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Franco JVA, Garegnani LI, Oltra GV, Metzendorf MI, Trivisonno LF, Sgarbossa N, Ducks D, Heldt K, Mumm R, Barnes B, Scheidt-Nave C. Long-Term Health Symptoms and Sequelae Following SARS-CoV-2 Infection: An Evidence Map. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9915. [PMID: 36011562 PMCID: PMC9408764 DOI: 10.3390/ijerph19169915] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 05/27/2023]
Abstract
Post-COVID-19 conditions, also known as 'Long-COVID-19', describe a longer and more complex course of illness than acute COVID-19 with no widely accepted uniform case definition. We aimed to map the available evidence on persistent symptoms and sequelae following SARS-CoV-2 in children and adults. We searched the Cochrane COVID-19 Study Register and the WHO COVID-19 Global literature on coronavirus disease database on 5 November 2021. We included longitudinal and cross-sectional studies and we extracted their characteristics, including the type of core outcomes for post-COVID-19 conditions. We included 565 studies (657 records). Most studies were uncontrolled cohort studies. The median follow-up time was 13 weeks (IQR 9 to 24). Only 72% of studies were conducted in high-income countries, 93% included unvaccinated adults with mild-to-critical disease, only 10% included children and adolescents, and less than 5% included children under the age of five. While most studies focused on health symptoms, including respiratory symptoms (71%), neurological symptoms (57%), fatigue (54%), pain (50%), mental functioning (43%), cardiovascular functioning (40%), and post-exertion symptoms (28%), cognitive function (26%), fewer studies assessed other symptoms such as overall recovery (24%), the need for rehabilitation (18%), health-related quality of life (16%), changes in work/occupation and study (10%), or survival related to long-COVID-19 (4%). There is a need for controlled cohort studies with long-term follow-up and a focus on overall recovery, health-related quality of life, and the ability to perform daily tasks. Studies need to be extended to later phases of the pandemic and countries with low resources.
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Affiliation(s)
- Juan Victor Ariel Franco
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Luis Ignacio Garegnani
- Research Department, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Gisela Viviana Oltra
- Research Department, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | | | - Nadia Sgarbossa
- Department of Health Science, Universidad Nacional de La Matanza, Buenos Aires B1754JEC, Argentina
| | - Denise Ducks
- Department of Epidemiology and Health Monitoring, Robert Koch-Institute, 13353 Berlin, Germany
| | - Katharina Heldt
- Department of Epidemiology and Health Monitoring, Robert Koch-Institute, 13353 Berlin, Germany
| | - Rebekka Mumm
- Department of Epidemiology and Health Monitoring, Robert Koch-Institute, 13353 Berlin, Germany
| | - Benjamin Barnes
- Department of Epidemiology and Health Monitoring, Robert Koch-Institute, 13353 Berlin, Germany
| | - Christa Scheidt-Nave
- Department of Epidemiology and Health Monitoring, Robert Koch-Institute, 13353 Berlin, Germany
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Huang MW, Gibson RC, Jayaram MB, Caroff SN. Antipsychotics for schizophrenia spectrum disorders with catatonic symptoms. Cochrane Database Syst Rev 2022; 7:CD013100. [PMID: 35844143 PMCID: PMC9289703 DOI: 10.1002/14651858.cd013100.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Whilst antipsychotics are the mainstay of treatment for schizophrenia spectrum disorders, there have been numerous attempts to identify biomarkers that can predict treatment response. One potential marker may be psychomotor abnormalities, including catatonic symptoms. Early studies suggested that catatonic symptoms predict poor treatment response, whilst anecdotal reports of rare adverse events have been invoked against antipsychotics. The efficacy and safety of antipsychotics in the treatment of this subtype of schizophrenia have rarely been studied in randomised controlled trials (RCTs). OBJECTIVES To compare the effects of any single antipsychotic medication with another antipsychotic or with other pharmacological agents, electroconvulsive therapy (ECT), other non-pharmacological neuromodulation therapies (e.g. transcranial magnetic stimulation), or placebo for treating positive, negative, and catatonic symptoms in people who have schizophrenia spectrum disorders with catatonic symptoms. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, the ISRCTN registry, and WHO ICTRP, on 19 September 2021. There were no language, date, document type, or publication status limitations for inclusion of records in the register. We also manually searched reference lists from the included studies, and contacted study authors when relevant. SELECTION CRITERIA All RCTs comparing any single antipsychotic medication with another antipsychotic or with other pharmacological agents, ECT, other non-pharmacological neuromodulation therapies, or placebo for people who have schizophrenia spectrum disorders with catatonic symptoms. DATA COLLECTION AND ANALYSIS two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we planned to calculate risk ratios and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we planned to calculate mean differences between groups and their 95% CI. We assessed risk of bias for the included studies, and created a summary of findings table; however, we did not assess the certainty of the evidence using the GRADE approach because there was no quantitative evidence in the included study. MAIN RESULTS Out of 53 identified reports, one RCT including 14 hospitalised adults with schizophrenia and catatonic symptoms met the inclusion criteria of the review. The study, which was conducted in India and lasted only three weeks, compared risperidone with ECT in people who did not respond to an initial lorazepam trial. There were no usable data reported on the primary efficacy outcomes of clinically important changes in positive, negative, or catatonic symptoms. Whilst both study groups improved in catatonia scores on the Bush-Francis Catatonia Rating Scale (BFCRS), the ECT group showed significantly greater improvement at week 3 endpoint (mean +/- estimated standard deviation; 0.68 +/- 4.58; N = 8) than the risperidone group (6.04 +/- 4.58; N = 6; P = 0.035 of a two-way analysis of variance (ANOVA) for repeated measures originally conducted in the trial). Similarly, both groups improved on the Positive and Negative Syndrome Scale (PANSS) scores by week 3, but ECT showed significantly greater improvement in positive symptoms scores compared with risperidone (P = 0.04). However, data on BFCRS scores in the ECT group appeared to be skewed, and mean PANSS scores were not reported, thereby precluding further analyses of both BFCRS and PANSS data according to the protocol. Although no cases of neuroleptic malignant syndrome were reported, extrapyramidal symptoms as a primary safety outcome were reported in three cases in the risperidone group. Conversely, headache (N = 6), memory loss (N = 4), and a prolonged seizure were reported in people receiving ECT. These adverse effects, which were assessed as specific for antipsychotics and ECT, respectively, were the only adverse effects reported in the study. However, the exact number of participants with adverse events was not clearly reported in both groups, precluding further analysis. Our results were based only on a single study with a very small sample size, short duration of treatment, unclear or high risk of bias due to unclear randomisation methods, possible imbalance in baseline characteristics, skewed data, and selective reporting. Data on outcomes of general functioning, global state, quality of life, and service use, as well as data on specific phenomenology and duration of catatonic symptoms, were not reported. AUTHORS' CONCLUSIONS We found only one small, short-term trial suggesting that risperidone may improve catatonic and positive symptoms scale scores amongst people with schizophrenia spectrum disorders and catatonic symptoms, but that ECT may result in greater improvement in the first three weeks of treatment. Due to small sample size, methodological shortcomings and brief duration of the study, as well as risk of bias, the evidence from this review is of very low quality. We are uncertain if these are true effects, limiting any conclusions that can be drawn from the evidence. No cases of neuroleptic malignant syndrome were reported, but we cannot rule out the risk of this or other rare adverse events in larger population samples. High-quality trials continue to be necessary to differentiate treatments for people with symptoms of catatonia in schizophrenia spectrum disorders. The lack of consensus on the psychopathology of catatonia remains a barrier to defining treatments for people with schizophrenia. Better understanding of the efficacy and safety of antipsychotics may clarify treatment for this unique subtype of schizophrenia.
