Antipsychotic drug use: McLean Hospital, 2002

A Naturalistic, Non-interventional Investigation of the Clinical and Sociodemographic Characteristics and Prescription Patterns in Patients With Psychotic Disorders at a Tertiary Care Facility in South Asia

OBJECTIVES

 This study aimed to evaluate the trends in the sociodemographic, clinical, and prescription characteristics of patients with psychotic illnesses seen in the outpatient psychiatry department of a tertiary care facility.

METHODS

 Between March 2021 and April 2022, a cross-sectional, prospective, observational, naturalistic, non-interventional study was conducted. A total of two hundred prescriptions were analyzed. To assess the rationality of prescriptions, World Health Organization (WHO) indicators were also computed.

RESULTS

 With a range of 18 to 75 years, the cohort's mean age was 40.26 years, and its average disease duration was 10.75 years. Sixty-seven patients (68.5%) were diagnosed with schizophrenia. Of the 200 prescriptions that were analyzed, 13 antipsychotic prescriptions were written 343 times. Olanzapine was prescribed as an antipsychotic the most frequently (132, 66%), followed by clozapine (75, 37.5%). Haloperidol (41, 20.5%), trifluoperazine (3, 1.5%), loxapine (1, 0.5%), and flupenthixol depot (1, 0.5%) were the most commonly prescribed typical antipsychotics. 91% (181/200) of patients received prescriptions for other drugs in addition to antipsychotics. Trihexyphenidyl (45%), escitalopram (30%), clonazepam (26.5%), sodium valproate (10%), propranolol (10.5%), and modafinil (9.5%) were the most frequently prescribed concurrent medicines. Forty-eight percent (95/200) of prescriptions demonstrated polypharmacy. Among patients, the frequency of antipsychotic prescriptions was 1 in 44% (88/200), 2 in 36.50% (73/200), 3 in 17% (34/200), 4 in 0.5% (1/200), and 5 again in 0.5% (1/200).  Conclusions: On average, the cohort of the current study was young. The commonest diagnosis was mainly schizophrenia. Atypical antipsychotics accounted for the majority of antipsychotic prescriptions in the current study. In this study, a high prevalence of polypharmacy was noted.

Childhood Trauma and Self-harm in Youths with Bipolar Disorders

BACKGROUND

Bipolar disorders (BD) in youth are associated with a high risk of self-harm behaviors. Childhood trauma (CT) is a relevant environmental stressor that is related to both BD diagnosis and self-harm in adulthood. It is not yet established whether CT may impact self-harm risk in youth. Therefore, the aim of this study was to investigate the distribution patterns of CT in youth BD with and without self-harm.

METHODS

We assessed 273 participants (aged 13-25 years), 96 youths with BD according to DSM-5 criteria and 177 healthy controls (HC). History of CT was obtained using the Childhood Trauma Questionnaire (CTQ). The association between CT and self-harm was tested using multivariate statistical models.

RESULTS

Over 45% of participants with BD reported lifetime self-harm. The BD Self-harm group reported more emotional abuse, emotional neglect, sexual abuse, and physical abuse than HC. The BD No-Self-harm group reported more emotional abuse than HC. The BD Self-harm group reported more emotional abuse and neglect than the BD No-Self-harm group. The BD Self-harm group also reported separated parents, hospitalizations, smoking, use of antiepileptics, antipsychotics and lithium. Emotional abuse was an independent predictor of self-harm in youths with BD.

CONCLUSION

Findings support the importance of assessing CT, in particular emotional abuse, in youth with BD at risk for self-harm.

Effect of affective temperament on illness characteristics of subjects with bipolar disorder and major depressive disorder

BACKGROUND

Affective temperaments represent the stable, biologically determined substrates of mood disorders. The relationship between affective temperaments and bipolar disorder (BD) or major depressive disorder (MDD) has been described. However, the strength of such relationship should be tested while considering other factors influencing the diagnosis of BD/MDD. Literature also lacks a comprehensive description of the interplay between affective temperament and characteristics of mood disorders. The aim of the present study is to address these issues.

METHODS

This is a multicentric observational study including 7 Italian university sites. Five-hundred-fifty-five euthymic subjects with BD/MDD were enrolled and further divided in those with hyperthymic (Hyper, N = 143), cyclothymic (Cyclo, N = 133), irritable (Irr, N = 49), dysthymic (Dysth, N = 155), and anxious (Anx N = 76) temperaments. Linear, binary, ordinal and logistic regressions were performed to assess the association between affective temperaments and i) diagnosis of BD/MDD; ii) characteristics of illness severity and course.

RESULTS

Hyper, Cyclo and Irr were more likely to be associated with BD, together with earlier age of onset and presence of a first-degree relative with BD. Anx and Dysth were more associated with MDD. Differences in association between affective temperaments and characteristics of BD/MDD were observed for hospital admissions, phase-related psychotic symptoms, length and type of depression, comorbidity and pharmacological intake.

LIMITATIONS

Small sample size, cross-sectional design, recall biases.

CONCLUSION

Specific affective temperaments were associated to certain characteristics of illness severity and course of BD or MDD. Evaluation of affective temperaments might help a deeper understanding of mood disorders.

Lithium use in childhood and adolescence, peripartum, and old age: an umbrella review

BACKGROUND

Lithium is one of the most consistently effective treatment for mood disorders. However, patients may show a high level of heterogeneity in treatment response across the lifespan. In particular, the benefits of lithium use may vary in special clinical conditions. The aim of this study was to test this hypothesis by conducting an umbrella review on the efficacy and safety of lithium in childhood and adolescence, peripartum and old age.

