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Verdoux H, Quiles C, de Leon J. Optimizing antidepressant and clozapine co-prescription in clinical practice: A systematic review and expert recommendations. Schizophr Res 2024; 268:243-251. [PMID: 37852856 DOI: 10.1016/j.schres.2023.10.003] [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: 05/28/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES To synthesize the information relevant for clinical practice on clozapine-antidepressant co-prescription concerning pharmacokinetic drug-drug interactions (DDI), adverse drug reactions (ADRs) associated with the co-prescription, antidepressant add-on for clozapine-resistant symptoms and antidepressant add-on for clozapine-induced ADRs. METHODS Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through April 2023. Data were synthesized narratively. RESULTS ADRs are most often induced by the co-prescription of antidepressants that inhibit CYP enzymes (fluvoxamine, fluoxetine, paroxetine). Fluvoxamine add-on is hazardous because of its potent inhibition of clozapine metabolism and has few indications (lowering daily number of clozapine tablets, reducing norclozapine-induced metabolic disturbances and other dose-dependent clozapine-induced ADRs). ADR frequency may be reduced by therapeutic drug monitoring and knowledge of other factors impacting clozapine metabolism (pneumonia, inflammation, smoking, etc.). Improvement of negative symptoms is the most documented beneficial effect of antidepressant add-on for clozapine-resistant psychotic symptoms. The add-on antidepressant should be chosen according to its safety profile regarding DDI with clozapine: antidepressants inhibiting clozapine metabolism or increasing the anticholinergic load should be avoided. Other indications of antidepressant add-on (affective or obsessive compulsive symptoms, sialorrhea, and enuresis) are poorly documented. CONCLUSION Antidepressant add-on to clozapine is associated with potential benefits in clozapine users as this strategy may contribute to reduce the burden of clozapine-resistant symptoms or of clozapine-induced ADRs. Further studies are needed to determine whether antidepressant add-on can reduce the risk of clozapine discontinuation.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.
| | - Clélia Quiles
- Centre Hospitalier Charles Perrens, F-33000 Bordeaux, France
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, Psychiatry and Neurosciences Research Group (CTS-549), USA; Institute of Neurosciences, University of Granada, Granada, Spain; Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Patel HP, Desai PH, Patel RV, Lodha SN, Gore AH, Patil PO, Desai BV, Desai DT, Vyas BA, Willcox MDP, Maulvi FA. Clozapine-laden carbon dots delivered to the brain via an intranasal pathway: Synthesis, characterization, ex vivo, and in vivo studies. Colloids Surf B Biointerfaces 2024; 237:113862. [PMID: 38518556 DOI: 10.1016/j.colsurfb.2024.113862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
Abstract
Clozapine, which is widely used to treat schizophrenia, shows low bioavailability due to poor solubility and high first-pass metabolism. The study aimed to design clozapine-loaded carbon dots (CDs) to enhance availability of the clozapine to the brain via intranasal pathway. The CDs were synthesized by pyrolysis of citric acid and urea at 200 °C by hydrothermal technique and characterized by photoluminescence, transmission electron microscopy (TEM), X-ray Photoelectron Spectrometer (XPS), and Fourier transform infrared spectrum (FTIR). The optimized clozapine-loaded CDs (CLZ-CDs-1:3-200) showed a quasi-spherical shape (9-12 nm) with stable blue fluorescence. The CDs showed high drug solubilization capacity (1.5 mg drug in 1 mg/ml CDs) with strong electrostatic interaction with clozapine (drug loading efficiency = 94.74%). The ex vivo release study performed using nasal goat mucosa showed sustained release of clozapine (43.89%) from CLZ-CDs-1:3-200 for 30 h. The ciliotoxicity study (histopathology) confirmed no toxicity to the nasal mucosal tissues using CDs. In the rat model (in vivo pharmacokinetic study), when CDs were administrated by the intranasal route, a significantly higher concentration of clozapine in the brain tissue (Cmax = 58.07 ± 5.36 μg/g and AUCt (µg/h*g) = 105.76 ± 12.31) was noted within a short time (tmax = 1 h) compared to clozapine suspension administered by intravenous route (Cmax = 20.99 ± 3.91 μg/g, AUC t (µg/h*g) = 56.89 ± 12.31, and tmax = 4 h). The high value of drug targeting efficiency (DTE, 486%) index and direct transport percentage (DTP, 58%) indicates the direct entry of clozapine-CDs in the brain via the olfactory route. In conclusion, designed CDs demonstrated a promising dosage form for targeted nose-to-brain delivery of clozapine for the effective treatment of schizophrenia.
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Affiliation(s)
- Hetal P Patel
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India.
| | - Priya H Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | | | - Sandesh N Lodha
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Anil H Gore
- Tarsadia Institute of Chemical Science, Uka Tarsadia University, Maliba Campus, Surat 394350, India
| | - Pravin O Patil
- Department of Pharmaceutical Chemistry, H. R. Patel Institute of Pharmaceutical Education and Research, Shirpur 425405, India
| | - Bhargavi V Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Ditixa T Desai
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Bhavin A Vyas
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India
| | - Mark D P Willcox
- School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Furqan A Maulvi
- Department of Pharmaceutics, Maliba Pharmacy College, Uka Tarsadia University, Surat 394350, India; School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales 2052, Australia.
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Dong Y, Zhu M, Li Y, Liu N, Wang X, Yang B, Li S, Li Z. Association of cytokines levels, psychopathology and cognition among CR-TRS patients with metabolic syndrome. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:47. [PMID: 38627438 PMCID: PMC11021544 DOI: 10.1038/s41537-024-00469-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
Clozapine-resistant treatment-refractory schizophrenia (CR-TRS) patients face significant clinical challenges. While links between metabolic syndrome (MetS) and inflammatory cytokines in schizophrenia have been established, the relationship between MetS and cytokine levels in CR-TRS patients remains unexplored. This study aimed to investigate the relationship between cytokines levels, clinical symptoms and cognitive impairments in CR-TRS patients, both with and without MetS. The study included 69 CR-TRS patients (31with MetS and 38 without MetS) and 84 healthy controls. The levels of IL-2, IL-6, TNF-α and routine biochemical parameters were measured. Psychopathological symptoms and cognitive function were assessed using the Positive and Negative Syndrome Scale (PANSS) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), respectively. We found that CR-TRS patients with MetS displayed lower cognitive function scores compared to those without MetS, even when accounting for potential confounders. TNF-α levels were significantly higher in CRTRS patients with MetS compared to those without MetS, demonstrating substantial pathophysiological potential for CR-TRS patients with MetS via receiver operating characteristic curve (ROC). In CR-TRS patients without MetS, IL-2 independently contributed to the total score and general psychopathology subscore of PANSS. Additionally, IL-6 exhibited an independent contribution to the positive subscore of PANSS. In terms of cognition function, IL-6 independently contributed to the delayed memory of RBANS in CR-TRS patients without MetS. TNF-α could potentially serve as a predictive marker for distinguishing between CR-TRS patients with/without MetS, while IL-2 and IL-6 could independently contribute to psychopathological symptoms or cognitive function in CRTRS patients without MetS. Our study provided insights into the potential interplay between cytokines, clinical symptoms and cognitive impairments in CR-TRS patients with/without MetS.
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Affiliation(s)
- Yeqing Dong
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Minghuan Zhu
- Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, China
| | - Yanzhe Li
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Nannan Liu
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Xinxu Wang
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China
| | - Bing Yang
- Department of Cell Biology, College of Basic Medical Sciences, Tianjin Medical University, Tianjin, 300070, China
| | - Shen Li
- Institute of Mental Health, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China.
- Psychoneuromodulation Center, Tianjin Anding Hospital, Mental Health Center of Tianjin Medical University, Tianjin, 300222, China.
| | - Zezhi Li
- Department of Nutritional and Metabolic Psychiatry, the Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, 510370, China.
- Guangdong Engineering Technology Research Center for Translational Medicine of Mental Disorders, Guangzhou, China.
- Key Laboratory of Neurogenetics and Channelopathies of Guangdong Province and the Ministry of Education of China, Guangzhou Medical University, Guangzhou, China.
- Jiangsu Key Laboratory of Neurodegeneration, Nanjing Medical University, Nanjing, China.