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Affiliation(s)
- Michael W Huang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Roger Carl Gibson
- Department of Community Health & Psychiatry, University of the West Indies, Mona, Jamaica
| | - Mahesh B Jayaram
- Department of Psychiatry, Melbourne Neuropsychiatry Centre, Melbourne, Australia
| | - Stanley N Caroff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Olanzapine Reduction From High Dose to Standard Dose: A Retrospective Chart Review. J Clin Psychopharmacol 2021; 41:676-680. [PMID: 34735100 DOI: 10.1097/jcp.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE/BACKGROUND Although high-dose olanzapine might be a treatment option in patients with treatment-resistant schizophrenia, it can be reduced to the standard dose after symptoms are stabilized. We examined the rate of olanzapine reduction from high to standard dose and whether this change was successful. METHODS/PROCEDURES We included patients who received high-dose olanzapine (>20 mg/d) for 4 weeks or longer at our hospital. First, we retrospectively followed the patients for 6 years and estimated the percentage of those whose olanzapine was reduced from high to standard dose. Second, we followed patients who received olanzapine reduction for 1 year and estimated the rate of success based on the study-defined criteria for unsuccessful reduction. We also explored factors associated with the dose reduction and successful results. FINDINGS/RESULTS Among 110 patients who received high-dose olanzapine treatment, 72 had their olanzapine dose reduced to the standard dose for 6 years; the duration of high-dose olanzapine treatment was significantly and negatively associated with a reduction in olanzapine (hazard ratio, 0.98; 95% confidence interval, 0.98-0.99). Among the patients whose olanzapine was reduced, 50 achieved successful reduction for 1 year. Among the reasons for the reduction, an unknown reason was significantly associated with successful reduction (hazard ratio, 4.93; 95% confidence interval, 1.55-22.8). IMPLICATIONS/CONCLUSIONS The findings suggest that high-dose olanzapine can be reduced to the standard dose after stabilization of symptoms in most patients with schizophrenia.
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Døssing E, Pagsberg AK. Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines. J ECT 2021; 37:158-170. [PMID: 34424874 DOI: 10.1097/yct.0000000000000761] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
ABSTRACT There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.
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Affiliation(s)
- Erik Døssing
- From the Child and Adolescent Mental Health Centre, Mental Health Services, Zealand Region, Roskilde
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Lee JS, Yun JY, Kang SH, Lee SJ, Choi JH, Nam B, Lee SH, Chung YC, Kim CH. Korean Medication Algorithm for Schizophrenia 2019, Second Revision: Treatment of Psychotic Symptoms. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2020; 18:386-394. [PMID: 32702217 PMCID: PMC7383009 DOI: 10.9758/cpn.2020.18.3.386] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/28/2020] [Accepted: 03/12/2020] [Indexed: 12/26/2022]
Abstract
Objective In 2001, the Korean College of Neuropsychopharmacology and the Korean Society for Schizophrenia Research developed the Korean Medication Algorithm Project for Schizophrenia (KMAP-SPR 2001, revised 2006) through a consensus of expert opinion. The present study was carried out to support the second revision of the KMAP-SPR. Methods Based on clinical guidelines and studies on the treatment of psychotic symptoms in schizophrenia, the Executive committee completed a draft of KMAP-SPR 2019. To obtain an expert consensus, a Review committee of 100 Korean psychiatrists was formed and 69 responded to a 30-item questionnaire. Based on their responses, the KMAP-SPR 2019 was finalized. Results The revised schizophrenia algorithm now consists of 5 stages. At Stage 1, monotherapy with atypical antipsychotics was recommended by expert reviewers as the first-line strategy. At Stage 2, most reviewers recommended the use of typical or atypical antipsychotic drugs not used at Stage 1. At Stage 3, many reviewers agreed with the administration of clozapine. At Stage 4, a combination of clozapine and other agents such as antipsychotics, mood stabilizers, antidepressants, or electroconvulsive therapy was recommended. At Stage 5, most reviewers recommended combined treatment with an antipsychotic other than clozapine; and a mood stabilizer, antidepressant, or electroconvulsive therapy. At any stage, prescribing long-acting injectable antipsychotics at the discretion of the clinician was recommended. Conclusion Compared with previous versions, the KMAP-SPR 2019 now recommends using clozapine earlier in treatment-refractory schizophrenia. In addition, the use of long-acting injectable antipsychotics is now considered to be available at any stage.
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Affiliation(s)
- Jung Suk Lee
- Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Je-Yeon Yun
- Department of Psychiatry, Seoul National University Hospital, Seoul, Korea.,Yeongeon Student Support Center, Seoul National University College of Medicine, Seoul, Korea
| | - Shi Hyun Kang
- Department of Adult Psychiatry, National Center for Mental Health, Seoul, Korea
| | - Seung Jae Lee
- Department of Psychiatry, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Joon-Ho Choi
- Department of Psychiatry, Hanyang University College of Medicine and Mental Health Institute, Seoul, Korea
| | - Beomwoo Nam
- Department of Psychiatry, Konkuk University School of Medicine, Chungju, Korea
| | - Seung-Hwan Lee
- Department of Psychiatry, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Young-Chul Chung
- Department of Psychiatry, Chonbuk National University Medical School, Jeonju, Korea
| | - Chan-Hyung Kim
- Institute of Behavioral Science in Medicine and Department of Psychiatry, Yonsei University College of Medicine, Seoul, Korea
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6
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Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, Norrie J, Hudson J, Bowe S, French P, Hutton P, Byrne R, Syrett S, Dudley R, McLeod HJ, Griffiths H, Barnes TR, Davies L, Shields G, Buck D, Tully S, Kingdon D. Cognitive-behavioural therapy for clozapine-resistant schizophrenia: the FOCUS RCT. Health Technol Assess 2020; 23:1-144. [PMID: 30806619 DOI: 10.3310/hta23070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clozapine (clozaril, Mylan Products Ltd) is a first-choice treatment for people with schizophrenia who have a poor response to standard antipsychotic medication. However, a significant number of patients who trial clozapine have an inadequate response and experience persistent symptoms, called clozapine-resistant schizophrenia (CRS). There is little evidence regarding the clinical effectiveness of pharmacological or psychological interventions for this population. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of cognitive-behavioural therapy (CBT) for people with CRS and to identify factors predicting outcome. DESIGN The Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial was a parallel-group, randomised, outcome-blinded evaluation trial. Randomisation was undertaken using permuted blocks of random size via a web-based platform. Data were analysed on an intention-to-treat (ITT) basis, using random-effects regression adjusted for site, age, sex and baseline symptoms. Cost-effectiveness analyses were carried out to determine whether or not CBT was associated with a greater number of quality-adjusted life-years (QALYs) and higher costs than treatment as usual (TAU). SETTING Secondary care mental health services in five cities in the UK. PARTICIPANTS People with CRS aged ≥ 16 years, with an International Classification of Diseases, Tenth Revision (ICD-10) schizophrenia spectrum diagnoses and who are experiencing psychotic symptoms. INTERVENTIONS Individual CBT included up to 30 hours of therapy delivered over 9 months. The comparator was TAU, which included care co-ordination from secondary care mental health services. MAIN OUTCOME MEASURES The primary outcome was the Positive and Negative Syndrome Scale (PANSS) total score at 21 months and the primary secondary outcome was PANSS total score at the end of treatment (9 months post randomisation). The health benefit measure for the economic evaluation was the QALY, estimated from the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), health status measure. Service use was measured to estimate costs. RESULTS Participants were allocated to CBT (n = 242) or TAU (n = 245). There was no significant difference between groups on the prespecified primary outcome [PANSS total score at 21 months was 0.89 points lower in the CBT arm than in the TAU arm, 95% confidence interval (CI) -3.32 to 1.55 points; p = 0.475], although PANSS total score at the end of treatment (9 months) was significantly lower in the CBT arm (-2.40 points, 95% CI -4.79 to -0.02 points; p = 0.049). CBT was associated with a net cost of £5378 (95% CI -£13,010 to £23,766) and a net QALY gain of 0.052 (95% CI 0.003 to 0.103 QALYs) compared with TAU. The cost-effectiveness acceptability analysis indicated a low likelihood that CBT was cost-effective, in the primary and sensitivity analyses (probability < 50%). In the CBT arm, 107 participants reported at least one adverse event (AE), whereas 104 participants in the TAU arm reported at least one AE (odds ratio 1.09, 95% CI 0.81 to 1.46; p = 0.58). CONCLUSIONS Cognitive-behavioural therapy for CRS was not superior to TAU on the primary outcome of total PANSS symptoms at 21 months, but was superior on total PANSS symptoms at 9 months (end of treatment). CBT was not found to be cost-effective in comparison with TAU. There was no suggestion that the addition of CBT to TAU caused adverse effects. Future work could investigate whether or not specific therapeutic techniques of CBT have value for some CRS individuals, how to identify those who may benefit and how to ensure that effects on symptoms can be sustained. TRIAL REGISTRATION Current Controlled Trials ISRCTN99672552. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Anthony P Morrison
