Gender Differences in the First-Year Antipsychotic Treatment for Chinese First-Episode Schizophrenia

Determining Ideal Management for Patients With Coexisting Prolactinomas and Psychiatric Symptoms: A Systematic Review

OBJECTIVE

Prolactinomas-pituitary tumors that overproduce prolactin-can cause various troublesome symptoms. Dopamine agonists (DAs) reduce prolactin production in the prolactin pathway, making them the first-line treatment for prolactinomas. However, the main side effect of DA treatment, hyperdopaminergia, is an explicit etiology for psychiatric side effects. Psychiatric conditions are often treated with dopamine antagonists, which can induce hyperprolactinemia. This presents a challenge for patients with both a prolactinoma and a preexisting psychiatric condition, as treatment of one condition could worsen the other. This review seeks to identify an adequate therapeutic regimen for patients with coexisting prolactinomas and psychiatric symptoms.

METHODS

This review examined PubMed citations from 1960 to 2023 published in English and involving human subjects. Case reports, case series, and cohort studies involving patients with concomitant prolactinomas and psychiatric symptoms, as validated by brain imaging, serologic prolactin levels, and medical history or chart reports of psychiatric symptoms, were included.

RESULTS

Thematic analysis included 23 reports involving 42 participants; 27 of the 42 patients experienced a significant reduction in prolactin levels and psychiatric symptoms (64%). Treatment of those 42 patients included discontinuing or altering antipsychotic/dopamine antagonist therapy or discontinuing DA therapy to reduce psychiatric symptoms, with surgery or radiation postpharmacotherapy as a last-line strategy. However, in some cases (reported in Tables 2 to 4), either psychiatric or prolactin-related symptoms recurred despite adjustment.

CONCLUSIONS

Clinicians may find it beneficial to prioritize specific antipsychotics (aripiprazole, olanzapine, ziprasidone, or clozapine) over others (risperidone, thioridazine, thiothixene, and remoxipride). Discontinuing DA medication at least periodically until the patient's condition improves may also be advisable. If these 2 initial approaches do not yield a significant improvement in symptom management, surgery or radiation therapy may be considered. As patients may respond differently to these therapies, our study still recommends a patient-centered approach.

Sex differences in autonomic adverse effects related to antipsychotic treatment and associated hormone profiles

Autonomic adverse effects of antipsychotic drugs (APs) cause clinical challenges, but few studies have investigated sex differences and their underlying biological pathways. Sex-specific regulation of relevant hormones could be involved. We investigated sex differences in autonomic adverse effects related to olanzapine, quetiapine, risperidone, and aripiprazole, and the role of hormones related to APs. Patients with severe mental disorders (N = 1318) were included and grouped based on AP monotherapy: olanzapine (N = 364), quetiapine (N = 211), risperidone (N = 102), aripiprazole (N = 138), and no AP (N = 503). Autonomic symptoms from the Udvalg for Kliniske Undersøgelser (UKU) side effect scale was analyzed with logistic regression, adjusting for age, diagnosis, and polypharmacy. Further, we analyzed associations between autonomic symptoms and hormones related to APs. We found associations between autonomic adverse effects and APs, with sex-specific risk for palpitations/tachycardia associated with hormonal changes related to APs. Results showed increased salivation associated with aripiprazole, reduced salivation with quetiapine, and nausea/vomiting and palpitations/tachycardia with olanzapine, and higher risk of nausea/vomiting, diarrhea, constipation, polyuria/polydipsia, and palpitations/tachycardia in females. Significant sex x AP interaction was found for palpitations/tachycardia, with higher risk in risperidone-treated males, which was associated with different hormone profiles of prolactin, cortisol, and insulin. Our findings implicate a role of several hormones in the sex-specific autonomic adverse effects related to APs.

Sulfur-containing amino acids and risk of schizophrenia

BACKGROUND

Schizophrenia is a chronic and complex severe psychiatric disorder. Male and female are different in their risks for schizophrenia for the biologic and sociocultural reasons. Homocysteine (Hcy), Cysteine (Cys), and methionine (Met) play important roles in metabolism, and the three amino acids may also be involved in pathogenesis of schizophrenia.

OBJECTIVE

This study aimed to test the associations between sulfur-containing amino acid blood levels and risk of schizophrenia, evaluating the different risk in male and female.

METHODS

We organized a case-control study on 876 individuals with schizophrenia and 913 age- and sex-matched healthy subjects as control group. The concentrations of Hcy, Cys and Met were measured by liquid chromatography-tandem mass spectrometry technology. Subsequently, restricted cubic spline was applied to explore full-range associations of these amino acids with schizophrenia. Interactions between levels of the three amino acids and sex on additive scale were also tested.