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Lin TC, Lin CH. Schizophrenia Patients Discharged on Clozapine Plus Long-Acting Injectable Antipsychotics From a Public Psychiatric Hospital in Taiwan, 2006-2021. Int J Neuropsychopharmacol 2023; 26:808-816. [PMID: 37616565 PMCID: PMC10674076 DOI: 10.1093/ijnp/pyad053] [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: 06/09/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Some schizophrenia patients treated with clozapine experience an inadequate response and adherence problems. The purpose of this study was to compare time to rehospitalization within 6 months in schizophrenia patients discharged on 3 clozapine regimens. Additionally, the temporal trend of prescription rate in each group was also explored. METHODS Schizophrenia patients discharged from the study hospital from January 1, 2006, to December 31, 2021, (n = 3271) were included in the analysis. The type of clozapine prescribed at discharge was divided into 3 groups: clozapine plus long-acting injectable antipsychotics (clozapine + LAIs), clozapine plus other oral antipsychotics (clozapine + OAPs), and clozapine monotherapy. Survival analysis was used to compare time to rehospitalization within 6 months after discharge among the 3 groups. The temporal trend in the prescription rate of each group was analyzed using the Cochran-Armitage Trend test. RESULTS Patients discharged on clozapine + LAIs had a significantly longer time to rehospitalization than those on clozapine + OAPs or clozapine monotherapy. The prescription rates of clozapine + LAIs and clozapine + OAPs significantly increased over time, whereas the prescription rates of clozapine monotherapy significantly decreased. CONCLUSIONS Compared with the clozapine + OAPs group, the clozapine + LAIs group had a lower risk of rehospitalization and a lower dose of clozapine prescribed. Therefore, if a second antipsychotic is required for patients who are taking clozapine alone, LAIs should be considered earlier.
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Affiliation(s)
- Ta-Chun Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
- Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
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Chakrabarti S. Clozapine resistant schizophrenia: Newer avenues of management. World J Psychiatry 2021; 11:429-448. [PMID: 34513606 PMCID: PMC8394694 DOI: 10.5498/wjp.v11.i8.429] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.
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Affiliation(s)
- Subho Chakrabarti
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Lin CH, Chan HY, Hsu CC, Chen FC. Temporal trends in clozapine use at time of discharge among people with schizophrenia at two public psychiatric hospitals in Taiwan, 2006-2017. Sci Rep 2020; 10:17984. [PMID: 33093511 PMCID: PMC7581717 DOI: 10.1038/s41598-020-75022-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/29/2020] [Indexed: 12/17/2022] Open
Abstract
Clozapine treatment remains the gold standard for treatment-resistant schizophrenia. This study aimed to describe temporal trends in clozapine use at discharge among patients with schizophrenia at two of the largest public psychiatric hospitals in Taiwan over a twelve-year period. Patients with schizophrenia discharged from the two study hospitals between 2006 and 2017 (n = 24,101) were included in the analysis. Antipsychotic augmentation was defined as concomitant use of a second antipsychotic as augmentation to clozapine treatment. Changes in the rate of clozapine use and antipsychotic augmentation at discharge over time were analyzed using the Cochran-Armitage trend test. Patients discharged on clozapine had significantly longer hospital stays than other patients. The rate of clozapine use at discharge increased from 13.8% to 20.0% over time (Z = 6.88, p < .0001). Concomitant use of anticholinergic medication was more common in patients receiving antipsychotic augmentation than clozapine antipsychotic monotherapy. Among patients discharged on clozapine, the rate of augmentation with a second antipsychotic increased from 19.1% to 36.2% over time (Z = 6.58, p < .0001). Among patients receiving antipsychotic augmentation, use of another second-generation antipsychotic as the augmentation agent grew from 32.6% to 65.5% over time (Z = 8.90, p < .0001). The increase in clozapine use was accompanied by an increase in concomitant use of a second antipsychotic as augmentation during the study period. Further studies are warranted to clarify the risk/benefit of this augmentation strategy. Clozapine may still be underutilized, and educational programs are needed to promote clinical use of clozapine.
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Affiliation(s)
- Ching-Hua Lin
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
- Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Yu Chan
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Long-Show Street, Taoyuan City, 33058, Taiwan.
- Department of Psychiatry, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chun-Chi Hsu
- Department of General Psychiatry, Taoyuan Psychiatric Center, No. 71, Long-Show Street, Taoyuan City, 33058, Taiwan
| | - Feng-Chua Chen
- Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
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Edinoff A, Ruoff MT, Ghaffar YT, Rezayev A, Jani D, Kaye AM, Cornett EM, Kaye AD, Viswanath O, Urits I. Cariprazine to Treat Schizophrenia and Bipolar Disorder in Adults. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:83-117. [PMID: 33012874 PMCID: PMC7511151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Purpose of Review Antipsychotics are the standard of care when it comes to the treatment of Schizophrenia, and they are often used in Bipolar as well. Their use can come with adverse effects such as extrapyramidal movements, metabolic complications as well as cardiovascular complications such as a prolonged QT interval. Treatment for these side effects ranges from the treatment of the complications up to the cessation of the medication, which could come at the expense of the user's stability. Both schizophrenia and bipolar disorder have an increased risk of suicide and increased morbidity. The purpose of this review presents the background, evidence, and indications for the use of the new second-generation antipsychotic Cariprazine, which has a primary function as a D3 and D2 partial agonist, with higher selectivity for the D3 receptor type. Recent Findings Schizophrenia is currently teated by dopamine antagonists and/or 5HT modulators, each with their own set of side effects. Bipolar disorder is mostly treated with mood stabilizers. Studies looking at the efficacy and safety of cariprazine have shown in two phase II trials and phase III trials the decrease in PANSS scores in schizophrenia. The most common adverse effects were akathisia, insomnia, constipation, and other extrapyramidal side effects. A unique side effect of Cariprazine caused bilateral cataract and cystic degeneration of the retina in the dog following daily oral administration for 13 weeks and/or 1 year and retinal degeneration in rats following daily oral administration for 2 years. Another study showed that cariprazine had significant efficacy in preventing relapse in patients with schizophrenia. The time to the loss of sustained remission was significantly longer (P = .0020) for cariprazine compared to placebo (hazard ratio = 0.51) during the double-blind treatment. 60.5% of patients treated with cariprazine and 34.9% of patients treated with placebo sustained remission through the final visit (odds ratio [OR] = 2.85; P = .0012; number needed to treat [NNT] = 4. Another Phase IIIb study looked at negative symptoms and used the Positive and Negative Syndrome Scale Factor Score for Negative Symptoms (PANSS-FSNS), and it found that the use of cariprazine, from baseline to week 26, led to a greater least-squares mean change in PANSS-FSNS than did risperidone. Another study looked at the quality of life years with the treatment of cariprazine and showed those treated with cariprazine had superior quality of life compared to those treated with risperidone. In terms of bipolar disorder, it showed a decrease in depressive symptoms as measured by decreased MADRs scores with a dose of 3.0mg/day. A phase II study looked at the use of cariprazine in mania or mix states and showed cariprazine significantly decreased YMRS scores compared to placebo, least-square mean difference of -6.1 (p < 0.001). The metabolic parameters demonstrated comparable changes except for fasting glucose in which cariprazine was associated with elevations in glucose levels compared to placebo (p < 0.05). Another phase III study showed significant differences in YMRS total score mean change between cariprazine versus placebo-treated group. Changes in metabolic profiles in all mentioned studies were minimal. Summary Cariprazine, in recent studies, has shown some promise in being able to treat both bipolar disorder in manic, depressed, and mixed states as well as schizophrenia. Side effects noted as adverse events in these studies are similar in profile to the medications that were developed in the past. With better relapse prevention, cariprazine could be a reasonable alternative clozapine.
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Affiliation(s)
- Amber Edinoff
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Miriam T Ruoff
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Yahya T Ghaffar
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Arthur Rezayev
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Devanshi Jani
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Adam M Kaye
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Elyse M Cornett
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Alan D Kaye
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Omar Viswanath
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Ivan Urits
- Edinoff, MD, Jani, MD, Louisiana State University Health Science Center Shreveport, Department of Psychiatry, and Behavioral Medicine. Ruoff, BA, Ghaffar, BS, Rezayev, BS, Louisiana State University Shreveport School of Medicine. Kaye, Pharm D, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Department of Pharmacy Practice, Stockton, CA. Cornett, PhD, Kaye, MD, PhD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA. Viswanath, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ. Urits, MD, Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
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8
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Li X, Yuan X, Kang Y, Pang L, Liu Y, Zhu Q, Lv L, Huang XF, Song X. A synergistic effect between family intervention and rTMS improves cognitive and negative symptoms in schizophrenia: A randomized controlled trial. J Psychiatr Res 2020; 126:81-91. [PMID: 32428747 DOI: 10.1016/j.jpsychires.2020.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The present study explored an efficient new therapy that combined repetitive transcranial magnetic stimulation (rTMS) and family intervention in addition to risperidone to improve schizophrenia. METHODS A randomized controlled trial (January 2016-September 2017) involving 200 patients, of which 188 patients completed the 12-week study, and 50 controls were conducted in the research. The patients were randomly assigned to 12 weeks of treatment with risperidone alone (risperidone group), rTMS and risperidone (rTMS group), family intervention and risperidone (family intervention group), rTMS and risperidone plus family intervention (combined group). MATRICS Consensus Cognitive Battery (MCCB) and the Positive and Negative Symptoms Scale (PANSS) were used to evaluate treatment efficacy. Repeated measures analysis of variance (RMANOVA) were performed to evaluate different treatment efficacy between four groups after 12 weeks of treatment. RESULTS (1) There were no significant differences in sex, age, education, cognitive function, or PANSS scores between the four groups at baseline (p's > 0.05). (2) There was a significant decrease in the PANSS scores and an increase in the MCCB scores after 12 weeks of treatment in all groups (time effect p's < 0.001). (3) The improvements in positive symptoms and negative symptoms were more obvious in the combined group than in other groups (p's < 0.05). (4) The combined group showed the superior effect in cognition function after 12 weeks. (5) And, interestingly, a remarkable synergistic effect between rTMS and family intervention therapy was observed. CONCLUSION There was a synergistic effect between rTMS and the family intervention as an effective combined therapy in improving schizophrenia. This study is registered with Chictr.org, number ChiCTR1900024422 (http://www.chictr.org.cn/edit.aspx?pid=34285&htm=4).