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Melissa Pyle
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Andrew Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matthias Schwannauer
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Douglas Turkington
- Academic Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust, Centre for Ageing and Vitality, Newcastle General Hospital, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Clinical Trials Unit, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK
| | - Paul French
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Hutton
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Rory Byrne
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Suzy Syrett
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Robert Dudley
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - Hamish J McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Griffiths
- Department of Clinical Psychology, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | | | - Linda Davies
- Division of Population Health, University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, University of Manchester, Manchester, UK
| | - Deborah Buck
- Division of Population Health, University of Manchester, Manchester, UK
| | - Sarah Tully
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Prestwich, UK.,Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - David Kingdon
- Department of Psychiatry, University of Southampton, Academic Centre, Southampton, UK
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Dysregulation of a specific immune-related network of genes biologically defines a subset of schizophrenia. Transl Psychiatry 2019; 9:156. [PMID: 31150013 PMCID: PMC6544656 DOI: 10.1038/s41398-019-0486-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 03/22/2019] [Accepted: 04/29/2019] [Indexed: 12/31/2022] Open
Abstract
Currently, the clinical diagnosis of schizophrenia relies solely on self-reporting and clinical interview, and likely comprises heterogeneous biological subsets. Such subsets may be defined by an underlying biology leading to solid biomarkers. A transgenic rat model modestly overexpressing the full-length, non-mutant Disrupted-in-Schizophrenia 1 (DISC1) protein (tgDISC1 rat) was generated that defines such a subset, inspired by our previous identification of insoluble DISC1 protein in post mortem brains from patients with chronic mental illness. Besides specific phenotypes such as DISC1 protein pathology, abnormal dopamine homeostasis, and changes in neuroanatomy and behavior, this animal model also shows subtle disturbances in overarching signaling pathways relevant for schizophrenia. In a reverse-translational approach, assuming that both the animal model and a patient subset share common disturbed signaling pathways, we identified differentially expressed transcripts from peripheral blood mononuclear cells of tgDISC1 rats that revealed an interconnected set of dysregulated genes, led by decreased expression of regulator of G-protein signaling 1 (RGS1), chemokine (C-C) ligand 4 (CCL4), and other immune-related transcripts enriched in T-cell and macrophage signaling and converging in one module after weighted gene correlation network analysis. Testing expression of this gene network in two independent cohorts of patients with schizophrenia versus healthy controls (n = 16/50 and n = 54/45) demonstrated similar expression changes. The two top markers RGS1 and CCL4 defined a subset of 27% of patients with 97% specificity. Thus, analogous aberrant signaling pathways can be identified by a blood test in an animal model and a corresponding schizophrenia patient subset, suggesting that in this animal model tailored pharmacotherapies for this patient subset could be achieved.
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Kelly DL, Love RC. Psychiatric pharmacist's role in overcoming barriers to clozapine use and improving management. Ment Health Clin 2019; 9:64-69. [PMID: 30842912 PMCID: PMC6398355 DOI: 10.9740/mhc.2019.03.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Clozapine is an antipsychotic that exhibits superior efficacy and effectiveness for those with schizophrenia and other serious mental illness. However, its side-effect profile and administrative burdens present challenges to its use. In the United States, the medication is grossly underused even though it may improve outcomes and reduce costs. Current barriers to use include lack of prescriber knowledge and confidence, negative prescriber attitudes, special monitoring requirements, administrative factors, lack of clozapine on formularies, lack of support and infrastructure to use the medication within many health systems, and inadequate understanding or acknowledgement of clozapine prescribing and risks by policy makers and payers. Approaches using interprofessional models of care, which include pharmacists specializing in psychiatric care, can help meet the needs of patients receiving clozapine. This article lays out the big picture of barriers to clozapine and how psychiatric pharmacists could play a role in improving access.
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9
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Bani-Fatemi A, Tasmim S, Graff A, Gerretsen P, Dada OO, Kennedy JL, Hettige N, Zai C, de Jesus D, de Bartolomeis A, De Luca V. The effect of ethnicity and immigration on treatment resistance in schizophrenia. Compr Psychiatry 2019; 89:28-32. [PMID: 30579127 DOI: 10.1016/j.comppsych.2018.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 11/01/2018] [Accepted: 12/05/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Treatment resistance is a common issue among schizophrenia patients undergoing antipsychotic treatment. According to the American Psychiatric Association (APA) guidelines, treatment-resistant status is defined as little or no symptom reduction to at least two antipsychotics at a therapeutic dose for a trial of at least six weeks. The aim of the current study is to determine whether ethnicity and migration are associated with treatment resistance. METHODS In a sample of 251 participants with schizophrenia spectrum disorders, we conducted cross-sectional assessments to collect information regarding self-identified ethnicity, immigration and treatment history. Ancestry was identified using 292 markers overlapping with the HapMap project. Using a regression analysis, we tested whether a history of migration, ethnicity or genetic ancestry were predictive of treatment resistance. RESULTS Our logistic regression model revealed no significant association between immigration (OR = 0.04; 95%CI = 0.35-3.07; p = 0.93) and treatment resistant schizophrenia. White Europeans did not show significant association with resistance status regardless of whether ethnicity was determined by self-report (OR = 1.89; 95%CI = 0.89-4.20; p = 0.105) or genetic analysis (OR = -0.73; 95%CI = -0.18-2.97; p = 0.667). CONCLUSION Neither ethnicity nor migrant status was significantly associated with treatment resistance in this Canadian study. However, these conclusions are limited by the small sample size of our investigation.
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Affiliation(s)
- Ali Bani-Fatemi
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Samia Tasmim
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ariel Graff
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Philip Gerretsen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Oluwagbenga O Dada
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - James L Kennedy
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Nuwan Hettige
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Clement Zai
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Danilo de Jesus
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada
| | | | - Vincenzo De Luca
- Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; University of Naples "Federico II", Naples, Italy.
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10
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Gazdag G, Ungvari GS. Electroconvulsive therapy: 80 years old and still going strong. World J Psychiatry 2019; 9:1-6. [PMID: 30631748 PMCID: PMC6323557 DOI: 10.5498/wjp.v9.i1.1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/29/2018] [Accepted: 12/11/2018] [Indexed: 02/05/2023] Open
Abstract
Electroconvulsive therapy (ECT), which is among the oldest and most controversial treatments in the field of psychiatry, has its 80th birthday this year. In this brief historical overview, the discovery of the therapeutic effects of convulsive therapy by Laszló Meduna, and the circumstances that motivated Ugo Cerletti and Lucio Bini to use electricity as a means of seizure induction are described. Meduna’s original theory about the antagonism between epilepsy and schizophrenia has been replaced by hypotheses on the mechanism of action of ECT. The position of ECT in modern psychiatry is also discussed with special attention to its most important clinical indications, including catatonia, and pre- and postpartum affective and psychotic states that are responsive to ECT and in which ECT may even be lifesaving. Adverse effects and comparison of ECT with recently developed brain stimulation methods are also reviewed. The negative media portrayal of ECT and its earlier misuse may have contributed to its negative professional and public perceptions indicated repeatedly in attitude surveys. This negative attitude has played an important role in the decreasing use of ECT in the developed world and a reduction in access to ECT, which constitutes a violation of psychiatric patients’ right to an effective treatment.
