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Correll CU, Arango C, Fagerlund B, Galderisi S, Kas MJ, Leucht S. Identification and treatment of individuals with childhood-onset and early-onset schizophrenia. Eur Neuropsychopharmacol 2024; 82:57-71. [PMID: 38492329 DOI: 10.1016/j.euroneuro.2024.02.005] [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: 08/24/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 03/18/2024]
Abstract
Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.
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Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry, Zucker Hillside Hospital, Northwell Health System, Glen Oaks, NY, USA.
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Birgitte Fagerlund
- Child and Adolescent Mental Health Center, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark; Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Silvana Galderisi
- Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Martien J Kas
- Groningen Institute for Evolutionary Life Sciences (GELIFES), Neurobiology, University of Groningen, the Netherlands
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Germany; Department of Psychiatry, Department of Psychosis Studies, and Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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2
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McCutcheon RA, Taylor D, Rubio J, Nour J, Pillinger T, Murray RM, Jauhar S. Does Slow and Steady Win the Race? Rates of Antipsychotic Discontinuation, Antipsychotic Dose, and Risk of Psychotic Relapse. Schizophr Bull 2024; 50:513-520. [PMID: 37797288 PMCID: PMC11059789 DOI: 10.1093/schbul/sbad139] [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] [Indexed: 10/07/2023]
Abstract
BACKGROUND Antipsychotics are recommended for prevention of relapse in schizophrenia. It is unclear whether increased risk of relapse following antipsychotic discontinuation is predominantly associated with an absolute magnitude of dose reduction or rate of antipsychotic reduction. Establishing the responsible mechanism is important because prolonged withdrawal schedules have been suggested to reduce risk of relapse. STUDY DESIGN Individual patient data from antipsychotic discontinuation studies were obtained. We estimated the occupancy of receptors over time using half-lives and median effective dose ED50 values obtained from pharmacokinetic and receptor occupancy studies. Hazard ratios for relapse events were calculated using Cox proportional hazards models to assess the influence of formulation (oral, 1-monthly, and 3-monthly injections). The change in hazard ratio over time was estimated, and the effect of time-varying covariates was calculated, including rate of occupancy reduction and absolute receptor occupancy. STUDY RESULTS Five studies including 1388 participants with schizophrenia were identified (k = 2: oral, k = 2: 1-monthly injection, k = 1: 3-monthly injection). Withdrawal of long-acting injectable medication did not lead to a lower hazard ratio compared with withdrawal of oral medication, and this included the period immediately following randomization. Hazard ratios were not associated with the rate of decline of receptor occupancy; however, they were associated with reduced absolute occupancy in trials of long-acting injections (P = .038). CONCLUSIONS Antipsychotic discontinuation is associated with an increased risk of psychotic relapse, related to receptor occupancy. Although relapse does not appear to be related to the rate of discontinuation, gradual discontinuation strategies may allow for easier antipsychotic reinstatement in case of symptomatic worsening.
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Affiliation(s)
- Robert A McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Jose Rubio
- Department of Psychiatry, Northwell Health, The Zucker Hillside Hospital, Glen Oaks, NY, USA
| | - Joseph Nour
- East London NHS Foundation Trust, London, UK
| | - Toby Pillinger
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Sameer Jauhar
- South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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3
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Walling DP, Shinde SN, Pogoda JM, Kharidia J, Laffont CM. An Open-Label Study to Assess Monthly Risperidone Injections (180 mg) Following Switch from Daily Oral Risperidone (6 mg) in Stable Schizophrenic Patients. Clin Drug Investig 2024; 44:251-260. [PMID: 38388986 PMCID: PMC10980608 DOI: 10.1007/s40261-024-01347-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND OBJECTIVE Long-acting injectable antipsychotics have shown benefits over oral medications with reduced hospitalization rates and improved health-related quality of life. RBP-7000 (PERSERIS®) is a monthly risperidone formulation (90 or 120 mg) for the treatment of schizophrenia administered by subcutaneous abdominal injection. The objective of this study was to assess a higher dose of 180 mg RBP-7000 and an alternate injection site. METHODS Following stabilization on 6 mg/day (3 mg twice daily) oral risperidone, clinically stable schizophrenic participants received 3 monthly doses of 180 mg RBP-7000 in the abdomen followed by a fourth monthly dose of 180 mg RBP-7000 in the upper arm (each dose administered as two 90-mg injections). The primary endpoint was the steady-state average plasma concentration (Cavg(ss)) of risperidone and total active moiety after oral and RBP-7000 administration. Secondary endpoints included measures of clinical efficacy (Positive and Negative Syndrome Scale, Clinical Global Impression Scale for Severity of Illness), safety, and local injection-site tolerability to assess the switch from oral risperidone and compare injection sites. RESULTS In all, 23 participants received at least one dose of RBP-7000, 16 received all four doses, and 15 completed the study. Monthly doses of 180 mg RBP-7000 provided similar Cavg(ss) of total active moiety compared with 6 mg/day oral risperidone. The pharmacokinetics of RBP-7000 were similar after injection in the abdomen versus upper arm. Clinical efficacy measures remained stable throughout the study. All RBP-7000 injections were well tolerated with no unexpected safety findings. CONCLUSIONS The results support the use of 180 mg RBP-7000 in schizophrenic patients stable on 6 mg/day oral risperidone and a second injection site in the upper arm. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03978832.
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Affiliation(s)
- David P Walling
- Collaborative Neuroscience Network, LLC, 12772 Valley View St. Ste 3, Garden Grove, CA, 92845, USA
| | - Sunita N Shinde
- Research and Development, Indivior Inc., 10710 Midlothian Turnpike, North Chesterfield, VA, 23235, USA
| | - Janice M Pogoda
- Research and Development, Indivior Inc., 10710 Midlothian Turnpike, North Chesterfield, VA, 23235, USA
| | - Jahnavi Kharidia
- Research and Development, Indivior Inc., 10710 Midlothian Turnpike, North Chesterfield, VA, 23235, USA
| | - Celine M Laffont
- Research and Development, Indivior Inc., 10710 Midlothian Turnpike, North Chesterfield, VA, 23235, USA.
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Mølgaard SN, Nielsen MØ, Roed K, Nielsen J. Clinical experiences of guided tapering of antipsychotics for patients with schizophrenia- a case series. BMC Psychiatry 2024; 24:240. [PMID: 38553687 PMCID: PMC10981298 DOI: 10.1186/s12888-024-05699-y] [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: 01/15/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND 80% of patients value information on treatment options as an important part of recovery, further patients with a history of psychotic episodes feel excluded from decision making about their antipsychotic treatment, and on top of that, mental health staff is prone to be reluctant to support shared decision making and medication tapering for patients with schizophrenia. This case series aims to demonstrate the tapering of antipsychotic medication and how guided tapering affects the patient's feeling of autonomy and psychiatric rehabilitation. CASE PRESENTATION We present six patients diagnosed with schizophrenia (International Classification of Mental and Behavioral Disorders- 10th Edition codes F20.0-5, F20.7-9) who underwent professionally guided tapering in our clinic. The clinic aims to guide the patients to identify the lowest possible dose of antipsychotic medication in a safe setting to minimise the risk of severe relapse. Two patients completely discontinued their antipsychotic medication, two suffered a relapse during tapering, one chose to stop the tapering at a low dose, and one patient with treatment resistant schizophrenia, which is still tapering down. CONCLUSIONS Reducing the antipsychotic dose increased emotional awareness in some patients (n = 4) helping them to develop better strategies to handle stress and increased feelings of recovery. Patients felt a greater sense of autonomy and empowerment during the tapering process, even when discontinuation was not possible. Increased awareness in patients and early intervention during relapse may prevent severe relapse. IMPACT AND IMPLICATIONS Some patients with schizophrenia might be over medicated, leading to unwanted side effects and the wish to reduce their medication. The patients in our study illustrate how guided tapering of antipsychotic medication done jointly with the patient can lead to improved emotional awareness and the development of effective symptom management strategies. This may in turn lead to a greater sense of empowerment and identity and give life more meaning, supporting the experience of personal recovery.
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Affiliation(s)
- Sofie Norlin Mølgaard
- Mental Health Center Glostrup, Copenhagen University Hospital, Unit for complicated schizophrenia, Glostrup, Denmark.
| | - Mette Ødegaard Nielsen
- Mental Health Center Glostrup, Copenhagen University Hospital, Unit for complicated schizophrenia, Glostrup, Denmark
| | - Kickan Roed
- Mental Health Centre Glostrup, Copenhagen University Hospital- Mental Health Services CPH, Centre for Applied Research in Mental Health Care, Glostrup, Denmark
| | - Jimmi Nielsen
- Mental Health Center Glostrup, Copenhagen University Hospital, Unit for complicated schizophrenia, Glostrup, Denmark
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Vinkers CH, Kupka RW, Penninx BW, Ruhé HG, van Gaalen JM, van Haaren PCF, Schellekens AFA, Jauhar S, Ramos-Quiroga JA, Vieta E, Tiihonen J, Veldman SE, Veling W, Vis R, de Wit LE, Luykx JJ. Discontinuation of psychotropic medication: a synthesis of evidence across medication classes. Mol Psychiatry 2024:10.1038/s41380-024-02445-4. [PMID: 38503923 DOI: 10.1038/s41380-024-02445-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/22/2023] [Accepted: 01/22/2024] [Indexed: 03/21/2024]
Abstract
Pharmacotherapy is an effective treatment modality across psychiatric disorders. Nevertheless, many patients discontinue their medication at some point. Evidence-based guidance for patients, clinicians, and policymakers on rational discontinuation strategies is vital to enable the best, personalized treatment for any given patient. Nonetheless, there is a scarcity of guidelines on discontinuation strategies. In this perspective, we therefore summarize and critically appraise the evidence on discontinuation of six major psychotropic medication classes: antidepressants, antipsychotics, benzodiazepines, mood stabilizers, opioids, and stimulants. For each medication class, a wide range of topics pertaining to each of the following questions are discussed: (1) Who can discontinue (e.g., what are risk factors for relapse?); (2) When to discontinue (e.g., after 1 year or several years of antidepressant use?); and (3) How to discontinue (e.g., what's the efficacy of dose reduction compared to full cessation and interventions to mitigate relapse risk?). We thus highlight how comparing the evidence across medication classes can identify knowledge gaps, which may pave the way for more integrated research on discontinuation.
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Affiliation(s)
- Christiaan H Vinkers
- Department of Psychiatry and Anatomy & Neurosciences, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, 1081 HV, Amsterdam, The Netherlands.
- Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, The Netherlands.
