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Cushnie AK, Bullock DN, Manea AM, Tang W, Zimmermann J, Heilbronner SR. The use of chemogenetic actuator ligands in nonhuman primate DREADDs-fMRI. CURRENT RESEARCH IN NEUROBIOLOGY 2022; 4:100072. [PMID: 36691404 PMCID: PMC9860110 DOI: 10.1016/j.crneur.2022.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/01/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) are engineered receptors that allow for genetically targeted, reversible manipulation of cellular activity via systemic drug administration. DREADD induced manipulations are initiated via the binding of an actuator ligand. Therefore, the use of DREADDs is contingent on the availability of actuator ligands. Actuator ligands low-dose clozapine (CLZ) and deschloroclozapine (DCZ) are highly selective for DREADDs, and, upon binding, induce physiological and behavioral changes in rodents and nonhuman primates (NHPs). Despite this reported specificity, both CLZ and DCZ have partial affinity for a variety of endogenous receptors and can induce dose-specific changes even in naïve animals. As such, this study aimed to examine the effects of CLZ and DCZ on resting-state functional connectivity (rs-FC) and intrinsic neural timescales (INTs) in naïve NHPs. In doing so, we evaluated whether CLZ and DCZ - in the absence of DREADDs - are inert by examining these ligands' effects on the intrinsic functional properties of the brain. Low-dose DCZ did not induce consistent changes in rs-FC or INTs prior to the expression of DREADDs; however, a high dose resulted in subject-specific changes in rs-FC and INTs. In contrast, CLZ administration induced consistent changes in rs-FC and INTs prior to DREADD expression in our subjects. Our results caution against the use of CLZ by explicitly demonstrating the impact of off-target effects that can confound experimental results. Altogether, these data endorse the use of low dose DCZ for future DREADD-based experiments.
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Affiliation(s)
- Adriana K. Cushnie
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Daniel N. Bullock
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Ana M.G. Manea
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Wei Tang
- Department of Computer Science, Program in Neuroscience, Indiana University Bloomington, Bloomington, IN, 47408, USA
| | - Jan Zimmermann
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Sarah R. Heilbronner
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Balcioglu YH, Gokcay H, Yesilkaya UH. One Plus One Sometimes Equals More Than Two: Long-acting Injectable Aripiprazole Adjunction in Clozapine-Resistant Schizophrenia. Clin Neuropharmacol 2021; 43:166-168. [PMID: 32947430 DOI: 10.1097/wnf.0000000000000404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In this report, we present a patient whose positive symptoms did not improve despite being treated with clozapine monotherapy at a therapeutic dose for 4 months, and whose symptoms began to resolve after aripiprazole long-acting injection adjunction to clozapine. A 22-year-old man was diagnosed as having schizophrenia last year in his first admission, with symptoms of auditory hallucinations, persecutory delusions, and associated social withdrawal. His positive symptoms did not improve despite being treated with risperidone, olanzapine, and paliperidone. Oral clozapine monotherapy was planned, and the daily dose was increased to provide a therapeutic plasma clozapine concentration and measured as effective (545 mg/dL). Aripiprazole long-acting injection 400 mg monthly was combined with the ongoing clozapine treatment for augmentation. One week after the third injection, a psychiatric examination revealed a significant improvement in the positive symptoms, and his caregivers confirmed an increase in the social interaction of the patient. Although we cannot postulate on a single exact mechanism for the increased efficacy of clozapine and aripiprazole combination, we may suggest that, at least for a subgroup of patients with schizophrenia who respond clinically to clozapine at a suboptimal level, combination with aripiprazole may be an effective therapeutic strategy.
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Affiliation(s)
- Yasin Hasan Balcioglu
- Department of Psychiatry, Bakirkoy Prof Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery
| | - Hasan Gokcay
- Department of Psychiatry, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Umit Haluk Yesilkaya
- Department of Psychiatry, Bakirkoy Prof Mazhar Osman Training and Research Hospital for Psychiatry, Neurology, and Neurosurgery
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Youn T, Jeong SH, Kim YS, Chung IW. Long-term clinical efficacy of maintenance electroconvulsive therapy in patients with treatment-resistant schizophrenia on clozapine. Psychiatry Res 2019; 273:759-766. [PMID: 31207863 DOI: 10.1016/j.psychres.2019.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
Electroconvulsive therapy (ECT) has been suggested as a treatment for augmenting the response to clozapine in patients that do not respond well to clozapine alone and maintenance ECT (M-ECT) had also been recommended to sustain improvement. This retrospective study of up to 2 years of observation was conducted to explore whether M-ECT is beneficial for long-term maintenance of the symptom remission elicited by acute ECT. Positive and Negative Syndrome Scale (PANSS) were plotted for each patient and compared using a linear mixed-effect model. A total of thirty-eight patients were followed and classified into three groups: (1) clozapine alone (CZP, n = 15), (2) acute ECT only (A-ECT, n = 11), and (3) acute ECT with M-ECT (M-ECT, n = 12). The mean number and interval of ECT sessions during the maintenance period in the M-ECT group were 39.0 ± 26.7 and 15.6 ± 8.4 days, respectively. The slope of the M-ECT group eventually declined, but that of the A-ECT group gradually increased back to the pre-ECT level. No persistent or serious adverse effects were observed. In conclusion, A-ECT augmented the effect of clozapine, but M-ECT was required for sustaining symptom improvement.
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Affiliation(s)
- Tak Youn
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, South Korea
| | - Yong Sik Kim
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - In Won Chung
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea.