RESULTS

Hcy levels at ≤29 μmol/L were associated with sharply increased risk of schizophrenia, inversely, Met was associated with sharply decreased risk of schizophrenia at levels ≤22 μmol/L. Increased Cys levels were associated with decreased risk of schizophrenia. Almost inverse associations were observed between Cys/Hcy and Met/Hcy ratios and schizophrenia. Significant synergistic interactions between levels of all the three amino acids and sex were discovered on an additive scale.

CONCLUSIONS

Our study suggests a close association between sulfur-containing amino acids and schizophrenia with different risk in male and female. Future studies are demanded to clarify the pathogenic role of Hcy, Cys and Met in schizophrenia.

Investigating the Effect of Adherence to Antipsychotic Therapy on the Length of Stay and Number of Hospitalizations in Patients with Schizophrenia - A Descriptive Analysis

Background

Optimizing long-term outcomes in schizophrenia treatment requires effective pharmacological interventions. Medication adherence is known to influence clinical outcomes, yet there is a scarcity of studies examining its correlation with factors like Length of Stay (LOS) and re-hospitalization frequency. These outcomes are crucial indicators of how medication adherence affects overall patient well-being.

Purpose

This study aims to describe the effect of medication adherence on the length of stay (LOS) and number of hospitalizations in patients with schizophrenia.

Patients and Methods

A total of 157 subjects from the West Java Psychiatric Hospital were included in this cross-sectional retrospective study. Data, including demographics, comorbidities, duration of illness, antipsychotic adherence, LOS, and the number of hospitalizations, were collected from the patients' medical records. All the data were analyzed using the Chi-Square (χ²) test with a significance level set at p < 0.05.

Results

Our findings showed that 88% of all schizophrenia inpatients were in the nonadherence group. The highest (40.7%) LOS (>30 days) was found in the non-adherence group with discontinued therapy/stopped therapy group, while the highest percentage of patients with less than five hospitalizations was identified in the obedient and regular therapy group (94.4%). In the statistical results, we observed a significant association between therapy adherence (p = 0.043) and therapy regimen (p = 0.014) with gender. Additionally, the distinction between male and female schizophrenia patients demonstrated statistical significance (p = 0.000).

Conclusion

In this study, therapy adherence and therapy regimen were found to have a significant association with gender, as well as differences between the number of male and female schizophrenia patients that were statistically significant. While other variables may exhibit clinical associations, their statistical significance has not been fully depicted. The results of this study could be preliminary study for subsequent observational studies.

Review of Male and Female Care Needs in Schizophrenia: A New Specialized Clinical Unit for Women

Women with schizophrenia require health interventions that differ, in many ways, from those of men. The aim of this paper is to review male and female care needs and describe a newly established care unit for the treatment of women with schizophrenia. After reviewing the literature on the differentiated needs of men and women with schizophrenia, we describe the new unit’s assessment, intervention, and evaluation measures. The program consists of (1) individual/group patient/family therapy, (2) therapeutic drug monitoring and adherence checks, (3) perinatal mental health, (4) medical liaison, (5) suicide prevention/intervention, (6) social services with special focus on parenting, domestic abuse, and sexual exploitation, (7) home-based services, (8) peer support, (9) occupational therapies (physical activity and leisure programs), and (10) psychoeducation for both patients and families. Still in the planning stage are quality evaluation of diagnostic assessment, personalized care, drug optimization, health screening (reproductive health, metabolic syndrome, cardiovascular health, cancer, menopausal status), and patient and family satisfaction with services provided. Woman-specific care represents an important resource that promises to deliver state-of-the-art treatment to women and, ideally, prevent mental illness in their offspring.

A systematic review on sex differences in adverse drug reactions related to psychotropic, cardiovascular, and analgesic medications

