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Sánchez P, Álamo C, Almendros M, Schlueter M, Tasoulas A, Martínez J. Extrapyramidal adverse events and anticholinergics use after the long-term treatment of patients with schizophrenia with the new long-acting antipsychotic Risperidone ISM ®: results from matching-adjusted indirect comparisons versus once-monthly formulations of Paliperidone palmitate and Aripiprazole monohydrate in 52-week studies. Ann Gen Psychiatry 2023; 22:33. [PMID: 37660132 PMCID: PMC10474682 DOI: 10.1186/s12991-023-00464-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Risperidone ISM® is a newly developed long-acting injectable (LAI) treatment for schizophrenia in adults. In the absence of head-to-head comparisons with other similar antipsychotics, the objective of this study was to generate indirect evidence of some aspects of the safety and tolerability of Risperidone ISM compared to other LAI antipsychotics for treatment of patients with schizophrenia in the maintenance treatment setting. METHODS A literature review was conducted systematically to identify maintenance treatment studies reporting safety and tolerability outcomes for LAI antipsychotic therapies. Following an assessment of between-trial heterogeneity, a matching-adjusted indirect comparison (MAIC) was performed to account for between-trial imbalances in patient characteristics and to generate comparative evidence for safety and tolerability endpoints. RESULTS The analysis showed that incidence of extrapyramidal symptoms (EPS) was found to be numerically, but not statistically significantly, lower in patients receiving Risperidone ISM than in those receiving Paliperidone palmitate (PP) (OR [95% CI] 0.63 [0.29, 1.38], p = 0.253) and statistically significantly lower than with Aripiprazole monohydrate once-monthly (AOM) (OR [95% CI] 0.25 [0.12, 0.53], p < 0.001). Use of anticholinergic agents for the alleviation of EPS was also shown to be significantly lower in Risperidone ISM patients than in those receiving PP (OR [95% CI] 0.29 [0.10, 0.83], p = 0.021) or AOM (OR [95% CI] 0.01 [0.003, 0.06], p < 0.001), suggesting a superior tolerability profile for clinically relevant EPS. Results from the sensitivity analyses comparing stabilized and stable patients receiving Risperidone ISM to those receiving AOM yielded similarly favorable conclusions in line with the base case analyses. CONCLUSIONS This MAIC is consistent with the safety and tolerability results obtained during the PRISMA-3 clinical trial in the long-term treatment of schizophrenia and suggests a favorable safety and tolerability profile in terms of EPS incidence and anticholinergic agent use, relative to other antipsychotic therapies used for treatment of patients with schizophrenia in the maintenance setting.
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Affiliation(s)
- Pedro Sánchez
- Hospital of Zamudio. Bizkaia Mental Health Network. Osakidetza Basque Health Service, Bilbao, Spain
- Faculty of Health Sciences. Department of Medicine, Deusto University, Bilbao, Spain
| | - Cecilio Álamo
- Department of Biomedical Sciences, Alcalá University. Alcalá de Henares, Madrid, Spain
| | - Marcos Almendros
- Medical Department, Laboratorios Farmacéuticos ROVI, S.A, Calle Alfonso Gómez, 45B. 28037, Madrid, Spain
| | | | | | - Javier Martínez
- Medical Department, Laboratorios Farmacéuticos ROVI, S.A, Calle Alfonso Gómez, 45B. 28037, Madrid, Spain.
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Li Q, Gong Y, Cui Y, Cheng C, Wang Y, Huang G, Gu W, Meng B, Wang M, Wu D, Zhao S, Yang X, Qin W, Sun J, Guo T. Efficacy of transcutaneous electrical acupoint stimulation for patients with first-episode schizophrenia: An 8-week, preliminary, randomized controlled trial. Psychiatry Res 2023; 325:115255. [PMID: 37245485 DOI: 10.1016/j.psychres.2023.115255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/09/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
Combination therapy with antipsychotics has been investigated for treating schizophrenia, and has shown clear advantages among non-invasive therapies. Transcutaneous electrical acupoint stimulation (TEAS) is a novel non-invasive treatment with definite efficacy in treating mental disorders. The current study aimed to investigate the efficacy of TEAS in further improving the psychotic symptoms in patients with first-episode schizophrenia (FES) being treated with pharmacological drugs. This 8-week, preliminary, sham-controlled, randomized clinical trial was conducted in patients with FES to compare the efficacy of TEAS and sham TEAS in combination with aripiprazole treatment. The primary outcome was a change in the Positive and Negative Syndrome Scale (PANSS) score after ending the intervention (Week 8). A total of 49 participants completed the whole treatment cycle. The linear mixed-effects regression for PANSS indicated a significant time × group interaction (F(2, 116)=9.79, p <0.001). The PANSS score differed by 8.77 points (95% CI, -2.07 to -15.47 points; p=.01) between the TEAS group and the sham TEAS group after 8 weeks of treatment; this difference was significant. This study indicates that 8 weeks of TEAS combined with aripiprazole treatment can effectively treat FES. Thus, TEAS is an effective combination therapy to improve the psychiatric symptoms of FES.
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Affiliation(s)
- Qifu Li
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Yi Gong
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Yapeng Cui
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Chen Cheng
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Yin Wang
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Gaoyangzi Huang
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Weiqiang Gu
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Bin Meng
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Mian Wang
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Dongniya Wu
- Yunnan University of Chinese Medicine Teaching Hospital/Kunming Psychiatry Hospital, Kunming, 650000, China
| | - Siwen Zhao
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Xuejuan Yang
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Wei Qin
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China
| | - Jinbo Sun
- Engineering Research Center of Molecular and Neuro Imaging of the Ministry of Education, School of Life Science and Technology, Xidian University, Xian, 710126, China.
| | - Taipin Guo
- School of Second Clinical Medicine/The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming 650500, China; Key Laboratory for Acupuncture, Moxibustion and Tuina Prevention and Treatment of Brain Diseases in Yunnan Universities, Kunming, China.
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Mutwalli H, Keeler JL, Bektas S, Dhopatkar N, Treasure J, Himmerich H. Eating cognitions, emotions and behaviour under treatment with second generation antipsychotics: A systematic review and meta-analysis. J Psychiatr Res 2023; 160:137-162. [PMID: 36804110 PMCID: PMC10682412 DOI: 10.1016/j.jpsychires.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/30/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023]
Abstract
Weight gain and metabolic disturbances are frequent in people treated with second generation antipsychotics (SGA). We aimed to investigate the effect of SGAs on eating behaviors, cognitions and emotions, as a possible contributor to this adverse effect. A systematic review and a meta-analysis were conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Original articles measuring outcomes relating to eating cognitions, behaviours and emotions, during treatment with SGAs were included in this review. A total of 92 papers with 11,274 participants were included from three scientific databases (PubMed, Web of Science and PsycInfo). Results were synthesized descriptively except for the continuous data where meta-analyses were performed and for the binary data where odds ratios were calculated. Hunger was increased in participants treated with SGAs with an odds ratio for appetite increase of 1.51 (95% CI [1.04, 1.97]; z = 6.40; p < 0.001). Compared to controls, our results showed that craving for fat and carbohydrates are the highest among other craving subscales. There was a small increase in dietary disinhibition (SMD = 0.40) and restrained eating (SMD = 0.43) in participants treated with SGAs compared to controls and substantial heterogeneity across studies reporting these eating traits. There were few studies examining other eating-related outcomes such as food addiction, satiety, fullness, caloric intake and dietary quality and habits. Understanding the mechanisms associated with appetite and eating-related psychopathology changes in patients treated with antipsychotics is needed to reliably inform the development of effective preventative strategies.
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Affiliation(s)
- Hiba Mutwalli
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Department of Clinical Nutrition, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Johanna Louise Keeler
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Sevgi Bektas
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Department of Psychology, Hacettepe University, Ankara, Turkey
| | - Namrata Dhopatkar
- Eating Disorders Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust (SLaM), London, UK
| | - Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Eating Disorders Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust (SLaM), London, UK
| | - Hubertus Himmerich
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Eating Disorders Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust (SLaM), London, UK
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Cookson J, Pimm J, Brentnall A. Partial agonists of dopamine receptors: theoretical principles of combining antipsychotics including partial agonists to treat schizophrenia. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
SUMMARY
Partial agonists such as aripiprazole are often used in addition to a full antagonist such as amisulpride, risperidone or olanzapine in an attempt to mitigate side-effects such as sedation, hyperprolactinaemia and weight gain. However, there can be unintended consequences, including worsening of psychosis. Moreover, previous exposure to a partial agonist may impair the subsequent response to a potent antipsychotic such as haloperidol used to control symptoms of relapse. To understand the mechanisms involved, a method is needed to compare potency in the pharmacological effects of different drugs used in combinations. This article is intended to explore and explain the theoretical principles based on the dopamine hypothesis of schizophrenia. We apply the method to analyse a recently described trial in which two full antagonists (olanzapine and amisulpride) are compared individually and in combination.