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Affiliation(s)
- Xue Li
- The First Affiliated Hospital/Zhengzhou University, Zhengzhou, China; Biological Psychiatry International Joint Laboratory of Henan, Zhengzhou University, Zhengzhou, China; Henan Psychiatric Transformation Research Key Laboratory, Zhengzhou University, Zhengzhou, China
| | - Xiuxia Yuan
- The First Affiliated Hospital/Zhengzhou University, Zhengzhou, China; Biological Psychiatry International Joint Laboratory of Henan, Zhengzhou University, Zhengzhou, China; Henan Psychiatric Transformation Research Key Laboratory, Zhengzhou University, Zhengzhou, China
| | - Yulin Kang
- Department of Biomedical Engineering, College of Engineering, Peking University, Beijing, China
| | - Lijuan Pang
- The First Affiliated Hospital/Zhengzhou University, Zhengzhou, China; Biological Psychiatry International Joint Laboratory of Henan, Zhengzhou University, Zhengzhou, China; Henan Psychiatric Transformation Research Key Laboratory, Zhengzhou University, Zhengzhou, China
| | - Yafei Liu
- The Supervision Bureau of the Health and Family Planning Commission, Wancheng District, Nanyang City, China
| | - Qiyue Zhu
- The First Affiliated Hospital/Zhengzhou University, Zhengzhou, China; Biological Psychiatry International Joint Laboratory of Henan, Zhengzhou University, Zhengzhou, China; Henan Psychiatric Transformation Research Key Laboratory, Zhengzhou University, Zhengzhou, China
| | - Luxian Lv
- Henan Province Mental Hospital, The Second Affiliated Hospital, Xinxiang Medical University, Xinxiang, China
| | - Xu-Feng Huang
- Illawarra Health and Medical Research Institute and School of Medicine, University of Wollongong, NSW2522, Australia.
| | - Xueqin Song
- The First Affiliated Hospital/Zhengzhou University, Zhengzhou, China; Biological Psychiatry International Joint Laboratory of Henan, Zhengzhou University, Zhengzhou, China; Henan Psychiatric Transformation Research Key Laboratory, Zhengzhou University, Zhengzhou, China.
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9
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De Stefano R, Bruno A, Muscatello MR, Cedro C, Cervino G, Fiorillo L. Fear and anxiety managing methods during dental treatments: a systematic review of recent data. ACTA ACUST UNITED AC 2020; 68:317-331. [PMID: 32052621 DOI: 10.23736/s0026-4970.19.04288-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The management of anxiety and fear of patients experiencing medical treatment is always a major issue. Dentistry is a branch of medicine that is daily in managing these problems, especially in the case of pediatric patients. Odontophobia can be managed in different ways, and the purpose of this study is to eventually review which methods are currently accepted and which are the most effective. EVIDENCE ACQUISITION The literature analysis was conducted on a number of articles, suitably skimmed, after a first research, obtained from the most common scientific databases. The number of works included in the review is 28. EVIDENCE SYNTHESIS From the RCTs evaluated we could highlight that there are different methods in the literature, equally effective and certainly conditioned by the systemic condition of the patient. Another chapter instead turns out to be that linked to the management of the syndromic patient. CONCLUSIONS It is clear that there are different methods and equally different ways to manage our patients in the event of non-cooperation in the case of dental care. In addition to proper management by the clinician, in the literature methods linked to audiovisual distractions, hypnosis or pharmacological methods that produce conscious sedation are effectively reported.
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Affiliation(s)
- Rosa De Stefano
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Maria R Muscatello
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Clemente Cedro
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Gabriele Cervino
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Luca Fiorillo
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy - .,Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, Luigi Vanvitelli University of Campania, Naples, Italy
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10
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Abstract
OBJECTIVES The risk of relapse after a successful acute course of treatment is a clinical challenge in electroconvulsive therapy (ECT) practice, particularly in patients with a history of marked resistance to previous treatments. Research suggests that a gradual decrease of ECT or its long-term continuation might be the best strategy. Notwithstanding, current studies do not address the role of continuation ECT in the truly refractory cases, that is, the clozapine-resistant patients. Our group published a randomized controlled trial of ECT augmentation of clozapine in clozapine-resistant patients with schizophrenia, where the augmentation was vastly superior in efficacy for the acute treatment. The aim of the current study is to evaluate the efficacy of continuation ECT for patients who showed response to the combination of acute ECT and clozapine for treatment-resistant schizophrenia. METHODS Continuation ECT was offered to all patients who completed the acute study and who met response criterion. We followed a tapered schedule of 4 weekly ECT sessions, followed by 4 ECT sessions every 2 weeks and 2 monthly ECT sessions for a total of 10 sessions. RESULTS Patients sustained the gains achieved with the acute course of ECT, and no individual patient presented with clinically relevant worsening of symptoms. Moreover, the long-term use of ECT was not associated with added adverse effects. CONCLUSIONS This is an open pilot study with a small sample size, and results should be interpreted accordingly, but this report offers a relevant starting point for much needed future studies.
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11
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Polese D, Fornaro M, Palermo M, De Luca V, de Bartolomeis A. Treatment-Resistant to Antipsychotics: A Resistance to Everything? Psychotherapy in Treatment-Resistant Schizophrenia and Nonaffective Psychosis: A 25-Year Systematic Review and Exploratory Meta-Analysis. Front Psychiatry 2019; 10:210. [PMID: 31057434 PMCID: PMC6478792 DOI: 10.3389/fpsyt.2019.00210] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background: Roughly 30% of schizophrenia patients fail to respond to at least two antipsychotic trials. Psychosis has been traditionally considered to be poorly sensitive to psychotherapy. Nevertheless, there is increasing evidence that psychological interventions could be considered in treatment-resistant psychosis (TRP). Despite the relevance of the issue and the emerging neurobiological underpinnings, no systematic reviews have been published. Here, we show a systematic review of psychotherapy interventions in TRP patients of the last 25 years. Methods: The MEDLINE/PubMed, ISI WEB of Knowledge, and Scopus databases were inquired from January 1, 1993, to August 1, 2018, for reports documenting augmentation or substitution with psychotherapy for treatment-resistant schizophrenia (TRS) and TRP patients. Quantitative data fetched by Randomized Controlled Trials (RCTs) were pooled for explorative meta-analysis. Results: Forty-two articles have been found. Cognitive behavioral therapy (CBT) was the most frequently recommended psychotherapy intervention for TRS (studies, n = 32, 76.2%), showing efficacy for general psychopathology and positive symptoms as documented by most of the studies, but with uncertain efficacy on negative symptoms. Other interventions showed similar results. The usefulness of group therapy was supported by the obtained evidence. Few studies focused on negative symptoms. Promising results were also reported for resistant early psychosis. Limitations: Measurement and publication bias due to the intrinsic limitations of the appraised original studies. Conclusions: CBT, psychosocial intervention, supportive counseling, psychodynamic psychotherapy, and other psychological interventions can be recommended for clinical practice. More studies are needed, especially for non-CBT interventions and for all psychotherapies on negative symptoms.
