Clozapine Prescripers-Dogmatic or Pragmatic?

Clozapine, amongst antipsychotics, has a unique composite mode of action that might translate into an expanded therapeutic potential on clinical grounds. Sorely, clozapine remains underutilized.

Gepirone-the latest antidepressant on market state-of-the-art or run-of-the-mill?

Gepirone was recently launched and FDA-approved for MDD. It belongs to azapirones group of psychotropics that is in popular use in Japan and China. Here, author wraps up current knowledge on gepirone contrasted with the older and cheaper anxiolytic buspirone.

Pregabalin Adjuventia Helped Risperidone-Induced Extrapyramidal Syndrome and Augmented Antipsychotic Response in an Adolescent with Schizophrenia

Here, authors report on an interesting case of early-onset of schizophrenia where adjunctive pregabalin alleviated risperidone-induced pseudoparkinsonism, helped with insomnia and agitation and boosted antipsychotic response with great tolerability. We wager that gabapentenoids can be a viable option in the niche of psychopharmacotherapy of schizophrenia in CAP population.

Anxiety disorders among children and adolescents during COVID-19 lockdowns and school closures: a cross-sectional study in Kuwait

Introduction

Investigating the epidemiology of mental health disorders resulting from COVID-19 intervention measures, primary school closures, and social isolation in children and adolescents needs to be prioritized over adults at the post-pandemic stage. Most preliminary psychosocial studies conducted during the pandemic have demonstrated that younger age groups are the most vulnerable to such implications. Thus, this study aims to estimate the probable prevalence of specific anxiety disorders in children and quantify their relationships with relevant demographic risk factors.

Methods

We used a cross-sectional study comprising 430 children aged between 8- and 18 years old living in Kuwait during the period of school closures as well as full and partial lockdowns. The survey included questions about participants' characteristics, children's anxiety using the Screen for Child Anxiety Related Emotional Disorders Questionnaire (SCARED) scale, and children's emotions and behaviours using the Strengths and Difficulties Questionnaire (SDQ). Univariate and multivariate logistic regression analyses were used to summarize the demographic and characteristics of the participants and their association with general, social, and generalized anxieties, as well as behavioural and emotional difficulties.

Results

We inferred that 24.83% of our participants had at least one anxiety disorder, while 20.19% were classified as abnormal on the SDQ scale. Our multivariate analysis revealed that lockdown duration and sex of the child were consistently significant predictors (p-values < 0.05) of the broad spectrum of selected mental disorders. Additionally, we inferred notable increases in the likelihood of mental disorders associated with the increased duration of lockdowns.

Conclusions

Our findings revealed preliminary insights into the vulnerability of young populations to the indirect negative impacts of strict public health measures during pandemic emergencies. Thus, authorities should consider such implications when planning and implementing similar interventions in future pandemics.

β-Blockers for Autism-Help or Hindrance?

A renewed interest in the use of β-blockers for neurodevelopmental disorders has recently resurfaced, notably as an addition to the limited psychopharmacological armamentarium of autism spectrum disorders (ASD). In this clinical perspective, authors decently argue this use could be advantageous and multi-folded for this population.

Treatment-Resistant Juvenile Depression-A Quicksand?

Though research in juvenile depression is advancing, evidence examining effective treatments for Treatment-resistant juvenile depression remains at large limited. There is a dire need for more studies to help guide clinicians navigating these challenging cases.

2023 FDA-approved psychotropic medications

As of June 2023, (US) FDA has granted approval for a number of psychotropic drugs on market that might usher an innovative sparkle in psychopharmacotherapy. This is a recap to update busy clinicians.

Takotsubo Cardiomyopathy Related to Duloxetine-Atomoxetine Combination in an Adolescent with ADHD and Comorbid GAD

Authors report on an interesting case of a teenager with attention-deficit/hyperactivity disorder and comorbid generalized anxiety disorder, who developed takotsubo cardiomyopathy subsequent to pharmacokinetic and pharmacodynamic interactions between atomoxetine, a selective norepinephrine reuptake inhibitor, and the antidepressant duloxetine. Clinicians should be mindful of the potential for cardiovascular adverse effects when prescribing agents that target noradrenergic receptors.

Transcranial Magnetic Stimulation (TMS) for Major Depressive Disorder-Modus Operandi!

Background

Transcranial magnetic stimulation (TMS) is effective in the management of treatment resistant major depressive disorder (MDD) and has recently become widely available. Our aim was to explore the literature for evidence of the mechanism of action.