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Haddad PM, Correll CU. The acute efficacy of antipsychotics in schizophrenia: a review of recent meta-analyses. Ther Adv Psychopharmacol 2018; 8:303-318. [PMID: 30344997 PMCID: PMC6180374 DOI: 10.1177/2045125318781475] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/04/2018] [Indexed: 12/19/2022] Open
Abstract
Schizophrenia is the eighth leading cause of disability worldwide in people aged 15-44 years. Before antidopaminergic antipsychotics were introduced in the 1950s, no effective medications existed for the treatment of schizophrenia. This review summarizes key meta-analytic findings regarding antipsychotic efficacy in the acute treatment of schizophrenia, including clozapine in treatment-resistant patients. In the most comprehensive meta-analysis of randomized controlled trials conducted in multi-episode schizophrenia, antipsychotics outperformed placebo regarding total symptoms, positive symptoms, negative symptoms, depressive symptoms, quality of life and social functioning. Amongst these outcomes, the standardized mean difference for overall symptoms was largest, that is, 0.47 (95% credible interval = 0.42-0.51), approaching a medium effect size, being reduced to 0.38 when publication bias and small-trial effects were accounted for. A comparison of two meta-analyses indicated that first-episode patients, compared with multi-episode patients, were more likely to have at least minimal treatment response [⩾20% Positive and Negative Syndrome Scale (PANSS)/Brief Psychiatric Rating Scale (BPRS) score reduction: 81% versus 51%] and good response (⩾50% PANSS/BPRS score reduction: 52% versus 23%). In multi-episode schizophrenia, no response or worsening after 2 weeks of a therapeutic antipsychotic dose was highly predictive of not achieving a good response at endpoint (median treatment = 6 weeks: specificity = 86%; positive predictive value = 90%), suggesting a change in treatment should be considered in such cases. In first-episode psychosis, adequately dosed antipsychotic treatment trials for more than 2 weeks are recommended before using no response or worsening as a decision point for aborting a given antipsychotic. In clearly defined treatment-resistant schizophrenia, clozapine generally outperformed other antipsychotics, especially when dosed appropriately (target = 3-6 months' duration; trough clozapine level ⩾350-400 μg/L) with a response rate (⩾20% PANSS/BPRS) of 33% by 3 months of treatment. High antipsychotic doses and psychotropic combinations are unlikely to be superior to standard doses of antipsychotic monotherapy. Acute antipsychotic efficacy in schizophrenia depends on the targeted symptom domain (greater efficacy: total and positive symptoms, lesser efficacy: negative symptoms, depressive symptoms, social functioning and quality of life). Greater antipsychotic efficacy is associated with higher total baseline symptom severity, treatment-naïveté/first-episode status, shorter illness duration, and trials that are nonindustry sponsored and that have a lower placebo effect. The heterogeneity of antipsychotic response across individuals and key symptom domains, the considerable degree of nonresponse/treatment resistance in multi-episode patients, and the adverse effect potential of antipsychotics are major limitations, underscoring the need to develop new medications for the treatment of schizophrenia. Drug development should include matching patient subgroups, which are identified by means of clinical and biomarker variables, to mechanisms of action of novel medications, targeting specific symptom domains, and investigating mechanisms of action other than dopaminergic blockade.
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Affiliation(s)
- Peter M Haddad
- Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar. Neuroscience and Psychiatry Unit, University of Manchester, Stopford Building, Oxford Road, Manchester, UK
| | - Christoph U Correll
- The Zucker Hillside Hospital, Psychiatry Research, Glen Oaks, NY, USA Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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7
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Shah P, Iwata Y, Plitman E, Brown EE, Caravaggio F, Kim J, Nakajima S, Hahn M, Remington G, Gerretsen P, Graff-Guerrero A. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: A systematic review. Psychiatry Res 2018; 268:114-122. [PMID: 30015109 DOI: 10.1016/j.psychres.2018.06.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/26/2018] [Accepted: 06/25/2018] [Indexed: 12/29/2022]
Abstract
Approximately one-third of patients with schizophrenia have treatment-resistant schizophrenia (TR-SCZ), which is a condition characterized by suboptimal response to antipsychotics other than clozapine. Importantly, treatment with clozapine-the only antipsychotic with an indication for TR-SCZ-is often delayed, which could contribute to negative outcomes. Given that the specific impact of delay in clozapine initiation is not well understood, we aimed to conduct a systematic search of the Ovid Medline® database to identify English language publications exploring the impact of delay in clozapine initiation on treatment outcomes in patients with TR-SCZ. Additionally, clinico-demographic factors associated with clozapine delay were examined. Our search identified four retrospective studies that showed an association between longer delay in clozapine initiation and poorer treatment outcomes, even after including covariates, such as age, sex, and duration of illness. In addition, we found six studies that showed an association between age and clozapine delay, but results with regard to other clinico-demographic variables were inconsistent. Overall, the available literature reveals a possible link between delay in clozapine use and poorer treatment outcomes in patients with TR-SCZ. However, given the relatively small number of studies on this clinically important topic, future research is warranted to draw more definitive conclusions.
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Affiliation(s)
- Parita Shah
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Yusuke Iwata
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Eric Plitman
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Eric E Brown
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Fernando Caravaggio
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julia Kim
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Shinichiro Nakajima
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo, Japan
| | - Margaret Hahn
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Gary Remington
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Philip Gerretsen
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada
| | - Ariel Graff-Guerrero
- Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Geriatric Mental Health Division, CAMH, University of Toronto, Toronto, Ontario, Canada; Campbell Family Mental Health Research Institute, CAMH, University of Toronto, Toronto, Ontario, Canada.
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Kim JH, Youn T, Choi JG, Jeong SH, Jung HY, Kim YS, Chung IW. Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia. Psychiatry Investig 2018; 15:829-835. [PMID: 30086612 PMCID: PMC6111217 DOI: 10.30773/pi.2018.05.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/15/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. METHODS Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. RESULTS Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. CONCLUSION Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.
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Affiliation(s)
- Jung Hyun Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Tak Youn
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Jun Gwon Choi
- Department of Anesthesiology and Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, Republic of Korea
| | - Hee Yeon Jung
- Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Psychiatry and Behavioral Science and Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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Demjaha A. On the brink of precision medicine for psychosis: Treating the patient, not the disease: A commentary on: Association between serum levels of glutamate and neurotrophic factors and response to clozapine treatment by Krivoy et al. 2017. Schizophr Res 2018; 193:487-488. [PMID: 28821358 DOI: 10.1016/j.schres.2017.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Arsime Demjaha
- Department of Psychosis Studies, Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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Woolley J, McGuire P. Neuroimaging in schizophrenia: what does it tell the clinician? ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.11.3.195] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neuroimaging has been used in clinical practice for over 30 years, but it is still perceived as rarely offering the psychiatrist much help in direct patient management. As newer imaging modalities are introduced (from computed tomography and positron and single photon emission tomography to magnetic and functional magnetic resonance imaging), the promise of imminent clinical utility is reawakened, only to fade as the innovation is shown to be another, albeit useful, research tool. The aim of this article is to update readers on some recent advances that are starting to align the research and clinical functions of neuroimaging. As imaging becomes more accessible and affordable there is real promise that both clinicians and patients will begin to benefit more directly.