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Affiliation(s)
- Daniela Polese
- Treatment Resistant Psychosis Unit and Laboratory of Molecular and Translational Psychiatry, Section of Psychiatry, University School of Medicine of Naples “Federico II”, Naples, Italy
- Department of Neuroscience, Psychiatric Unit, Sant’Andrea University Hospital, “Sapienza” University of Rome, Rome, Italy
| | - Michele Fornaro
- Treatment Resistant Psychosis Unit and Laboratory of Molecular and Translational Psychiatry, Section of Psychiatry, University School of Medicine of Naples “Federico II”, Naples, Italy
| | - Mario Palermo
- Treatment Resistant Psychosis Unit and Laboratory of Molecular and Translational Psychiatry, Section of Psychiatry, University School of Medicine of Naples “Federico II”, Naples, Italy
| | - Vincenzo De Luca
- Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Andrea de Bartolomeis
- Treatment Resistant Psychosis Unit and Laboratory of Molecular and Translational Psychiatry, Section of Psychiatry, University School of Medicine of Naples “Federico II”, Naples, Italy
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12
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Wagner E, Löhrs L, Siskind D, Honer WG, Falkai P, Hasan A. Clozapine augmentation strategies - a systematic meta-review of available evidence. Treatment options for clozapine resistance. J Psychopharmacol 2019; 33:423-435. [PMID: 30696332 DOI: 10.1177/0269881118822171] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Treatment options for clozapine resistance are diverse whereas, in contrast, the evidence for augmentation or combination strategies is sparse. AIMS We aimed to extract levels of evidence from available data and extrapolate recommendations for clinical practice. METHODS We conducted a systematic literature search in the PubMed/MEDLINE database and in the Cochrane database. Included meta-analyses were assessed using Scottish Intercollegiate Guidelines Network criteria, with symptom improvement as the endpoint, in order to develop a recommendation grade for each clinical strategy identified. RESULTS Our search identified 21 meta-analyses of clozapine combination or augmentation strategies. No strategies met Grade A criteria. Strategies meeting Grade B included combinations with first- or second-generation antipsychotics, augmentation with electroconvulsive therapy for persistent positive symptoms, and combination with certain antidepressants (fluoxetine, duloxetine, citalopram) for persistent negative symptoms. Augmentation strategies with mood-stabilisers, anticonvulsants, glutamatergics, repetitive transcranial magnetic stimulation, transcranial direct current stimulation or cognitive behavioural therapy met Grades C-D criteria only. CONCLUSION More high-quality clinical trials are needed to evaluate the efficacy of add-on treatments for symptom improvement in patients with clozapine resistance. Applying definitions of clozapine resistance would improve the reporting of future clinical trials. Augmentation with second-generation antipsychotics and first-generation antipsychotics can be beneficial, but the supporting evidence is from low-quality studies. Electroconvulsive therapy may be effective for clozapine-resistant positive symptoms.
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Affiliation(s)
- Elias Wagner
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Lisa Löhrs
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Dan Siskind
- 2 School of Medicine, University of Queensland, Brisbane, QLD, Australia.,3 Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - William G Honer
- 4 Department of Psychiatry, The University of British Columbia, Vancouver, BC, Canada
| | - Peter Falkai
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Alkomiet Hasan
- 1 Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
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13
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Youn T, Jeong SH, Kim YS, Chung IW. Long-term clinical efficacy of maintenance electroconvulsive therapy in patients with treatment-resistant schizophrenia on clozapine. Psychiatry Res 2019; 273:759-766. [PMID: 31207863 DOI: 10.1016/j.psychres.2019.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/04/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
Electroconvulsive therapy (ECT) has been suggested as a treatment for augmenting the response to clozapine in patients that do not respond well to clozapine alone and maintenance ECT (M-ECT) had also been recommended to sustain improvement. This retrospective study of up to 2 years of observation was conducted to explore whether M-ECT is beneficial for long-term maintenance of the symptom remission elicited by acute ECT. Positive and Negative Syndrome Scale (PANSS) were plotted for each patient and compared using a linear mixed-effect model. A total of thirty-eight patients were followed and classified into three groups: (1) clozapine alone (CZP, n = 15), (2) acute ECT only (A-ECT, n = 11), and (3) acute ECT with M-ECT (M-ECT, n = 12). The mean number and interval of ECT sessions during the maintenance period in the M-ECT group were 39.0 ± 26.7 and 15.6 ± 8.4 days, respectively. The slope of the M-ECT group eventually declined, but that of the A-ECT group gradually increased back to the pre-ECT level. No persistent or serious adverse effects were observed. In conclusion, A-ECT augmented the effect of clozapine, but M-ECT was required for sustaining symptom improvement.
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Affiliation(s)
- Tak Youn
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, South Korea
| | - Yong Sik Kim
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea
| | - In Won Chung
- Department of Psychiatry and Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, South Korea; Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, South Korea.
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14
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Bartoli F, Crocamo C, Di Brita C, Esposito G, Tabacchi TI, Verrengia E, Clerici M, Carrà G. Adjunctive second-generation antipsychotics for specific symptom domains of schizophrenia resistant to clozapine: A meta-analysis. J Psychiatr Res 2019; 108:24-33. [PMID: 30447508 DOI: 10.1016/j.jpsychires.2018.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023]
Abstract
A fair amount of subjects with schizophrenia do not respond to clozapine and are defined 'ultra-resistant'. In this systematic review and meta-analysis, we tested the efficacy of adjunctive second-generation antipsychotics (SGAs) for main symptom domains (positive, negative, and depressive symptoms) in individuals with clozapine-resistant schizophrenia. We searched main electronic databases till December 2017. We included twelve double-blind, randomized, placebo-controlled trials (RCTs), evaluating the efficacy of SGAs for clozapine non/partial responders. We did not find any difference between SGAs and placebo (standardized mean difference, SMD = -0.21; p = 0.170; I2 = 68.0%) in improving positive symptoms. The effect size varied according to RCT duration (p = 0.025) and assessment methods (p = 0.016). Low-moderate effects of SGAs on both negative (SMD = -0.38; p = 0.005; I2 = 62.7%) and depressive symptoms (SMD = -0.35; p = 0.003; I2 = 4.9%), were estimated. In sum, our meta-analysis highlights the lack of efficacy of SGAs as add-on treatment for positive symptoms in clozapine-resistant schizophrenia. A small benefit of SGAs was estimated for both negative and depressive symptoms. Further RCTs are needed to establish efficacy and tolerability of SGAs or other augmentation strategies for different symptoms of clozapine-resistant schizophrenia.
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Affiliation(s)
- Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy.
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Carmen Di Brita
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | | | | | - Enrica Verrengia
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy; Division of Psychiatry, University College London, London, W1T 7NF, UK
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15
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Boazak M, Goldsmith DR, Cotes RO. Mask Off? Lithium Augmentation for Clozapine Rechallenge After Neutropenia or Agranulocytosis: Discontinuation Might Be Risky. Prim Care Companion CNS Disord 2018; 20. [PMID: 30549484 DOI: 10.4088/pcc.18l02282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Mina Boazak
- .,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David R Goldsmith
- PSTAR Clinic, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert O Cotes
- PSTAR Clinic, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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16
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Lin CH, Lin CH, Chang YC, Huang YJ, Chen PW, Yang HT, Lane HY. Sodium Benzoate, a D-Amino Acid Oxidase Inhibitor, Added to Clozapine for the Treatment of Schizophrenia: A Randomized, Double-Blind, Placebo-Controlled Trial. Biol Psychiatry 2018; 84:422-432. [PMID: 29397899 DOI: 10.1016/j.biopsych.2017.12.006] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clozapine is the last-line antipsychotic agent for refractory schizophrenia. To date, there is no convincing evidence for augmentation on clozapine. Activation of N-methyl-D-aspartate receptors, including inhibition of D-amino acid oxidase that may metabolize D-amino acids, has been reported to be beneficial for patients receiving antipsychotics other than clozapine. This study aimed to examine the efficacy and safety of a D-amino acid oxidase inhibitor, sodium benzoate, for schizophrenia patients who had poor response to clozapine. METHODS We conducted a randomized, double-blind, placebo-controlled trial. Sixty schizophrenia inpatients that had been stabilized with clozapine were allocated into three groups for 6 weeks' add-on treatment of 1 g/day sodium benzoate, 2 g/day sodium benzoate, or placebo. The primary outcome measures were Positive and Negative Syndrome Scale (PANSS) total score, Scale for the Assessment of Negative Symptoms, Quality of Life Scale, and Global Assessment of Functioning. Side effects and cognitive functions were also measured. RESULTS Both doses of sodium benzoate produced better improvement than placebo in the Scale for the Assessment of Negative Symptoms. The 2 g/day sodium benzoate also produced better improvement than placebo in PANSS-total score, PANSS-positive score, and Quality of Life Scale. Sodium benzoate was well tolerated without evident side effects. The changes of catalase, an antioxidant, were different among the three groups and correlated with the improvement of PANSS-total score and PANSS-positive score in the sodium benzoate group. CONCLUSIONS Sodium benzoate adjuvant therapy improved symptomatology of patients with clozapine-resistant schizophrenia. Further studies are warranted to elucidate the optimal dose and treatment duration as well as the mechanisms of sodium benzoate for clozapine-resistant schizophrenia.
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Affiliation(s)
- Chieh-Hsin Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan; Center for General Education, Cheng Shiu University, Kaohsiung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Ching-Hua Lin
- Department of Adult Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Yue-Cune Chang
- Department of Mathematics, Tamkang University, Taipei, Taiwan
| | - Yu-Jhen Huang
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
| | - Po-Wei Chen
- Department of Psychiatry, Taichung Chin-Ho Hospital, Taichung, Taiwan
| | - Hui-Ting Yang
- Department of Nutrition, China Medical University, Taichung, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan.
