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Martin M, Braillon A. [Comment on: "French Expert advice on the management of valproate in childbearing and pregnant women with bipolar disorder"]. L'ENCEPHALE 2023; 49:323-324. [PMID: 37095050 DOI: 10.1016/j.encep.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023]
Abstract
Professor Marlene Freeman of Massachusset General Hospital's answer to the question "How should I prescribe valproic acid (for psychiatric disorders) to women of childbearing age?" is "Don't do it at all."
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Hefner G, Wolff J, Toto S, Reißner P, Klimke A. Off-label use of antidepressants, antipsychotics, and mood-stabilizers in psychiatry. J Neural Transm (Vienna) 2022; 129:1353-1365. [PMID: 36070009 DOI: 10.1007/s00702-022-02542-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
Off-label drug prescribing in psychiatry is increasing. Many psychotropic drugs are approved for psychopathologic syndromes rather than based on international standard diagnostic classification systems which might facilitate the clinical decision for off-label prescriptions. The objective of this study was to analyze the prevalence and category of off-label use of psychotropic drugs. The study was conducted in 10 psychiatric hospitals in Germany over a period of 2 years. Prescription data of all patients were retrospectively analyzed after identification of antidepressants, antipsychotics, and mood-stabilizers, which were classified as off-label according to the German prescribing information and diagnostic classification according to ICD-10. In total, 53,909 patient cases (46% female) with a mean age of 46.8 (SD: 18) years were included in the study. 30.2% of the cases received at least one off-label prescription of a psychotropic drug during hospital stay. Off-label prevalence rates differed markedly between different diagnostic groups (ICD-10 F0/G3: 47%, F1: 33%, F2: 25%, F3: 21%, F4: 27%, F6: 46%, F7: 84%). The most often off-label prescribed drugs were quetiapine and mirtazapine for organic mental disorders (F0/G3), valproate and quetiapine in patients with disorders due to psychoactive substance use (F1), valproate in patients with psychotic disorders (F2), and risperidone and olanzapine in patients with affective disorders (F3). The prevalence rate of psychotropic off-label prescriptions is high if restricted to product description and ICD-10 diagnosis. Therefore, current psychiatric guidelines should drug-specifically issue this problem by defining psychiatric off-label indications based on a clear benefit-risk assessment.
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Affiliation(s)
- Gudrun Hefner
- Psychiatric Hospital, Vitos Clinic for Forensic Psychiatry, Kloster-Eberbach-Straße 4, 65346, Eltville, Germany.
| | - Jan Wolff
- Peter L. Reichertz Institute for Medical Informatics, Hannover Medical School, Hannover, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Pamela Reißner
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany
| | - Ansgar Klimke
- Department of Psychiatry and Psychotherapy, Vitos Klinikum Hochtaunus, Friedrichsdorf, Germany.,Heinrich-Heine-University, Duesseldorf, Germany
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Neurobehavioral Differences of Valproate and Risperidone on MK-801 Inducing Acute Hyperlocomotion in Mice. Behav Neurol 2022; 2022:1048463. [PMID: 35251367 PMCID: PMC8890888 DOI: 10.1155/2022/1048463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/23/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The glutamate system plays a major role in the development of neuropsychiatric disorders such as addiction, epilepsy, dementia, and psychosis. MK-801 (dizocilpine), an uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist, could increase locomotor activity and stereotyped neurobehaviors mimicking schizophrenic-like features in the mouse model. The study would explore the neuropharmacological differences of risperidone and valproic acid on the MK-801-induced neurobehavioral changes. Methods The subjects were male C57BL/6J mice obtained from the National Laboratory Animal Center. Drug effects were assessed using the open field with a video-tracking system and gaiting tests. After habitation, risperidone (0, 0.1 mg/kg) or valproic acid (0, 200 mg/kg) was injected and ran locomotion for 30 mins. Sequentially, mice were followed by intraperitoneal injection (i.p.) with MK-801 (0, 0.2 mg/kg) and ran locomotion for 60 mins. Gaiting behaviors such as step angles, stride lengths, and stance widths were measured following the study drugs. Results The results showed that risperidone and valproic acid alone could not alter the locomotor activities. Following the MK-801 injection, the travelled distance and speed in the entire open field dramatically increased. The dose 0.1 mg/kg of risperidone could totally inhibit the MK-801-induced hyperlocomotion compared with that of the saline-injected group (p < 0.001). The valproic acid (200 mg/kg) partially suppressed the hyperlocomotion which is induced by MK801. Conclusion The more dominant effect of risperidone to rescue MK-801 induced hyperlocomotion compared with that of valproic acid. The partial suppression of valproic acid may imply the psychopharmacological evidence as adjuvant effect to treat psychotic patients through tuning glutamatergic neurotransmission.