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands.
| | - Ralph W Kupka
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Brenda W Penninx
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Jakob M van Gaalen
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul C F van Haaren
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
| | - Sameer Jauhar
- Centre for Affective Disorders, Psychological Medicine, IoPPN, King's College, London, UK
| | - Josep A Ramos-Quiroga
- Department of Mental Health, Hospital Universitari Vall d'Hebron, Barcelona, Catalonia, Spain
- Group of Psychiatry, Mental Health and Addictions, Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
- Biomedical Network Research Centre on Mental Health (CIBERSAM), Barcelona, Catalonia, Spain
- Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Vieta
- Bipolar and Depressive Disorders Unit, Hospital Clinic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, 11364, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
- Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Stijn E Veldman
- Department of Psychiatry, Radboudumc, Radboud University, Nijmegen, The Netherlands
- Donders Institute for Brain, Cognition and Behavior, Radboud University, Nijmegen, The Netherlands
- Nijmegen Institute for Scientist Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
- Novadic-Kentron Addiction Care, Vught, The Netherlands
| | - Wim Veling
- Department of Psychiatry, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Roeland Vis
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Laura E de Wit
- Department of Psychiatry, St. Antonius Hospital, Nieuwegein/Utrecht, The Netherlands
| | - Jurjen J Luykx
- GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam Neuroscience and Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
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6
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Salazar de Pablo G, Guinart D, Armendariz A, Aymerich C, Catalan A, Alameda L, Rogdaki M, Martinez Baringo E, Soler-Vidal J, Oliver D, Rubio JM, Arango C, Kane JM, Fusar-Poli P, Correll CU. Duration of Untreated Psychosis and Outcomes in First-Episode Psychosis: Systematic Review and Meta-analysis of Early Detection and Intervention Strategies. Schizophr Bull 2024:sbae017. [PMID: 38491933 DOI: 10.1093/schbul/sbae017] [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] [Indexed: 03/18/2024]
Abstract
BACKGROUND The role of duration of untreated psychosis (DUP) as an early detection and intervention target to improve outcomes for individuals with first-episode psychosis is unknown. STUDY DESIGN PRISMA/MOOSE-compliant systematic review to identify studies until February 1, 2023, with an intervention and a control group, reporting DUP in both groups. Random effects meta-analysis to evaluate (1) differences in DUP in early detection/intervention services vs the control group, (2) the efficacy of early detection strategies regarding eight real-world outcomes at baseline (service entry), and (3) the efficacy of early intervention strategies on ten real-world outcomes at follow-up. We conducted quality assessment, heterogeneity, publication bias, and meta-regression analyses (PROSPERO: CRD42020163640). STUDY RESULTS From 6229 citations, 33 intervention studies were retrieved. The intervention group achieved a small DUP reduction (Hedges' g = 0.168, 95% CI = 0.055-0.283) vs the control group. The early detection group had better functioning levels (g = 0.281, 95% CI = 0.073-0.488) at baseline. Both groups did not differ regarding total psychopathology, admission rates, quality of life, positive/negative/depressive symptoms, and employment rates (P > .05). Early interventions improved quality of life (g = 0.600, 95% CI = 0.408-0.791), employment rates (g = 0.427, 95% CI = 0.135-0.718), negative symptoms (g = 0.417, 95% CI = 0.153-0.682), relapse rates (g = 0.364, 95% CI = 0.117-0.612), admissions rates (g = 0.335, 95% CI = 0.198-0.468), total psychopathology (g = 0.298, 95% CI = 0.014-0.582), depressive symptoms (g = 0.268, 95% CI = 0.008-0.528), and functioning (g = 0.180, 95% CI = 0.065-0.295) at follow-up but not positive symptoms or remission (P > .05). CONCLUSIONS Comparing interventions targeting DUP and control groups, the impact of early detection strategies on DUP and other correlates is limited. However, the impact of early intervention was significant regarding relevant outcomes, underscoring the importance of supporting early intervention services worldwide.
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Affiliation(s)
- Gonzalo Salazar de Pablo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychosis Studies, Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Child and Adolescent Mental Health Services, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Daniel Guinart
- Institut de Salut Mental, Hospital del Mar, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
- Department of Psychiatry, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Alvaro Armendariz
- Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Etiopatogenia i Tractament Dels Trastorns Mental Severs (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Claudia Aymerich
- Psychiatry Department, Basurto University Hospital, Biocruces Bizkaia Health Research Institute, OSI Bilbao-Basurto, Barakaldo, Bizkaia, Spain
| | - Ana Catalan
- Department of Psychosis Studies, Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Psychiatry Department, Basurto University Hospital, Biocruces Bizkaia Health Research Institute, OSI Bilbao-Basurto, Barakaldo, Bizkaia, Spain
| | - Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- TiPP Program Department of Psychiatry, Service of General Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
- Department of Psychiatry, Centro Investigación Biomedica en Red de Salud Mental (CIBERSAM), Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, University of Sevilla, Sevilla, Spain
| | - Maria Rogdaki
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Estrella Martinez Baringo
- Department of Child and Adolescent Psychiatry, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Spain
| | - Joan Soler-Vidal
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), ISCIII, Barcelona, Spain
- Hospital Benito Menni CASM, Hermanas Hospitalarias, Sant Boi de Llobregat, Spain
| | - Dominic Oliver
- Department of Psychosis Studies, Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
- NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- OPEN Early Detection Service, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Jose M Rubio
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - John M Kane
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Paolo Fusar-Poli
- Department of Psychosis Studies, Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK
- Maudsley Biomedical Research Centre, National Institute for Health Research, South London and Maudsley NHS Foundation Trust, London, UK
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Center for Psychiatric Neuroscience, The Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
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7
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Farhat LC, Flores JM, Avila-Quintero VJ, Polanczyk GV, Cipriani A, Furukawa TA, Bloch MH, Cortese S. Treatment Outcomes With Licensed and Unlicensed Stimulant Doses for Adults With Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. JAMA Psychiatry 2024; 81:157-166. [PMID: 37878348 PMCID: PMC10600727 DOI: 10.1001/jamapsychiatry.2023.3985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Stimulants (methylphenidate and amphetamines) are often prescribed at unlicensed doses for adults with attention-deficit/hyperactivity disorder (ADHD). Whether dose escalation beyond US Food and Drug Administration recommendations is associated with positive risk benefits is unclear. Objective To investigate the impact, based on averages, of stimulant doses on treatment outcomes in adults with ADHD and to determine, based on averages, whether unlicensed doses are associated with positive risk benefits compared with licensed doses. Data Sources Twelve databases, including published (PubMed, Cochrane Library, Embase, Web of Sciences) and unpublished (ClinicalTrials.gov) literature, up to February 22, 2023, without language restrictions. Study Selection Two researchers independently screened records to identify double-blinded randomized clinical trials of stimulants against placebo in adults (18 years and older) with ADHD. Data Extraction and Synthesis Aggregate data were extracted and synthesized in random-effects dose-response meta-analyses and network meta-analyses. Main Outcome Measures Change in ADHD symptoms and discontinuations due to adverse events. Results A total of 47 randomized clinical trials (7714 participants; mean age, 35 (SD, 11) years; 4204 male [56%]) were included. For methylphenidate, dose-response curves indicated additional reductions of symptoms with increments in doses, but the gains were progressively smaller and accompanied by continued additional risk of adverse events dropouts. Network meta-analyses showed that unlicensed doses were associated with greater reductions of symptoms compared with licensed doses (standardized mean difference [SMD], -0.23; 95% CI, -0.44 to -0.02; very low certainty of evidence), but the additional gain was small and accompanied by increased risk of adverse event dropouts (odds ratio, 2.02; 95% CI, 1.19-3.43; moderate certainty of evidence). For amphetamines, the dose-response curve approached a plateau and increments in doses did not indicate additional reductions of symptoms, but there were continued increments in the risk of adverse event dropouts. Network meta-analysis did not identify differences between unlicensed and licensed doses for reductions of symptoms (SMD, -0.08; 95% CI, -0.24 to 0.08; very low certainty of evidence). Conclusions and Relevance Based on group averages, unlicensed doses of stimulants may not have positive risk benefits compared with licensed doses for adults with ADHD. In general, practitioners should consider unlicensed doses cautiously. Practitioners may trial unlicensed doses if needed and tolerated but should be aware that there may not be large gains in the response to the medication with those further increments in dose. However, the findings are averages and will not generalize to every patient.
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Affiliation(s)
- Luis C. Farhat
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - José M. Flores
- Division of Child & Adolescent Psychiatry, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, California
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | | | - Guilherme V. Polanczyk
- Department of Psychiatry, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, United Kingdom
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/ School of Public Health, Kyoto, Japan
| | - Michael H. Bloch
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Samuele Cortese
- Center for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
- Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Solent NHS Trust, Southampton, United Kingdom
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, New York
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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8
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Efthimiou O, Taipale H, Radua J, Schneider-Thoma J, Pinzón-Espinosa J, Ortuño M, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Tanskanen A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Efficacy and effectiveness of antipsychotics in schizophrenia: network meta-analyses combining evidence from randomised controlled trials and real-world data. Lancet Psychiatry 2024; 11:102-111. [PMID: 38215784 DOI: 10.1016/s2215-0366(23)00366-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND There is debate about the generalisability of results from randomised clinical trials (RCTs) to real-world settings. Studying outcomes of treatments for schizophrenia can shed light on this issue and inform treatment guidelines. We therefore compared the efficacy and effectiveness of antipsychotics for relapse prevention in schizophrenia and estimated overall treatment effects using all available RCT and real-world evidence. METHODS We conducted network meta-analyses using individual participant data from Swedish and Finnish national registries and aggregate data from RCTs. The target population was adults (age >18 and <65 years) with schizophrenia and schizoaffective disorder with stabilised symptoms. We analysed each registry separately to obtain hazard ratios (HRs) and 95% CIs for relapse within 6 months post-antipsychotic initiation as our main outcome. Interventions studied were antipsychotics, no antipsychotic use, and placebo. We compared HRs versus a reference drug (oral haloperidol) between registries, and between registry individuals who would be eligible and ineligible for RCTs, using the ratio of HRs. We synthesised evidence using network meta-analysis and compared results from our network meta-analysis of real-world data with our network meta-analysis of RCT data, including oral versus long-acting injectable (LAI) formulations. Finally, we conducted a joint real-world and RCT network meta-analysis. FINDINGS We included 90 469 individuals from the Swedish and Finnish registries (mean age 45·9 [SD 14·6] years; 43 025 [47·5%] women and 47 467 [52·5%] men, ethnicity data unavailable) and 10 091 individuals from 30 RCTs (mean age 39·6 years [SD 11·7]; 3724 [36·9%] women and 6367 [63·1%] men, 6022 White [59·7%]). We found good agreement in effectiveness of antipsychotics between Swedish and Finnish registries (HR ratio 0·97, 95% CI 0·88-1·08). Drug effectiveness versus no antipsychotic was larger in RCT-eligible than RCT-ineligible individuals (HR ratio 1·40 [1·24-1·59]). Efficacy versus placebo in RCTs was larger than effectiveness versus no antipsychotic in real-world (HR ratio 2·58 [2·02-3·30]). We found no evidence of differences between effectiveness and efficacy for between-drug comparisons (HR ratio vs oral haloperidol 1·17 [0·83-1·65], where HR ratio >1 means superior effectiveness in real-world to RCTs), except for LAI versus oral comparisons (HR ratio 0·73 [0·53-0·99], indicating superior effectiveness in real-world data relative to RCTs). The real-world network meta-analysis showed clozapine was most effective, followed by olanzapine LAI. The RCT network meta-analysis exhibited heterogeneity and inconsistency. The joint real-world and RCT network meta-analysis identified olanzapine as the most efficacious antipsychotic amongst those present in both RCTs and the real world registries. INTERPRETATION LAI antipsychotics perform slightly better in the real world than according to RCTs. Otherwise, RCT evidence was in line with real-world evidence for most between-drug comparisons, but RCTs might overestimate effectiveness of antipsychotics observed in routine care settings. Our results further the understanding of the generalisability of RCT findings to clinical practice and can inform preferential prescribing guidelines. FUNDING None.
