discussed in light of the Psychiatric Association of Turkey Guideline for Treatment of Schizophrenia, other recent national and international guidelines as well as expert consensus reports in the literature. Finally, practical considerations will be suggested.
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Affiliation(s)
- Umut Kirli
- Ege University, Institute on Drug Abuse, Toxicology and Pharmaceutical Science, İzmir, Turkey
| | - Köksal Alptekın
- Dokuz Eylül University, School of Medicine, Department of Psychiatry, İzmir, Turkey.,Dokuz Eylül University, Institute of Health Sciences, Department of Neuroscience, İzmir, Turkey
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21
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Jansen AG, Jansen PR, Savage JE, Kraft J, Skarabis N, Polderman TJC, Dieleman GC. The predictive capacity of psychiatric and psychological polygenic risk scores for distinguishing cases in a child and adolescent psychiatric sample from controls. J Child Psychol Psychiatry 2021; 62:1079-1089. [PMID: 33825194 PMCID: PMC8453516 DOI: 10.1111/jcpp.13370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 10/30/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Psychiatric traits are heritable, highly comorbid and genetically correlated, suggesting that genetic effects that are shared across disorders are at play. The aim of the present study is to quantify the predictive capacity of common genetic variation of a variety of traits, as captured by their PRS, to predict case-control status in a child and adolescent psychiatric sample including controls to reveal which traits contribute to the shared genetic risk across disorders. METHOD Polygenic risk scores (PRS) of 14 traits were used as predictor phenotypes to predict case-control status in a clinical sample. Clinical cases (N = 1,402), age 1-21, diagnostic categories: Autism spectrum disorders (N = 492), Attention-deficit/ hyperactivity disorders (N = 471), Anxiety (N = 293), disruptive behaviors (N = 101), eating disorders (N = 97), OCD (N = 43), Tic disorder (N = 50), Disorder of infancy, childhood or adolescence NOS (N = 65), depression (N = 64), motor, learning and communication disorders (N = 59), Anorexia Nervosa (N = 48), somatoform disorders (N = 47), Trauma/stress (N = 39) and controls (N = 1,448, age 17-84) of European ancestry. First, these 14 PRS were tested in univariate regression analyses. The traits that significantly predicted case-control status were included in a multivariable regression model to investigate the gain in explained variance when leveraging the genetic effects of multiple traits simultaneously. RESULTS In the univariate analyses, we observed significant associations between clinical status and the PRS of educational attainment (EA), smoking initiation (SI), intelligence, neuroticism, alcohol dependence, ADHD, major depression and anti-social behavior. EA (p-value: 3.53E-20, explained variance: 3.99%, OR: 0.66), and SI (p-value: 4.77E-10, explained variance: 1.91%, OR: 1.33) were the most predictive traits. In the multivariable analysis with these eight significant traits, EA and SI, remained significant predictors. The explained variance of the PRS in the model with these eight traits combined was 5.9%. CONCLUSION Our study provides more insights into the genetic signal that is shared between childhood and adolescent psychiatric disorders. As such, our findings might guide future studies on psychiatric comorbidity and offer insights into shared etiology between psychiatric disorders. The increase in explained variance when leveraging the genetic signal of different predictor traits supports a multivariable approach to optimize precision accuracy for general psychopathology.