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Abstract
Schizophrenia continues to challenge services: recent advances in antipsychotic drug treatment and psychosocial interventions are hindered by non-adherence, disengagement and substance misuse. Furthermore, new side-effect concerns attach to atypical drugs, and psychosocial interventions may be underresourced or of unproven benefit. It is important to address all issues with which patients, families and carers need assistance, and to take a well-informed, creative approach to pharmacological treatment, using medication according to individual patient need rather than mechanistic adherence to guidelines. Psychiatrists should be realistic in their expectations of patient outcome, accepting outcomes that fall short of recovery and imply long-term supportive care, and insisting that this care be available to their patients. Psychiatrists should support early diagnosis and intervention as being possibly the only means to alleviate the burden of long-term schizophrenia for patients, families and services.
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Abstract
People with schizophrenia die prematurely. Their illness, its treatment and their lifestyle all contribute to the excess morbidity and mortality. Lifestyle ‘choices' (e.g. poor diet, low rates of physical activity and increased likelihood to smoke cigarettes) predispose them to poor physical health and comorbid medical diseases. In addition, weight gain and obesity are a consequence of most antipsychotics, particularly the atypicals. Excessive body weight increases the risk of morbidity and mortality, and is the biggest risk factor for type II diabetes in schizophrenia. Much of the excess mortality of schizophrenia is preventable through lifestyle and risk factor modification and the treatment of common diseases, but the potential for improving outcomes in this area is only starting to be addressed.
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Abstract
BACKGROUND Schizophrenia and related disorders such as schizophreniform and schizoaffective disorder are serious mental illnesses characterised by profound disruptions in thinking and speech, emotional processes, behaviour and sense of self. Clozapine is useful in the treatment of schizophrenia and related disorders, particularly when other antipsychotic medications have failed. It improves positive symptoms (such as delusions and hallucinations) and negative symptoms (such as withdrawal and poverty of speech). However, it is unclear what dose of clozapine is most effective with the least side effects. OBJECTIVES To compare the efficacy and tolerability of clozapine at different doses and to identify the optimal dose of clozapine in the treatment of schizophrenia, schizophreniform and schizoaffective disorders. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (August 2011 and 8 December 2016). SELECTION CRITERIA All relevant randomised controlled trials (RCTs), irrespective of blinding status or language, that compared the effects of clozapine at different doses in people with schizophrenia and related disorders, diagnosed by any criteria. DATA COLLECTION AND ANALYSIS We independently inspected citations from the searches, identified relevant abstracts, obtained full articles of relevant abstracts, and classified trials as included or excluded. We included trials that met our inclusion criteria and reported useable data. For dichotomous data, we calculated the relative risk (RR) and the 95% confidence interval (CI) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) again based on a random-effects model. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. MAIN RESULTS We identified five studies that could be included. Each compared the effects of clozapine at very low dose (up to 149 mg/day), low dose (150 mg/day to 300 mg/day) and standard dose (301 mg/day to 600 mg/day). Four of the five included studies were based on a small number of participants. We rated all the evidence reported for the main outcomes of interest as low or very low quality. No data were available for the main outcomes of global state, service use or quality of life. Very low dose compared to low doseWe found no evidence of effect on mental state between low and very low doses of clozapine in terms of average Brief Psychiatric Rating Scale-Anchored (BPRS-A) endpoint score (1 RCT, n = 31, MD 3.55, 95% CI -4.50 to 11.60, very low quality evidence). One study found no difference between groups in body mass index (BMI) in the short term (1 RCT, n = 59, MD -0.10, 95% CI -0.95 to 0.75, low-quality evidence). Very low dose compared to standard doseWe found no evidence of effect on mental state between very low doses and standard doses of clozapine in terms of average BPRS-A endpoint score (1 RCT, n = 31, MD 6.67, 95% CI -2.09 to 15.43, very low quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 58, MD 0.10, 95% CI -0.76 to 0.96, low-quality evidence) Low dose compared to standard doseWe found no evidence of effect on mental state between low doses and standard doses of clozapine in terms of both clinician-assessed clinical improvement (2 RCTs, n = 141, RR 0.76, 95% CI 0.36 to 1.61, medium-quality evidence) and clinically important response as more than 30% change in BPRS score (1 RCT, n = 176, RR 0.93, 95% CI 0.78 to 1.10, medium-quality evidence). One study found no difference between groups in BMI in the short term (1 RCT, n = 57, MD 0.20, 95% CI -0.84 to 1.24, low-quality evidence).We found some evidence of effect for other adverse effect outcomes; however, the data were again limited. Very low dose compared to low doseThere was limited evidence that serum triglycerides were lower at low-dose clozapine compared to very low dose in the short term (1 RCT, n = 59, MD 1.00, 95% CI 0.51 to 1.49). Low dose compared to standard doseWeight gain was lower at very low dose compared to standard dose (1 RCT, n = 27, MD -2.70, 95% CI -5.38 to -0.02). Glucose level one hour after meal was also lower at very lose dose (1 RCT, n = 58, MD -1.60, 95% CI -2.90 to -0.30). Total cholesterol levels were higher at very low compared to standard dose (1 RCT, n = 58, n = 58, MD 1.00, 95% CI 0.20 to 1.80). Low dose compared to standard doseThere was evidence of fewer adverse effects, measured as lower TESS scores, in the low-dose group in the short term (2 RCTs, n = 266, MD -3.99, 95% CI -5.75 to -2.24); and in one study there was evidence that the incidence of lethargy (RR 0.77, 95% CI 0.60 to 0.97), hypersalivation (RR 0.70, 95% CI 0.57 to 0.84), dizziness (RR 0.56, 95% CI 0.39 to 0.81) and tachycardia (RR 0.57, 95% CI 0.45 to 0.71) was less at low dose compared to standard dose. AUTHORS' CONCLUSIONS We found no evidence of effect on mental state between standard, low and very low dose regimes, but we did not identify any trials on high or very high doses of clozapine. BMI measurements were similar between groups in the short term, although weight gain was less at very low dose compared to standard dose in one study. There was limited evidence that the incidence of some adverse effects was greater at standard dose compared to lower dose regimes. We found very little useful data and the evidence available is generally of low or very low quality. More studies are needed to validate our findings and report on outcomes such as relapse, remission, social functioning, service utilisation, cost-effectiveness, satisfaction with care, and quality of life. There is a particular lack of medium- or long-term outcome data, and on dose regimes above the standard rate.
