Mortality in schizophrenia. Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study

Development of a simultaneous LC-MS/MS analytical method for plasma: 16 antipsychotics approved in Japan and 4 drug metabolites

The increased risk of adverse drug reactions due to the concomitant use of antipsychotics is problematic in the treatment of schizophrenia. Therefore, the simultaneous analysis of their plasma concentrations is required. In this study, we developed a simultaneous liquid chromatography/tandem mass spectrometry (LC-MS/MS) method for analyzing plasma antipsychotics approved in Japan for therapeutic drug monitoring (TDM) applications. First, we counted the prescriptions for 16 antipsychotics and concomitant drugs used at the Tohoku University Hospital. LC-MS/MS was used for the simultaneous analysis of 16 antipsychotics and four drug metabolites. This analysis was conducted using a combination of selected reaction monitoring mode and reversed-phase chromatography. Following the examination of the MS/MS and LC conditions, an analytical method validation test was conducted. The developed method was used to analyze plasma antipsychotic levels in patients with schizophrenia. One-third of the patients received treatment with multiple antipsychotics. Under LC-MS/MS conditions, LC separation was performed using a combination of a C18 column and ammonium formate-based mobile phases with a gradient flow. The calibration curves were optimized by adjusting the ion abundance, and 11 compounds met the criteria for intra- and inter-day reproducibility tests. Some stability test results did not meet these criteria; therefore, further investigation is required. The developed method permitted the measurement of all the plasma parameters, including concentrations above the therapeutic range. Therefore, this method may be useful in the daily TDM practice of antipsychotics.

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

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

How can we best help this patient? Exploring mental health therapists’ reflections on medication-free care for patients with psychosis in Norway

Background

Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment.

Methods

We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky’s theoretical framework on the role public health workers play in policy implementation.

Findings

Following Norway’s new policy was challenging for the therapists in our study, particularly balancing a patient’s needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients’ conditions worsening.

Conclusions

Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work.

Trial registration: N/A.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00529-8.

Mortality and non-use of antipsychotic drugs after acute admission in schizophrenia: A prospective total-cohort study

BACKGROUND

In society at large, it is debated whether use of antipsychotic drugs is associated with increased or decreased mortality among patients with schizophrenia. Large register studies have demonstrated an increased mortality risk associated with non-use of antipsychotic drugs, but prospective studies are missing.

AIMS

To investigate the association between mortality and non-use of antipsychotics in patients with schizophrenia.

METHOD

An open cohort study included and followed all patients with a discharge-diagnosis of schizophrenia consecutively admitted to a psychiatric acute unit at Haukeland University Hospital, Bergen, Norway during a 10 year period (n = 696). Cox multiple regression analyses were conducted with use of antipsychotic drugs as a time dependent variable, and periods of use and non-use were compared within individual patients. Adjustments were made for gender, age at index admission, number of acute psychiatric hospital admissions, excessive use of alcohol and illicit substances and use of benzodiazepines and antidepressants.

RESULTS

A total of 68 (9.8%) deaths were registered during follow-up. Of these, 40 (59%) had natural causes, whereas 26 (38%) had unnatural causes. Non-use of antipsychotics was associated with 2.15 (p = .01, CI: 1.24-3.72) times higher mortality risk compared to use of antipsychotics. The difference in mortality risk between use and non-use of antipsychotic drugs was age dependent, with the largest risk difference in young patients.

CONCLUSIONS

Non-use of antipsychotic drugs was associated with twofold increased mortality risk in patients with schizophrenia.

Identification of a High-risk Subgroup With Malignant Mitral Valve Prolapse Who Are Predisposed to Sudden Cardiac Death: A Review

Mitral valve prolapse (MVP) affects approximately 170 million people worldwide; however, phenotypically, there is a wide variety of heterogeneity. In particular subsets, the incidence of sudden cardiac death is calculated to be 998 per 100,000 person-years, which is significantly increased when compared with the general population of MVP patients. Individuals with high-risk features have been identified as young females with bileaflet MVP and electrocardiogram findings of frequent complex ectopy, ST-T wave changes, and inferior T wave inversions. Supplemental imaging modalities in this subgroup demonstrate redundant leaflets and chordae on 2-dimensional transthoracic echocardiography along with varying severity of mitral annular disjunction. Detailed morphologic assessment by 3-dimensional echocardiography provides a quantitative assessment of annular disjunction along with left ventricular longitudinal and basal circumferential strain patterns. Late gadolinium enhancement on cardiac magnetic resonance imaging identifies diffuse and isolated left ventricle fibrosis involving the fascicles and papillary muscles, which has been visualized in isolation during autopsy. Findings of this review propose that sudden cardiac death as a result of malignant arrhythmias arises from automaticity, complex ectopy, and reentry at the level of the fascicles and papillary muscles. The repetitive mechanical stress provides a nidus for the development of both micro- and macrofibrosis easily identified by late gadolinium enhancement on cardiac magnetic resonance imaging. Escalation to electrophysiology studies and early intervention could provide new targeted lifesaving therapies.

Real-world effectiveness of olanzapine and risperidone in the treatment of schizophrenia in Brazil over a 16-year follow-up period; findings and implications

Introduction: Antipsychotics are widely prescribed for patients with schizophrenia. The Brazilian public health system provides these patients free of charge to patients and it is pertinent to evaluate their benefits.Objective: To evaluate the effectiveness of olanzapine and risperidone in the treatment of patients with schizophrenia in the real-world and assessing risk factors for their discontinuation through a national non-concurrent cohort with 16 years of follow-up.Methods: Three SUS administrative databases were integrated by deterministic-probabilistic linkage. After patients were matched (1:1) for psychiatric hospitalization, year of receiving the antipsychotic, sex, and age, considering either olanzapine or risperidone at study entry. Kaplan-Meier was used to estimate the cumulative probabilities of discontinuation of treatment and associated factors were identified. Sensitivity analyses were performed.Results: 3416 pairs of patients were included. Olanzapine had a longer time until discontinuation of treatment (p = 0.021), and risperidone had a higher risk of discontinuation (p = 0.021). Among patients persistent for at least 24 months, there was no statistically significant difference.Conclusion: Olanzapine demonstrated superior real-world effectiveness over risperidone, in terms of survival and psychiatric hospitalization. This superiority was not sustained in all analyses.

Viewpoint: do antipsychotics protect against early death? A critical view

In the past 15 years, researchers utilizing prescription databases to assess medication usage have concluded that antipsychotics reduce mortality in patients diagnosed with schizophrenia and other psychotic disorders. These findings stand in contrast to studies in non-psychiatric patients that have found that antipsychotics, because of their adverse effects on physical health, increase the risk of early death. A critical review of the evidence reveals that the worry remains. There is reason to conclude that antipsychotics contribute to the 'mortality gap' between the seriously mentally ill and the general population and that the database studies are plagued with methodological and reporting issues. Most importantly, the database studies tell of mortality rates within a drug-centered paradigm of care, which confounds any comparison of mortality risks when patients are on or off antipsychotics.

Does antipsychotic combination therapy reduce the risk of hospitalization in schizophrenia?