METHODS

We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify systematic reviews/meta-analyses on the efficacy and/or safety of lithium in mood disorders in special clinical conditions: (i) childhood and adolescence; (ii) peripartum (pregnancy, postpartum and lactation); (iii) old age. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool was used to assess the risk of bias. Overlap in primary studies across systematic reviews was calculated through the Corrected Covered Area (CCA).

RESULTS

We included 20 independent studies, for a total of 8209 individuals treated with lithium. Regarding paediatric age, efficacy and safety results suggested that lithium may be superior to placebo in bipolar disorders (BD) and not associated with serious adverse events. Nevertheless, primary available data are very limited. Efficacy in paediatric major depressive disorder (MDD) is not clear. During peripartum, lithium use was superior to non-lithium in preventing mood episodes and it was associated with low risk of congenital anomalies and with normal child neurodevelopment. Regarding old age, limited evidence supported lithium as an effective treatment in BD and resistant MDD; low doses should be used in this population. Systematic reviews on paediatric age showed the lowest risk of bias (80% of the studies at low risk). The CCA range of included studies was 13-47%.

CONCLUSIONS

This umbrella review supports the use of lithium across the lifespan, including special clinical condition. Nevertheless, more studies with increased methodological homogeneity are needed.

Second messengers and their importance for novel drug treatments of patients with bipolar disorder

Second messenger systems, like the cyclic nucleotide, glycogen synthase kinase-3β, phosphoinositide, and arachidonic acid cascades, are involved in bipolar disorder (BD). We investigated their role on the development of novel therapeutic drugs using second messenger mechanisms. PubMed search and narrative review. We used all relevant keywords for each second messenger cascade combining it with BD and related terms and combined all with novel/innovative treatments/drugs. Our search produced 31 papers most were reviews, and focussed on the PI3K/AKT-GSK-3β/Nrf2-NF-ĸB pathways. Only two human randomized clinical trials were identified, of ebselen, an antioxidant, and celecoxib, a cyclooxygenase-2 inhibitor, both with poor unsatisfactory results. Despite the fact that all second messenger systems are involved in the pathophysiology of BD, there are few experiments with novel drugs using these mechanisms. These mechanisms are a neglected and potentially major opportunity to transform the treatment of bipolar illness.

Difficulties in emotion regulation in bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Bipolar disorder (BD) is a severe mental disorder characterized by mood swings and functional impairment. Although alterations in emotional regulation (ER) are a key feature, a comprehensive meta-analysis on abnormalities in emotion regulation in BD is still lacking.

METHODS

We performed a random-effects meta-analysis on studies comparing the ER measured with the Difficulties in Emotion Regulation Scale (DERS) in BD and healthy controls (HC) or borderline personality disorder (BPD) and calculated the standardized mean difference (SMD) of the total DERS score between those with BD and HC (primary outcome). Secondary outcomes were the SMD of the DERS subscales between BD and HC, as well as the SMD of the total score of DERS and the subscales between BD and BPD.

RESULTS

Twelve studies (858 BD, 540 BPD, 285 HC) were included. Compared to HC, BD showed significantly higher total DERS score (k=8, SMD 0.962, p<0.001) and subscale scores, including non-acceptance (k=6, SMD=0.85, p<0.001), goal-directed behavior (k=6, SMD=0.894, p<0.001), impulse control (k=6, SMD=1.08, p<0.001), strategies (k=6, SMD=1.25, p<0.001) and emotional clarity (k=6, SMD=0.694, p=0.001). Relative to BPD, BD presented significantly lower scores in all the DERS subscales. Sensitivity analyses confirmed the main analyses. The age of the participants and sample size moderated the primary outcome.

LIMITATIONS

The small number of studies and the cross-sectional design limit the generalizability of the results.

CONCLUSIONS

Our findings suggest that alterations of specific ER abilities are present in BD and their magnitude is smaller relative to BPD. Future therapeutic interventions should target ER strategies.

The Attentional Boost Effect in Young and Adult Euthymic Bipolar Patients and Healthy Controls

In the Attentional Boost Effect (ABE), stimuli encoded with to-be-responded targets are later recognized more accurately than stimuli encoded with to-be-ignored distractors. While this effect is robust in young adults, evidence regarding healthy older adults and clinical populations is sparse. The present study investigated whether a significant ABE is present in bipolar patients (BP), who, even in the euthymic phase, suffer from attentional deficits, and whether the effect is modulated by age. Young and adult euthymic BP and healthy controls (HC) presented with a sequence of pictures paired with target or distractor squares were asked to pay attention to the pictures and press the spacebar when a target square appeared. After a 15-min interval, their memory of the pictures was tested in a recognition task. The performance in the detection task was lower in BP than in HC, in both age groups. More importantly, neither young nor adult BP exhibited a significant ABE; for HC, a robust ABE was only found in young participants. The results suggest that the increase in the attentional demands of the detection task in BP and in adult HC draws resources away from the encoding of target-associated stimuli, resulting in elimination of the ABE. Clinical implications are discussed.