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Affiliation(s)
- Arija G. Jansen
- Department of Complex Trait Genetics, Center for Neurogenomics and Cognitive ResearchVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of Child and Adolescent Psychiatry/PsychologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Philip R. Jansen
- Department of Complex Trait Genetics, Center for Neurogenomics and Cognitive ResearchVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of Child and Adolescent Psychiatry/PsychologyErasmus University Medical CenterRotterdamThe Netherlands
- Department of Clinical GeneticsAmsterdam UMC, Vrije Universiteit Medical CenterAmsterdamThe Netherlands
| | - Jeanne E. Savage
- Department of Complex Trait Genetics, Center for Neurogenomics and Cognitive ResearchVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Julia Kraft
- Department of Psychiatry and PsychotherapyCharité, Universitätsmedizin BerlinBerlinGermany
- Berlin School of Mind and BrainHumboldt University of BerlinBerlinGermany
| | - Nora Skarabis
- Department of Psychiatry and PsychotherapyCharité, Universitätsmedizin BerlinBerlinGermany
| | - Tinca J. C. Polderman
- Department of Complex Trait Genetics, Center for Neurogenomics and Cognitive ResearchVrije Universiteit AmsterdamAmsterdamThe Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMCVrije Universiteit Amsterdam, Amsterdam Public HealthAmsterdamThe Netherlands
| | - Gwen C. Dieleman
- Department of Child and Adolescent Psychiatry/PsychologyErasmus University Medical CenterRotterdamThe Netherlands
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Fulone I, Silva MT, Lopes LC. Gender differences in the use of atypical antipsychotics in early-onset schizophrenia: a nationwide population-based study in Brazil. BMC Psychiatry 2021; 21:320. [PMID: 34187418 PMCID: PMC8243572 DOI: 10.1186/s12888-021-03327-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/14/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The use of atypical antipsychotics for the treatment of schizophrenia and other mental disorders in populations under 18 years of age is increasing worldwide. Little is known about treatment patterns and the influence of gender differences, which may be a predictor of clinical outcomes. The aim of this study was to investigate gender differences in the use of atypical antipsychotics in patients with early-onset schizophrenia (EOS) assisted by the public health system in Brazil. METHODS We conducted a cross-sectional study of outpatients with EOS aged 10 to 17 years who received at least one provision of atypical antipsychotics (clozapine, olanzapine, risperidone, quetiapine or ziprasidone) from a large Brazilian pharmaceutical assistance programme. Data were retrieved from a nationwide administrative database from 2008 to 2017. RESULTS Of the 49,943 patients with EOS, 63.5% were males, and the mean age was 13.6 years old. The patients were using risperidone (62.5%), olanzapine (19.6%), quetiapine (12.4%), ziprasidone (3.3%) and clozapine (2.2%). We found gender differences, especially in the 13-17 year age group (65.1% for males vs. 34.9% for females, p < 0.001), in the use of risperidone (72.1% for males vs. 27.9% for females, p < 0.001) and olanzapine (66.5% for males vs. 33.5% for females, p < 0.001). Only in the 13 to 17 years age group were the prescribed doses of olanzapine (p = 0.012) and quetiapine (p = 0.041) slightly higher for males than for females. CONCLUSIONS Our findings showed gender differences among patients diagnosed with EOS and who received atypical antipsychotics. More attention should be devoted to gender differences in research and clinical practice.
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Affiliation(s)
- Izabela Fulone
- grid.442238.b0000 0001 1882 0259Pharmaceutical Sciences Graduate Course, University of Sorocaba, UNISO, Sorocaba/State of São Paulo, Brazil
| | - Marcus Tolentino Silva
- grid.442238.b0000 0001 1882 0259Pharmaceutical Sciences Graduate Course, University of Sorocaba, UNISO, Sorocaba/State of São Paulo, Brazil
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Graduate Course, University of Sorocaba, UNISO, Sorocaba/State of São Paulo, Brazil.
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Komaryk A, Elbe D, Burgess L. Retrospective Review of Clozapine Use in Children and Adolescents. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2021; 30:36-48. [PMID: 33552171 PMCID: PMC7837516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/30/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Literature describing use of clozapine by children and adolescents is limited. The primary study objective was to assess the patterns of clozapine use in an inpatient child and adolescent population. METHODS A retrospective review of child and adolescent inpatients receiving clozapine at a Canadian children's hospital from January 2000 through December 2014 was conducted. Interdisciplinary comprehensive data collection was conducted by experienced clinicians. Baseline population characteristics and psychiatric illness risk factors were captured. Illness symptoms and severity were assessed retrospectively using validated measures including the Brief Psychiatric Rating Scale (BPRS), Children's Global Assessment Scale (CGAS) and Clinical Global Impressions (CGI) scales. Estimated clozapine dosing requirements for each patient to achieve a serum level associated with response was calculated. Clozapine-related adverse events were captured. RESULTS Twenty-eight inpatients (64% female) receiving clozapine during the study period were identified. Mean age at clozapine initiation was 15.8 years. Twenty-three patients (82%) were taking clozapine at discharge, and of these, 22 patients (96%) experienced at least minimal improvement in BPRS and CGAS scores. Patients took a mean of 33.1 days from clozapine start to reach their maximum clozapine dosage, a mean maximum of 57% of their estimated clozapine dose requirement. Mean length of stay following clozapine initiation was 60.7 days. We observed a high rate of benign hematological adverse events, but no episodes of severe neutropenia. The majority of patients were of ethnicity associated with high risk for metabolic adverse events. CONCLUSION Most hospitalized, treatment-refractory children requiring clozapine clinically improve despite experiencing high, but largely manageable, adverse event rates.