INTRODUCTION

: Despite treatment with antipsychotic medication, approximately 1/3 of individuals with schizophrenia will fail to have an adequate response. To treat these patients, a commonly utilized approach is antipsychotic combination therapy. Antipsychotic combination therapy is controversial with mixed efficacy and tolerability results. It is also unclear if antipsychotic combination therapy reduces or increases the risk of psychiatric hospitalization.

AREAS COVERED

: The authors review the prevalence, efficacy and tolerability concerns, and rationale behind antipsychotic combination therapy. Evidence comparing antipsychotic monotherapy vs polypharmacy using hospitalization as an outcome measure is summarized.

EXPERT OPINION

: Psychiatric rehospitalization is a useful measure of treatment effectiveness, incorporating aspects of treatment efficacy and tolerability. The evidence comparing the impact of antipsychotic monotherapy vs combination therapy on rehospitalization is mixed. Evidence is primarily retrospective in nature, and there is high heterogeneity between studies, which could partially explain the mixed results. There is likely a subset of patients for whom antipsychotic combination therapy reduces the risk of hospitalization greater than antipsychotic monotherapy. Patients should be treated individually taking into account their specific pattern of response.

Mortality risk from long-term treatment with antipsychotic polypharmacy vs monotherapy among adults with serious mental illness: A systematic review and meta-analysis of observational studies

BACKGROUND

Long-term use of more than one concurrent antipsychotic [antipsychotic polypharmacy (APP)] is widely believed to contribute to excess mortality in people with serious mental illness (SMI) compared to those taking only one antipsychotic (monotherapy). However, no conclusive evidence is available.

METHODS

We conducted a systematic search in 6 major electronic databases from inception until December 2019, identifying observational studies examining the association between mortality and exposure to long-term APP vs monotherapy. Studies were eligible if they adopted a follow-up design and antipsychotic exposure was >3 months among adults with SMI. We determined the pooled mortality risk using random-effects meta-analyses. The review was registered in PROSPERO (CRD42019148044).

RESULTS

A total of 12 studies fulfilled all eligibility criteria reporting quantitative data for 834, 534 person years. No difference was found in the association between all-cause mortality and APP vs monotherapy use, in both crude (rate ratio = 0.94, 95% CI 0.81-1.10, p = 0.446; I² = 83.2%, p < 0.001; 10 studies) and adjusted models (adjusted HR = 0.98, 95% CI 0.80-1.19, p = 0.802; I² = 58.3%, p < 0.05; 5 studies). Meta-regression did not identify any moderators influencing all-cause mortality risk. For natural causes of death, risk estimates followed the same pattern: (i) crude rate ratio = 0.88, 95% CI 0.67-1.14, p = 0.324; I² = 77.7%, p = 0.01 (5 studies); (ii) adjusted HR = 1.04, 95% CI 0.90-1.99, p = 0.590; I² = 0.0%, p = 0.744 (5 studies).

CONCLUSION

Mortality risk of APP use in people with SMI appears to be comparable to that of monotherapy use, although work to date remains heterogeneous, precluding firm conclusions from made. Complex real-world clinical scenarios may be contributing to this lack of variation between these two types of antipsychotic use.

"It means so much for me to have a choice": a qualitative study providing first-person perspectives on medication-free treatment in mental health care

BACKGROUND

In 2016, the Western Norway Regional Health Authority started to integrate more evidence-based psychosocial interventions into the existing mental health care, emphasizing the right for persons with psychosis to choose medication-free treatment. This change emerged from the debate on the effectiveness and adverse effects of the use of antipsychotic medication. Aspects beyond symptom reduction, such as interpersonal relationships, increased understanding of one's own pattern of suffering, hope and motivation, are all considered important for the personal recovery process.

METHODS

This study explores whether these aspects were present in users' descriptions of their recovery processes within the medication-free treatment programme in Bergen, Western Norway. We interviewed ten patients diagnosed with psychosis who were eligible for medication-free services about their treatment experiences. Data were analysed using Attride-Stirling's thematic network approach.

RESULTS

The findings show a global theme relating to personal recovery processes facilitated by the provision of more psychosocial treatment options, with three organizing subthemes: interpersonal relationships between patients and therapists, the patient's understanding of personal patterns of suffering, and personal motivation for self-agency in the recovery process. Participants described an improved relationship with therapists compared to previous experiences. Integrating more evidence-based psychosocial interventions into existing mental health services facilitated learning experiences regarding the choice of treatment, particularly the discontinuation of medication, and appeared to support participants' increased self-agency and motivation in their personal recovery processes.

CONCLUSION

Health care in Norway is perhaps one step closer to optimizing care for people with psychosis, allowing for more patient choice and improving the dialogue and hence the interpersonal relationship between the patient and the therapist. Personal patterns of suffering can be explored within a system aiming to support and have a higher level of acceptance for the discontinuation of medication. Such a system requires personal agency in the treatment regimen, with more focus on personal coping strategies and more personal responsibility for the recovery process.

The 12-year trend report of antipsychotic usage in a nationwide claims database derived from four million people in Japan

The current study aimed to describe the use of antipsychotics to clarify the gap between clinical guidelines and health care practice in Japan. We used data from the JMDC Claims Database (JMDC Inc., Tokyo, Japan), a nationwide claims database, from 2005 to 2016. Antipsychotics were defined as drugs coded as N05A with the Anatomical Therapeutic and Chemical (ATC) codes. We described the annual changes in proportions based on the number of patients prescribed any antipsychotics. From the database of 4,081,102 people, the data of 12,382 patients was extracted by applying the following exclusion criteria: no use of antipsychotics, missing the prescription date or dose, inpatients, prescribed antipsychotics only for use as needed, prescribed only injectable antipsychotics except for long-acting injections (LAIs), without schizophrenia as the primary disease, not exceeding 75 mg/day chlorpromazine equivalent, and less than 18 years old. The use of second-generation antipsychotics (SGA) has been expanding, while the use of first-generation antipsychotics has been decreasing. Aripiprazole accounted for the highest proportion of prescribed antipsychotics (31.9%) in 2016. Even though clozapine is categorized as a SGA, it accounted for a paltry 0.2%. The proportion of prescribed antipsychotics accounted for by LAIs was less than 5%. Although the use of antipsychotics for schizophrenia in Japan mostly corresponds to various clinical guidelines, limited use of clozapine and LAIs was identified. Further research focusing on the factors affecting the prescription of these underused antipsychotics may help advance the pharmacological therapy of schizophrenia.

Recent trends in antipsychotic polypharmacy in the treatment of schizophrenia

Ichihashi et al reported that 43% of patients had antipsychotic polypharmacy. Number of antipsychotics used in patients with schizophrenia in Japan was the greatest among Asian countries. However, the antipsychotic polypharmacy rate in Japan decreased gradually. Recent systematic review, meta‐analysis and meta‐regression analysis demonstrated that antipsychotic augmentation was superior to monotherapy. However, several cohort studies have suggested a significant association between antipsychotic daily dose and mortality. In addition, most pharmacokinetic interactions with antipsychotics occur at the metabolic level and usually involve changes in the activity of the major drug‐metabolizing enzymes involved in their biotransformation. Thus, avoidance of unnecessary polypharmacy, knowledge of the interaction profiles of individual agents, and careful individualization of dosage based on close evaluation of clinical response and possibly plasma drug concentrations are essential to prevent and minimize potentially adverse drug interactions in patients receiving antipsychotics.