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Dymond A, Afonso D, Green W. Cost analysis of lurasidone for the treatment of schizophrenia in adolescents and adults within the United Kingdom. BMC Health Serv Res 2022; 22:1084. [PMID: 36002828 PMCID: PMC9404623 DOI: 10.1186/s12913-022-08436-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Schizophrenia is a serious mental health condition characterised by distortions in thought processes, perception, mood, sense of self, and behaviour. Lurasidone, a second-generation atypical antipsychotic, represents an additional treatment option alongside existing antipsychotics for adolescents and adults with schizophrenia. An economic model was developed to evaluate the incremental costs of lurasidone as a first-line treatment option compared to existing antipsychotics. METHODS A Markov model was developed to estimate the cost impact of lurasidone as a first-line treatment option for both adolescents and adults. The sequence-based model incorporated the following health states: stable (no relapse or discontinuation), discontinuation (due to adverse events or other reasons), and relapse. Data used to determine the movement of patients between health states were obtained from network meta-analyses (NMAs). The time horizon ranged from three to five years (depending on the patient population) and a six-weekly cycle length was used. Unit costs and resource use were reflective of the UK NHS and Personal Social Services and consisted of the following categories: outpatient, adverse events, primary and residential care. Extensive deterministic sensitivity analysis was undertaken to assess the level of uncertainty associated with the base case results. RESULTS Lurasidone is demonstrated to be cost-saving as a first-line treatment within the adolescent and adult populations when compared to second-line and third-line respectively. Lurasidone is more expensive in terms of treatment costs, resource use (in the stable health state) and the treatment of adverse events. However, these costs are outweighed by the savings associated with the relapse health state. Lurasidone remains cost-saving when inputs are varied in sensitivity analysis and scenario analysis. CONCLUSIONS Lurasidone is a cost-saving first-line treatment for schizophrenia for both adolescents and adults.
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Affiliation(s)
- Amy Dymond
- York Health Economics Consortium (YHEC), York, UK.
| | | | - Will Green
- York Health Economics Consortium (YHEC), York, UK
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6
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Ostuzzi G, Bertolini F, Tedeschi F, Vita G, Brambilla P, del Fabro L, Gastaldon C, Papola D, Purgato M, Nosari G, Del Giovane C, Correll C, Barbui C. Oral and long-acting antipsychotics for relapse prevention in schizophrenia-spectrum disorders: a network meta-analysis of 92 randomized trials including 22,645 participants. World Psychiatry 2022; 21:295-307. [PMID: 35524620 PMCID: PMC9077618 DOI: 10.1002/wps.20972] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
According to current evidence and guidelines, continued antipsychotic treatment is key for preventing relapse in people with schizophrenia-spectrum disorders, but evidence-based recommendations for the choice of the individual antipsychotic for maintenance treatment are lacking. Although oral antipsychotics are often prescribed first line for practical reasons, long-acting injectable antipsychotics (LAIs) are a valuable resource to tackle adherence issues since the earliest phase of disease. Medline, EMBASE, PsycINFO, CENTRAL and CINAHL databases and online registers were searched to identify randomized controlled trials comparing LAIs or oral antipsychotics head-to-head or against placebo, published until June 2021. Relative risks and standardized mean differences were pooled using random-effects pairwise and network meta-analysis. The primary outcomes were relapse and dropout due to adverse events. We used the Cochrane Risk of Bias tool to assess study quality, and the CINeMA approach to assess the confidence of pooled estimates. Of 100 eligible trials, 92 (N=22,645) provided usable data for meta-analyses. Regarding relapse prevention, the vast majority of the 31 included treatments outperformed placebo. Compared to placebo, "high" confidence in the results was found for (in descending order of effect magnitude) amisulpride-oral (OS), olanzapine-OS, aripiprazole-LAI, olanzapine-LAI, aripiprazole-OS, paliperidone-OS, and ziprasidone-OS. "Moderate" confidence in the results was found for paliperidone-LAI 1-monthly, iloperidone-OS, fluphenazine-OS, brexpiprazole-OS, paliperidone-LAI 1-monthly, asenapine-OS, haloperidol-OS, quetiapine-OS, cariprazine-OS, and lurasidone-OS. Regarding tolerability, none of the antipsychotics was significantly worse than placebo, but confidence was poor, with only aripiprazole (both LAI and OS) showing "moderate" confidence levels. Based on these findings, olanzapine, aripiprazole and paliperidone are the best choices for the maintenance treatment of schizophrenia-spectrum disorders, considering that both LAI and oral formulations of these antipsychotics are among the best-performing treatments and have the highest confidence of evidence for relapse prevention. This finding is of particular relevance for low- and middle-income countries and constrained-resource settings, where few medications may be selected. Results from this network meta-analysis can inform clinical guidelines and national and international drug regulation policies.
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Affiliation(s)
- Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Federico Bertolini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Giovanni Vita
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Paolo Brambilla
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Lorenzo del Fabro
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
| | - Guido Nosari
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly,Department of Neurosciences and Mental HealthFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Cinzia Del Giovane
- Institute of Primary Health CareUniversity of BernBernSwitzerland,Population Health LaboratoryUniversity of FribourgFribourgSwitzerland
| | - Christoph U. Correll
- Department of PsychiatryZucker Hillside HospitalGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineZucker School of Medicine at Hofstra/NorthwellHempsteadNYUSA,Department of Child and Adolescent PsychiatryCharité Universitätsmedizin BerlinBerlinGermany
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryUniversity of VeronaVeronaItaly
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Gumley AI, Bradstreet S, Ainsworth J, Allan S, Alvarez-Jimenez M, Birchwood M, Briggs A, Bucci S, Cotton S, Engel L, French P, Lederman R, Lewis S, Machin M, MacLennan G, McLeod H, McMeekin N, Mihalopoulos C, Morton E, Norrie J, Reilly F, Schwannauer M, Singh SP, Sundram S, Thompson A, Williams C, Yung A, Aucott L, Farhall J, Gleeson J. Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT. Health Technol Assess 2022; 26:1-174. [PMID: 35639493 DOI: 10.3310/hlze0479] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Relapse is a major determinant of outcome for people with a diagnosis of schizophrenia. Early warning signs frequently precede relapse. A recent Cochrane Review found low-quality evidence to suggest a positive effect of early warning signs interventions on hospitalisation and relapse. OBJECTIVE How feasible is a study to investigate the clinical effectiveness and cost-effectiveness of a digital intervention to recognise and promptly manage early warning signs of relapse in schizophrenia with the aim of preventing relapse? DESIGN A multicentre, two-arm, parallel-group cluster randomised controlled trial involving eight community mental health services, with 12-month follow-up. SETTINGS Glasgow, UK, and Melbourne, Australia. PARTICIPANTS Service users were aged > 16 years and had a schizophrenia spectrum disorder with evidence of a relapse within the previous 2 years. Carers were eligible for inclusion if they were nominated by an eligible service user. INTERVENTIONS The Early signs Monitoring to Prevent relapse in psychosis and prOmote Wellbeing, Engagement, and Recovery (EMPOWER) intervention was designed to enable participants to monitor changes in their well-being daily using a mobile phone, blended with peer support. Clinical triage of changes in well-being that were suggestive of early signs of relapse was enabled through an algorithm that triggered a check-in prompt that informed a relapse prevention pathway, if warranted. MAIN OUTCOME MEASURES The main outcomes were feasibility of the trial and feasibility, acceptability and usability of the intervention, as well as safety and performance. Candidate co-primary outcomes were relapse and fear of relapse. RESULTS We recruited 86 service users, of whom 73 were randomised (42 to EMPOWER and 31 to treatment as usual). Primary outcome data were collected for 84% of participants at 12 months. Feasibility data for people using the smartphone application (app) suggested that the app was easy to use and had a positive impact on motivations and intentions in relation to mental health. Actual app usage was high, with 91% of users who completed the baseline period meeting our a priori criterion of acceptable engagement (> 33%). The median time to discontinuation of > 33% app usage was 32 weeks (95% confidence interval 14 weeks to ∞). There were 8 out of 33 (24%) relapses in the EMPOWER arm and 13 out of 28 (46%) in the treatment-as-usual arm. Fewer participants in the EMPOWER arm had a relapse (relative risk 0.50, 95% confidence interval 0.26 to 0.98), and time to first relapse (hazard ratio 0.32, 95% confidence interval 0.14 to 0.74) was longer in the EMPOWER arm than in the treatment-as-usual group. At 12 months, EMPOWER participants were less fearful of having a relapse than those in the treatment-as-usual arm (mean difference -4.29, 95% confidence interval -7.29 to -1.28). EMPOWER was more costly and more effective, resulting in an incremental cost-effectiveness ratio of £3041. This incremental cost-effectiveness ratio would be considered cost-effective when using the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. LIMITATIONS This was a feasibility study and the outcomes detected cannot be taken as evidence of efficacy or effectiveness. CONCLUSIONS A trial of digital technology to monitor early warning signs that blended with peer support and clinical triage to detect and prevent relapse is feasible. FUTURE WORK A main trial with a sample size of 500 (assuming 90% power and 20% dropout) would detect a clinically meaningful reduction in relapse (relative risk 0.7) and improvement in other variables (effect sizes 0.3-0.4). TRIAL REGISTRATION This trial is registered as ISRCTN99559262. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 27. See the NIHR Journals Library website for further project information. Funding in Australia was provided by the National Health and Medical Research Council (APP1095879).