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Affiliation(s)
- Orestis Efthimiou
- Institute of Primary Health Care, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Department of Psychiatry, University of Oxford, Oxford, UK
| | - Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; School of Pharmacy, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joaquim Radua
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden; Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain; Early Psychosis, Interventions and Clinical Detection Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Justo Pinzón-Espinosa
- Department of Medicine, School of Medicine, University of Barcelona, Barcelona, Catalonia, Spain; Department of Psychiatry, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Sant Pau Mental Health Group, Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain; Department of Clinical Psychiatry, School of Medicine, University of Panama, Panama; Adult Outpatient Clinic, Fundació Pere Mata Terres de l'Ebre, Amposta, Tarragona, Spain
| | - Maria Ortuño
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain
| | - Christiaan H Vinkers
- Department of Psychiatry and Anatomy & Neurosciences, Amsterdam University Medical Centre, location Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, Netherlands; GGZ inGeest Mental Health Care, Amsterdam, Netherlands
| | - Ellenor Mittendorfer-Rutz
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Narcís Cardoner
- Sant Pau Mental Health Group, Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain; Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Paolo Fusar-Poli
- Early Psychosis, Interventions and Clinical Detection Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy; OASIS Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK; Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Eduard Vieta
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBERSAM, University of Barcelona, Barcelona, Catalonia, Spain; Department of Psychiatry and Psychology, Hospital Clinic, Neurosciences Institute, University of Barcelona, Barcelona, Catalonia, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Centre for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Jurjen J Luykx
- Department of Psychiatry, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands; Amsterdam Public Health, Mental Health Program and Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, Netherlands; GGZ inGeest Mental Health Care, Amsterdam, Netherlands; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, Netherlands; Outpatient Second Opinion Clinic, GGNet Mental Health, Warnsveld, Netherlands.
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9
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Koops S, Allott K, de Haan L, Chen E, Hui C, Killackey E, Long M, Moncrieff J, Sommer I, Stürup AE, Wunderink L, Begemann M. Addressing the Evidence to Practice Gap: What to Expect From International Antipsychotic Dose Reduction Studies in the Tapering Anti-Psychotics and Evaluating Recovery Consortium. Schizophr Bull 2024; 50:5-8. [PMID: 37625022 PMCID: PMC10754158 DOI: 10.1093/schbul/sbad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Affiliation(s)
- Sanne Koops
- Department of Psychiatry, University Medical Center Groningen, Rijksuniversiteit Groningen, Groningen, The Netherlands
| | - Kelly Allott
- Orygen, Melbourne, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lieuwe de Haan
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam, The Netherlands
- Arkin, Institute for Mental Health, Amsterdam, The Netherlands
| | - Eric Chen
- Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Christy Hui
- Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Eoin Killackey
- Orygen, Melbourne, VIC, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Maria Long
- Division of Psychiatry, University College London, London, United Kingdom
- Department of Health Services Research and Management, City University, London, United Kingdom
| | - Joanna Moncrieff
- Division of Psychiatry, University College London, London, United Kingdom
| | - Iris Sommer
- Department of Psychiatry, University Medical Center Groningen, Rijksuniversiteit Groningen, Groningen, The Netherlands
| | - Anne Emilie Stürup
- Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lex Wunderink
- Department of Psychiatry, University Medical Center Groningen, Rijksuniversiteit Groningen, Groningen, The Netherlands
| | - Marieke Begemann
- Department of Psychiatry, University Medical Center Groningen, Rijksuniversiteit Groningen, Groningen, The Netherlands
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10
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Lagreula J, Dagenais-Beaulé V, de Timary P, Elens L, Dalleur O. Prescribing and deprescribing trends in schizophrenia: An overview of inpatients in Belgium and in the Canadian province of Québec. Basic Clin Pharmacol Toxicol 2023; 133:691-702. [PMID: 36988426 DOI: 10.1111/bcpt.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Abstract
Although switching to antipsychotic monotherapy improves patient outcomes in schizophrenia, antipsychotic deprescribing is rarely performed, and its use varies between countries, as do psychotropic prescribing patterns. This study aimed to determine factors associated with antipsychotic deprescribing at discharge after a psychiatric hospitalization and to compare psychotropic prescribing patterns between Belgium and Québec, Canada. Data on adult inpatients with schizophrenia were collected retrospectively in seven hospitals. At discharge, the number of antipsychotics had decreased in 22.2% of the 63 Canadian patients and 9.9% of the 516 Belgian patients. A number of factors increased the likelihood of antipsychotic deprescribing: a hospitalization in the Canadian hospital (aOR = 4.13, 95% CI 1.48-11.5), living in a residential facility (aOR = 2.51, 95% CI 1.05-4.39), ≥2 previous antipsychotic trials (aOR = 15.38, 95% CI 3.62-65.36), having an antipsychotic side effect (aOR = 1.86, 95% CI 1.01-3.44) and being in a general hospital (aOR = 2.28, 95% CI 1.09-4.75). Patients on a long-acting injectable antipsychotic (aOR = 0.51, 95% CI 0.26-0.98), with prior clozapine use (aOR = 0.36, 95% CI 0.13-0.95), greater antipsychotic exposure (aOR = 0.35, 95% CI 0.2-0.61) and more hypno-sedatives (aOR = 0.65, 95% CI 0.43-0.98), were less likely to be deprescribed. Specific deprescribing interventions could target patients who are less likely to be deprescribed.
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Affiliation(s)
- Juliette Lagreula
- Clinical Pharmacy Research Group (CLIP)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Fonds de la Recherche Scientifique - FNRS, Brussels, Belgium
| | - Vincent Dagenais-Beaulé
- Pharmacy Department & Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Québec, Canada
| | - Philippe de Timary
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
- Adult Psychiatry Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Louvain Center for Toxicology and Applied Pharmacology (LTAP)-Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Olivia Dalleur
- Clinical Pharmacy Research Group (CLIP)-Louvain Drug Research Institute (LDRI), UCLouvain, Brussels, Belgium
- Pharmacy Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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11
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Vita A, Barlati S, Deste G, Nibbio G, Penn DL, Pinkham AE, McIntyre RS, Harvey PD. Life engagement in people living with schizophrenia: predictors and correlates of patient life engagement in a large sample of people living in the community. Psychol Med 2023; 53:7943-7952. [PMID: 37522514 PMCID: PMC10755242 DOI: 10.1017/s0033291723002106] [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: 01/24/2023] [Revised: 06/24/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Life engagement represents a holistic concept that encompasses outcomes reflecting life-fulfilment, well-being and participation in valued and meaningful activities, which is recently gaining attention and scientific interest. Despite its conceptual importance and its relevance, life engagement represents a largely unexplored domain in schizophrenia. The aims of the present study were to independently assess correlates and predictors of patient life engagement in a large and well-characterized sample of schizophrenia patients. METHODS To assess the impact of different demographic, clinical, cognitive and functional parameters on life engagement in a large sample of patients with schizophrenia, data from the social cognition psychometric evaluation project were analyzed. RESULTS Overall schizophrenia and depressive symptom severity, premorbid IQ, neurocognitive performance, social cognition performance both in the emotion processing and theory of mind domains, functional capacity, social skills performance and real-world functioning in different areas all emerged as correlates of patient life engagement. Greater symptom severity and greater impairment in real-world interpersonal relationships, social skills, functional capacity and work outcomes emerged as individual predictors of greater limitations in life engagement. CONCLUSIONS Life engagement in people living with schizophrenia represents a holistic and complex construct, with several different clinical, cognitive and functional correlates. These features represent potential treatment targets to improve the clinical condition and also facilitate the process of recovery and the overall well-being of people living with schizophrenia.
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Affiliation(s)
- Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Giacomo Deste
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Gabriele Nibbio
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - David L. Penn
- Department of Psychology, University of North Carolina, Chapel Hill, NC, USA
- School of Psychology, Australian Catholic University, Melbourne, VIC, Australia
| | - Amy E. Pinkham
- Department of Psychology, School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, USA
| | - Roger S. McIntyre
- Department of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada
- Brain and Discovery Foundation (BCDF), Toronto, Canada
| | - Philip D. Harvey
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Research Service, Miami VA Healthcare System, Miami, FL, USA
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12
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Liu CC, Hsieh MH, Chien YL, Liu CM, Lin YT, Hwang TJ, Hwu HG. Guided antipsychotic reduction to reach minimum effective dose (GARMED) in patients with remitted psychosis: a 2-year randomized controlled trial with a naturalistic cohort. Psychol Med 2023; 53:7078-7086. [PMID: 36896797 PMCID: PMC10719630 DOI: 10.1017/s0033291723000429] [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: 10/30/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Patients with remitted psychosis face a dilemma between the wish to discontinue antipsychotics and the risk of relapse. We test if an operationalized guided-dose-reduction algorithm can help reach a lower effective dose without increased risks of relapse. METHODS A 2-year open-label randomized prospective comparative cohort trial from Aug 2017 to Sep 2022. Patients with a history of schizophrenia-related psychotic disorders under stable medications and symptoms were eligible, randomized 2:1 into guided dose reduction group (GDR) v. maintenance treatment group (MT1), together with a group of naturalistic maintenance controls (MT2). We observed if the relapse rates would be different between 3 groups, to what extent the dose could be reduced, and if GDR patients could have improved functioning and quality of life. RESULTS A total of 96 patients, comprised 51, 24, and 21 patients in GDR, MT1, and MT2 groups, respectively. During follow-up, 14 patients (14.6%) relapsed, including 6, 4, and 4 from GDR, MT1, and MT2, statistically no difference between groups. In total, 74.5% of GDR patients could stay well under a lower dose, including 18 patients (35.3%) conducting 4 consecutive dose-tapering and staying well after reducing 58.5% of their baseline dose. The GDR group exhibited improved clinical outcomes and endorsed better quality of life. CONCLUSIONS GDR is a feasible approach as the majority of patients had a chance to taper antipsychotics to certain extents. Still, 25.5% of GDR patients could not successfully decrease any dose, including 11.8% experienced relapse, a risk comparable to their maintenance counterparts.
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Affiliation(s)
- Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming H. Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ling Chien
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Gwo Hwu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, 10002, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
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13
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Leucht S, Bighelli I, Siafis S, Schneider-Thoma J, Davis JM. Antipsychotic dose reduction: unclear benefits but certain risks. Lancet Psychiatry 2023; 10:819-821. [PMID: 37778354 DOI: 10.1016/s2215-0366(23)00308-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich 81675, Germany.
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich 81675, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich 81675, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich 81675, Germany
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14
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McAdam MKT, Baldessarini RJ, Murphy AL, Gardner DM. Second International Consensus Study of Antipsychotic Dosing (ICSAD-2). J Psychopharmacol 2023; 37:982-991. [PMID: 37842908 PMCID: PMC10612374 DOI: 10.1177/02698811231205688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Expert consensus-based clinically equivalent dose estimates and dosing recommendations can provide valuable support for the use of drugs for psychosis in clinical practice and research. AIMS This second International Consensus Study of Antipsychotic Dosing provides dosing equivalencies and recommendations for newer drugs for psychosis and previously reported drugs with low consensus. METHODS We used a two-step Delphi survey process to establish and update consensus with a broad, international sample of clinical and research experts regarding 26 drug formulations to obtain dosing recommendations (start, target range, and maximum) and estimates of clinically equivalent doses for the treatment of schizophrenia. Reference agents for equivalent dose estimates were oral olanzapine 20 mg/day for 15 oral and 7 long-acting injectable (LAI) agents and intramuscular haloperidol 5 mg for 4 short-acting injectable (SAI) agents. We also provide a contemporary list of equivalency estimates and dosing recommendations for a total of 44 oral, 16 LAI, and 14 SAI drugs for psychosis. RESULTS Survey participants (N = 72) from 24 countries provided equivalency estimates and dosing recommendations for oral, LAI, and SAI formulations. Consensus improved from survey stages I to II. The final consensus was highest for LAI formulations, intermediate for oral agents, and lowest for SAI formulations of drugs for psychosis. CONCLUSIONS As randomized, controlled, fixed, multiple-dose trials to optimize the dosing of drugs for psychosis remain rare, expert consensus remains a useful alternative for estimating clinical dosing equivalents. The present findings can support clinical practice, guideline development, and research design and interpretation involving drugs for psychosis.