Physical Functional Limitations in a First-Admission Cohort at Midlife: Findings From the Suffolk County Mental Health Project

BACKGROUND

Psychosis is a risk factor for aging-related conditions and early mortality. Little is known about the age-specific risk of objectively measured physical functional limitations among individuals with serious mental illness.

METHODS

The Suffolk County Mental Health Project is a prospective study of individuals hospitalized for the first time for psychosis. To assess physical functioning at midlife and to identify emerging risk factors for older-age changes, 101 participants with schizophrenia (mean age = 47.2, SD = 8.0 years; 41.6% female) and 112 participants with other psychoses (mean age = 48.2, SD = 9.5 years; 45.5% female) were assessed for chair-rise and balance limitations 20 years after diagnosis. A never-psychotic comparison group of 237 age/sex/geographically matched community controls was similarly assessed (mean age = 50.3, SD = 8.8 years; 44.7% female). Logistic regression was used to examine group differences in prevalence of poor performance and demographic, medical, and treatment correlates.

RESULTS

Chair-rise limitations (45.5% [35.8-55.3]) and balance limitations (17.2% [9.8-24.5]) were common in individuals with schizophrenia. Prevalence of chair-rise limitations was higher in schizophrenia (46.3%) than in other psychotic disorders (31.9%) and never-psychotic group (22.1%), whereas risk of balance limitations was higher in schizophrenia (17.2%) compared with never-psychotic controls (8.1%). Schizophrenia was a significant risk factor for chair-rise (adjusted odds ratio = 3.01 [1.79-5.08], p < .001) and balance limitations (adjusted odds ratio = 2.63, [1.25-5.51], p = .010). Multivariable analysis of symptom severity found avolition was associated with chair-rise limitations, but not balance, independent of diagnosis.

CONCLUSION

Physical limitations are crucial because they identify existing problems with mobility and portend an increased risk of disability and death. Because participants with schizophrenia were at increased risk of physical limitations, assessments of chair-rise and balance limitations may be critical to monitoring individuals with psychosis.

National database study on the use of long-acting antipsychotic injections and hospital readmission proportions in patients with schizophrenia in Japan

AIM

It is important to investigate the current prescription status and clinical outcomes of patients with schizophrenia receiving long-acting antipsychotic injections. We aimed to determine the prescription proportion of long-acting antipsychotic injections and hospital readmission proportions of patients with schizophrenia in Japan.

METHODS

An open dataset was created using data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patient records with the term 'schizophrenia' were included. In Analysis 1, antipsychotic prescription proportions were determined for outpatients who had visited psychiatric facilities between 1 February 2015 and 31 March 2017. In Analysis 2, patients who had been discharged from a psychiatric facility and had received a long-acting antipsychotic injection prescription within 90 days after initial discharge were selected; then, their readmission proportion was examined for 365 days after the initial discharge.

RESULTS

The long-acting antipsychotic injection prescription proportion was 3.5% for outpatients with schizophrenia receiving antipsychotics. The readmission proportion was 41.0% in the entire patient population, 36.2% in patients receiving typical long-acting antipsychotic injections alone, and 23.5% in patients receiving atypical long-acting antipsychotic injections alone.

CONCLUSION

Long-acting antipsychotic injections are not yet widely used in Japan. The readmission proportion was lower in the patients receiving atypical than typical long-acting antipsychotics injections. The results may provide important basic information to develop new future research questions but should be interpreted with caution because generalizability may be limited by the use of aggregated data and the data structure of the database used.

Psychopharmacological Treatment of Schizophrenia Over Time in 30 908 Inpatients: Data From the AMSP Study

BACKGROUND

Psychotropic drugs are the cornerstone of schizophrenia treatment, often requiring lifelong treatment. Data on pharmacotherapy in inpatient settings are lacking.

METHODS

Prescription data of schizophrenic inpatients within the time period 2000-2015 were obtained from the database of the Drug Safety Program in Psychiatry (AMSP). Data were collected at 2 index dates per year; the prescription patterns and changes over time were analyzed.

RESULTS

Among 30 908 inpatients (mean age 41.6 years, 57.8% males), the drug classes administered most often were antipsychotics (94.8%), tranquilizers (32%), antidepressants (16.5%), antiparkinsonians (16%), anticonvulsants (14.1%), hypnotics (8.1%), and lithium (2.1%). The use of second-generation antipsychotics significantly increased from 62.8% in 2000 to 88.9% in 2015 (P < .001), whereas the prescription of first-generation antipsychotics decreased from 46.6% in 2000 to 24.7% in 2015 (P < .001). The administration of long-acting injectable antipsychotics decreased from 15.2% in 2000 to 11.7% in 2015 (P = .006). Clopazine was the most often used antipsychotic, having been used for 21.3% of all patients. Polypharmacy rates (≥5 drugs) increased from 19% in 2000 to 26.5% in 2015. Psychiatric polypharmacy (≥3 psychotropic drugs) was present in 44.7% of patients.

CONCLUSIONS

Combinations of antipsychotics and augmentation therapies with other drug classes are frequently prescribed for schizophrenic patients. Though treatment resistance and unsatisfactory functional outcomes reflect clinical necessity, further prospective studies are needed on real-world prescription patterns in schizophrenia to evaluate the efficacy and safety of this common practice.

Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis

BACKGROUND

While recent meta-analyses have reported the superiority of antipsychotic polypharmacy (APP) over antipsychotic monotherapy (APM) in schizophrenia, switching to APM can be beneficial in terms of side effects. To determine whether patients receiving APP should switch to APM or stay on APP, we conducted a systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) examining a switch from APP to APM vs. staying on APP were systematically selected from a previous meta-analysis comparing APP with APM in patients with schizophrenia. In addition, we conducted an updated systematic literature search using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Data on study discontinuation, relapse, psychopathology, neurocognition, extrapyramidal symptoms, and body weight/body mass index (BMI) were extracted and synthesized.

RESULTS

A total of 6 RCTs involving 341 patients were included. All studies examined a switch from 2 antipsychotic agents to a single agent. Clozapine-treated patients were included in 3 studies. There was a significant difference in study discontinuation due to all causes in favor of staying on APP (N = 6, n = 341, RR = 2.28, 95% CI = 1.50-3.46, P < 0.001). There were no significant differences in relapse, any psychopathology, neurocognition, extrapyramidal symptoms, or body weight/BMI between the 2 groups. The quality of evidence was low to very low.

CONCLUSIONS

The findings suggest that clinicians should closely monitor patient condition when switching to APM after receiving 2 antipsychotics. Given the low to very low overall quality of the evidence, the findings should be considered preliminary and inconclusive.

Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia

IMPORTANCE

The effectiveness of antipsychotic polypharmacy in schizophrenia relapse prevention is controversial, and use of multiple agents is generally believed to impair physical well-being.