The Koukopoulos mixed depression rating scale (KMDRS) and the assessment of mixed symptoms during the perinatal period

BACKGROUND

Mixed symptoms in depression may underlie bipolar diathesis rather than unipolarity. Uncovering mixed depression (MxD) is crucial for appropriate management, especially in the perinatal period, as it may affect treatment planning and impact future child development. We used a scale specific for identifying MxD and tested its validity in pregnant and postpartum women with depression.

METHODS

Women developing a major depressive episode (MDE) during their perinatal period extending from pregnancy to one year postpartum from November-2012 through June-2019 were assessed with BPRS-18, EPDS, CGI-S, GAF, HAM-A, HAM-D, Koukopoulos' Mixed Depression Rating Scale (KMDRS), TEMPS, and YMRS. They were classified, based on KMDRS criteria, as with mixed (MxD) or without (nonMxD) mixed symptoms. We conducted ROC analysis and performed factor analysis of the KMDRS.

RESULTS

Of 45 included, MxD (N = 19) were biased towards diagnosis of bipolar disorder and nonMxD (N = 26) towards major depressive disorder. Other sociodemographic variables did not differ significantly between MxD and nonMxD. MxD scored higher on total YMRS, BPRS, and KMDRS, and on KMDRS-6 Subjective Feelings of Irritability and KMDRS-12 Suicidal Impulsiveness items. The KMDRS correlated in the entire sample, in MxD and nonMxD, with the YMRS and the BPRS, while correlating with the HAM-D in nonMxD only. The KMDRS showed acceptable AUC distribution, with a 68% sensitivity and 58% specificity. Best-fit was three-factor-structure, explaining 54.66% of cumulative variance.

LIMITATIONS

Small sample and cross-sectional design.

CONCLUSIONS

The KMDRS is fit for investigating MxD along with the YMRS and the BPRS in perinatal women with a MDE.

Melancholia: does this ancient concept have contemporary utility?

Many efforts have been made to develop coherent and clinically useful categories of depressive illness, especially to facilitate prediction of morbidity and guide treatment-response. They include proposals to resurrect the ancient concept of melancholia, as a form of severe depression with particular symptomatic and proposed psychobiological characteristics. However, modern research is inconsistent in supporting differences between melancholic and nonmelancholic depression. In our recent study of over 3200 patient-subjects with DSM-5 major depressive episodes with/without melancholic characteristics, and matched for illness severity, prevalence of melancholic features was 35.2% with remarkably few clinical and demographic differences between melancholic and nonmelancholic subjects. Also, our systematic review of trials comparing melancholic and nonmelancholic subjects found little difference in responses to antidepressant treatments. These findings indicate that the concept of melancholia may have limited value for clinical prediction and treatment-selection. Overlap of symptoms in melancholic and nonmelancholic depression, based on DSM criteria, may limit distinction of melancholia; alternative definitions can be sought, and psychomotor retardation is a particularly strong differentiating feature. For now, however, melancholia seems best considered a state-dependent depression-type strongly associated with greater symptomatic severity, rather than a distinct syndrome. Its DSM-5 current status as a depression-type specifier seems appropriate, and it may be a logical target for genetic and other biomedical studies.

Clinical response and metabolic effects of lithium in 323 mood disorder patients

BACKGROUND

Lithium is the mainstay for the maintenance treatment of mood disorders (MD), but its efficacy needs to be weighed against its side effects profile. Here, we assessed retrospectively the clinical response to long-term lithium treatment, as well as the rate of associated metabolic side effects.

METHODS

Clinical data were collected from patients treated with lithium for at least 12 months at the Lucio Bini Center for Mood Disorders in Cagliari, Italy. Clinical response was determined as the difference in number of mood episodes and percent of illness time before and during lithium treatment. Symptomatic values of metabolic parameters (plasma levels of glucose, cholesterol, urea nitrogen [BUN], creatinine, TSH, white blood cells [WBC]), and Body Mass Index (BMI) were determined.

RESULTS

We studied 323 MD patients (60.2% women). The percent of illness time was significantly reduced for both depressive (F = 4.94, p<0.0001), and manic (F = 3.95, p < 0.0001) episodes, whereas the rates of episodes/year were significantly reduced for mania (F = 2.01, p = 0.02), but not for depression (F = 1.54, p = 0.06). Rates of MD patients with symptomatic values of metabolic parameters were 14.3% for WBC ≥10,000/µl, 26.9% for glucose levels ≥100 mg/dl, 54.2% for cholesterol levels ≥200 mg/dl, 7.5% for BUN ≥50 mg/dl, 21.9% for creatinine levels ≥1.2 mg/dl, and 20.9% for TSH levels ≥3.50 mU/l.

CONCLUSIONS

Long-term lithium treatment was clinically effective, but the rates of metabolic effects were substantial although some of them were also associated with older age. Lithium-treated patients should receive accurate clinical monitoring to decrease the impact of long-term side effects.

Clinical Picture, Temperament, and Personality of Patients with Mixed States

The construct of mixed states is a robust clinical entity with a high variability of prevalence according to different diagnostic criteria. Despite the changes over the years, current official diagnostic criteria still have poor clinical usefulness. Premorbid characteristics with a potential high clinical importance such as temperament, personality, and emotional reactivity are understudied in patients with mixed states and excluded from the current nosologic systems. The authors provide an overview of current nosography and clinical pictures of mixed states and discuss the role of temperament, personality, and emotional reactivity in mixed states.

