Use of lithium, carbamazepine, and valproic acid in a state-operated psychiatric hospital

Specific Anti-hostility Effects of Atypical Antipsychotics in Persons with Schizophrenia: From Clozapine to Cariprazine

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate the anti-hostility effects of available atypical antipsychotic agents.

ABSTRACT

In addition to hallucinations and delusions, persons with schizophrenia may exhibit hostility. In clinical trials of antipsychotics, hostility is routinely measured as part of rating scales such as the Brief Psychiatric Rating Scale or Positive and Negative Syndrome Scale. The availability of the atypical antipsychotic clozapine in 1989 led to the observation that it is possible to have a treatment effect on hostility that is independent of the treatment effect on hallucinations or delusions, and independent of general sedative effects. The data supporting this notion of a specific anti-hostility effect are the most robust for clozapine as the data include specifically designed randomized, controlled clinical trials. A specific anti-hostility effect is also observable to various degrees with most of the other atypical antipsychotics, as evidenced in post hoc analyses of clinical trials originally conducted for regulatory purposes, supplemented by post hoc analyses of large effectiveness trials. The generalizability of these studies, however, may be limited. Participants in these trials were not selected for aggressive and hostile behavior. Some of the studies also excluded patients with substance use disorders. The latter is particularly important because alcohol and substance use are well known to increase risk for hostility and aggression. Nevertheless, the repeated demonstrations of the specificity of an anti-hostility effect (in terms of statistical independence of effects on other positive symptoms and of sedation) are of potential clinical importance.

Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009)

INTRODUCTION

To date no study has compared the treatment patterns for schizophrenia specifically between China and Japan. This study examined the cross-national differences in the use of psychotropic drugs and electroconvulsive therapy (ECT) in schizophrenia.

METHOD

Data on 3248 schizophrenia inpatients (n = 1524 in China and n = 1724 in Japan) were collected by either chart review or interviews during the designated 3 study periods between 2001 and 2009. Patients' socio-demographic and clinical characteristics, prescriptions of psychotropic drugs, and ECT use were recorded using a standardized protocol and data collection procedure.

RESULTS

Multivariate analyses revealed that compared to their Japanese counterparts, Chinese inpatients had a shorter length of current hospitalization, were significantly less frequently prescribed second-generation antipsychotics (except clozapine), antipsychotic polypharmacy, benzodiazepines, and mood stabilizers, and more likely to receive clozapine, antidepressants, and ECT.

DISCUSSION

Substantial variations in inpatient treatment patterns for schizophrenia were found between China and Japan. The common use of ECT and clozapine in Chinese inpatients and the frequent use of antipsychotic polypharmacy and high antipsychotic doses in Japanese inpatients need to be addressed.

Trends in the access to and the use of antipsychotic medications and psychotropic co-treatments in Asian patients with schizophrenia

To date, antipsychotics remain the mainstay of treatment for schizophrenia and related disorders although other psychotropic medications and non-pharmaceutical interventions have been used adjunctively in some patients and settings. Regular surveys on access to and prescription patterns of psychotropic medications in clinical practice are an important and efficient way of examining the use and time trends of treatments in a given population and region. Unlike developed Western countries, Asian countries have not fully undergone deinstitutionalisation of the severely and chronically mentally ill, and community-based mental health services are still under-developed. As a result, a large number of psychiatric patients still receive treatments in psychiatric hospitals. Moreover, there have been very limited studies examining access to and prescription patterns of psychotropic medications for schizophrenia patients in Asian countries. In this paper, we focus on the only international project on the use of psychotropic medications in schizophrenia patients in selected East and Southeast Asian countries/territories summarising its major findings. Most of the first- and second-generation antipsychotics (FGAs and SGAs) are available in Asian countries, but the access to psychotropic medications is largely affected by socio-cultural and historical contexts, health insurance schemes, health care policy, medication cost and consumers' preference across different countries/territories. Overall, the proportional use of FGAs, high dose antipsychotic treatment and antipsychotic polypharmacy have decreased, while the use of SGAs and antidepressants have increased and the utilisation of benzodiazepines and mood stabilisers has remained relatively stable over time. However, within these general trends, there is great inter-country variation regarding the psychotropic prescribing patterns and trends in Asian schizophrenia patients that also seems to differ from data in many Western countries.