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Affiliation(s)
- Gábor Gazdag
- First Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest 1204, Hungary
- Department of Psychiatry and Psychotherapy, Semmelweis University Medical School, 1083 Budapest, Hungary
| | - Gabor S Ungvari
- University of Notre Dame, Fremantle, WA 6009, Australia
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, WA 6009, Australia
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11
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Huang MW, Gibson RC, Moberg PJ, Caroff SN. Antipsychotics for schizophrenia spectrum disorders with catatonic symptoms. Cochrane Database Syst Rev 2018; 2018:CD013100. [PMCID: PMC6517291 DOI: 10.1002/14651858.cd013100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of antipsychotic medications versus placebo, other medications, or ECT for treating positive, negative, and catatonic symptoms in people who have schizophrenia spectrum disorders with associated catatonic signs or symptoms.
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Affiliation(s)
- Michael W Huang
- University of PennsylvaniaPerelman School of MedicinePhiladelphiaUSA
| | - Roger Carl Gibson
- University of the West IndiesDepartment of Community Health & PsychiatryHospital Ring RoadUniversity Hospital of the West IndiesMonaJamaicaKgn 7
| | - Paul J Moberg
- University of PennsylvaniaPerelman School of MedicinePhiladelphiaUSA
| | - Stanley N Caroff
- University of PennsylvaniaPerelman School of MedicinePhiladelphiaUSA
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12
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Taylor C, Fertal JC, Liao S. Refractory Schizophrenia, Attempted Suicide, and Withdrawal of Life Support: A Clinical Ethics Case Report. J Pain Symptom Manage 2018; 56:153-157. [PMID: 29496535 DOI: 10.1016/j.jpainsymman.2018.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Withdrawal of life support for an individual with refractory schizophrenia after attempted suicide remains controversial. Discussion regarding prognosis of mental illness and the distinction between somatic and mental illness brings out many ethical issues. This article will examine the role and weight of severe persistent mental illness in the withdrawal of life support after attempted suicide. CASE DESCRIPTION A 30-year-old gentleman with deafness and schizophrenia was admitted with multiple self-inflicted visceral stab wounds. He developed postoperative complications necessitating ongoing critical care. The parties involved were as follows: the patient, his parents, the critical care trauma service, the palliative and psychiatry consult services, and the ethics committee. Over the patient's hospital course, his parents struggled to reconcile his poor preinjury quality of life with his ongoing need for intensive medical intervention. The primary and consulting teams were required to integrate differing perspectives on the patient's past responsiveness to treatment and the extent to which additional efforts might advance his quality of life and limit his future suffering and suicidality. The patient's surrogate decision makers unanimously requested withdrawal of life support. An ethics committee convened to address the question of whether refractory schizophrenia can produce so poor a quality of life as to merit the withdrawal of life-sustaining measures after a suicide attempt. Consensus was achieved, and life-sustaining measures were subsequently withdrawn, allowing the patient to pass away peacefully in an inpatient hospice facility.
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Affiliation(s)
- Cory Taylor
- University of Kansas School of Medicine, Kansas City, Kansas, USA.
| | | | - Solomon Liao
- UC Irvine Medical Center, Orange, California, USA
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13
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Rozet I, Rozet M, Borisovskaya A. Anesthesia for Electroconvulsive Therapy: an Update. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0283-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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14
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Gałaszkiewicz J, Rębisz K, Morylowska-Topolska J, Karakuła-Juchnowicz H, Kozak G. Clozapine-resistant schizophrenia – non pharmacological augmentation methods. CURRENT PROBLEMS OF PSYCHIATRY 2018. [DOI: 10.1515/cpp-2017-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Clozapine is the drug of choice for drug-resistant schizophrenia, but despite its use, 30-40% patients fail to achieve satisfactory therapeutic effects. In such situations, augmentation attempts are made by both pharmacological and non-pharmacological methods. To date, most of the work has been devoted to pharmacological strategies, much less to augemantation of clozapine with electroconvulsive therapy (C+ECT), transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS).
Aim: The aim of the work is to present biological, non-pharmacological augmentation treatment methods with clozapine.
Material and methods: A review of the literature on non-pharmacological augmentation treatment methods with clozapine was made. PubMed database was searched using key words: drug-resistant schizophrenia, clozapine, ECT, transcranial magnetic stimulation, transcranial electrical stimulation and time descriptors: 1980-2017.
Results: Most studies on the possibility of increasing the efficacy of clozapine was devoted to combination therapy with clozapine + electric treatments. They have shown improved efficacy when using these two methods simultaneously from 37.5 to 100%. The only randomized trial so far has also confirmed the effectiveness of this procedure. Despite the described side effects of tachycardia or prolonged seizures, most studies indicate the safety and efficacy of combined use of clozapine and electroconvulsive therapy. Transcranial magnetic stimulation also appears to be a safe method in patients treated with clozapine. However, further research is needed before ECT can be included in standard TRS treatment algorithms. The data for combining transcranial electrical stimulation with clozapine, come only from descriptions of cases and need to be confirmed in controlled studies.
Conclusions: The results of studies on the possibility of increasing the effectiveness of clozapine using biological non-pharmacological treatment methods indicate a potentially beneficial effect of this type of methods in breaking the super-resistance in schizophrenia. Combination of clozapine and ECT can be considered as the most recommended strategy among these treatment methods.
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Affiliation(s)
- Joanna Gałaszkiewicz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | - Krzysztof Rębisz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | | | | | - Gustaw Kozak
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
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Patchan K, Vyas G, Hackman AL, Mackowick M, Richardson CM, Love RC, Wonodi I, Sayer MA, Glassman M, Feldman S, Kelly DL. Clozapine in Reducing Aggression and Violence in Forensic Populations. Psychiatr Q 2018; 89:157-168. [PMID: 28643049 PMCID: PMC5930356 DOI: 10.1007/s11126-017-9521-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.
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Affiliation(s)
- Kathleen Patchan
- Department of Psychiatry, University of Maryland School of Medicine, 630 W Fayette St, Baltimore, MD, 21201, USA
| | - Gopal Vyas
- Spring Grove Hospital and Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - Ann L Hackman
- Department of Psychiatry, University of Maryland School of Medicine, 630 W Fayette St, Baltimore, MD, 21201, USA
| | - Marie Mackowick
- Clifton T. Perkins Hospital Center, 8450 Dorsey Run Rd, Jessup, MD, 20794, USA
| | - Charles M Richardson
- Spring Grove Hospital and Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - Raymond C Love
- School of Pharmacy, University of Maryland, 20 N Pine St, Baltimore, MD, 21201, USA
| | - Ikwunga Wonodi
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - MacKenzie A Sayer
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - Matthew Glassman
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - Stephanie Feldman
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA
| | - Deanna L Kelly
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, PO Box 21247, Baltimore, MD, 21228, USA.