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Affiliation(s)
| | - Ross J Baldessarini
- International Consortium for Mood & Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Andrea L Murphy
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - David M Gardner
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
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15
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Fond G, Mallet J, Urbach M, Benros ME, Berk M, Billeci M, Boyer L, Correll CU, Fornaro M, Kulkarni J, Leboyer M, Llorca PM, Misdrahi D, Rey R, Schürhoff F, Solmi M, Sommer IEC, Stahl SM, Pignon B, Berna F. Adjunctive agents to antipsychotics in schizophrenia: a systematic umbrella review and recommendations for amino acids, hormonal therapies and anti-inflammatory drugs. BMJ MENTAL HEALTH 2023; 26:e300771. [PMID: 37852631 PMCID: PMC10583081 DOI: 10.1136/bmjment-2023-300771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/02/2023] [Indexed: 10/20/2023]
Abstract
QUESTION This umbrella review and guidelines aimed to provide evidence to support the rational choice of selected adjunctive therapies for schizophrenia. STUDY SELECTION AND ANALYSIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and World Federation of Societies of Biological Psychiatry (WFSBP)-grading recommendations, 63 randomised control trials (RCTs) (of which 4219 unique participants have completed the RCTs) and 29 meta-analyses were analysed. FINDINGS Provisional recommendations (WFSBP-grade 1) could be made for two molecules in augmentation to antipsychotics: (1) N-acetyl-cysteine (NAC, 1200-3600 mg/day, for >12 consecutive weeks) in improving negative symptoms, general psychopathology (positive and negative syndrome scale for schizophrenia (PANSS) general psychopathology factor (G)-G subscale), with the RCTs with the longer duration showing the most robust findings; (2) polyunsaturated fatty acids (3000 mg/day of eicosapentaenoic acid, for >12 weeks) in improving general psychopathology. Weaker recommendations (ie, WFSBP-grade 2) could be drawn for sarcosine (2 g/day) and minocycline (200-300 mg/day) for improving negative symptoms in chronic schizophrenia (not early schizophrenia), and NAC for improving positive symptoms and cognition. Weak recommendations are not ready for clinical practice. There is provisional evidence that oestrogens and raloxifene are effective in some patients, but further research is needed to determine their benefit/risk ratio. CONCLUSIONS The results of this umbrella review should be interpreted with caution as the number of RCTs included in the meta-analyses was generally small and the effect sizes were weak or medium. For NAC, two RCTs with low risk of bias have provided conflicting results and the WFSBP-grade recommendation included also the results of meta-analyses. These drugs could be provisionally prescribed for patients for whom no other treatments have been effective, but they should be discontinued if they prove ineffective.
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Affiliation(s)
- Guillaume Fond
- Department of psychiatry, Assistance Publique des Hôpitaux de Marseille, Marseille, France
- Fondation FondaMental, Creteil, France
- CEReSS-Health Service Research and Quality of Life Center, AMU, Marseille, France
| | - Jasmina Mallet
- Fondation FondaMental, Creteil, France
- Department of Psychiatry, Louis Mourier Hospital, Colombes, France
| | - Mathieu Urbach
- Fondation FondaMental, Creteil, France
- Department of Adult Psychiatry and Addictology, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Michael Eriksen Benros
- Copenhagen Research Center for Biological and Precision Psychiatry, Mental Health Centre Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Berk
- Deakin University, School of Medicine, and Barwon Health; IMPACT, the Institute for Mental and Physical Health and Clinical Translation; Orygen The National Centre of Excellence in Youth Mental Health, The Florey Institute of Neuroscience and Mental Health and the Department of Psychiatry, University of Melbourne and the Department of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Martina Billeci
- Department of Neuroscience, Reproductive Sciences, and Dentistry, Section of Psychiatry, Federico II University of Naples, Naples, Italy
| | - Laurent Boyer
- CEReSS-Health Service Research and Quality of Life Center, AMU, Marseille, France
- Département d'information médicale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Christoph U Correll
- Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, New York, USA
- Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
- German Center for Mental Health (DZPG), partner site Berlin, Berlin, Germany
| | - Michele Fornaro
- Department of Neuroscience, Reproductive Sciences, and Dentistry, Section of Psychiatry, Federico II University of Naples, Naples, Italy
| | - Jayashri Kulkarni
- Department of Psychiatry, Monash Alfred Psychiatry Research Centre, Alfred Hospital and Monash University Central Clinical School, Monash University,607StKildaRd, Level4, Melbourne, Victoria, Australia 3004, Melbourne, Victoria, Australia
| | - Marion Leboyer
- Fondation FondaMental, Creteil, France
- Department of psychiatry, Univ Paris-Est-Créteil (UPEC), AP-HP, Hôpitaux Universitaires « H. Mondor », DMU IMPACT, INSERM U955, IMRB, translational Neuropsychiatry, F-94010 Creteil, France, Créteil, France
| | - Pierre-Michel Llorca
- Fondation FondaMental, Creteil, France
- Département de psychiatrie, Université Clermont Auvergne, CMP-B CHU, CNRS,Clermont Auvergne INP, Institut Pascal, Clermont-Ferrand, France
| | - David Misdrahi
- Fondation FondaMental, Creteil, France
- Departement de Psychiatrie Générale et Universitaire, Centre Hospitalier Charles Perrens; Univ. Bordeaux, CNRS, UMR 5287, F-33000, INCIA, Bordeaux, France
| | - Romain Rey
- Fondation FondaMental, Creteil, France
- Schizophrenia Expert Centre, Le Vinatier Hospital; INSERM, U1028; CNRS, UMR5292; University Lyon 1; Lyon Neuroscience Research Center, PSYR2 Team, Lyon, France
| | - Franck Schürhoff
- Fondation FondaMental, Creteil, France
- Department of psychiatry, Univ Paris-Est-Créteil (UPEC), AP-HP, Hôpitaux Universitaires « H. Mondor », DMU IMPACT, INSERM U955, IMRB, translational Neuropsychiatry, F-94010 Creteil, France, Créteil, France
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
- Department of Mental Health, The Champlain First Episode Psychosis Program, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program University of Ottawa, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Iris E C Sommer
- Department of Psychiatry, University Medical Center Groningen (UMCG), Groningen, The Netherlands
| | - Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Baptiste Pignon
- Fondation FondaMental, Creteil, France
- Department of psychiatry, Univ Paris-Est-Créteil (UPEC), AP-HP, Hôpitaux Universitaires « H. Mondor », DMU IMPACT, INSERM U955, IMRB, translational Neuropsychiatry, F-94010 Creteil, France, Créteil, France
| | - Fabrice Berna
- Fondation FondaMental, Creteil, France
- Psychiatry, Strasbourg University Hospital, University of Strasbourg, Strasbourg, France
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O’Neill JR, Taylor DM, Horowitz MA. Implementing gradual, hyperbolic tapering of long-acting injectable antipsychotics by prolonging the inter-dose interval: an in silico modelling study. Ther Adv Psychopharmacol 2023; 13:20451253231198463. [PMID: 37719449 PMCID: PMC10501077 DOI: 10.1177/20451253231198463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023] Open
Abstract
Gradual, hyperbolic tapering has been proposed as a method to reduce the risk of withdrawal effects and potential relapse of an underlying condition by minimising disruption of existing equilibria. We applied hyperbolic tapering principles in silico to long-acting aripiprazole to generate regimens for withdrawal in clinical practice. We derived thresholds for taper rates using existing studies and consensus. Using pharmacokinetic data for aripiprazole long-acting injectable antipsychotic (ALAI), we conducted in silico modelling to examine the impact of abrupt cessation of long-acting injectable antipsychotic (LAI) medication and the effect of prolonging inter-dose interval on plasma aripiprazole levels and consequent D2 occupancy. We also modelled transitions from LAI medication to oral medication. Regimens were designed to afford a rate of reduction between 5 and 12.5 percentage points of D2 occupancy per month. Abrupt discontinuation of ALAI was shown to lead to a maximal D2 occupancy reduction of 16.8 percentage points per month; prolongation of the inter-dose interval of ALAI produced a slower reduction. Specifically, hyperbolic tapering was afforded by prolongation of a 400 mg ALAI inter-dose interval from 4 to 7 weeks, before reducing the dose to 300 mg ALAI. This could then be administered at up to 4-week (for 6% maximal D2 occupancy change), 6-week (9% change) or 7-week (11% change) intervals. Switching to oral medication - 5, 2.5 and 1.25 mg for the three regimens, respectively - is required for ALAI to complete full cessation to prevent too rapid a reduction in D2 occupancy. Oral medication should probably be maintained at a consistent dose for 3-6 months before further reductions to account for residual LAI being concurrently eliminated. Hyperbolic dose tapering is possible with ALAI through prolongation of the inter-dose interval and may reduce the risk of relapse compared to abrupt discontinuation of LAI medication.
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Affiliation(s)
- James R. O’Neill
- South West Yorkshire Partnership NHS Foundation Trust, Newton Lodge, Ouchthorpe Lane, Wakefield WF1 3SP, UK
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17
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Liu CC, Hsieh MH, Chien YL, Liu CM, Lin YT, Hwang TJ, Hwu HG. Dose-tapering trajectories in patients with remitted psychosis undergoing guided antipsychotic reduction to reach minimum effective dose. Eur Psychiatry 2023; 66:e66. [PMID: 37578111 PMCID: PMC10594210 DOI: 10.1192/j.eurpsy.2023.2440] [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: 04/11/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Patients with remitted psychosis wish to reduce antipsychotic doses yet facing increased risks of relapse. Examining dose-tapering processes may provide insights to re-evaluate the risk-to-benefit balance. We aimed to depict and subgroup tapering trajectories, and explore factors associated with different dose-reduction patterns. METHODS A 2-year open-label randomized prospective comparative trial from August 2017 to September 2022 in Taiwan. Patients with a history of schizophrenia-related psychotic disorders under stable medications and symptoms were eligible, randomizing a proportion to conduct guided dose reduction. We depicted the trajectories of individual patients and named subgroups based on dose-tapering patterns. Predictors of baseline characteristics for designated subgroups were examined by logistic regression analysis; changes in outcomes were compared by paired t-test. RESULTS Fifty-one patients undergoing guided dose reduction, 18 (35.3%) reduced 4 steps consecutively (sequential reducers, SR), 14 (27.5%) reduced 1 to 3 steps (modest reducers, MR), 3 (5.9%) re-escalated to previous level (alert reducers, AR), 7 (13.7%) returned to baseline level (baseline returners, BR), 6 (11.7%) relapsed (failed reducers, FR) and 3 (5.9%) withdrew without relapse (early exits, EE). Patients with a history of relapse assumed a conservative dose-tapering pace; only the SR subgroup exhibited significant improvements in functioning and quality of life while failing to identify variables for predicting who would become SR or FR. CONCLUSIONS Guided dose reduction comprises dynamic processes with differences between individual trajectories. The proposed naming of dose-tapering patterns/subgroups provides a framework depicting patients undergoing dose-tapering. Longer-term observation and more flexible tapering approaches are anticipated to reveal favorable outcomes.
