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Kang N, Kim SH, Kim J, Kim S, Jang J, Yoon H, Lee J, Kim M, Kim YS, Kwon JS. Association between initial clozapine titration and pneumonia risk among patients with schizophrenia in a Korean tertiary hospital. Schizophr Res 2024; 268:107-113. [PMID: 37770376 DOI: 10.1016/j.schres.2023.09.029] [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: 07/31/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023]
Abstract
Pneumonia is a significant adverse drug reaction (ADR) associated with clozapine, characterized by high mortality and potential linkage with other inflammatory responses. Despite the critical nature, research regarding the development of pneumonia during initial clozapine titration remains limited. This retrospective study included 1408 Korean inpatients with schizophrenia spectrum disorders. Data were collected from January 2000 to January 2023. Pneumonia developed in 3.5 % of patients within 8 weeks of clozapine initiation. Patients who developed pneumonia were taking a greater number and higher dose of antipsychotics at baseline (2.14 vs. 1.58, p < 0.001; 25.64 vs. 19.34, p = 0.012). The average onset occurred 17.24 days after initiation, on an average dose of 151.28 mg/day. Titration was either paused or slowed in most of these patients, with no reported fatalities. The types of pneumonia included aspiration pneumonia, mycoplasma pneumonia, bronchopneumonia, and COVID-19 pneumonia. Myocarditis, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and urinary tract infections were also identified. Logistic regression analysis revealed that a greater number of concomitant antipsychotics (odds ratio [OR] = 1.59, p = 0.027) and concomitant benzodiazepine use (OR = 2.33, p = 0.005) at baseline were associated with an increased risk of pneumonia. Overall, pneumonia development during clozapine titration is linked with other inflammatory ADRs, suggesting a shared immunological mechanism. Close monitoring is recommended, especially for patients taking multiple antipsychotics and benzodiazepines. Further studies involving repeated measures of clozapine concentrations at trough and steady state, along with a more detailed description of pneumonia types, are warranted.
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Affiliation(s)
- Nuree Kang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Se Hyun Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jayoun Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sungkyu Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinhyeok Jang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heesoo Yoon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeonghoon Lee
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Minah Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong Sik Kim
- Department of Psychiatry, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Jun Soo Kwon
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea; Department of Psychiatry, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea; Institute of Human Behavioral Medicine, SNU-MRC, Seoul, Republic of Korea
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2
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Cheng B, Bai Y, Liu L, Meng P, Cheng S, Yang X, Pan C, Wei W, Liu H, Jia Y, Wen Y, Zhang F. Mendelian randomization study of the relationship between blood and urine biomarkers and schizophrenia in the UK Biobank cohort. COMMUNICATIONS MEDICINE 2024; 4:40. [PMID: 38454150 PMCID: PMC10920902 DOI: 10.1038/s43856-024-00467-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/26/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The identification of suitable biomarkers is of crucial clinical importance for the early diagnosis of treatment-resistant schizophrenia (TRS). This study aims to comprehensively analyze the association between TRS and blood and urine biomarkers. METHODS Candidate TRS-related single nucleotide polymorphisms (SNPs) were obtained from a recent genome-wide association study. The UK Biobank cohort, comprising 376,807 subjects with blood and urine biomarker testing data, was used to calculate the polygenic risk score (PRS) for TRS. Pearson correlation analyses were performed to evaluate the correlation between TRS PRS and each of the biomarkers, using calculated TRS PRS as the instrumental variables. Bidirectional two-sample Mendelian randomization (MR) was used to assess potential causal associations between candidate biomarkers with TRS. RESULTS Here we identify a significant association between TRS PRS and phosphate (r = 0.007, P = 1.96 × 10-4). Sex subgroup analyses identify seven and three candidate biomarkers associated with TRS PRS in male and female participants, respectively. For example, total protein and phosphate for males, creatinine and phosphate for females. Bidirectional two-sample MR analyses indicate that TRS is negatively associated with cholesterol (estimate = -0.363, P = 0.008). Conversely, TRS is positively associated with total protein (estimate = 0.137, P = 0.027), mean corpuscular volume (estimate = 0.032, P = 2.25 × 10-5), and mean corpuscular hemoglobin (estimate = 0.018, P = 0.007). CONCLUSIONS Our findings provide insights into the roles of blood and urine biomarkers in the early detection and treatment of TRS.
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Affiliation(s)
- Bolun Cheng
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Yunfeng Bai
- School of Public Health, Shaanxi University of Chinese Medicine, 712046, Xianyang, China
| | - Li Liu
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Peilin Meng
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Shiqiang Cheng
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Xuena Yang
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Chuyu Pan
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Wenming Wei
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Huan Liu
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Yumeng Jia
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Yan Wen
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China
| | - Feng Zhang
- Key Laboratory of Trace Elements and Endemic Diseases (Xi'an Jiaotong University), National Health and Family Planning Commission, 710061, Xi'an, China.
- Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, 710061, Xi'an, China.
- Collaborative Innovation Center of Endemic Disease and Health Promotion for Silk Road Region, School of Public Health, Health Science Center, Xi'an Jiaotong University, 710061, Xi'an, China.
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Jakobsen MI, Austin SF, Storebø OJ, Nielsen J, Simonsen E. Non-prescribing of clozapine for outpatients with schizophrenia in real-world settings: The clinicians' perspectives. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2023; 9:91. [PMID: 38135678 PMCID: PMC10746712 DOI: 10.1038/s41537-023-00423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
Clozapine is the gold standard for treating treatment-resistant schizophrenia although continuously underutilized. Previous surveys of clinicians have found that some of the most frequently cited barriers to clozapine prescribing are related to the blood-monitoring requirements. However, these surveys tend to explore general perspectives and may not reflect the true impact of different barriers in real-world outpatient settings. This study aimed to explore this issue. First, by surveying the clinicians responsible for the treatment of 39 clozapine-eligible, yet clozapine-naive, outpatients with schizophrenia. Then, based on the survey results, explanatory interviews with the participating psychiatrists were conducted and analyzed thematically. The most frequently cited reason for non-prescribing of clozapine was the expected non-compliance with blood-monitoring requirements; however, overall stability and/or severe mental illness was chosen as the most important reason in most patient-cases. The qualitative analysis highlighted the combined impact of standard clinical practice, personal experiences, and organizational constraints on clozapine utility.
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Grants
- This study is part of a PhD project funded by the Mental Health Services of Region Zealand Psychiatry East, Roskilde, Denmark, The Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark, and the Psychiatric Centre Glostrup, Unit for Complicated Schizophrenia, the Mental Health Services of The Capital Region of Denmark, in collaboration. Due to the funding by the Psychiatric Research Unit, Region Zealand Psychiatry, the study is partially funded by a private donation favoring patient-oriented research within the region.
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Affiliation(s)
- Michelle Iris Jakobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Psychiatric Research Unit East, Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.
| | - Stephen Fitzgerald Austin
- Psychiatric Research Unit East, Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark
- The Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Ole Jakob Storebø
- The Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jimmi Nielsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Centre Glostrup, Unit for Complicated Schizophrenia, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark
| | - Erik Simonsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Research Unit East, Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark
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4
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Han J, Allison S, Looi JCL, Chan SKW, Bastiampillai T. A systematic review of the role of clozapine for severe borderline personality disorder. Psychopharmacology (Berl) 2023; 240:2015-2031. [PMID: 37572113 PMCID: PMC10506937 DOI: 10.1007/s00213-023-06431-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/21/2023] [Indexed: 08/14/2023]
Abstract
RATIONALE Clozapine is a unique medication with a potential role in the treatment of severe borderline personality disorder (BPD). OBJECTIVES The review examines the effectiveness of clozapine as a medication for management for severe BPD with high risk of suicide, violence or imprisonment, and aims to help guide clinical practice in managing severe BPD. METHODS A database search of the terms "Clozapine" AND "BPD"; "Antipsychotics" AND "BPD"; "Clozapine" AND "Borderline Personality Disorder"; and "Antipsychotics" AND "Borderline Personality Disorder" were performed in CINAHL, Cochrane Library, Embase, Medline, PsychINFO, PubMed, and Web of Science. Full-text articles of clinical clozapine use for BPD were included for review. RESULTS A total of 24 articles consisting of 1 randomised control trial, 10 non-controlled trials, and 13 case reports were identified. Most of the studies reported benefits from clozapine when used for severe BPD. Many of the studies focused on clozapine use in BPD patients at high risk of suicide. Results from these non-controlled and case reports support the use of clozapine in patients with severe BPD at high risk of suicide. CONCLUSION There may be a role for clozapine in treating severe treatment refractory BPD, especially for those patients at high risk of suicide and frequent hospitalisations.
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Affiliation(s)
- Joshua Han
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
| | - Stephen Allison
- Discipline of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Consortrium of Australian-Academic Psychiatrists for Independent Policy and Research Analysis (CAPIPRA), ACT, Canberra, Australia
| | - Jeffrey C L Looi
- Consortrium of Australian-Academic Psychiatrists for Independent Policy and Research Analysis (CAPIPRA), ACT, Canberra, Australia
- Academic Unit of Psychiatry and Addiction Medicine, The Australian National University School of Medicine and Psychology, Canberra Hospital, Canberra, ACT, Australia
| | - Sherry Kit Wa Chan
- Department of Psychiatry, the School of Clinical Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong
| | - Tarun Bastiampillai
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Discipline of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Department of Psychiatry, Monash University, Wellington Road, Clayton, Victoria, Australia
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5
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Grasa E, Seppälä J, Alonso-Solis A, Haapea M, Isohanni M, Miettunen J, Caro Mendivelso J, Almazan C, Rubinstein K, Caspi A, Unoka Z, Farkas K, Usall J, Ochoa S, van der Graaf S, Jewell C, Triantafillou A, Stevens M, Reixach E, Berdun J, Corripio I. m-RESIST, a Mobile Therapeutic Intervention for Treatment-Resistant Schizophrenia: Feasibility, Acceptability, and Usability Study. JMIR Form Res 2023; 7:e46179. [PMID: 37389933 PMCID: PMC10365616 DOI: 10.2196/46179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND In the European Union, around 5 million people are affected by psychotic disorders, and approximately 30%-50% of people with schizophrenia have treatment-resistant schizophrenia (TRS). Mobile health (mHealth) interventions may be effective in preventing relapses, increasing treatment adherence, and managing some of the symptoms of schizophrenia. People with schizophrenia seem willing and able to use smartphones to monitor their symptoms and engage in therapeutic interventions. mHealth studies have been performed with other clinical populations but not in populations with TRS. OBJECTIVE The purpose of this study was to present the 3-month prospective results of the m-RESIST intervention. This study aims to assess the feasibility, acceptability, and usability of the m-RESIST intervention and the satisfaction among patients with TRS after using this intervention. METHODS A prospective multicenter feasibility study without a control group was undertaken with patients with TRS. This study was performed at 3 sites: Sant Pau Hospital (Barcelona, Spain), Semmelweis University (Budapest, Hungary), and Sheba Medical Center and Gertner Institute of Epidemiology and Health Policy Research (Ramat-Gan, Israel). The m-RESIST intervention consisted of a smartwatch, a mobile app, a web-based platform, and a tailored therapeutic program. The m-RESIST intervention was delivered to patients with TRS and assisted by mental health care providers (psychiatrists and psychologists). Feasibility, usability, acceptability, and user satisfaction were measured. RESULTS This study was performed with 39 patients with TRS. The dropout rate was 18% (7/39), the main reasons being as follows: loss to follow-up, clinical worsening, physical discomfort of the smartwatch, and social stigma. Patients' acceptance of m-RESIST ranged from moderate to high. The m-RESIST intervention could provide better control of the illness and appropriate care, together with offering user-friendly and easy-to-use technology. In terms of user experience, patients indicated that m-RESIST enabled easier and quicker communication with clinicians and made them feel more protected and safer. Patients' satisfaction was generally good: 78% (25/32) considered the quality of service as good or excellent, 84% (27/32) reported that they would use it again, and 94% (30/32) reported that they were mostly satisfied. CONCLUSIONS The m-RESIST project has provided the basis for a new modular program based on novel technology: the m-RESIST intervention. This program was well-accepted by patients in terms of acceptability, usability, and satisfaction. Our results offer an encouraging starting point regarding mHealth technologies for patients with TRS. TRIAL REGISTRATION ClinicalTrials.gov NCT03064776; https://clinicaltrials.gov/ct2/show/record/NCT03064776. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2017-021346.