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Affiliation(s)
- Andrew I Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Simon Bradstreet
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John Ainsworth
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephanie Allan
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Maximillian Birchwood
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sue Cotton
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Lidia Engel
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Paul French
- Department of Nursing, Manchester Metropolitan University, Manchester, UK
| | - Reeva Lederman
- School of Computing and Information Systems, Melbourne School of Engineering, University of Melbourne, Melbourne, VIC, Australia
| | - Shôn Lewis
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Hamish McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cathy Mihalopoulos
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Emma Morton
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Swaran P Singh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Suresh Sundram
- Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Andrew Thompson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris Williams
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alison Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Farhall
- Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia.,NorthWestern Mental Health, Melbourne, VIC, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre, Australian Catholic University, Melbourne, VIC, Australia
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Gazzellone MJ, Oliver D, Groll D, Gomes FA. Atypical antipsychotics, dystonia, and psychotic depression: old solutions for new problems. J Psychiatry Neurosci 2022; 47:E194-E195. [PMID: 35508330 PMCID: PMC9074803 DOI: 10.1503/jpn.220037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Matthew J Gazzellone
- From the Department of Psychiatry, Queen's University, Kingston, Ont., Canada (Gazzellone, Oliver, Groll, Gomes)
| | - Dijana Oliver
- From the Department of Psychiatry, Queen's University, Kingston, Ont., Canada (Gazzellone, Oliver, Groll, Gomes)
| | - Dianne Groll
- From the Department of Psychiatry, Queen's University, Kingston, Ont., Canada (Gazzellone, Oliver, Groll, Gomes)
| | - Fabiano A Gomes
- From the Department of Psychiatry, Queen's University, Kingston, Ont., Canada (Gazzellone, Oliver, Groll, Gomes)
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9
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Schneider-Thoma J, Chalkou K, Dörries C, Bighelli I, Ceraso A, Huhn M, Siafis S, Davis JM, Cipriani A, Furukawa TA, Salanti G, Leucht S. Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis. Lancet 2022; 399:824-836. [PMID: 35219395 DOI: 10.1016/s0140-6736(21)01997-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Schizophrenia is a common, severe, and usually chronic disorder. Maintenance treatment with antipsychotic drugs can prevent relapse but also causes side-effects. We aimed to compare the efficacy and tolerability of antipsychotics as maintenance treatment for non-treatment resistant patients with schizophrenia. METHODS In this systematic review and network meta-analysis, we searched, without language restrictions, the Cochrane Schizophrenia Group's specialised register between database inception and April 27, 2020, PubMed from April 1, 2020, to Jan 15, 2021, and the lists of included studies from related systematic reviews. We included randomised controlled trials (RCTs; ≥12 weeks of follow-up) that recruited adult participants with schizophrenia or schizoaffective disorder with stable symptoms who were treated with antipsychotics (monotherapy; oral or long-acting injectable) or placebo. We excluded RCTs of participants with specific comorbidities or treatment resistance. In duplicate, two authors independently selected eligible RCTs and extracted aggregate data. The primary outcome was the number of participants who relapsed and was analysed by random-effects, Bayesian network meta-analyses. The study was registered on PROSPERO, CRD42016049022. FINDINGS We identified 4157 references through our search, from which 501 references on 127 RCTs of 32 antipsychotics (comprising 18 152 participants) were included. 100 studies including 16 812 participants and 30 antipsychotics contributed to our network meta-analysis of the primary outcome. All antipsychotics had risk ratios (RRs) less than 1·00 when compared with placebo for relapse prevention and almost all had 95% credible intervals (CrIs) excluding no effect. RRs ranged from 0·20 (95% CrI 0·05-0·41) for paliperidone oral to 0·65 (0·16-1·14) for cariprazine oral (moderate-to-low confidence in estimates). Generally, we interpret that there was no clear evidence for the superiority of specific antipsychotics in terms of relapse prevention because most comparisons between antipsychotics included a probability of no difference. INTERPRETATION As we found no clear differences between antipsychotics for relapse prevention, we conclude that the choice of antipsychotic for maintenance treatment should be guided mainly by their tolerability. FUNDING The German Ministry of Education and Research and Oxford Health Biomedical Research Centre.
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Affiliation(s)
- Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Konstantina Chalkou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carola Dörries
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Anna Ceraso
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maximilian Huhn
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany; Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Erlangen, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA; Department of Psychiatry, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK; Research and Development Department, Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan; Department of Clinical Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
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Peters E, Shamloo A, Lodhi RJ, Marcoux G, Jackson K, Halayka S, Balbuena L. Medication Gaps and Antipsychotic Polypharmacy in Previously Hospitalized Schizophrenia Patients: An Electronic Cohort Study in Three Canadian Provinces. Front Psychiatry 2022; 13:917361. [PMID: 35782434 PMCID: PMC9243750 DOI: 10.3389/fpsyt.2022.917361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Real world evidence about antipsychotics focuses on rehospitalization. Modeling the time course of pharmacotherapy would show patients' adherence to medications and physicians' adherence to medication guidelines. We aimed to calculate the cumulative time spent in second generation antipsychotics (SGAs), gaps, antipsychotic polypharmacy, and clozapine in discharged schizophrenia patients. METHODS Hospitalization and pharmacy dispensing data from 2008-2018 in Manitoba, Saskatchewan, and British Columbia were linked and an electronic cohort (N = 2,997) was created (mean follow-up: 49 months, SD = 38). Cohort members were required to have a minimum of 6 weeks medicated with aripiprazole, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone. RESULTS The multistate model predicted that schizophrenia patients accumulated 44 months in SGA monotherapy, 4 months in polypharmacy, 11 months in medication gaps and 17 days in clozapine over a 5-year period. The majority of transitions were between SGA and medication gap. Accumulated time in medication gaps was seven times as much as in clozapine. Each 10% delay in SGA initiation post-discharge was associated with a 2, 1, and 6% higher risk for polypharmacy (95% CI: 1.01-1.02), gap (95% CI: 1.01-1.01), and clozapine (95% CI: 1.04-1.08), respectively. INTERPRETATION Schizophrenia patients accumulated more time unmedicated and in polypharmacy compared to clozapine. Either treatment guidelines for schizophrenia are not followed, or real-world challenges hamper their implementation.
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Affiliation(s)
- Evyn Peters
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada
| | - Arash Shamloo
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada
| | - Rohit J Lodhi
- Department of Psychiatry, University of Western Ontario, London, ON, Canada
| | - Gene Marcoux
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kylie Jackson
- Mental Health Outpatient Services, Saskatchewan Health Authority, Prince Albert, SK, Canada
| | | | - Lloyd Balbuena
- Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada
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11
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Cookson J, Pimm J. Partial agonists of dopamine receptors: mechanisms and clinical effects of aripiprazole, brexpiprazole and cariprazine. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2021.49] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SUMMARY
Aripiprazole, brexpiprazole and cariprazine are partial dopamine (and serotonin) agonists developed as novel antipsychotics. This article discusses their pharmacology, evidence on their licensed and off-licence uses (including psychosis, mania, bipolar depression, Tourette syndrome and autism spectrum disorder) and side-effects. In schizophrenia, they have a low risk of Parkinsonism or hyperprolactinaemia, cause modest increases in body weight and are of moderate efficacy.