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Paton C, Citrome L, Fernandez-Egea E, Rendora O, Barnes TRE. Who is prescribed valproate and how carefully is this treatment reviewed in UK mental health services? Data from a clinical audit. Ther Adv Psychopharmacol 2022; 12:20451253221110016. [PMID: 36051503 PMCID: PMC9425878 DOI: 10.1177/20451253221110016] [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: 02/13/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The licensed indications for valproate are narrow, yet this medication is commonly prescribed in mental health services. OBJECTIVES To explore the target symptoms/behaviours for which valproate is prescribed and how well the efficacy and tolerability of this treatment are monitored in routine clinical practice. DESIGN An audit-based quality improvement (QI) programme in UK mental health services. METHODS Information on valproate prescribing was collected from clinical records using a bespoke data collection tool. RESULTS Sixty-four NHS mental health Trusts/healthcare organisations submitted data on valproate treatment for 5320 patients. Valproate was clearly prescribed for a licensed indication in 1995 (38%) patients, off-label in 1987 (37%) while the indication was uncertain/not available in 1338 (25%). Of the 919 patients started on valproate treatment within the past year, between a half and two-thirds had each of the relevant baseline physical health checks documented. In 539 (59%) of these patients, valproate was prescribed for an unlicensed indication; the prescription was recognised as off-label in 363 (67%), 20 (6%) of whom were documented as having had this explained to them. Of 631 patients prescribed valproate for between 3 months and a year, early on-treatment assessments of response and side effects were documented in 441 (70%) and 332 (53%), respectively. Of 4401 patients treated for more than a year, annual on-treatment reviews of clinical response and side effects were documented in 2771 (63%) and 2140 (49%), respectively. CONCLUSION Our data suggest the majority of prescriptions for valproate in mental health services are not for a licensed indication. Furthermore, patients rarely receive an explanation that their valproate prescription is off-label, perhaps partly because the licensed indications are not widely understood by prescribers. Given the very limited evidence for efficacy for the off-label uses of valproate, failure to routinely conduct early on-treatment and annual reviews of the benefits and side effects of this medication may result in patients remaining on ineffective and poorly tolerated treatment by default.
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Affiliation(s)
- Carol Paton
- Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, 21 Prescot Street, Whitechapel, London E1 8BB, UK.,Division of Psychiatry, Imperial College London, London, UK
| | - Leslie Citrome
- Department of Psychiatry and Behavioural Sciences, New York Medical College, New York, USA
| | - Emilio Fernandez-Egea
- Department of Psychiatry and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK.,Cambridge Psychosis Centre, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Olivia Rendora
- Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Thomas R E Barnes
- Division of Psychiatry, Imperial College London, London, UK.,Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
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Patterns and Predictors of Off-Label Drug Prescribing in Psychiatric Practice: A Qualitative Study. PHARMACY 2021; 9:pharmacy9040203. [PMID: 34941635 PMCID: PMC8703660 DOI: 10.3390/pharmacy9040203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Off-label drug prescribing (OLDP) must be based on strong scientific evidence to make sure that patients get the optimum therapeutic outcomes. Adherence to the prerequisites is determined by the physicians’ attitude and knowledge. In this context, the present study was conducted with the goal of investigating psychiatrists’ perceptions of the use of OLDP in their clinical practice. A total of 14 psychiatrists were interviewed using a semi-structured interview guide. Thematic content analysis was performed. Data saturation was achieved at the 12th interview. Six major themes and fifteen subthemes emerged from qualitative interviews. Among the major themes were knowledge and concepts about the off-label drugs, attitude and current practice of prescribing off-label drugs, and rationale of prescribing and suggestions for reducing the use of off-label drugs. Almost all of the respondents interviewed provided detailed comments concerning the OLDP concept, depicted an optimistic approach and deemed that OLDP is quite common in psychiatry. Off-label usage of benzodiazepines such as clonazepam, diazepam and lorazepam in mania, depression, and obsessive–compulsive disorder were commonly reported. It was observed that the majority of the respondents did not inform the patients before prescribing off-label drugs. The present findings revealed that respondents had awareness; however, they depicted diverse attitudes towards prescribing off-label drugs. Further education and sensitization in regions with impoverished knowledge would certainly assist in preventing the risks associated with the use of OLDP.