Mixed States: Historical Impact and Evolution of the Concept

Mixed states have been discussed for more than 2 millennia. The theoretic conception of the coexistence of presumably opposite symptoms of mood or of different psychic domains is well established, although obscured by the presumed separation between bipolar and depressive disorders. Moreover, the lack of response to treatments and severe psychopathology raise important issues requiring urgent solution. The aim of this article was to review the development of the concept of mixed states from the classic literature to modern nosologic systems and to claim for the need of a new paradigm to address the still-open issues about mixed states.

Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations

Lithium has been a gold standard in the treatment of bipolar disorder (BD) for several decades. Despite a general reduction in the use of lithium over the past several years, it is effective in the management of both manic and depressive episodes in BD and continues to be recommended as a first-line mood stabilizer. This review provides an overview of the pharmacology of lithium and highlights its clinical profile in the management of BD, focusing on the potential advantages of prolonged-release (PR) versus immediate-release (IR) formulations of lithium. A literature search using PubMed was performed to identify articles describing IR and PR lithium in BD using specific search terms like ‘lithium’, ‘prolonged-release’, ‘sustained-release’, ‘extended-release’, ‘bipolar disorder’, ‘adherence’ and ‘compliance’. Relevant pharmacodynamic and pharmacokinetic data were also included. Several clinical trials suggested that lithium is effective in the treatment of acute mania and prophylaxis of BD and reduces the risk of suicide in patients with BD; it may also be used in combination with other drugs in the treatment of bipolar depression. Treatment with lithium must be monitored to avoid lithium-associated toxicity. The prolonged PR formulation of lithium has several advantages including consistent serum lithium concentrations, fewer adverse events and improved adherence to therapy. Although direct comparative studies between PR and IR formulations of lithium are primarily limited to pharmacokinetic studies, PR formulation of lithium provides potential advantages over IR formulation and can be effectively used in the management of BD with lesser adverse events.

Amygdala and hippocampus volumes are differently affected by childhood trauma in patients with bipolar disorders and healthy controls

OBJECTIVES

Volumetric studies on deep gray matter structures in bipolar disorder (BP) have reported contrasting results. Childhood trauma, a relevant environmental stressor for BP, could account for the variability of the results, modulating differences in the amygdala and hippocampus in patients with BP compared with healthy controls (HC). Our study aimed to test this hypothesis.

METHODS

We assessed 105 outpatients, diagnosed with bipolar disorder type I (BP-I) or bipolar disorder type II (BP-II) according to DSM-IV-TR criteria, and 113 HC subjects. History of childhood trauma was obtained using the Childhood Trauma Questionnaire (CTQ). High-resolution magnetic resonance imaging was performed on all subjects and volumes of the amygdala, hippocampus, nucleus accumbens, caudate, pallidum, putamen, and thalamus were measured using FreeSurfer.

RESULTS

Patients with BP showed a global reduction of deep gray matter volumes compared to HCs. However, childhood trauma modulated the impact of the diagnosis specifically on the amygdala and hippocampus. Childhood trauma was associated with bilateral decreased volumes in HCs and increased volumes in patients with BP.

CONCLUSIONS

The results suggest that childhood trauma may have a different effect in health and disease on volumes of gray matter in the amygdala and hippocampus, which are brain areas specifically involved in response to stress and emotion processing.

Insula and amygdala resting-state functional connectivity differentiate bipolar from unipolar depression

OBJECTIVE

Distinguishing depressive episodes due to bipolar disorder (BD) or major depressive disorder (MDD) solely on clinical grounds is challenging. We aimed at comparing resting-state functional connectivity (rsFC) of regions subserving emotional regulation in similarly depressed BD and MDD.

METHOD

We enrolled 76 in-patients (BD, n = 36; MDD, n = 40) and 40 healthy controls (HC). A seed-based approach was used to identify regions showing different rsFC with the insula and the amygdala. Insular and amygdalar parcellations were then performed along with diagnostic accuracy of the main findings.

RESULTS

Lower rsFC between the left insula and the left mid-dorsolateral prefrontal cortex and between bilateral insula and right frontopolar prefrontal cortex (FPPFC) was observed in BD compared to MDD and HC. These results were driven by the dorsal anterior and posterior insula (PI). Lower rsFC between the right amygdala and the left anterior hippocampus was observed in MDD compared to BD and HC. These results were driven by the centromedial and laterobasal amygdala. Left PI/right FPPC rsFC showed 78% accuracy differentiating BD and MDD.

CONCLUSION

rsFC of amygdala and insula distinguished between depressed BD and MDD. The observed differences suggest the possibility of differential pathophysiological mechanisms of emotional dysfunction in bipolar and unipolar depression.

Who's the Leader, Mania or Depression? Predominant Polarity and Alcohol/Polysubstance Use in Bipolar Disorders

BACKGROUND

Predominant polarity characterises patients who mainly manifest recurrences of depression or mania/hypomania. Alcohol use disorder (AUD) and polysubstance use (PSU), which often complicate bipolar disorder (BD) and affect its clinical course, can influence predominant polarity. Nevertheless, previous studies have not clarified if BD patients differ in predominant polarity from BD patients with substance use disorder (SUD) comorbidity.

OBJECTIVE

The aim of this study was to compare predominant polarity between BD without SUD, BD with AUD and BD with PSU. We also investigated the association between predominant polarity and first episode polarity in each diagnostic group.