OBJECTIVE

To study the association of specific antipsychotic combinations with psychiatric rehospitalization.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide cohort study, the risk of psychiatric rehospitalization was used as a marker for relapse among 62 250 patients with schizophrenia during the use of 29 different antipsychotic monotherapy and polypharmacy types between January 1, 1996, and December 31, 2015, in a comprehensive, nationwide cohort in Finland. We conducted analysis of the data from April 24 to June 15, 2018. Rehospitalization risks were investigated by using within-individual analyses to minimize selection bias.

MAIN OUTCOMES AND MEASURES

Hazard ratio (HR) for psychiatric rehospitalization during use of polypharmacy vs during monotherapy within the same individual.

RESULTS

In the total cohort, including 62 250 patients, 31 257 individuals (50.2%) were men, and the median age was 45.6 (interquartile range, 34.6-57.9) years. The clozapine plus aripiprazole combination was associated with the lowest risk of psychiatric rehospitalization in the total cohort, being superior to clozapine, the monotherapy associated with the best outcomes, with a difference of 14% (HR, 0.86; 95% CI, 0.79-0.94) in the analysis including all polypharmacy periods, and 18% in the conservatively defined polypharmacy analysis excluding periods shorter than 90 days (HR, 0.82; 95% CI, 0.75-0.89; P < .001). Among patients with their first episode of schizophrenia, these differences between clozapine plus aripiprazole vs clozapine monotherapy were greater (difference, 22%; HR, 0.78; 95% CI, 0.63-0.96 in the analysis including all polypharmacy periods, and difference, 23%; HR, 0.77; 95% CI, 0.63-0.95 in the conservatively defined polypharmacy analysis). At the aggregate level, any antipsychotic polypharmacy was associated with a 7% to 13% lower risk of psychiatric rehospitalization compared with any monotherapy (ranging from HR, 0.87; 95% CI, 0.85-0.88, to HR, 0.93; 95% CI, 0.91-0.95; P < .001). Clozapine was the only monotherapy among the 10 best treatments. Results on all-cause and somatic hospitalization, mortality, and other sensitivity analyses were in line with the primary outcomes.

CONCLUSIONS AND RELEVANCE

Combining aripiprazole with clozapine was associated with the lowest risk of rehospitalization, indicating that certain types of polypharmacy may be feasible in the treatment of schizophrenia. Because add-on treatments are started when monotherapy is no longer sufficient to control for worsening of symptoms, it is likely that the effect sizes for polypharmacy are underestimates. Although the results do not indicate that all types of polypharmacy are beneficial, the current treatment guidelines should modify their categorical recommendations discouraging all antipsychotic polypharmacy in the maintenance treatment of schizophrenia.

Antipsychotics and risk of natural death in patients with schizophrenia

Background: Research on antipsychotics and early mortality in schizophrenia has arisen from Western countries and results show that mortality from natural causes is obviously increased in schizophrenia. China, differs largely from Western countries in health and social welfare systems, and Asian patients are more susceptible to side-effects and might require less antipsychotics than their Western counterparts. We, therefore, investigated the association between antipsychotic use and increased mortality from natural causes among patients with schizophrenia in China. Methods: We conducted a population-based nested case-control study using patients' hardcopy archives obtained from the Severe Mental Health Disorder Systems of Chengdu between January 1, 2006 and December 31, 2013. We identified all schizophrenic patients aged 18-65 years who died of natural causes in 2013 (N=157), and their age- and gender-matched controls (N=444). Results: Antipsychotic use was more frequent in controls than in cases (59.9% vs 32.5%). Risk of death decreased significantly in those receiving antipsychotic monotherapy (adjusted odds ratio=0.27, 95% CI=0.16-0.46) and antipsychotic polypharmacy (adjusted odds ratio=0.29, 95% CI=0.12-0.70) than antipsychotic-free patients. Compared with monotherapy, antipsychotic-free treatment was associated with prominently increased mortality (adjusted odds ratio=3.64, 95% CI=2.18-6.08). When stratified by age and gender, the results remained unchanged. Conclusion: Antipsychotic monotherapy significantly decreased mortality from natural causes in schizophrenic patients while antipsychotic polypharmacy did not contribute to the excess mortality and deserves further clarification. We need to improve the physical health of schizophrenic patients and promote health education among community mental health staff and primary caregivers.

Dying Too Soon: Excess Mortality in Severe Mental Illness

Aims: We aimed to identify baseline predictors of mortality in patients with a severe mental illness (SMI) over a 6-year period and to describe mortality rates as standardised mortality ratios (SMRs). We hypothesised that cardiovascular diseases, older age, cigarette smoking, more severe psychiatric symptoms and more severe psychotropic side effects, and alcohol or drug use were independent risk factors for mortality. Method: Medical examinations were conducted at baseline in a cohort of 322 SMI patients. SMRs were estimated after 6 years and an evaluation was made of the impact of a wide range of variables on survival time. Results: Almost 11% of the SMI patients had died at the end of the study period. All-cause SMRs were 4.51 (95% CI 3.07-5.95) for all SMI patients (4.89, 95% CI 2.97-6.80 for men, and 3.94, 95% CI 1.78-6.10 for women). Natural causes accounted for 86% of excess mortality and unnatural causes for 14%. Cardiovascular disease was a major contributor to this excess mortality. Multivariate Cox regression analyses showed that premature death was associated with a longer history of tobacco use (HR: 1.03, 95% CI 1.02-1.03) and more severe symptoms of disorganisation (HR: 2.36, 95% CI 2.21-2.52). Conclusions: The high SMR and the incidence of cardiovascular disease-related death in SMI patients in our study justify concern. This study underscores the urgent need for interventions to reduce excess mortality in patients with SMI.

Predicting parkinsonism side-effects of antipsychotic polypharmacy prescribed in secondary mental healthcare

BACKGROUND

Computer-modelling approaches have the potential to predict the interactions between different antipsychotics and provide guidance for polypharmacy.

AIMS

To evaluate the accuracy of the quantitative systems pharmacology platform to predict parkinsonism side-effects in patients prescribed antipsychotic polypharmacy.

METHODS

Using anonymized data from South London and Maudsley NHS Foundation Trust electronic health records we applied quantitative systems pharmacology, a neurophysiology-based computer model of humanized neuronal circuits, to predict the risk for parkinsonism symptoms in patients with schizophrenia prescribed two concomitant antipsychotics. The performance of the quantitative systems pharmacology model was compared with the performance of simple parameters such as: combination of affinity constants (1/K_sum); sum of D₂R occupancies (D₂R) and chlorpromazine equivalent dose.

RESULTS

We identified 832 patients with schizophrenia who were receiving two antipsychotics for six or more months, between 1 January 2007 and 31 December 2014. The area under the receiver operating characteristic (AUROC) curve for the quantitative systems pharmacology model was 0.66 ( p = 0.01), while AUROCs for D₂R, 1/K_sum and chlorpromazine equivalent dose were 0.52 ( p = 0.350), 0.53 ( p = 0.347) and 0.52 ( p = 0.330) respectively.

CONCLUSION

Our results indicate that quantitative systems pharmacology has the potential to predict the risk of parkinsonism associated with antipsychotic polypharmacy from minimal source information, and thus might have potential decision-support applicability in clinical settings.