Frequency of physical restraint and its associations with demographic and clinical characteristics in a Chinese psychiatric institution

PURPOSE

Physical restraint (PR) is a highly controversal topic in psychiatry. Little is known about PR among psychiatric inpatients in China. This study examined the frequency of PR and its relationships with demographic and clinical characteristics among a large psychiatric institution in the Hunan Province, China.

DESIGN AND METHODS

The study included a consecutively assessed sample of 160 psychiatric inpatients. Sociodemographic and clinical data including use of PR were collected from the medical records using a form designed for this study and confirmed via interview.

FINDINGS

The frequency of PR was 51.3% in the whole sample; 63.2% among female and 39.2% among male patients. In multiple logistic regression analysis PR was independently associated with male gender (p = 0.001, odds ratio [OR] = 0.2, 95% confidence interval [CI] 0.1-0.6), less outpatient treatment prior to admission (p = 0.03, OR = 0.3, 95% CI 0.1-0.9), more frequent use of mood stabilizers (p = 0.002, OR = 5.6, 95% CI 1.9-16.7), more aggressive behavior prior to admission (p = 0.002, OR = 1.1, 95% CI 1.04-1.2), and younger age (p = 0.04, OR = 0.97, 95% CI 0.93-0.99).

PRACTICE IMPLICATIONS

PR is very common in clinical practice in China. Its demographic and clinical correlates are similar to findings in Western settings.

Epidemiology and treatment of mood disorders in a day hospital setting from 1996 to 2007: an Italian study

BACKGROUND

THE PRESENT STUDY AIMED: to assess prescribing patterns in the treatment of major depression, bipolar disorder type I, cyclothymia, and dysthymia from 1996 to 2007 in a day hospital setting; to evaluate the prevalence of the above-mentioned mood disorders and gender distribution; and to relate familiality, comorbidity, and marital status to each diagnosis.

METHODS

Medical records for 777 day hospital patients with a diagnosis of major depression, bipolar disorder type I, cyclothymia, or dysthymia were grouped into two 6-year periods so as to compare the prescribing patterns of tricyclic antidepressants, selective serotonin reuptake inhibitors, noradrenergic reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, first-generation antipsychotics, second-generation antipsychotics, and mood stabilizers. Gender, prevalence, familiality, comorbidity, and marital status were related to each diagnosis.

RESULTS

The most common mood disorder, with a female preponderance, was major depression, regardless of marital status. High percentages of familiality and comorbidity were found for major depression, while a reduction was found in the utilization of tricyclic antidepressants. There was no statistically significant difference in rates of prescription of selective serotonin reuptake inhibitors and noradrenergic reuptake inhibitors, but some irregularities were found upon evaluating each diagnosis (eg, increased utilization of these agents in dysthymia and major depression, respectively). There was an increase in prescriptions for serotonin and norepinephrine reuptake inhibitors, but no marked differences in utilization of noradrenergic and specific serotonergic antidepressants, which remained basically low. There was no significant difference in prescribing of first-generation antipsychotic agents, although a reduction was found. There was a significant increase in utilization of second-generation antipsychotics and mood stabilizers.

CONCLUSION

Our epidemiological findings are consistent with data reported in the literature regarding the high prevalence of major depression among the mood disorders, as well as the impact of familiality and comorbidity. Analysis of prescribing patterns for antidepressants, antipsychotics, and mood stabilizers in the treatment of mood disorders shows a shift from older to newer drugs, and wider use of mood stabilizers.

Sex differences in use of psychotropic drugs and drug-induced side effects in schizophrenia patients: findings of the Research on Asia Psychotropic Prescription (REAP) studies

OBJECTIVE

The aim of this study was to investigate the sex differences in prescribing patterns of psychotropic drugs and drug-induced side effects in schizophrenia patients in Asia using the data of the Research on Asian Psychotropic Prescription Pattern (REAP) surveys.