Method

We examined our own accumulating TMS library, the reference lists of all available papers and used a search engine to collect information. We collated and examined this information under relevant heading.

Results

TMS produces a large number of physiological changes including site of stimulation neurochemical, brain wave and blood flow effects, and distant structure effects including neurotransmitter effects and volume increase. TMS also corrects generalized and local functional connectivity (FC) abnormalities which are a feature of MDD.

Conclusion

TMS produces a range of physiological changes. It is unclear which of these underpin its antidepressant. It is likely more than one work synergistically to this end-almost certainly the capacity to correct MDD induced FC abnormalities makes a strong antidepressant contribution.

Probable Olanzapine-Related Idiopathic Intracranial Hypertension in an Adolescent With First-Episode Psychosis

Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) secondary to psychotropic drugs is a very rare occurrence. Lithium is typically the culprit agent. Here, authors report on an interesting case of an adolescent with early-onset schizophrenia that develops a reversible IIH putatively related to olanzapine-induced weight gain. This is followed by discussion of purported pharmacodynamic mechanisms and brief review of literature. Clinicians should be cognizant to this serious complication given the propensity of the majority of atypical antipsychotics to induce significant weight gain especially in younger population.

Clinical Indications of Memantine in Psychiatry-Science or Art?

Background

Memenatine is USFDA approved for dementia of Alzheimer's disease. Apart from this indication, trend of its use in psychiatry is on the rise addressing a multitude of disorders.

Study question

Memantine remains one of only few psychotropic drugs with antiglutamate activity. This might impart it a therapeutic potential in treatment-resistant major psychiatric disorders characterized by neuroprogression. We reviewed memantine basic pharmacology and its diversifying clinical indications while examining the extant evidence.

Methods

EMBASE, Ovid MEDLINE, PubMed, Scopus, Web of Science, and Cochrane Database of Systemic Reviews were searched for all relevant studies up to date of November, 2022.

Results

Sound evidence supports use of memantine for major neuro-cognitive disorder due to Alzheimer's disease and severe vascular dementia, obsessive-compulsive disorder, treatment-resistant schizophrenia, and, ADHD. Modicum evidence supports use of memantine for PTSD, GAD and pathological gambling. Less compelling evidence is present for use in catatonia. No evidence supports use for core symptoms of autism spectrum disorder.

Conclusions

Memantine is an important addition to the psychopharmacological armamentarium. Level of evidence supporting the use of memantine in these off-label indications is highly variable, and hence, sound clinical judgment is necessary for its proper use and placement in real-life psychiatric practice and psychopharmacotherapy algorithms.

Treatment of Parental Depression and Reduced Risk in Offspring-Does It Have Anything to Do with Offspring Gender?

Objective

There is an increased risk for depression in the offspring of depressed parents. This is in part mediated by maladaptive parenting. Females are more vulnerable to parenting behavior and were found to be at increased risk of depression compared to male offspring of depressed parents. Previous work suggested a reduced risk for depression in the offspring of parents with remitted depression. Offspring gender differences in this association were rarely considered. Here, we are examining the hypothesis that female offspring are more likely to benefit from treating parental depression using data from the U.S. National Comorbidity Survey Replication (NCS-R).

Method

The NCS-R is a nationally representative household survey of adults 18 years and older carried out between February 2001 and April 2003. The World Health Organization World Mental Health Composite International Diagnostic Interview (WHO WMH-CIDI) was used to assess DSM-IV Major Depressive Disorder (MDD). Multiple logistic regressions were used to assess the association between parental treatment and offspring risk for MDD. An interaction term was added to study the effect of offspring's gender on this risk.

Results

The age-adjusted odds ratio for treatment of parental depression was 1.15 (95% CI: 0.78, 1.72). There was no effect modification by gender (p = 0.42). Surprisingly, treatment of parental depression did not reduce their offspring's risk for depression.

Conclusion

Gender of the offspring had no effect on the risk of depression in the adult offspring of treated versus untreated depressed parents. A focus on mediators like parenting behavior and its gender specific effect needs to be explored in future studies.

ADHD-A Clinician's Bird's Eye View of Current Status and New Vistas!

Objectives

Literature on ADHD has taken long strides recently as heaps of new data are pouring in through countless papers. Here, authors try to outline changing paradigms in ADHD practice. DSM-5 changes regarding the typology and diagnostic criteria are highlighted. Overview of co-morbidities, associations, developmental trajectories, and syndromic continuity across lifespan is outlined. Recent insights into aetiology and diagnostic tools are briefly discussed. New medications in the pipeline are also described.

