1
|
Casetta C, Santosh P, Bayley R, Bisson J, Byford S, Dixon C, Drake RJ, Elvins R, Emsley R, Fung N, Hayes D, Howes O, James A, James K, Jones R, Killaspy H, Lennox B, Marchant L, McGuire P, Oloyede E, Rogdaki M, Upthegrove R, Walters J, Egerton A, MacCabe JH. CLEAR - clozapine in early psychosis: study protocol for a multi-centre, randomised controlled trial of clozapine vs other antipsychotics for young people with treatment resistant schizophrenia in real world settings. BMC Psychiatry 2024; 24:122. [PMID: 38355533 PMCID: PMC10865566 DOI: 10.1186/s12888-023-05397-1] [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: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clozapine is an antipsychotic drug with unique efficacy, and it is the only recommended treatment for treatment-resistant schizophrenia (TRS: failure to respond to at least two different antipsychotics). However, clozapine is also associated with a range of adverse effects which restrict its use, including blood dyscrasias, for which haematological monitoring is required. As treatment resistance is recognised earlier in the illness, the question of whether clozapine should be prescribed in children and young people is increasingly important. However, most research to date has been in older, chronic patients, and evidence regarding the efficacy and safety of clozapine in people under age 25 is lacking. The CLEAR (CLozapine in EARly psychosis) trial will assess whether clozapine is more effective than treatment as usual (TAU), at the level of clinical symptoms, patient rated outcomes, quality of life and cost-effectiveness in people below 25 years of age. Additionally, a nested biomarker study will investigate the mechanisms of action of clozapine compared to TAU. METHODS AND DESIGN This is the protocol of a multi-centre, open label, blind-rated, randomised controlled effectiveness trial of clozapine vs TAU (any other oral antipsychotic monotherapy licenced in the British National Formulary) for 12 weeks in 260 children and young people with TRS (12-24 years old). AIM AND OBJECTIVES The primary outcome is the change in blind-rated Positive and Negative Syndrome Scale scores at 12 weeks from baseline. Secondary outcomes include blind-rated Clinical Global Impression, patient-rated outcomes, quality of life, adverse effects, and treatment adherence. Patients will be followed up for 12 months and will be invited to give consent for longer term follow-up using clinical records and potential re-contact for further research. For mechanism of action, change in brain magnetic resonance imaging (MRI) biomarkers and peripheral inflammatory markers will be measured over 12 weeks. DISCUSSION The CLEAR trial will contribute knowledge on clozapine effectiveness, safety and cost-effectiveness compared to standard antipsychotics in young people with TRS, and the results may guide future clinical treatment recommendation for early psychosis. TRIAL REGISTRATION ISRCTN Number: 37176025, IRAS Number: 1004947. TRIAL STATUS In set-up. Protocol version 4.0 01/08/23. Current up to date protocol available here: https://fundingawards.nihr.ac.uk/award/NIHR131175# /.
Collapse
Affiliation(s)
- C Casetta
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - P Santosh
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Bayley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - S Byford
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C Dixon
- Wonford House Hospital, Devon Partnership NHS Trust, Exeter, UK
| | - R J Drake
- Division of Psychology & Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - R Elvins
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - R Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - N Fung
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - D Hayes
- South London and Maudsley NHS Foundation Trust, London, UK
| | - O Howes
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A James
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - K James
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - R Jones
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - H Killaspy
- Division of Psychiatry, University College London, London, UK
| | - B Lennox
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - L Marchant
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - P McGuire
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - E Oloyede
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - M Rogdaki
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - R Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Womens and Childrens NHS Foundation Trust, Birmingham, UK
| | - J Walters
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK
| | - A Egerton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - J H MacCabe
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
2
|
Babinet MN, Demily C, Michael GA. A new scale for the screening of childhood early psychotic symptoms. Psychiatry Res 2023; 327:115418. [PMID: 37598627 DOI: 10.1016/j.psychres.2023.115418] [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: 06/09/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/22/2023]
Abstract
This study aimed to develop a new scale, the Early Psychotic Symptoms screening scale (EPSy), to assess the prodromes of psychotic symptoms in children aged 4 to 13 years. Two versions were proposed: one to assess the child's current behavior and one to assess the child's behavior when he/she was 2 years old. The second aim of this study was to investigate the presence of these symptoms at the age of 2 years and their evolution up to the child's current age. The analysis of EPSy identified three main factors, namely mistrust/paranoia, perceptual aberrations/hallucinations and disorganized symptoms. It has good psychometric properties. Data also shows that, independently of the participant's age, the total score on the 2-years-old version predicts the total score on the current-age version, and this is also the case for each individual factor. Finally, it is of clinical interest since it makes it possible to describe symptomatology both at age 2 and at the child's present age depending on the group to which the children are assigned (control children, psychotic children, non-psychotic children).