METHOD

The prescription patterns of 6,441 schizophrenia inpatients in six Asian countries and regions were investigated during the 2001-2009 period. The patients' socio-demographic and clinical characteristics and their prescriptions for psychotropic drugs were recorded using a standardized protocol and data collection procedure.

RESULTS

Univariate analyses found the following factors to be significantly associated with the male sex: a younger age, higher doses of antipsychotics, less prominent delusions and hallucinations, more prominent negative symptoms, less likelihood of a prescription for second-generation antipsychotics (SGAs), greater use of antipsychotic polypharmacy, mood stabilizers and depot antipsychotics, more frequent tardive dyskinesia (TD), and less weight gain. In multivariate analyses, fewer prescriptions for SGAs, greater use of mood stabilizers, anticholinergics, antipsychotic polypharmacy and depot antipsychotics, extrapyramidal side effects (EPS) and TD, and less weight gain were independently associated with the male sex.

CONCLUSIONS

Sex is one of the independent contributors to psychotropic prescription and side effects in Asian schizophrenia patients. Psychopharmacological treatment guidelines for schizophrenia should consider the sexes separately.

Heterogeneity of violence in schizophrenia and implications for long-term treatment

AIMS

Most patients with schizophrenia are not violent. However, persistent violent behaviour in a minority of patients presents a therapeutic challenge. Published treatment guidelines and most pharmacological and epidemiological literature on violence in schizophrenia treat overt physical aggression as a homogeneous phenomenon. The aim of this review is to address the subtyping of violent behaviour in schizophrenia, and to relate the subtypes to treatment.

METHOD

Literature describing subtypes of violence in schizophrenia and the treatment of this problem was reviewed. 'Schizophrenia', 'violence', 'aggression', 'hostility' and 'personality disorders' were the principal search terms describing behaviours. Generic names of individual atypical antipsychotics and mood stabilisers were used in treatment searches.

RESULTS

There are at least three aetiological subtypes of violence in schizophrenia (i) that related directly to positive psychotic symptoms, (ii) impulsive violence and (iii) violence stemming from comorbidity with personality disorders, particularly psychopathy. Current treatment of violence in schizophrenia relies on antipsychotics and mood stabilisers. The evidence of effectiveness is relatively strong for clozapine, but inconsistent for other treatments. No systematic recommendations relating the treatment to aetiological subtypes of violence were found.

DISCUSSION

The inconsistent effectiveness of the current treatments of violent behaviour in schizophrenia is due, at least in part, to the aetiological heterogeneity of that behaviour. We should not expect that any given pharmacological treatment will be equally effective in reducing violent behaviour caused by psychosis, impaired impulse control or personality disorder.

CONCLUSION

Violence in schizophrenia is aetiologically heterogeneous. This heterogeneity has therapeutic implications that impact clinical practice today and should be further explored in future studies.

Risperidone alone versus risperidone plus valproate in the treatment of patients with schizophrenia and hostility

The objective of the study was to compare the antiaggressive efficacy of risperidone monotherapy versus risperidone plus valproate in patients with schizophrenia. This was an 8-week open-label randomized parallel group clinical trial in hospitalized adults diagnosed with schizophrenia and with hostile behavior. Patients were randomly assigned to receive risperidone alone (n=16) or risperidone plus valproate (n=17). To minimize bias, raters were blinded to the assigned treatment arm. Outcome measures included the Positive and Negative Syndrome Scale (PANSS), Buss-Durkee Hostility Inventory (BDHI), Barratt Impulsiveness Scale (BIS), Nurses Observation Scale for Inpatient Evaluation (NOSIE), and the Overt Aggression Scale (OAS). Although significantly fewer patients randomized to monotherapy completed the study (chi(2)=8.62, d.f.=1, P=0.003), no significant differences between monotherapy or combination treatment were observed in change of the BDHI, BIS, NOSIE, PANSS total scores, OAS measures of aggressive behavior or the hostility item of the PANSS. In conclusion, although patients receiving combination treatment were more likely to complete the study, we were unable to detect a meaningful advantage for combination therapy as measured by rating scales.