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16
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Moeller S, Kalkwarf N, Lücke C, Ortiz D, Jahn S, Först C, Braun N, Philipsen A, Müller HH. Achieving stable remission with maintenance electroconvulsive therapy in a patient with treatment-resistant schizophrenia: A case report. Medicine (Baltimore) 2017; 96:e8813. [PMID: 29310360 PMCID: PMC5728761 DOI: 10.1097/md.0000000000008813] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Up to one third of all schizophrenic patients are classified as having treatment-resistant schizophrenia (TRS). This subgroup faces remarkable medical and psychosocial damages, and pharmacotherapy is often limited due to nonresponse and/or side effects. Maintenance electroconvulsive therapy (M-ECT) might be effective in TRS. PATIENT CONCERNS We present a case of a 26-year-old male patient with a TRS. DIAGNOSES He received a treatment series of ECT sessions and a course of 24 M-ECTs. INTERVENTIONS The entire treatment was tolerated without significant side effects. OUTCOMES Moreover, the Psychotic Symptom Rating Scale (PSYRATS) scores for both positive and negative symptoms decreased and remained stable over the course of M-ECT. LESSONS Because of the remarkable improvement in the negative and positive symptom clusters, we propose systematic examinations in the field of M-ECT in TRS patients. These studies should integrate long-term outcome and tolerance measurements, gaining insight into the optimal duration of treatment for this indication.
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Affiliation(s)
- Sebastian Moeller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Neele Kalkwarf
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Caroline Lücke
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Diana Ortiz
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Sonja Jahn
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Christiane Först
- Geriatric Psychiatry
- ECT Unit, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany
| | - Niclas Braun
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Alexandra Philipsen
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
| | - Helge H.O. Müller
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy—University Hospital
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Abstract
OBJECTIVE We investigated the association between clinical outcome and the recommendations of a pharmacogenetic test (Neuropharmagen) in patients with a variety of psychiatric conditions whose previous treatment regimen had failed. METHODS This retrospective, naturalistic, multicenter study included adult psychiatric patients (depression, psychosis, anxiety, bipolar, etc.) who had been seen at 3 private clinics. All patients had received pharmacogenetic testing (Neuropharmagen) and were classified depending on whether or not their post-test treatment regimen followed the test recommendations. Clinical severity was assessed with the Clinical Global Impression of Severity (CGI-S) at baseline (pre-test) and 3-month follow-up, and adverse events were recorded. RESULTS 182 patients were available for analysis. After multivariate adjustment, patients whose treatment followed the test recommendations had odds of improvement about 4 times greater than patients whose treatment did not follow the recommendations (adjusted OR=3.86, 95%CI 1.36-10.95; p=0.011). Importantly, psychiatric diagnosis did not significantly affect the odds of improvement. Also, in the subpopulation with baseline CGI-S score >3 (N=170), the rate of stabilization at follow-up (defined as CGI-S≤3) was significantly higher in patients whose treatment followed the pharmacogenetic recommendations (p=0.033). There was no apparent difference in the incidence of adverse events (6 patients in each group). CONCLUSIONS Non-drug naïve patients whose treatment followed the recommendations of pharmacogenetic testing were more likely to improve their condition than patients whose treatment did not. These results are consistent with previous clinical research on depressed patients, and this study also suggests that this benefit can be extended to psychiatric conditions other than depression.
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18
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Mullinax S, Shokraneh F, Wilson MP, Adams CE. Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials. J Emerg Med 2017; 53:524-529. [PMID: 28739149 DOI: 10.1016/j.jemermed.2017.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 04/04/2017] [Accepted: 04/25/2017] [Indexed: 10/24/2022]
Abstract
BACKGROUND Understanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies. OBJECTIVE The objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations for the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients. METHODS The Cochrane Schizophrenia Group's Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review. RESULTS Two oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychotics were similarly effective to intramuscular first-generation antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles. CONCLUSIONS This scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.
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Affiliation(s)
- Samuel Mullinax
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) Lab, Little Rock, Arkansas
| | - Farhad Shokraneh
- Neurosciences Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran; Cochrane Schizophrenia Group, Institute of Mental Health - University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom
| | - Michael P Wilson
- Department of Emergency Medicine Behavioral Emergences Research (DEMBER) Lab, Little Rock, Arkansas; Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Clive E Adams
- Cochrane Schizophrenia Group, Institute of Mental Health - University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom
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19
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Rimessi A, Pavan C, Ioannidi E, Nigro F, Morganti C, Brugnoli A, Longo F, Gardin C, Ferroni L, Morari M, Vindigni V, Zavan B, Pinton P. Protein Kinase C β: a New Target Therapy to Prevent the Long-Term Atypical Antipsychotic-Induced Weight Gain. Neuropsychopharmacology 2017; 42:1491-1501. [PMID: 28128334 PMCID: PMC5436118 DOI: 10.1038/npp.2017.20] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/03/2017] [Accepted: 01/21/2017] [Indexed: 12/21/2022]
Abstract
Antipsychotic drugs are currently used in clinical practice for a variety of mental disorders. Among them, clozapine is the most effective medication for treatment-resistant schizophrenia and is most helpful in controlling aggression and the suicidal behavior in schizophrenia and schizoaffective disorder. Although clozapine is associated with a low likelihood of extrapyramidal symptoms and other neurological side effects, it is well known for the weight gain and metabolic side effects, which expose the patient to a greater risk of cardiovascular disorders and premature death, as well as psychosocial issues, leading to non-adherence to therapy. The mechanisms underlying these iatrogenic metabolic disorders are still controversial. We have therefore investigated the in vivo effects of the selective PKCβ inhibitor, ruboxistaurin (LY-333531), in a preclinical model of long-term clozapine-induced weight gain. Cell biology, biochemistry, and behavioral tests have been performed in wild-type and PKCβ knockout mice to investigate the contribution of endogenous PKCβ and its pharmacological inhibition to the psychomotor effects of clozapine. Finally, we also shed light on a novel aspect of the mechanism underlying the clozapine-induced weight gain, demonstrating that the clozapine-dependent PKCβ activation promotes the inhibition of the lipid droplet-selective autophagy process. This paves the way to new therapeutic approaches to this serious complication of clozapine therapy.
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Affiliation(s)
- Alessandro Rimessi
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Chiara Pavan
- Unit of Psychiatry, Department of Neurosciences NPSRR, University of Padua, Padua, Italy
| | - Elli Ioannidi
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Federica Nigro
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Claudia Morganti
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy
| | - Alberto Brugnoli
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Francesco Longo
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Chiara Gardin
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Letizia Ferroni
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Michele Morari
- Department of Medical Sciences, Section of Pharmacology, Neuroscience Center and National Institute of Neuroscience, University of Ferrara, Ferrara, Italy
| | - Vincenzo Vindigni
- Unit of Plastic Surgery, Department of Neurosciences NPSRR, University of Padua, Padua, Italy
| | - Barbara Zavan
- Department of Biomedical Sciences, University of Padua, Padua, Italy
| | - Paolo Pinton
- Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Ferrara, Italy,Department of Morphology, Surgery and Experimental Medicine, Section of Pathology, Oncology and Experimental Biology, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70 (c/o CUBO), Ferrara 44121, Italy, Tel: +0039 0532455802, Fax: +0039 0532455351, E-mail:
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20
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Deng H, Adams CE. Traditional Chinese medicine for schizophrenia: A survey of randomized trials. Asia Pac Psychiatry 2017; 9. [PMID: 27734592 DOI: 10.1111/appy.12265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/26/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To survey the reports of randomized trials of traditional Chinese medicine (TCM) interventions for schizophrenia and produce a broad overview of this type of research activity in this area. METHOD We searched the Cochrane Schizophrenia Group's comprehensive Trials Register (January 2016), selected all relevant randomized trials, and extracted the data within each study. Finally, we sought relevant reviews on the Cochrane Library. RESULTS We initially screened 423 articles from which we identified 378 relevant studies randomizing 35 341 participants (average study size 94, SD 60). There were 7 herbs used as single medicine, 4 compositions or extractions, more than 144 herbal mixes, and 7 TCM principles reported for schizophrenia. Nonpharmacological interventions of TCM included acupuncture and exercise. The most commonly evaluated treatments are Ginkgo biloba, acupuncture, Wendan decoction, and Shugan Jieyu Capsule. There are 3 directly relevant Cochrane reviews. CONCLUSIONS Most treatment approaches-and some in common use-have only one or two relevant small trials. Some coordination of effort would help ensure that further well-designed appropriately sized randomized trials are conducted. Systematic reviews should be performed in this field but with titles that take into account the complexity of TCM.
