Psychotropic combination in schizophrenia

Concurrent antipsychotic use in older adults treated with antidepressants in Asia

AIM

Depressive disorders are common in old age. Antipsychotics (APs) are often used as an adjunctive treatment with antidepressants (ADs) in this population but its patterns of use in Asia are not known. This study explored the rate of combination of APs and ADs in older adult psychiatric patients in Asia.

METHODS

This is a secondary analysis of the database of a multicentre study which recorded participants' basic demographical and clinical data in standardised format in 10 Asian countries and territories. The data were analysed using univariate and multivariate logistic regression analyses.

RESULTS

A total of 955 older adult psychiatric in- and outpatients were included in this study. The proportion of concurrent AP and AD use was 32.0%, ranging from 23.3% in Korea to 44.0% in Taiwan. Multivariate logistic regression analysis found that younger age, inpatient status and diagnosis of schizophrenia, anxiety and other mental disorders were significantly related to a higher proportion of concurrent use of APs and ADs.

CONCLUSION

Around a third of older adult psychiatric patients had concurrent AP and AD use in the Asian countries/regions surveyed. Considering the uncertain effectiveness and questionable safety of the AP and AD combination in this patient population, such should be cautiously used.

Current and potential pharmacological and psychosocial interventions for anxiety symptoms and disorders in patients with schizophrenia: structured review

OBJECTIVE

Between 30% and 62% of patients with schizophrenia present with co-morbid anxiety disorders that are associated with increased overall burden. Our aim was to summarize current and potential interventions for anxiety in schizophrenia.

DESIGN

Structured review, summarizing pharmacological and psychosocial interventions used to reduce anxiety in schizophrenia and psychosis.

RESULTS

Antipsychotics have been shown to reduce anxiety, increase anxiety, or have no effect. These may be augmented with another antipsychotic, anxiolytic, or antidepressant. Novel agents, such as L-theanine, pregabalin, and cycloserine, show promise in attenuating anxiety in schizophrenia. Psychosocial therapies have been developed to reduce the distress of schizophrenia. Cognitive behavioural therapy (CBT) has shown that benefit and refinements in the therapy have been successful, for example, for managing worry in schizophrenia. CBT usually involves more than 16 sessions, as short courses of CBT do not attenuate the presentation of anxiety in schizophrenia. To address time and cost, the development of manualized CBT to address anxiety in schizophrenia is being developed.

CONCLUSIONS

The presence of coexisting anxiety symptoms and co-morbid anxiety disorders should be ascertained when assessing patients with schizophrenia or other psychoses as a range of pharmacological and psychosocial treatments are available.

[Use of antidepressants in the treatment of negative symptoms of schizophrenia]

Negative symptoms account for a clinical dimension of schizophrenia. They are partly the cause of functional disability of this disease. Clinical experience shows that antipsychotics have little or no effect on these symptoms. The aim of this review is to gather existing data on the treatment of negative symptoms with antidepressants. The combination of antipsychotics with antidepressants is a therapeutic strategy commonly used for the treatment of these symptoms. The pro-dopaminergic effects of antidepressants explain their effectiveness on negative symptoms. There are many comparative, randomized, controlled studies evaluating the efficacy of antidepressant associated with antipsychotic for the treatment of negative symptoms. Furthermore three meta-analyses have been conducted. The overall results suggest that the use of antidepressants may contribute to clinical improvement of negative symptoms in schizophrenia. The limitations of these studies are the small number of patients included and the definition and assessment of negative symptoms. The existing scales are not sufficiently discriminating. Further research using new measurement tools should help refine these results.

Augmentation with antidepressants in schizophrenia treatment: benefit or risk

We focused on the application of antidepressants in schizophrenia treatment in this review. Augmentation of antidepressants with antipsychotics is a common clinical practice to treat resistant symptoms in schizophrenia, including depressive symptoms, negative symptoms, comorbid obsessive-compulsive symptoms, and other psychotic manifestations. However, recent systematic review of the clinical effects of antidepressants is lacking. In this review, we have selected and summarized current literature on the use of antidepressants in patients with schizophrenia; the patterns of use and effectiveness, as well as risks and drug-drug interactions of this clinical practice are discussed in detail, with particular emphasis on the treatment of depressive symptoms in schizophrenia.

Adjunctive antidepressant prescriptions for hospitalized patients with schizophrenia in Asia (2001-2009)

INTRODUCTION

Little is known about the prescription patterns of adjunctive antidepressants in Asian schizophrenia patients. This study aimed to examine trends in the use of antidepressants and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009.

METHODS

A total of 6,761 hospitalized schizophrenia patients in nine Asian countries and territories were examined: 2,399 in 2001, 2,136 in 2004 and 2,226 in 2009. Patients' socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure.

RESULTS

The proportion of antidepressant prescription was 6.8% in the whole sample; 5.3% in 2001, 6.5% in 2004 and 8.7% in 2009. There were wide inter-country variations at each survey ranging from 0.9% in Hong Kong to 15.3% in Singapore in 2001; from 1.9% in Korea to 15.4% in Singapore in 2004; and from 2.7% in Japan to 22.0% in Singapore in 2009. Multiple logistic regression analysis of the whole sample revealed that patients on antidepressants were younger, more likely to receive benzodiazepines and have significant extrapyramidal side-effects and less likely to have significant positive symptoms.