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Affiliation(s)
- Ardelle Komaryk
- Family Nurse Practitioner; Healthy Minds Centre, BC Children's Hospital, Vancouver, British Columbia
| | - Dean Elbe
- Clinical Pharmacy Specialist, Child & Adolescent Mental Health; Healthy Minds Centre, BC Children's Hospital, Vancouver, British Columbia; Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia; Associate Member, Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Leah Burgess
- Registered Psychologist; Healthy Minds Centre, BC Children's Hospital, Vancouver, British Columbia
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24
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Alves MR, Bergamaschi CDC, Sorrilha FB, Fulone I, Barberato-Filho S, Mayer RCF, Melo DOD, Lopes L. Critical appraisal and comparison of recommendations of clinical practice guidelines for treatment of schizophrenia in children and adolescents: a methodological survey protocol. BMJ Open 2020; 10:e038646. [PMID: 32938601 PMCID: PMC7497528 DOI: 10.1136/bmjopen-2020-038646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The number of clinical practice guidelines (CPGs) have increased substantially mainly in the paediatric area of mental health. However, little is known about the quality or how recommendations for the treatment of disorders such as schizophrenia in children and adolescents have changed over time. The aim of this study will be to assess the quality of the development of CPGs for the treatment and management of schizophrenia in children and adolescents over time using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool and to compare the recommendations and interventions described in these documents. METHODS AND ANALYSIS CPGs will be identified using a prospective protocol through a systematic search of multiple databases (Medline, Embase, Health Systems Evidence, Epistemonikos, Lilacs, etc) and guideline websites from 2004 to December 2020. The quality of the guidelines will be assessed by three reviewers, independently using the AGREE II. CPGs will be considered of high-quality if they scored ≥60% in four or more domains of the AGREE II instrument. Non-parametric tests will be used to test for the change of quality over time. We will summarise the different evidence grading systems and compare the recommendations. ETHICS AND DISSEMINATION Ethical approval is not required since it is a literature-based study. Future results of the research can be submitted for publication in scientific journals of high impact, peer reviewed and also published in national and international conferences. The results derived from this study will contribute to the improvement of health institutions and policies, informing about existing recommendation guidelines and about deficiencies and qualities found in those. This study may also identify key areas for future research. This study may guide the search and choice for high quality CPGs by health policy makers and health professionals and subsidise future adaptations. PROTOCOL REGISTRATION NUMBER CRD42020164899.