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12
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A high-fat diet, but not haloperidol or olanzapine administration, increases activated microglial expression in the rat brain. Neurosci Lett 2021; 757:135976. [PMID: 34023409 DOI: 10.1016/j.neulet.2021.135976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 04/28/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
This study examined the effects of chronic treatment of the antipsychotic drugs, haloperidol and olanzapine, on microglial activation in the brain. In addition, we explored the interaction of these antipsychotic drugs with normal and high-fat diet. In order to measure activated microglial expression, we used [3H] PK11195 in vitro autoradiography. Male Sprague Dawley rats were given a diet of either regular chow diet or a high-fat diet, and assigned either water, haloperidol drinking solution (1.5 mg/kg), or olanzapine drinking solution (10 mg/kg) for four weeks. Following treatment, rats were euthanized and brains extracted for [3H] PK11195 autoradiography. Rats on 4 weeks of a high-fat diet showed increased [3H] PK11195 binding compared to rats on a normal diet in the temporal association cortex (19 %), ectorhinal cortex (17 %), entorhinal cortex (18 %), and perirhinal cortex (18 %), irrespective of drug treatment. These are regions associated with memory, sensory, and visual processing. Rats treated with either haloperidol or olanzapine showed no differences in [3H] PK11195 binding compared to the control group. However, there were differences between the 2 different antipsychotic medications themselves. Haloperidol increased [3H] PK11195 binding in the amygdala (23 %), ectorhinal cortex (24 %), and perihinal cortex (29 %), compared to olanzapine. These results corroborate a known role of a high-fat diet and central inflammatory changes but suggest no role of these antipsychotic drugs in promoting neuroinflammation across 4 weeks compared to normal control rats.
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13
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Kearns B, Cooper K, Cantrell A, Thomas C. Schizophrenia Treatment with Second-Generation Antipsychotics: A Multi-Country Comparison of the Costs of Cardiovascular and Metabolic Adverse Events and Weight Gain. Neuropsychiatr Dis Treat 2021; 17:125-137. [PMID: 33505160 PMCID: PMC7829121 DOI: 10.2147/ndt.s282856] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Cardiovascular and metabolic adverse events are costly to treat, and their incidence is increased amongst people with schizophrenia, with different rates observed for second-generation antipsychotics. To inform treatment choice, this study sought to estimate the lifetime costs associated with antipsychotic choice, and how these costs varied across European countries. METHODS Systematic searches were conducted to identify evidence on effectiveness and costs. A Markov model was developed to assess the costs of ten antipsychotics: aripiprazole, brexpiprazole, cariprazine, lumateperone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone and ziprasidone. Costs were obtained for seven countries: Italy, Hungary, France, Slovenia, Spain, Sweden and the UK. The costs considered were adverse events (including diabetes, myocardial infarction, stroke and weight gain), drug costs, relapse, treatment discontinuation and schizophrenia management. Two adult populations were modelled; initiating either acute or maintenance treatment, with a lifetime horizon for both. RESULTS Lurasidone was associated with the lowest lifetime costs amongst patients initiating acute treatment compared to all other atypical antipsychotics considered. The second lowest costs were for ziprasidone. These results were observed for all seven countries. The main drivers of cost differences were rates of diabetes and cardiovascular diseases, which were lowest for lurasidone, followed by ziprasidone then lumateperone. Costs for managing weight gain were lowest for lurasidone and ziprasidone. Similar results were observed for patients initiating maintenance treatment. CONCLUSION Diabetes and cardiovascular events are large drivers of lifetime costs for people with schizophrenia. Lurasidone is predicted to have the lowest rates of these adverse events, and so the lowest costs amongst patients initiating acute treatment in seven European countries compared to nine other antipsychotics. Future research should investigate the individual costs of relapse management, including differences in the costs and proportions of hospitalizations.
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Affiliation(s)
- Benjamin Kearns
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Chloe Thomas
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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14
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Sakurai H, Yasui-Furukori N, Suzuki T, Uchida H, Baba H, Watanabe K, Inada K, Kikuchi YS, Kikuchi T, Katsuki A, Kishida I, Kato M. Pharmacological Treatment of Schizophrenia: Japanese Expert Consensus. PHARMACOPSYCHIATRY 2021; 54:60-67. [PMID: 33434943 PMCID: PMC7946533 DOI: 10.1055/a-1324-3517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction
Conventional treatment guidelines of schizophrenia do not necessarily provide solutions on clinically important issues.
Methods
A total of 141 certified psychiatrists of the Japanese Society of Clinical Neuropsychopharmacology evaluated treatment options regarding 19 clinically relevant situations in the treatment of schizophrenia with a 9-point scale (1=“disagree” and 9=“agree”).
Results
First-line antipsychotics varied depending on predominant symptoms: risperidone (mean±standard deviation score, 7.9±1.4), olanzapine (7.5±1.6), and aripiprazole (6.9±1.9) were more likely selected for positive symptoms; aripiprazole (7.6±1.6) for negative symptoms; aripiprazole (7.3±1.9), olanzapine (7.2±1.9), and quetiapine (6.9±1.9) for depression and anxiety; and olanzapine (7.9±1.5) and risperidone (7.5±1.5) for excitement and aggression. While only aripiprazole was categorized as a first-line treatment for relapse prevention (7.6±1.0) in patients without noticeable symptoms, aripiprazole (8.0±1.6) and brexpiprazole (6.9±2.3) were categorized as such for social integration. First-line treatments in patients who are vulnerable to extrapyramidal symptoms include quetiapine (7.5±2.0) and aripiprazole (6.9±2.1).
Discussion
These clinical recommendations represent the expert consensus on the use of a particular antipsychotic medication for a particular situation, filling a current gap in the literature.
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Affiliation(s)
- Hitoshi Sakurai
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Baba
- Department of Psychiatry & Behavioral Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Koichiro Watanabe
- Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University School of Medicine, Tokyo Japan
| | | | - Toshiaki Kikuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Asuka Katsuki
- Department of Psychiatry, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Ikuko Kishida
- Fujisawa Hospital, Kanagawa, Japan.,Department of Psychiatry, Yokohama City University School of Medicine, Kanagawa, Japan
| | - Masaki Kato
- Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan
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15
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Bertolini F, Ostuzzi G, Pievani M, Aguglia A, Bartoli F, Bortolaso P, Callegari C, Caroleo M, Carrà G, Corbo M, D'Agostino A, De Fazio P, Magliocco F, Martinotti G, Ostinelli EG, Piccinelli MP, Tedeschi F, Barbui C. Comparing Long-Acting Antipsychotic Discontinuation Rates Under Ordinary Clinical Circumstances: A Survival Analysis from an Observational, Pragmatic Study. CNS Drugs 2021; 35:655-665. [PMID: 33779944 PMCID: PMC8219561 DOI: 10.1007/s40263-021-00809-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent guidelines suggested a wider use of long-acting injectable antipsychotics (LAI) than previously, but naturalistic data on the consequences of LAI use in terms of discontinuation rates and associated factors are still sparse, making it hard for clinicians to be informed on plausible treatment courses. OBJECTIVE Our objective was to assess, under real-world clinical circumstances, LAI discontinuation rates over a period of 12 months after a first prescription, reasons for discontinuation, and associated factors. METHODS The STAR Network 'Depot Study' was a naturalistic, multicentre, observational prospective study that enrolled subjects initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centres were assessed at baseline and at 6 and 12 months of follow-up. Psychopathology, drug attitude and treatment adherence were measured using the Brief Psychiatric Rating Scale, the Drug Attitude Inventory and the Kemp scale, respectively. RESULTS The study followed 394 participants for 12 months. The overall discontinuation rate at 12 months was 39.3% (95% confidence interval [CI] 34.4-44.3), with paliperidone LAI being the least discontinued LAI (33.9%; 95% CI 25.3-43.5) and olanzapine LAI the most discontinued (62.5%; 95% CI 35.4-84.8). The most frequent reason for discontinuation was onset of adverse events (32.9%; 95% CI 25.6-40.9) followed by participant refusal of the medication (20.6%; 95% CI 14.6-27.9). Medication adherence at baseline was negatively associated with discontinuation risk (hazard ratio [HR] 0.853; 95% CI 0.742-0.981; p = 0.026), whereas being prescribed olanzapine LAI was associated with increased discontinuation risk compared with being prescribed paliperidone LAI (HR 2.156; 95% CI 1.003-4.634; p = 0.049). CONCLUSIONS Clinicians should be aware that LAI discontinuation is a frequent occurrence. LAI choice should be carefully discussed with the patient, taking into account individual characteristics and possible obstacles related to the practicalities of each formulation.