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17
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Kim JH, Youn T, Choi JG, Jeong SH, Jung HY, Kim YS, Chung IW. Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia. Psychiatry Investig 2018; 15:829-835. [PMID: 30086612 PMCID: PMC6111217 DOI: 10.30773/pi.2018.05.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/15/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. METHODS Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. RESULTS Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. CONCLUSION Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.
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Affiliation(s)
- Jung Hyun Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Tak Youn
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Jun Gwon Choi
- Department of Anesthesiology and Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Seong Hoon Jeong
- Department of Psychiatry, Eulji University Hospital, Daejeon, Republic of Korea
| | - Hee Yeon Jung
- Department of Psychiatry, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.,Department of Psychiatry and Behavioral Science and Institute of Human Behavioral Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry & Electroconvulsive Therapy Center, Dongguk University International Hospital, Goyang, Republic of Korea.,Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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18
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Barnes TR, Leeson V, Paton C, Marston L, Osborn DP, Kumar R, Keown P, Zafar R, Iqbal K, Singh V, Fridrich P, Fitzgerald Z, Bagalkote H, Haddad PM, Husni M, Amos T. Amisulpride augmentation of clozapine for treatment-refractory schizophrenia: a double-blind, placebo-controlled trial. Ther Adv Psychopharmacol 2018; 8:185-197. [PMID: 29977519 PMCID: PMC6022882 DOI: 10.1177/2045125318762365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/01/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A second antipsychotic is commonly added to clozapine to treat refractory schizophrenia, notwithstanding the limited evidence to support such practice. METHODS The efficacy and adverse effects of this pharmacological strategy were examined in a double-blind, placebo-controlled, 12-week randomized trial of clozapine augmentation with amisulpride, involving 68 adults with treatment-resistant schizophrenia and persistent symptoms despite a predefined trial of clozapine. RESULTS There were no statistically significant differences between the amisulpride and placebo groups on the primary outcome measure (clinical response defined as a 20% reduction in total Positive and Negative Syndrome Scale score) or other mental state measures. However, the trial under recruited and was therefore underpowered to detect differences in the primary outcome, meaning that acceptance of the null hypothesis carries an increased risk of type II error. The findings suggested that amisulpride-treated participants were more likely to fulfil the clinical response criterion, odds ratio 1.17 (95% confidence interval 0.40-3.42) and have a greater reduction in negative symptoms, but these numerical differences were not statistically significant and only evident at 12 weeks. A significantly higher proportion of participants in the amisulpride group had at least one adverse event compared with the control group (p = 0.014), and these were more likely to be cardiac symptoms. CONCLUSIONS Treatment for more than 6 weeks may be required for an adequate trial of clozapine augmentation with amisulpride. The greater side-effect burden associated with this treatment strategy highlights the need for safety and tolerability monitoring, including vigilance for indicators of cardiac abnormalities, when it is used in either a clinical or research setting.
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Affiliation(s)
- Thomas R.E. Barnes
- Centre for Psychiatry, Hammersmith Hospital Campus, Imperial College London, 7th Floor Commonwealth Building, Du Cane Road, London W12 0NN, UK
| | | | - Carol Paton
- Centre for Psychiatry, Imperial College London, UK
- Oxleas NHS Foundation Trust, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, UK
- PRIMENT Clinical Trials Unit, University College London, UK
| | - David P. Osborn
- Division of Psychiatry, University College London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Raj Kumar
- Tees, Esk and Wear Valley NHS Foundation Trust, Billingham, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Newcastle University, Newcastle-upon-Tyne, UK
| | - Rameez Zafar
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Vineet Singh
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Pavel Fridrich
- North Essex Partnership University NHS Foundation Trust, Harlow, UK
| | | | | | - Peter M. Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Mariwan Husni
- Central and North West London NHS Foundation Trust, London, UK
- Northern Ontario School of Medicine, Ontario, Canada
| | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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19
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Barnes TR, Leeson VC, Paton C, Marston L, Davies L, Whittaker W, Osborn D, Kumar R, Keown P, Zafar R, Iqbal K, Singh V, Fridrich P, Fitzgerald Z, Bagalkote H, Haddad PM, Husni M, Amos T. Amisulpride augmentation in clozapine-unresponsive schizophrenia (AMICUS): a double-blind, placebo-controlled, randomised trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-56. [PMID: 28869006 DOI: 10.3310/hta21490] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND When treatment-refractory schizophrenia shows an insufficient response to a trial of clozapine, clinicians commonly add a second antipsychotic, despite the lack of robust evidence to justify this practice. OBJECTIVES The main objectives of the study were to establish the clinical effectiveness and cost-effectiveness of augmentation of clozapine medication with a second antipsychotic, amisulpride, for the management of treatment-resistant schizophrenia. DESIGN The study was a multicentre, double-blind, individually randomised, placebo-controlled trial with follow-up at 12 weeks. SETTINGS The study was set in NHS multidisciplinary teams in adult psychiatry. PARTICIPANTS Eligible participants were people aged 18-65 years with treatment-resistant schizophrenia unresponsive, at a criterion level of persistent symptom severity and impaired social function, to an adequate trial of clozapine monotherapy. INTERVENTIONS Interventions comprised clozapine augmentation over 12 weeks with amisulpride or placebo. Participants received 400 mg of amisulpride or two matching placebo capsules for the first 4 weeks, after which there was a clinical option to titrate the dosage of amisulpride up to 800 mg or four matching placebo capsules for the remaining 8 weeks. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of 'responders', using a criterion response threshold of a 20% reduction in total score on the Positive and Negative Syndrome Scale. RESULTS A total of 68 participants were randomised. Compared with the participants assigned to placebo, those receiving amisulpride had a greater chance of being a responder by the 12-week follow-up (odds ratio 1.17, 95% confidence interval 0.40 to 3.42) and a greater improvement in negative symptoms, although neither finding had been present at 6-week follow-up and neither was statistically significant. Amisulpride was associated with a greater side effect burden, including cardiac side effects. Economic analyses indicated that amisulpride augmentation has the potential to be cost-effective in the short term [net saving of between £329 and £2011; no difference in quality-adjusted life-years (QALYs)] and possibly in the longer term. LIMITATIONS The trial under-recruited and, therefore, the power of statistical analysis to detect significant differences between the active and placebo groups was limited. The economic analyses indicated high uncertainty because of the short duration and relatively small number of participants. CONCLUSIONS The risk-benefit of amisulpride augmentation of clozapine for schizophrenia that has shown an insufficient response to a trial of clozapine monotherapy is worthy of further investigation in larger studies. The size and extent of the side effect burden identified for the amisulpride-clozapine combination may partly reflect the comprehensive assessment of side effects in this study. The design of future trials of such a treatment strategy should take into account that a clinical response may be not be evident within the 4- to 6-week follow-up period usually considered adequate in studies of antipsychotic treatment of acute psychotic episodes. Economic evaluation indicated the need for larger, longer-term studies to address uncertainty about the extent of savings because of amisulpride and impact on QALYs. The extent and nature of the side effect burden identified for the amisulpride-clozapine combination has implications for the nature and frequency of safety and tolerability monitoring of clozapine augmentation with a second antipsychotic in both clinical and research settings. TRIAL REGISTRATION EudraCT number 2010-018963-40 and Current Controlled Trials ISRCTN68824876. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 49. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Thomas Re Barnes
- Centre for Mental Health, Imperial College London, London, UK.,West London Mental Health NHS Trust, London, UK
| | - Verity C Leeson
- Centre for Mental Health, Imperial College London, London, UK
| | - Carol Paton
- Centre for Mental Health, Imperial College London, London, UK.,Oxleas NHS Foundation Trust, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Linda Davies
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - William Whittaker
- Centre for Health Economics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK.,Camden and Islington NHS Foundation Trust, London, UK
| | - Raj Kumar
- Tees, Esk and Wear Valley NHS Foundation Trust, Billingham, UK
| | - Patrick Keown
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Rameez Zafar
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Vineet Singh
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Pavel Fridrich
- North Essex Partnership University NHS Foundation Trust, Chelmsford, UK
| | | | | | - Peter M Haddad
- Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK.,Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Mariwan Husni
- Central and North West London NHS Foundation Trust, London, UK.,Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Tim Amos
- Avon and Wiltshire Mental Health Partnership NHS Trust, Bristol, UK.,School of Social and Community Medicine, University of Bristol, Bristol, UK
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20
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Gałaszkiewicz J, Rębisz K, Morylowska-Topolska J, Karakuła-Juchnowicz H, Kozak G. Clozapine-resistant schizophrenia – non pharmacological augmentation methods. CURRENT PROBLEMS OF PSYCHIATRY 2018. [DOI: 10.1515/cpp-2017-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Clozapine is the drug of choice for drug-resistant schizophrenia, but despite its use, 30-40% patients fail to achieve satisfactory therapeutic effects. In such situations, augmentation attempts are made by both pharmacological and non-pharmacological methods. To date, most of the work has been devoted to pharmacological strategies, much less to augemantation of clozapine with electroconvulsive therapy (C+ECT), transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS).