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Affiliation(s)
- Selvizhi Subramanian
- Morecambe Community Mental Health TeamDepartment of PsychiatryVictoria HouseThornton RDMorecambeUKLA4 5NN
| | - Birgit A Völlm
- University of Nottingham Innovation ParkDivision of Psychiatry & Applied PsychologyInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Nick Huband
- University of Nottingham Innovation ParkDivision of Psychiatry & Applied PsychologyInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
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Kim HS, Kim SH, Lee NY, Youn T, Lee JH, Chung S, Kim YS, Chung IW. Effectiveness of Electroconvulsive Therapy Augmentation on Clozapine-Resistant Schizophrenia. Psychiatry Investig 2017; 14:58-62. [PMID: 28096876 PMCID: PMC5240461 DOI: 10.4306/pi.2017.14.1.58] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE This retrospective case series study of the effectiveness of electroconvulsive therapy (ECT) augmentation on clozapine-resistant schizophrenia was conducted by EMR review. METHODS Clozapine-resistance was defined as persistent psychotic symptoms despite at least 12 weeks of clozapine administration with blood levels over 350 ng/mL in order to rule out pseudo-resistance. Seven in-patients who were taking clozapine and treated with ECT were selected. We analyzed the psychopathology and subscales changed by ECT. RESULTS The average number of ECT sessions was 13.4 (±4.6). Total Positive and Negative Syndrome Scale (PANSS) score was significantly reduced by 17.9 (±12.8) points (p=0.0384) on average, which represented a reduction of 25.5% (±14.3). 71.4% (5/7) of patients were identified as clinical remission, with at least a 20% reduction in PANSS score. PANSS reduction was associated with number of ECT sessions, stimulus level in the final session, and blood clozapine levels before ECT. However, the negative subscale on the PANSS were not reduced by ECT in any patient. We did not observe any persistent adverse cognitive effects. CONCLUSION This study supports that ECT augmentation on clozapine-resistant schizophrenia reveals clinically effective and safe. Further research should be done involving a larger number of patients to investigate the effectiveness of clozapine/ECT combination therapy.
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Affiliation(s)
- Hye Sung Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Nam Young Lee
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Tak Youn
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Jeoung Hyuk Lee
- Department of Anesthesia & Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Seunghyun Chung
- Department of Anesthesia & Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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Maximizing clozapine utilization while minimizing blood dyscrasias: evaluation of patient demographics and severity of events. Int Clin Psychopharmacol 2016; 31:76-83. [PMID: 26565383 DOI: 10.1097/yic.0000000000000108] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine whether patient characteristics such as age, sex, race/ethnicity, and frequency of monitoring play a role in clozapine-related blood dyscrasias. This study examined all neutropenic events to identify any potential demographic qualities that may pose increased risk to individuals receiving clozapine treatment in accordance with the FDA guidelines released in 2005. These guidelines required the addition of absolute neutrophil count (ANC) tests in addition to white blood cell (WBC) counts to regular monitoring and a reduction in the frequency of testing to once monthly after 1 year of satisfactory WBC counts and ANCs. The previous schedule neither included ANC testing nor allowed for further reductions in the frequency of testing after 1 year, with patients continuing to be tested every 2 weeks indefinitely. This is a retrospective, closed chart review of all patients who received clozapine at the State Psychiatric Center and experienced a leukopenic/neutropenic event and/or who had a substantial drop in WBC/ANC from January 2009 to December 2011. A subset of patients who were identified as achieving 'non-rechallengeable' status with either an ANC and/or WBC threshold value from 2001 to 2014 were also examined. This protocol was approved by the New York State Psychiatric Institute Institutional Review Board. A total of 193 patients were included in the study. Males experienced more total events at 6.4 events per person compared with 5.2 events per woman. White patients had 6.5 total events per person compared with 4.2 total events per Black patient; however, Black patients experienced more moderate leukopenia/granulocytopenia events compared with Whites. Regardless of race or ethnicity, patients in the 40-49-year age range had the most events at 8.1 events per person and also presented with the highest number of moderate leukopenia/granulocytopenia events as did those scheduled for weekly monitoring. Conversely, the majority of patients with no recorded events were female and either 20-29 or 60-69 years of age. In total, 16 patients were exclusively designated as non-rechallengeable from 2001 to 2014 and only had one single blood event prompting this clozapine monitoring status. Of these 16 patient events, seven were White males, eight were White females, and one was a Black female with roughly 40% of those patients in the 50-59-year age group. Currently published predictions on possible demographic risk groups may not reflect clinical experience and may pose unnecessary treatment barriers in the provision of clozapine. Although the healthcare team should be aware of the possible demographic predictors of blood dyscrasias when using clozapine, treatment goals and monitoring strategies must be individualized to ensure successful clozapine therapy.