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Affiliation(s)
- Federico Bertolini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy.
| | - Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Michela Pievani
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Andrea Aguglia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
| | - Paola Bortolaso
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria-ASST Sette Laghi, Varese, Italy
| | - Camilla Callegari
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria-ASST Sette Laghi, Varese, Italy
| | - Mariarita Caroleo
- Department of Health Sciences, Psychiatric Unit, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
- Division of Psychiatry, University College of London, London, UK
| | - Mariangela Corbo
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Armando D'Agostino
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
- Department of Mental Health, San Paolo Hospital, Milan, Italy
| | - Pasquale De Fazio
- Azienda Ospedaliera Universitaria Mater Domini, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Fabio Magliocco
- Department of Health Sciences, Psychiatric Unit, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, University "G. d'Annunzio", Chieti, Italy
| | - Edoardo Giuseppe Ostinelli
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
- Department of Mental Health, San Paolo Hospital, Milan, Italy
| | - Marco Piero Piccinelli
- Department of Medicine and Surgery, Division of Psychiatry, University of Insubria-ASST Sette Laghi, Varese, Italy
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation; Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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16
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Ceraso A, Lin JJ, Schneider-Thoma J, Siafis S, Tardy M, Komossa K, Heres S, Kissling W, Davis JM, Leucht S. Maintenance treatment with antipsychotic drugs for schizophrenia. Cochrane Database Syst Rev 2020; 8:CD008016. [PMID: 32840872 PMCID: PMC9702459 DOI: 10.1002/14651858.cd008016.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The symptoms and signs of schizophrenia have been linked to high levels of dopamine in specific areas of the brain (limbic system). Antipsychotic drugs block the transmission of dopamine in the brain and reduce the acute symptoms of the disorder. An original version of the current review, published in 2012, examined whether antipsychotic drugs are also effective for relapse prevention. This is the updated version of the aforesaid review. OBJECTIVES To review the effects of maintaining antipsychotic drugs for people with schizophrenia compared to withdrawing these agents. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (12 November 2008, 10 October 2017, 3 July 2018, 11 September 2019). SELECTION CRITERIA We included all randomised trials comparing maintenance treatment with antipsychotic drugs and placebo for people with schizophrenia or schizophrenia-like psychoses. DATA COLLECTION AND ANALYSIS We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) or standardised mean differences (SMD), again based on a random-effects model. MAIN RESULTS The review currently includes 75 randomised controlled trials (RCTs) involving 9145 participants comparing antipsychotic medication with placebo. The trials were published from 1959 to 2017 and their size ranged between 14 and 420 participants. In many studies the methods of randomisation, allocation and blinding were poorly reported. However, restricting the analysis to studies at low risk of bias gave similar results. Although this and other potential sources of bias limited the overall quality, the efficacy of antipsychotic drugs for maintenance treatment in schizophrenia was clear. Antipsychotic drugs were more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 24% versus placebo 61%, 30 RCTs, n = 4249, RR 0.38, 95% CI 0.32 to 0.45, number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 3; high-certainty evidence). Hospitalisation was also reduced, however, the baseline risk was lower (drug 7% versus placebo 18%, 21 RCTs, n = 3558, RR 0.43, 95% CI 0.32 to 0.57, NNTB 8, 95% CI 6 to 14; high-certainty evidence). More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at seven to 12 months: drug 36% versus placebo 62%, 24 RCTs, n = 3951, RR 0.56, 95% CI 0.48 to 0.65, NNTB 4, 95% CI 3 to 5; high-certainty evidence) and due to inefficacy of treatment (at seven to 12 months: drug 18% versus placebo 46%, 24 RCTs, n = 3951, RR 0.37, 95% CI 0.31 to 0.44, NNTB 3, 95% CI 3 to 4). Quality of life might be better in drug-treated participants (7 RCTs, n = 1573 SMD -0.32, 95% CI to -0.57 to -0.07; low-certainty evidence); probably the same for social functioning (15 RCTs, n = 3588, SMD -0.43, 95% CI -0.53 to -0.34; moderate-certainty evidence). Underpowered data revealed no evidence of a difference between groups for the outcome 'Death due to suicide' (drug 0.04% versus placebo 0.1%, 19 RCTs, n = 4634, RR 0.60, 95% CI 0.12 to 2.97,low-certainty evidence) and for the number of participants in employment (at 9 to 15 months, drug 39% versus placebo 34%, 3 RCTs, n = 593, RR 1.08, 95% CI 0.82 to 1.41, low certainty evidence). Antipsychotic drugs (as a group and irrespective of duration) were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 14% versus placebo 8%, 29 RCTs, n = 5276, RR 1.52, 95% CI 1.25 to 1.85, number needed to treat for an additional harmful outcome (NNTH) 20, 95% CI 14 to 50), sedation (drug 8% versus placebo 5%, 18 RCTs, n = 4078, RR 1.52, 95% CI 1.24 to 1.86, NNTH 50, 95% CI not significant), and weight gain (drug 9% versus placebo 6%, 19 RCTs, n = 4767, RR 1.69, 95% CI 1.21 to 2.35, NNTH 25, 95% CI 20 to 50). AUTHORS' CONCLUSIONS For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.
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Affiliation(s)
- Anna Ceraso
- Department of Clinical and Experimental Sciences, Section of Psychiatry, University of Brescia, Brescia, Italy
| | - Jessie Jingxia Lin
- School of Nursing, The University of Hong Kong, Hong Kong SAR, Hong Kong
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Magdolna Tardy
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München Klinikum rechts der Isar, München, Germany
| | - Katja Komossa
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - Werner Kissling
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Munich, Germany
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17
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Systematic review of the methods of health economic models assessing antipsychotic medication for schizophrenia. PLoS One 2020; 15:e0234996. [PMID: 32649663 PMCID: PMC7351140 DOI: 10.1371/journal.pone.0234996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Numerous economic models have assessed the cost-effectiveness of antipsychotic medications in schizophrenia. It is important to understand what key impacts of antipsychotic medications were considered in the existing models and limitations of existing models in order to inform the development of future models. OBJECTIVES This systematic review aims to identify which clinical benefits, clinical harms, costs and cost savings of antipsychotic medication have been considered by existing models, to assess quality of existing models and to suggest good practice recommendations for future economic models of antipsychotic medications. METHODS An electronic search was performed on multiple databases (MEDLINE, EMBASE, PsycInfo, Cochrane database of systematic reviews, The NHS Economic Evaluation Database and Health Technology Assessment database) to identify economic models of schizophrenia published between 2005-2020. Two independent reviewers selected studies for inclusion. Study quality was assessed using the National Institute for Health and Care Excellence (NICE) checklist and the Cooper hierarchy. Key impacts of antipsychotic medications considered by exiting models were descriptively summarised. RESULTS Sixty models were included. Existing models varied greatly in key impacts of antipsychotic medication included in the model, especially in clinical outcomes used for assessing reduction in psychotic symptoms and types of adverse events considered in the model. Quality of existing models was generally low due to failure to capture the health and cost impact of adverse events of antipsychotic medications and input data not obtained from best available source. Good practices for modelling antipsychotic medications are suggested. DISCUSSIONS This review highlights inconsistency in key impacts considered by different models, and limitations of the existing models. Recommendations on future research are provided.
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Kaufman KR. BJPsych Open fifth anniversary editorial: history, accomplishments, trajectory and passion. BJPsych Open 2020; 6:e52. [PMID: 32475364 PMCID: PMC7345524 DOI: 10.1192/bjo.2020.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BJPsych Open has come of age. This editorial celebrates the journal's fifth anniversary by reviewing the history of BJPsych Open, what we have accomplished, where we strive to go (our planned trajectory) and the passion of being an Editor-in-Chief.