Collapse
Affiliation(s)
- Marie-Noëlle Babinet
- Centre de Rérence Maladies Rares Troubles du Comportement d'Origine Génétique (GénoPsy Lyon), Centre d'excellence Autisme iMIND, Centre Hospitalier Le Vinatier, UMR 5229, CNRS & Université Lyon 1, 95 Boulevard Pinel, Bron 69500, France; Unité de Recherche Étude des Mécanismes Cognitifs, Université Lumière Lyon 2, Université de Lyon, 5 avenue Pierre Mendes-France, Bron 69676 CEDEX, France.
| | - Caroline Demily
- Centre de Rérence Maladies Rares Troubles du Comportement d'Origine Génétique (GénoPsy Lyon), Centre d'excellence Autisme iMIND, Centre Hospitalier Le Vinatier, UMR 5229, CNRS & Université Lyon 1, 95 Boulevard Pinel, Bron 69500, France
| | - George A Michael
- Unité de Recherche Étude des Mécanismes Cognitifs, Université Lumière Lyon 2, Université de Lyon, 5 avenue Pierre Mendes-France, Bron 69676 CEDEX, France
| |
Collapse
|
3
|
Tuncturk M, Ermis C, Buyuktaskin D, Turan S, Saglam Y, Alarslan S, Guler D, Sut E, Unutmaz G, Guzel AB, Atay Canbek O, Inal N, Karacetin G, Hazell P. Electroconvulsive therapy or clozapine for adolescents with treatment-resistant schizophrenia: an explorative analysis on symptom dimensions. Int J Psychiatry Clin Pract 2023; 27:257-263. [PMID: 36576216 DOI: 10.1080/13651501.2022.2160764] [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: 08/08/2022] [Revised: 11/16/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This study sought to compare pre-intervention patient characteristics and post-intervention outcomes in a naturalistic sample of adolescent inpatients with treatment-resistant psychotic symptoms who received either electroconvulsive therapy (ECT) or clozapine. METHODS Data of adolescents with schizophrenia/schizoaffective disorder receiving ECT or clozapine were retrospectively collected from two tertiary-care psychiatry-teaching university hospitals. Subscale scores of the Positive and Negative Symptom Scale (PANSS) factors were calculated according to the five-factor solution. Baseline demographics, illness characteristics, and post-intervention outcomes were compared. RESULTS There was no significant difference between patients receiving ECT (n = 13) and clozapine (n = 66) in terms of age, sex, and the duration of hospital stay. The ECT group more commonly had higher overall illness and aggression severity. Smoking was less frequent in the clozapine group. Baseline resistance/excitement symptom severity was significantly higher in the ECT group, while positive, negative, affect, disorganisation, and total symptom scores were not. Both interventions provided a significant reduction in PANSS scores with large effect sizes. CONCLUSION Both ECT and clozapine yielded high effectiveness rates in adolescents with treatment-resistant schizophrenia/schizoaffective disorder. Youth receiving ECT were generally more activated than those who received clozapine.
Collapse
Affiliation(s)
- Mustafa Tuncturk
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | | | | | - Serkan Turan
- Department of Child and Adolescent Psychiatry, Uludag University School of Medicine, Bursa, Turkey
| | - Yesim Saglam
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Sezen Alarslan
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Duru Guler
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ekin Sut
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Guldal Unutmaz
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ayse Beste Guzel
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Ozge Atay Canbek
- Department of Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Neslihan Inal
- Department of Child and Adolescent Psychiatry, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Gul Karacetin
- Department of Child and Adolescent Psychiatry, University of Health Sciences, Bakirkoy Prof Dr Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Philip Hazell
- Specialty of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| |
Collapse
|
4
|
Gupta N, Gupta M, Esang M. Lost in Translation: Challenges in the Diagnosis and Treatment of Early-Onset Schizophrenia. Cureus 2023; 15:e39488. [PMID: 37362509 PMCID: PMC10290525 DOI: 10.7759/cureus.39488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.