Methods

EMBASE, Ovid MEDLINE, PubMed, Scopus, Web of Science, and Cochrane Database of Systemic Reviews were searched for all relevant updates in ADHD literature as of June, 2022.

Results

DSM-5 brought about changes to the diagnostic criteria of ADHD. These included replacing types with presentations, pushing age to 12, and, incorporating adult diagnostic criteria. In the same vein, DSM-5 allows now for diagnosing concurrent ADHD and ASD. Associations of ADHD to allergy, obesity, sleep disorders, and, epilepsy have been demonstrated in recent literature. Neurocircuity underlying ADHD has been extended beyond frontal-striatal to include CTC as well as DMN accounting for ADHD heterogeneity. NEBA was FDA-approved to differentiate ADHD from hyperkinetic ID. Atypical antipsychotics use to address behavioural facets in ADHD is on the rise with no solid evidence-base. α-2 agonists are FDA-approved as monotherapy or adjunctive to stimulants. Pharmacogenetic testing is readily available for ADHD. Different formulations of stimulants abound on the market widening clinicians' repertoire. Stimulant-related exacerbation of anxiety and tics were challenged in recent studies. Drugs for ADHD in the pipeline include-dasotraline, armodafinil, tipepidine, edivoxetine, metadoxine, and memantine.

Conclusions

Literature on ADHD keeps expanding towards advancing our understanding of the complex and heterogeneous intricacies of this commonplace neurodevelopmental disorder and hence informing better decisions on how best to manage its diverse cognitive, behavioural, social and medical facets.

The Future of Schizophrenia Psychopharmacotherapy: More Antipsychotic Atypicality? Guess So!

No single neurotransmitter aberration could explain the heterogeneity of schizophrenia syndrome and thus, treatment strategies capitalizing solely on a single neurotransmitter system (e.g., DA blockade) is less likely to be fully successful on clinical grounds. Hence, there is a pressing need to develop newer antipsychotics above and beyond DA antagonism. In this regard, authors brief on five agents that sound pretty promising and might usher in a new sparkle in the psychopharmacotherapy of schizophrenia. This paper is a sequel for authors' previous article on future of schizophrenia psychopharmacotherapy.

Newly FDA-approved psychotropic medications

As of August 2022, (US) FDA has granted approval for a number of psychotropic drugs on market that might usher an innovative sparkle in psychopharmacotherapy. This is a recap to update busy clinicians.

One Hundred Courses of Cluster Maintenance Transcranial Magnetic Stimulation (CM TMS)-A Clinical Audit Study

Objective

Major depressive disorder (MDD) which comes to transcranial magnetic stimulation (TMS) is prone to relapse. Cluster maintenance (CM) TMS is courses of 5 treatments delivered over 2.5-5 days, separated by monthly or greater non-treatment periods. Our aim was to characterize the outcomes of 100 courses of CM TMS.

Method

This was a Quality Assurance/Clinical Audit study. We studied consecutive CM TMS courses provided to private hospital inpatients. Mood was rated (on admission and discharge) using the six-item Hamilton depression rating (HAMD6) and the Clinical Global Impression - Severity (CGI-S) scales. We also applied recent STAR*D criteria which are designed to measure the 'clinical change' expected to impact patient function [16].

Results

For the total sample, using the HAMD6, 83% of courses featured relapse or partial relapse on admission, and 81% featured remission on discharge. Of 46 courses featuring HAMD6 relapse on admission, 74% featured remission on discharge. For the 100 courses the HAMD6 discharge scores were significantly lower than the admission scores (p = 2.0 × 10-24), as were the CGI-S scores (p = 1.8 × 10-25). Using STAR*D criteria for people in relapse or partial relapse on admission, CM TMS provided least a 'clinically meaningful' outcome in 82% of the cases.

Conclusion

For courses featuring relapse or partial relapse on admission, CM TMS converted greater than 70% to remission at discharge. It produced statistically significant reductions in HAMD6 and CGI-S scores, and using STAR*D criteria, at least 'clinically meaningful' change was extensively demonstrated. This evidence indicates CM TMS should be readily available to people living with relapsing MDD.

Agomelatine Monotherapy for Autism-A Case Report

ASD is commonly associated with a host of challenging behaviours. Pharmacotherapy is indicated if psycho-social and educational interventions fail. Atypical antipsychotics have the strongest evidence-base so far, with both risperidone and aripiprazole are FDA-approved. Unfortunately, their use is fraught with metabolic and neuro-hormonal side effects. Here, authors report on a case of ASD/mild ID with behavioural dyscontrol that failed multiple psychotropic trials and ultimately responded favourably to agomelatine monotherapy. This was achieved with excellent tolerability. This might open new venues in such complicated cases.