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Affiliation(s)
- Kenneth R Kaufman
- Departments of Psychiatry, Neurology and Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Jersey, USA; and Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
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Jin H, Tappenden P, MacCabe JH, Robinson S, Byford S. Evaluation of the Cost-effectiveness of Services for Schizophrenia in the UK Across the Entire Care Pathway in a Single Whole-Disease Model. JAMA Netw Open 2020; 3:e205888. [PMID: 32459356 PMCID: PMC7254180 DOI: 10.1001/jamanetworkopen.2020.5888] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE The existing economic models for schizophrenia often have 3 limitations; namely, they do not cover nonpharmacologic interventions, they report inconsistent conclusions for antipsychotics, and they have poor methodologic quality. OBJECTIVES To develop a whole-disease model for schizophrenia and use it to inform resource allocation decisions across the entire care pathway for schizophrenia in the UK. DESIGN, SETTING, AND PARTICIPANTS This decision analytical model used a whole-disease model to simulate the entire disease and treatment pathway among a simulated cohort of 200 000 individuals at clinical high risk of psychoses or with a diagnosis of psychosis or schizophrenia being treated in primary, secondary, and tertiary care in the UK. Data were collected March 2016 to December 2018 and analyzed December 2018 to April 2019. EXPOSURES The whole-disease model used discrete event simulation; its structure and input data were informed by published literature and expert opinion. Analyses were conducted from the perspective of the National Health Service and Personal Social Services over a lifetime horizon. Key interventions assessed included cognitive behavioral therapy, antipsychotic medication, family intervention, inpatient care, and crisis resolution and home treatment team. MAIN OUTCOMES AND MEASURES Life-time costs and quality-adjusted life-years. RESULTS In the simulated cohort of 200 000 individuals (mean [SD] age, 23.5 [5.1] years; 120 800 [60.4%] men), 66 400 (33.2%) were not at risk of psychosis, 69 800 (34.9%) were at clinical high risk of psychosis, and 63 800 (31.9%) had psychosis. The results of the whole-disease model suggest the following interventions are likely to be cost-effective at a willingness-to-pay threshold of £20 000 ($25 552) per quality-adjusted life-year: practice as usual plus cognitive behavioral therapy for individuals at clinical high risk of psychosis (probability vs practice as usual alone, 0.96); a mix of hospital admission and crisis resolution and home treatment team for individuals with acute psychosis (probability vs hospital admission alone, 0.99); amisulpride (probability vs all other antipsychotics, 0.39), risperidone (probability vs all other antipsychotics, 0.30), or olanzapine (probability vs all other antipsychotics, 0.17) combined with family intervention for individuals with first-episode psychosis (probability vs family intervention or medication alone, 0.58); and clozapine for individuals with treatment-resistant schizophrenia (probability vs other medications, 0.81). CONCLUSIONS AND RELEVANCE The results of this study suggest that the current schizophrenia service configuration is not optimal. Cost savings and/or additional quality-adjusted life-years may be gained by replacing current interventions with more cost-effective interventions.
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Affiliation(s)
- Huajie Jin
- King’s Health Economics, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Paul Tappenden
- Health Economics and Decision Science, University of Sheffield School of Health and Related Research, Sheffield, United Kingdom
| | - James H. MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Stewart Robinson
- Loughborough University School of Business and Economics, Loughborough, United Kingdom
| | - Sarah Byford
- King’s Health Economics, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
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Jia J, Shen J, Liu FH, Wong HK, Yang XJ, Wu QJ, Zhang H, Wang HN, Tan QR, Zhang ZJ. Effectiveness of Electroacupuncture and Electroconvulsive Therapy as Additional Treatment in Hospitalized Patients With Schizophrenia: A Retrospective Controlled Study. Front Psychol 2019; 10:2306. [PMID: 31681100 PMCID: PMC6804524 DOI: 10.3389/fpsyg.2019.02306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/27/2019] [Indexed: 12/18/2022] Open
Abstract
Electroacupuncture (EA) and electroconvulsive therapy (ECT) are often used in the management of schizophrenia. This study sought to determine whether additional EA and ECT could augment antipsychotic response and reduce related side effects. In this retrospective controlled study, 287 hospitalized schizophrenic patients who received antipsychotics (controls, n = 50) alone or combined with EA (n = 101), ECT (n = 55) or both (EA + ECT, n = 81) were identified. EA and ECT were conducted for 5 and 3 sessions per week, respectively, with a maximum of 12 sessions for ECT during hospitalization. The Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to assess the severity of psychotic symptoms. Clinical response on SAPS and SANS, weight gain, and adverse events were compared. Survival analysis revealed that the ECT and EA + ECT groups had markedly greater clinical response rate than controls on SAPS [72.7 and 90.1% vs. 64.0%; relative risk (RR), 1.974 and 2.628, respectively, P ≤ 0.004] and on SANS (67.3 and 70.4% vs. 42.0%; RR, 1.951 and 2.009, respectively, P ≤ 0.015). A significantly greater response rate on SANS than controls was also observed in the EA group (64.4% vs. 42.0%; RR = 1.938, P = 0.008). EA-containing regimens remarkably reduced weight gain and incidences of headache, insomnia, dry mouth, and electrocardiographic abnormalities. These results suggest that EA and ECT can serve as additional treatment for enhancing antipsychotic response and reduce the side effects in hospitalized patients with schizophrenia. Clinical Trial Registration: http://www.chictr.org.cn/showprojen.aspx?proj=38901, identifier ChiCTR1900023563.
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Affiliation(s)
- Jie Jia
- Department of Psychiatry, Xi'an Mental Health Center, Xi'an, China
| | - Jun Shen
- Department of Psychiatry, Xi'an Mental Health Center, Xi'an, China
| | - Fei-Hu Liu
- Department of Psychiatry, Xi'an Mental Health Center, Xi'an, China
| | - Hei Kiu Wong
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Xin-Jing Yang
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Qiang-Ju Wu
- Department of Psychiatry, Xi'an Mental Health Center, Xi'an, China
| | - Hui Zhang
- Department of Psychiatry, Xi'an Mental Health Center, Xi'an, China
| | - Hua-Ning Wang
- Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Qing-Rong Tan
- Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Kaar SJ, Gobjila C, Butler E, Henderson C, Howes OD. Making decisions about antipsychotics: a qualitative study of patient experience and the development of a decision aid. BMC Psychiatry 2019; 19:309. [PMID: 31646985 PMCID: PMC6806500 DOI: 10.1186/s12888-019-2304-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Shared decision making is a widely accepted standard of patient-centred care that leads to improved clinical outcomes, yet it is commonly underutilised in the field of mental health. Furthermore, little is known regarding patient decision making around antipsychotic medication, which is often poorly adhered to. We aim to explore psychiatric patients' experiences of antipsychotic medication decision making in order to develop a patient decision aid to promote shared decision making. METHODS Focus groups were conducted with patients with chronic psychotic illnesses (n = 20) who had previously made a decision about taking or changing antipsychotic medication. Transcripts were coded and analysed for thematic content and continued until thematic saturation. These themes subsequently informed the development of a decision aid with the help of expert guidance. Further patient input was sought using the think aloud method (n = 3). RESULTS Twenty-three patients participated in the study. Thematic analysis revealed that 'adverse effects' was the most common theme identified by patients surrounding antipsychotic medication decision-making followed by 'mode and time of administration', 'symptom control' and 'autonomy'. The final decision aid is included to provoke further discussion and development of such aids. CONCLUSIONS Patients commonly report negative experiences of antipsychotic medication, in particular side-effects, which remain critical to future decision making around antipsychotic medication. Clinical encounters that increase patient knowledge and maximise autonomy in order to prevent early negative experiences with antipsychotic medication are likely to be beneficial.