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Affiliation(s)
- Hongyong Deng
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Clive E Adams
- Cochrane Schizophrenia Group, Institute of Mental Health, University of Nottingham, Nottingham, UK
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Molins C, Roldán A, Corripio I, Isohanni M, Miettunen J, Seppälä J, Seppälä A, Koponen H, Moilanen J, Jääskeläinen E. Response to antipsychotic drugs in treatment-resistant schizophrenia: Conclusions based on systematic review. Schizophr Res 2016; 178:64-67. [PMID: 27650195 DOI: 10.1016/j.schres.2016.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 11/18/2022]
Affiliation(s)
- C Molins
- Department of Psychiatry, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - A Roldán
- Department of Psychiatry, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - I Corripio
- Department of Psychiatry, Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Hospital de la Santa Creu i Sant Pau, Barcelona, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - M Isohanni
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Psychiatry, Oulu University Hospital, Oulu, Finland
| | - J Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Research Unit for Clinical Neuroscience, Department of Psychiatry, University of Oulu, Oulu, Finland
| | - J Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Department of Psychiatry, South-Savo Hospital District, Mikkeli, Finland; Department of Psychiatry, Carea - Kymenlaakso Social and Health Services, Finland
| | - A Seppälä
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - H Koponen
- University of Helsinki and Helsinki University Hospital, Psychiatry, Finland
| | - J Moilanen
- Department of Psychiatry, Oulu University Hospital, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland; Research Unit for Clinical Neuroscience, Department of Psychiatry, University of Oulu, Oulu, Finland
| | - E Jääskeläinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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22
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Veerman SRT, Schulte PFJ, Smith JD, de Haan L. Memantine augmentation in clozapine-refractory schizophrenia: a randomized, double-blind, placebo-controlled crossover study. Psychol Med 2016; 46:1909-21. [PMID: 27048954 PMCID: PMC4954262 DOI: 10.1017/s0033291716000398] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/30/2015] [Accepted: 02/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dysfunction of neuroplasticity due to N-methyl-d-aspartate (NMDA) receptor hypofunction may be a causal factor for memory and executive dysfunctioning in schizophrenia. Deregulation of NMDA transmission in the prefrontal cortex may also explain negative and positive symptoms. Clozapine augmentation with memantine targets altered NMDA receptor-mediated neurotransmission in schizophrenia and showed substantial beneficial effects on several symptom domains in a small proof-of-concept study. We evaluate effects of memantine add-on treatment to clozapine for memory and executive function, and negative and positive symptoms in schizophrenia. METHOD Clozapine-treated patients with refractory schizophrenia were randomly assigned to 12 weeks of double-blind adjunctive treatment with memantine (n = 26) or placebo (n = 26). Crossover occurred after a 2-week placebo wash-out period. Primary endpoints were change from baseline to 12 weeks treatment and 14 weeks to 26 weeks treatment on memory and executive function using the Cambridge Neuropsychological Test Automated Battery (CANTAB), Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression Severity Scale (CGI-S). Side effects were assessed using the Liverpool University Neuroleptic Side-Effect Rating Scale. RESULTS When compared with placebo, memantine improved a composite memory score comprising verbal recognition memory and paired associates learning task scores on the CANTAB (effect size = 0.30) and PANSS negative subscale score (effect size = 0.29). Side effects were mild and transient. CONCLUSIONS In patients with clozapine-treated refractory schizophrenia, memantine addition significantly improved verbal and visual memory and negative symptoms without serious adverse effects. These results justify further investigations on long-term memantine augmentation to clozapine in treatment-resistant schizophrenia.
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Affiliation(s)
- S. R. T. Veerman
- Mental Health Service Organization North Holland
North, Community Mental Health Division, Flexible Assertive
Community Treatment, Alkmaar, The
Netherlands
| | - P. F. J. Schulte
- Mental Health Service Organization North Holland
North, Division for Specialized Treatment, Treatment Center for
Bipolar Disorders, Alkmaar, The
Netherlands
| | - J. D. Smith
- Department of Psychiatry and Behavioral
Sciences, Northwestern University, Feinberg School of Medicine,
Center for Prevention Implementation Methodology, Chicago,
IL, USA
| | - L. de Haan
- Early Psychosis Department,
Academic Medical Center, University of Amsterdam, Academic Psychiatric
Center, Arkin, Amsterdam,
The Netherlands
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Abstract
Although treatment-resistant schizophrenia (TRS) was described 50 years ago and has a gold standard treatment with clozapine based on well-defined criteria, there is still a matter of great interest and controversy. In terms of the underlying mechanisms of the development of TRS, progress has been made for the elucidation of the neurochemical mechanisms. Structural neuroimaging studies have shown that patients with TRS have significant reduction of the prefrontal cortex volume when compared with non- TRS. This article updates and enhances our previous review with new evidence mainly derived from new studies, clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- Helio Elkis
- Instituto de Psiquiatria HC- FMUSP, Rua Ovidio Pires de Campos 785-São Paulo, SP-05403-010, Brazil.
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Cargnin S, Massarotti A, Terrazzino S. BDNF Val66Met and clinical response to antipsychotic drugs: A systematic review and meta-analysis. Eur Psychiatry 2016; 33:45-53. [PMID: 26854986 DOI: 10.1016/j.eurpsy.2015.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The polymorphic brain-derived neurotrophic factor (BDNF) gene has been postulated to be involved in inter-individual variability response to antipsychotic drugs. PURPOSE To perform a qualitative and quantitative synthesis of studies evaluating the influence of BDNF genetic variation on clinical response to antipsychotics. METHODS The review protocol was published in the PROSPERO database (Reg. n(o) CRD42015024614). A comprehensive search was performed through PubMed, Web of Knowledge and Cochrane databases up to July 2015. The methodological quality of identified studies was assessed using the MINORS criteria. Publication bias was estimated and potential sources of heterogeneity were investigated via meta-regression, subgroup and sensitivity analyses. RESULTS Nine studies including a total of 2461 antipsychotic-treated patients fulfilled inclusion criteria for meta-analysis of BDNF Val66Met. Using the random-effects model, the pooled results showed no significant association with antipsychotic response for the dominant (Met carriers vs Val/Val, OR: 0.93, 95% CI: 0.72-1.19, P=0.55), codominant (Met/Met vs Val/Val, OR: 0.82, 95% CI: 0.59-1.15, P=0.25), recessive (Met/Met vs Val carriers, OR: 0.81, 95% CI 0.60-1.10, P=0.18) or the allelic contrast (Met vs Val, OR: 0.92, 95% CI 0.76-1.10, P=0.34). Visual inspection of funnel plots and further evaluation with Egger's test did not suggest evidence of publication bias. Despite lack of significant heterogeneity in most comparisons, no evidence of association also emerged in the subgroup and sensitivity analyses conducted. CONCLUSION The present meta-analysis excludes a clinically relevant effect of BDNF Val66Met on antipsychotic drug response per se. Nevertheless, further investigation is still needed to clarify in well-designed, large sample-based studies, the impact of BDNF haplotypes containing the Val66Met polymorphism.
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Affiliation(s)
- S Cargnin
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy
| | - A Massarotti
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy
| | - S Terrazzino
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy.