Collapse
Affiliation(s)
- Nihit Gupta
- Psychiatry, Dayton Children's Hospital, Dayton, USA
| | - Mayank Gupta
- Psychiatry and Behavioral Sciences, Southwood Psychiatric Hospital, Pittsburgh, USA
| | - Michael Esang
- Psychiatry and Behavioral Sciences, Clarion Psychiatric Center, Clarion, USA
| |
Collapse
|
5
|
Rizvi A, Reyazuddin M, Shaan F. Low Dose Clozapine in Early Onset Resistant Schizophrenia: Case Report and Two Year Follow-up. J Am Acad Child Adolesc Psychiatry 2023:S0890-8567(23)00181-8. [PMID: 37075891 DOI: 10.1016/j.jaac.2023.03.014] [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: 11/25/2022] [Revised: 03/04/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
Childhood-onset schizophrenia (COS) is considered a rare and severe form of schizophrenia, with onset before age 13 and only half of affected patients responding to nonclozapine antipsychotics.1 These patients with resistant COS show favorable responses to clozapine, but with higher adverse effects than seen in adults. Some resistant cases respond at a lower dose with minimal adverse effects.2 However, it is unclear which patients will respond to a low dose and how long one should wait before increasing the dose of clozapine. We report a patient with resistant COS who showed a favorable but delayed-onset response to low-dose clozapine.
Collapse
Affiliation(s)
- Abid Rizvi
- West Virginia University, Morgantown, West Virginia.
| | | | | |
Collapse
|
6
|
Regional clozapine, ECT and lithium usage inversely associated with excess suicide rates in male adolescents. Nat Commun 2023; 14:1281. [PMID: 36918566 PMCID: PMC10015020 DOI: 10.1038/s41467-023-36973-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/20/2023] [Indexed: 03/16/2023] Open
Abstract
Advanced psychiatric treatments remain uncertain in preventing suicide among adolescents. Across the 21 Swedish regions, using nationwide registers between 2016-2020, we found negative correlation between adolescent excess suicide mortality (AESM) and regional frequencies of clozapine, ECT, and lithium (CEL) usage among adolescents (β = -0.613, p = 0.0003, 95% CI: -0.338, -0.889) and males (β = -0.404, p = 0.009, 95% CI: -0.130, -0.678). No correlation was found among females (p = 0.197). Highest CEL usage among male adolescents was seen in regions with lowest quartile (Q1) AESM (W = 74, p = 0.012). Regional CEL treatment frequency in 15-19-year-olds was related to lower AESM in males, reflecting potential treatment efficacy, treatment compliance or better-quality mental health care. Suicide prevention may benefit from early recognition and CEL treatment for severe mental illness in male adolescents. The results indicate association but further research, using independent samples and both prospective and observational methodologies, is needed to confirm causality.
Collapse
|
7
|
Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution. J Child Neurol 2023; 38:216-222. [PMID: 37165651 DOI: 10.1177/08830738231156804] [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] [Indexed: 02/24/2023]
Abstract
New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.
Collapse
|
8
|
Correll CU, Fusar-Poli P, Leucht S, Karow A, Maric N, Moreno C, Nordentoft M, Raballo A. Treatment Approaches for First Episode and Early-Phase Schizophrenia in Adolescents and Young Adults: A Delphi Consensus Report from Europe. Neuropsychiatr Dis Treat 2022; 18:201-219. [PMID: 35177905 PMCID: PMC8843859 DOI: 10.2147/ndt.s345066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/13/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Although first-episode psychosis (FEP) in youth, particularly early-onset schizophrenia (EOS), is managed similarly to adult-onset schizophrenia, few antipsychotics are approved for people aged 13-18 years. We aimed to explore areas of uncertainty in EOS management and provide evidence-based recommendations to mental health specialists. We used the Delphi methodology to gain knowledge in areas lacking evidence-based strategies. This standardized methodology consists of the development of a questionnaire by content experts, which is then submitted to a broader panel of professionals (panelists) to survey their level of agreement on the topics proposed. MATERIALS AND METHODS The developed questionnaire covered patient management from diagnosis to maintenance treatment and was administered to a broader panel of specialists across Europe. Based on an analysis of responses received in this first round, the items that needed further insight were submitted to the panel for a second round and then reanalysed. RESULTS An initial set of 90 items was developed; in round I, consensus was reached for 83/90 items (92%), while it was reached for 7/11 (64%) of the items sent out for rerating in round II. Feedback for rounds I and II was obtained from 54/92 and 48/54 approached experts, respectively. There was broad agreement on diagnostic standards, multimodal approaches and focus on adverse events, but uncertainty in terms of pharmacological strategies (including clozapine) in case of failure and antipsychotic dosing in younger patients. CONCLUSION Despite knowledge about diagnostic clues and integrated management of EOS, this study highlights the lack of standardization in treating EOS, with safety arguments having a major role in the decision-making process. Targeted clinical trials and systematic dissemination across Europe of current scientific evidence on the value of early intervention services is hoped to contribute to standardized and improved quality care for patients with early-phase psychosis and schizophrenia.