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Affiliation(s)
- Maíra Ramos Alves
- Graduate Course of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, São Paulo, Brazil
| | | | - Flávia Blaseck Sorrilha
- Graduate Course of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, São Paulo, Brazil
| | - Izabela Fulone
- Graduate Course of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, São Paulo, Brazil
| | - Silvio Barberato-Filho
- Graduate Course of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, São Paulo, Brazil
| | | | - Daniela Oliveira de Melo
- Graduate Course of Pharmaceutical Sciences, Universidade Federal de Sao Paulo, São Paulo, São Paulo, Brazil
| | - Luciane Lopes
- Graduate Course of Pharmaceutical Sciences, Universidade de Sorocaba, Sorocaba, São Paulo, Brazil
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25
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Bahji A, Carlone D, Altomare J. Acceptability and efficacy of naltrexone for criminal justice-involved individuals with opioid use disorder: a systematic review and meta-analysis. Addiction 2020; 115:1413-1425. [PMID: 31863669 DOI: 10.1111/add.14946] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS Criminal justice-involved individuals carry a disproportionately higher burden of opioid use disorder (OUD) than those not involved with the criminal justice system, and are often unable to access opioid agonist therapies such as methadone and buprenorphine. The opioid receptor antagonist naltrexone (NTX) is effective for the prevention of relapse to OUD and may be more acceptable in criminal justice settings. The objectives of this review were to: (1) provide an overall summary effect across studies for the efficacy and acceptability of oral and injectable NTX for the treatment of OUD among criminal justice-involved individuals and (2) examine systematic variations in study results to explain heterogeneity among study-specific effects. METHODS Systematic review and meta-analysis of 1045 patients across 11 studies (10 randomized controlled trials, one quasi-experimental study). All available outcomes were pooled using random-effects meta-analysis. Subgroup analyses were conducted for oral and injectable naltrexone; meta-regression analyses were conducted for socio-demographic and study-level characteristics. RESULTS NTX improved retention in treatment [risk ratio (RR) = 1.31; 95% confidence interval (CI) = 1.05, 1.63], reduced rates of re-incarceration (RR = 0.70, 95% CI = 0.54-0.92), reduced opioid relapse (RR = 0.63, 95% CI = 0.53-0.76) and improved opioid abstinence (RR = 1.38, 95% CI = 1.16-1.65). While NTX was associated with a greater burden of adverse events overall (RR = 1.49, 95% CI = 1.13-1.95), the findings were inconclusive as to whether or not a difference was present for the number of serious adverse events or overdoses. CONCLUSIONS Naltrexone appears to be efficacious and acceptable for the treatment of opioid use disorder among criminal justice-involved individuals; however, the risk for adverse events must be weighed against the potential benefits.
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Affiliation(s)
- Anees Bahji
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Department of Psychiatry, Queen's University, Kingston, Canada
| | - David Carlone
- Department of Psychiatry, Queen's University, Kingston, Canada
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26
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Arango C, Ng-Mak D, Finn E, Byrne A, Loebel A. Lurasidone compared to other atypical antipsychotic monotherapies for adolescent schizophrenia: a systematic literature review and network meta-analysis. Eur Child Adolesc Psychiatry 2020; 29:1195-1205. [PMID: 31758359 PMCID: PMC7497364 DOI: 10.1007/s00787-019-01425-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 10/12/2019] [Indexed: 02/07/2023]
Abstract
This network meta-analysis assessed the efficacy and tolerability of lurasidone versus other oral atypical antipsychotic monotherapies in adolescent schizophrenia. A systematic literature review identified 13 randomized controlled trials of antipsychotics in adolescents with schizophrenia-spectrum disorders. A Bayesian network meta-analysis compared lurasidone to aripiprazole, asenapine, clozapine, olanzapine, paliperidone extended-release (ER), quetiapine, risperidone, and ziprasidone. Outcomes included Positive and Negative Syndrome Scale (PANSS), Clinical Global Impressions-Severity (CGI-S), weight gain, all-cause discontinuation, extrapyramidal symptoms (EPS), and akathisia. Results were reported as median differences for continuous outcomes and odds ratios (ORs) for binary outcomes, along with 95% credible intervals (95% CrI). Lurasidone was significantly more efficacious than placebo on the PANSS (- 7.95, 95% CrI - 11.76 to - 4.16) and CGI-S (- 0.44, 95% CrI - 0.67 to - 0.22) scores. Lurasidone was associated with similar weight gain to placebo and statistically significantly less weight gain versus olanzapine (- 3.62 kg, 95% CrI - 4.84 kg to - 2.41 kg), quetiapine (- 2.13 kg, 95% CrI - 3.20 kg to - 1.08 kg), risperidone (- 1.16 kg, 95% CrI - 2.14 kg to - 0.17 kg), asenapine (- 0.98 kg, 95% CrI - 1.71 kg to - 0.24 kg), and paliperidone ER (- 0.85 kg, 95% CrI - 1.57 kg to - 0.14 kg). The odds of all-cause discontinuation were significantly lower for lurasidone than aripiprazole (OR = 0.28, 95% CrI 0.10-0.76) and paliperidone ER (OR = 0.25, 95% CrI 0.08-0.81) and comparable to other antipsychotics. Rates of EPS and akathisia were similar for lurasidone and other atypical antipsychotics. In this network meta-analysis of atypical antipsychotics in adolescent schizophrenia, lurasidone was associated with similar efficacy, less weight gain, and lower risk of all-cause discontinuation compared to other oral atypical antipsychotics.