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Affiliation(s)
- Eva Grasa
- Mental Health, Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
| | - Jussi Seppälä
- Social Insurance Institution of Finland, Kuopio, Finland
- Research Unit of Population Health, University of Oulu, Oulu, Finland
| | - Anna Alonso-Solis
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
- Mental Health Division, Fundació Althaia, Xarxa Assistencial Universitaria de Manresa, Manresa, Spain
| | - Marianne Haapea
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Psychiatry, Oulu University Hospital, Oulu, Finland
| | - Matti Isohanni
- Research Unit of Population Health, University of Oulu, Oulu, Finland
| | - Jouko Miettunen
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | | | - Cari Almazan
- Agency for Health Quality and Assessment of Catalonia (AQuAS), Barcelona, Spain
| | - Katya Rubinstein
- The Gertner Institute of Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Asaf Caspi
- The Gertner Institute of Epidemiology and Health Policy Research, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Zsolt Unoka
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Kinga Farkas
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
| | - Judith Usall
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Etiopatogènia i tractament dels trastorns mentals greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Susana Ochoa
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Etiopatogènia i tractament dels trastorns mentals greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | | | | | | | - Matthias Stevens
- EDiT Department, imec, Ghent/Antwerp, Belgium
- Solutions Department, imec, Leuven, Belgium
| | - Elisenda Reixach
- TicSalut Health Department, Generalitat de Catalunya, Barcelona, Spain
| | - Jesus Berdun
- Digital Health Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
| | - Iluminada Corripio
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
- Mental Health and Psychiatry Department, Vic Hospital Consortium, Vic, Spain
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Hudon A, Beaudoin M, Phraxayavong K, Potvin S, Dumais A. Unsupervised Machine Learning Driven Analysis of Verbatims of Treatment-Resistant Schizophrenia Patients Having Followed Avatar Therapy. J Pers Med 2023; 13:jpm13050801. [PMID: 37240971 DOI: 10.3390/jpm13050801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The therapeutic mechanisms underlying psychotherapeutic interventions for individuals with treatment-resistant schizophrenia are mostly unknown. One of these treatment techniques is avatar therapy (AT), in which the patient engages in immersive sessions while interacting with an avatar representing their primary persistent auditory verbal hallucination. The aim of this study was to conduct an unsupervised machine-learning analysis of verbatims of treatment-resistant schizophrenia patients that have followed AT. The second aim of the study was to compare the data clusters obtained from the unsupervised machine-learning analysis with previously conducted qualitative analysis. (2) Methods: A k-means algorithm was performed over the immersive-session verbatims of 18 patients suffering from treatment-resistant schizophrenia who followed AT to cluster interactions of the avatar and the patient. Data were pre-processed using vectorization and data reduction. (3): Results: Three clusters of interactions were identified for the avatar's interactions whereas four clusters were identified for the patient's interactions. (4) Conclusion: This study was the first attempt to conduct unsupervised machine learning on AT and provided a quantitative insight into the inner interactions that take place during immersive sessions. The use of unsupervised machine learning could yield a better understanding of the type of interactions that take place in AT and their clinical implications.
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Affiliation(s)
- Alexandre Hudon
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3J4, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Mélissa Beaudoin
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3J4, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Kingsada Phraxayavong
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3J4, Canada
- Services et Recherches Psychiatriques AD, Montreal, QC H1C 1H1, Canada
| | - Stéphane Potvin
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3J4, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Alexandre Dumais
- Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, QC H1N 3J4, Canada
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Services et Recherches Psychiatriques AD, Montreal, QC H1C 1H1, Canada
- Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, QC H1C 1H1, Canada
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7
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Jakobsen MI, Schaug JP, Nielsen J, Simonsen E. Antipsychotic prescribing practices for outpatients with schizophrenia and reasons for non-clozapine treatment - Data from a Danish quality assessment audit. Nord J Psychiatry 2023:1-10. [PMID: 36651766 DOI: 10.1080/08039488.2022.2160878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Clozapine is the gold standard for treating treatment-resistant schizophrenia (TRS) although widely underutilised. Both organisational, patient- and clinician related reasons for the underutilisation have been reported, however, the clinical impact of either in real-world settings is not fully elucidated. AIM This audit aimed to evaluate the local antipsychotic (AP) prescribing practices for outpatients with schizophrenia and to assess the spectrum and prevalence of journalised reasons for non-clozapine treatment amongst eligible outpatients. METHODS Data on demographics, current and former AP treatments, as well as documented reasons for non-clozapine treatment, was extracted through chart audit. RESULTS Of the 668 affiliated outpatients with schizophrenia, 43% were treated with AP polytherapy (APP) and 19.6% with clozapine. The most prevalent reason for clozapine discontinuation was related to side effects whereas the most prevalent reason for refusal or omission of clozapine treatment was related to the associated monitoring regimen. CONCLUSIONS This audit showed that APP prescribing is a highly prevalent practice in our services when treating outpatients with schizophrenia and that clozapine is underutilised in a 'last resort' manner. The blood-monitoring regimen associated with clozapine treatment was found to be an important factor in the underutilisation. It seemed, however, that the monitoring constituted a barrier for different reasons, requiring different approaches to remedy. Future studies, directly involving both patients and clinicians in the identification and management of the most clinically relevant barriers and their corresponding facilitators, are warranted.
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Affiliation(s)
- Michelle I Jakobsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie P Schaug
- Psychiatric Research Unit, Centre for Evidence-Based Psychiatry, Region Zealand Psychiatry, Slagelse, Denmark
| | - Jimmi Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Psychiatric Centre Glostrup, The Mental Health Services in the Capital Region of Denmark, Glostrup, Denmark
| | - Erik Simonsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Russo M, Ignjatovic-Ristic D, Cohen D, Arenliu A, Bajraktarov S, Dzubur Kulenovic A, Injac Stevovic L, Maric N, Novotni A, Jovanovic N. Clozapine prescription rates in Southeast Europe: A cross-sectional study. Front Psychiatry 2023; 14:1123246. [PMID: 37113539 PMCID: PMC10126685 DOI: 10.3389/fpsyt.2023.1123246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/25/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction International reports indicate that clozapine is under prescribed. Yet, this has not been explored in Southeast European (SEE) countries. This cross-sectional study investigates clozapine prescription rates in a sample of 401 outpatients with psychosis from Bosnia and Herzegovina, Kosovo by United Nations resolution, North Macedonia, Montenegro and Serbia. Methods Descriptive analysis was used to explore clozapine prescription rates; daily antipsychotic dosage was calculated and converted into olanzapine equivalents. Patients receiving clozapine were compared to those not receiving clozapine; next those that were on clozapine monotherapy were compared to those who were on clozapine polytherapy regime. Results It was showed that clozapine was prescribed to 37.7% of patients (with cross-country variation: from 25% in North Macedonia to 43.8% in Montenegro), with average dose of 130.7 mg/daily. The majority of patients on clozapine (70.5%) were prescribed at least one more antipsychotic (the most frequent combination was with haloperidol). Discussion Our findings suggested that clozapine prescription rate in SEE outpatients is higher than in Western Europe. The average dose is significantly below the optimal therapeutic dosage recommended by clinical guidelines, and clozapine polytherapy is common. This might indicate that clozapine is prescribed mainly for its sedative effect rather than antipsychotic. We hope that this finding will be taken up by relevant stakeholders to address this non-evidence-based practice.
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Affiliation(s)
- Manuela Russo
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
- *Correspondence: Manuela Russo,
| | | | - Dan Cohen
- MHO North-Holland North, Heerhugowaard, Netherlands
| | - Aliriza Arenliu
- Department of Psychology, University of Pristina, Pristina, Kosovo by United Nations Resolution
| | | | | | | | - Nadja Maric
- Faculty of Medicine, Institute of Mental Health, University of Belgrade, Belgrade, Serbia
| | - Antoni Novotni
- University Clinic of Psychiatry, Skopje, North Macedonia
| | - Nikolina Jovanovic
- Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
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9
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Wadoo O, Latoo J, Alabdulla M, Eltorki Y, Riaz S, Karim MA, Abu-Hafizah M, Reagu S. Clozapine prescribing practice and trends in Qatar: First national observational study. Brain Behav 2022; 12:e2617. [PMID: 35647930 PMCID: PMC9304832 DOI: 10.1002/brb3.2617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/13/2022] [Accepted: 04/24/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Clozapine is the gold standard in the management of treatment-resistant schizophrenia. Despite its clinically proven efficacy clozapine utilization is variable globally and published evidence is suggestive of its underutilization. Research from the Arab region on clozapine utilization is limited. The aim of our descriptive observational study was to evaluate the prescribing practice of clozapine and its sociodemographic and clinical corelates in the State of Qatar. METHODS The study is a retrospective case-note review of all patients maintained on clozapine, in the calendar year 2020. Data were collected on sociodemographic characteristics of the patients; antipsychotic trials before initiating clozapine; and clinical characteristics of the patients, including their diagnoses leading to prescription of clozapine, duration of illness, psychiatric hospitalizations, and co-morbidities. RESULTS During the study period, 100 patients were maintained on clozapine. Patients were mostly Qatari and non-Qatari Arab males. Prescription rates were significantly different for Qatari patients when compared to non-Qatari patients. Most patients had a chronic illness with the age of onset of illness in early adulthood and were diagnosed with schizophrenia or schizoaffective disorder. The mean daily dose of clozapine was 325 mg. Eighty percent of the patients received two or more antipsychotic trials before initiating clozapine. Sixty-eight percent of the patients had more than two antipsychotic trials before initiating Clozapine. One third of patients had no history of psychiatric hospitalizations, and one quarter had five or more previous psychiatric hospitalizations. Of the psychiatric comorbidities, mood and substance use disorders were common. Of medical comorbidities, endocrine and metabolic disorders were common. CONCLUSION Despite apparent underutilization, the Clozapine prescribing rates in Qatar are comparable to countries with plasma monitoring systems when framed within Qatar's unique demographic context. However, there still is a significant delay in Clozapine initiation despite its clinical superiority. STRENGTHS AND LIMITATIONS OF THIS STUDY First study on Clozapine utilization from the Middle-East and North-Africa region. This study examined prescribing of clozapine in a national cohort of patients in Qatar. Provides insight into sociodemographic and clinical correlates of clozapine prescribing in a country with 90% migrants. Limited by the completeness of the information contained in the patients' medical charts.
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Affiliation(s)
- Ovais Wadoo
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
| | - Javed Latoo
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Majid Alabdulla
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
| | - Yassin Eltorki
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Sadaf Riaz
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Mustafa Abdul Karim
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,Department of Psychiatry, College of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | - Shuja Reagu
- Mental Health Services, Hamad Medical Corporation, Doha, Qatar.,Department of Psychiatry, College of Medicine, Weill Cornell Medicine, Doha, Qatar
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10
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Abstract
Recognizing futility is a challenging aspect of clinical medicine, particularly in psychiatry. We present a case of a man who suffered from clozapine-resistant schizophrenia. His illness was characterized by prominent religious delusions and severe self-starvation. Neither the intensity of his symptoms nor his quality of life improved with available psychiatric interventions, and he experienced significant iatrogenic harms from enforced treatments. Recognizing clinical futility, in collaboration with a diverse multidisciplinary team, and making a clear shift to a patient-centered palliative approach allowed the patient's treatment team to prioritize his autonomy and subjective meaning in his final months. Such approaches are understudied in psychiatry and warrant greater attention.
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11
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Khau M, Tabbane K, Bloom D, Abadi S, Villemus C, Rabinovitch M, Shah JL, Veillette A, Iyer SN, Boksa P, Joober R. Measurement Based Care in a first episode psychosis program: Development of an algorithm of care based on the Clinical Global Impressions Scale. J Psychiatr Res 2022; 150:8-16. [PMID: 35339740 DOI: 10.1016/j.jpsychires.2022.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/26/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adherence to therapeutic guidelines in psychiatry is anchored and facilitated by rating scales. However, they are rarely used in routine care, particularly for psychotic disorders. Consequently, adherence to treatment guidelines are not ideal and patient outcomes are often sub-optimal. In this study, we used the clinician-rated Clinical Global Impressions Scale (CGI) to implement a measurement-based care (MBC) approach and derive indices of quality of care at a first episode psychosis (FEP) program. METHODS At the individual level, an algorithm was created using CGI scores and their changes over time to define the concept of Patient Requiring Clinical Attention (PRCA) that encompasses several categories (e.g. episode of severity, treatment inertia, or treatment resistance). At the service level, CGI scores were used to derive several indices of quality of care: severity of illness and its change over time, conformity to the use of low doses of antipsychotic medications, and clozapine offer index. RESULTS 135 Patients were included in this study of whom 19 patients were identified as PRCA. Of these, 12 (63%) received timely medication, and 7 (37%) were suspected cases of therapeutic inertia. Additionally, 15 patients met criteria for treatment resistance of whom 7 were offered clozapine (47%). At the service level, the average CGI improved by 2 points from baseline to month 1 and average doses of antipsychotic medications prescribed were in line with prescription guidelines for FEP patients. CONCLUSION The proposed CGI-based treatment algorithm and service evaluation strategy can help to optimize quality care and services for patients.