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Tekin M, Kaya-Yertutanol FD, Çevreli B, Özdoğru AA, Kulaksız H, Uzbay İT. Sodium valproate improves sensorimotor gating deficit induced by sleep deprivation at low doses. Turk J Med Sci 2021; 51:1521-1530. [PMID: 33517611 PMCID: PMC8283464 DOI: 10.3906/sag-2011-229] [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: 11/23/2020] [Accepted: 01/30/2021] [Indexed: 11/03/2022] Open
Abstract
Background/aim Sleep deprivation disrupts prepulse inhibition of acoustic startle reflex and can be used to mimic psychosis in ex- perimental animals. On the other hand, it is also a model for other disorders of sensory processing, including migraine. This study aims to assess the effects of sodium valproate, a drug that is used in a variety of neuropsychiatric disorders, on normal and disrupted sensorimotor gating in rats. Materials and methods Sixty-two Wistar albino rats were randomly distributed into 8 groups. Subchronic and intraperitoneal sodium valproate were administrated to the sleep-deprived and nonsleep-deprived rats by either 50–100 or 200 mg/kg/day. Prepulse inhibition test and locomotor activity test were performed. Sleep deprivation induced by the modified multiple platform method. Results Sleep deprivation impaired prepulse inhibition, decreased startle amplitude, and increased locomotor activity. Sodium valpro- ate did not significantly alter prepulse inhibition and locomotor activity in nonsleep-deprived and sleep-deprived groups. On the other hand, all doses decreased locomotor activity in drug-treated groups, and low dose improved sensorimotor gating and startle amplitude after sleep deprivation. Conclusion Low-dose sodium valproate improves sleep deprivation-disrupted sensorimotor gating, and this finding may rationalize the use of sodium valproate in psychotic states and other sensory processing disorders. Dose-dependent effects of sodium valproate on sensorimotor gating should be investigated in detail.
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Affiliation(s)
- Muhammet Tekin
- Applied Psychology Master’s Program, Institute of Health Sciences, Üsküdar University, İstanbul, Turkey
| | - Fatma Duygu Kaya-Yertutanol
- Department of Psychiatry, Faculty of Medicine, Üsküdar University, İstanbul, Turkey,Neuropsychopharmacology Practice and Research Center, Üsküdar University, İstanbul, Turkey
| | - Burcu Çevreli
- Neuropsychopharmacology Practice and Research Center, Üsküdar University, İstanbul, Turkey
| | - Asil Ali Özdoğru
- Department of Psychology, Faculty of Humanities and Social Sciences, Üsküdar University, İstanbul, Turkey
| | - Hamza Kulaksız
- Neuroscience Master’s Program, Institute of Health Sciences, Üsküdar University, İstanbul, Turkey
| | - İ. Tayfun Uzbay
- Neuropsychopharmacology Practice and Research Center, Üsküdar University, İstanbul, Turkey,Department of Medical Pharmacology, Faculty of Medicine, Üsküdar University, İstanbul, Turkey
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Bellissima BL, Vara A, Helsby N, Garavan F, Tingle MD. Incidence and investigation of potential risk-factors for clozapine-associated myocarditis and cardiomyopathy in a New Zealand cohort. Psychiatry Res 2021; 299:113873. [PMID: 33799127 DOI: 10.1016/j.psychres.2021.113873] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 03/13/2021] [Indexed: 11/18/2022]
Abstract
Clozapine is a uniquely effective antipsychotic indicated for treatment-resistant schizophrenia. However, its use is underutilised and often delayed for years due to potential adverse reactions including myocarditis and cardiomyopathy. The purpose of this study was to conduct a retrospective review of the clinical records of patients initiating clozapine in the Auckland District Health Board (ADHB) region to determine the incidence of clozapine-associated myocarditis and cardiomyopathy and to identify potential risk factors associated with these cardiotoxicities. The incidence of clozapine-associated myocarditis and cardiomyopathy over a two-year period in the ADHB region was 3.8% and 1.3% respectively.
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Affiliation(s)
- Brandi L Bellissima
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Alisha Vara
- Auckland Regional Psychiatric Registrar Training Programme, Auckland District Health Board, 2 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Nuala Helsby
- Department of Molecular Medicine and Pathology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | - Fintan Garavan
- Department of Forensic Pathology, Auckland District Health Board, LabPlus, Auckland City Hospital, Gate 4, Grafton Road PO Box 110031, Auckland, New Zealand
| | - Malcolm D Tingle
- Department of Pharmacology and Clinical Pharmacology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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8
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Richetto J, Meyer U. Epigenetic Modifications in Schizophrenia and Related Disorders: Molecular Scars of Environmental Exposures and Source of Phenotypic Variability. Biol Psychiatry 2021; 89:215-226. [PMID: 32381277 DOI: 10.1016/j.biopsych.2020.03.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/19/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Epigenetic modifications are increasingly recognized to play a role in the etiology and pathophysiology of schizophrenia and other psychiatric disorders with developmental origins. Here, we summarize clinical and preclinical findings of epigenetic alterations in schizophrenia and relevant disease models and discuss their putative origin. Recent findings suggest that certain schizophrenia risk loci can influence stochastic variation in gene expression through epigenetic processes, highlighting the intricate interaction between genetic and epigenetic control of neurodevelopmental trajectories. In addition, a substantial portion of epigenetic alterations in schizophrenia and related disorders may be acquired through environmental factors and may be manifested as molecular "scars." Some of these scars can influence brain functions throughout the entire lifespan and may even be transmitted across generations via epigenetic germline inheritance. Epigenetic modifications, whether caused by genetic or environmental factors, are plausible molecular sources of phenotypic heterogeneity and offer a target for therapeutic interventions. The further elucidation of epigenetic modifications thus may increase our knowledge regarding schizophrenia's heterogeneous etiology and pathophysiology and, in the long term, may advance personalized treatments through the use of biomarker-guided epigenetic interventions.