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Affiliation(s)
- Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón. IiSGM, School of Medicine, Universidad Complutense, CIBERSAM. Av. Séneca 2, 28040 Madrid, Spain
| | - Daisy Ng-Mak
- Sunovion Pharmaceuticals Inc, 84 Waterford Drive, Marlborough, MA, 01752, USA.
| | - Elaine Finn
- IQVIA, 210 Pentonville Rd, London, N1 9JY UK
| | - Aidan Byrne
- IQVIA, 210 Pentonville Rd, London, N1 9JY UK
| | - Antony Loebel
- Sunovion Pharmaceuticals Inc, One Bridge Plaza North, Suite 510, Fort Lee, NJ 07024 USA
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Chronic low-grade peripheral inflammation is associated with ultra resistant schizophrenia. Results from the FACE-SZ cohort. Eur Arch Psychiatry Clin Neurosci 2019; 269:985-992. [PMID: 29808267 DOI: 10.1007/s00406-018-0908-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/17/2018] [Indexed: 12/26/2022]
Abstract
A high rate of patients with schizophrenia (SZ) does not sufficiently respond to antipsychotic medication, which is associated with relapses and poor outcomes. Chronic peripheral inflammation has been repeatedly associated with schizophrenia risk and particularly to poor responders to treatment as usual with cognitive impairment in SZ subjects. The objective of present study was to confirm if ultra resistance to treatment in schizophrenia (UTRS) was associated to chronic peripheral inflammation in a non-selected sample of community-dwelling outpatients with schizophrenia. Participants were consecutively included in the network of the FondaMental Expert Centers for Schizophrenia and received a thorough clinical assessment, including recording of current treatment. Current psychotic symptomatology was evaluated by the Positive and Negative Syndrome scale for Schizophrenia (PANSS). UTRS was defined by current clozapine treatment + PANSS total score ≥ 70. Functioning was evaluated by the Global Assessment of Functioning scale. High sensitivity CRP (hs-CRP) was measured for each participant as a proxy to define peripheral low-grade inflammation. 609 stabilized community-dwelling SZ subjects (mean age = 32.5 years, 73.6% male gender) have been included. 60 (9.9%) patients were classified in the UTRS group. In multivariate analyses, UTRS has been associated independently with chronic peripheral inflammation (OR = 2.6 [1.2-5.7], p = 0.01), illness duration (0R = 1.1 [1.0-1.2], p = 0.02) and impaired functioning (OR = 0.9 [0.9-0.9], p = 0.0002) after adjustment for age, sex, current daily tobacco smoking, metabolic syndrome and antidepressant consumption. Peripheral low-grade inflammation is associated with UTRS. Future studies should explore if anti-inflammatory strategies are effective in UTRS with chronic low-grade peripheral inflammation.
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28
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Hui CLM, Lam BST, Lee EHM, Chan SKW, Chang WC, Suen YN, Chen EYH. A systematic review of clinical guidelines on choice, dose, and duration of antipsychotics treatment in first- and multi-episode schizophrenia. Int Rev Psychiatry 2019; 31:441-459. [PMID: 31225767 DOI: 10.1080/09540261.2019.1613965] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Clinical guidelines provide evidence-based recommendations to regulate pharmacological treatment of psychotic disorders. However, the quality of evidence, country of origin, and publication dates of such guidelines vary, which leads to discrepancies between recommendations. This systematic review aimed to examine consensus and disparities between clinical recommendations on the choice, dose, and duration of antipsychotic treatment for first- and multi-episode schizophrenia patients. A literature search through The Cochrane Library, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Sciences, and relevant bibliographies revealed 24 guidelines that met the inclusion criteria. The guidelines indicated mostly consistent recommendations regarding the optimal dose range of antipsychotics, while guidance with regards to the choice and duration of treatment remains somewhat controversial. Current trends in guidelines emphasize that there is simply no 'one-size-fits-all' method to manage schizophrenia patients. Further research is needed not only to address discrepancies between guidelines, but also to justify the gap between theory and practice.
