Prescription of antipsychotic and concomitant medications for adult Asian schizophrenia patients: Findings of the 2016 Research on Asian Psychotropic Prescription Patterns (REAP) survey

OBJECTIVE

Regular surveys are important to monitor the use of psychotropic medications in clinical practice. This study examined the psychotropic prescription patterns in adult Asian schizophrenia patients based on the data of the Research on Asian Psychotropic Prescription (REAP) 2016 survey.

METHODS

This cross-sectional survey across 15 Asian countries/territories collected socio-demographic and clinical data with standardized procedures between March and May 2016. The socio-demographic and clinical characteristics of the patients were recorded with a standardized questionnaire.

RESULTS

Altogether 3,537 adult patients with schizophrenia were consecutively screened and enrolled in the survey. The mean age was 38.66 ± 11.55 years and 59.7% of the sample were male. The mean dose of antipsychotics in chlorpromazine equivalents (CPZeq) was 424 ± 376 mg/day; 31.3% and 80.8% received first- and second- generation antipsychotics, respectively and 42.6% had antipsychotic polypharmacy, 11.7% had antidepressants, 13.7% had mood stabilizers, 27.8% had benzodiazepines, and 45.6% had anticholinergics.

CONCLUSIONS

Psychotropic prescription patterns in Asian adult patients with schizophrenia varied across countries. Regular surveys on psychotropic medications for schizophrenia are important to monitor pharmacotherapy practice in Asia.

Leading indicators of community-based violent events among adults with mental illness

BACKGROUND

The public health, public safety and clinical implications of violent events among adults with mental illness are significant; however, the causes and consequences of violence and victimization among adults with mental illness are complex and not well understood, which limits the effectiveness of clinical interventions and risk management strategies. This study examined interrelationships between violence, victimization, psychiatric symptoms, substance use, homelessness and in-patient treatment over time.

METHOD

Available data were integrated from four longitudinal studies of adults with mental illness. Assessments took place at baseline, and at 1, 3, 6, 9, 12, 15, 18, 24, 30 and 36 months, depending on the parent studies' protocol. Data were analysed with the autoregressive cross-lag model.

RESULTS

Violence and victimization were leading indicators of each other and affective symptoms were a leading indicator of both. Drug and alcohol use were leading indicators of violence and victimization, respectively. All psychiatric symptom clusters - affective, positive, negative, disorganized cognitive processing - increased the likelihood of experiencing at least one subsequent symptom cluster. Sensitivity analyses identified few group-based differences in the magnitude of effects in this heterogeneous sample.

CONCLUSIONS

Violent events demonstrated unique and shared indicators and consequences over time. Findings indicate mechanisms for reducing violent events, including trauma-informed therapy, targeting internalizing and externalizing affective symptoms with cognitive-behavioral and psychopharmacological interventions, and integrating substance use and psychiatric care. Finally, mental illness and violence and victimization research should move beyond demonstrating concomitant relationships and instead focus on lagged effects with improved spatio-temporal contiguity.

Escalated Aggressive Behavior: New Pharmacotherapeutic Approaches and Opportunities

Psychopharmacologic studies of aggressive behavior in animals under controlled laboratory conditions have been instrumental in developing and evaluating specific and effective novel drug treatments that reduce aggressive behavior. An initial contribution of this research is to create experimental conditions that enable the display of aggressive and defensive acts and postures in species that engage in either dominance or territorial or maternal aggression. Quantitative ethological analyses allow the precise delineation of the sequential organization of aggressive bursts, providing a benchmark for assessing excessive or pathological forms of aggressive behavior. A second contribution of preclinical research is the development of experimental models of escalated forms of aggressive behavior, such as focusing on genetic predispositions or social provocations and frustrative experiences. A critical role of preclinical research is in the pharmacological and neurochemical analysis of aggressive behavior; for example, a host of undesirable side effects prompted a shift from classic dopaminergic neuroleptic compounds to the more recently developed atypical neuroleptics with effective and more specific anti-aggressive effects. The long-established role of brain serotonin in impulsive and escalated forms of aggressive behavior continues to be a focus of preclinical studies. New evidence differentiates dynamic state changes in corticolimbic serotonergic neurons during the termination of aggressive behavior from the deficient-serotonin trait in violence-prone individuals. It can be anticipated that currently developed tools for targeting the genes that code for specific subtypes of serotonin receptors will offer new therapeutic options for reducing aggressive behavior, and the 5-HT(1B) receptor appears to be a promising target. The modulation of GABA and GABA(A) receptors by 5-HT in corticolimbic neurons promises to be particularly relevant for specific forms of escalated aggressive behavior such as alcohol-heightened aggression.