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Affiliation(s)
- Juliet Richetto
- Institute of Pharmacology and Toxicology, University of Zurich-Vetsuisse, and Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland.
| | - Urs Meyer
- Institute of Pharmacology and Toxicology, University of Zurich-Vetsuisse, and Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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Ortiz JF, Ruxmohan S, Gomez J, Lalama HA, Taylor A, Smith DW. Management of Self-Injurious Behavior, Aggression, and Psychogenic Non-Epileptic Seizures in Patients With Tuberous Sclerosis: A Case Report With a Review of Literature. Cureus 2020; 12:e11715. [PMID: 33391947 PMCID: PMC7772104 DOI: 10.7759/cureus.11715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Lim WK, Chew QH, He YL, Si TM, Chiu FKH, Xiang YT, Kato TA, Kanba S, Shinfuku N, Lee MS, Park SC, Park YC, Chong MY, Lin SK, Yang SY, Tripathi A, Avasthi A, Grover S, Kallivayalil RA, Udomratn P, Chee KY, Tanra AJ, Rabbani MG, Javed A, Kathiarachchi S, Waas D, Myint WA, Sartorius N, Tran VC, Nguyen KV, Tan CH, Baldessarini RJ, Sim K. Coprescription of mood stabilizers in schizophrenia, dosing, and clinical correlates: An international study. Hum Psychopharmacol 2020; 35:1-7. [PMID: 32738085 DOI: 10.1002/hup.2752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Studies examining coprescription and dosages of mood stabilizers (MSs) with antipsychotics for psychotic disorders are infrequent. Based on sparse extant data and clinical experience, we hypothesized that adjunctive MS use would be associated with certain demographic (e.g., younger age), clinical factors (e.g., longer illness duration), and characteristics of antipsychotic treatment (e.g., multiple or high antipsychotic doses). METHODS Within an Asian research consortium focusing on pharmaco-epidemiological factors in schizophrenia, we evaluated rates of MS coprescription, including high doses (>1000 mg/day lithium-equivalents) and clinical correlates. RESULTS Among 3557 subjects diagnosed with schizophrenia in 14 Asian countries, MSs were coprescribed with antipsychotics in 13.6% (n = 485) of the sample, with 10.9% (n = 53) on a high dose. Adjunctive MS treatment was associated (all p < 0.005) with demographic (female sex and younger age), setting (country and hospitalization), illness (longer duration, more hospitalizations, non-remission of illness, behavioral disorganization, aggression, affective symptoms, and social-occupational dysfunction), and treatment-related factors (higher antipsychotic dose, multiple antipsychotics, higher body mass index, and greater sedation). Patients given high doses of MSs had a less favorable illness course, more behavioral disorganization, poorer functioning, and higher antipsychotic doses. CONCLUSIONS Schizophrenia patients receiving adjunctive MS treatment in Asian psychiatric centers are more severely ill and less responsive to simpler treatment regimens.
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Affiliation(s)
| | | | - Yan-Ling He
- Department of Psychiatric Epidemiology, Shanghai Mental Health Center, Shanghai, China
| | - Tian-Mei Si
- Institute of Mental Health, Peking University, Beijing, China
| | | | - Yu-Tao Xiang
- Faculty of Health Sciences, University of Macau, Macau, China
| | - Takahiro A Kato
- Department of Neuropsychiatry, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Shigenobu Kanba
- Department of Neuropsychiatry, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | | | - Min-Soo Lee
- Department of Psychiatry, College of Medicine, Korea University, Seoul, South Korea
| | - Seon-Cheol Park
- Department of Psychiatry, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Yong-Chon Park
- Department of Psychiatry, Hanyang University, Seoul, South Korea
| | - Mian-Yoon Chong
- Department of Psychiatry, Kaoshiung Chang Gung Memorial Hospital and Chang Gung University School of Medicine, Kaohsiung, Taiwan
| | - Shih-Ku Lin
- Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Shu-Yu Yang
- Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Adarsh Tripathi
- Department of Psychiatry, King George's Medical University, Lucknow, India
| | - Ajit Avasthi
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Pichet Udomratn
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Kok Yoon Chee
- Department of Psychiatry & Mental Health, Tunku Abdul Rahman Institute of Neurosciences, Kuala Lumpur, Malaysia
| | - Andi J Tanra
- Department of Psychiatry, Hasanuddin University Faculty of Medicine, Makassar, Indonesia
| | | | - Afzal Javed
- Pakistan Psychiatric Research Center, Fountain House, Lahore, Pakistan
| | | | - Dulshika Waas
- Department of Psychiatry, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - Wing Aung Myint
- Mental Health Society, Myanmar Medical Association, Yangon, Myanmar
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | | | | | - Chay-Hoon Tan
- Department of Pharmacology, National University Hospital, Singapore, Singapore
| | - Ross J Baldessarini
- International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, Massachusetts, USA
| | - Kang Sim
- Institute of Mental Health, Singapore, Singapore