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Affiliation(s)
- Christy L M Hui
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China
| | - Bertha S T Lam
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China
| | - Edwin H M Lee
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China
| | - Sherry K W Chan
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China.,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong , Hong Kong SAR , PR China
| | - Wing C Chang
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China.,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong , Hong Kong SAR , PR China
| | - Y N Suen
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China
| | - Eric Y H Chen
- Department of Psychiatry, University of Hong Kong , Hong Kong SAR , PR China.,State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong , Hong Kong SAR , PR China
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29
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Rodrigues R, MacDougall AG, Zou G, Lebenbaum M, Kurdyak P, Li L, Shariff SZ, Anderson KK. Involuntary hospitalization among young people with early psychosis: A population-based study using health administrative data. Schizophr Res 2019; 208:276-284. [PMID: 30728106 DOI: 10.1016/j.schres.2019.01.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Early psychosis is an important window for establishing long-term trajectories. Involuntary hospitalization during this period may impact subsequent service engagement in people with newly diagnosed psychotic disorder. However, population-based studies of involuntary hospitalization in early psychosis are lacking. We sought to estimate the proportion of people aged 16 to 35 years with early psychosis in Ontario who are hospitalized involuntarily at first admission, and to identify the associated risk factors and outcomes. METHODS Using linked population-based health administrative data, we identified incident cases of non-affective psychosis over a five-year period (2009-2013) and followed cases for two years to ascertain the first psychiatric hospitalization. We used modified Poisson regression to model sociodemographic, clinical, and service-related risk factors, and compared service-related outcomes for cases admitted on an involuntary versus voluntary basis. RESULTS Among 17,725 incident cases of non-affective psychosis, 38% were hospitalized within two years, and 81% of these admissions occurred on an involuntary basis (26% of cohort). Sociodemographic factors associated with an increased risk of involuntary admission included younger age (16-20), and first-generation migrant status. The strongest risk factors were poor illness insight, recent police involvement, and admission to a general (versus psychiatric) hospital. Outcomes associated with involuntary admission included increased likelihood of control intervention use and a shorter length of stay. CONCLUSIONS One in four young people with first-episode psychosis will have an involuntary admission early in the course of their illness. Our findings highlight areas for intervention to improve pathways to care for people with psychotic disorder.
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Affiliation(s)
- Rebecca Rodrigues
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Arlene G MacDougall
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Guangyong Zou
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Paul Kurdyak
- Institute for Clinical Evaluate Sciences, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Lihua Li
- Institute for Clinical Evaluate Sciences, Toronto, ON, Canada
| | | | - Kelly K Anderson
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Institute for Clinical Evaluate Sciences, Toronto, ON, Canada.
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30
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Cortese S, Tomlinson A, Cipriani A. Meta-Review: Network Meta-Analyses in Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2019; 58:167-179. [PMID: 30738544 DOI: 10.1016/j.jaac.2018.07.891] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/25/2018] [Accepted: 08/15/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Network meta-analyses (NMAs) are gaining traction as the preferred method for evidence synthesis of intervention studies. This review aimed to summarize the basics of NMAs and conduct a meta-review of available NMAs on the treatment of child and adolescent psychiatric disorders by appraising their quality. METHOD PubMed (Medline), PsycInfo, Embase, Ovid Medline, and Web of Knowledge were systematically searched (last update January 9, 2018). The quality of each included NMA was appraised using the AMSTAR-2 tool and the PRISMA-NMA checklist, which includes specific items for NMAs. RESULTS Eighteen NMAs (6 on attention-deficit/hyperactivity disorder; 4 on psychotic disorders; 2 on depression; 2 on anxiety disorders; 1 on obsessive-compulsive disorder; 1 on disruptive behavior disorder, 1 on bipolar disorder, and 1 on antipsychotics across disorders) were retrieved. Results from the AMSTAR-2 assessment showed that only 27% of appraised NMAs were rated as moderate quality; most were rated as low (33%) or critically low (40%) quality. Only 3 of the appraised NMAs reported on all PRISMA-NMA items specific for NMAs; the network structure was graphically presented in most NMAs (80%), and inconsistency was described in only 47%. CONCLUSION Given the paucity of head-to-head trials in child and adolescent psychiatry, NMAs have the potential to contribute to the field, because they provide evidence-based hierarchies for treatment decision making, even in the absence of trials directly comparing at least 2 treatments. However, because of important limitations in the included NMAs, additional methodologically sound NMAs are needed to inform future guidelines and clinical practice in child and adolescent psychiatry.