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Affiliation(s)
- S J Kaar
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK.
| | - C Gobjila
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK
| | - E Butler
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK
| | - C Henderson
- Health Service and Population Research, Psychological and Systems Sciences, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, SE5 8AZ, UK
| | - O D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, PO63 De Crespigny Park, London, SE5 8AF, UK.,Psychiatric Imaging Group, MRC London Institute of Medical Sciences, Imperial College, Hammersmith Hospital, London, UK
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Kishimoto T, Hagi K, Nitta M, Kane JM, Correll CU. Long-term effectiveness of oral second-generation antipsychotics in patients with schizophrenia and related disorders: a systematic review and meta-analysis of direct head-to-head comparisons. World Psychiatry 2019; 18:208-224. [PMID: 31059621 PMCID: PMC6502423 DOI: 10.1002/wps.20632] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Second-generation antipsychotics (SGAs) are recommended for maintenance treatment in schizophrenia. However, comparative long-term effectiveness among SGAs is unclear. Here we provide a systematic review and meta-analysis of randomized trials lasting ≥⃒6 months comparing SGAs head-to-head in schizophrenia and related disorders. The primary outcome was all-cause discontinuation. Secondary outcomes included efficacy and tolerability, i.e., psychopathology, inefficacy-related and intolerability-related discontinuation, relapse, hospitalization, remission, functioning, quality of life, and adverse events. Pooled risk ratio and standardized mean difference were calculated using random-effects models. Across 59 studies (N=45,787), lasting 47.4±32.1 weeks (range 24-186), no consistent superiority of any SGA emerged across efficacy and tolerability outcomes. Regarding all-cause discontinuation, clozapine, olanzapine and risperidone were significantly (p<0.05) superior to several other SGAs, while quetiapine was inferior to several other SGAs. As to psychopathology, clozapine and olanzapine were superior to several other SGAs, while quetiapine and ziprasidone were inferior to several other SGAs. Data for other efficacy outcomes were sparse. Regarding intolerability-related discontinuation, risperidone was superior and clozapine was inferior to several other SGAs. Concerning weight gain, olanzapine was worse than all other compared non-clozapine SGAs, and risperidone was significantly worse than several other SGAs. As to prolactin increase, risperidone and amisulpride were significantly worse than several other SGAs. Regarding parkinsonism, olanzapine was superior to risperidone, without significant differences pertaining to akathisia. Concerning sedation and somnolence, clozapine and quetiapine were significantly worse than some other SGAs. In summary, different long-term SGA efficacy and tolerability patterns emerged. The long-term risk-benefit profiles of specific SGAs need to be tailored to individual patients to optimize maintenance treatment outcomes.
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Affiliation(s)
- Taishiro Kishimoto
- Keio University School of MedicineTokyoJapan,Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen OaksNew YorkNYUSA,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, HempsteadNew YorkNYUSA,Feinstein Institute for Medical Research, ManhassetNew YorkNYUSA
| | - Katsuhiko Hagi
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen OaksNew YorkNYUSA,Sumitomo Dainippon Pharma Co., Ltd.TokyoJapan
| | | | - John M. Kane
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen OaksNew YorkNYUSA,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, HempsteadNew YorkNYUSA,Feinstein Institute for Medical Research, ManhassetNew YorkNYUSA
| | - Christoph U. Correll
- Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen OaksNew YorkNYUSA,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, HempsteadNew YorkNYUSA,Feinstein Institute for Medical Research, ManhassetNew YorkNYUSA,Department of Child and Adolescent PsychiatryCharité UniversitätsmedizinBerlinGermany
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Wubeshet YS, Mohammed OS, Desse TA. Prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients at Amanuel Mental Specialized Hospital, central Ethiopia: cross-sectional study. BMC Psychiatry 2019; 19:32. [PMID: 30658604 PMCID: PMC6339381 DOI: 10.1186/s12888-018-1999-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/26/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND First-generation antipsychotics (FGAs) are associated with a range of adverse events which can significantly reduce patients' quality of life and contribute to non-adherence. The aim of this study was to assess the prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients. METHODS The study was conducted at Amanuel Mental Specialized Hospital from March to June, 2017. Data from patients were collected using a pretested structured questionnaire. Demographics and side effects of antipsychotics were collected by face to face interview. Clinical characteristics, medications and previous history of adverse drug events were extracted from medical records using data abstraction format. The data were analyzed using statistical software for social sciences (SPSS) version 20. Descriptive statistics and chi-square tests were done. Statistical significance was considered at p < 0.05. RESULTS Out of 356 participants, 300 of them had complete data and were included in the study. The mean age of participants was 33.71 ± 10.2 years. The majority, 195(65.0%), of participants were males. Most of the participants, 293(97.7%), developed FGA medication induced side effects. One hundred sixty three (54.3%) participants were treated with Trihexyphenidyl for FGAs induced side effects. Dose reduction of antipsychotics was done for 51(17.0%) participants. Most of the participants' side effects were not managed according to American Psychiatric Association guideline; 178 (82.4%). The most common types of FGAs induced side effects were cardiovascular side effects 169(56.3%); sedation and CNS side effects 149(49.6%); and extrapyramidal side effects 114(38.0%). There is a significant association between occurrence of side effects of FGAs and duration of illness (P = 0.04). CONCLUSIONS The prevalence of first generation antipsychotics induced side effects was high. However, management practice of the side effects was minimal.
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Affiliation(s)
- Yirgalem Shewakena Wubeshet
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Oumer Sada Mohammed
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tigestu Alemu Desse
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Aydın N, Aytaç HM, Yazıcı E, Yılmaz D, Çetinay Aydın P, Yüksel Yalçın G, Kadıoğlu Y, Canbay C, Terzioğlu M, Şenol O, Çakmak C, Özer A. Rediscovery of penicillin of psychiatry: haloperidol decanoate. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1533190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Nazan Aydın
- Department of Psychology, Humanities and Social Sciences Faculty, Üsküdar University, İstanbul, Turkey
| | - Hasan Mervan Aytaç
- Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey
| | - Esra Yazıcı
- Department of Psychiatry, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Doğan Yılmaz
- Van Training and Research Hospital, Department of Psychiatry, Bakirkoy Research & Training Hospital for Psychiatry, Neurology and Neurosurgery, Alcohol and Drug Research Treatment and Training Center (AMATEM), İstanbul, Turkey
| | - Pınar Çetinay Aydın
- Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey
| | | | - Yücel Kadıoğlu
- Department of Analytical Chemistry, Faculty of Pharmacy, Atatürk University, Erzurum, Turkey
| | - Cana Canbay
- Van Training and Research Hospital, Department of Psychiatry, Bakirkoy Research & Training Hospital for Psychiatry, Neurology and Neurosurgery, Alcohol and Drug Research Treatment and Training Center (AMATEM), İstanbul, Turkey
| | - Merve Terzioğlu
- Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey
| | - Onur Şenol
- Department of Analytical Chemistry, Faculty of Pharmacy, Atatürk University, Erzurum, Turkey
| | - Cavide Çakmak
- Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey
| | - Aysel Özer
- Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disease Education and Research Hospital, Istanbul, Turkey
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Russu A, Kern Sliwa J, Ravenstijn P, Singh A, Mathews M, Kim E, Gopal S. Maintenance dose conversion between oral risperidone and paliperidone palmitate 1 month: Practical guidance based on pharmacokinetic simulations. Int J Clin Pract 2018; 72:e13089. [PMID: 29707876 PMCID: PMC6175146 DOI: 10.1111/ijcp.13089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
AIM We assessed the dosage strengths of paliperidone palmitate 1-month (PP1M) long-acting injectable resulting in similar steady-state (SS) exposures to the dosage strengths of oral risperidone using pharmacokinetic (PK) simulations. METHODS Population PK simulations of SS PK were performed using the PK models of oral risperidone and PP1M. The concentrations of active moiety (risperidone + paliperidone) from risperidone were compared to paliperidone concentrations resulting from PP1M administration. Similarity was assessed via graphical evaluation of median and 90% prediction intervals of SS PK profiles over 28 days. RESULTS Oral risperidone doses of 1, 2, 3, 4, and 6 mg/d are expected to result in similar SS PK as PP1M doses of 25, 50, 75, 100, and 150 mg eq. (which correspond to 39, 78, 117, 156, and 234 mg of paliperidone palmitate) respectively (ie 25-fold dose conversion factor from oral risperidone to PP1M). CONCLUSIONS This study provides clinicians with a practical guidance to establish suitable maintenance dose levels of PP1M and oral risperidone when transitioning patients from one formulation to another.