Background and objective: Adverse drug reactions (ADRs) are the main safety concerns of clinically used medications. Accumulating evidence has shown that ADRs can affect men and women differently, which suggests sex as a biological predictor in the risk of ADRs. This review aims to summarize the current state of knowledge on sex differences in ADRs with the focus on the commonly used psychotropic, cardiovascular, and analgesic medications, and to aid clinical decision making and future mechanistic investigations on this topic. Methods: PubMed search was performed with combinations of the following terms: over 1,800 drugs of interests, sex difference (and its related terms), and side effects (and its related terms), which yielded over 400 unique articles. Articles related to psychotropic, cardiovascular, and analgesic medications were included in the subsequent full-text review. Characteristics and the main findings (male-biased, female-biased, or not sex biased ADRs) of each included article were collected, and the results were summarized by drug class and/or individual drug. Results: Twenty-six articles studying sex differences in ADRs of six psychotropic medications, ten cardiovascular medications, and one analgesic medication were included in this review. The main findings of these articles suggested that more than half of the ADRs being evaluated showed sex difference pattern in occurrence rate. For instance, lithium was found to cause more thyroid dysfunction in women, and amisulpride induced prolactin increase was more pronounced in women than in men. Some serious ADRs were also found to exert sex difference pattern, such as clozapine induced neutropenia was more prevalent in women whereas simvastatin/atorvastatin-related abnormal liver functions were more pronounced in men.

Antipsychotic medication for women with schizophrenia spectrum disorders

There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.

Evaluation of an educational wellness program by sex differences in community-dwelling Japanese patients with schizophrenia

This study was a 24-week non-randomized controlled trial aimed at investigating the effects of lifestyle education by sex in patients with schizophrenia. The data was collected and analyzed for 75 subjects at five facilities in Aomori, Japan. Mean weight and BMI decreased in both biologically male and female subjects over a 24-Week study period in the Intervention group, but were maintenance or increase in the control Group. Although, when compared with the control group by ANCOVA (Analysis of Covariance), there were significant differences in body weight, BMI, and body fat percentage in the biologically male participants in the Intervention group, but not in the females. For the biologically males in the Intervention group, sex differences were speculated to affect weight loss strategies, such as using a pedometer to incorporate walking into their daily routine. Thus, when implementing lifestyle improvement education program, it is recommended to implement a program that considers sex differences.

Effects of Adherence to Pharmacological Treatment on the Recovery of Patients with Schizophrenia

The aim of this study was to evaluate the effects of adherence to antipsychotic treatment on the recovery of patients with schizophrenia in northern Chile. One hundred and fifty-one patients diagnosed with schizophrenia completed the Drug Attitude Inventory (DAI-10), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Recovery Assessment Scale (RAS-24), sociodemographic information, and clinical and treatment characteristics of patients with schizophrenia. Multivariate analysis with multiple linear regression was then performed to identify variables that were potentially associated with the recovery assessment (variable criterion). A significant association was found between adherence to antipsychotic medication and the Willing to Ask for Help dimension of Recovery (β = 0.239, p = 0.005). Association of clinical and socio-demographic variables with recovery were identified: negative symptoms with Personal Confidence and Hope (β = -0.341, p = 0.001) and Goal and Success Orientation (β = -0.266, p = 0.014); cognitive symptoms with Willing to Ask for Help (β = -0.305, p = 0.018) and no domination by symptoms (β = -0.351, p = 0.005); marital status with reliance on others (β = -0.181, p = 0.045); age with Personal Confidence and Hope (β = -0.217, p = 0.021), Goal and Success Orientation (β = -0.296, p = 0.003), and no domination by symptoms (β = 0.214, p = 0.025). Adherence has a positive relationship with personal recovery in this sample of Chilean patients with schizophrenia.

The Pharmacodynamics of Antipsychotic Drugs in Women and Men

Background: Animal and human experiments have confirmed sex differences in the expression of hepatic enzymes that metabolize antipsychotic drugs and that may, in this way, be partly responsible for the clinical sex/gender differences observed in the efficacy and tolerability of antipsychotic treatment. Aim: The aim of this mini review is to synthesize the literature on the pharmacodynamics of male/female differential response to antipsychotic drugs. Method: Relevant search terms were used to search for pre-clinical and human trials and analysis of antipsychotic differential drug response and occurrence/severity of adverse effects in women and men. Results: The search found that sex influences drug response via the amount of a given drug that enters the brain and the number of neurotransmitter receptors to which it can bind. Consequently, sex partly determines the efficacy of a specific drug and its liability to induce unwanted effects. There are other factors that can overshadow or enhance the dimorphic effect of sex, for instance, the host's age, hormonal status, diet and life style as well as the molecular structure of the drug and its dose, and the method of its administration. Most of all, the host's individual genetics affects each step of a drug's pharmacodynamics. Conclusion: On average, women's psychotic symptoms respond to antipsychotic drugs at doses lower than men's. This means that many women may be de facto overdosed and, thus, experience unnecessary adverse effects. That being said, factors such as genetics and age probably determine drug response and tolerability to a greater degree than do biological sex or gender social roles.