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Wagner E, Oviedo-Salcedo T, Pelzer N, Strube W, Maurus I, Gutwinski S, Schreiter S, Kleymann P, Morgenroth CL, Okhuijsen-Pfeifer C, Luykx JJ, Falkai P, Schneider-Axmann T, Hasan A. Effects of Smoking Status on Remission and Metabolic and Cognitive Outcomes in Schizophrenia Patients Treated with Clozapine. PHARMACOPSYCHIATRY 2020; 53:273-283. [PMID: 32757178 DOI: 10.1055/a-1208-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Even though clozapine is the recommended last-resort antipsychotic, many patients fail to respond and show treatment-refractory psychotic symptoms. Smoking has been suggested as a possible risk factor for poor clozapine response, hampering remission and negatively impacting somatic outcomes. METHODS Our aim was to test whether smoking status is associated with remission rates and other symptomatic and somatic outcomes. We therefore assessed remission rates according to The Remission in Schizophrenia Working Group (RSWG) criteria, and metabolic and cognitive outcomes among patients with schizophrenia-spectrum disorders treated with clozapine for at least 6 months. For analyses, we grouped our cohort into 3 groups according to clozapine treatment duration (6 months, 2 years, 5 years). RESULTS One hundred five patients were included in our analyses and grouped according to their clozapine treatment duration. In the 6-months analyses, patients who smoked were significantly more likely to be younger of age (p=0.002) despite on average shorter duration of clozapine treatment (p=0.041) and significantly more likely to be treated with mood-stabilizing co-medication (p=0.030) compared to nonsmokers. Remission rates (p=0.490), as well as a set of metabolic and cognitive variables did not differ between the 2 groups. A related pattern could be observed for the 2- and 5-years analyses. CONCLUSIONS Smoking behavior among clozapine-treated schizophrenia patients might delineate a cohort with an earlier onset of the disease. Nevertheless, most findings comparing disease-specific and clinical outcomes among smokers and nonsmokers were negative. Further research is needed to identify strategies to overcome insufficient remission rates in this patient group.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Tatiana Oviedo-Salcedo
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Nicola Pelzer
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Strube
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Isabel Maurus
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | - Stefanie Schreiter
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | - Phillip Kleymann
- Department of Psychiatry and Psychotherapy, Charité Berlin, Berlin, Germany
| | | | - Cynthia Okhuijsen-Pfeifer
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jurjen J Luykx
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Translational Neuroscience, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,GGNet Mental Health, second opinion outpatient clinic
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Schneider-Axmann
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics of the University Augsburg, Bezirkskrankenhaus Augsburg, University of Augsburg, Augsburg, Germany
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12
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Lee DK, Lee H, Park K, Joh E, Kim CE, Ryu S. Common gray and white matter abnormalities in schizophrenia and bipolar disorder. PLoS One 2020; 15:e0232826. [PMID: 32379845 PMCID: PMC7205291 DOI: 10.1371/journal.pone.0232826] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 04/22/2020] [Indexed: 12/15/2022] Open
Abstract
This study aimed to investigate abnormalities in the gray matter and white matter (GM and WM, respectively) that are shared between schizophrenia (SZ) and bipolar disorder (BD). We used 3T-magnetic resonance imaging to examine patients with SZ, BD, or healthy control (HC) subjects (aged 20–50 years, N = 65 in each group). We generated modulated GM maps through voxel-based morphometry (VBM) for T1-weighted images and skeletonized fractional anisotropy, mean diffusion, and radial diffusivity maps through tract-based special statistics (TBSS) methods for diffusion tensor imaging (DTI) data. These data were analyzed using a generalized linear model with pairwise comparisons between groups with a family-wise error corrected P < 0.017. The VBM analysis revealed widespread decreases in GM volume in SZ compared to HC, but patients with BD showed GM volume deficits limited to the right thalamus and left insular lobe. The TBSS analysis showed alterations of DTI parameters in widespread WM tracts both in SZ and BD patients compared to HC. The two disorders had WM alterations in the corpus callosum, superior longitudinal fasciculus, internal capsule, external capsule, posterior thalamic radiation, and fornix. However, we observed no differences in GM volume or WM integrity between SZ and BD. The study results suggest that GM volume deficits in the thalamus and insular lobe along with widespread disruptions of WM integrity might be the common neural mechanisms underlying the pathologies of SZ and BD.