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Affiliation(s)
- Michelle Khau
- Integrated Program of Neuroscience, McGill University, Montreal, Qc, Canada; Douglas Mental Health University Institute, Verdun, Qc, Canada
| | - Karim Tabbane
- Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - David Bloom
- Douglas Mental Health University Institute, Verdun, Qc, Canada
| | - Sherezad Abadi
- Douglas Mental Health University Institute, Verdun, Qc, Canada
| | - Celine Villemus
- Douglas Mental Health University Institute, Verdun, Qc, Canada
| | - Mark Rabinovitch
- Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - Jai L Shah
- Integrated Program of Neuroscience, McGill University, Montreal, Qc, Canada; Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | | | - Srividya N Iyer
- Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - Patricia Boksa
- Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - Ridha Joober
- Douglas Mental Health University Institute, Verdun, Qc, Canada; Department of Psychiatry, McGill University, Montreal, Qc, Canada.
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12
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Pro-inflammatory cytokine levels are elevated in female patients with schizophrenia treated with clozapine. Psychopharmacology (Berl) 2022; 239:765-771. [PMID: 35080634 DOI: 10.1007/s00213-022-06067-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023]
Abstract
RATIONALE AND OBJECTIVE In this study, we hypothesized that the chronic use of clozapine affects cytokine expression and has a greater effect on female patients than on male patients. The aims of this study were to detect (1) whether serum cytokine levels were altered in patients with chronic schizophrenia after clozapine treatment compared with age- and sex-matched healthy controls, (2) whether there was a gender difference in serum cytokine levels after clozapine treatment, and (3) whether there was a correlation between serum cytokine levels and clozapine daily dosage in patients with schizophrenia. METHODS Forty-nine inpatients with schizophrenia treated with clozapine and fifty-three sex- and age-matched healthy controls were recruited. The patients' psychiatric symptoms were measured by the Positive and Negative Syndrome Scale (PANSS). Blood samples from both patients and healthy controls were collected. Serum IL-1β, IL-2, IL-6, IL-17, IFN-γ, and TNF-α levels were measured in duplicate by sandwich enzyme-linked immunosorbent assay. RESULTS We found that chronic clozapine treatment in patients with schizophrenia resulted in the abnormal expression of serum cytokines, such as IL-2, IL-6, IL-17, and TNF-α, compared with the healthy controls. In addition, there was a gender difference in the abnormal expression of cytokines between male and female patients with schizophrenia. In the female group, IL-2 serum levels were lower than those in the male group. Interestingly, there was a positive correlation between serum IL-2 levels and the daily clozapine dosage in female patients with schizophrenia. CONCLUSION Findings from our study have shown clear evidence that clozapine had a greater effect on immune function in female patients with schizophrenia.
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13
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Pardiñas AF, Smart SE, Willcocks IR, Holmans PA, Dennison CA, Lynham AJ, Legge SE, Baune BT, Bigdeli TB, Cairns MJ, Corvin A, Fanous AH, Frank J, Kelly B, McQuillin A, Melle I, Mortensen PB, Mowry BJ, Pato CN, Periyasamy S, Rietschel M, Rujescu D, Simonsen C, St Clair D, Tooney P, Wu JQ, Andreassen OA, Kowalec K, Sullivan PF, Murray RM, Owen MJ, MacCabe JH, O’Donovan MC, Walters JTR, Ajnakina O, Alameda L, Barnes TRE, Berardi D, Bonora E, Camporesi S, Cleusix M, Conus P, Crespo-Facorro B, D'Andrea G, Demjaha A, Do KQ, Doody GA, Eap CB, Ferchiou A, Di Forti M, Guidi L, Homman L, Jenni R, Joyce EM, Kassoumeri L, Khadimallah I, Lastrina O, Muratori R, Noyan H, O'Neill FA, Pignon B, Restellini R, Richard JR, Schürhoff F, Španiel F, Szöke A, Tarricone I, Tortelli A, Üçok A, Vázquez-Bourgon J. Interaction Testing and Polygenic Risk Scoring to Estimate the Association of Common Genetic Variants With Treatment Resistance in Schizophrenia. JAMA Psychiatry 2022; 79:260-269. [PMID: 35019943 PMCID: PMC8756361 DOI: 10.1001/jamapsychiatry.2021.3799] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE About 20% to 30% of people with schizophrenia have psychotic symptoms that do not respond adequately to first-line antipsychotic treatment. This clinical presentation, chronic and highly disabling, is known as treatment-resistant schizophrenia (TRS). The causes of treatment resistance and their relationships with causes underlying schizophrenia are largely unknown. Adequately powered genetic studies of TRS are scarce because of the difficulty in collecting data from well-characterized TRS cohorts. OBJECTIVE To examine the genetic architecture of TRS through the reassessment of genetic data from schizophrenia studies and its validation in carefully ascertained clinical samples. DESIGN, SETTING, AND PARTICIPANTS Two case-control genome-wide association studies (GWASs) of schizophrenia were performed in which the case samples were defined as individuals with TRS (n = 10 501) and individuals with non-TRS (n = 20 325). The differences in effect sizes for allelic associations were then determined between both studies, the reasoning being such differences reflect treatment resistance instead of schizophrenia. Genotype data were retrieved from the CLOZUK and Psychiatric Genomics Consortium (PGC) schizophrenia studies. The output was validated using polygenic risk score (PRS) profiling of 2 independent schizophrenia cohorts with TRS and non-TRS: a prevalence sample with 817 individuals (Cardiff Cognition in Schizophrenia [CardiffCOGS]) and an incidence sample with 563 individuals (Genetics Workstream of the Schizophrenia Treatment Resistance and Therapeutic Advances [STRATA-G]). MAIN OUTCOMES AND MEASURES GWAS of treatment resistance in schizophrenia. The results of the GWAS were compared with complex polygenic traits through a genetic correlation approach and were used for PRS analysis on the independent validation cohorts using the same TRS definition. RESULTS The study included a total of 85 490 participants (48 635 [56.9%] male) in its GWAS stage and 1380 participants (859 [62.2%] male) in its PRS validation stage. Treatment resistance in schizophrenia emerged as a polygenic trait with detectable heritability (1% to 4%), and several traits related to intelligence and cognition were found to be genetically correlated with it (genetic correlation, 0.41-0.69). PRS analysis in the CardiffCOGS prevalence sample showed a positive association between TRS and a history of taking clozapine (r2 = 2.03%; P = .001), which was replicated in the STRATA-G incidence sample (r2 = 1.09%; P = .04). CONCLUSIONS AND RELEVANCE In this GWAS, common genetic variants were differentially associated with TRS, and these associations may have been obscured through the amalgamation of large GWAS samples in previous studies of broadly defined schizophrenia. Findings of this study suggest the validity of meta-analytic approaches for studies on patient outcomes, including treatment resistance.
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Affiliation(s)
- Antonio F. Pardiñas
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sophie E. Smart
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom,Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Isabella R. Willcocks
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Peter A. Holmans
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Charlotte A. Dennison
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Amy J. Lynham
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sophie E. Legge
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Bernhard T. Baune
- Department of Psychiatry, University of Münster, Münster, Germany,Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, Australia,The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia
| | - Tim B. Bigdeli
- Department of Psychiatry and the Behavioral Sciences, State University of New York Downstate Medical Center, Brooklyn,Institute for Genomic Health, State University of New York Downstate Medical Center, Brooklyn,Department of Psychiatry, Veterans Affairs New York Harbor Healthcare System, Brooklyn
| | - Murray J. Cairns
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, Australia,Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, Australia,Hunter Medical Research Institute, Newcastle, Australia
| | - Aiden Corvin
- Neuropsychiatric Genetics Research Group, Department of Psychiatry, Trinity College Dublin, Dublin, Ireland
| | - Ayman H. Fanous
- Department of Psychiatry and the Behavioral Sciences, State University of New York Downstate Medical Center, Brooklyn,Institute for Genomic Health, State University of New York Downstate Medical Center, Brooklyn
| | - Josef Frank
- Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Mannheim, Germany
| | - Brian Kelly
- School of Medicine & Public Health, The University of Newcastle, Newcastle, Australia
| | - Andrew McQuillin
- Molecular Psychiatry Laboratory, Division of Psychiatry, University College London, London, United Kingdom
| | - Ingrid Melle
- Norwegian Centre for Mental Disorders Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Division of Mental Health and Addiction, Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
| | - Preben B. Mortensen
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark,The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark
| | - Bryan J. Mowry
- Queensland Brain Institute, The University of Queensland, Brisbane, Australia,Queensland Centre for Mental Health Research, The University of Queensland, Brisbane, Australia
| | - Carlos N. Pato
- Department of Psychiatry and Behavioral Sciences, State University of New York Downstate Medical Center, Brooklyn,Department of Psychiatry and Zilkha Neurogenetics Institute, Keck School of Medicine, University of Southern California, Los Angeles,Institute for Genomic Health, State University of New York Downstate Medical Center, Brooklyn
| | - Sathish Periyasamy
- Queensland Brain Institute, The University of Queensland, Brisbane, Australia,Queensland Centre for Mental Health Research, The University of Queensland, Brisbane, Australia
| | - Marcella Rietschel
- Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Mannheim, Germany
| | - Dan Rujescu
- University Clinic and Outpatient Clinic for Psychiatry, Psychotherapy and Psychosomatics, Martin Luther University of Halle-Wittenberg, Halle, Germany,Division of General Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Carmen Simonsen
- Norwegian Centre for Mental Disorders Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Early Intervention in Psychosis Advisory Unit for South-East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - David St Clair
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Paul Tooney
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, Australia,Hunter Medical Research Institute, Newcastle, Australia
| | - Jing Qin Wu
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Ole A. Andreassen
- Norwegian Centre for Mental Disorders Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Division of Mental Health and Addiction, Institute of Clinical Medicine, Oslo University Hospital, Oslo, Norway
| | - Kaarina Kowalec
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Patrick F. Sullivan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Psychiatry, Icahn School of Medicine, Mount Sinai Hospital, New York, New York,Department of Genetics, University of North Carolina, Chapel Hill
| | - Robin M. Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Michael J. Owen
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James H. MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Michael C. O’Donovan
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - James T. R. Walters
- MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Olesya Ajnakina
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, University of London, London, United Kingdom.,Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,Centro de Investigacion Biomedica en Red de Salud Mental, Spanish Network for Research in Mental Health, Sevilla, Spain.,Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio, Departamento de Psiquiatria, Universidad de Sevilla, Sevilla, Spain.,Treatment and Early Intervention in Psychosis Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Thomas R E Barnes
- Division of Psychiatry, Imperial College London, London, United Kingdom
| | - Domenico Berardi
- Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Elena Bonora
- Department of Medical and Surgical Sciences, Bologna Transcultural Psychosomatic Team, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sara Camporesi
- Treatment and Early Intervention in Psychosis Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland.,Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Martine Cleusix
- Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Philippe Conus
- Treatment and Early Intervention in Psychosis Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Benedicto Crespo-Facorro
- Centro de Investigacion Biomedica en Red de Salud Mental, Spanish Network for Research in Mental Health, Sevilla, Spain.,Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio, Departamento de Psiquiatria, Universidad de Sevilla, Sevilla, Spain
| | - Giuseppe D'Andrea
- Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Arsime Demjaha
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Kim Q Do
- Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Gillian A Doody
- Department of Medical Education, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, United Kingdom
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, University of Lausanne, Prilly, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Aziz Ferchiou
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France
| | - Marta Di Forti
- Social Genetics and Developmental Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley National Health Service Mental Health Foundation Trust, London, United Kingdom
| | - Lorenzo Guidi
- Department of Medical and Surgical Sciences, Bologna Transcultural Psychosomatic Team, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Lina Homman
- Department of Social and Welfare Studies, Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.,Centre For Public Health, Institute Of Clinical Sciences, Queens University Belfast, Belfast, United Kingdom
| | - Raoul Jenni
- Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Eileen M Joyce
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Laura Kassoumeri
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Inès Khadimallah
- Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Ornella Lastrina
- Department of Biomedical and Neuro-motor Sciences, Psychiatry Unit, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Roberto Muratori
- Department of Medical and Surgical Sciences, Bologna Transcultural Psychosomatic Team, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Handan Noyan
- Faculty of Social Sciences, Department of Psychology, Beykoz University, Istanbul, Turkey
| | - Francis A O'Neill
- Centre For Public Health, Institute Of Clinical Sciences, Queens University Belfast, Belfast, United Kingdom
| | - Baptiste Pignon
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires HMondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie, Fédération Hospitalo-Universitaire de Médecine de Précision, Créteil, France
| | - Romeo Restellini
- Treatment and Early Intervention in Psychosis Program, Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland.,Unit for Research in Schizophrenia, Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean-Romain Richard
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France
| | - Franck Schürhoff
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires HMondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie, Fédération Hospitalo-Universitaire de Médecine de Précision, Créteil, France
| | - Filip Španiel
- Department of Applied Neuroscience and Neuroimaging, National Institute of Mental Health, Klecany, Czechia.,Department of Psychiatry and Medical Psychology, Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Andrei Szöke
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France.,Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires HMondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie, Fédération Hospitalo-Universitaire de Médecine de Précision, Créteil, France
| | - Ilaria Tarricone
- Department of Medical and Surgical Sciences, Bologna Transcultural Psychosomatic Team, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea Tortelli
- University Paris-Est Créteil, Institut national de la santé et de la recherche médicale, Mondor Institute for Biomedical Research, Translational Neuropsychiatry, Fondation FondaMental, Créteil, France.,Groupe Hospitalier Universitaire Psychiatrie Neurosciences Paris, Pôle Psychiatrie Précarité, Paris, France
| | - Alp Üçok
- Department of Psychiatry, Istanbul University, Istanbul, Turkey
| | - Javier Vázquez-Bourgon
- Department of Psychiatry, University Hospital Marques de Valdecilla-Instituto de Investigación Marques de Valdecilla, Santander, Spain.,Department of Medicine and Psychiatry, School of Medicine, University of Cantabria, Santander, Spain.,Centro de Investigacion Biomedica en Red de Salud Mental, Spanish Network for Research in Mental Health, Santander, Spain
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14
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Vasiliu O. Third-generation antipsychotics in patients with schizophrenia and non-responsivity or intolerance to clozapine regimen: What is the evidence? Front Psychiatry 2022; 13:1069432. [PMID: 36523870 PMCID: PMC9744942 DOI: 10.3389/fpsyt.2022.1069432] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/02/2022] [Indexed: 11/30/2022] Open
Abstract
Clozapine is considered « the golden standard » for the management of treatment-resistant schizophrenia, but many patients do not present adequate responsivity even to this antipsychotic. If we add the need to strictly monitor the hematologic and cardiometabolic adverse events during each clozapine trial and the difficulty of preserving therapeutic adherence in patients with low insight, residual negative/positive symptoms, or economic challenges, then the necessity of exploring alternative interventions for these patients becomes obvious. Also, in case of intolerance to clozapine or where clozapine did not induce remission, clinicians have to find new ways to help their patients. Switching to other antipsychotics or using these agents as add-ons to clozapine are the main interventions explored in this review, for patients with schizophrenia resistant to clozapine (ultra-resistant schizophrenia, URS). When clozapine intolerance is detected, conversion to another antipsychotic with distinct pharmacologic properties or formulation (e.g., long-acting intramuscular injectable agents, LAI) may be a useful option. Third-generation antipsychotics (TGA) have been selected for their distinct pharmacodynamically profile, which allows, at a theoretical level, their use in combination with clozapine. This narrative review is based on searching four electronic databases, that retrieved 19 primary and secondary reports on aripiprazole (seven case reports or case series presenting 24 patients; nine clinical trials, and three systematic reviews/meta-analyses), two primary reports on brexpiprazole (case report and case series, N = 3 patients), and six primary reports on cariprazine (case reports and case series, N = 14 patients). Based on the information collected from these reports, which included oral and LAI formulations, the TGA most supported by evidence for the augmentation of clozapine is aripiprazole (high-and medium-quality data), followed by cariprazine (low-quality data). Brexpiprazole has not yet been systematically explored for this indication, and in the case of lumateperone, no report could be found. The efficacy of aripiprazole and cariprazine was supported in the domains of positive, negative, and general symptoms, and aripiprazole may positively impact the metabolic profile in patients with URS. Also, adding TGA may lead to a decrease in the dose of clozapine concomitantly administered. More data derived from good quality research are needed in order to confirm the circumstances of TGAs recommendation in patients with URS, either as monotherapy, or added to clozapine.