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Ahmed AO, Murphy CF, Latoussakis V, McGovern KE, English J, Bloch A, Anthony DT, Savitz AJ. An examination of neurocognition and symptoms as predictors of post-hospital community tenure in treatment resistant schizophrenia. Psychiatry Res 2016; 236:47-52. [PMID: 26778628 DOI: 10.1016/j.psychres.2016.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/10/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
Neurocognition and psychopathology are robust predictors of community functioning and relapse/rehospitalization in schizophrenia. Existing studies are however limited because they have ignored the most chronic, treatment-resistant patients. Moreover, the prediction of functional outcomes has yet to be extended to the duration of community tenure, an indicator of the capacity of chronically-hospitalized patients to gain traction in the community. The current study examined neurocognition and symptom severity at discharge as potential predictors of community tenure in chronically-hospitalized treatment-resistant patients. The study recruited 90 people with treatment-resistant schizophrenia who received services on an inpatient unit. Participants completed measures of psychopathology and neurocognition prior to discharge. Following discharge, participants were tracked at current residences six months and one year post-discharge to assess community tenure. The percentage of individuals who continued to live in the community at 12-month follow-up was 51%. Severe negative symptoms but not neurocognitive impairment or positive symptoms was a significant predictor of shorter post-hospital community tenure. Of the negative symptoms domain, anhedonia-asociality proved to be the most relevant predictor of community tenure in the sample. The capacity to elicit goal-directed behaviors in response to anticipated physical and social rewards may be an important treatment target for sustaining community tenure.
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Affiliation(s)
- Anthony O Ahmed
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA.
| | - Christopher F Murphy
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Vassilios Latoussakis
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Kelly E McGovern
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Judith English
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Andrew Bloch
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Donna T Anthony
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
| | - Adam J Savitz
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA
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De Hert M, De Beugher A, Sweers K, Wampers M, Correll CU, Cohen D. Knowledge of Psychiatric Nurses About the Potentially Lethal Side-Effects of Clozapine. Arch Psychiatr Nurs 2016; 30:79-83. [PMID: 26804506 DOI: 10.1016/j.apnu.2015.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/15/2015] [Accepted: 09/15/2015] [Indexed: 11/24/2022]
Abstract
Clozapine is an antipsychotic with superior efficacy in treatment refractory patients, and has unique anti-suicidal properties and a low propensity to cause extrapyramidal side-effects. Despite these advantages, clozapine utilization is low. This can in part be explained by a number of potentially lethal side effects of clozapine. Next to psychiatrists nurses play a crucial role in the long-term management of patients with schizophrenia. It is therefore important that nurses know, inform and monitor patients about the specific side-effects of clozapine. A recent study of psychiatrists published in 2011 has shown that there was a gap in the knowledge about side-effects of clozapine. The knowledge about side-effects of clozapine in nurses has never been studied. This cross-sectional study evaluated the knowledge base regarding the safety of clozapine, and its potential mediators, of psychiatric nurses in 3 psychiatric hospitals in Belgium with a specifically developed questionnaire based on the literature and expert opinion (3 clozapine experts). A total of 85 nurses completed the questionnaire. The mean total score was 6.1 of a potential maximum score of 18. Only 3 of the 18 multiple choice knowledge questions were answered correctly by more than 50% of nurses. Only 24.9% of participants passed the test (>50% correct answers). Nurses working on psychosis units were more likely to pass the test (xx.y% vs yy.z%, p=0.0124). There was a trend that nurses with a lower nursing diploma were more likely to fail the test (p=0.0561). Our study clearly identifies a large gap in the basic knowledge of psychiatric nurses about clozapine and its side-effects. Knowledge could be increased by more emphasis on the topic in nurse's training curricula as well as targeted onsite training. Only 23.5% of participants indicate that there was sufficient information in their basic nursing training.
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Affiliation(s)
- Marc De Hert
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | - Annelien De Beugher
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | - Kim Sweers
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium.
| | - Martien Wampers
- University Psychiatric Centre KU Leuven, Campus Kortenberg, Kortenberg, KU Leuven Department of Neurosciences, Belgium
| | | | - Dan Cohen
- Department of Epidemiology, University of Groningen, The Netherlands
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Mikell CB, Sinha S, Sheth SA. Neurosurgery for schizophrenia: an update on pathophysiology and a novel therapeutic target. J Neurosurg 2015; 124:917-28. [PMID: 26517767 DOI: 10.3171/2015.4.jns15120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The main objectives of this review were to provide an update on the progress made in understanding specific circuit abnormalities leading to psychotic symptoms in schizophrenia and to propose rational targets for therapeutic deep brain stimulation (DBS). Refractory schizophrenia remains a major unsolved clinical problem, with 10%-30% of patients not responding to standard treatment options. Progress made over the last decade was analyzed through reviewing structural and functional neuroimaging studies in humans, along with studies of animal models of schizophrenia. The authors reviewed theories implicating dysfunction in dopaminergic and glutamatergic signaling in the pathophysiology of the disorder, paying particular attention to neurosurgically relevant nodes in the circuit. In this context, the authors focused on an important pathological circuit involving the associative striatum, anterior hippocampus, and ventral striatum, and discuss the possibility of targeting these nodes for therapeutic neuromodulation with DBS. Finally, the authors examined ethical considerations in the treatment of these vulnerable patients. The functional anatomy of neural circuits relevant to schizophrenia remains of great interest to neurosurgeons and psychiatrists and lends itself to the development of specific targets for neuromodulation. Ongoing progress in the understanding of these structures will be critical to the development of potential neurosurgical treatments of schizophrenia.
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Affiliation(s)
- Charles B Mikell
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
| | - Saurabh Sinha
- Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sameer A Sheth
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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Wang J, Cao H, Liao Y, Liu W, Tan L, Tang Y, Chen J, Xu X, Li H, Luo C, Liu C, Ries Merikangas K, Calhoun V, Tang J, Shugart YY, Chen X. Three dysconnectivity patterns in treatment-resistant schizophrenia patients and their unaffected siblings. NEUROIMAGE-CLINICAL 2015; 8:95-103. [PMID: 26106532 PMCID: PMC4473730 DOI: 10.1016/j.nicl.2015.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 01/17/2023]
Abstract
Among individuals diagnosed with schizophrenia, approximately 20%–33% are recognized as treatment-resistant schizophrenia (TRS) patients. These TRS patients suffer more severely from the disease but struggle to benefit from existing antipsychotic treatments. A few recent studies suggested that schizophrenia may be caused by impaired synaptic plasticity that manifests as functional dysconnectivity in the brain, however, few of those studies focused on the functional connectivity changes in the brains of TRS groups. In this study, we compared the whole brain connectivity variations in TRS patients, their unaffected siblings, and healthy controls. Connectivity network features between and within the 116 automated anatomical labeling (AAL) brain regions were calculated and compared using maps created with three contrasts: patient vs. control, patient vs. sibling, and sibling vs. control. To evaluate the predictive power of the selected features, we performed a multivariate classification approach. We also evaluated the influence of six important clinical measures (e.g. age, education level) on the connectivity features. This study identified abnormal significant connectivity changes of three patterns in TRS patients and their unaffected siblings: 1) 69 patient-specific connectivity (PCN); 2) 102 shared connectivity (SCN); and 3) 457 unshared connectivity (UCN). While the first two patterns were widely reported by previous non-TRS specific studies, we were among the first to report widespread significant connectivity differences between TRS patient groups and their healthy sibling groups. Observations of this study may provide new insights for the understanding of the neurophysiological mechanisms of TRS. We first compared global functional connectivity in treatment-resistant schizophrenia and their unaffected siblings. Widespread unshared significant functional connectivity in unaffected siblings of treatment-resistant schizophrenia We studied the association of brain connectivity to clinical measures.