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Affiliation(s)
- Samuele Cortese
- Center for Innovation in Mental Health, Academic Unit of Psychology and Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK; the Solent NHS Trust, Southampton; the New York University Child Study Center, New York, NY; and the Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, UK.
| | | | - Andrea Cipriani
- Warneford Hospital and Oxford Health NHS Foundation Trust, University of Oxford, UK
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Abstract
PURPOSE OF REVIEW This narrative review synthesized recent research related to obesity in adolescents with psychiatric disorders, with a focus on epidemiology, mechanisms, and weight management approaches. The paper reviews literature on depressive and anxiety disorders, bipolar disorder, and schizophrenia spectrum and other psychotic disorders. RECENT FINDINGS Depression has a bidirectional relationship with obesity. Bipolar disorder and schizophrenia spectrum disorders, and their treatments, increase the risk of developing obesity. Mechanisms underlying this weight gain include lifestyle and environmental factors and psychiatric medications, though emerging evidence has also suggested the role of genetic and neuroendocrine processes. Evidence about the most effective treatments for obesity in adolescents with psychiatric disorders remains limited. Adolescents with psychiatric disorders are at high risk for obesity. Close monitoring for increases in weight and cardiometabolic risk factors with use of antipsychotic and mood-stabilizing medications is recommended. Clinical trials are needed that test the efficacy of weight management strategies for this population.
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Affiliation(s)
- Ariana M. Chao
- University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences;,Perelman School of Medicine at the University of Pennsylvania, Department of Psychiatry
| | - Thomas A. Wadden
- Perelman School of Medicine at the University of Pennsylvania, Department of Psychiatry
| | - Robert I. Berkowitz
- Perelman School of Medicine at the University of Pennsylvania, Department of Psychiatry;,Children’s Hospital of Philadelphia, Department of Child and Adolescent Psychiatry and Behavioral Sciences
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32
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Crocker CE, Tibbo PG. Confused Connections? Targeting White Matter to Address Treatment Resistant Schizophrenia. Front Pharmacol 2018; 9:1172. [PMID: 30405407 PMCID: PMC6201564 DOI: 10.3389/fphar.2018.01172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/28/2018] [Indexed: 12/14/2022] Open
Abstract
Despite development of comprehensive approaches to treat schizophrenia and other psychotic disorders and improve outcomes, there remains a proportion (approximately one-third) of patients who are treatment resistant and will not have remission of psychotic symptoms despite adequate trials of pharmacotherapy. This level of treatment response is stable across all stages of the spectrum of psychotic disorders, including early phase psychosis and chronic schizophrenia. Our current pharmacotherapies are beneficial in decreasing positive symptomology in most cases, however, with little to no impact on negative or cognitive symptoms. Not all individuals with treatment resistant psychosis unfortunately, even benefit from the potential pharmacological reductions in positive symptoms. The existing pharmacotherapy for psychosis is targeted at neurotransmitter receptors. The current first and second generation antipsychotic medications all act on dopamine type 2 receptors with the second generation drugs also interacting significantly with serotonin type 1 and 2 receptors, and with varying pharmacodynamic profiles overall. This focus on developing dopaminergic/serotonergic antipsychotics, while beneficial, has not reduced the proportion of patients experiencing treatment resistance to date. Another pharmacological approach is imperative to address treatment resistance both for response overall and for negative symptoms in particular. There is research suggesting that changes in white matter integrity occur in schizophrenia and these may be more associated with cognition and even negative symptomology. Here we review the evidence that white matter abnormalities in the brain may be contributing to the symptomology of psychotic disorders. Additionally, we propose that white matter may be a viable pharmacological target for pharmacoresistant schizophrenia and discuss current treatments in development for schizophrenia that target white matter.
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Affiliation(s)
- Candice E Crocker
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada.,Department of Diagnostic Imaging, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
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