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Affiliation(s)
- Chen-Chung Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming H. Hsieh
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ling Chien
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Lin
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tzung-Jeng Hwang
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hai-Gwo Hwu
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
- Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan
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18
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Siafis S, Wu H, Wang D, Burschinski A, Nomura N, Takeuchi H, Schneider-Thoma J, Davis JM, Leucht S. Antipsychotic dose, dopamine D2 receptor occupancy and extrapyramidal side-effects: a systematic review and dose-response meta-analysis. Mol Psychiatry 2023; 28:3267-3277. [PMID: 37537284 PMCID: PMC10618092 DOI: 10.1038/s41380-023-02203-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
Antipsychotic drugs differ in their propensity to cause extrapyramidal side-effects (EPS), but their dose-effects are unclear. Therefore, we conducted a systematic review and dose-response meta-analysis. We searched multiple electronic databases up to 20.02.2023 for fixed-dose studies investigating 16 second-generation antipsychotics and haloperidol (all formulations and administration routes) in adults with acute exacerbations of schizophrenia. The primary outcome was the number of participants receiving antiparkinsonian medication, and if not available, the number of participants with extrapyramidal side-effects (EPS) and the mean scores of EPS rating scales were used as proxies. The effect-size was odds ratio (ORs) compared with placebo. One-stage random-effects dose-response meta-analyses with restricted cubic splines were conducted to estimate the dose-response curves. We also examined the relationship between dopamine D2 receptor (D2R) occupancy and ORs by estimating occupancies from administrated doses. We included data from 110 studies with 382 dose arms (37193 participants). Most studies were short-term with median duration of 6 weeks (range 3-26 weeks). Almost all antipsychotics were associated with dose-dependent EPS with varied degrees and the maximum ORs ranged from OR = 1.57 95%CI [0.97, 2.56] for aripiprazole to OR = 7.56 95%CI [3.16, 18.08] for haloperidol at 30 mg/d. Exceptions were quetiapine and sertindole with negligible risks across all doses. There was very low quality of findings for cariprazine, iloperidone, and zotepine, and no data for clozapine. The D2R occupancy curves showed that the risk increased substantially when D2R occupancy exceeded 75-85%, except for D2R partial agonists that had smaller ORs albeit high D2R occupancies. In conclusion, we found that the risk of EPS increases with rising doses and differs substantially in magnitude among antipsychotics, yet exceptions were quetiapine and sertindole with negligible risks. Our data provided additional insights into the current D2R therapeutic window for EPS.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Hui Wu
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dongfang Wang
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Angelika Burschinski
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Nobuyuki Nomura
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago, Chicago, IL, USA
- Maryland Psychiatric Research Center, Baltimore, MD, USA
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
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19
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du Plessis S, Chand GB, Erus G, Phahladira L, Luckhoff HK, Smit R, Asmal L, Wolf DH, Davatzikos C, Emsley R. Two Neuroanatomical Signatures in Schizophrenia: Expression Strengths Over the First 2 Years of Treatment and Their Relationships to Neurodevelopmental Compromise and Antipsychotic Treatment. Schizophr Bull 2023; 49:1067-1077. [PMID: 37043772 PMCID: PMC10318886 DOI: 10.1093/schbul/sbad040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND AND HYPOTHESIS Two machine learning derived neuroanatomical signatures were recently described. Signature 1 is associated with widespread grey matter volume reductions and signature 2 with larger basal ganglia and internal capsule volumes. We hypothesized that they represent the neurodevelopmental and treatment-responsive components of schizophrenia respectively. STUDY DESIGN We assessed the expression strength trajectories of these signatures and evaluated their relationships with indicators of neurodevelopmental compromise and with antipsychotic treatment effects in 83 previously minimally treated individuals with a first episode of a schizophrenia spectrum disorder who received standardized treatment and underwent comprehensive clinical, cognitive and neuroimaging assessments over 24 months. Ninety-six matched healthy case-controls were included. STUDY RESULTS Linear mixed effect repeated measures models indicated that the patients had stronger expression of signature 1 than controls that remained stable over time and was not related to treatment. Stronger signature 1 expression showed trend associations with lower educational attainment, poorer sensory integration, and worse cognitive performance for working memory, verbal learning and reasoning and problem solving. The most striking finding was that signature 2 expression was similar for patients and controls at baseline but increased significantly with treatment in the patients. Greater increase in signature 2 expression was associated with larger reductions in PANSS total score and increases in BMI and not associated with neurodevelopmental indices. CONCLUSIONS These findings provide supporting evidence for two distinct neuroanatomical signatures representing the neurodevelopmental and treatment-responsive components of schizophrenia.
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Affiliation(s)
- Stefan du Plessis
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
| | - Ganesh B Chand
- Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Radiology and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis
| | - Guray Erus
- Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lebogang Phahladira
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
| | - Hilmar K Luckhoff
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
| | - Retha Smit
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
| | - Laila Asmal
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
| | - Daniel H Wolf
- Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Christos Davatzikos
- Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robin Emsley
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Campus, Cape Town, South Africa
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20
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Luykx JJ, Gonzalez-Diaz JM, Guu TW, van der Horst MZ, van Dellen E, Boks MP, Guloksuz S, DeLisi LE, Sommer IE, Cummins R, Shiers D, Lee J, Every-Palmer S, Mhalla A, Chadly Z, Chan SKW, Cotes RO, Takahashi S, Benros ME, Wagner E, Correll CU, Hasan A, Siskind D, Endres D, MacCabe J, Tiihonen J. An international research agenda for clozapine-resistant schizophrenia. Lancet Psychiatry 2023:S2215-0366(23)00109-8. [PMID: 37329895 DOI: 10.1016/s2215-0366(23)00109-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/24/2023] [Accepted: 03/17/2023] [Indexed: 06/19/2023]
Abstract
Treatment-resistant symptoms occur in about a third of patients with schizophrenia and are associated with a substantial reduction in their quality of life. The development of new treatment options for clozapine-resistant schizophrenia constitutes a crucial, unmet need in psychiatry. Additionally, an overview of past and possible future research avenues to optimise the early detection, diagnosis, and management of clozapine-resistant schizophrenia is unavailable. In this Health Policy, we discuss the ongoing challenges associated with clozapine-resistant schizophrenia faced by patients and health-care providers worldwide to improve the understanding of this condition. We then revisit several clozapine guidelines, the diagnostic tests and treatment options for clozapine-resistant schizophrenia, and currently applied research approaches in clozapine-resistant schizophrenia. We also suggest methodologies and targets for future research, divided into innovative nosology-oriented field trials (eg, examining dimensional symptom staging), translational approaches (eg, genetics), epidemiological research (eg, real-world studies), and interventional studies (eg, non-traditional trial designs incorporating lived experiences and caregivers' perspectives). Finally, we note that low-income and middle-income countries are under-represented in studies on clozapine-resistant schizophrenia and propose an agenda to guide multinational research on the cause and treatment of clozapine-resistant schizophrenia. We hope that this research agenda will empower better global representation of patients living with clozapine-resistant schizophrenia and ultimately improve their functional outcomes and quality of life.
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Affiliation(s)
- Jurjen J Luykx
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, Netherlands; Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; GGNet Mental Health, Warnsveld, Netherlands.
| | - Jairo M Gonzalez-Diaz
- Barcelona Clínic Schizophrenia Unit, Neurosciences Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; UR Center for Mental Health, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia; Clínica Nuestra Señora de la Paz, Orden Hospitalaria de San Juan de Dios, Bogotá, Colombia
| | - Ta-Wei Guu
- Department of Old Age Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK; Division of Psychiatry, Department of Internal Medicine, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Marte Z van der Horst
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; GGNet Mental Health, Warnsveld, Netherlands
| | - Edwin van Dellen
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Jette, Belgium
| | - Marco P Boks
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sinan Guloksuz
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, Netherlands; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn E DeLisi
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Iris E Sommer
- Department of Biomedical Sciences of Cells and Systems, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - David Shiers
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, UK
| | - Jimmy Lee
- Department of Psychosis, Institute of Mental Health, Singapore; Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Ahmed Mhalla
- Department of Psychiatry, Fattouma Bourguiba Hospital, Faculty of Medicine of Monastir, University of Monastir, Monastir, Tunisia
| | - Zohra Chadly
- Department of Pharmacology, Fattouma Bourguiba Hospital, Faculty of Medicine of Monastir, University of Monastir, Monastir, Tunisia
| | - Sherry K W Chan
- Department of Psychiatry, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Robert O Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Shun Takahashi
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Japan; Graduate School of Rehabilitation Science, Osaka Metropolitan University, Habikino, Japan; Clinical Research and Education Center, Asakayama General Hospital, Sakai, Japan; Department of Neuropsychiatry, Wakayama Medical University, Wakayama, Japan
| | - Michael E Benros
- Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Elias Wagner
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitaetsmedizin Berlin, Berlin, Germany; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Augsburg, Medical Faculty, Augsburg, Germany
| | - Dan Siskind
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia; Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - James MacCabe
- Department of Psychosis Studies, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, and Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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21
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Furukawa Y, Luo Y, Funada S, Onishi A, Ostinelli E, Hamza T, Furukawa TA, Kataoka Y. Optimal duration of antibiotic treatment for community-acquired pneumonia in adults: a systematic review and duration-effect meta-analysis. BMJ Open 2023; 13:e061023. [PMID: 36948555 PMCID: PMC10040075 DOI: 10.1136/bmjopen-2022-061023] [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] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVES To find the optimal treatment duration with antibiotics for community-acquired pneumonia (CAP) in adults. DESIGN Systematic review and duration-effect meta-analysis. DATA SOURCES MEDLINE, Embase and CENTRAL through 25 August 2021. ELIGIBILITY CRITERIA All randomised controlled trials comparing the same antibiotics used at the same daily dosage but for different durations for CAP in adults. Both outpatients and inpatients were included but not those admitted to intensive care units. We imposed no date, language or publication status restriction. DATA EXTRACTION AND SYNTHESIS Data extraction by two independent reviewers. We conducted a random-effects, one-stage duration-effect meta-analysis with restricted cubic splines. We tested the non-inferiority with the prespecified non-inferiority margin of 10% examined against 10 days . The primary outcome was clinical improvement on day 15 (range 7-45 days). SECONDARY OUTCOMES all-cause mortality, serious adverse events and clinical improvement on day 30 (15-60 days). RESULTS We included nine trials (2399 patients with a mean (SD) age of 61.2 (22.1); 39% women). The duration-effect curve was monotonic with longer duration leading to a lower probability of improvement, and shorter treatment duration (3-9 days) was likely to be non-inferior to 10-day treatment. Harmful outcome curves indicated no association. The weighted average percentage of the primary outcome in the 10-day treatment arms was 68%. Using that average, the absolute clinical improvement rates of the following durations were: 3-day treatment 75% (95% CI: 68% to 81%), 5-day treatment 72% (95% CI: 66% to 78%) and 7-day treatment 69% (95% CI: 61% to 76%). CONCLUSIONS Shorter treatment duration (3-5 days) probably offers the optimal balance between efficacy and treatment burden for treating CAP in adults if they achieved clinical stability. However, the small number of included studies and the overall moderate-to-high risk of bias may compromise the certainty of the results. Further research on the shorter duration range is required. PROSPERO REGISTRATION NUMBER CRD 42021273357.