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Affiliation(s)
- Jicai Wang
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China ; Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province 650032, China
| | - Hongbao Cao
- Unit on Statistical Genomics, National Institute of Mental Health, NIH, Bethesda 20892, USA
| | - Yanhui Liao
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China
| | - Weiqing Liu
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China ; Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province 650032, China
| | - Liwen Tan
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China
| | - Yanqing Tang
- Department of Psychiatry, The First Affiliated Hospital, China Medical University, Shenyang, Liaoning Province 110001, China
| | - Jindong Chen
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China
| | - Xiufeng Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province 650032, China
| | - Haijun Li
- Department of radiology, the first people's hospital of Kunming, Kunming, Yunnan province, China, 650011
| | - Chunrong Luo
- Department of radiology, the first people's hospital of Kunming, Kunming, Yunnan province, China, 650011
| | - Chunyu Liu
- State Key Laboratory of Medical Genetics, Central South University, Changsha, Hunan 410078, China
| | - Kathleen Ries Merikangas
- Genetic Epidemiology Research Branch, Intramural Research Program, National Institute of Mental Health, Bethesda, MD 20892, USA
| | - Vince Calhoun
- Mind Research Network, Albuquerque, NM 87131, USA ; Department of Electrical and Computer Engineering at the University of New Mexico, Albuquerque, NM 87106, USA
| | - Jinsong Tang
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China ; Unit on Statistical Genomics, National Institute of Mental Health, NIH, Bethesda 20892, USA
| | - Yin Yao Shugart
- Unit on Statistical Genomics, National Institute of Mental Health, NIH, Bethesda 20892, USA
| | - Xiaogang Chen
- Institute of Mental Health, The Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, Hunan 410011, China ; State Key Laboratory of Medical Genetics, Central South University, Changsha, Hunan 410078, China ; National Technology of Institute of Psychiatry, Central South University, Changsha, Hunan 410011, China
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Comorbidity of Obsessive-Compulsive Disorder and Schizophrenia in an Adolescent. Case Rep Psychiatry 2015; 2015:136835. [PMID: 26483984 PMCID: PMC4592891 DOI: 10.1155/2015/136835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/06/2015] [Indexed: 11/26/2022] Open
Abstract
We report a case of a girl with a history of obsessive-compulsive disorder (OCD) subsequently exhibiting psychosis. She never attained remission since the outset. Initially she seemed to be resistant to most antipsychotics, namely, risperidone, haloperidol, paliperidone, quetiapine, and clozapine. However, she later responded remarkably better to risperidone after it was reintroduced for the second time. Recognizing and understanding the various pathogenesis of OCD or obsessive-compulsive symptoms (OCS) in schizophrenia are vital in laying out plan to manage the patient effectively.
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Cheng F, Zhao Z. Machine learning-based prediction of drug-drug interactions by integrating drug phenotypic, therapeutic, chemical, and genomic properties. J Am Med Inform Assoc 2014; 21:e278-86. [PMID: 24644270 DOI: 10.1136/amiajnl-2013-002512] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Drug-drug interactions (DDIs) are an important consideration in both drug development and clinical application, especially for co-administered medications. While it is necessary to identify all possible DDIs during clinical trials, DDIs are frequently reported after the drugs are approved for clinical use, and they are a common cause of adverse drug reactions (ADR) and increasing healthcare costs. Computational prediction may assist in identifying potential DDIs during clinical trials. METHODS Here we propose a heterogeneous network-assisted inference (HNAI) framework to assist with the prediction of DDIs. First, we constructed a comprehensive DDI network that contained 6946 unique DDI pairs connecting 721 approved drugs based on DrugBank data. Next, we calculated drug-drug pair similarities using four features: phenotypic similarity based on a comprehensive drug-ADR network, therapeutic similarity based on the drug Anatomical Therapeutic Chemical classification system, chemical structural similarity from SMILES data, and genomic similarity based on a large drug-target interaction network built using the DrugBank and Therapeutic Target Database. Finally, we applied five predictive models in the HNAI framework: naive Bayes, decision tree, k-nearest neighbor, logistic regression, and support vector machine, respectively. RESULTS The area under the receiver operating characteristic curve of the HNAI models is 0.67 as evaluated using fivefold cross-validation. Using antipsychotic drugs as an example, several HNAI-predicted DDIs that involve weight gain and cytochrome P450 inhibition were supported by literature resources. CONCLUSIONS Through machine learning-based integration of drug phenotypic, therapeutic, structural, and genomic similarities, we demonstrated that HNAI is promising for uncovering DDIs in drug development and postmarketing surveillance.