METHOD

We evaluated predominant polarity (≥2:1 lifetime depressive vs. manic/hypomanic episodes) in 218 DSM-IV-TR BD patients. Specifically, data were obtained from 86 patients with BD without SUD, 69 patients with BD and AUD, and 63 patients with BD and PSU with alcohol as the primary substance abused.

RESULTS

The three groups significantly differed for predominant polarity. The most common predominant polarity in BD without SUD was manic, while in BD with AUD and in BD with PSU it was depressive. Uncertain predominant polarity was the least common in BD without SUD and BD with PSU, whereas in BD with AUD, manic predominant polarity was least common. Predominant polarity matched onset polarity in all groups.

CONCLUSION

BD without SUD, BD with AUD, and BD with PSU have different predominant polarities. The correspondence between predominant polarity and polarity at the onset may impact diagnosis and treatment of BD.

Free Interval Duration: Clinical Evidence of the Primary Role of Excitement in Bipolar Disorder

BACKGROUND

Cyclicity is the essential feature of Bipolar disorder, but the effect of different cycle patterns on the clinical features is poorly understood. Moreover, no studies investigated the relationship between mania and depression inside the manic-depressive cycle.

OBJECTIVE

The aim of this study is to verify the presence of a relationship between the manic and the depressive phase during the course of bipolar disorder.

METHOD

160 consecutive patients with BD type I were recruited and followed for a mean period of 10 years. During the follow-up period, four types of euthymic phases were collected: free intervals present between a depressive and a manic/hypomanic episode (D-M); free intervals present between a manic/hypomanic and a depressive episode (M-D); free intervals present between two depressive episodes (D-D); free intervals present between two manic/hypomanic episodes (M-M). One-way ANOVA using the groups as independent variable and the duration of the free intervals as dependent variables was used. Furthermore, ANOVA was followed by Fisher's Protected Least Significant Difference post-hoc test to measure between-group differences.

RESULTS

M-D-free interval phases were shorter than D-M-free intervals. M-D intervals were the shortest ones, the D-D and D-M did not differ, and the M-M were the longest.

CONCLUSION

The strict temporal link between manic and depressive phases supports the idea that the manic-depressive cycle usually begins with a manic episode, and that the subsequent depression is often the consequence of subsiding mania.

Trends in the use of antipsychotics in the Israeli inpatient population, 2004-2013

Background

Although serious mental illneses are treated with both typical and atypical antipsychotic grugs, trends in their use in psychiatric inpatient population in Israel are unrecognized. The aim of this study was to detect trends in the use of typical and atypical antipsychotic drugs in the Israeli inpatient psychiatric population throughout the last decade.

Methods

Data regarding allocation of typical and atypical antipsychotics, over the period 2004 to 2013, were extracted from the electronic records of SAREL, Israel’s largest private supplier of drugs to healthcare and medical facilities. The data were converted to defined daily doses (DDD) per 1000 inpatients per day.

Results

Usage of the ten atypical antipsychotic agents allocated through Israel’s national health care system increased by 73 %, from 128.09 DDD/1000 inpatients/day in 2004 to 221.69 DDD/1000 inpatients/day in 2013. This rise from 2004 to 2013 was largely due to a 1.6-fold increase in the administration of olanzapine (48.31 to 79.57 DDD/1000 inpatients/day), a 4.4-fold increase of quetiapine (9.74 to 43.04 DDD/1000 inpatients/day) and 3.7-fold increase of amisulpride (5.54 to 20.38 DDD/1000 inpatients/day). At the same period, the total utilization of 12 main typical antipsychotics decreased by 15.5 %, from 148.67 DDD/1000 inpatients/day in 2004 to 125.57 DDD/1000 inpatients/day in 2013. Over the entire period, total DDDs of both classes of antipsychotics (typical and atypical) increased by 38 %.

Conclusions

Similar to trends in the treatment of psychiatric outpatients in other countries, there was a substantial increase in the administration of atypical antipsychotic drugs to the Israeli psychiatric inpatient population across the study period. A decrease in the use of typical antipsychotics (substitution), polypharmacy, administration for more indications (supplementation) and the use of larger doses of antipsychotics may account, in part, for this increase. The findings have implications for mental health policy in the context of the Mental Health Care System Reform. Systematic studies on appropriate dosing of antipsychotics and augmentation strategies are warranted.

Hippocampal subfield volumes in short- and long-term lithium-treated patients with bipolar I disorder

OBJECTIVES

Patients diagnosed with bipolar disorder (BP) may experience hippocampal atrophy. Lithium exposure has been associated with increased hippocampal volumes. However, its effects on hippocampal subfields remain to be clarified.

METHODS

We investigated the effects of short- and long-term lithium exposure on the hippocampus and its subfields in patients affected by bipolar I disorder (BP-I). Hippocampal subfields and total hippocampal volumes were measured in 60 subjects divided into four groups: 15 patients with BP-I who were never exposed to lithium [no-exposure group (NE)], 15 patients with BP-I exposed to lithium for < 24 months [short-exposure group (SE)], 15 patients with BP-I exposed to lithium for > 24 months [long-exposure group (LE)], and 15 healthy control subjects (HC).

RESULTS

The SE and NE groups showed smaller total hippocampal volumes and smaller bilateral cornu ammonis CA2-3, CA4-dentate gyrus (DG), presubiculum, and subiculum volumes compared with HC. The LE group showed larger total hippocampal volumes and bilateral CA2-3, left CA4-DG, left presubiculum, and right subiculum volumes compared with the NE group, and larger volumes of the right CA2-3, left CA4-DG, left presubiculum, and right subiculum compared with the SE group. No differences were found between the LE group and HC or between the SE and NE groups.