Long-term antipsychotic polypharmacy prescribing in secondary mental health care and the risk of mortality

OBJECTIVES

To investigate the association between long-term antipsychotic polypharmacy use and mortality; and determine whether this risk varies by cause of death and antipsychotic dose.

METHODS

Using data from a large anonymised mental healthcare database, we identified all adult patients with serious mental illness (SMI) who had been prescribed a single antipsychotic or polypharmacy, for six or more months between 2007 and 2014. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical factors and smoking, to examine the association between APP use and the risk of death.

RESULTS

We identified 10 945 adults with SMI who had been prescribed long-term antipsychotic monotherapy (76.9%) or APP (23.1%). Patients on long-term APP had a small elevated risk of mortality, which was significant in some but not all models. The adjusted hazard ratios for death from natural and unnatural causes associated with APP were 1.2 (0.9-1.4, P = 0.111) and 1.1 (0.7-1.9, P = 0.619) respectively. The strengths of the associations between APP and mortality outcomes were similar after further adjusting for % BNF antipsychotic dose (P = 0.031) or olanzapine equivalence (P = 0.088).

CONCLUSION

The findings suggest that the effect of long-term APP on mortality is not clear-cut, with limited evidence to indicate an association, even after controlling for the effect of dose.

Characteristics of Medicaid Recipients Receiving Persistent Antipsychotic Polypharmacy

Antipsychotic polypharmacy (APP) is a common strategy despite guidelines advising against this practice. This article seeks to quantify the prevalence and correlates of APP using Medicaid Analytic eXtract files from 2003 to 2004. Nineteen percent of Medicaid recipients who received an antipsychotic were treated with APP. Individuals who received APP were more likely to be white, male, disabled, between the ages of 18-29, diagnosed with a psychotic disorder, and diagnosed with a higher number of psychiatric conditions. Geographic variation in APP rates was also observed. Quality improvement initiatives may help reduce APP for medically vulnerable patients.

Prevalence and correlates of antipsychotic polypharmacy in Hong Kong

BACKGROUND

Antipsychotic polypharmacy (APP) remains a common practice despite inconclusive empirical evidence of additional efficacy and potential exacerbation of side effects. Previous studies suggest APP rate is notably high in East Asia. This paper aims to investigate the prevalence and correlates of APP in Hong Kong.

METHOD

This was a cross-sectional study of 728 patients with psychosis. The demographics and clinical information, including age, gender, diagnosis, hospitalization history, and medication were collected. Chi-square tests and logistic regression analyses were used to study correlates of APP.

RESULTS

The APP rate for psychosis was 24.2% (n = 728) and that for schizophrenia was 26.0% (n = 611), both considerably lower than our previous local data and that from East Asian regions. The most widely used APP prescription fell within the atypical/atypical combination (i.e., Amisulpride/Clozapine and Paliperidone/Olanzapine), and Olanzapine was the most commonly prescribed antipsychotic. At least 75% of APP patients with psychosis took at least one type of atypical antipsychotics in their medical regimen. Typical/typical polypharmacy was associated with older age and use of antiparkinson drugs. Typical/atypical polypharmacy was associated with the use of antiparkinson drugs and anxiolytics, as well as inpatient status. Atypical/atypical polypharmacy was associated with younger age, inpatient status, and the use of mood stabilizers.

CONCLUSION

Overall, our study highlights a relatively low APP rate in Hong Kong when compared to other countries in East Asia. Age, inpatient status and use of antiparkinson drugs, anxiolytics and mood stabilizers were associated with use of APP.

A survey of in-patient and out-patient antipsychotic prescriptions in Hong Kong

Aims and Method

Antipsychotic prescriptions were analysed for a large sample of psychiatric in-patients and out-patients in Hong Kong. Case notes for patients receiving high doses were reviewed and compared with the most recent consensus statement issued by the Royal College of Psychiatrists.

Results

Demographic and prescription data were obtained from 1254 in-patients and 19 986 out-patients. Antipsychotic medications were prescribed to 1129 in-patients and 7520 out-patients, with 9.2% of in-patients and 1.8% of out-patients receiving a high dose. Almost all case notes failed to record the clinical indications for high-dose prescribing or that the patient had been informed. Electrocardiograms were performed in a very small proportion of patients receiving a high dose.

Clinical Implications

Low levels of adherence to established guidelines for high-dose antipsychotic prescription were found in this study, with clinical and medico-legal implications. The results of this study highlight the need for staff education and regular audit of antipsychotic doses in the in-patient and out-patient setting.

Clozapine antipsychotic polypharmacy: audit of use and patient monitoring

Aims and method

We audited prescribing within our area to ascertain how widespread the practice of antipsychotic polypharmacy using clozapine was, and whether it was being carried out within existing standards, including those of high-dose monitoring when required.

Results

Data on 169 patients were reviewed in year one, rising to 193 in year three. Around 30% of patients on clozapine received additional antipsychotic medication. A disturbingly low proportion of patients on clozapine whose antipsychotic polypharmacy brought them into the high-dose range were being monitored appropriately after three audit cycles (the proportion rose from 10% in cycle 1 to 28% in cycle 3). A wide range of additional antipsychotic medications was used.

Clinical implications

Clozapine antipsychotic polypharmacy was prevalent at just below a third of all patients in this review. Prescribers should be alert to the fact that clozapine antipsychotic polypharmacy can push patients into the high-dose range and ensure appropriate monitoring.

Antipsychotic polypharmacy: review of mechanisms, mortality and management

Antipsychotic polypharmacy is an increasingly encountered clinical scenario. This review considers the reasons behind antipsychotic polypharmacy and the patterns of its use. We also consider the evidence of effectiveness of combined therapyv.monotherapy and the rationale behind the potentially beneficial combinations that are used. The potential dangers of antipsychotic polypharmacy are also discussed and the limited research regarding switching from polypharmacy to monotherapy is reviewed. Some provisional recommendations regarding antipsychotic polypharmacy are proposed.

Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention

Cardiac safety of antipsychotic drugs continues to be a concern for both typical and atypical antipsychotics. Risk appears greatest in those with pre-existing cardiac disease but many patients may have occult cardiovascular disease. In addition, several drugs appear to increase the likelihood of diabetes and weight gain, which may have an additive adverse effect. On the basis of risk of sudden cardiac death and risk of QTc prolongation we suggest considering antipsychotics in two categories – higher and lower risk. Of most concern is the use of large cumulative doses of antipsychotics that are sometimes given inadvertently by different prescribers. Clinicians need to be aware how to read an ECG, and how to monitor physical parameters and interpret the significance of QTc prolongation in relation to antipsychotic prescribing. We suggest provisional guidance on antipsychotic monitoring in relation to cardiac safety but acknowledge that future studies will help clarify which antipsychotic drugs and which concomitant risk factors are most important for those with and without established cardiac disease.

Audit of combination and high-dose antipsychotic treatment in the community

Aims and method

To estimate the community prevalence of combination antipsychotic therapy and high-dose antipsychotic treatment via audit. Patients with an ICD-10 diagnosis of schizophrenia were identified through the NHS Greater Glasgow and Clyde Health Board patient information management system and their mental health records examined.