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Affiliation(s)
- Yuki Furukawa
- Department of Psychiatry, Tokyo Musashino Hospital, Tokyo, Japan
- Department of Neuropsychiatry, University of Tokyo Hospital, Tokyo, Japan
| | - Yan Luo
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Funada
- Department of Urology, Kyoto University, Kyoto, Japan
- Health Promotion and Human Behavior, Kyoto University, Kyoto, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Tasnim Hamza
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Toshi A Furukawa
- Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Department of Community Medicine, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto, Japan
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22
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Taipale H, Tanskanen A, Tiihonen J. Safety of Antipsychotic Polypharmacy Versus Monotherapy in a Nationwide Cohort of 61,889 Patients With Schizophrenia. Am J Psychiatry 2023; 180:377-385. [PMID: 36945825 DOI: 10.1176/appi.ajp.20220446] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES The authors sought to study the safety of antipsychotic polypharmacy compared with monotherapy in specific dosage categories. METHODS Patients with schizophrenia (N=61,889; median follow-up, 14.8 years [IQR=7.4-22.0]) were identified from the Finnish nationwide inpatient care register and followed up over the period 1996-2017. Antipsychotic polypharmacy was compared with monotherapy in seven dosage categories (<0.4, 0.4-<0.6, 0.6-<0.9, 0.9-<1.1, 1.1-<1.4, 1.4-<1.6, and ≥1.6 defined daily doses [DDDs] per day) in terms of risk of severe physical morbidity, indicated by nonpsychiatric and cardiovascular hospitalizations (adjusted hazard ratio). Within-individual analysis was used in an effort to eliminate selection bias. RESULTS The mean age of the cohort was 46.7 years (SD=16.0), and 50.3% (N=31,104) were men. Among patients who had used both monotherapy and polypharmacy, the risk of nonpsychiatric hospitalization was significantly lower during polypharmacy use at all total dosage categories above 1.1 DDDs/day with differences up to -13% than during monotherapy use of the same dosage category (for 1.1-<1.4 DDDs/day, adjusted hazard ratio=0.91, 95% CI=0.87-0.95; for 1.4-<1.6 DDDs/day, adjusted hazard ratio=0.91, 95% CI=0.86-0.96; and for ≥1.6 DDDs/day, adjusted hazard ratio=0.87, 95% CI=0.84-0.89). The risk of cardiovascular hospitalization was significantly lower for polypharmacy at the highest total dosage category (-18%, adjusted hazard ratio=0.82, 95% CI=0.72-0.94). The results from the comparisons between monotherapy and no use and between polypharmacy and no use were in line with the primary comparison of polypharmacy and monotherapy within the same individual. Comparison of any polypharmacy use with any monotherapy use showed no significant difference for nonpsychiatric or cardiovascular hospitalization. CONCLUSIONS The results show that antipsychotic monotherapy is not associated with a lower risk of hospitalization for severe physical health problems when compared with antipsychotic polypharmacy. Treatment guidelines should not encourage use of monotherapy instead of antipsychotic polypharmacy without any existing evidence on the safety issues.
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Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Taipale, Tanskanen, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, and Center for Psychiatry Research, Stockholm City Council, Stockholm (Taipale, Tanskanen, Tiihonen); School of Pharmacy, University of Eastern Finland, Kuopio, Finland (Taipale); Population Health Unit, Finnish Institute for Health and Welfare, Helsinki (Tanskanen); Neuroscience Center, University of Helsinki, Helsinki (Tiihonen)
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Taipale, Tanskanen, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, and Center for Psychiatry Research, Stockholm City Council, Stockholm (Taipale, Tanskanen, Tiihonen); School of Pharmacy, University of Eastern Finland, Kuopio, Finland (Taipale); Population Health Unit, Finnish Institute for Health and Welfare, Helsinki (Tanskanen); Neuroscience Center, University of Helsinki, Helsinki (Tiihonen)
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland (Taipale, Tanskanen, Tiihonen); Department of Clinical Neuroscience, Karolinska Institutet, and Center for Psychiatry Research, Stockholm City Council, Stockholm (Taipale, Tanskanen, Tiihonen); School of Pharmacy, University of Eastern Finland, Kuopio, Finland (Taipale); Population Health Unit, Finnish Institute for Health and Welfare, Helsinki (Tanskanen); Neuroscience Center, University of Helsinki, Helsinki (Tiihonen)
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23
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Bogers JPAM, Hambarian G, Walburgh Schmidt N, Vermeulen JM, de Haan L. Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia. A Meta-Analysis of Randomized Controlled Trials. Schizophr Bull 2023; 49:11-23. [PMID: 36200866 PMCID: PMC9810020 DOI: 10.1093/schbul/sbac138] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND HYPOTHESIS Although maintenance treatment with antipsychotics protects against psychotic relapse, high doses may hamper recovery. Therefore, dose reduction or discontinuation may be considered in patients with chronic schizophrenia. Here, we identified risk factors for psychotic relapse when doses are reduced. STUDY DESIGN We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through January 2021 and reviewed randomized controlled trials (RCTs) that reported relapse rates after antipsychotic dose reduction or discontinuation in patients with chronic schizophrenia. We calculated relative risks (RRs) with 95% confidence intervals (CIs) per person-year and sought to identify potential risk factors for relapse. The study is registered with PROSPERO (CRD42017058296). STUDY RESULTS Forty-seven RCTs (54 patient cohorts, 1746 person-years) were included. The RR for psychotic relapse with dose reduction/discontinuation versus maintenance treatment was 2.3 per person-year (95% CI: 1.9 to 2.8). The RR was higher with antipsychotic discontinuation, dose reduction to less than 3-5 mg haloperidol equivalent (HE), or relatively rapid dose reduction (<10 weeks). The RR was lower with long-acting injectable agents versus oral antipsychotic dose reduction. Other factors that increased the risk of psychotic relapse were younger age and short follow-up time. CONCLUSIONS Clinicians should take several risk factors for psychotic relapse into account when considering dose reduction in patients with chronic schizophrenia. Studies of a relatively fast reduction in antipsychotic dose support a minimum dose of 3-5 mg HE. However, if the dose is tapered more gradually, relapses related to medication withdrawal might be avoided, possibly enabling lower-end doses to be achieved.
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Affiliation(s)
- Jan P A M Bogers
- High Care Clinics and Rivierduinen Academy, Mental Health Services Rivierduinen, Leiden, The Netherlands
| | | | | | - Jentien M Vermeulen
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lieuwe de Haan
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, The Netherlands
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24
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Rodolico A, Siafis S, Bighelli I, Samara MT, Hansen WP, Salomone S, Aguglia E, Cutrufelli P, Bauer I, Baeckers L, Leucht S. Antipsychotic dose reduction compared to dose continuation for people with schizophrenia. Cochrane Database Syst Rev 2022; 11:CD014384. [PMID: 36420692 PMCID: PMC9685497 DOI: 10.1002/14651858.cd014384.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antipsychotic drugs are the mainstay treatment for schizophrenia, yet they are associated with diverse and potentially dose-related side effects which can reduce quality of life. For this reason, the lowest possible doses of antipsychotics are generally recommended, but higher doses are often used in clinical practice. It is still unclear if and how antipsychotic doses could be reduced safely in order to minimise the adverse-effect burden without increasing the risk of relapse. OBJECTIVES To assess the efficacy and safety of reducing antipsychotic dose compared to continuing the current dose for people with schizophrenia. SEARCH METHODS We conducted a systematic search on 10 February 2021 at the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. We also inspected the reference lists of included studies and previous reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing any dose reduction against continuation in people with schizophrenia or related disorders who were stabilised on their current antipsychotic treatment. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened relevant records for inclusion, extracted data from eligible studies, and assessed the risk of bias using RoB 2. We contacted study authors for missing data and additional information. Our primary outcomes were clinically important change in quality of life, rehospitalisations and dropouts due to adverse effects; key secondary outcomes were clinically important change in functioning, relapse, dropouts for any reason, and at least one adverse effect. We also examined scales measuring symptoms, quality of life, and functioning as well as a comprehensive list of specific adverse effects. We pooled outcomes at the endpoint preferably closest to one year. We evaluated the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 25 RCTs, of which 22 studies provided data with 2635 participants (average age 38.4 years old). The median study sample size was 60 participants (ranging from 18 to 466 participants) and length was 37 weeks (ranging from 12 weeks to 2 years). There were variations in the dose reduction strategies in terms of speed of reduction (i.e. gradual in about half of the studies (within 2 to 16 weeks) and abrupt in the other half), and in terms of degree of reduction (i.e. median planned reduction of 66% of the dose up to complete withdrawal in three studies). We assessed risk of bias across outcomes predominantly as some concerns or high risk. No study reported data on the number of participants with a clinically important change in quality of life or functioning, and only eight studies reported continuous data on scales measuring quality of life or functioning. There was no difference between dose reduction and continuation on scales measuring quality of life (standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.17 to 0.15, 6 RCTs, n = 719, I2 = 0%, moderate certainty evidence) and scales measuring functioning (SMD 0.03, 95% CI -0.10 to 0.17, 6 RCTs, n = 966, I2 = 0%, high certainty evidence). Dose reduction in comparison to continuation may increase the risk of rehospitalisation based on data from eight studies with estimable effect sizes; however, the 95% CI does not exclude the possibility of no difference (risk ratio (RR) 1.53, 95% CI 0.84 to 2.81, 8 RCTs, n = 1413, I2 = 59% (moderate heterogeneity), very low certainty evidence). Similarly, dose reduction increased the risk of relapse based on data from 20 studies (RR 2.16, 95% CI 1.52 to 3.06, 20 RCTs, n = 2481, I2 = 70% (substantial heterogeneity), low certainty evidence). More participants in the dose reduction group in comparison to the continuation group left the study early due to adverse effects (RR 2.20, 95% CI 1.39 to 3.49, 6 RCTs with estimable effect sizes, n = 1079, I2 = 0%, moderate certainty evidence) and for any reason (RR 1.38, 95% CI 1.05 to 1.81, 12 RCTs, n = 1551, I2 = 48% (moderate heterogeneity), moderate certainty evidence). Lastly, there was no difference between the dose reduction and continuation groups in the number of participants with at least one adverse effect based on data from four studies with estimable effect sizes (RR 1.03, 95% CI 0.94 to 1.12, 5 RCTs, n = 998 (4 RCTs, n = 980 with estimable effect sizes), I2 = 0%, moderate certainty evidence). AUTHORS' CONCLUSIONS: This review synthesised the latest evidence on the reduction of antipsychotic doses for stable individuals with schizophrenia. There was no difference between dose reduction and continuation groups in quality of life, functioning, and number of participants with at least one adverse effect. However, there was a higher risk for relapse and dropouts, and potentially for rehospitalisations, with dose reduction. Of note, the majority of the trials focused on relapse prevention rather potential beneficial outcomes on quality of life, functioning, and adverse effects, and in some studies there was rapid and substantial reduction of doses. Further well-designed RCTs are therefore needed to provide more definitive answers.