Aim: The aim of the work is to present biological, non-pharmacological augmentation treatment methods with clozapine.
Material and methods: A review of the literature on non-pharmacological augmentation treatment methods with clozapine was made. PubMed database was searched using key words: drug-resistant schizophrenia, clozapine, ECT, transcranial magnetic stimulation, transcranial electrical stimulation and time descriptors: 1980-2017.
Results: Most studies on the possibility of increasing the efficacy of clozapine was devoted to combination therapy with clozapine + electric treatments. They have shown improved efficacy when using these two methods simultaneously from 37.5 to 100%. The only randomized trial so far has also confirmed the effectiveness of this procedure. Despite the described side effects of tachycardia or prolonged seizures, most studies indicate the safety and efficacy of combined use of clozapine and electroconvulsive therapy. Transcranial magnetic stimulation also appears to be a safe method in patients treated with clozapine. However, further research is needed before ECT can be included in standard TRS treatment algorithms. The data for combining transcranial electrical stimulation with clozapine, come only from descriptions of cases and need to be confirmed in controlled studies.
Conclusions: The results of studies on the possibility of increasing the effectiveness of clozapine using biological non-pharmacological treatment methods indicate a potentially beneficial effect of this type of methods in breaking the super-resistance in schizophrenia. Combination of clozapine and ECT can be considered as the most recommended strategy among these treatment methods.
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Affiliation(s)
- Joanna Gałaszkiewicz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | - Krzysztof Rębisz
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
| | | | | | - Gustaw Kozak
- I Department of Psychiatry, Psychotherapy and Early Intervention , Medical University of Lublin
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21
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Zheng W, Li XH, Cai DB, Yang XH, Ungvari GS, Ng CH, Ning YP, Xiang YT. Adjunctive azapirone for schizophrenia: A meta-analysis of randomized, double-blind, placebo-controlled trials. Eur Neuropsychopharmacol 2018; 28:149-158. [PMID: 29174529 DOI: 10.1016/j.euroneuro.2017.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/27/2017] [Accepted: 11/03/2017] [Indexed: 12/19/2022]
Abstract
Azapirones, which are serotonin1A (5-HT1A) receptor partial agonists, have been used as an adjunctive treatment for schizophrenia with mixed results. This is a meta-analysis of the efficacy and tolerability of azapirones for schizophrenia based on randomized, double-blind, placebo-controlled trials (RCTs). English and Chinese databases were systematically and independently searched by two investigators. Data were extracted and analyzed using the RevMan software (version 5.3). Seven RCTs (n = 368) of azapirones (buspirone in 6 RCTs and tandospirone in 1 RCT) were identified and analyzed. Only adjunctive buspirone outperformed placebo regarding total psychopathology [standardized mean difference: -1.03 (95% confidence interval (CI): -1.91, -0.15), P = 0.02; I2 = 92%], but the significance disappeared in sensitivity analysis after removing two outlying studies, and in 10 of the 12 subgroup analyses. In 5 RCTs examining neurocognitive function of azapirones, only 2 RCTs found the superiority of buspirone in improving attention/speeded motor performance, verbal and performance intelligence. Adjunctive buspirone outperformed placebo regarding extrapyramidal symptoms [SMD:-0.51, (95%CI: -0.99, -0.02), P = 0.04; I2 = 0%]. Similar rates of discontinuation [risk ratio:1.06 (95%CI:0.54, 2.07), P = 0.86, I2 = 0%] and adverse drug reactions were found between both groups. Adjunctive buspirone and tandospirone failed to show efficacy for psychotic symptoms, but adjunctive buspirone may be associated with improvement in extrapyramidal symptoms and cognitive deficits in schizophrenia. Due to the preliminary nature of this meta-analysis, larger sample size and higher quality RCTs are needed to confirm these finding.
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Affiliation(s)
- Wei Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Xiao-Hong Li
- The National Clinical Research Center for Mental Disorders, China &Center of Depression, Beijing Institute for Brain Disorders & Mood Disorders Center, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Dong-Bin Cai
- Clinics of Chinese Medicine, the First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xin-Hu Yang
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China
| | - Gabor S Ungvari
- The University of Notre Dame Australia / Graylands Hospital, Perth, Australia
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Ping Ning
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
| | - Yu-Tao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macao SAR, China.
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22
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Remington G, Addington D, Honer W, Ismail Z, Raedler T, Teehan M. Guidelines for the Pharmacotherapy of Schizophrenia in Adults. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:604-616. [PMID: 28703015 PMCID: PMC5593252 DOI: 10.1177/0706743717720448] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The present guidelines address the pharmacotherapy of schizophrenia in adults across different stages, phases, and symptom domains. METHOD Guidelines were developed using the ADAPTE process, which takes advantage of existing guidelines. Six guidelines were identified for adaptation, with recommendations extracted from each. For those specific to the pharmacotherapy of schizophrenia in adults, a working group selected between guidelines and recommendations to create an adapted guideline. RESULTS Recommendations can be categorized into 6 areas that include 1) first-episode schizophrenia, 2) acute exacerbation, 3) relapse prevention and maintenance treatment, 4) treatment-resistant schizophrenia, 5) clozapine-resistant schizophrenia, and 6) specific symptom domains. For each category, recommendations are made based on the available evidence, which is discussed and linked to other established guidelines. CONCLUSIONS In most cases, evidence-based recommendations are made that can be used to guide current clinical treatment and decision making. Notably, however, there is a paucity of established evidence to guide treatment decision making in the case of clozapine-resistant schizophrenia, a subsample that represents a sizable proportion of those with schizophrenia.
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Affiliation(s)
- Gary Remington
- Departments of Psychiatry and Psychological Clinical Science, University of Toronto, Toronto, Canada
- Schizophrenia Division, Continuing Care and Recovery Program, Centre for Addiction and Mental Health (CAMH), Toronto, Canada
| | - Donald Addington
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute and Matheson Centre for Mental Health Research and Education, Calgary, Canada
| | - William Honer
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Zahinoor Ismail
- Hotchkiss Brain Institute and Matheson Centre for Mental Health Research and Education, Calgary, Canada
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Thomas Raedler
- Psychopharmacology Research Unit, Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Michael Teehan
- Department of Psychiatry, Dalhousie University, Halifax, Canada
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23
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Predictors of Nonhospitalization and Functional Response in Clozapine Treatment: A Nationwide, Population-Based Cohort Study. J Clin Psychopharmacol 2017; 37:148-154. [PMID: 28225745 DOI: 10.1097/jcp.0000000000000649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clozapine remains the only evidence-based treatment for treatment-resistant schizophrenia, and prediction of clozapine response is important in developing stratified treatment. We studied potential predictors of clozapine response, applying functional assessments as well as service use. PROCEDURES We performed a nationwide cohort study among all individuals diagnosed with schizophrenia in Denmark after 1995 (age, ≥18 years) who initiated clozapine treatment between 2004 and 2011 with a Global Assessment of Functioning (GAF-F) score registered at clozapine initiation. During up to 2-year follow-up, clinical response was defined as (a) no further hospitalization with schizophrenia or (b) improvement in GAF-F score (moderate improvement: increase, ≥10; substantial improvement: increase, ≥20; and GAF-F, ≥50). We performed Cox regression analysis and report adjusted hazard rate ratios (HRRs; 95% confidence intervals [95% CIs]). RESULTS Among 502 clozapine users with a registered GAF-F score, 232 (46.2%) remained out of hospital, 96 (19.1%) achieved moderate functional improvement, and 29 (5.8%) substantial functional improvement. Of all potential predictors, voluntary status at clozapine initiation showed borderline statistical significance with nonhospitalization (HRR, 1.61; 95% CI, 0.97-2.67). Regarding functional improvement, living with a partner was the strongest predictor with an almost threefold increased HRR (2.78; 95% CI, 1.07-7.23). Female sex was only nonsignificantly associated with functional improvement, whereas the chance of substantial improvement decreased by 15% (HRR, 0.85; 95% CI, 0.72-1.00) for each year delay in clozapine initiation among females. CONCLUSIONS Living with a partner was the strongest predictor of functioning after clozapine initiation in this study. Although potentially indicating better premorbid functioning, this finding stresses the need and importance of social support during the course of the treatment independent of clinical factors.