Results

In audit 1, 135 records were examined. The age range of patients was 24–74 years; 73% were male. Twelve per cent were on combined antipsychotic treatment and 3.7% required high-dose antipsychotics. Sixty-nine per cent of patients had documented in their record the reason for combined antipsychotic treatment compared with 40% on high-dose antipsychotics. In audit 2 (1 year later), 150 records were examined. Demographic details and prescription patterns remained similar to that of audit 1. However, 10% of patients received combined antipsychotic therapy and 2% remained on high-dose antipsychotics. Documented reasons for combination therapy increased to 87%, and to 67% for patients on high-dose antipsychotics.

Clinical implications

We need robust clinical trials, overcoming the problems of clinical effectiveness and clinical efficiency, to establish the merits of preferred antipsychotic combinations, as combination and high-dose antipsychotic treatments are unlikely to be eliminated in clinical practice in the foreseeable future.

Electrocardiogram interpretation skills in psychiatry trainees

Aims and method

To assess the competence of psychiatry trainees in identifying major abnormalities in a 12-lead electrocardiogram (ECG). This was a three-stage prospective study. In stage 1, selected ECG traces were presented to the trainees. They were then asked to comment on any abnormalities of note on the ECG traces. In stage 2, an ECG e-book was made available to the trainees and the survey repeated. In stage 3, ECG workshop sessions were introduced in the mandatory teaching programme and the survey was repeated.

Results

The number of correct responses after the introduction of the workshops were significantly more when compared with correct responses in stage 2 (P= 0.0002), and stage 1 (P= 0.0091). When compared with stage 1, the correct responses in stage 2 actually showed deterioration (P= 0.0284).

Clinical implications

Our study not only shows that providing access to an e-book is not enough to improve these skills, it also shows that ECG refresher sessions improved the diagnostic accuracy markedly.

Sudden cardiac death and antipsychotics. Part 1: Risk factors and mechanisms

Mortality from causes other than suicide is higher than expected in schizophrenia. Cardiovascular causes are most common, accounting for the majority of the 5% of sudden and unexpected deaths. Most cases have no clear explanation on post-mortem examination (‘sudden unexplained deaths’) and are thought to result from fatal arrhythmias. Prospective studies show that people with prolongation of the QT interval beyond 500 ms are at increased risk of serious arrhythmias such as ventricular tachycardia and torsade de pointes. In about 1 in 10 cases, the torsade is fatal. Most antipsychotics prolong the QTc interval in overdose but some prolong it even at therapeutic doses. Droperidol, sertindole and ziprasidone extend the QT interval by an average of 15–35 ms; quetiapine, haloperidol and olanzapine by 5 ms, to 15 ms. There is only an approximate relationship between QT prolongation and risk of sudden death, and the risk related to antipsychotics is thought to increase in people with pre-existing cardiac disease, those taking multiple QT-acting drugs and those taking antipsychotics at high dose for long periods. There is little evidence of an association with route of administration. More data are required to clarify to what extent people with mental health difficulties who die suddenly have pre-existing cardiac disease.

Competence of psychiatric clinicians in interpreting electrocardiograms and QT intervals: can they do this? Does it matter?

Aims and Method

We assessed the abilities of trainee and consultant psychiatrists in reading and interpreting electrocardiograms (ECGs) and QT intervals using a questionnaire and standardised ECG.

Results

Only 5% of our sample of trainee and consultant psychiatrists could correctly indicate a QTc interval. Performances on other measures, such as rate were also poor, with senior house officers performing better than consultants.

Clinical Implications

The increased awareness of problems caused by antipsychotics has not been reflected in improved knowledge of ECGs among psychiatrists. Machines do not reliably calculate QT intervals. We therefore urge better training and understanding of ECGs for psychiatrists.

Psychotropic medication and the heart

Psychotropic literature in recent years has become very concerned with the cardiac safety of certain psychotropic medication. This paper reviews some of the cardiac factors to be considered in the safer selection of psychotropic drugs for the vulnerable patient in everyday clinical practice.

Antipsychotic polypharmacy – confusion reigns

Polypharmacy is usually employed where single drugs are considered insufficiently effective. Some polypharmacy is rational and evidence based, some neither. Antipsychotic polypharmacy remains stubbornly widespread despite condemnation of the practice by numerous bodies. The practice could not be said to be evidence based. Its persistence probably stems from a well-meaning desire to improve response and from confusion about the mechanism of action of antipsychotics. In particular, the concept that more antipsychotic(s) must always be, or might be, ‘better’ is virtually groundless. Nonetheless, some specific antipsychotic polypharmacy regimens have shown particular benefits on adverse effect profiles. Targeted, evidence-based polypharmacy may be the way forward.

Antipsychotic combinations for schizophrenia

BACKGROUND

Many people with schizophrenia do not achieve a satisfactory treatment response with their initial antipsychotic drug treatment. Sometimes a second antipsychotic, in combination with the first, is used in these situations.

OBJECTIVES

To examine whether:1. treatment with antipsychotic combinations is effective for schizophrenia; and2. treatment with antipsychotic combinations is safe for the same illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's register which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, time, document type, or publication status limitations for inclusion of records in the register. We ran searches in September 2010, August 2012 and January 2016. We checked for additional trials in the reference lists of included trials.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials comparing antipsychotic combinations with antipsychotic monotherapy for the treatment of schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently extracted data from the included studies. We analysed dichotomous data using risk ratios (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean difference (MD) with a 95% CIs. For the meta-analysis we used a random-effects model. We used GRADE to complete a 'Summary of findings' table and assessed risk of bias for included studies.

MAIN RESULTS

Sixty-two studies are included in the review, 31 of these compared clozapine monotherapy with clozapine combination. We considered the risk of bias in the included studies to be moderate to high. The majority of trials had unclear allocation concealment, method of randomisation and blinding, and were not free of selective reporting.There is some limited evidence that combination therapy is superior to monotherapy in improving clinical response (RR 0.73, 95% CI 0.63 to 0.85; participants = 2364; studies = 29, very low-quality evidence), although subgroup analyses show that the positive result was due to the studies with clozapine in both the monotherapy and combination groups (RR 0.66, 95% CI 0.53 to 0.83; participants = 1127; studies = 17). Few studies reported on rate of relapse, most likely due to the short length of the studies. Overall, a combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in preventing relapse (RR 0.63, 95% CI 0.31 to 1.29; participants = 512; studies = 3, very low-quality evidence), but the pooled data showed high heterogeneity (I² = 82%). A combination of antipsychotics was not superior or inferior to antipsychotic monotherapy in reducing the number of participants discontinuing treatment early (RR 0.89, 95% CI 0.73 to 1.07; participants = 3103; studies = 43, low-quality evidence). No difference was found between treatment groups in the number of participants hospitalised (RR 0.96, 95% CI 0.36 to 2.55; participants = 202; studies = 3, low-quality evidence) . We did not find evidence of a difference between treatment groups in serious adverse events or those requiring discontinuation (RR 1.05, 95% CI 0.65 to 1.69; participants = 2398; studies = 30, very low-quality evidence). There is as lack of evidence on clinically important change in quality of life, with only four studies reporting average endpoint or change data for this outcome on three different scales, none of which showed a difference between treatment groups.