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Affiliation(s)
- Octavian Vasiliu
- Department of Psychiatry, Dr. Carol Davila University Emergency Central Military Hospital, Bucharest, Romania
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15
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Carthy E, Ellender T. Histamine, Neuroinflammation and Neurodevelopment: A Review. Front Neurosci 2021; 15:680214. [PMID: 34335160 PMCID: PMC8317266 DOI: 10.3389/fnins.2021.680214] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/18/2021] [Indexed: 12/16/2022] Open
Abstract
The biogenic amine, histamine, has been shown to critically modulate inflammatory processes as well as the properties of neurons and synapses in the brain, and is also implicated in the emergence of neurodevelopmental disorders. Indeed, a reduction in the synthesis of this neuromodulator has been associated with the disorders Tourette's syndrome and obsessive-compulsive disorder, with evidence that this may be through the disruption of the corticostriatal circuitry during development. Furthermore, neuroinflammation has been associated with alterations in brain development, e.g., impacting synaptic plasticity and synaptogenesis, and there are suggestions that histamine deficiency may leave the developing brain more vulnerable to proinflammatory insults. While most studies have focused on neuronal sources of histamine it remains unclear to what extent other (non-neuronal) sources of histamine, e.g., from mast cells and other sources, can impact brain development. The few studies that have started exploring this in vitro, and more limited in vivo, would indicate that non-neuronal released histamine and other preformed mediators can influence microglial-mediated neuroinflammation which can impact brain development. In this Review we will summarize the state of the field with regard to non-neuronal sources of histamine and its impact on both neuroinflammation and brain development in key neural circuits that underpin neurodevelopmental disorders. We will also discuss whether histamine receptor modulators have been efficacious in the treatment of neurodevelopmental disorders in both preclinical and clinical studies. This could represent an important area of future research as early modulation of histamine from neuronal as well as non-neuronal sources may provide novel therapeutic targets in these disorders.
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Affiliation(s)
- Elliott Carthy
- Department of Pharmacology, University of Oxford, Oxford, United Kingdom
| | - Tommas Ellender
- Department of Pharmacology, University of Oxford, Oxford, United Kingdom
- Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
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16
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Abstract
PURPOSE This study aimed to document the treatment trajectories and clozapine use in first-episode psychosis patients and to document the underlying reasons for using or not using clozapine in patients not achieving psychosis remission. METHODS We conducted a retrospective chart audit of patients aged 18 to 30 years having DSM-5 diagnoses of schizophrenia spectrum psychotic disorders treated in 3 Canadian early intervention programs for psychosis. The severity of the patient's illness (using the Clinical Global Impression Severity [CGI-S] scale) and remission of psychosis were rated before and after each antipsychotic trial. RESULTS One hundred and forty-seven patients were included in the study. There were 19.7% patients exposed to clozapine after an average of 2.4 antipsychotic trials and a mean delay of 470.8 days. There were 75.9% patients who improved their CGI-S score (mean improvement, 2.5) after the clozapine trial and 62.1% achieved a CGI-S score ≤3. Full remission of psychosis on clozapine was achieved in 69.0% of the patients. Clozapine was successfully used for some patients with a nonadherent profile in our sample (eg, personality disorder, substance use disorder). Although the mean duration of clozapine trials during the observation period was 688.6 days, no patient discontinued clozapine because of adherence issues. CONCLUSIONS Clozapine use in these early intervention programs were at a rate consistent to what is expected from the literature and allowed a majority of patients to achieve remission of psychosis and to experience a robust improvement of severity of illness.
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17
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Iqbal E, Govind R, Romero A, Dzahini O, Broadbent M, Stewart R, Smith T, Kim CH, Werbeloff N, MacCabe JH, Dobson RJB, Ibrahim ZM. The side effect profile of Clozapine in real world data of three large mental health hospitals. PLoS One 2020; 15:e0243437. [PMID: 33290433 PMCID: PMC7723266 DOI: 10.1371/journal.pone.0243437] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 11/22/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Mining the data contained within Electronic Health Records (EHRs) can potentially generate a greater understanding of medication effects in the real world, complementing what we know from Randomised control trials (RCTs). We Propose a text mining approach to detect adverse events and medication episodes from the clinical text to enhance our understanding of adverse effects related to Clozapine, the most effective antipsychotic drug for the management of treatment-resistant schizophrenia, but underutilised due to concerns over its side effects. MATERIAL AND METHODS We used data from de-identified EHRs of three mental health trusts in the UK (>50 million documents, over 500,000 patients, 2835 of which were prescribed Clozapine). We explored the prevalence of 33 adverse effects by age, gender, ethnicity, smoking status and admission type three months before and after the patients started Clozapine treatment. Where possible, we compared the prevalence of adverse effects with those reported in the Side Effects Resource (SIDER). RESULTS Sedation, fatigue, agitation, dizziness, hypersalivation, weight gain, tachycardia, headache, constipation and confusion were amongst the highest recorded Clozapine adverse effect in the three months following the start of treatment. Higher percentages of all adverse effects were found in the first month of Clozapine therapy. Using a significance level of (p< 0.05) our chi-square tests show a significant association between most of the ADRs and smoking status and hospital admission, and some in gender, ethnicity and age groups in all trusts hospitals. Later we combined the data from the three trusts hospitals to estimate the average effect of ADRs in each monthly interval. In gender and ethnicity, the results show significant association in 7 out of 33 ADRs, smoking status shows significant association in 21 out of 33 ADRs and hospital admission shows the significant association in 30 out of 33 ADRs. CONCLUSION A better understanding of how drugs work in the real world can complement clinical trials.
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Affiliation(s)
- Ehtesham Iqbal
- The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Risha Govind
- The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Alvin Romero
- SLAM BioResource for Mental Health, South London and Maudsley NHS Foundation Trust and King’s College London, London, United Kingdom
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Matthew Broadbent
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation, London, United Kingdom
- Biomedical Research Unit for Dementia, South London and Maudsley NHS Foundation, London, United Kingdom
| | - Robert Stewart
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation, London, United Kingdom
- Biomedical Research Unit for Dementia, South London and Maudsley NHS Foundation, London, United Kingdom
- Department of Health Service & Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Tanya Smith
- Oxford Health NHS Foundation Trust, Oxford, United Kingdom
- NIHR Oxford Health Biomedical Research Centre, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Chi-Hun Kim
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Nomi Werbeloff
- UCL Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington, NHS Foundation Trust, London, United Kingdom
| | - James H. MacCabe
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation, London, United Kingdom
- Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, United Kingdom
| | - Richard J. B. Dobson
- The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation, London, United Kingdom
- Biomedical Research Unit for Dementia, South London and Maudsley NHS Foundation, London, United Kingdom
- The Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals, London, United Kingdom
| | - Zina M. Ibrahim
- The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation, London, United Kingdom
- Biomedical Research Unit for Dementia, South London and Maudsley NHS Foundation, London, United Kingdom
- The Farr Institute of Health Informatics Research, UCL Institute of Health Informatics, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals, London, United Kingdom
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18
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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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Correll C, Cañas F, Larmo I, Levy P, Montes JM, Fagiolini A, Papageorgiou G, Rossi A, Sturlason R, Zink M. Individualizing antipsychotic treatment selection in schizophrenia: characteristics of empirically derived patient subgroups. Eur Psychiatry 2020; 26:3-16. [DOI: 10.1016/s0924-9338(11)71709-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AbstractTreatment of schizophrenia with antipsychotic drugs is frequently sub-optimal. One reason for this may be heterogeneity between patients with schizophrenia. The objectives of this study were to identify patient, disease and treatment attributes that are important for physicians in choosing an antipsychotic drug, and to identify empirically subgroups of patients who may respond differentially to antipsychotic drugs. The survey was conducted by structured interview of 744 randomly-selected psychiatrists in four European countries who recruited 3996 patients with schizophrenia. Information on 39 variables was collected. Multiple component analysis was used to identify dimensions that explained the variance between patients. Three axes, accounting for 99% of the variance, were associated with disease severity (64%), socioeconomic status (27%) and patient autonomy (8%). These dimensions discriminated between six discrete patient subgroups, identified using ascending hierarchical classification analysis. The six subgroups differed regarding educational level, illness severity, autonomy, symptom presentation, addictive behaviors, comorbidities and cardiometabolic risk factors. Subgroup 1 patients had moderately severe physician-rated disease and addictive behaviours (23.2%); Subgroup 2 patients were well-integrated and autonomous with mild to moderate disease (6.7%); Subgroup 3 patients were less well-integrated with mild to moderate disease, living alone (11.2%); Subgroup 4 patients were women with low education levels (5.4%), Subgroup 5 patients were young men with severe disease (36.8%); and Subgroup 6 patients were poorly-integrated with moderately severe disease, needing caregiver support (16.7%). The presence of these subgroups, which require confirmation and extension regarding potentially identifiable biological markers, may help individualizing treatment in patients with schizophrenia.
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20
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Beck K, McCutcheon R, Stephenson L, Schilderman M, Patel N, Ramsay R, Howes OD. Prevalence of treatment-resistant psychoses in the community: A naturalistic study. J Psychopharmacol 2019; 33:1248-1253. [PMID: 31241396 DOI: 10.1177/0269881119855995] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Treatment-resistant schizophrenia (TRS) is a major cause of disability. Clozapine is currently the only antipsychotic medication licensed for its treatment. However, the rate of treatment resistance among outpatients with schizophrenia or other psychoses, and the rate of use of clozapine among them, is not known. AIMS The aims of this study are (a) to determine the point prevalence of treatment-resistant psychosis in a community sample, and (b) to determine the number of patients with TRS who have never had a clozapine trial. METHOD Clinico-demographic data were extracted from the case notes for 202 patients from two community mental-health teams. RESULTS We found that 56% (99/176) had a diagnosis of TRS, and 52% (51/99) of these patients had never been treated with clozapine. Patients of non-white ethnicity were less likely to have had a clozapine trial (p=0.009). The point prevalence of treatment resistance within the bipolar affective disorder sample was 19% (5/26). CONCLUSION These findings suggest that TRS is common in the community mental-health team, and a large proportion of these patients have not received clozapine. These findings indicate that identifying and treating treatment resistance should be a focus of community services for schizophrenia.