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24
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Yoshimura B, Yada Y, So R, Takaki M, Yamada N. The critical treatment window of clozapine in treatment-resistant schizophrenia: Secondary analysis of an observational study. Psychiatry Res 2017; 250:65-70. [PMID: 28142068 DOI: 10.1016/j.psychres.2017.01.064] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 01/20/2017] [Accepted: 01/22/2017] [Indexed: 01/29/2023]
Abstract
Previous studies have suggested that a delay in initiating clozapine is one of the predictors of outcomes in treatment-resistant schizophrenia (TRS). However, whether there is a critical treatment window of clozapine in TRS and the duration of that window remain unclear. We conducted a secondary analysis of a previously published observational study using a retrospective chart review of 105 patients with TRS who were treated with clozapine. We included 90 patients who remained on clozapine for at least 3 months. The delay in initiating clozapine was an independent contributor to symptomatic improvement based on treatment with clozapine by multiple linear regression analysis. A receiver operating characteristic curve analysis (area under the curve: 0.78) confirmed 2.8 years was the best predictive cut-off value of delay in initiating clozapine for responses in patients treated with clozapine (sensitivity: 0.66, specificity: 0.84). In patients with a delay in initiating clozapine of ≤2.8 years and a delay in initiating clozapine of >2.8 years, the response rates were 81.6% and 30.8% (risk ratio=2.65; 95% confidence interval, 1.80, 3.63), respectively. Clinicians should reduce the delay in initiating clozapine to less than 3 years to improve symptomatic outcomes in TRS and to prevent clozapine-resistant schizophrenia.
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Affiliation(s)
- Bunta Yoshimura
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan; Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Yuji Yada
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan.
| | - Ryuhei So
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan.
| | - Manabu Takaki
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
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25
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A Case of Resistant Schizophrenia Successfully Treated With Clozapine/Long-acting Injectable Aripiprazole Combination. Clin Neuropharmacol 2017; 39:322-324. [PMID: 27764052 DOI: 10.1097/wnf.0000000000000191] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) is a condition characterized by intense symptom severity and poor response to different antipsychotic agents. The first therapeutic option in TRS is clozapine, but often high/medium doses are not tolerated. Adding an oral antipsychotic to low doses of clozapine is a promising strategy in the management of TRS. On the contrary, there are few data on combined clozapine/long-acting injectable (LAI) medications, and none on clozapine/LAI-aripiprazole. CASE A 21-year-old male schizophrenic patient, resistant to several oral and LAI medications, partially improved after clozapine 300 mg/d treatment. Unfortunately, he also reported excessive sedation and an episode of myoclonus, so clozapine was reduced to 150 mg/d, but no additional benefits were observed. Subsequently, LAI-aripiprazole (first 200 mg/mo, then 400 mg/mo) was added, and the patient's conditions dramatically improved over time. After 1 year of observation, symptoms reduction was 50% or greater, without significant adverse events. CONCLUSIONS Clozapine use in TRS is often reduced or delayed due to the fear of serious adverse effects. Adding LAI-aripiprazole to low doses of clozapine may be a useful therapeutic option to obtain a good efficacy/tolerability balance.
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26
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Kim HS, Kim SH, Lee NY, Youn T, Lee JH, Chung S, Kim YS, Chung IW. Effectiveness of Electroconvulsive Therapy Augmentation on Clozapine-Resistant Schizophrenia. Psychiatry Investig 2017; 14:58-62. [PMID: 28096876 PMCID: PMC5240461 DOI: 10.4306/pi.2017.14.1.58] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE This retrospective case series study of the effectiveness of electroconvulsive therapy (ECT) augmentation on clozapine-resistant schizophrenia was conducted by EMR review. METHODS Clozapine-resistance was defined as persistent psychotic symptoms despite at least 12 weeks of clozapine administration with blood levels over 350 ng/mL in order to rule out pseudo-resistance. Seven in-patients who were taking clozapine and treated with ECT were selected. We analyzed the psychopathology and subscales changed by ECT. RESULTS The average number of ECT sessions was 13.4 (±4.6). Total Positive and Negative Syndrome Scale (PANSS) score was significantly reduced by 17.9 (±12.8) points (p=0.0384) on average, which represented a reduction of 25.5% (±14.3). 71.4% (5/7) of patients were identified as clinical remission, with at least a 20% reduction in PANSS score. PANSS reduction was associated with number of ECT sessions, stimulus level in the final session, and blood clozapine levels before ECT. However, the negative subscale on the PANSS were not reduced by ECT in any patient. We did not observe any persistent adverse cognitive effects. CONCLUSION This study supports that ECT augmentation on clozapine-resistant schizophrenia reveals clinically effective and safe. Further research should be done involving a larger number of patients to investigate the effectiveness of clozapine/ECT combination therapy.
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Affiliation(s)
- Hye Sung Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Nam Young Lee
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Tak Youn
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Jeoung Hyuk Lee
- Department of Anesthesia & Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Seunghyun Chung
- Department of Anesthesia & Pain Medicine, Dongguk University International Hospital, Goyang, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - In Won Chung
- Department of Psychiatry, Dongguk University International Hospital, Goyang, Republic of Korea
- Institute of Clinical Psychopharmacology, Dongguk University College of Medicine, Goyang, Republic of Korea
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27
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Zheng W, Xiang YT, Xiang YQ, Li XB, Ungvari GS, Chiu HFK, Correll CU. Efficacy and safety of adjunctive topiramate for schizophrenia: a meta-analysis of randomized controlled trials. Acta Psychiatr Scand 2016; 134:385-398. [PMID: 27585549 DOI: 10.1111/acps.12631] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To systematically examine the randomized controlled trial (RCT) evidence regarding efficacy and tolerability of topiramate cotreatment with antipsychotics in schizophrenia-spectrum disorders. METHODS Random-effects meta-analysis of RCTs of topiramate cotreatment with antipsychotics vs. placebo/ongoing antipsychotic treatment in schizophrenia-spectrum disorders. Standardized or weighted mean difference (SMD/WMD), risk ratio (RR) ±95% confidence intervals (CIs), and number needed to harm (NNH) were calculated. RESULTS Across 16 RCTs (n = 934, duration = 11.8 ± 5.6 weeks), topiramate outperformed the comparator regarding change/endpoint of total (SMD: -0.58, 95% CI: -0.82, -0.35, P < 0.00001), positive (SMD: -0.37, 95% CI: -0.61, -0.14, P = 0.002), negative (SMD: -0.58, 95% CI: -0.87, -0.29, P < 0.0001), and general symptoms (SMD: -0.68, 95% CI: -0.95, -0.40, P < 0.00001). Furthermore, topiramate was superior regarding body weight (WMD: -2.75 kg, 95% CI: -4.03, -1.47, P < 0.0001), body mass index (BMI) (WMD: -1.77, 95% CI: -2.38, -1.15, P < 0.00001), triglycerides (P = 0.006), and insulin levels (P < 0.00001). Superiority regarding psychopathology and body weight/BMI was consistent across Chinese/Asian and Western RCTs, double-blind and open designs, clozapine and non-clozapine cotreatment, augmentation and co-initiation RCTs, and higher and lower quality RCTs. In meta-regression analyses, topiramate's efficacy for total symptoms was moderated by shorter illness duration (P = 0.047), while weight loss was greater in prevention/co-initiation vs. intervention/augmentation RCTs (-4.11 kg, 95% CI: -6.70, -1.52 vs. -1.41 kg, 95% CI: -2.23, -0.59, P < 0.001). All-cause discontinuation was similar between topiramate and comparators (RR: 1.28, 95% CI: 0.91, 1.81, P = 0.16). While topiramate led to more concentration/attention difficulties (P = 0.03, NNH = 8, 95% CI=4-25), psychomotor slowing (P = 0.02, NNH = 7, 95% CI = 4-25), and paresthesia (P = 0.05, NNH = 2, 95% CI = 4-33), it led to less ≥7% weight gain (P = 0.0001, NNH = 2, 95% CI = 2-3) and constipation (P = 0.04, NNH = 9, 95% CI = 5-100) than the comparator. CONCLUSIONS These results indicate that adjunctive topiramate to antipsychotics is an effective and safe treatment choice for symptomatic improvement and weight reduction in patients with schizophrenia-spectrum disorders.