AUTHORS' CONCLUSIONS

Currently, most evidence regarding the use of antipsychotic combinations comes from short-term trials, limiting the assessment of long-term efficacy and safety. We found very low-quality evidence that a combination of antipsychotics may improve the clinical response. We also found low-quality evidence that a combination of antipsychotics is may make no difference at preventing participants from leaving the study early, preventing relapse and/or causing more serious adverse events than monotherapy.

Prevalence of and factors associated with antipsychotic polypharmacy in patients with serious mental illness: Findings from a cross-sectional study in an upper-middle-income country

Objective:

The aim of our study was to examine the prevalence of and factors associated with antipsychotic polypharmacy (APP) among patients with serious mental illness in the current South African health care context.

Methods:

We collected data on patient, illness, and treatment characteristics of patients discharged on one or more antipsychotic agents from January to June 2014. We analyzed the associations of APP with demographic and clinical variables using hierarchical multivariable logistic regression, and examined prescription patterns.

Results:

The prevalence of APP in our study population of 577 patients was 28.4%. Demographic and clinical characteristics significantly associated with APP included age > 29, male sex, diagnosis of schizophrenia, comorbid intellectual disability, comorbid substance use, greater number of hospital admissions, and high-dose prescribing. First-generation antipsychotics and long-acting injectable preparations were prominent in APP combinations. Co-prescription of anticholinergic agents and sodium valproate demonstrated a significant association with APP.

Conclusion:

APP appears common in our population, despite lack of evidence for the practice and possible risk of harm. Our findings suggest a complex interplay among patient, illness, and treatment factors relevant to APP in our setting that could be targeted for intervention.

Paliperidone palmitate: Japanese postmarketing mortality results in patients with schizophrenia

OBJECTIVE

Paliperidone palmitate once-monthly injectable (PP1M) is approved in Japan and other countries for the treatment of schizophrenia. During the 6 month Japanese early postmarketing phase vigilance (EPPV) period, 32 deaths were reported. This report reviews potential contributing factors to the fatal outcomes in the PP1M-treated population.

RESEARCH DESIGN AND METHODS

All spontaneously reported adverse events following PP1M use received during EPPV from 19 November 2013 to 18 May 2014 were entered into the global safety database and these events were analyzed.

RESULTS

During the EPPV period, 10,962 patients were estimated to have been treated with PP1M in Japan. The mortality reporting rate during this EPPV period was higher than that observed in the US or globally after PP1M launch (5.84, 0.43, and 0.38 per 1000 patient-years, respectively), but was consistent with the mortality incidence rates (10.2 per 1000 person-years) observed during interventional clinical studies in Japan and in observational patient cohorts. Of the 32 deaths reported during the Japanese PP1M EPPV period, 19/32 (59.4%) were in patients over 50 years of age, 23/32 (71.9%) reported cardiovascular risk factors and 25/32 (78.1%) received antipsychotic polypharmacy.

CONCLUSIONS

Based on this review of the 32 fatal cases in the PP1M EPPV period, the observed death rate does not necessarily result from a risk with PP1M treatment in Japanese patients. The higher mortality reporting rates in Japan may be attributed to a variety of factors: the effectiveness of mortality reporting in the unique Japanese EPPV program, the advanced age of the fatal cases, high cardiovascular risk factors, multiple underlying diseases and high antipsychotic polypharmacy among the cases with fatal outcomes.

Blonanserin Augmentation of Atypical Antipsychotics in Patients with Schizophrenia-Who Benefits from Blonanserin Augmentation?: An Open-Label, Prospective, Multicenter Study

OBJECTIVE

The purpose of this study was to investigate the efficacy and tolerability of atypical antipsychotics (AAPs) with augmentation by blonanserin in schizophrenic patients.

METHODS

aA total of 100 patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP were recruited in this 12-week, open-label, non-comparative, multicenter study. Blonanserin was added to their existing AAP regimen, which was maintained during the study period. Efficacy was primarily evaluated using the Positive and Negative Syndrome Scale (PANSS) at baseline and at weeks 2, 4, 8, and 12. Predictors for PANSS response (≥20% reduction) were investigated.

RESULTS

The PANSS total score was significantly decreased at 12 weeks of blonanserin augmentation (-21.0±18.1, F=105.849, p<0.001). Moreover, 51.0% of participants experienced a response at week 12. Premature discontinuation of blonanserin occurred in 17 patients (17.0%); 4 of these patients dropped out due to adverse events. The patients who benefited the most from blonanserin were those with severe symptoms despite a treatment with a higher dose of AAP.

CONCLUSION

Blonanserin augmentation could be an effective strategy for patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP.

Predictors of long-term (≥6months) antipsychotic polypharmacy prescribing in secondary mental healthcare

INTRODUCTION

The predictors of long-term antipsychotic polypharmacy (APP) initiation are poorly understood. Existing research has been hampered by residual confounding, failure to exclude cross-titration, and difficulties in separating the timing of predictors and APP administration.

MATERIALS AND METHODS

Using data from the South London and Maudsley (SLaM) case register, we identified all adult patients with serious mental illness (SMI) who were receiving care between 1st July 2011 and 30th June 2012. Exposures measured between 1st July and 31st December 2011 included socio-demographic, socioeconomic, clinical and service use characteristics. We then determined if long-term APP (six or more months) had been initiated between 1st January and 30th June 2012. Multivariable logistic regression models, adjusted for socio-demographic and socioeconomic factors, were built to investigate the associations between the above factors and the initiation of long-term APP.

RESULTS

We identified 6857 adults with SMI receiving SLaM care, of whom 115 (1.7%) were newly prescribed long-term APP. In the adjusted models, predictors of long-term APP initiation included: symptoms (severity of hallucinations and/or delusions), previous treatments (clozapine and long-acting injectable antipsychotic agents), service use (more contact with outpatient services, community treatment order receipt), social factors (higher area-level deprivation, homelessness) and socio-demographic status (younger age, not in a relationship).

CONCLUSION

Our findings highlight that certain patient groups are at an increased risk for long-term APP initiation. Identifying these groups earlier in their treatment could encourage clinicians to employ a broader range of interventions in addition to pharmacotherapy to reduce the risk of APP prescribing.

The physical health of people with schizophrenia in Asia: Baseline findings from a physical health check programme

WHAT IS KNOWN ON THE SUBJECT?: Physical health problems, especially cardiovascular disease and metabolic disorders are far more common in people with severe mental illness (SMI) than the general population. While there are a considerable number of studies that have examined the physical health and health behaviours of people with SMI in Western countries, there have been few studies that have done this in Asia. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Unhealthy body mass index (BMI) values were observed in 44% of Thai service users diagnosed with schizophrenia despite desirable levels of exercise and relatively good diets being reported by the majority of participants. Being prescribed two or more antipsychotics was significantly associated with greater body weight and a higher BMI than in people prescribed only one antipsychotic. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals in Asia should be particularly aware of the additional risks of obesity that seem to be associated with antipsychotic polypharmacy when they are promoting the physical health of people with schizophrenia.