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Affiliation(s)
- Alberto Russu
- Janssen Research & Developmenta Division of Janssen Pharmaceutica NVBeerseBelgium
| | | | - Paulien Ravenstijn
- Janssen Research & Developmenta Division of Janssen Pharmaceutica NVBeerseBelgium
| | - Arun Singh
- Janssen Research & DevelopmentTitusvilleNJUSA
| | | | - Edward Kim
- Janssen Scientific Affairs, LLCTitusvilleNJUSA
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Sankaranarayanan A, Wilding H, Neill E, Castle D. A Critical Systematic Review of Evidence for Cannabinoids in the Treatment of Schizophrenia. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180409-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Noordsy DL, Glynn SM, Sugar CA, O’Keefe CT, Marder SR. Risperidone versus olanzapine among patients with schizophrenia participating in supported employment: Eighteen-month outcomes. J Psychiatr Res 2017; 95:299-307. [PMID: 28942217 PMCID: PMC5653420 DOI: 10.1016/j.jpsychires.2017.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/15/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
This study compares the efficacy and tolerability of olanzapine versus risperidone among patients with schizophrenia who are established in outpatient psychiatric care and entering supported employment. A multicenter, randomized, double-blind trial was conducted among 107 outpatients with schizophrenia, who were cross-titrated to flexible dose risperidone or olanzapine over 2 weeks. Clinical endpoints included time to hospitalization and persistence on assigned medication. Weight, laboratory tests, psychopathology, neurologic side effects, social adjustment and role functioning were assessed at 3-6 month intervals. Data were analyzed first by randomized treatment, and then reassessed controlling for prior medication treatment. The proportion of patients on assigned medication at 18 months was 30.9% for risperidone and 37.3% for olanzapine. Mean doses were 6.4 ± 3.2 mg daily for risperidone, and 17.0 ± 5.0 mg daily for olanzapine. The groups did not differ significantly in time to medication discontinuation, first hospitalization or first employment. There were few differences in psychopathology, laboratory, or neurological assessments between groups at 18 months. Patients randomized to olanzapine gained modestly more weight. Controlling for pre-randomization medication suggested improvement in some aspects of psychopathology from switching medications; however, switching from olanzapine to risperidone was associated with more hospitalizations. Risperidone and olanzapine have similar efficacy and tolerability in patients with schizophrenia who are participating in supported employment. Randomization to olanzapine was associated with more weight gain, but randomization from olanzapine to risperidone appeared to be associated with a greater likelihood of hospitalization. Careful monitoring of metabolic effects and participation in supported employment may have contributed to minimal weight gain and metabolic effects.
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Affiliation(s)
- Douglas L. Noordsy
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA
| | - Shirley M. Glynn
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA,VA Greater Los Angeles, Los Angeles, CA
| | - Catherine A. Sugar
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA,Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA
| | | | - Stephen R. Marder
- Semel Institute for Neuroscience at UCLA, Los Angeles, CA,VA Greater Los Angeles, Los Angeles, CA
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Selvakumar N, Kuppili PP, Bharadwaj B, Kandasamy P. The forgotten entity of cycloid psychosis. Asian J Psychiatr 2017; 30:33-34. [PMID: 28728052 DOI: 10.1016/j.ajp.2017.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/03/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Nivedhitha Selvakumar
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry 605006, India.
| | - Pooja Patnaik Kuppili
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry 605006, India.
| | - Balaji Bharadwaj
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry 605006, India.
| | - Preeti Kandasamy
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry 605006, India.
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Zhang Y, Liu Y, Su Y, You Y, Ma Y, Yang G, Song Y, Liu X, Wang M, Zhang L, Kou C. The metabolic side effects of 12 antipsychotic drugs used for the treatment of schizophrenia on glucose: a network meta-analysis. BMC Psychiatry 2017; 17:373. [PMID: 29162032 PMCID: PMC5698995 DOI: 10.1186/s12888-017-1539-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/13/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Antipsychotics have serious metabolic side effects on blood glucose. However, the comparative influence of these drugs on blood glucose levels has not been comprehensively evaluated. We conducted a network meta-analysis to create a hierarchy of the side effects of 12 antipsychotic drugs on changes in blood glucose levels. METHODS A systematic search of the PubMed, EMBASE and Cochrane databases (last search June 2016) was conducted to identify studies that reported randomized controlled trials (RCTs) comparing changes in blood glucose levels between patients receiving one of 12 antipsychotic drugs or a placebo for the treatment of schizophrenia or related disorders. The studies we searched were limited to those published in English. Two reviewers independently extracted data. The primary outcome of interest was changes in fasting glucose levels. RESULTS We included 47 studies with 114 relevant arms. Of the antipsychotic drugs, only olanzapine was associated with significantly increased glucose levels compared to a placebo (mean difference (MD) = 3.95, 95% confidence interval (CI) = 0.14 to 7.76). Moreover, olanzapine was associated with a significantly greater change in the glucose levels than ziprasidone (MD = 5.51, 95% CI = 1.62 to 9.39), lurasidone (MD = 5.58, 95% CI = 0.53 to 10.64) or risperidone (MD = 3.05, 95% CI = 0.87 to 5.22). Ziprasidone and lurasidone were associated with minimal glucose changes compared to the other antipsychotics. CONCLUSIONS Olanzapine was associated with a significantly greater change in blood glucose levels than ziprasidone, lurasidone, risperidone or placebo treatment. The application of a hierarchy of glucose metabolism-related side effects may help clinicians tailor the choice of antipsychotic drug to meet the needs of individual patients.
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Affiliation(s)
- Yangyu Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yingyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yingying Su
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yueyue You
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yue Ma
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Guang Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Yan Song
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Xinyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Mohan Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Lili Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
| | - Changgui Kou
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin Province 130021 China
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30
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Qiu HZ, Ye ZJ, Liang MZ, Huang YQ, Liu W, Lu ZD. Effect of an art brut therapy program called go beyond the schizophrenia (GBTS) on prison inmates with schizophrenia in mainland China-A randomized, longitudinal, and controlled trial. Clin Psychol Psychother 2017; 24:1069-1078. [PMID: 28078741 DOI: 10.1002/cpp.2069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 11/08/2016] [Accepted: 12/08/2016] [Indexed: 10/13/2023]
Abstract
UNLABELLED Creative arts therapies are proven to promote an interconnection between body and mind, but there are major obstacles for providing therapeutic services in prisons due to inmates' inherent mistrust for verbal disclosure and rigid self-defenses, especially among inmates with schizophrenia. Thus, we developed a structured and quantitative art brut therapy program called go beyond the schizophrenia to actually measure the benefits of art therapy on prison inmates in mainland China. Upon completion of the program, the intervention group reported a decrease in anxiety, depression, anger, and negative psychiatric symptoms and showed better compliance with rules, socialization with peers, compliance with medications, and regular sleeping patterns after 16 weekly sessions of go beyond the schizophrenia. This article concludes that the art brut therapy was effective for the inmates with schizophrenia in mainland China and provides encouraging data on how to enhance mental health for inmates with schizophrenia. KEY PRACTITIONER MESSAGE Art brut therapy can reduce emotional distress and negative psychiatric symptoms among Chinese inmates. Arts brut therapy can enhance Chinese inmates' compliance with rules, socialization with peers, compliance with medicines, and regular sleeping patterns. Arts brut therapy in conjunction with medication is highly recommended for recovery of Chinese inmates with schizophrenia, especially for patients with negative symptoms.
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Affiliation(s)
- Hong-Zhong Qiu
- College of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Zeng-Jie Ye
- College of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Mu-Zi Liang
- College of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Yue-Qun Huang
- Prison of Yangjiang, Yangjiang, Guangdong Province, China
| | - Wei Liu
- Prison of Yangjiang, Yangjiang, Guangdong Province, China
| | - Zhi-Dong Lu
- Prison of Yangjiang, Yangjiang, Guangdong Province, China
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31
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Morrison P, Stomski NJ. Carers’ Perspectives on Mental Health Consumers’ Use of Antipsychotic Medication: A Multidimensional Scalogram Analysis. CONTEMPORARY FAMILY THERAPY 2017. [DOI: 10.1007/s10591-017-9423-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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32
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Attard A, Larkin M. Art therapy for people with psychosis: a narrative review of the literature. Lancet Psychiatry 2016; 3:1067-1078. [PMID: 27528095 DOI: 10.1016/s2215-0366(16)30146-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 06/06/2016] [Accepted: 06/13/2016] [Indexed: 12/15/2022]
Abstract
Art therapy enables individuals to use art to creatively express themselves and communicate differently with themselves, others, and their reality. The National Institute for Health and Clinical Excellence guidelines for psychosis and schizophrenia suggest that arts therapies, which include art therapy, are considered to improve negative symptoms of psychosis. We examined the effectiveness of art therapy for people with psychosis and explored whether art therapy is a meaningful and acceptable intervention in this Review. Seven electronic databases were searched for empirical papers that concerned the use of art therapy for adults with psychosis that were published from 2007 onwards. The search identified 18 papers. High-quality quantitative articles provided inconclusive evidence for the effectiveness of art therapy in adults with psychosis. However, high-quality qualitative articles indicated that therapists and clients considered art therapy to be a beneficial, meaningful, and acceptable intervention, although this conclusion was based on a small number of studies. In this Review, we discuss the theoretical, clinical, and methodological issues in light of the development of more robust research, which is needed to corroborate individuals' experiences and guide evidence-based practice.
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Affiliation(s)
- Angelica Attard
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Michael Larkin
- School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
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