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Affiliation(s)
- Alessandro Rodolico
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Catania, Italy
| | - Spyridon Siafis
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Irene Bighelli
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Myrto T Samara
- Department of Psychiatry, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | | | - Salvatore Salomone
- Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Catania, Italy
| | - Pierfelice Cutrufelli
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, Catania, Italy
| | - Ingrid Bauer
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Lio Baeckers
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- Section for Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
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25
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Ostuzzi G, Vita G, Bertolini F, Tedeschi F, De Luca B, Gastaldon C, Nosé M, Papola D, Purgato M, Del Giovane C, Correll CU, Barbui C. Continuing, reducing, switching, or stopping antipsychotics in individuals with schizophrenia-spectrum disorders who are clinically stable: a systematic review and network meta-analysis. Lancet Psychiatry 2022; 9:614-624. [PMID: 35753323 DOI: 10.1016/s2215-0366(22)00158-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although antipsychotic maintenance treatment is widely recommended to prevent relapse in chronic psychoses, evidence-based guidelines do not provide clear indications on different maintenance treatment strategies, including continuing the antipsychotic at standard doses, reducing the dose, switching to another antipsychotic, or even stopping the antipsychotic. We aimed to compare the effectiveness of these maintenance treatment strategies, hypothesising the superiority of all strategies over stopping, and of continuing at standard doses over both switching and reducing the dose. METHODS We did a systematic review and network meta-analysis of randomized controlled trials (RCTs) that investigated antipsychotics for relapse prevention in adults with schizophrenia-spectrum disorders who were clinically stable, and which compared four treatment strategies: continuing the current antipsychotic at standard doses recommended for acute treatment; reducing the current antipsychotic dose; switching to a different antipsychotic; and stopping the antipsychotic and replacing it with placebo. We excluded RCTs with fewer than 25 individuals, a prerandomisation washout period greater than 4 weeks, a follow-up shorter than 6 weeks, and those recruiting treatment-resistant individuals. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, CENTRAL, and online trial registers for published and unpublished RCTs from inception to Sept 1, 2021, combining terms describing all available antipsychotics, and terms describing continuation, maintenance, or long-term treatment for schizophrenia-spectrum disorders. Relative risks (RRs) and standardised mean differences were pooled using random-effects pairwise and network meta-analyses. We assessed risk of bias of each RCT with the Cochrane Risk-of-Bias 2 tool, and confidence of pooled estimates with CINeMA. The primary outcome was relapse prevention. The study protocol was registered in advance in the Open Science Forum registry. FINDINGS Of 3936 records identified, 119 records, reporting on 101 RCTs, were eligible, 98 of which (including 13 988 individuals) provided data that could be meta-analysed for at least one outcome. The mean proportion of female participants per study was 38% (range 0-100; median 39%, IQR 29-50), whereas for male participants it was 62% (range 0-100; median 61%, IQR 50-71), and the overall mean age was 38·8 years (range 23·2-63·9; median 39·3, IQR 35·0-43·9). Of the 98 RCTs meta-analysed, 89·8% were done in high-income and upper-middle-income countries. The ethnic group White or so-called Caucasian was the most represented (mean 56% participants per study), although this information was relatively scarce. All continuation strategies were significantly more effective in preventing relapse than stopping antipsychotic treatment, with a large risk reduction for continuing at standard doses (RR 0·37, 95% CI 0·32-0·43; number-needed-to-treat [NNT] 3·17, 95% CI 2·94-3·51) and antipsychotic switching (RR 0·44, 0·37-0·53; NNT 3·57, 3·17-4·25), and moderate risk reduction for dose reduction (RR 0·68, 0·51-0·90; NNT 6·25, 4·08-20·00). Continuing and switching antipsychotics did not differ significantly (RR 0·84, 0·69-1·02; with lower values favouring continuing), whereas reducing antipsychotic dose was outperformed by both continuing (RR 0·55, 0·42-0·71; NNT 4·44, 3·45-6·90) and switching (RR 0·65, 0·47-0·89; NNT 5·17, 3·77-18·18). Results were supported by moderate confidence of evidence and confirmed by secondary analyses and by several sensitivity and subgroup analyses, including removing studies with abrupt antipsychotic discontinuation or fast tapering (≤4 weeks). No tolerability differences emerged between treatment strategies. According to the Cochrane Risk-of-Bias tool, version 2, 16·8% of included RCTs had an overall high risk of bias for the primary outcome. We found moderate heterogeneity (τ2=0·13; I2=61%) and no overall incoherence for the primary analysis. Results were supported by moderate confidence of evidence and confirmed by secondary analyses. INTERPRETATION Contrary to our original hypothesis, we found that continuing antipsychotic treatment at standard doses or switching to a different antipsychotic are similarly effective treatment strategies, whereas reducing antipsychotic doses below standard doses is associated with higher risk of relapse than the other two maintenance treatment strategies and should therefore be limited to selected cases. Despite limitations, including moderate heterogeneity and moderate certainty of evidence, these results are of pragmatic relevance for clinicians, and should support the update of evidence-based guidelines. FUNDING None.
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Affiliation(s)
- Giovanni Ostuzzi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy.
| | - Giovanni Vita
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Federico Bertolini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Federico Tedeschi
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Beatrice De Luca
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Chiara Gastaldon
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Michela Nosé
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Davide Papola
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Cinzia Del Giovane
- Statistics and Methodology Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA; Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra and Northwell, Hempstead, NY, USA; Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine, and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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26
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Lopez-Morinigo JD, Leucht S, Arango C. Pharmacological Treatment of Early-Onset Schizophrenia: A Critical Review, Evidence-Based Clinical Guidance and Unmet Needs. PHARMACOPSYCHIATRY 2022; 55:233-245. [PMID: 35777418 PMCID: PMC9458343 DOI: 10.1055/a-1854-0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Early-onset schizophrenia (EOS) – onset before age 18 – is linked
with great disease burden and disability. Decision-making for EOS
pharmacological treatment may be challenging due to conflicting information from
evidence and guidelines and unidentified care needs may remain unmet. We searched for systematic reviews, meta-analyses and umbrella reviews of EOS
pharmacological treatment published in PubMed over the past 10 years and
selected five clinical guidelines from Europe, North-America and Australia.
Based on predefined outcomes, we critically compared the evidence supporting
EOS-approved drugs in Europe and/or North-America with guidelines
recommendations. We also evaluated the coverage of these outcomes to identify
unmet needs. One systematic review, nine meta-analyses and two umbrella reviews (k=203
trials, N=81,289 participants, including duplicated samples across
selected articles) were retrieved. Evidence supported the efficacy of
aripiprazole, clozapine, haloperidol, lurasidone, molindone, olanzapine,
quetiapine, risperidone and paliperidone in EOS, all of which obtained approval
for EOS either in Europe and/or in North-America. Cognition, functioning
and quality of life, suicidal behaviour and mortality and services utilisation
and cost-effectiveness were poorly covered/uncovered. Among the antipsychotics approved for EOS, aripiprazole, lurasidone, molindone,
risperidone, paliperidone and quetiapine emerged as efficacious and comparably
safe options. Olanzapine is known for a high risk of weight gain and haloperidol
for extrapyramidal side-effects. Treatment-resistant patients should be offered
clozapine. Future long-term trials looking at cognition, functioning, quality of
life, suicidal behaviour, mortality, services utilisation and cost-effectiveness
are warranted. Closer multi-agency collaboration may bridge the gap between
evidence, guidelines and approved drugs.
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Affiliation(s)
- Javier-David Lopez-Morinigo
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Ismaninger Straße 22, Munich, Germany
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, School of Medicine, Universidad Complutense, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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27
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Berna F, Schorr B, Javelot H, Dormegny-Jeanjean LC, Foucher JR. Real-world effectiveness studies of low doses of antipsychotics. Lancet Psychiatry 2022; 9:536. [PMID: 35717954 DOI: 10.1016/s2215-0366(22)00107-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Fabrice Berna
- Institut national de la santé et de la recherche médicale U1114, University of Strasbourg, Strasbourg, France; Department of Psychiatry, Strasbourg University Hospital, Strasbourg 67091, France; Fondation FondaMental, Creteil, France.
| | - Benoit Schorr
- Institut national de la santé et de la recherche médicale U1114, University of Strasbourg, Strasbourg, France; Department of Psychiatry, Strasbourg University Hospital, Strasbourg 67091, France; Fondation FondaMental, Creteil, France
| | - Hervé Javelot
- Etablissement Public de Santé Alsace Nord, Brumath, France
| | - Ludovic C Dormegny-Jeanjean
- Department of Psychiatry, Strasbourg University Hospital, Strasbourg 67091, France; French National Centre for Scientific Research UMR7357, Strasbourg, France
| | - Jack R Foucher
- Department of Psychiatry, Strasbourg University Hospital, Strasbourg 67091, France; French National Centre for Scientific Research UMR7357, Strasbourg, France
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28
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Davis JM, Jin H. Choosing an Optimal Antipsychotic Dose for Relapse Prevention. Schizophr Bull 2022; 48:723-725. [PMID: 35536691 PMCID: PMC9212106 DOI: 10.1093/schbul/sbac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- John M Davis
- To whom correspondence should be addressed; Department of Psychiatry, University of IL at Chicago, Chicago, IL, USA; e-mail:
| | - Hua Jin
- Department of Psychiatry, University of California at San Diego, San Diego CA, USA
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29
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Taipale H, Tanskanen A, Luykx JJ, Solmi M, Leucht S, Correll CU, Tiihonen J. Optimal Doses of Specific Antipsychotics for Relapse Prevention in a Nationwide Cohort of Patients with Schizophrenia. Schizophr Bull 2022; 48:774-784. [PMID: 35524479 PMCID: PMC9212108 DOI: 10.1093/schbul/sbac039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND HYPOTHESIS Optimal doses of most antipsychotics in the maintenance treatment of schizophrenia are unknown. We aimed to study the risk of severe relapse indicated by rehospitalization for different dose categories of 15 most frequently used antipsychotics in monotherapy in Finland. STUDY METHODS We studied the risk of rehospitalization (Adjusted Hazard Ratio, aHR) associated with six antipsychotic monotherapy dose categories (as time-varying dose, measured in defined daily dose, DDDs/day) in a nationwide cohort of persons diagnosed with schizophrenia (n = 61 889), using within-individual analyses to eliminate selection bias. STUDY RESULTS Among the 15 most widely used antipsychotics, 13 had a U- or J-shaped dose-response curve, showing the lowest risks of relapse for doses of 0.6-<1.1 DDDs/day vs nonuse of antipsychotics. The exceptions were oral perphenazine (aHR = 0.72, 95% CI = 0.68-0.76, <0.6 DDDs/day), and olanzapine-long-acting injectable (LAI), which had the lowest aHR of any antipsychotic (aHR = 0.17, 95% CI = 0.11-0.25, 1.4-<1.6 DDDs/day). Certain risperidone and perphenazine doses <0.9 DDD/day were associated with 21%-45% lower risk of rehospitalization (P < .001) than the standard dose of 0.9-1.1 DDD/day (ie, 5 mg for risperidone and 30 mg for perphenazine). CONCLUSIONS For most antipsychotics, the risk of severe relapse was the lowest during use of standard dose. Our results suggest that olanzapine LAI is highly effective in dose ranges >0.9 DDD/day, and especially at 1.4-<1.6 DDDs/day (405 mg/4 weeks) associated with substantially lower risk of rehospitalization than any dose of any other antipsychotic. The current WHO standard dose definitions appear to be clearly too high for perphenazine and somewhat too high for risperidone.