DISCUSSION

Unlike findings in Western countries, adjunctive antidepressant prescription for schizophrenia was not common in Asia. The frequency of antidepressant prescription varied among countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining antidepressant use in Asia.

Antipsychotic Medication Utilization Trends Among Texas Veterans: 1997–2002

Background

An antipsychotic utilization pattern has evolved substantially over the past 20 years or so due to the introduction of the second-generation antipsychotics (SGAs) and the increasing understanding of their adverse effect profile.

Objective

To understand antipsychotic utilization trends (including monotherapy, antipsychotic switching, and combination therapy) and to investigate factors associated with antipsychotic index medication selection (SGAs vs first-generation antipsychotics [FGAs]) among Texas veterans.

Methods

Data were taken from the Veterans Administration North Texas Health Care System (VANTHCS) and South Texas Veterans Health Care System (STVHCS) from January 1996 to December 2003. Adults with continuous enrollment (1 y before and after the Index date) who had newly initiated antipsychotic therapy were included. Prescriptions were followed for up to 12 months. Descriptive analyses examined utilization trends; logistic regression evaluated factors associated with antipsychotic index medication selection.

Results:

A total of 8096 patients were included in the study (VANTHCS n = 4477; STVHCS n = 3619), with the majority being male (93.6%) and white (62.6%) and nearly naif aged 55 years or older (44.1%). Between 1997 and 2002, antipsychotic prescriptions changed from primarily FGAs (1997:71.7%; 1999; 25.2%; 2002: 5.7%) to SGAs. Over the 6-year time frame, risperidone (31.0%) and olanzapine (30.7%) were most commonly prescribed. The overall combination therapy slightly increased over time (4.3%), switching to another antipsychotic remained stable (14.2%), and antipsychotic monotherapy remained dominant (81.5%). Hispanic and black patients were less likely than white patients to be initiated on SGAs. Patients who were older, had hypertension, and were in STVHCS were less likely to start on SGAs. Patients with dyslipidemia, bipolar disorder, and treatment in recent years were more likely to start on SGAs

Conclusions:

SGAs have replaced FGAs as first-line medications for patients with mental disorders. Race, age, physical comorbidities (ie, dyslipidemia, hypertension), and treatment initiation year were important factors in index medication selection.

Patterns and frequency of atypical antipsychotic prescribing in psychiatric medical centers: a cross-sectional national survey

Studies describing atypical antipsychotics when compared with conventional antipsychotic drugs are few in France. This study aimed to describe the frequency and characteristics of atypical antipsychotic prescribing. A cross-sectional national survey was conducted from February to June 2003 in a random sample of 100 volunteer French psychiatrists practicing in public psychiatric medical centers. Each psychiatrist was asked to complete a questionnaire for patients to whom at least one antipsychotic was prescribed during the period of the survey. The characteristics of the patients treated with atypical antipsychotics were identified with a logistic regression model. A total of 1733 patients were included in the study. The main diagnoses were schizophrenia (46.1%) and other psychoses (40.8%), followed by mood disorders (10%) and other psychiatric disorders (2.5%). Among these patients, 56% had at least one prescription of an atypical antipsychotic, 42.1% at least one conventional antipsychotic with immediate action and 29.9% at least one conventional antipsychotic with delayed action. Seventy percent of patients were treated with single-drug atypical antipsychotics. Compared with conventional antipsychotics with immediate action, atypical antipsychotics were less likely to be prescribed to patients over 35 years of age [odds ratio (OR) 0.4; 95% confidence interval (CI) 0.3-0.6], with duration of illness >10 years (OR 0.5; 95% CI 0.3-0.7), and were less likely to be used with concomitant corrector agents for neurological side effects (OR 0.4; 95% CI 0.3-0.6). This study shows the important use of atypical antipsychotic drugs especially in schizophrenic patients and younger patients.

Antipsychotics dosage and antiparkinsonian prescriptions

Background

To study the link between the dosage of several antipsychotics and the prescription of antiparkinsonians in an observational study.

Methods

In the context of a national naturalistic prospective observational study, a database containing all the prescriptions from 100 French psychiatrists during the year 2002 was analysed. The inclusion criteria were a diagnosis of schizophrenia or schizoaffective disorder and age over 18. The mean dosage of antipsychotics with and without antiparkinsonians was compared. Since there were multiple prescriptions for a given subject, generalised mixed linear models were also used to study the link between antiparkinsonian prescription and antipsychotic dosage.

Results

antiparkinsonians were prescribed to 32,9% of the patients. Two groups of antipsychotics were observed relating to differences in dosage when an antiparkinsonian was co prescribed or not : a first group, where the mean dosage was higher with antiparkinsonians (risperidone, amisulpride and haloperidol) and a second group (clozapine, olanzapine), in which antiparkinsonian co prescription was not related to the dosage of antipsychotics.

Conclusion

As a conclusion, it can be said that it is important to consider the dosage and the type of antipsychotic in the treatment of patients suffering of schizophrenia, because neurological side effects are frequent and can impair quality of life. Moreover the prescription of antiparkinsonians can lead to different side effects such anticholinergic effects.