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Affiliation(s)
- Dong-Kyun Lee
- Department of Mental Health Research, National Center for Mental Health, Seoul, Republic of Korea
| | - Hyeongrae Lee
- Department of Mental Health Research, National Center for Mental Health, Seoul, Republic of Korea
| | - Kyeongwoo Park
- Department of Clinical Psychology, National Center for Mental Health, Seoul, Republic of Korea
| | - Euwon Joh
- Department of Mental Health Research, National Center for Mental Health, Seoul, Republic of Korea
| | - Chul-Eung Kim
- Mental Health Research Institute, National Center for Mental Health, Seoul, Republic of Korea
| | - Seunghyong Ryu
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
- * E-mail:
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The Effect of Valproic Acid on Olanzapine Serum Concentration: A Study Including 2791 Patients Treated With Olanzapine Tablets or Long-Acting Injections. J Clin Psychopharmacol 2020; 39:561-566. [PMID: 31688390 DOI: 10.1097/jcp.0000000000001126] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The combination of olanzapine and valproic acid (VPA) is regularly prescribed in the treatment of bipolar or schizoaffective disorders. The VPA has been shown to reduce olanzapine concentration, but the mechanism behind this interaction remains unknown. We aimed to investigate the effect of VPA on olanzapine concentration during oral versus long-acting injectable (LAI) formulation in a real-life setting. METHODS From a therapeutic drug monitoring service, prescribed doses and serum concentrations from 2791 olanzapine-treated patients (9433 measurements) were included. RESULTS The number of patients on olanzapine-LAI treatment was 328, whereas 2463 were using oral olanzapine. The frequency of patients comedicated with VPA was 9.4% for olanzapine tablets and 5.8% for olanzapine-LAI. The VPA had no effect on olanzapine dose-adjusted concentrations in LAI users (1.6 vs 1.7 [ng/mL]/[mg/d]; P = 0.38), whereas in the oral group the dose-adjusted olanzapine concentration was lower in VPA users (2.2 vs 2.7 [ng/mL]/[mg/d]; P < 0.001). For smokers in the oral olanzapine group using VPA, 8.7% of the measurements were in the subtherapeutic range (<10 ng/mL) compared with 6.0% in nonusers (P = 0.003). IMPLICATIONS These findings show that the VPA-olanzapine interaction involves a presystemic mechanism and is therefore restricted to oral olanzapine treatment. For oral treatment of olanzapine, comedication with VPA implies a risk of insufficient effect, which may be of clinical relevance in smokers in particular. Thus, it is important to be aware of the interaction potential with VPA during oral olanzapine use, whereas for LAI-treated patients fewer precautions are required from a pharmacokinetic point of view.
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Prescription of Valproate-Containing Medicines in Women of Childbearing Potential who have Psychiatric Disorders: Is It Worth the Risk? CNS Drugs 2020; 34:163-169. [PMID: 31845215 DOI: 10.1007/s40263-019-00694-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Valproate-containing medicines have long been used in psychiatric practice, principally in the treatment of acute manic episodes, as augmentation agents in the treatment of bipolar and unipolar depressive episodes, and in the prophylaxis of bipolar affective disorder. Many babies are still being born with the adverse consequences of valproate exposure in utero, which include congenital malformations, neurodevelopmental delay, and increased risks of attention-deficit hyperactivity disorder and autism spectrum disorder. Previous measures designed to better inform women about the risks associated with valproate have not been sufficiently effective. This review highlights recent recommendations from influential regulatory and advisory bodies, summarises the relative efficacy and tolerability of valproate preparations in the psychiatric conditions for which they have often been prescribed, and offers practical guidance for the withdrawal and replacement of valproate-containing medicines in women with psychiatric disorders.
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Association between electroencephalogram changes and plasma clozapine levels in clozapine-treated patients. Int Clin Psychopharmacol 2019; 34:131-137. [PMID: 30855515 DOI: 10.1097/yic.0000000000000255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This retrospective observational study was performed to investigate electroencephalogram abnormalities in clozapine-treated patients with refractory schizophrenia or bipolar disorder. The electroencephalogram and plasma clozapine and norclozapine levels in 71 patients were measured on the same day. Fifty-nine patients (85.9%) had a diagnosis of schizophrenia, and 12 patients (14.1%) had a diagnosis of bipolar disorder. The mean daily clozapine dose was 242.9 ± 105.5 mg (range 25-500 mg), and the mean plasma clozapine and norclozapine levels were 429.4 ± 264.1 and 197.8 ± 132.6 ng/ml, respectively. Twenty-five patients (35.2%) were taking valproate in combination with clozapine. electroencephalogram abnormalities were found in 51 (71.8%) patients. No patient reported clinical seizures. Plasma clozapine level was significantly associated with electroencephalogram abnormalities and was identified as a significant predictor of electroencephalogram abnormalities in a logistic regression analysis. The plasma norclozapine levels of patients taking both clozapine and valproic acid were significantly lower than those of patients treated with clozapine alone. These results demonstrate that electroencephalogram abnormalities are closely correlated with plasma clozapine levels. Valproate reduced plasma norclozapine levels. Simultaneous monitoring of electroencephalogram and plasma clozapine levels was useful for adjusting clozapine doses, improving clinical efficacy, and preventing the side effects of clozapine treatment.