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Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,School of Pharmacy, University of Eastern Finland, Kuopio, Finland,Center for Psychiatry Research, Stockholm City Council
, Stockholm, Sweden
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Center for Psychiatry Research, Stockholm City Council
, Stockholm, Sweden,Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Jurjen J Luykx
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,GGNet Mental Health, Warnsveld, The Netherlands
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada,Department of Mental Health, The Ottawa Hospital, Ottawa, ON, Canada,Ottawa Hospital Research Institute (OHRI), Clinical Epidemiology Program, University of Ottawa, Ottawa, ON, Canada
| | - Stefan Leucht
- Section Evidence Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, München, Germany
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jari Tiihonen
- To whom correspondence should be addressed; tel: +358 50 3418363, fax: +358 17 3682419, e-mail:
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Joo SW, Kim H, Jo YT, Ahn S, Choi YJ, Choi W, Park S, Lee J. Risk of treatment discontinuation and psychiatric hospitalization associated with early dose reduction of antipsychotic treatment in first-episode schizophrenia: A nationwide, health insurance data-based study. Psychiatry Clin Neurosci 2022; 76:195-200. [PMID: 35233892 DOI: 10.1111/pcn.13341] [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: 12/03/2021] [Revised: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 01/10/2023]
Abstract
AIM We investigated the impact of early dose reduction of antipsychotic treatment on the risk of treatment discontinuation and psychiatric hospitalization in patients with first-episode schizophrenia (FES). METHODS The Health Insurance Review Agency database in South Korea was used to include 16 153 patients with FES. At 6 months from their diagnosis, the patients were categorized by the magnitude of dose reduction (no reduction, 0%-50%, and >50%). With a reference of no reduction, the risk of treatment discontinuation and psychiatric hospitalization associated with dose reduction in the 1-year follow-up period after the first 6 months was examined with a Cox proportional hazard ratio model stratified by the mean daily olanzapine-equivalent dose in the first 3 months (<10, 10 to 20, >20 mg/day). RESULTS A >50% dose reduction was associated with an increased risk of treatment discontinuation in all subgroups (<10 mg/day: hazard ratio [HR] =1.44, 95% confidence interval [CI] =1.24-1.67 [P <0.01]; 10-20 mg/day: HR =1.60, 95% CI =1.37-1.86 [P <0.01]; and >20 mg/day: HR =1.62, 95% CI =1.37-1.91 [P <0.01]). In the subgroup taking <10 mg/day, an association of 0%-50% dose reduction with an increased risk of treatment discontinuation was observed (HR =1.20, 95% CI =1.09-1.31; P <0.01). A > 50% dose reduction was associated with increased risk of psychiatric hospitalization only in the subgroup taking <10 mg/day (HR =1.48, 95% CI =1.21-1.80; P <0.01). CONCLUSIONS Our results suggest that an above certain dose of antipsychotic drugs is required to prevent psychiatric hospitalization, and extensive dose reduction of antipsychotic drugs could result in a higher risk of treatment discontinuation.
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Affiliation(s)
- Sung Woo Joo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Harin Kim
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Tak Jo
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soojin Ahn
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Jae Choi
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woohyeok Choi
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soyeon Park
- Department of Psychiatry, Medical Foundation Yongin Mental Hospital, Yongin, Republic of Korea
| | - Jungsun Lee
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Differences in the prophylactic effect of serum lithium levels on depression and mania in bipolar disorder: A dose-response meta-analysis. Eur Neuropsychopharmacol 2022; 58:20-29. [PMID: 35158229 DOI: 10.1016/j.euroneuro.2022.01.112] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023]
Abstract
The optimal serum lithium levels for preventing the recurrence of mood episodes in bipolar disorder are controversial, especially when polarity is considered. The present study aimed to comprehensively examine the dose-response relationship between lithium concentration and risk of recurrence of mood episodes. We conducted a systematic search of major databases before January 2021 (PROSPERO: CRD42021235812). A one-stage, random-effects, restricted cubic splines model was used to estimate the dose-response relationship between lithium concentration and risk of recurrence of any or specific mood episodes (depression or mania). The effect size is shown as odds ratio (OR). Our meta-analysis included six randomised controlled trials with a total of 975 participants. The dose-response curve showed that increased serum concentrations were associated with a gradual decrease in the risk of any mood episodes (OR 0.50 at 0.60 mmol/l, OR 0.15 at 1.20 mmol/l). The risk of depression decreased slightly with a concentration of 0.60 mmol/l (OR 0.83) but dropped rapidly as the concentration increased to 1.20 mmol/l (OR 0.39). By contrast, the risk for mania initially decreased steadily (OR 0.44), but decreased only marginally (OR 0.30) as the concentration increased. To reduce the recurrence risk to 56%, prevention of depression required a higher concentration than that required for mania (1.13 mmol/l vs. 0.60 mmol/l). Our results suggest a negative dose-response relationship between serum lithium levels and risk of recurrence. In particular, the different preventive effects of serum concentration on depression and mania will be an important clinical reference.
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Taipale H, Tanskanen A, Correll CU, Tiihonen J. Real-world effectiveness of antipsychotic doses for relapse prevention in patients with first-episode schizophrenia in Finland: a nationwide, register-based cohort study. Lancet Psychiatry 2022; 9:271-279. [PMID: 35182475 DOI: 10.1016/s2215-0366(22)00015-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antipsychotic doses for relapse prevention in patients with first-episode schizophrenia that have the highest likelihood of success are unknown. We aimed to study the evolution of antipsychotic dose and risk of severe relapse indicated by psychiatric rehospitalisation associated with antipsychotic use and specific dose categories. METHODS We did a nationwide, register-based cohort study in Finland. Patients were identified from the nationwide Hospital Discharge register, which records all inpatient hospital stays. Patients with first-episode schizophrenia diagnosed as inpatients and who were 45 years or younger were followed-up for 5 years of illness or until a fifth relapse episode. The primary measure was rehospitalisation due to psychosis, which was used as a marker of relapse and defined as inpatient hospital care with an ICD-10 code of F20-F29 diagnosis recorded as the main discharge diagnosis. Time between relapses was required to be at least 30 days to be considered a next relapse. Antipsychotic use was derived from the prescription register. Dose was summed from all concomitant antipsychotics. Antipsychotic effectiveness for preventing rehospitalisation was studied using within-individual analyses to eliminate selection bias, stratifying time to before and after the second relapse. FINDINGS In total, the study population comprised 5367 patients, of whom 3444 (64·2%) were men and 1923 (35·8%) were women, with a mean age of 29·5 years (SD 7·8) at the start of follow-up. Ethnicity data were not available. 3058 (57·0%) of 5367 patients required hospitalisations. In these patients, the mean dose increased gradually after each new relapse from 1·22 defined daily doses per day (95% CI 1·18-1·26) before the first relapse to 1·56 defined daily doses per day (1·48-1·64) before the fifth relapse. Adjusted hazard ratio (aHR) for rehospitalisation with antipsychotic use versus non-use increased from 0·42 (95% CI 0·35-0·51) before the second relapse to 0·78 (0·62-0·99) after the second relapse (p<0·0001), indicating markedly decreased effectiveness. Analysing specific dose categories revealed a U-shaped curve, showing the lowest rehospitalisation risk during use of the standard dose (0·9 to <1·1 defined daily doses per day) before but not after the second relapse. Low dose (<0·6 defined daily doses per day) was associated with substantially higher rehospitalisation risk (aHR 1·54 [95% CI 1·06-2·24]) versus standard dose before the second relapse, but not after the second relapse (1·11 [0·76-1·62]), owing to reduced effectiveness of all doses after the second relapse. INTERPRETATION The effectiveness of antipsychotics for relapse prevention decreased substantially after the second relapse. Therefore, prevention of the second relapse is essential, and all patients should receive sufficient antipsychotic doses and enhanced relapse prevention efforts after their first relapse. FUNDING Academy of Finland and Finnish Ministry of Social Affairs and Health.
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Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; School of Pharmacy, University of Eastern Finland, Kuopio, Finland; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden.
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden; Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Christoph U Correll
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, NY, USA; Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden; Neuroscience Center, University of Helsinki, Helsinki, Finland
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Horowitz MA, Macaulay A, Taylor D. Limitations in Research on Maintenance Treatment for Individuals With Schizophrenia. JAMA Psychiatry 2022; 79:83-85. [PMID: 34817553 DOI: 10.1001/jamapsychiatry.2021.3400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mark Abie Horowitz
- Research and Development, Goodmayes Hospital, North East London National Health Service Foundation Trust, Goodmayes, Ilford, United Kingdom
| | - Alex Macaulay
- Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - David Taylor
- Pharmacy Department, South London and Maudsley National Health Service Foundation Trust, London, United Kingdom
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Therapeutic Reference Range for Aripiprazole in Schizophrenia Revised: a Systematic Review and Metaanalysis. Psychopharmacology (Berl) 2022; 239:3377-3391. [PMID: 36195732 PMCID: PMC9584998 DOI: 10.1007/s00213-022-06233-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
RATIONALE While one of the basic axioms of pharmacology postulates that there is a relationship between the concentration and effects of a drug, the value of measuring blood levels is questioned by many clinicians. This is due to the often-missing validation of therapeutic reference ranges. OBJECTIVES Here, we present a prototypical meta-analysis of the relationships between blood levels of aripiprazole, its target engagement in the human brain, and clinical effects and side effects in patients with schizophrenia and related disorders. METHODS The relevant literature was systematically searched and reviewed for aripiprazole oral and injectable formulations. Population-based concentration ranges were computed (N = 3,373) and pharmacokinetic influences investigated. RESULTS Fifty-three study cohorts met the eligibility criteria. Twenty-nine studies report blood level after oral, 15 after injectable formulations, and nine were positron emission tomography studies. Conflicting evidence for a relationship between concentration, efficacy, and side effects exists (assigned level of evidence low, C; and absent, D). Population-based reference ranges are well in-line with findings from neuroimaging data and individual efficacy studies. We suggest a therapeutic reference range of 120-270 ng/ml and 180-380 ng/ml, respectively, for aripiprazole and its active moiety for the treatment of schizophrenia and related disorders. CONCLUSIONS High interindividual variability and the influence of CYP2D6 genotypes gives a special indication for Therapeutic Drug Monitoring of oral and long-acting aripiprazole. A starting dose of 10 mg will in most patients result in effective concentrations in blood and brain. 5 mg will be sufficient for known poor metabolizers.
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Højlund M, Haddad PM, Correll CU. Limitations in Research on Maintenance Treatment for Individuals With Schizophrenia. JAMA Psychiatry 2022; 79:85-86. [PMID: 34817573 DOI: 10.1001/jamapsychiatry.2021.3452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mikkel Højlund
- Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark
| | - Peter M Haddad
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, United Kingdom
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36
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Leucht S, Siafis S, Davis JM. Limitations in Research on Maintenance Treatment for Individuals With Schizophrenia-Reply. JAMA Psychiatry 2022; 79:86-87. [PMID: 34817572 DOI: 10.1001/jamapsychiatry.2021.3403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany.,Institute of Psychiatry, Psychology and Neuroscience, Department of Psychiatry, Department of Psychosis Studies, King's College London, London, United Kingdom
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - John M Davis
- Psychiatric Institute, University of Illinois at Chicago.,Johns Hopkins University, Baltimore, Maryland
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