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25
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Aydin M, Ilhan BC, Calisir S, Yildirim S, Eren I. Continuing clozapine treatment with lithium in schizophrenic patients with neutropenia or leukopenia: brief review of literature with case reports. Ther Adv Psychopharmacol 2016; 6:33-8. [PMID: 26913176 PMCID: PMC4749743 DOI: 10.1177/2045125315624063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Clozapine is a second-generation antipsychotic used for treatment-resistant schizophrenia. Despite its effectiveness, clozapine is largely underused due to serious side effects such as leukopenia or neutropenia. We aimed to review whether to continue, discontinue or rechallenge clozapine treatment after such haematological side effects. METHODS We reviewed and summarized the literature on the use of clozapine, how to deal with its side effects, and suitable options in case of any haematological problems. Then, we described several cases successfully treated with clozapine and lithium after development of neutropenia or leukopenia. RESULTS We present three patients with treatment-resistant schizophrenia. While they had demonstrated poor response to multiple antipsychotic trials, clozapine was started. Clozapine induced neutropenia; or leukopenia developed in some cases that was successfully reversed after lithium onset. Increased serious side effects related with coprescription of lithium and clozapine were not observed. CONCLUSION Lithium increases neutrophil and total white blood cell count as a side effect that may be useful in patients who develop neutropenia or leukopenia while being treated with clozapine.
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Affiliation(s)
- Memduha Aydin
- Konya Training and Research Hospital, Department of Psychiatry, Selcuklu, 42130, Konya, Turkey
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Heggdal D, Fosse R, Hammer J. Basal Exposure Therapy: A New Approach for Treatment-Resistant Patients with Severe and Composite Mental Disorders. Front Psychiatry 2016; 7:198. [PMID: 28066272 PMCID: PMC5165038 DOI: 10.3389/fpsyt.2016.00198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 11/29/2016] [Indexed: 01/24/2023] Open
Abstract
New treatment approaches are needed for patients with severe and composite mental disorders who are resistant to conventional treatments. Such treatment-resistant patients often have diagnoses of psychotic or bipolar disorders or severe personality disorders and comorbid conditions. In this study, we evaluate basal exposure therapy (BET), a novel ward-integrated psychotherapeutic approach for these patients. Central to BET is the conceptualization of undifferentiated existential fear as basic to the patients' problem, exposure to this fear, and the therapeutic platform complementary external regulation, which integrates and governs the totality of interventions throughout the treatment process. BET is administered at a locked-door ward with 6 patient beds and 13.5 full-time employees, including a psychiatrist and 2 psychologists. Thirty-eight patients who had completed BET were included, all but two being female, mean age 29.9 years. Fourteen patients had a diagnosis of schizophrenia or schizoaffective disorder (F20/25), eight had bipolar disorder or recurrent depressive disorder (F31/33), eight had diagnoses in the F40-48 domain (neurotic, stress-related, and somatoform disorders), five were diagnosed with emotionally unstable personality disorder (F60.3), and three patients had other diagnoses. Twenty of the patients (53%) had more than one ICD-10 diagnosis. Average treatment time in BET was 13 months, ranging from 2 to 72 months. Time-series data show significant improvements in symptoms and functioning from enrollment to discharge, with effect sizes at 0.76 for the Dissociation Experience Scale, 0.93 for the Brief Symptom Inventory, 1.47 for the Avoidance and Action Questionnaire, and 1.42 and 1.56, respectively, for the functioning and symptom subscales of the Global Assessment of Functioning Scale. In addition, the patients used significantly less antiepileptic, antipsychotic, anxiolytic, and antidepressant medications at discharge than at treatment enrollment. Patient improvement across treatment was associated with the following duration of time in BET, the successful completions of the exposure component of BET, positive changes in experiential avoidance as measured with the Acceptance and Action Questionnaire, and high symptom levels and low levels of functioning at treatment start. The findings indicate that BET may be a promising inpatient psychotherapeutic approach for previously treatment-resistant patients with severe and comorbid conditions.
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Affiliation(s)
- Didrik Heggdal
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust , Lier , Norway
| | - Roar Fosse
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust , Lier , Norway
| | - Jan Hammer
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust , Lier , Norway
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Wang W, Pu C, Jiang J, Cao X, Wang J, Zhao M, Li C. Efficacy and safety of treating patients with refractory schizophrenia with antipsychotic medication and adjunctive electroconvulsive therapy: a systematic review and meta-analysis. SHANGHAI ARCHIVES OF PSYCHIATRY 2015; 27:206-19. [PMID: 26549957 PMCID: PMC4621286 DOI: 10.11919/j.issn.1002-0829.215093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The efficacy and safety of the combined treatment of refractory schizophrenia with
antipsychotic medications and electroconvulsive therapy (ECT) remain uncertain. Aims Conduct systematic review and meta-analysis of available literature in English and Chinese about ECT in
the treatment of refractory schizophrenia. Methods English and Chinese databases were searched for studies published prior to May 20, 2015
regarding the efficacy and safety of the combined treatment of refractory schizophrenia with antipsychotic
medications and ECT. Two researchers selected and evaluated studies independently using pre-defined
criteria. Review Manager 5.3 software was used for data analysis. Results A total of 22 randomized control studies, 18 of which were conducted in mainland China, were
included in the analysis. Meta-analysis of data from 18 of the 22 studies with a pooled sample of 1394
individuals found that compared to treatment with antipsychotic medications alone, combined treatment
with antipsychotic medications and ECT had significantly higher rates of achieving study-specific criteria of
‘clinical improvement’ (RR=1.25, 95%CI=1.14-1.37). Based on the Grades of Recommendation, Assessment,
Development, and Evaluation (GRADE) criteria, the quality of evidence for this assessment of efficacy was
‘moderate’. However, the proportion of participants who experienced headache during the treatment was
significantly higher in the combined treatment group (RR=9.10, 95%CI=3.97-20.86, based on a pooled sample
of 517 from 8 studies) and the proportion who experienced memory impairment was also higher in the
combined treatment group (RR=6.48, 95%CI=3.54-11.87, based on a pooled sample of 577 from 7 studies).
The quality of evidence about these adverse events was rated as ‘very low’. Conclusions There are very few high quality randomized controlled clinical trials about the combination of
antipsychotic medications and ECT in the treatment of refractory schizophrenia. This meta-analysis found
that the combination of antipsychotic medications and ECT could improve psychiatric symptoms in patients
with refractory schizophrenia, but the incomplete methodological information provided for most of the
studies, publication bias (favoring studies with better outcomes in the combined treatment group), and
the low quality of evidence about adverse outcomes, cognitive impairment, and overall functioning raise
questions about the validity of the results.
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Affiliation(s)
- Wenzheng Wang
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengcheng Pu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiangling Jiang
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyi Cao
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jijun Wang
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Zhao
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunbo Li
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Delayed initiation of clozapine may be related to poor response in treatment-resistant schizophrenia. Int Clin Psychopharmacol 2015; 30:290-5. [PMID: 26163875 DOI: 10.1097/yic.0000000000000086] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of this retrospective chart-review study was to investigate the relationship between delayed commencement of clozapine and the level of response in treatment-resistant schizophrenia (TRS). We included 162 patients with schizophrenia who used clozapine. The mean delay until starting clozapine after fulfillment of the TRS criteria was 29 months. The delay was shorter in those who gained benefit from clozapine (P=0.04), those who were treated in a specialized psychosis outpatient unit (P=0.01), and in men (P=0.009), and it correlated with age (P<0.001). The delay in starting clozapine and the maximum clozapine dose were independent contributors toward the response to clozapine in the logistic regression analysis. Moreover, of those who gained considerable benefit from clozapine, the patients were younger (P=0.01), the duration of illness before clozapine treatment was shorter (P=0.001), and the numbers of adequate antipsychotic trials before the use of clozapine were fewer (P=0.05). Our findings suggest that efforts aimed at reducing the delay for starting clozapine may increase the effectiveness of clozapine in TRS.