ABSTRACT

Introduction People with schizophrenia have worse physical health than the general population, and studies in developed countries demonstrate that their health behaviours are often undesirable. However, as no similar studies have been conducted in Asian countries with emerging healthcare systems, the physical health promotion challenges in these settings is unknown. Aim To identify and explore relationships between cardiometabolic health risks, lifestyle and treatment characteristics in people with schizophrenia in Thailand. Method This cross-sectional study reports the baseline findings from a physical health check programme using the Thai version of the Health Improvement Profile. Results Despite desirable levels of exercise and relatively good diets being reported by most of the 105 service users, unhealthy body mass index values were observed in 44% of participants. A BMI>23 kg/m² and central obesity was found to be most likely in women. Being prescribed antipsychotic polypharmacy was significantly associated with a higher BMI than in people prescribed monotherapy. Implications for Practice Mental health professionals in Asia should be aware of the additional risks of obesity that are associated with antipsychotic polypharmacy and may benefit from additional training in order that they may advocate for service users within medication reviews to minimize the potential iatrogenic effects of treatment.

Antipsychotic polypharmacy and augmentation strategies prior to clozapine initiation: a historical cohort study of 310 adults with treatment-resistant schizophrenic disorders

RATIONALE

Antipsychotic polypharmacy (APP) is commonly used in schizophrenia despite a lack of robust evidence for efficacy, as well as evidence of increased rates of adverse drug reactions and mortality.

OBJECTIVES

We sought to examine APP and the use of other adjunctive medications in patients with treatment-resistant schizophrenic disorders (ICD-10 diagnoses F20-F29) immediately prior to clozapine initiation, and to investigate clinical and sociodemographic factors associated with APP use in this setting.

METHODS

Analysis of case notes from 310 patients receiving their first course of clozapine at the South London and Maudsley NHS Trust (SLaM) was undertaken using the Clinical Record Interactive Search (CRIS) case register. Medication taken immediately prior to clozapine initiation was recorded, and global clinical severity was assessed at time points throughout the year prior to medication assessment using the Clinical Global Impression - Severity scale (CGI-S). Logistic regression was used to investigate factors associated with APP.

RESULTS

The point prevalence of APP prior to clozapine initiation was 13.6% (n=42), with 32.6% of subjects prescribed adjuvant psychotropic medications. APP was associated with increasing number of adjuvant medications (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.27-3.06), concurrent depot antipsychotic prescription (OR 2.64, CI 1.24-5.62), concurrent antidepressant prescription (OR 4.40, CI 1.82-10.63) and a CGI-S over the previous year within the two middle quartiles (Quartile 2 vs 1 OR 6.19, CI 1.81-21.10; Quartile 3 vs 1 OR 4.45, CI 1.29-15.37; Quartile 4 vs 1 OR 1.88, CI 0.45-7.13).

CONCLUSIONS

APP and augmentation of antipsychotics with antidepressants, mood stabilizers and benzodiazepines are being employed in treatment-resistant schizophrenia prior to clozapine. The conservative APP rate observed may have been influenced by an initiative within SLaM that reduced APP rates during the study window. Efforts to reduce the use of poorly evidenced prescribing should focus on adjuvant medications as well as APP.

Safety and tolerability of antipsychotic co-treatment in patients with schizophrenia: results from a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Antipsychotic co-treatment is common in schizophrenia, despite lacking evidence for its efficacy and safety. Areas: We conducted a systematic search of PubMed/PsycInfo/CJN/WangFan/CBM without language restrictions from database inception until 05/25/2015 for randomized trials comparing antipsychotic monotherapy with antipsychotic co-treatment in ≥20 adults with schizophrenia reporting meta-analyzable adverse events (AEs) data. Meta-analyzing 67 studies (n=4,861, duration=10.3±5.2 weeks), antipsychotic co-treatment was similar to monotherapy regarding intolerability-related discontinuation (risk ratio (RR)=0.84, 95% confidence interval (CI)=0.53-1.33, p=0.455). While incidence of ≥1 AE was lower with antipsychotic co-treatment (RR=0.77, 95%CI=0.66-0.90, p=0.001), these results were solely driven by open-label and efficacy-focused studies. Adjunctive D2-antagonists lead to less nausea (RR=0.220, 95%CI=0.06-0.87, p=0.030) and insomnia (RR=0.26, 95%CI=0.08-0.86, p=0.028), but higher prolactin (SMD=2.20, 95%CI=0.43-3.96, p=0.015). Conversely, adjunctive partial D2-agonists (aripiprazole=100%) resulted in lower electrocardiogram abnormalities (RR=0.43, 95%CI=0.25-0.73, p=0.002), constipation (RR=0.45, 95%CI=0.25-0.79, p=0.006), drooling/hypersalivation (RR=0.14, 95%CI=0.07-0.29, p<0.001), prolactin (SMD=-1.77, 95%CI=-2.38, -1.15, p<0.001), total and LDL-cholesterol (SMD=-0.33, 95%CI=-0.55, -0.11, p=0.003; SMD=-0.33, 95%CI=-0.54, -0.10, p=0.004).

EXPERT OPINION

No double-blind evidence for altered AE burden associated with antipsychotic co-treatment was found. However, AEs were insufficiently and incompletely reported and follow-up duration was modest. Adjunctive partial D2-agonists might be beneficial for counteracting several AEs. High-quality, long-term studies that comprehensively assess AEs are needed.

Antipsychotic use and unexpected death: a hospital-based case-control study

OBJECTIVE

To examine the risk of unexpected death in patients prescribed an antipsychotic. Unexpected death was defined as death occurring within 7 days of the onset of acute symptoms.

METHOD

A case-control study conducted on events occurring between July 2009 and January 2011 in a UK mental health trust providing in-patient and out-patient services.

RESULTS

The study included 100 cases (deaths) and 436 unmatched controls. Current users of antipsychotics had a lower risk of unexpected death than non-users--adjusted odds ratio (OR) 0.48 (95% CI 0.24-0.94, P = 0.033). A significant reduction in risk was seen for second-generation [adjusted OR 0.42 (95% CI 0.21-0.86, P = 0.018)], but not first-generation agents [adjusted OR 0.83 (95% CI 0.31-2.20, P = 0.706)]. Treatment with antipsychotics for any duration was associated with reduced risk. Dose and route of administration did not affect risk. In a planned secondary analysis not adjusting for cardiovascular disease, prescription of an antipsychotic was not associated with increased risk of unexpected death [adjusted OR 0.56 (95% CI 0.28-1.08, P = 0.084)].

CONCLUSION

Our findings do not support an association between current antipsychotic use and increased risk of unexpected death.

Multitarget drug discovery projects in CNS diseases: quantitative systems pharmacology as a possible path forward

Clinical development in brain diseases has one of the lowest success rates in the pharmaceutical industry, and many promising rationally designed single-target R&D projects fail in expensive Phase III trials. By contrast, successful older CNS drugs do have a rich pharmacology. This article will provide arguments suggesting that highly selective single-target drugs are not sufficiently powerful to restore complex neuronal circuit homeostasis. A rationally designed multitarget project can be derisked by dialing in an additional symptomatic treatment effect on top of a disease modification target. Alternatively, we expand upon a hypothetical workflow example using a humanized computer-based quantitative systems pharmacology platform. The hope is that incorporating rationally multipharmacology drug discovery could potentially lead to more impactful polypharmacy drugs.