CONCLUSIONS

Long-term, but not short-term, exposure to lithium treatment may exert neuroprotective effects on specific hippocampal subfields linked to disease progression.

Anabolic-androgenic steroid use and psychopathology in athletes. A systematic review

The use of anabolic-androgenic steroids (AASs) by professional and recreational athletes is increasing worldwide. The underlying motivations are mainly performance enhancement and body image improvement. AAS abuse and dependence, which are specifically classified and coded by the DSM-5, are not uncommon. AAS-using athletes are frequently present with psychiatric symptoms and disorders, mainly somatoform and eating, but also mood, and schizophrenia-related disorders. Some psychiatric disorders are typical of athletes, like muscle dysmorphia. This raises the issue of whether AAS use causes these disorders in athletes, by determining neuroadaptive changes in the reward neural circuit or by exacerbating stress vulnerability, or rather these are athletes with premorbid abnormal personalities or a history of psychiatric disorders who are attracted to AAS use, prompted by the desire to improve their appearance and control their weights. This may predispose to eating disorders, but AASs also show mood destabilizing effects, with longterm use inducing depression and short-term hypomania; withdrawal/discontinuation may be accompanied by depression. The effects of AASs on anxiety behavior are unclear and studies are inconsistent. AASs are also linked to psychotic behavior. The psychological characteristics that could prompt athletes to use AASs have not been elucidated.

Metabolic syndrome in psychiatrically hospitalized patients treated with antipsychotics and other psychotropics

OBJECTIVE

We evaluated prevalence and risk factors for metabolic syndrome in inpatients treated with antipsychotics, with or without other psychotropic drugs. Although the literature on metabolic syndrome in psychiatry has expanded in recent years, we seek to elucidate some of the remaining gaps by examining a severely and chronically ill population heavily treated with pharmacological agents.

METHODS

With data from medical records of 589 adults hospitalized at McLean Hospital in 2010 and 2011, we used standard statistical analyses to characterize risks and covariates of metabolic syndrome.

RESULTS

With prior antipsychotic treatment, prevalence of metabolic syndrome was 29.5%. The syndrome was strongly associated with being overweight (≥25 kg/m(2) in 60.1% of subjects), older age, longer treatment-exposure, schizoaffective diagnosis (39.8%), more illness-episodes or hospitalizations, polytherapy, and higher total daily chlorpromazine-equivalent doses, but not sex. Notably, metabolic syndrome risk was greater among young, antipsychotic treated patients (15.5-fold at age ≤25 years).

CONCLUSIONS

The findings extend information on the association of metabolic syndrome with antipsychotic treatment. Metabolic syndrome was found in 30% of antipsychotic-exposed inpatients. Risk was surprisingly high in young persons and after brief treatment-exposure, and psychotropic polytherapy increased risk.

Antipsychotic treatment among youth in foster care

OBJECTIVE

Despite national concerns over high rates of antipsychotic medication use among youth in foster care, concomitant antipsychotic use has not been examined. In this study, concomitant antipsychotic use among Medicaid-enrolled youth in foster care was compared with disabled or low-income Medicaid-enrolled youth.

PATIENTS AND METHODS

The sample included 16 969 youths younger than 20 years who were continuously enrolled in a Mid-Atlantic state Medicaid program and had ≥1 claim with a psychiatric diagnosis and ≥1 antipsychotic claim in 2003. Antipsychotic treatment was characterized by days of any use and concomitant use with ≥2 overlapping antipsychotics for >30 days. Medicaid program categories were foster care, disabled (Supplemental Security Income), and Temporary Assistance for Needy Families (TANF). Multicategory involvement for youths in foster care was classified as foster care/Supplemental Security Income, foster care/TANF, and foster care/adoption. We used multivariate analyses, adjusting for demographics, psychiatric comorbidities, and other psychotropic use, to assess associations between Medicaid program category and concomitant antipsychotic use.

RESULTS

Average antipsychotic use ranged from 222 ± 110 days in foster care to only 135 ± 101 days in TANF (P < .001). Concomitant use for ≥180 days was 19% in foster care only and 24% in foster care/adoption compared with <15% in the other categories. Conduct disorder and antidepressant or mood-stabilizer use was associated with a higher likelihood of concomitant antipsychotic use (P < .0001).

CONCLUSIONS

Additional study is needed to assess the clinical rationale, safety, and outcomes of concomitant antipsychotic use and to inform statewide policies for monitoring and oversight of antipsychotic use among youths in the foster care system.

Changes in medication practices for hospitalized psychiatric patients: 2009 versus 2004

BACKGROUND

We tested the hypothesis that combinations and total daily doses of psychotropics for hospitalized patients diagnosed with major psychiatric disorders are rising.

METHODS

We evaluated McLean Hospital records of 481 consecutive inpatients with DSM-IV schizophrenia, schizoaffective, or bipolar disorders in 2004 (n = 278) or 2009 (n = 203) to compare characteristics and treatments.