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Affiliation(s)
- Katherine Beck
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
- South London and the Maudsley NHS Foundation Trust, London, UK
- MRC London Institute of Medical Sciences, Hammersmith Hospital Campus, London, UK
| | - Robert McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
- South London and the Maudsley NHS Foundation Trust, London, UK
- MRC London Institute of Medical Sciences, Hammersmith Hospital Campus, London, UK
| | - Lucy Stephenson
- South London and the Maudsley NHS Foundation Trust, London, UK
| | | | - Natasha Patel
- South London and the Maudsley NHS Foundation Trust, London, UK
| | - Rosalind Ramsay
- South London and the Maudsley NHS Foundation Trust, London, UK
| | - Oliver D Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, UK
- South London and the Maudsley NHS Foundation Trust, London, UK
- MRC London Institute of Medical Sciences, Hammersmith Hospital Campus, London, UK
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21
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Patrón de uso de clozapina en España. Variabilidad e infraprescripción. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 12:151-162. [DOI: 10.1016/j.rpsm.2018.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/11/2018] [Accepted: 02/14/2018] [Indexed: 01/22/2023]
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22
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Thien K, O'Donoghue B. Delays and barriers to the commencement of clozapine in eligible people with a psychotic disorder: A literature review. Early Interv Psychiatry 2019; 13:18-23. [PMID: 29984888 DOI: 10.1111/eip.12683] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 05/16/2018] [Indexed: 01/08/2023]
Abstract
AIM While the majority of individuals with a first episode of psychosis (FEP) achieve symptomatic remission with the appropriate treatment, there is a small but significant proportion who do not achieve remission of symptoms despite adequate treatment with at least two antipsychotic medications (termed treatment resistance). Clozapine is indicated in individuals who fulfil the criteria for treatment-resistant schizophrenia, however, despite it being the most effective antipsychotic medication, there can be delays in the commencement of clozapine in eligible patients. METHODS A systematic search was performed to identify articles reporting either the time taken to commence clozapine (or delays) in eligible individuals or articles reporting barriers to the commencement of clozapine. The initial search generated 5588 articles and of these, 18 were eligible. RESULTS 13 studies described delays in commencing clozapine and five studies reported on the barriers to the commencement of clozapine. The duration of delay from when an individual was deemed eligible for clozapine treatment to the time of clozapine commencement ranged from 19.3 weeks to 5.5 years. In addition, the duration of illness prior to clozapine initiation ranged from 1.1 to 9.7 years. It was found that some clinicians were more inclined to prescribe antipsychotic polypharmacy or doses higher than recommended than to prescribe clozapine. CONCLUSIONS Delays in commencing clozapine have been consistently demonstrated. Early intervention for psychosis services are the ideal settings to identify individuals with persistent positive psychotic symptoms and commence clozapine if indicated.
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Affiliation(s)
- Kristen Thien
- Research Organisation, Orygen, the National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Brian O'Donoghue
- Research Organisation, Orygen, the National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria, Australia.,Youth Mental Health Clinical Service, Orygen Youth Health, Parkville, Victoria, Australia
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23
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Correll CU, Brevig T, Brain C. Exploration of Treatment-Resistant Schizophrenia Subtypes Based on a Survey of 204 US Psychiatrists. Neuropsychiatr Dis Treat 2019; 15:3461-3473. [PMID: 31908461 PMCID: PMC6927567 DOI: 10.2147/ndt.s234813] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/21/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To explore and describe potential subgroups within the treatment-resistant schizophrenia (TRS) population, using data from a survey of US psychiatrists. METHODS Psychiatrists completed an online survey of demographic/clinical characteristics and treatment history for two of their patients with TRS. Patients were stratified according to number of suicide attempts, number of hospitalizations, employment status, and TRS onset time frame. RESULTS Of the 408 patients with TRS described by psychiatrists, 37.5% had ≥1 suicide attempt, 78.9% had ≥2 hospitalizations, 74.5% were unemployed, 45.0% had TRS onset within 5 years of first treatment (a further 8.0% had TRS from first treatment), and 31.5% had TRS onset after 5 years (15.5% unknown). Patients with ≥1 (vs 0) suicide attempts had statistically significantly more psychiatric (3.6 vs 2.2) and physical (2.2 vs 1.6) comorbidities. Patients with ≥2 (vs ≤1) hospitalizations were statistically significantly more likely to have hallucinations, conceptual disorganization, social withdrawal, and cognitive dysfunction, and had more psychiatric (3.0 vs 1.9) and physical (2.0 vs 1.1) comorbidities. Unemployed (vs employed) patients were statistically significantly more likely to have delusions, hallucinations, blunted affect, social withdrawal, and cognitive dysfunction, and had more psychiatric (2.9 vs 2.3) and physical (2.1 vs 1.2) comorbidities. Patients with TRS onset ≤5 (vs >5) years were statistically significantly younger (35.0 vs 43.7 years), less likely to have hallucinations and social withdrawal, and had fewer psychiatric (2.6 vs 3.3) and physical (1.7 vs 2.3) comorbidities. CONCLUSIONS Greater clinical burden in TRS is associated with greater illness severity and chronicity markers, suggesting a dimensional gradient from non-TRS to mild-moderate and more severe forms of TRS. Time to onset of TRS may have implications for outcomes, with data indicating greater burden in those with late-onset TRS. Accumulation of illness over time may be more important than time to onset.
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Affiliation(s)
- Christoph U Correll
- The Zucker Hillside Hospital, Department of Psychiatry, Glen Oaks, NY, USA.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA.,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Berlin, Germany
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24
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Crocker CE, Tibbo PG. Confused Connections? Targeting White Matter to Address Treatment Resistant Schizophrenia. Front Pharmacol 2018; 9:1172. [PMID: 30405407 PMCID: PMC6201564 DOI: 10.3389/fphar.2018.01172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/28/2018] [Indexed: 12/14/2022] Open
Abstract
Despite development of comprehensive approaches to treat schizophrenia and other psychotic disorders and improve outcomes, there remains a proportion (approximately one-third) of patients who are treatment resistant and will not have remission of psychotic symptoms despite adequate trials of pharmacotherapy. This level of treatment response is stable across all stages of the spectrum of psychotic disorders, including early phase psychosis and chronic schizophrenia. Our current pharmacotherapies are beneficial in decreasing positive symptomology in most cases, however, with little to no impact on negative or cognitive symptoms. Not all individuals with treatment resistant psychosis unfortunately, even benefit from the potential pharmacological reductions in positive symptoms. The existing pharmacotherapy for psychosis is targeted at neurotransmitter receptors. The current first and second generation antipsychotic medications all act on dopamine type 2 receptors with the second generation drugs also interacting significantly with serotonin type 1 and 2 receptors, and with varying pharmacodynamic profiles overall. This focus on developing dopaminergic/serotonergic antipsychotics, while beneficial, has not reduced the proportion of patients experiencing treatment resistance to date. Another pharmacological approach is imperative to address treatment resistance both for response overall and for negative symptoms in particular. There is research suggesting that changes in white matter integrity occur in schizophrenia and these may be more associated with cognition and even negative symptomology. Here we review the evidence that white matter abnormalities in the brain may be contributing to the symptomology of psychotic disorders. Additionally, we propose that white matter may be a viable pharmacological target for pharmacoresistant schizophrenia and discuss current treatments in development for schizophrenia that target white matter.
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Affiliation(s)
- Candice E Crocker
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada.,Department of Diagnostic Imaging, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
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Vanes LD, Mouchlianitis E, Collier T, Averbeck BB, Shergill SS. Differential neural reward mechanisms in treatment-responsive and treatment-resistant schizophrenia. Psychol Med 2018; 48:2418-2427. [PMID: 29439750 PMCID: PMC6704377 DOI: 10.1017/s0033291718000041] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The significant proportion of schizophrenia patients refractory to treatment, primarily directed at the dopamine system, suggests that multiple mechanisms may underlie psychotic symptoms. Reinforcement learning tasks have been employed in schizophrenia to assess dopaminergic functioning and reward processing, but these have not directly compared groups of treatment-refractory and non-refractory patients. METHODS In the current functional magnetic resonance imaging study, 21 patients with treatment-resistant schizophrenia (TRS), 21 patients with non-treatment-resistant schizophrenia (NTR), and 24 healthy controls (HC) performed a probabilistic reinforcement learning task, utilizing emotionally valenced face stimuli which elicit a social bias toward happy faces. Behavior was characterized with a reinforcement learning model. Trial-wise reward prediction error (RPE)-related neural activation and the differential impact of emotional bias on these reward signals were compared between groups. RESULTS Patients showed impaired reinforcement learning relative to controls, while all groups demonstrated an emotional bias favoring happy faces. The pattern of RPE signaling was similar in the HC and TRS groups, whereas NTR patients showed significant attenuation of RPE-related activation in striatal, thalamic, precentral, parietal, and cerebellar regions. TRS patients, but not NTR patients, showed a positive relationship between emotional bias and RPE signal during negative feedback in bilateral thalamus and caudate. CONCLUSION TRS can be dissociated from NTR on the basis of a different neural mechanism underlying reinforcement learning. The data support the hypothesis that a favorable response to antipsychotic treatment is contingent on dopaminergic dysfunction, characterized by aberrant RPE signaling, whereas treatment resistance may be characterized by an abnormality of a non-dopaminergic mechanism - a glutamatergic mechanism would be a possible candidate.
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Affiliation(s)
- Lucy D Vanes
- Institute of Psychiatry, Psychology and Neuroscience,de Crespigny Park,London, SE5 8AF,UK
| | - Elias Mouchlianitis
- Institute of Psychiatry, Psychology and Neuroscience,de Crespigny Park,London, SE5 8AF,UK
| | - Tracy Collier
- Institute of Psychiatry, Psychology and Neuroscience,de Crespigny Park,London, SE5 8AF,UK
| | - Bruno B Averbeck
- Unit on Learning and Decision Making, Laboratory of Neuropsychology,NIMH,NIH, Bethesda, MD 20892,USA
| | - Sukhi S Shergill
- Institute of Psychiatry, Psychology and Neuroscience,de Crespigny Park,London, SE5 8AF,UK
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Thien K, Bowtell M, Eaton S, Bardell-Williams M, Downey L, Ratheesh A, McGorry P, O'Donoghue B. Clozapine use in early psychosis. Schizophr Res 2018. [PMID: 29525463 DOI: 10.1016/j.schres.2018.02.054] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The superior efficacy of clozapine in treatment resistant schizophrenia has been clearly demonstrated, yet there are often delays in the commencement of clozapine. In this study, we aimed to determine; the proportion of young people with a first episode of psychosis (FEP) who would be considered eligible for clozapine treatment, the theoretical delay in commencing clozapine and to compare the outcomes of those treated with clozapine to those who were eligible but not treated with clozapine. METHODS This study was conducted at Orygen Youth Health (OYH), a youth mental health service for young people aged 15-24. All clients who were treated at the Early Psychosis Prevention and Intervention Centre (EPPIC) clinic between 01.01.2011 and 31.12.2013 were included. RESULTS 544 young people presented with a FEP in the study period and 9.4% (N = 51) subsequently fulfilled criteria for treatment-resistant schizophrenia. Of these individuals, thirty (58.8%) were commenced on clozapine, in addition to a further eleven. The median delay to the commencement of clozapine was 42 weeks (I.Q.R. = 7.5-64). Of those commenced on clozapine, 76.6% achieved remission of positive psychotic symptoms and 50% were in employment or education by the time of discharge or transfer to the adult mental health services. The rate of discontinuation of clozapine was 24.4% and 60.0% of discontinuations were due to cardiac complications and the remainder were due to non-compliance. CONCLUSIONS These findings suggest that early intervention for psychosis services have a crucial role in ensuring timely initiation of clozapine in individuals with a diagnosis of treatment-resistant schizophrenia.
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Affiliation(s)
- Kristen Thien
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Meghan Bowtell
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Scott Eaton
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Melissa Bardell-Williams
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Linglee Downey
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Aswin Ratheesh
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia; Orygen Youth Health, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Patrick McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia
| | - Brian O'Donoghue
- Orygen, The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, Victoria 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, 35 Poplar Road, Parkville, Victoria 3052, Australia; Orygen Youth Health, 35 Poplar Road, Parkville, Victoria 3052, Australia.