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Affiliation(s)
- Feixiong Cheng
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Zhongming Zhao
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA Department of Cancer Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Schumann G, Binder EB, Holte A, de Kloet ER, Oedegaard KJ, Robbins TW, Walker-Tilley TR, Bitter I, Brown VJ, Buitelaar J, Ciccocioppo R, Cools R, Escera C, Fleischhacker W, Flor H, Frith CD, Heinz A, Johnsen E, Kirschbaum C, Klingberg T, Lesch KP, Lewis S, Maier W, Mann K, Martinot JL, Meyer-Lindenberg A, Müller CP, Müller WE, Nutt DJ, Persico A, Perugi G, Pessiglione M, Preuss UW, Roiser JP, Rossini PM, Rybakowski JK, Sandi C, Stephan KE, Undurraga J, Vieta E, van der Wee N, Wykes T, Haro JM, Wittchen HU. Stratified medicine for mental disorders. Eur Neuropsychopharmacol 2014; 24:5-50. [PMID: 24176673 DOI: 10.1016/j.euroneuro.2013.09.010] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 09/09/2013] [Accepted: 09/26/2013] [Indexed: 12/13/2022]
Abstract
There is recognition that biomedical research into the causes of mental disorders and their treatment needs to adopt new approaches to research. Novel biomedical techniques have advanced our understanding of how the brain develops and is shaped by behaviour and environment. This has led to the advent of stratified medicine, which translates advances in basic research by targeting aetiological mechanisms underlying mental disorder. The resulting increase in diagnostic precision and targeted treatments may provide a window of opportunity to address the large public health burden, and individual suffering associated with mental disorders. While mental health and mental disorders have significant representation in the "health, demographic change and wellbeing" challenge identified in Horizon 2020, the framework programme for research and innovation of the European Commission (2014-2020), and in national funding agencies, clear advice on a potential strategy for mental health research investment is needed. The development of such a strategy is supported by the EC-funded "Roadmap for Mental Health Research" (ROAMER) which will provide recommendations for a European mental health research strategy integrating the areas of biomedicine, psychology, public health well being, research integration and structuring, and stakeholder participation. Leading experts on biomedical research on mental disorders have provided an assessment of the state of the art in core psychopathological domains, including arousal and stress regulation, affect, cognition social processes, comorbidity and pharmacotherapy. They have identified major advances and promising methods and pointed out gaps to be addressed in order to achieve the promise of a stratified medicine for mental disorders.
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Affiliation(s)
- Gunter Schumann
- MRC-Social Genetic Developmental Psychiatry Centre, Institute of Psychiatry, King's College London, PO80, 16 De Crespigny Park, London SE5 8AF, UK.
| | | | - Arne Holte
- Norwegian Institute of Public Health, Oslo, Norway
| | - E Ronald de Kloet
- Department of Endocrinology and Metabolism, Leiden University Medical Centre and Medical Pharmacology, LACDR, Leiden University, The Netherlands
| | - Ketil J Oedegaard
- Department of Clinical Medicine, Section of Psychiatry, University of Bergen and Psychiatric division, Health Bergen, Norway
| | - Trevor W Robbins
- Behavioural and Clinical Neuroscience Institute and Department of Psychology, Cambridge University, Cambridge, UK
| | - Tom R Walker-Tilley
- MRC-Social Genetic Developmental Psychiatry Centre, Institute of Psychiatry, King's College London, PO80, 16 De Crespigny Park, London SE5 8AF, UK
| | - Istvan Bitter
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Verity J Brown
- Department of Psychology, University of St Andrews, St Andrews, UK
| | - Jan Buitelaar
- Department of Cognitive Neuroscience, University Medical Center, St Radboud and Karakter Child and Adolescent Psychiatry University Center, Nijmegen, The Netherlands
| | - Roberto Ciccocioppo
- Department of Experimental Medicine and Public Health, University of Camerino, Camerino, Macerata, Italy
| | | | - Carles Escera
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
| | - Wolfgang Fleischhacker
- Department of Psychiatry and Psychotherapy, Medical University Innsbruck, Innsbruck, Austria
| | - Herta Flor
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Chris D Frith
- Wellcome Trust Centre for Neuroimaging, University College London, London, UK
| | - Andreas Heinz
- Berlin School of Mind and Brain, Bernstein Center for Computational Neuroscience (BCCN), Clinic for Psychiatry and Psychotherapy, Charité - Universitätsmedizin, Berlin, Germany
| | - Erik Johnsen
- Department of Clinical Medicine, Section of Psychiatry, University of Bergen and Psychiatric division, Health Bergen, Norway
| | - Clemens Kirschbaum
- Technische Universität Dresden, Department of Psychology, Dresden, Germany
| | | | - Klaus-Peter Lesch
- Division of Molecular Psychiatry, Laboratory of Translational Neuroscience, University of Würzburg, Würzburg, Germany and Department of Neuroscience, School of Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Shon Lewis
- University of Manchester, Manchester, UK
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Karl Mann
- Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, Mannheim, Germany
| | - Jean-Luc Martinot
- Institut National de la Santé et de la Recherche Médicale, INSERM CEA Unit 1000 "Imaging & Psychiatry", University Paris Sud, Orsay; AP-HP Department of Adolescent Psychopathology and Medicine, Maison de Solenn, University Paris Descartes, Paris, France
| | - Andreas Meyer-Lindenberg
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christian P Müller
- Psychiatric University Hospital, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Walter E Müller
- Department of Pharmacology, Biocenter Niederursel, University of Frankfurt, Frankfurt, Germany
| | - David J Nutt
- Neuropsychopharmacology Unit, Division of Brain Sciences, Imperial College, London, UK
| | - Antonio Persico
- Child and Adolescent Neuropsychiatry Unit & Laboratory of Molecular Psychiatry and Neurogenetics, University Campus Bio-Medico, Rome, Italy
| | - Giulio Perugi
- Department of Psychiatry, University of Pisa, Pisa, Italy
| | - Mathias Pessiglione
- Institut du Cerveau et de la Moelle épinière (ICM), Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Ulrich W Preuss
- Department of Psychiatry, Psychotherapy and Psychosomatics, Martin-Luther-University of Halle-Wittenberg, Halle/Saale, Germany
| | - Jonathan P Roiser
- Institute of Cognitive Neuroscience, University College London, London, UK
| | - Paolo M Rossini
- Department of Geriatrics, Neuroscience & Orthopaedics, Catholic University of Sacred Heart, Policlinico A. Gemelli, Rome, Italy
| | - Janusz K Rybakowski
- Department of Adult Psychiatry, Poznan University of Medical Sciences, Poznan, Poland
| | - Carmen Sandi
- Laboratory of Behavioural Genetics, Brain Mind Institute, EPFL, Lausanne, Switzerland
| | - Klaas E Stephan
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Juan Undurraga
- Translational Neuromodeling Unit (TNU), Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Eduard Vieta