RESULTS

In 2009, Clinical Global Impression (CGI)-severity scores were 6% lower at intake and improved 1.7 times more than in 2004, as hospitalization-length decreased by 12%. Polytherapy (> or = 2 psychotropics) increased in 2009 (affective or schizoaffective disorders > schizophrenia). Total psychotropics/patient (3.1-3.2) remained stable but mood-stabilizers/patient increased markedly and antipsychotics/patient decreased somewhat in 2009. Antipsychotic-choice (2009) ranked: quetiapine, aripiprazole, risperidone, and others; mood-stabilizers ranked: lamotrigine, valproate, lithium, and others (1/4 off-label). In 2009, final total antipsychotic doses (mg/day) increased by 97%, and mood-stabilizers by 75%. Adverse-effect rates fell by half. Factors differing independently for 2009 versus 2004 ranked: (a) more CGI improvement, (b) more mood-stabilizers/patient, (c) lower admission CGI scores, and (c) higher total antipsychotic dose.

COMMENT

Combinations and doses of antipsychotic and mood-stabilizing drugs for inpatients increased markedly (2004 vs. 2009) without consistent correspondence of agents/person and doses, without apparent increase in major adverse effects, and with possibly superior clinical improvement.

Rational use and rationale for use: psychiatric medication at an Argentine institution for intellectual disability

This article describes obstacles to the rational use of psychiatric drugs in a 1000-bed institution for people with intellectual disability employing the WHO framework for rationality. Quantitative data were collected from 98 charts and qualitative data from 14 individuals in this case study. Eight-three percent of patients were taking psychiatric medications, even though 67% of these had no psychiatric diagnosis. Antipsychotics were the first-order treatment; antidepressants were rarely prescribed. These prescribing patterns are influenced by institutional culture, including an emic construct of retardation as a form of psychosis. Low staff-to-patient ratios, a lack of non-medical treatments, and the hospitalization of patients for social reasons also contribute to medication misuse.

Explicit versus implicit review to explore combination antipsychotic prescribing

OBJECTIVE

To use structured implicit review following large-scale explicit audit of antipsychotic polyprescribing to: (1) determine the true rate of antipsychotic polytherapy that deviated from best practice for schizophrenia treatment; and (2) assess whether explicit antipsychotic polytherapy criterion was appropriate for identifying patients at risk for medication problems and assessing quality of care.

METHODS

Antipsychotic prescribing was reviewed for outpatients in four public health services in Auckland, New Zealand on 31 October 2004 (T1). Schizophrenia patients in one service (n = 794) prescribed antipsychotic polytherapy (n = 84, 10.6%) were followed up 10 months later (T2). Historical medication summaries were prepared for those remaining on polytherapy, including diagnosis, clinical problems and treatment plan. Criteria for structured implicit review and rating form for quality of antipsychotic management were piloted. All medication summaries were independently rated by two reviewers, and a third independent rater reviewed summaries where disagreement was found.

RESULTS

Forty-nine patients remained on long-term polytherapy at T2 (6.2% of original population). All but two cases included a second-generation antipsychotic. At T2, average polytherapy duration was 35.8 months, and average antipsychotic dose was 699 mg day(-1) chlorpromazine equivalents. Two raters achieved agreement for 24/49 summaries, and the remaining 25 were rated independently by a third reviewer. Consensus agreement of antipsychotic management (by two raters) was reached for 44/49 cases (89.8%). Polytherapy was rated 'well-justified' in 32.7%, 'some justification' in 10.2% and 'lacked justification' in 46.9% cases. The final rate of polytherapy deviating from best practice reduced from 10.6% to 3.5% when short-term polytherapy was excluded, and details of the clinical situation and care plan were included in implicit review.

CONCLUSIONS

Audit of prescribing in routine practice using explicit guideline-based criteria may be a useful baseline performance indicator. It does not provide an accurate measurement of quality of care because it overestimates the deviation rate from good practice. It may also identify complex patients at risk for poor treatment outcomes who may benefit from structured treatment review.

Low doses of antipsychotic drugs for hospitalized schizophrenia patients in East Asia: 2004 vs. 2001

We test the hypothesis of increasing prevalence of low-dose antipsychotic use (300 mg/d chlorpromazine-equivalent) in East Asia and examine clinical correlates of conservative dosing. Rates of low-dose antipsychotic prescription were determined for 4535 patients with DSM-IV diagnosis of schizophrenia in six East Asian countries and territories, with comparisons analysed for 2004 vs. 2001. Between 2001 (n=2399 subjects) and 2004 (n=2136 subjects), prescription rates for low doses of antipsychotic drugs (APDs) increased from 24.8% to 44.0% (p<0.001). Low doses were more likely among older patients (p=0.005), during first-lifetime hospitalizations (p<0.001), and among patients with less prominent delusions, hallucinations or disorganized speech (all p<0.05). Multivariate modelling indicated that low doses were strongly associated with older age, first admission, sampling year (2004>2001), less use of antipsychotic polytherapy (all p<0.001) and depot antipsychotics (p=0.009). Conservative dosing of APDs was increasingly prevalent in East Asia. Our findings suggest characteristics of patients who may be particularly likely to require low antipsychotic doses.

Antipsychotic prescriptions in a university hospital outpatient population in Turkey: a retrospective database analysis, 2005-2006

OBJECTIVE

The aim of this study is to document the sociodemographic and the clinical profile of patients who are on antipsychotic (AP) medication prescribed in outpatient mental health clinic of a university hospital.

METHODS

A retrospective chart review was conducted for all outpatient files between 2005 and 2006 at the Zonguldak Karaelmas University, Medical Faculty Hospital, Department of Psychiatry in Turkey. All patients prescribed AP with regular follow up were recruited for the study. The type of AP and the route of administration were recorded. The diagnosis, age and gender of the patients were also evaluated.