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Disrupted sphingolipid metabolism following acute clozapine and olanzapine administration. J Biomed Sci 2018; 25:40. [PMID: 29720183 PMCID: PMC5932814 DOI: 10.1186/s12929-018-0437-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/12/2018] [Indexed: 12/21/2022] Open
Abstract
Background Second generation antipsychotics (SGAs) induce glucometabolic side-effects, such as hyperglycemia and insulin resistance, which pose a therapeutic challenge for mental illness. Sphingolipids play a role in glycaemic balance and insulin resistance. Endoplasmic reticulum (ER) stress contributes to impaired insulin signalling and whole-body glucose intolerance. Diabetogenic SGA effects on ER stress and sphingolipids, such as ceramide and sphingomyelin, in peripheral metabolic tissues are unknown. This study aimed to investigate the acute effects of clozapine and olanzapine on ceramide and sphingomyelin levels, and protein expression of key enzymes involved in lipid and glucose metabolism, in the liver and skeletal muscle. Methods Female rats were administered olanzapine (1 mg/kg), clozapine (12 mg/kg), or vehicle (control) and euthanized 1-h later. Ceramide and sphingomyelin levels were examined using electrospray ionization (ESI) mass spectrometry. Expression of lipid enzymes (ceramide synthase 2 (CerS2), elongation of very long-chain fatty acid 1 (ELOVL1), fatty acid synthase (FAS) and acetyl CoA carboxylase 1 (ACC1)), ER stress markers (inositol-requiring enzyme 1 (IRE1) and eukaryotic initiation factor (eIF2α) were also examined. Results Clozapine caused robust reductions in hepatic ceramide and sphingolipid levels (p < 0.0001), upregulated CerS2 (p < 0.05) and ELOVL1 (+ 37%) and induced significant hyperglycemia (vs controls). In contrast, olanzapine increased hepatic sphingomyelin levels (p < 0.05 vs controls). SGAs did not alter sphingolipid levels in the muscle. Clozapine increased (+ 52.5%) hepatic eIF2α phosphorylation, demonstrating evidence of activation of the PERK/eIF2α ER stress axis. Hepatic IRE1, FAS and ACC1 were unaltered. Conclusions This study provides the first evidence that diabetogenic SGAs disrupt hepatic sphingolipid homeostasis within 1-h of administration. Sphingolipids may be key candidates in the mechanisms underlying the diabetes side-effects of SGAs; however, further research is required.
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White matter changes in treatment refractory schizophrenia: Does cognitive control and myelination matter? NEUROIMAGE-CLINICAL 2018; 18:186-191. [PMID: 29387534 PMCID: PMC5789151 DOI: 10.1016/j.nicl.2018.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/14/2018] [Indexed: 01/14/2023]
Abstract
Widespread white matter abnormalities have been reported in schizophrenia, a disorder frequently characterised as a dysconnection syndrome. White matter connectivity in schizophrenia has been predominantly investigated using diffusion weighted imaging, with reductions in fractional anisotropy throughout the brain often interpreted as an indicator of abnormal myelination. However, diffusion weighted imaging lacks specificity and as such a number of microstructural factors besides myelin may be contributing to these results. We utilised multicomponent driven equilibrium single pulse observation of T1 and T2 (mcDESPOT) in medicated patients with chronic schizophrenia, stratified by treatment response status, and healthy controls, in order to assess myelin water fraction (MWF) in these groups. In addition, we assessed cognitive control using the Stroop task to investigate how response inhibition relates to myelination in patients and controls. Both treatment resistant (n = 22) and treatment responsive (n = 21) patients showed reduced MWF compared to healthy controls (n = 24) in bilateral fronto-occipital fasciculi, particularly evident in the vicinity of the striatum und extending to the cerebellum, with no difference between patient groups. Patients showed greater reaction time interference on the Stroop task compared to healthy controls, with no difference between patient groups. Stroop interference was significantly negatively correlated with MWF in the corpus callosum across groups, and MWF differences in this region mediated the behavioural group effects on the Stroop task. These findings support the suitability of mcDESPOT as a myelin-specific measure of abnormal connectivity in schizophrenia, and suggest that treatment resistant schizophrenia is not characterised by more severe abnormalities in myelination or cognitive control compared to treatment responsive schizophrenia. Treatment resistant and responsive schizophrenia patients show reduced myelin water fraction compared to healthy controls Myelin water fraction in the corpus callosum is related to performance on a cognitive control task Myelin water fraction in the corpus callosum mediates differences in a cognitive control task between patients and controls
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Abstract
SummaryUp to a third of patients with schizophrenia develop treatment resistance. Clozapine has been established as the most effective antipsychotic medication for treatment-resistant schizophrenia. However, it is significantly underutilised in this population. Possible reasons include clinicians' lack of experience with the drug and negative attitudes towards it. African-Caribbean patients are less likely to be treated with clozapine compared with their White counterparts and more likely to have treatment discontinued due to perceived risk of agranulocytosis. This paper discusses the current evidence relating to the underuse of clozapine and factors responsible for this.
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Abstract
PURPOSE/BACKGROUND For approximately one third of individuals treated for psychosis or schizophrenia, antipsychotic medications will have little or no therapeutic benefit. Clozapine remains the sole medication approved for treatment-resistant schizophrenia, and studies have demonstrated its superior efficacy in reducing psychotic symptoms. METHODS/PROCEDURES Data were collected from the medical records of people who originally presented with a first-episode psychosis between 1995 and 1999 (N = 171). Data were obtained from first presentation up to December 31, 2013 or until the patient was discharged or transferred. Information on service use and physical health was gathered using a data collection template designed specifically for this audit. FINDINGS/RESULTS Twenty-eight (16.3%) of the cohort were prescribed clozapine. Data were available for 24 individuals. Of this clozapine subsample, the mean age at baseline was 23.11 (SD = 4.58); 82.14% (n = 23) were male; and 82.14% (n = 23) had a baseline diagnosis of schizophrenia. The mean time to first trial of clozapine was 6.7 years. The mean number of antipsychotics prescribed before clozapine trial was 4.85. After the initiation of clozapine, the mean number of hospital admissions reduced from 6.04 per year to 0.88 per year. IMPLICATIONS/CONCLUSIONS Nearly 1 in 5 of the original cohort was considered to have a suboptimal response to trials of antipsychotic medication. The use of clozapine for treatment-resistant schizophrenia is underutilized, and better understanding of the barriers to prescribing clozapine is necessary given the implications for patient's quality of life and hospital admission rates. Physical health data further emphasizes the importance of physical health monitoring in this vulnerable population.
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McMillan SS, Jacobs S, Wilson L, Theodoros T, Robinson G, Anderson C, Mihala G, Wheeler AJ. Antipsychotic prescribing for vulnerable populations: a clinical audit at an acute Australian mental health unit at two-time points. BMC Psychiatry 2017; 17:139. [PMID: 28407747 PMCID: PMC5390470 DOI: 10.1186/s12888-017-1295-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/31/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Antipsychotics are recognised as a critical intervention for schizophrenia and bipolar disorder. Guidelines globally endorse the routine practice of antipsychotic monotherapy, at the minimum effective dose. Even in treatment-resistant schizophrenia, clozapine use is endorsed before combining antipsychotics. This aim of this study was to review antipsychotic polytherapy alone, high-dose therapy alone, polytherapy and high-dose prescribing patterns in adults discharged from an inpatient mental health unit at two time-points, and the alignment of this prescribing with clinical guideline recommendations. Additionally, associations with polytherapy and high-dose antipsychotic prescribing, including patient and clinical characteristics, were explored. METHODS A retrospective clinical audit of 400 adults (200 patients at two different time-points) discharged with at least one antipsychotic. Preliminary findings and education sessions were provided to physicians between Cohorts. Outcomes (polytherapy alone, high-dose therapy alone, polytherapy and high-dose therapy) were compared between study Cohorts using chi-squared and rank-sum tests. Associations between outcomes and covariates were assessed using multivariable logistic regression. RESULTS Most patients (62.5%) were discharged on a single antipsychotic within the recommended dose range. There was a clear preference for prescribing second generation antipsychotics, and in this respect, prescribing is aligned with current evidence-based guidelines. However, sub-optimal prescribing practices were identified for both Cohorts in relation to polytherapy and high-dose antipsychotic rates. Involuntary treatment, frequent hospitalisations and previous clozapine use significantly increased the risk of all three prescribing outcomes at discharge. CONCLUSIONS In a significant minority, antipsychotic prescribing did not align with clinical guidelines despite increased training, indicating that the education program alone was ineffective at positively influencing antipsychotic prescribing practices. Further consideration should be given when prescribing antipsychotics for involuntary patients, people with frequent hospitalisations, and those who have previously trialled clozapine.
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Affiliation(s)
- Sara S McMillan
- Menzies Health Insitute, Griffith University, Brisbane, Australia.
| | - Sara Jacobs
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Louise Wilson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Theo Theodoros
- grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Royal Australia and New Zealand College of Psychiatrists Trainee, Melbourne, Victoria Australia ,Metro South Addiction and Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Gail Robinson
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.1003.2Faculty of Medicine, University of Queensland, Brisbane, Australia ,Metro North Mental Health Services, Department of Health, Brisbane, Queensland Australia
| | - Claire Anderson
- grid.4563.4Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Gabor Mihala
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia
| | - Amanda J Wheeler
- grid.1022.1Menzies Health Insitute, Griffith University, Brisbane, Australia ,grid.9654.eFaculty of Medical and Health Sciences, Auckland University, Auckland, New Zealand
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Williams R, Malla A, Roy MA, Joober R, Manchanda R, Tibbo P, Banks N, Agid O. What Is the Place of Clozapine in the Treatment of Early Psychosis in Canada? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:109-114. [PMID: 27310245 PMCID: PMC5298522 DOI: 10.1177/0706743716651049] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Research and development of early intervention (EI) services for first-episode psychosis have brought much-needed transformation of service delivery for this serious mental disorder to many jurisdictions. The effectiveness of the EI model of service delivery is contingent on timely access to all evidence-informed treatment interventions, including a rational approach to pharmacotherapy. In this perspective paper, we present a brief review of the well-established effectiveness of clozapine in patients who clearly show lack of response to regular antipsychotic therapy. We concentrate, in particular, on the need to identify eligibility for clozapine therapy very early on following failure of treatment on 2 antipsychotic medications. We suggest that attention to the low use of clozapine in the very early phase of treatment of psychosis may be of particular value, as the response to clozapine at this stage is likely to produce larger benefits in other domains of outcomes because of the greater retention of patients' personal and social agency.