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Abstract
OBJECTIVE This paper aims to review the available evidence for the use of clozapine and electroconvulsive therapy (ECT) in combination. METHODOLOGY Electronic searches were carried out to identify reports describing the combined use of clozapine and ECT. RESULTS Forty reports including 208 patients were identified. The majority of reports were in the form of case reports and case series, with few retrospective and open-label studies. The majority of patients were aged between 18 and 65 years and diagnosed with schizophrenia or schizoaffective disorder. Most of the patients refractory to clozapine were started on ECT as an augmentation therapy; however, in some reports, both ECT and clozapine were started concurrently, and in few cases clozapine was started after ECT. In terms of effectiveness, 37.5-100% patients improved in short-term, and sustained long-term improvement (3 weeks to 24 months) was described in few studies. In terms of the side-effect profile, five patients each had delirium and tachycardia and only four patients were described to have prolonged seizures. Overall, the combination was considered effective and safe. CONCLUSION There is evidence for the effectiveness and safety of the clozapine-ECT combination and it should be used in patients with treatment-resistant schizophrenia who do not respond to clozapine.
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Whitney Z, Procyshyn RM, Fredrikson DH, Barr AM. Treatment of clozapine-associated weight gain: a systematic review. Eur J Clin Pharmacol 2015; 71:389-401. [PMID: 25627831 DOI: 10.1007/s00228-015-1807-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 01/12/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE Clozapine is an antipsychotic drug with superior efficacy in treatment-resistant schizophrenia. Clozapine is associated with a low likelihood of extrapyramidal symptoms and other neurological side-effects but a high propensity to induce weight gain and general metabolic dysregulation. Various pharmacological and behavioral treatment approaches for reducing clozapine-associated weight gain exist in the literature; however, there are currently no clear clinical guidelines as to which method is preferred. The aim of the current review is to systematically summarize studies that have studied both pharmacological and non-pharmacological interventions to attenuate or reverse clozapine-associated weight gain. METHODS A systematic review of EMBASE and MEDLINE databases of all articles published prior to January 2014 was conducted. Seventeen studies were identified as meeting inclusion criteria and included in the review. RESULTS Aripiprazole, fluvoxamine, metformin, and topiramate appear to be beneficial; however, available data are limited to between one and three randomized controlled trials per intervention. Orlistat shows beneficial effects, but in males only. Behavioral and nutritional interventions also show modest effects on decreasing clozapine-associated weight gain, although only a small number of such studies exist. CONCLUSIONS While a number of pharmacological interventions can produce modest weight loss, each may be associated with negative side effects, which should be considered before beginning treatment. Given the pressing need to improve cardiometabolic health in most clozapine-treated patients, substantially more research is needed to develop sound clinical practice guidelines for the treatment of clozapine-associated weight gain.
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Affiliation(s)
- Z Whitney
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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Anderson SG, Livingston M, Couchman L, Smith DJ, Connolly M, Miller J, Flanagan RJ, Heald AH. Sex differences in plasma clozapine and norclozapine concentrations in clinical practice and in relation to body mass index and plasma glucose concentrations: a retrospective survey. Ann Gen Psychiatry 2015; 14:39. [PMID: 26583040 PMCID: PMC4650861 DOI: 10.1186/s12991-015-0075-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clozapine is widely prescribed and, although effective, can cause weight gain and dysglycemia. The dysmetabolic effects of clozapine are thought to be more prevalent in women with this gender on average attaining 17 % higher plasma clozapine concentrations than men. METHODS We investigated the relationship between dose, body mass index (BMI), plasma glucose concentration, and plasma clozapine and N-desmethylclozapine (norclozapine) concentrations in 100 individuals with a severe enduring mental illness. RESULTS Mean (10th/90th percentile) plasma clozapine concentrations were higher for women [0.49 (0.27-0.79) mg/L] compared with men [0.44 (0.26-0.70) mg/L] (F = 2.2; p = 0.035). There was no significant gender difference in the prescribed clozapine dose. BMI was significantly higher in women [mean (95 % CI) = 34.5 (26.0-45.3)] for females compared with 32.5 (25.2-41.0) for males. Overall, BMI increased by 0.7 kg/m(2) over a mean follow-up period of 210 days. A lower proportion, 41 % of women had a fasting blood glucose ≤6.0 mmol/L (<6.0 mmol/L is defined by the International Diabetes Federation as normal glucose handling), compared with 88 % of men (χ (2) = 18.6, p < 0.0001). CONCLUSIONS We have shown that mean BMI and blood glucose concentrations are higher in women prescribed clozapine than in men. Women also tended to attain higher plasma clozapine concentrations than men. The higher BMI and blood glucose in women may relate to higher tissue exposure to clozapine, as a consequence of sex differences in drug metabolism.
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Affiliation(s)
- Simon G Anderson
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK ; The George Institute for Global Health, Nuffield Department of Population Health, Oxford Martin School, University of Oxford, Oxford, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Lewis Couchman
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel J Smith
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Moira Connolly
- Intensive Psychiatric Care Unit, Gartnavel Royal Hospital, Glasgow, UK
| | - Joan Miller
- Pharmacy, Prestwich Hospital, Prestwich, Greater Manchester, UK
| | - Robert J Flanagan
- Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK
| | - A H Heald
- Department of Medicine, Leighton Hospital, Crewe, CW1 4QJ UK ; School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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de Bartolomeis A, Tomasetti C, Iasevoli F. Update on the Mechanism of Action of Aripiprazole: Translational Insights into Antipsychotic Strategies Beyond Dopamine Receptor Antagonism. CNS Drugs 2015; 29:773-99. [PMID: 26346901 PMCID: PMC4602118 DOI: 10.1007/s40263-015-0278-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Dopamine partial agonism and functional selectivity have been innovative strategies in the pharmacological treatment of schizophrenia and mood disorders and have shifted the concept of dopamine modulation beyond the established approach of dopamine D2 receptor (D2R) antagonism. Despite the fact that aripiprazole was introduced in therapy more than 12 years ago, many questions are still unresolved regarding the complexity of the effects of this agent on signal transduction and intracellular pathways, in part linked to its pleiotropic receptor profile. The complexity of the mechanism of action has progressively shifted the conceptualization of this agent from partial agonism to functional selectivity. From the induction of early genes to modulation of scaffolding proteins and activation of transcription factors, aripiprazole has been shown to affect multiple cellular pathways and several cortical and subcortical neurotransmitter circuitries. Growing evidence shows that, beyond the consequences of D2R occupancy, aripiprazole has a unique neurobiology among available antipsychotics. The effect of chronic administration of aripiprazole on D2R affinity state and number has been especially highlighted, with relevant translational implications for long-term treatment of psychosis. The hypothesized effects of aripiprazole on cell-protective mechanisms and neurite growth, as well as the differential effects on intracellular pathways [i.e. extracellular signal-regulated kinase (ERK)] compared with full D2R antagonists, suggest further exploration of these targets by novel and future biased ligand compounds. This review aims to recapitulate the main neurobiological effects of aripiprazole and discuss the potential implications for upcoming improvements in schizophrenia therapy based on dopamine modulation beyond D2R antagonism.
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Affiliation(s)
- Andrea de Bartolomeis
- Unit of Treatment Resistant Psychosis, Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine of Napoli "Federico II", Via Pansini, 5, Edificio n.18, 3rd floor, 80131, Naples, Italy.
| | - Carmine Tomasetti
- Unit of Treatment Resistant Psychosis, Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine of Napoli "Federico II", Via Pansini, 5, Edificio n.18, 3rd floor, 80131, Naples, Italy
| | - Felice Iasevoli
- Unit of Treatment Resistant Psychosis, Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, University School of Medicine of Napoli "Federico II", Via Pansini, 5, Edificio n.18, 3rd floor, 80131, Naples, Italy
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