Pleiotropic contributions of nitric oxide to aggressive behavior

Male mice with targeted deletion of the genes encoding the neuronal (NOS-1-/- or nNOS-/-) isoform of nitric oxide synthase display altered aggressive behaviors. Male nNOS-1-/- mice are more aggressive than wild-type (WT) mice in all testing paradigms. Testosterone is necessary, but not sufficient, for evoking the persistent aggression, and that serotonin (5-HT) metabolism is altered in male nNOS-1-/- mice. The specific deletion of the nNOS-1 gene not only results in a lack of nNOS-1 protein, but in common with many genes, affects several 'down-stream' processes. In this review, we address whether the elevated aggression in male nNOS-1-/- mice reflects pleiotropic effects of the nNOS-1 gene on pain sensitivity, 'anxiety-like', or 'depressive-like' behaviors. For example, male nNOS-1-/- mice display increased sensitivity to painful stimuli, which may prolong aggressive interactions. Despite elevated corticosterone concentrations, nNOS-1 knockout mice appear to be less 'anxious' or fearful than WT mice. Male nNOS-1-/- mice display longer latencies to right themselves on an inverted platform and spend more time in the center of an open field than WT mice. Because of reduced serotonin turnover, the excessive aggressiveness displayed by nNOS-1-/- mice may be symptomatic of a depressive-like syndrome. However, nNOS-1-/- mice rarely display behavioral 'despair' when assessed with the Porsolt forced swim test; rather, nNOS-1-/- mice show vigorous swimming throughout the assessment suggesting that the aggressive behavior does not represent depressive-like behavior. Importantly, aggressive behavior is not a unitary process, but is the result of complex interactions among several physiological, motivational, and behavioral systems, with contributions from the social as well as the physical environment. Lastly, the multiple, and often unanticipated, effects of targeted gene disruption on aggressive behavior are considered.

Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part I: a review

OBJECTIVES

To review the evidence for the safety and efficacy of nonpharmacological and pharmacological treatments for aggression in children and adolescents.

METHOD

and searches (1990-present) were conducted for double-blind, placebo-controlled studies of atypical antipsychotics for aggression and for literature on the use of other pharmacological agents and psychosocial interventions for aggression. Case reports and adult literature regarding the safety of atypical antipsychotics were used where controlled data for youth were lacking.

RESULTS

Controlled data on the treatment of aggression in youth is scarce. Psychosocial interventions may be effective alone or in combination with pharmacological treatments. Psychotropic agents (e.g., stimulants, mood stabilizers, beta-blockers) have also been shown to have limited efficacy in reducing aggression. Antipsychotics, particularly the atypical antipsychotics, show substantial efficacy in the treatment of aggression in selected pediatric populations. Atypical antipsychotics are generally associated with fewer extrapyramidal symptoms than are typical antipsychotics.

CONCLUSIONS

Psychosocial interventions and atypical antipsychotics are promising treatments for aggression in youth. Double-blind studies should examine the safety and efficacy of atypical antipsychotics compared to each other and to medications from other classes, the efficacy of specific medications for different subtypes of aggression, combining various psychotropic medications, optimal dosages, and long-term safety.

Atypical antipsychotics for acute agitation. New intramuscular options offer advantages

Violent or threatening behavior is a common reason for a visit to the emergency department. Patients with aggressive behavior must first be assessed for the possibility of comorbid medical conditions, which can complicate management. The introduction of intramuscular preparations of atypical antipsychotics provides new treatment options for acute agitation. These agents appear to be fast-acting and well tolerated and do not induce the akathisia of the older neuroleptic agents. Short-term sedation with lorazepam remains a safe and effective choice for managing acute agitation, in particular when withdrawal from alcohol may be a precipitating factor. However, lorazepam does not address the psychotic symptoms that may be at the core of much of this behavior. The intramuscular preparations of the atypical antipsychotics will probably supplant the intramuscular formulations of the older neuroleptics, much in the same way that the oral forms of these agents have become the agents of choice in treating psychosis. In addition, development of depot preparations of atypical antipsychotics is progressing rapidly. These products may further revolutionize the emergency and postemergency care of psychotic patients.

Violent patients in the emergency setting

Violent or threatening behavior is a common reason for presentation to the ED. Patients with aggressive behavior must first be assessed for the possibility of comorbid medical conditions. Acute withdrawal from alcohol or sedatives needs to be ruled out. Short-term sedation with lorazepam is a safe and effective choice for managing patients with acute agitation. The use of typical neuroleptics may lead to side effects, such as akathisia, which may in turn precipitate additional agitation. This may be obviated with the introduction of IM preparations of atypical antipsychotics.

Atypical antipsychotics in the treatment of the persistently aggressive psychotic patient: methodological concerns

Aggressive behavior of psychotic patients impacts all aspects of their clinical care. Better treatments to address this problem are needed, and atypical antipsychotics, such as clozapine, risperidone, and perhaps quetiapine, have shown promise. However, studying the psychopharmacology of aggression is difficult because of the many methodological problems that arise in the design of appropriate clinical trials. These include imprecise definitions of aggression, the difficulty of measuring outcome because of the relative rarity of aggressive events, bias in the selection of patients for study, inadequate and inappropriate control groups, and inattention to comorbidities and concomitant medications in analyzing results. Since the usual outcome measure is the aggressive event rate, a large sample size and lengthy baseline and trial periods are required when this rate is low. Furthermore, formidable practical and ethical obstacles interfere with the many sound techniques (e.g. randomization) used in typical designs of psychopharmacological clinical trials. Current research methods should be modified and new ones developed in order to progress in assessing the antiaggressive effects of treatments.

Current Understanding of Violence and Aggression: Assessment and Treatment

Links between violence, aggression, and mental illness are well documented. Despite this association, our current understanding of the causation and optimal treatment of aggression remains limited. This lack of knowledge is alarming because nurses treating patients with mentally illness are frequent targets of patient aggression. Consequently, the aim of this article is to provide contemporary information regarding the concept of patient aggression, assessment of violent behavior, and implementation of treatment interventions. A review of pharmacological and psychosocial strategies are presented as well. These findings provide psychiatric nurses with a conceptual model as well as practical interventions for patient aggression.