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Abstract
PURPOSE Little is known regarding the trend of polypharmacy in Asia. We used data from 5 Asian countries to examine the patterns of antidepressant (AD) prescription and trends of psychotropic polypharmacy over time. METHODS We used the cross-sectional, pharmacoepidemiological data from 2004 and 2013 REAP-AD (Research on Asian Psychotropic Prescription Patterns for Antidepressants) to examine the patterns of AD prescriptions in clinical settings in China, Japan, Korea, Singapore, and Taiwan. We compared the trend in polypharmacy (ie, concomitant use of ≥2 classes of psychotropic) among individuals receiving AD prescriptions in 2004 and 2013 using multivariable logistic regression models in different diagnostic categories. RESULTS The proportion of patients with psychotropic polypharmacy decreased from 2004 to 2013 in all 3 diagnostic categories, including mood disorders (adjusted odds ratio [aOR], 0.44 [0.35-0.56]; P < 0.001), anxiety disorders (aOR, 0.58 [0.36-0.94]; P = 0.028), and psychotic disorders (aOR, 0.18 [0.05-0.60]; P = 0.006). Among individuals with AD prescriptions, concomitant use of anxiolytics (including sedative-hypnotics) decreased in patients with mood disorders (aOR, 0.34 [0.27-0.42]; P < 0.001) and anxiety disorders (aOR, 0.43 [0.27-0.67]; P < 0.001). In contrast, concomitant use of antipsychotics in patients with mood disorders increased (aOR, 1.43 [1.15-1.77]; P = 0.001), and concomitant use of mood stabilizers in patients with psychotic disorders also increased (aOR, 3.49 [1.50-8.14]; P = 0.004). CONCLUSIONS This is the first study examining trends in psychotropic polypharmacy in East Asia. We found a generally decreasing trend of psychotropic polypharmacy in contrast to the increasing trend reported from Western countries. These findings could offer significant implications for health system reform or policy making.
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Leahy LG. Off-Label Prescribing and Polypharmacy: Minimizing the Risks. J Psychosoc Nurs Ment Health Serv 2017; 55:17-22. [PMID: 28218925 DOI: 10.3928/02793695-20170210-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Off-label prescribing and polypharmacy are commonplace in today's health care environment. Patients are treated with multiple medications obtained through multiple providers, and all too frequently, there is no collaboration amongst professionals. Nurses can address these issues by educating themselves and their patients regarding medication indications and uses, side effects, risks, and benefits. By exploring a patient's medication reconciliation, including over-the-counter agents, and identifying the U.S. Food and Drug Administration-approved indications, as well as potential off-label uses and overlapping side effects of the medications prescribed, nurses can facilitate collaboration among prescribers to reduce polypharmacy, minimize medication side effects, and alleviate drug-drug interactions, while improving patient outcomes and quality of life. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 17-22.].
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Metabolic Syndrome in South African Patients with Severe Mental Illness: Prevalence and Associated Risk Factors. PLoS One 2016; 11:e0149209. [PMID: 26882230 PMCID: PMC4755575 DOI: 10.1371/journal.pone.0149209] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/28/2016] [Indexed: 01/16/2023] Open
Abstract
Background There is a surge of cardiovascular disease (CVD) in Africa. CVD is the leading cause of mortality among patients with severe mental illness (SMI) in developed countries, with little evidence from the African context. Objective To determine the prevalence and risk factors for MetS among South African patients with SMI. Method In a cross sectional study, individuals with SMI treated with antipsychotics and a control group without a mental illness, matched for age, gender and ethnicity were evaluated for MetS using the 2009 Joint Interim statement (JIS) criteria. Results Of the 276 study group subjects, 65.9% were male, 84.1% black African, 9.1% white, 5.4% of Indian descent and 1.5% coloured (mixed race) with a mean age of 34.7 years (±12.5). Schizophrenia was the most common diagnosis (73.2%) and 40% were taking first generation antipsychotics. The prevalence of MetS was 23.2% (M: 15.4%, F: 38.3%) in the study group and 19.9% (M: 11.9%, F: 36.3%) in the control group (p = 0.4). MetS prevalence was significantly higher in study subjects over 55 years compared to controls (p = 0.03). Increased waist circumference (p< 0.001) and low high density lipoprotein (HDL) cholesterol (p = 0.003) were significantly more prevalent in study subjects compared to controls. In study subjects, risk factors associated with MetS included age (OR: 1.09, 95% CI 1.06–1.12, p < 0.001), female gender (OR: 2.19, 95% CI 1.06–4.55, p = 0.035) and Indian descent (OR: 5.84, 95% CI 1.66–20.52, p = 0.006) but not class of antipsychotic (p = 0.26). Conclusion The overall MetS prevalence was not increased in patients with SMI compared to controls; however, the higher prevalence of the individual components (HDL cholesterol and waist circumference) suggests an increased risk for CVD, especially in patients over 55 years.