RESULTS

We reviewed 1606 patients' files. APs were prescribed in 27.6% of the patients. Atypical antipsychotics (AAPs) represented 75.1% and typical antipsychotics (TAPs) represented 24.9% of all antipsychotic prescriptions in our study. The main psychiatric diagnoses associated with a TAP prescription were: psychotic disorders (6.5%), major affective disorders (49.5%), anxiety disorders (36.4%), and other psychiatric diseases (7.4%). The main psychiatric diagnoses associated with an AAP prescription were: psychotic disorders (35.1%), major affective disorders (31.1%), anxiety disorders (27.8%), somatoform disorders (2.4%) and other psychiatric diseases (6.4%). Twenty-eight of these patients (6.3%) were prescribed more than one AP, 45 patients were prescribed mood stabilizer (10.2%) and 272 patients were prescribed antidepressant agents (61.2%) in addition to AP.

CONCLUSIONS

The results reflect the particular use of AAPs in present study population. In line with the published data, the results of this study show that AAPs and TAPs are widely used in those with major affective disorders and psychotic disorders. These findings also underline the widespread off-label use of APs in the treatment of other psychiatric disorders.

Hospital use of antipsychotic drugs: polytherapy

OBJECTIVE

Growing acceptance of new psychotropic drugs encouraged a survey of current use of antipsychotic drugs alone and in combinations, with comparisons with previous findings.

METHOD

Records from a random sample of McLean Hospital (Belmont, Mass) inpatients treated with an antipsychotic from March to May 2004 were reviewed for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, discharge diagnosis; all current psychotropic drug treatments; initial, peak, and final chlorpromazine-equivalent milligram-per-day dose of antipsychotics (APD); initial, peak, and final lithium-equivalent dose (milligram per day) of mood stabilizers (MS); weight change; clinical status at admission and discharge; and days of hospitalization.

RESULTS

In the 305 inpatients sampled (n = 184 women, 60.3%), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, clinical conditions ranked as follows: major affective (n = 161, 52.8%), psychotic (n = 99, 32.5%), and other disorders (n = 45, 14.8%). Modern drugs comprised 92% of antipsychotic prescriptions, and quetiapine (usually at low doses) was most frequently prescribed. "Polytherapy" (simultaneous treatment with > or =2 psychotropic agents) at discharge was identified in 80% of antipsychotic-treated patients. Use of at least 2 antipsychotics (in 23% of cases) was associated with a 2.8-fold increase in total dose vs monotherapy (651 +/- 403 vs 232 +/- 205 mg/d). Total antipsychotic doses also were higher with mood stabilizer (most often divalproex) or sedative (usually high-potency benzodiazepine) cotreatment, use of older neuroleptics, psychotic-disorder diagnoses, and substance use comorbidity. Polytherapy was not associated with superior clinical improvement or shorter hospitalization but was associated with higher body weight.

CONCLUSIONS

Polytherapy involving antipsychotic drugs continues to increase despite limited empirical evidence for greater effectiveness or of safety of such combinations.

Changes in the treatment of acute psychosis in a German public hospital from 1998 to 2004

INTRODUCTION

The aim of our study was to investigate antipsychotic treatment strategies in acute schizophrenic episodes in a German university hospital.

METHODS

Documented pharmacological procedures in the first six weeks of acute episodes of schizophrenia in the years 1998 (n = 108), 2001 (n = 92), and 2004 (n = 94) were analyzed. Inclusion criteria were: admission voluntary and involuntary as inpatient to our acute ward with a diagnosis of F20x according to ICD 10.

RESULTS

Atypical antipsychotics (AAP) were significant more frequently used in the first week of treatment in 2001 and 2004 compared to the year 1998. Switching to AAP occurred significantly earlier in 2001 and 2004 (after 7.6 +/- 7 days in 1998, 3.5 +/- 5 days in 2001 and 2.3 +/- 5 days in 2004; P < 0.002). In all three years prescription of high potent typical antipsychotics decreased during the first six weeks of treatment. Involuntary treatment (P < 0.001) and age (P = 0.001) were significantly correlated to initial prescription of AAP. Involuntary admitted patients received more often a combination of high-potent conventional high potent typical neuroleptics and AAP (48% vs. 24%, P = 0.007).

CONCLUSION

Second generation atypicals are used more frequently according to current guidelines and switching from conventional medications occurs earlier.

Psychotropic drug prescription in a psychiatric university hospital in Germany

A retrospective survey on drug prescription over a 5-year period (1998 to 2003) in 1,540 inpatients in a psychiatric university hospital in Germany was carried out. The aim was to establish a basis for a monitoring of prescription habits and for pharmacoeconomic considerations. It was established that there was only a slight increase in polyvalent drug use between 1998 and 2003. The results are presented in more detail in relation to the diagnosis of organic mental disorders, drug abuse disorders, schizophrenia, mood disorders and personality disorders. Newer atypical antipsychotics, SSRIs and mood stabilizers were increased across diagnoses while lithium and clozapine were prescribed less frequently. The rare occurrence of monotherapy in general might reflect a common trend in psychiatry fostering polydrug use. Studies of this type are biased by the fact that local habits of prescription do not allow generalisation of the findings. Such surveys should be carried out more frequently and simultaneously in different centers. Critical comparisons could help to optimize treatment.