- Bipolar Disorders Programme, Institute of Neuroscience, Hospital Clínic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Nic van der Wee
- Leiden Institute for Brain and Cogntion/Psychiatric Neuroimaging, Dept. of Psychiatry, Leiden University Medical Center, The Netherlands
| | - Til Wykes
- Department of Psychology, Institute of Psychiatry, King's College London, UK
| | - Josep Maria Haro
- Parc Sanitari Sant Joan de Déu, University of Barcelona, CIBERSAM, Barcelona, Spain
| | - Hans Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
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Clozapine augmented with amisulpride in 3 cases of treatment-resistant early- and very early-onset schizophrenia. J Clin Psychopharmacol 2013; 33:572-4. [PMID: 23764685 DOI: 10.1097/jcp.0b013e3182946719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
AIMS To estimate the prevalence of limited health literacy in patients receiving clozapine for schizophrenia. To develop and produce a pharmacist-designed clozapine patient information leaflet (PIL) which has a higher readability score than the company-produced PIL. STUDY DESIGN This was a cross sectional prevalence study. METHODS Ethical approval for the study was granted by the local ethics committee. Patients, over 18 years, attending the Clozapine Clinic of a Cork urban teaching hospital, were asked to participate in the study. Demographics such as gender, age, employment and smoking status, were gathered from all participants. The total daily clozapine dose, duration of clozapine treatment, and information regarding the clozapine DVD was also noted. The Rapid Estimate of Adult Literacy in Medicine (REALM) health literacy (HL) screening tool was then administered to each patient. A user-friendly PIL on clozapine was designed by the pharmacist, which was assessed for readability and compared to the company-produced PIL using the FRES and FKGL. Data were analysed using SPSS Version 15. RESULTS Forty patients (65% male, 95% unemployed and 70% smokers) of average age 38.0 years (+/- 11.2) completed the REALM. The average score was 60.6 (+/- 8.7). Twenty-nine patients (72.5%) were found to have "adequate" health literacy. The remaining eleven patients were found to have either "marginal" or "low" health literacy. The pharmacist-designed PIL would have been readable by 95% of the study population, in contrast to 72.5% with the company-designed PIL. CONCLUSIONS More than a quarter of the population were found to have marginal or low health literacy. Patient information should be matched to the health literacy level of the target population.
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Röhricht F, Gadhia S, Alam R, Willis M. Auditing clinical outcomes after introducing off-licence prescribing of atypical antipsychotic melperone for patients with treatment refractory schizophrenia. ScientificWorldJournal 2012; 2012:512047. [PMID: 22566771 PMCID: PMC3330679 DOI: 10.1100/2012/512047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/07/2011] [Indexed: 12/02/2022] Open
Abstract
Aims and Method. To evaluate the practical utility of off-licence prescribing and clinical outcomes of treatment with atypical antipsychotic Melperone. Method: Prospective data collection on patient's clinical characteristics and outcomes. Results. 17 patients with a diagnosis of refractory schizophrenia were identified as suitable for off-license prescribing of Melperone and commenced treatment (13 were previously treated with Clozapine). Seven of those currently remain on Melperone (41%), and for six patents, the BPRS symptom scores reduced significantly over time (24–61%) additionally patients displayed improvements of their quality of life. Six patients were discontinued due to noncompliance and/or side effects. Melperone was ineffective in the other four patients. Clinical Implications. The example of a small group of patients responding well to a comparably safe and inexpensive atypical antipsychotic with favourable side effect profile should encourage clinicians to use this tool as third-line treatment and to conduct more systematic clinical research.
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Affiliation(s)
- Frank Röhricht
- Newham Centre for Mental Health, East London NHS Foundation Trust and University of Essex, London E13 8SP, UK.
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Barnes TRE. Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2011; 25:567-620. [PMID: 21292923 DOI: 10.1177/0269881110391123] [Citation(s) in RCA: 239] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.
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Affiliation(s)
- Thomas R E Barnes
- Centre for Mental Health, Imperial College, Charing Cross Campus, London, UK.
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Gillespie M. Relapse in long-term conditions: learning from mental health methods. ACTA ACUST UNITED AC 2011; 19:1236-42. [PMID: 21042252 DOI: 10.12968/bjon.2010.19.19.79298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Within the UK, health-related policy and legislation have supported a shift towards a more pluralistic provision of health care in order to meet the challenges associated with the shifting demographics in society (Scottish Executive Health Department, 2009). The management of long-term conditions such as diabetes, heart disease and asthma, is recognized as a priority (Department of Health, 2009), with recognition that these long-term disorders share many similarities with serious mental health problems (Loggernberg, 2008), and suggestions that interventions already applied within the mental health setting are transferable across heathcare settings (Fleming et al, 2010). The application of one such intervention is discussed in this article.
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Lang UE, Willbring M, von Golitschek R, Schmeisser A, Matschke K, Malte Tugtekin S. Clozapine-induced myocarditis after long-term treatment: case presentation and clinical perspectives. J Psychopharmacol 2008; 22:576-80. [PMID: 18308817 DOI: 10.1177/0269881107082136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Clozapine is the drug of choice for treatment-resistant schizophrenia. Prompted by a patient who developed reversible clozapine-induced myocarditis after long-term treatment with clozapine for several years for chronic-resistant schizophrenia, we undertook a review of the relevant literature. Concerning the myocarditis, the patient recovered rapidly by withdrawal of clozapine and with supportive management. Psychiatric stabilisation of the patient was at least possible with a combination of quetiapine (600 mg) and amisulpride (800 mg). Well-designed studies with the aim to specifically investigate treatment options after clozapine are limited and clinical possibilities are discussed in this paper. Olanzapine and combinations using non-clozapine atypical neuroleptics have partly shown improvement, whereas evidence for successful augmentation with mood stabilisers, anticonvulsants or electroconvulsive therapy in treatment-resistant schizophrenia is limited.
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Affiliation(s)
- U E Lang
- Department of Psychiatry and Psychotherapy, Charité Medicine Berlin, Campus Mitte, Berlin, Germany.
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