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Affiliation(s)
- W Zheng
- The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital), Guangzhou, China.
| | - Y-T Xiang
- The National Clinical Research Center for Mental Disorders, China & Beijing Anding Hospital, Capital Medical University, Beijing, China. .,Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macao, China.
| | - Y-Q Xiang
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - X-B Li
- Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - G S Ungvari
- The University of Notre Dame Australia/Marian Centre, Perth, WA, Australia.,School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
| | - H F K Chiu
- Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, China
| | - C U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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Acetyl-l-Carnitine Augmentation of Clozapine in Partial-Responder Schizophrenia: A 12-Week, Open-Label Uncontrolled Preliminary Study. Clin Neuropharmacol 2016; 39:277-280. [DOI: 10.1097/wnf.0000000000000170] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Yang Y, Cheng X, Xu Q, Li R, Liu Z, Wang L, Zhang Y, Ren G, Liu J. The maintenance of modified electroconvulsive therapy combined with risperidone is better than risperidone alone in preventing relapse of schizophrenia and improving cognitive function. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:823-828. [PMID: 27759808 DOI: 10.1590/0004-282x20160130] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/15/2016] [Indexed: 11/21/2022]
Abstract
ABSTRACT Objective To evaluate the effect of maintenance modified electroconvulsive therapy (MECT) on schizophrenic patients. Methods From June 2012 to June 2014, 62 patients with schizophrenia, who had recovered from a successful course of acute MECT, were recruited. Thirty-one patients received maintenance MECT and risperidone, as the experimental group. Another 31 patients were enrolled in the control group, and received risperidone only. The effects on cognitive functions, clinical symptoms and relapse rate were determined. Results Patients in the experimental group had a lower relapse rate and longer relapse-free survival time than the controls. Relative to the baseline evaluation, patients showed statistically significant improvement in verbal memory and visual memory. At the final assessment, the scores of verbal and visual memory were remarkably lower in the experimental group than the controls but there was no significant difference in other tests. Conclusion Maintenance MECT plus medication is superior to medication alone in preventing relapse and improving cognitive function.
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Affiliation(s)
- Ying Yang
- Shandong University, China; Shandong Mental Health Center, China
| | | | | | - Renjun Li
- Shandong Mental Health Center, China
| | | | | | - Yanqing Zhang
- Qilu Children’s Hospital of Shandong University, China
| | | | - Jintong Liu
- Shandong University, China; Shandong Mental Health Center, China
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Veerman SRT, Schulte PFJ, Smith JD, de Haan L. Memantine augmentation in clozapine-refractory schizophrenia: a randomized, double-blind, placebo-controlled crossover study. Psychol Med 2016; 46:1909-21. [PMID: 27048954 PMCID: PMC4954262 DOI: 10.1017/s0033291716000398] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/30/2015] [Accepted: 02/04/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dysfunction of neuroplasticity due to N-methyl-d-aspartate (NMDA) receptor hypofunction may be a causal factor for memory and executive dysfunctioning in schizophrenia. Deregulation of NMDA transmission in the prefrontal cortex may also explain negative and positive symptoms. Clozapine augmentation with memantine targets altered NMDA receptor-mediated neurotransmission in schizophrenia and showed substantial beneficial effects on several symptom domains in a small proof-of-concept study. We evaluate effects of memantine add-on treatment to clozapine for memory and executive function, and negative and positive symptoms in schizophrenia. METHOD Clozapine-treated patients with refractory schizophrenia were randomly assigned to 12 weeks of double-blind adjunctive treatment with memantine (n = 26) or placebo (n = 26). Crossover occurred after a 2-week placebo wash-out period. Primary endpoints were change from baseline to 12 weeks treatment and 14 weeks to 26 weeks treatment on memory and executive function using the Cambridge Neuropsychological Test Automated Battery (CANTAB), Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression Severity Scale (CGI-S). Side effects were assessed using the Liverpool University Neuroleptic Side-Effect Rating Scale. RESULTS When compared with placebo, memantine improved a composite memory score comprising verbal recognition memory and paired associates learning task scores on the CANTAB (effect size = 0.30) and PANSS negative subscale score (effect size = 0.29). Side effects were mild and transient. CONCLUSIONS In patients with clozapine-treated refractory schizophrenia, memantine addition significantly improved verbal and visual memory and negative symptoms without serious adverse effects. These results justify further investigations on long-term memantine augmentation to clozapine in treatment-resistant schizophrenia.
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Affiliation(s)
- S. R. T. Veerman
- Mental Health Service Organization North Holland
North, Community Mental Health Division, Flexible Assertive
Community Treatment, Alkmaar, The
Netherlands
| | - P. F. J. Schulte
- Mental Health Service Organization North Holland
North, Division for Specialized Treatment, Treatment Center for
Bipolar Disorders, Alkmaar, The
Netherlands
| | - J. D. Smith
- Department of Psychiatry and Behavioral
Sciences, Northwestern University, Feinberg School of Medicine,
Center for Prevention Implementation Methodology, Chicago,
IL, USA
| | - L. de Haan
- Early Psychosis Department,
Academic Medical Center, University of Amsterdam, Academic Psychiatric
Center, Arkin, Amsterdam,
The Netherlands
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Arumugham SS, Thirthalli J, Andrade C. Efficacy and safety of combining clozapine with electrical or magnetic brain stimulation in treatment-refractory schizophrenia. Expert Rev Clin Pharmacol 2016; 9:1245-52. [DOI: 10.1080/17512433.2016.1200971] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Shyam Sundar Arumugham
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, India
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Grover S, Balachander S, Chakarabarti S, Avasthi A. Prescription practices and attitude of psychiatrists towards clozapine: A survey of psychiatrists from India. Asian J Psychiatr 2015; 18:57-65. [PMID: 26498722 DOI: 10.1016/j.ajp.2015.09.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 09/20/2015] [Accepted: 09/28/2015] [Indexed: 01/17/2023]
Abstract
AIM To assess the attitude of psychiatrists towards clozapine and also to evaluate the prescription practices of psychiatrists for clozapine. METHODOLOGY An email survey was sent to 3381 psychiatrists from India, of whom 548 (16.2%) responded. RESULTS Mean number of years in clinical practice was 12.59 (SD-10.1) for participating psychiatrists. Majority of the participants rated their knowledge about clozapine to be good (61.5%)/very good (34.5%). The primary indication for use of clozapine for almost all the participants was treatment resistance and most of the psychiatrists initiated clozapine either in the dose of 25mg OD (44.3%) or 12.5mg OD (37%). Half (51.8%) of the psychiatrists preferred to use clozapine as BD dosing schedule, and median doses required to stabilize the patients ranged from 137.5 to 400mg/day. Once the clozapine dose had been stabilized, about half (51%) of the psychiatrists advised blood monitoring at monthly intervals. Almost all psychiatrists rated effectiveness of clozapine to be better than other antipsychotics. In terms of tolerability, 45.3% of the psychiatrists rated it as 'same as other antipsychotics' and 15.9% rated it as better than other antipsychotics. Most common patient and therapist related factors associated with reluctance to start clozapine were history of poor medication compliance and need for monitoring, respectively. Upon reviewing the prescription of other psychiatrists, participating psychiatrists reported that in about 28.46% of patients clozapine was not prescribed though indicated. CONCLUSIONS This survey suggests that clozapine is underused in India, although psychiatrists have adequate knowledge about the drug but many psychiatrists have negative attitude towards clozapine.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Srinivas Balachander
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Subho Chakarabarti
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Ajit Avasthi
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Correlation between delay in initiating clozapine and symptomatic improvement. Schizophr Res 2015; 168:585-6. [PMID: 26255084 DOI: 10.1016/j.schres.2015.07.045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 07/21/2015] [Accepted: 07/25/2015] [Indexed: 01/21/2023]
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Emotion processing in treatment-resistant schizophrenia patients treated with clozapine: An fMRI study. Schizophr Res 2015; 168:377-80. [PMID: 26255082 DOI: 10.1016/j.schres.2015.07.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/20/2015] [Accepted: 07/26/2015] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To examine the neural correlates of emotion processing in treatment-resistant patients with schizophrenia (SCZ-TR). METHODS Twenty-two SCZ-TR patients on clozapine, 24 schizophrenia patients on antipsychotics other than clozapine, and 39 healthy controls were scanned using functional neuroimaging while viewing positive, negative and neutral images. RESULTS Emotionally-laden images (positive and negative) elicited hyper-activations in the dorso-medial prefrontal cortex and left cerebellum in SCZ-TR patients, compared to the two other groups. Similarly, neutral images prompted hyper-activations in the cingulate gyrus in SCZ-TR patients, relative to the two other groups. CONCLUSIONS Treatment resistance is associated with neuro-functional hyper-activations in schizophrenia patients during emotion processing.
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Abstract
PURPOSE OF REVIEW This article reviews the recent evidence for therapeutic strategies for patients with treatment-resistant schizophrenia (TRS) not responding to or only partially responding to clozapine. RECENT FINDINGS A number of pharmacological and nonpharmacological biological approaches for clozapine-resistant TRS have been evaluated in clinical trials. Among these, the evidence supporting clozapine augmentation by pharmacological approaches is weak and the reported benefits were modest at best. However, the results of a recent randomized trial suggest that electroconvulsive therapy (ECT) may be efficacious for the short-term treatment of patients with clozapine-resistant TRS. SUMMARY There is currently insufficient evidence for efficacy of pharmacological augmentation strategies to clozapine. ECT may be a promising option, but further research is necessary to confirm its long-term effects. Moreover, further controlled studies are warranted to clarify the potential of other biological and psychosocial approaches to serve as adjuvant treatments in patients with clozapine-resistant TRS.
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