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Affiliation(s)
- Richard Williams
- 1 Department of Psychiatry, University of British Columbia, Victoria, British Columbia
| | - Ashok Malla
- 2 Department of Psychiatry, McGill University, Montréal, Québec.,3 Prevention and Early Intervention Program for the Psychoses, Douglas Mental Health University Institute, Montréal, Québec
| | - Marc-Andre Roy
- 4 Département de Psychiatrie et Neurosciences, Faculté de Médecine de l'Université Laval, Québec, Québec.,5 Clinique Notre-Dame des Victoires, Centre intégré universitaire de la Capitale Nationale, Québec, Québec
| | - Ridha Joober
- 2 Department of Psychiatry, McGill University, Montréal, Québec.,3 Prevention and Early Intervention Program for the Psychoses, Douglas Mental Health University Institute, Montréal, Québec
| | - Rahul Manchanda
- 6 Psychiatry, Western University, London, Ontario.,7 Prevention and Early Intervention Program for Psychoses, London Health Sciences Centre, London, Ontario
| | - Phil Tibbo
- 8 Dalhousie University, Halifax, Nova Scotia.,9 Nova Scotia Early Psychosis Program, Halifax, Nova Scotia
| | - Nicola Banks
- 10 Canadian Consortium for Early Intervention in Psychosis, Hamilton, Ontario
| | - Ofer Agid
- 11 Complex Mental Illness Program/Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario.,12 Department of Psychiatry, University of Toronto, Toronto, Ontario
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Bugarski-Kirola D, Iwata N, Sameljak S, Reid C, Blaettler T, Millar L, Marques TR, Garibaldi G, Kapur S. Efficacy and safety of adjunctive bitopertin versus placebo in patients with suboptimally controlled symptoms of schizophrenia treated with antipsychotics: results from three phase 3, randomised, double-blind, parallel-group, placebo-controlled, multicentre studies in the SearchLyte clinical trial programme. Lancet Psychiatry 2016; 3:1115-1128. [PMID: 27816567 DOI: 10.1016/s2215-0366(16)30344-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 08/11/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Many patients with schizophrenia require high doses of medication for their ongoing psychotic symptoms. Glutamate theories and findings from studies showing efficacy of sarcosine, an endogenous, non-selective glycine-reuptake inhibitor mediated by GlyT1, offer an alternative approach. We undertook the SearchLyte trial programme to examine the efficacy of bitopertin, a selective GlyT1-mediated glycine-reuptake inhibitor, as an adjunctive treatment to ongoing antipsychotic treatment. METHODS SearchLyte consisted of three phase 3, randomised, double-blind, parallel-group, placebo-controlled, multicentre studies done in outpatient clinics in Asia, Europe, and North and South America (TwiLyte done at 109 sites, NightLyte at 84, and MoonLyte at 87). Participants were male and female outpatients, aged at least 18 years, meeting DSM-IV criteria for schizophrenia with suboptimally controlled positive symptoms despite treatment with antipsychotics. Inclusion criteria included a Positive and Negative Syndrome Scale (PANSS) total score of at least 70 and antipsychotic treatment stability for the past 12 weeks before randomisation. Key exclusion criteria included meeting criteria for symptomatic remission or previous treatment with a GlyT1 inhibitor or any other investigational drug. After a screening or 4-week prospective stabilisation period, we randomly assigned participants (1:1:1) to a 12-week, double-blind treatment of either placebo or one of two fixed doses of oral, once-daily bitopertin (10 or 20 mg in TwiLyte and NightLyte; 5 or 10 mg in MoonLyte) added to their current antipsychotic medicine. After completion of 12 weeks' treatment, the study design allowed for additional double-blind treatment for 40 weeks to assess maintenance of the effect, followed by a randomised 4-week washout period to assess withdrawal effects. Subsequently, all patients were offered the opportunity to receive bitopertin treatment in a 3-year follow-up. The primary efficacy endpoint was the mean change from baseline in the PANSS Positive Symptom Factor Score (PSFS) at week 12, analysed in the modified intention-to-treat population. The trials were registered at ClinicalTrials.gov (numbers NCT01235520 [TwiLyte], NCT01235585 [MoonLyte], and NCT01235559 [NightLyte]). FINDINGS Between Nov 19, 2010, and Dec 12, 2014, we randomly assigned 1794 patients to treatment, of whom 1772 were treated and analysed. MoonLyte was discontinued in September, 2014, on the basis of results from futility analyses. Across studies and treatment arms, most patients completed 12 weeks of treatment (505 in TwiLyte, 517 in NightLyte, and 506 in MoonLyte). Only one study, NightLyte, met the primary endpoint where the PANSS PSFS significantly differed from placebo at week 12, and only in the 10-mg arm: mean difference in score -1·37, 95% CI -2·27 to -0·47; p=0·0028. Improvements from baseline for the bitopertin 20-mg arm in Nightlyte were not significant compared with placebo: -3·77, 95% CI -4·40 to -3·14; p=0·3142. Results from the other two studies also did not differ from placebo (TwiLyte 0·58, 95% CI -0·34 to 1·50, p=0·22 for 10 mg and 0·43, -0·49 to 1·36, p=0·36 for 20 mg; MoonLyte 0·06, 95% CI -0·79 to 0·92, p=0·88 for 5 mg and 0·44, -0·41 to 1·28, p=0·31 for 10 mg). Placebo responses varied across studies and might have contributed to the differences in efficacy between studies. Four deaths occurred during the 12-week treatment period, three in NightLyte (upper gastrointestinal haemorrhage, alcohol poisoning and related head injury, and a completed suicide) and one in MoonLyte (myocardial infarction in a patient with pre-existing risk factors). Only the death by suicide was deemed related to the study drug. The incidence of serious adverse events was low across treatment groups in all three studies; psychiatric disorders were the most frequently reported serious adverse events and the most frequent cause of adverse events leading to discontinuation. INTERPRETATION Only one of six active treatment arms across the three studies offered an advantage of adjunctive bitopertin over placebo for the treatment of suboptimally controlled symptoms of schizophrenia. The small improvement associated with bitopertin together with the varying placebo response suggests that adjunctive bitopertin treatment might offer only modest benefit to suboptimal responders to antipsychotics, if any. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
| | - Nakao Iwata
- Department of Psychiatry, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | | | | | | | | | - Tiago Reis Marques
- Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
| | | | - Shitij Kapur
- Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK
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Kar N, Barreto S, Chandavarkar R. Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2016; 14:323-329. [PMID: 27776383 PMCID: PMC5083942 DOI: 10.9758/cpn.2016.14.4.323] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/20/2016] [Accepted: 02/21/2016] [Indexed: 01/16/2023]
Abstract
Clozapine is effective in treatment resistant schizophrenia; however, it is underutilised probably because of its side effects. The side effects are also the potential reasons for clozapine discontinuation. A mandatory requirement for its use is regular monitoring of white blood cell count and absolute neutrophil count. However there are many side effects that need monitoring in clinical practice considering their seriousness. This article tries to summarise the clinical concerns surrounding the serious side effects of clozapine some of which are associated with fatalities and presents a comprehensive way to monitor patients on clozapine in clinical practice. It emphasizes the need to broaden the monitoring beyond the mandatory investigations. This may help in improving the safety in clinical practice and increasing clinician confidence for greater and appropriate use of this effective intervention.
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Affiliation(s)
- Nilamadhab Kar
- Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom
| | - Socorro Barreto
- Black Country Partnership NHS Foundation Trust, Wolverhampton, United Kingdom
| | - Rahul Chandavarkar
- North Staffordshire Combined Healthcare NHS Trust, Stoke-on-Trent, United Kingdom
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Walter A, Suenderhauf C, Smieskova R, Lenz C, Harrisberger F, Schmidt A, Vogel T, Lang UE, Riecher-Rössler A, Eckert A, Borgwardt S. Altered Insular Function during Aberrant Salience Processing in Relation to the Severity of Psychotic Symptoms. Front Psychiatry 2016; 7:189. [PMID: 27933003 PMCID: PMC5120113 DOI: 10.3389/fpsyt.2016.00189] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/09/2016] [Indexed: 12/31/2022] Open
Abstract
There is strong evidence for abnormal salience processing in patients with psychotic experiences. In particular, there are indications that the degree of aberrant salience processing increases with the severity of positive symptoms. The aim of the present study was to elucidate this relationship by means of brain imaging. Functional magnetic resonance imaging was acquired to assess hemodynamic responses during the Salience Attribution Test, a paradigm for reaction time that measures aberrant salience to irrelevant stimulus features. We included 42 patients who were diagnosed as having a psychotic disorder and divided them into two groups according to the severity of their positive symptoms. Whole brain analysis was performed using Statistical Parametric Mapping. We found no significant behavioral differences with respect to task performance. Patients with more positive symptoms showed increased hemodynamic responses in the left insula corresponding to aberrant salience than in patients with less positive symptoms. In addition, left insula activation correlated negatively with cumulative antipsychotic medication. Aberrant salience processing in the insula may be increased in psychosis, depending on the severity of positive symptoms. This study indicates that clinically similar psychosis manifestations share the same functional characteristics. In addition, our results suggest that antipsychotic medication can modulate insular function.
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Affiliation(s)
- Anna Walter
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - Renata Smieskova
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Claudia Lenz
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - André Schmidt
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Tobias Vogel
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Undine E. Lang
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | | | - Anne Eckert
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Stefan Borgwardt
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
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Ingimarsson O, MacCabe JH, Haraldsson M, Jónsdóttir H, Sigurdsson E. Clozapine treatment and discontinuation in Iceland: A national longitudinal study using electronic patient records. Nord J Psychiatry 2016; 70:450-5. [PMID: 27049594 DOI: 10.3109/08039488.2016.1155234] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Clozapine is the only drug approved for treatment-resistant schizophrenia. There is evidence that clozapine is underutilized. AIMS To evaluate the initiation and discontinuation of clozapine at Landspitali University Hospital in Iceland and the prevalence of antipsychotic polypharmacy in clozapine-treated patients. METHODS The study is a part of an ongoing longitudinal study of schizophrenia in Iceland. We identified 201 patients on clozapine or who have been on clozapine by using a keyword search in the electronic health records and by reviewing their medical records. RESULTS Mean age at first treatment with clozapine was 37.8 years. Mean follow-up period on clozapine was 11 years. After 20 years of treatment 71.2% of patients were still on clozapine. After one year of treatment 84.4% of patients were still receiving clozapine treatment. We estimate that 11.4% of patients with schizophrenia in Iceland are taking clozapine and that 16% have been treated with clozapine at some point. Polypharmacy is common, since nearly 2/3, 65.6%, of patients taking clozapine use at least one other antipsychotic and 16.9% are also receiving depot injections. CONCLUSIONS We need to increase the awareness of psychiatrists in Iceland with regard to treatment with clozapine, since only about half of the estimated population of patients with treatment-resistant schizophrenia in Iceland have ever been treated with clozapine. Nearly two thirds of patients who are prescribed clozapine in Iceland remain on it long-term.
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Affiliation(s)
- Oddur Ingimarsson
- a Faculty of Medicine , School of Health Sciences, University of Iceland , Reykjavik , Iceland ;,b Mental Health Services, Landspitali University Hospital , Reykjavik , Iceland
| | - James H MacCabe
- c Kings College London , UK ;,d National Psychosis Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust , London , UK
| | - Magnús Haraldsson
- a Faculty of Medicine , School of Health Sciences, University of Iceland , Reykjavik , Iceland ;,b Mental Health Services, Landspitali University Hospital , Reykjavik , Iceland
| | - Halldóra Jónsdóttir
- a Faculty of Medicine , School of Health Sciences, University of Iceland , Reykjavik , Iceland ;,b Mental Health Services, Landspitali University Hospital , Reykjavik , Iceland
| | - Engilbert Sigurdsson
- a Faculty of Medicine , School of Health Sciences, University of Iceland , Reykjavik , Iceland ;,b Mental Health Services, Landspitali University Hospital , Reykjavik , Iceland
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Citrome L, McEvoy JP, Saklad SR. A Guide to the Management of Clozapine-Related Tolerability and Safety Concerns. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2016:CSRP.SACI.070816. [PMID: 27454214 DOI: 10.3371/csrp.saci.070816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Clozapine is a highly effective antipsychotic medication, which provides a range of significant benefits for patients with schizophrenia, and is the standard of care for treatment-resistant schizophrenia as well as for reducing the risk of suicidal behaviors in schizophrenia and schizoaffective disorder. However, clozapine is widely underutilized, largely because prescribing clinicians lack experience in prescribing it and managing its adverse events (AEs). Clozapine is associated with 3 uncommon but immediately dangerous AEs, agranulocytosis, myocarditis/cardiomyopathy, and seizures, as well as AEs that may become dangerous if neglected, including weight gain, metabolic syndrome and constipation, and others that are annoying or distressing such as sedation, nighttime enuresis and hypersalivation. Because of the risk of agranulocytosis, clozapine formulations are available only through restricted distribution via a patient registry, with mandatory, systematized monitoring for absolute neutrophil count using a specific algorithm. We identified articles on managing clozapine-associated AEs by searching PubMed using appropriate keywords and search techniques for each topic. A review of the prevalence and clinical characteristics of clozapine-associated AEs shows that these risks can be managed efficiently and effectively. The absolute risks for both agranulocytosis and myocarditis/cardiomyopathy are low, diminish after the first 6 months, and are further reduced with appropriate monitoring. Weight gain/metabolic disorders and constipation, which develop more gradually, can be mitigated with regular monitoring and timely interventions. Sedation, hypersalivation, and enuresis are common but manageable with ameliorative measures and/or medications.
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Affiliation(s)
| | | | - Stephen R Saklad
- 3 College of Pharmacy, University of Texas at Austin, Austin, TX, USA
- 4 Pharmacotherapy Education and Research Center, UT Health Science Center San Antonio, San Antonio, TX, USA
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Abstract
Although treatment-resistant schizophrenia (TRS) was described 50 years ago and has a gold standard treatment with clozapine based on well-defined criteria, there is still a matter of great interest and controversy. In terms of the underlying mechanisms of the development of TRS, progress has been made for the elucidation of the neurochemical mechanisms. Structural neuroimaging studies have shown that patients with TRS have significant reduction of the prefrontal cortex volume when compared with non- TRS. This article updates and enhances our previous review with new evidence mainly derived from new studies, clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- Helio Elkis
- Instituto de Psiquiatria HC- FMUSP, Rua Ovidio Pires de Campos 785-São Paulo, SP-05403-010, Brazil.
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Clozapine Underutilization in the Treatment of Schizophrenia: How Can Clozapine Prescription Rates Be Improved? J Clin Psychopharmacol 2016; 36:109-11. [PMID: 26872120 DOI: 10.1097/jcp.0000000000000478] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ketamine and suicidal ideation in depression: Jumping the gun? Pharmacol Res 2015; 99:23-35. [DOI: 10.1016/j.phrs.2015.05.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/05/2015] [Accepted: 05/06/2015] [Indexed: 02/07/2023]
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McCutcheon R, Beck K, Bloomfield MA, Marques TR, Rogdaki M, Howes OD. Treatment resistant or resistant to treatment? Antipsychotic plasma levels in patients with poorly controlled psychotic symptoms. J Psychopharmacol 2015; 29:892-7. [PMID: 25788157 PMCID: PMC4902121 DOI: 10.1177/0269881115576688] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A large proportion of individuals with schizophrenia show an inadequate response to treatment with antipsychotics. It can be unclear whether this is secondary to subtherapeutic antipsychotic plasma levels or to medication ineffectiveness. The purpose of the present study was to determine the extent of subtherapeutic antipsychotic plasma levels in a group of patients clinically identified as treatment-resistant. In addition we investigated the frequency of antipsychotic plasma level monitoring in standard clinical practice. Antipsychotic plasma levels were measured in 36 patients identified as having treatment-resistant schizophrenia by their treating clinicians. Sixteen (44%) patients showed either undetectable (19%) or subtherapeutic levels (25%), and 20 (56%) patients had levels in the therapeutic range. Subtherapeutic plasma levels were significantly associated with black ethnicity, shorter duration of current treatment and antipsychotics other than olanzapine and amisulpride. Antipsychotic plasma levels had been measured in only one patient in the year prior to our study. We found over one-third of patients identified as treatment-resistant have subtherapeutic antipsychotic levels. This indicates that they may be under-treated rather than treatment-resistant, and thus should receive different management. Currently the measurement of antipsychotic levels may be under-utilised.