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Tseng PT, Chen YW, Chung W, Tu KY, Wang HY, Wu CK, Lin PY. Significant Effect of Valproate Augmentation Therapy in Patients With Schizophrenia: A Meta-analysis Study. Medicine (Baltimore) 2016; 95:e2475. [PMID: 26825886 PMCID: PMC5291556 DOI: 10.1097/md.0000000000002475] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 12/13/2015] [Accepted: 12/16/2015] [Indexed: 11/25/2022] Open
Abstract
Valproate is an anticonvulsant, which is also widely used for treating psychiatric disorders. Some clinical trials have demonstrated benefits of valproate augmentation therapy in schizophrenia. Previous meta-analysis showed inconsistent findings because of limited literature at that time. The aim of this study is to update the newer published data by conducting a meta-analysis of clinical efficacy of valproate augmentation therapy in patients with schizophrenia or schizoaffective disorder. Data sources include electronic research through platform of PubMed. Study eligibility criteria, participants, and interventions were as follows: the inclusion criteria included articles discussing comparisons of the treatment effect in schizophrenic patients treated with antipsychotic augmented with valproate and antipsychotics with/without placebo; articles on clinical trials in humans. The exclusion criteria were case reports or series and nonclinical trials. We compared the effect between antipsychotic treatment with valproate augmentation and antipsychotic monotherapy. Data from clinical trials were pooled by random-effects model, and possible confounding variables were examined through meta-regression and subgroup analysis. Data from 11 articles including 889 patients were included into current meta-analysis. We found patients treated with antipsychotics with valproate augmentation showed significantly more improvement in total psychopathology than those treated with antipsychotics only (P = 0.02). Results from open trials, but not from randomized controlled trials (P = 0.20), showed significant improvement (P = 0.01). In addition, the significance only persisted in the studies conducted with a shorter treatment duration (P < 0.001) rather than longer treatment duration (P = 0.23). There is no difference in the dropout rate between valproate augmentation and antipsychotic treatment only (P = 0.14). We could not perform a detailed meta-analysis for every category of antipsychotics, long-term effect, and safety profiles of valproate augmentation therapy in maintenance treatment, safety in pregnant patients, and subtype of schizophrenia. Our meta-analysis highlights the significantly better treatment effect with valproate augmentation therapy in patients with schizophrenia or schizoaffective disorder, and provides important evidence for supporting the practice of valproate augmentation therapy in these patients.
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Affiliation(s)
- Ping-Tao Tseng
- From the Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Taiwan (P-TT, WC, K-YT, H-YW, C-KW); Department of Neurology, E-Da Hospital, Kaohsiung, Taiwan (Y-WC); Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (P-YL); and Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan (P-YL)
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Charlotte M, Schwartz E, Slade E, Medoff D, Li L, Dixon L, Kilbourne AM, Kreyenbuhl J. Gender differences in mood stabilizer medications prescribed to Veterans with serious mental illness. J Affect Disord 2015; 188:112-7. [PMID: 26361066 PMCID: PMC5909958 DOI: 10.1016/j.jad.2015.08.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/13/2015] [Accepted: 08/28/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Mood stabilizer medications (MSMs) can induce significant weight gain and other metabolic side effects. Research suggests that women are more susceptible to psychotropic medication-induced metabolic side effects than men. We examined gender differences in the likelihood of receiving an MSM with a lower liability for weight gain using data from the U.S. Department of Veterans Affairs (VA) healthcare system. METHODS We identified 3823 VA patients with a schizophrenia or bipolar disorder diagnosis who initiated treatment with a MSM between 10/2006 and 9/2011. We used multivariable logistic regression analysis to examine gender differences in the likelihood of incident prescription of MSMs with low versus medium/high metabolic risk, adjusting for fiscal year of prescribing and demographic, mental health, and physical health characteristics. RESULTS Overall, 47% of women were prescribed a low metabolic risk MSM compared to 26% of men (p<0.0001). In multivariable analysis, women were 2.19 times as likely as men to be prescribed a low metabolic risk MSM (95% CI: 1.84-2.60, p<0.0001). Several demographic and clinical covariates were also independently related to prescribing of MSMs by level of metabolic risk. LIMITATIONS This study used retrospective administrative data collected from a VA healthcare system database, which does not allow us to understand the context in which MSM treatment decisions were made. CONCLUSIONS Prescribing choices for MSMs by VA mental health prescribers and female Veterans may reflect a growing awareness of the potential adverse health consequences of these treatments in women.
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Affiliation(s)
- Melanie Charlotte
- University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore, MD, United States.
| | - Elana Schwartz
- VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore MD
| | - Eric Slade
- VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore MD and University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore MD
| | - Deborah Medoff
- VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore MD and University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore MD
| | - Lan Li
- University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore MD
| | - Lisa Dixon
- Center for Practice Innovations, New York State Psychiatric Institute, Department of Psychiatry, Columbia University, New York, NY
| | - Amy M. Kilbourne
- Quality Enhancement Research Initiative, VA Health Services Research and Development (HSR&D Program), Washington DC and Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Julie Kreyenbuhl
- VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore MD and University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore MD
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Szyf M. Prospects for the development of epigenetic drugs for CNS conditions. Nat Rev Drug Discov 2015; 14:461-74. [DOI: 10.1038/nrd4580] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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