Safety considerations in pharmacotherapy of bipolar disorder

Bipolar disorder is a chronic, frequently relapsing illness with a prevalence of 1.2% to 3.4% in the general population. It is associated with high disability, higher comorbidity due to medical illnesses, and significant social and economical consequences for patients, their families, and society. The episodic nature of this disease warrants rational use of medications and proper monitoring for adverse events. Various drug classes, such as mood stabilizers, antipsychotics, benzodiazepines, and antidepressants, are used for the acute and maintenance treatment of bipolar disorder. Each group of drugs is associated with wide array of adverse events and drug interactions, which are the main hurdles in treatment outcome and compliance. Common side effects seen with several agents, particularly antipsychotics, are somnolence, weight gain, extrapyramidal symptoms, dyslipidemia, type-2 diabetes, and hyperprolactinemia. Major drug interactions are seen with drugs such as carbamazepine, due to hepatic enzyme induction. Adverse effects such as somnolence are tolerability concerns and can be managed easily; others, such as diabetes mellitus, are safety concerns. It is prudent to have precise knowledge of the individual drug's side-effect profile, pharmacokinetics, and pharmacodynamics, to plan a treatment regimen. More research is needed to understand potential risks of various drugs and to devise and incorporate monitoring protocols in the treatment regimen.

Valproate

OBJECTIVES

This article summarizes the role of valproate as a treatment for bipolar disorder and related conditions.

METHODS

Published studies and reviews were systematically reviewed. Results from randomized, parallel group, double-blind, placebo-controlled studies that included an active comparator are emphasized.

RESULTS

Valproate is an effective treatment for manic patients. Valproate was superior to placebo in one 1-year randomized, parallel group study in rate of recurrence requiring discontinuation, rate of depression requiring discontinuation, total early termination and time to 25% of patients relapsing with mania, and in controlling mild depressive symptoms. On some measures, including time to development of a manic episode, valproate did not differ from placebo. Assessments of maintenance efficacy of valproate and other putative prophylactic treatments for bipolar disorder are problematic, because of the need to analyze multiple indices of efficacy, and practical and ethical issues that limit generalizability of results of placebo-controlled studies. Valproate has some advantages over lithium in treatment of mania for persons with more severe illnesses. Valproate benefits a broader spectrum of bipolar conditions than lithium. Valproate appears at best modestly effective for bipolar depression. Used in combination with several other treatments, additive benefits result, that are greater than with any of the treatments as monotherapy. Side effects are generally mild and manageable, particularly with divalproex. Weight gain and pharmacokinetic interaction with lamotrigine are perhaps the most consistent problems in use. Valproate contributes to neural tube defects if taken during the first trimester of pregnancy, and this risk must be conveyed to women.

CONCLUSIONS

Valproate is an effective and useful treatment for bipolar disorder. Studies clarifying its spectrum of efficacy, its safety and efficacy in combination regimens, and its mechanisms of action are warranted.

Role of newer medications for bipolar disorder

The quest for additional effective therapies for bipolar study commenced in the 1960s, even before regulatory approval of lithium. This was driven by the recognition that patient response to lithium varied from excellent to poor; thus, significant numbers of patients faced its frequent adverse effects and risks without sustaining any benefit. These needed advances have been slowed by the unusual difficulties of studying bipolar disorder in controlled, rigorously designed protocols. These difficulties are reviewed both from the perspective of their effects on research and on clinical practice. In addition, the results of two blinded, placebo-controlled studies of divalproex in the treatment of acute mania are compared with results from earlier open and comparator studies. The comparisons indicate that open-study results with divalproex and other forms of valproic acid have yielded results quite similar to those observed under rigorous study conditions. Whereas substantial evidence exists regarding the efficacy of divalproex and carbamazepine and their roles in treating patients with bipolar disorder, studies evaluating other putative mood-stabilizing agents and antidepressants in bipolar disorder are few in number and inconsistent in results. With few exceptions, studies of these latter drugs do not provide clear guidelines for treatment.