Probable Risperidone-Associated Acute Pancreatitis in a Child with ADHD

Psychotropic-induced pancreatitis is rare and even rarer in pediatric population. Here, authors report on an interesting case of risperidone-induced pancreatitis in a child with ADHD comorbid with conduct disorder. Clinicians should be mindful of this remote, yet serious, side effect.

Possible Lurasidone-Associated Dose-Dependent QTc Prolongation in First-Episode Psychosis

This case is one of the earliest to report on lurasidone-related QTc prolongation in a dose-dependent fashion in CAP population at therapeutic doses. Although these reports remain scarce, it behoves prescribers to be vigilant and mindful of these unusual but serious side effects especially in setting of cumulative risks.

Top-Up Clozapine for Risperidone LAI-Related Acute Dystonia and TR Bipolar in an Adolescent with ID-Putting the Cart before the Horse?

Objectives

Young patients with intellectual disability (ID) have both diagnostic and therapeutic challenges. These include, inter alia, diagnostic overshadowing, diagnostic slippage and heightened vulnerability to adverse drug reactions. These would portent a generally poor prognostication.

Methods

This is a case-study of an adolescent with intellectual disability long-hospitalized for co-morbid treatment-resistant bipolar mood disorder that failed to respond to ECT. Patient partially responded to LAI risperidone with repeated ADRs. Top-up with low-dose clozapine (100 mg/d) was pursued.

Results

Low-dose clozapine top-up complemented therapeutic response (mood lability and paranoia) and strikingly safeguarded effectively against risperidone-related extrapyramidal side effects.

Conclusions

Add-on clozapine remains a viable option, albeit off-label, in young patients with ID and treatment-resistant affective/schizophreniform psychoses. Clozapine has an edge over other agents in the setting of dyskinesias.

Therapeutic use of melatonin in schizophrenia-more than meets the eye!

Adjunctive melatonin use in schizophrenia, as supported by a modicum of evidence, has multiple transcending chronobiotic actions, including fixing concurrent sleep problems to bona fide augmentative antipsychotic actions, mitigating the risk of tardive dyskinesias, curbing the drastic metabolic syndrome and ultimately providing neuroprotective actions. Its use is rather an art than science!

Cannabis for psychiatric disorders - Has The Pendulum Swung Too Far?

Strong interest in cannabinoids as potential treatment for psychiatric disorders has led to numerous studies. Particularly, cannabidiol (CBD) has promise as a pharmacotherapy for psychotic disorders as well as anxiety disorders. Herein we shed some light on therapeutic potential while examining extant evidence. Literature is still nascent. This should be balanced against the ubiquitous use of cannabis in patients with psychiatric disorders that has been strongly tied to frequent relapses and heightened violence.

Low-Dose Risperidone for an Autistic Child with Comorbid ARFID and Misophonia

Avoidant/Restrictive Food Intake Disorder and misophonia seem to be overrepresented in autism spectrum disorder. Literature is mute on psychopharmacotherapy in these complex presentations. Here, authors report on a challenging case of low-functioning ASD child with comorbid ARFID and misophonia that responded favorably to a low-dose risperidone. This is followed by a brief discussion of purported pharmacodynamic mechanisms and relevant literature.

Successful Add-on Viloxazine to Clozapine-Responsive Schizophrenia Mitigated Cognitive, Negative and Metabolic Domains

Early-onset schizophrenia is notorious for poor prognostication and treatment-refractoriness. Clozapine remains a viable option, albeit off-label, but is clearly underutilized in this population. Use is typically fraught with panoply of drastic side effects. Here, authors report on an adolescent case with schizophrenia that responded ultimately to clozapine. Add-on viloxazine was advantageous spanning different symptom domains, mitigating metabolic parameters and addressing clozapine-sialorrhea. This might open new venues for such complicated, yet commonplace, clinical scenarios.

Depression: A Gut "Microbiome" Feeling!

ABSTRACT

Burgeoning body of evidence from neuroscience is pouring in highlighting a potential association between gut microbiota with the pathophysiology of depression and anxiety. Manipulation of gut microbiota may be then useful to decode this role and to provide novel therapeutics for major depressive disorder (MDD), developing microbiota-related biomarkers to stratify patients at risk and to delineate more homogeneous biotypes of MDD.