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Affiliation(s)
- Robert McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Katherine Beck
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK
| | - Michael A.P. Bloomfield
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK,Psychiatric Imaging Group, MRC Clinical Sciences Centre, Institute of Clinical Science, Imperial College London, UK
| | - Tiago Reis Marques
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK
| | - Maria Rogdaki
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK
| | - Oliver D. Howes
- Department of Psychosis Studies, Institute of Psychiatry, King’s College London, UK,Psychiatric Imaging Group, MRC Clinical Sciences Centre, Institute of Clinical Science, Imperial College London, UK
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Grover S, Hazari N, Chakrabarti S, Avasthi A. Delay in initiation of clozapine: a retrospective study from a tertiary care hospital in North India. Psychiatry Res 2015; 226:181-5. [PMID: 25619433 DOI: 10.1016/j.psychres.2014.12.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/30/2014] [Accepted: 12/31/2014] [Indexed: 02/05/2023]
Abstract
This study aimed to assess the delay in initiation of clozapine, number of adequate antipsychotic trials prior to starting clozapine and practice of polypharmacy prior to starting clozapine. A retrospective study design was followed. Treatment records of 200 patients started on clozapine during the period of January 2006-June 2014 were reviewed. The mean delay in clozapine initiation was 1.93 (S.D. 1.82) years and median was 1.5 years. Mean of 3 (S.D. 1.18) adequate antipsychotic trials was given prior to considering clozapine and 27.5% patients had received polypharmacy prior to clozapine. Factors related to delay in starting of clozapine included higher age, longer duration of illness, age more than 20 years of age, polypharmacy, use of an adequate trial of typical antipsychotic medication, patients from urban locality and those with onset of illness prior to introduction of clozapine into Indian market. Findings of the present study suggest that there is a delay of 1.5-2 years in starting of clozapine and about one-fourth of patients receive polypharmacy prior to receiving clozapine. These finding suggests that there is a need to change the prescribing habits to reduce the delay in starting of clozapine.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post-Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Nandita Hazari
- Department of Psychiatry, Post-Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Subho Chakrabarti
- 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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Abstract
The glutamate and dopamine hypotheses are leading theories of the pathoaetiology of schizophrenia. Both were initially based on indirect evidence from pharmacological studies supported by post-mortem findings, but have since been substantially advanced by new lines of evidence from in vivo imaging studies. This review provides an update on the latest findings on dopamine and glutamate abnormalities in schizophrenia, focusing on in vivo neuroimaging studies in patients and clinical high-risk groups, and considers their implications for understanding the biology and treatment of schizophrenia. These findings have refined both the dopamine and glutamate hypotheses, enabling greater anatomical and functional specificity, and have been complemented by preclinical evidence showing how the risk factors for schizophrenia impact on the dopamine and glutamate systems. The implications of this new evidence for understanding the development and treatment of schizophrenia are considered, and the gaps in current knowledge highlighted. Finally, the evidence for an integrated model of the interactions between the glutamate and dopamine systems is reviewed, and future directions discussed.
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Affiliation(s)
- Oliver Howes
- Psychiatric Imaging, MRC Clinical Sciences Centre, Hammersmith Hospital, London, UK Institute of Psychiatry, King's College London, London, UK
| | - Rob McCutcheon
- Psychiatric Imaging, MRC Clinical Sciences Centre, Hammersmith Hospital, London, UK Institute of Psychiatry, King's College London, London, UK
| | - James Stone
- Psychiatric Imaging, MRC Clinical Sciences Centre, Hammersmith Hospital, London, UK Institute of Psychiatry, King's College London, London, UK
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Beck K, McCutcheon R, Bloomfield MAP, Gaughran F, Reis Marques T, MacCabe J, Selvaraj S, Taylor D, Howes OD. The practical management of refractory schizophrenia--the Maudsley Treatment REview and Assessment Team service approach. Acta Psychiatr Scand 2014; 130:427-38. [PMID: 25201058 DOI: 10.1111/acps.12327] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe a practical approach to the community management of treatment-resistant schizophrenia (TRS). METHOD A descriptive review of an approach to the assessment and management of patients with TRS, including the community titration of clozapine treatment, and a report of the management recommendations for the first one hundred patients assessed by the Treatment REview and Assessment Team (TREAT). RESULTS The standardized model for the community assessment, management and titration of clozapine is described. To date, 137 patients have been referred to this service and 100 patients (72%) attended for assessment. Of these, 33 have been initiated on clozapine while fifteen have had clozapine recommended but have not wished to undertake clozapine treatment. Other management options recommended have included augmentation strategies and long-acting injectable antipsychotics. CONCLUSION The service had increased the number of patients receiving community assessment and initiation of clozapine by five-fold relative to the rate prior to the establishment of the service. The large number of referrals and high attendance rate indicates that there is clinical demand for the model. Systematic evaluation is required to determine the clinical and cost-effectiveness of this model and its potential application to other clinical settings.
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Affiliation(s)
- K Beck
- Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK
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Haddad PM, Brain C, Scott J. Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies. Patient Relat Outcome Meas 2014; 5:43-62. [PMID: 25061342 PMCID: PMC4085309 DOI: 10.2147/prom.s42735] [Citation(s) in RCA: 340] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness's association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.
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Affiliation(s)
- Peter M Haddad
- Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK
- Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK
| | - Cecilia Brain
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Sweden
- Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Scott
- Academic Psychiatry, Institute of Neuroscience, Newcastle University, London, UK
- Centre for Affective Disorders, Institute of Psychiatry, London, UK
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Affiliation(s)
- Evanthia Achilla
- Centre for the Economics of Mental and Physical Health, Health Service and Population Research Department, Institute of Psychiatry, King's College London, London SE5 8AF, UK
| | - Paul McCrone
- Centre for the Economics of Mental and Physical Health, Health Service and Population Research Department, Institute of Psychiatry, King's College London, London SE5 8AF, UK.
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Fleischhacker WW, Arango C, Arteel P, Barnes TRE, Carpenter W, Duckworth K, Galderisi S, Halpern L, Knapp M, Marder SR, Moller M, Sartorius N, Woodruff P. Schizophrenia--time to commit to policy change. Schizophr Bull 2014; 40 Suppl 3:S165-94. [PMID: 24778411 PMCID: PMC4002061 DOI: 10.1093/schbul/sbu006] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Care and outcomes for people with schizophrenia have improved in recent years, but further progress is needed to help more individuals achieve an independent and fulfilled life. This report sets out the current need, informs policy makers and all relevant stakeholders who influence care quality, and supports their commitment to creating a better future. The authors recommend the following policy actions, based on research evidence, stakeholder consultation, and examples of best practice worldwide. (1) Provide an evidence-based, integrated care package for people with schizophrenia that addresses their mental and physical health needs. (2) Provide support for people with schizophrenia to enter and to remain in their community, and develop mechanisms to help guide them through the complex benefit and employment systems. (3) Provide concrete support, information, and educational programs to families and carers on how to enhance care for an individual living with schizophrenia in a manner that entails minimal disruption to their lives. (4) All stakeholders, including organizations that support people living with schizophrenia, should be consulted to regularly revise, update, and improve policy on the management of schizophrenia. (5) Provide support, which is proportionate to the impact of the disease, for research and development of new treatments. (6) Establish adequately funded, ongoing, and regular awareness-raising campaigns that form an integral part of routine plans of action. Implementation of the above recommendations will require engagement by every stakeholder, but with commitment from all, change can be achieved.
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Affiliation(s)
- W. Wolfgang Fleischhacker
- Department of Psychiatry and Psychotherapy, Medical University Innsbruck, Innsbruck, Austria;,*To whom correspondence should be addressed; Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria; tel: +43-512-504-23669, fax: +43-512-504-25267, e-mail:
| | - Celso Arango
- Hospital General Universitario Gregorio Marañón, CIBERSAM, Madrid, Spain
| | | | - Thomas R. E. Barnes
- Imperial College Centre for Mental Health, Faculty of Medicine, Imperial College London and West London Mental Health NHS Trust, London, UK
| | - William Carpenter
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore, MD
| | | | - Silvana Galderisi
- Department of Psychiatry, Second University of Naples, Naples, Italy
| | | | - Martin Knapp
- London School of Economics and the Institute of Psychiatry, King’s College London, London, UK
| | - Stephen R. Marder
- Semel Institute, UCLA, VA Desert Pacific Mental Illness Research Education and Clinical Center, Los Angeles, CA
| | - Mary Moller
- Past President, American Psychiatric Nurses Association, Yale School of Nursing, New Haven, CT
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | - Peter Woodruff
- Academic Faculty, Royal College of Psychiatrists, London, UK
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Alessi-Severini S, Le Dorze JA, Nguyen D, Honcharik P, Eleff M. Clozapine prescribing in a Canadian outpatient population. PLoS One 2013; 8:e83539. [PMID: 24358290 PMCID: PMC3865160 DOI: 10.1371/journal.pone.0083539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 11/05/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Description of demographics of an outpatient population of clozapine users. METHODS Retrospective chart review study of an urban population diagnosed with schizophrenia. Assessment of therapeutic histories in relation to clinical practice guidelines. RESULTS Seventy-seven of the 467 patients were on clozapine therapy. Average patients' age was 39.4 ± 11.8 years) and 68% were males. The majority of patients (68%) had tried 3 or more antipsychotics before switching to clozapine, 21% had tried two and 11% had tried one. Median length of therapy prior to clozapine initiation was 8.9 years in males and 7.7 years in females. CONCLUSION Until 2010, the use of clozapine was often delayed and more than 2 antipsychotic medications were tried for relatively long periods of time before patients were switched to this effective agent.
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Affiliation(s)
| | | | - David Nguyen
- Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia Honcharik
- Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmaceutical Services, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Michael Eleff
- Department of Psychiatry, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Role of MKP-1 (DUSP1) in clozapine-induced effects on the ERK1/2 signaling pathway in the rat frontal cortex. Psychopharmacology (Berl) 2013; 230:425-37. [PMID: 23771439 DOI: 10.1007/s00213-013-3165-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 05/30/2013] [Indexed: 10/26/2022]
Abstract
RATIONALE Clozapine affects the extracellular signal-regulated kinase 1/2 (ERK1/2) pathway in the brain, which plays an important role in its antipsychotic action. However, previous findings are inconsistent, and related molecular mechanisms require further clarification. OBJECTIVES Time- and dose-dependent effects of clozapine on the ERK1/2 pathway and its regulatory mechanism were investigated in rat frontal cortex. METHODS AND RESULTS At 15, 30, 60, and 120 min after intraperitoneal injection of clozapine (5, 10, and 20 mg/kg), changes in ERK1/2, its upstream canonical kinases (Raf1 and mitogen-activated protein kinase kinase 1/2 [MEK1/2]), and its downstream molecule (p90 ribosomal S6 kinase [p90RSK]) were investigated in rat frontal cortex. At 15 min, p-Raf1, p-MEK1/2, p-ERK1/2, and p-p90RSK all increased dose-dependently. At 30 min, p-ERK1/2 and p-p90RSK showed no significant changes, while dose-dependent increases in p-Raf1 and p-MEK1/2 were found. At 60 and 120 min, although p-ERK1/2 and p-p90RSK decreased, increases in p-Raf1 and p-MEK1/2 were maintained. A clozapine-induced reduction in ERK1/2 phosphorylation was evident at both tyrosine and threonine residues, suggesting the involvement of dual specificity phosphatases (DUSPs; mitogen-activated protein kinase phosphatases [MKPs]). mRNA expression of seven Dusps that can dephosphorylate ERK1/2 were examined; Mkp-1 (Dusp1) mRNA increased following clozapine treatment. Moreover, MKP-1 protein and phosphatase activity increased, and binding of MKP-1 to ERK1/2 was also upregulated by clozapine administration. CONCLUSIONS In rat frontal cortex, clozapine regulates ERK1/2 phosphorylation via MKP-1, which induces uncoupling between Raf1-MEK1/2 and ERK1/2-p90RSK activity. These findings suggest an important role of MKP-1 in the mechanism of action of clozapine.
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Affiliation(s)
- Dieter Naber
- Department of Psychiatry and Psychotherapy; Centre of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf; Martinistrasse 52; 20246; Hamburg; Germany
| | - Martin Lambert
- Department of Psychiatry and Psychotherapy; Centre of Psychosocial Medicine, University Medical Center Hamburg-Eppendorf; Martinistrasse 52; 20246; Hamburg; Germany
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