Collapse
Affiliation(s)
- Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry and Molecular Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY, USA
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- OASIS service, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Stefan Leucht
- Section Evidence-Based Medicine in Psychiatry and Psychotherapy, Department of Psychiatry and Psychotherapy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Anne Karow
- Department of Psychiatry and Psychotherapy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Nadja Maric
- Faculty of Medicine, University of Belgrade and Institute of Mental Health, Belgrade, Serbia
| | - Carmen Moreno
- 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
| | - Merete Nordentoft
- CORE-Copenhagen Research Centre for Mental Health, Mental Health Services in the Capital Region, Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Raballo
- Section of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia, Perugia, Italy
- Centre for Translational, Phenomenological and Developmental Psychopathology (CTPDP), Perugia University Hospital, Perugia, Italy
| |
Collapse
|
9
|
Adnan M, Motiwala F, Trivedi C, Sultana T, Mansuri Z, Jain S. Clozapine for Management of Childhood and Adolescent-Onset Schizophrenia: A Systematic Review and Meta-Analysis. J Child Adolesc Psychopharmacol 2022; 32:2-11. [PMID: 35099269 DOI: 10.1089/cap.2021.0092] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Schizophrenia at a young age deserves investigation because of the greater severity and burden of illness on individuals and health care than its adult onset. For this study, we included both childhood-onset schizophrenia and early-onset schizophrenia. We used the common term "childhood and adolescent-onset schizophrenia (CAOS)" for either type. This systematic review provides an overview of the clinical use, efficacy, and safety of clozapine treatment in managing CAOS. Methods: We conducted a systematic literature search in PubMed, Embase, and PsycINFO databases. We searched for randomized controlled trials (RCTs), open-label studies (OLSs), review articles, meta-analytic and observational studies. Our literature search resulted in 1242 search results. After the title, abstract, and full article review, 18 studies qualified (double-blind RCTs n = 4; OLS n = 4; observational studies n = 7; case reports n = 3). Results: Clozapine use in CAOS was generally well tolerated and not associated with any fatalities. Clozapine use in the short term (6 weeks) and long term (2-9 years) was superior in efficacy than other antipsychotics in CAOS management. Improvement in overall symptoms was maintained during long-term follow-up over the years in OLSs. Clozapine appeared to have a favorable clinical response and shorter hospital stays. Sedation and hypersalivation were commonly reported (90%), constipation was next in frequency (13%-50%). Neutropenia was seen in 6%-15% of cases and agranulocytosis (<0.1%). Although weight gain was common (up to 64%), followed by metabolic changes (8%-22%), treatment-onset diabetes was less frequent (<6%). Akathisia, tachycardia, and blood pressure changes were less commonly seen. Conclusions: Limited studies indicate that clozapine is a safe and efficacious option for CAOS management. We need large-scale and well-designed long-term RCTs for the use of clozapine in the management of CAOS.
Collapse
Affiliation(s)
- Mahwish Adnan
- Department of Psychiatry, Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Fatima Motiwala
- Department of Psychiatry, Texas Tech University Health Science Center at Odessa/Permian Basin Odessa, Midland, Texas, USA
| | - Chintan Trivedi
- Department of Psychiatry, Texas Tech University Health Science Center at Odessa/Permian Basin Odessa, Midland, Texas, USA
| | - Tania Sultana
- Department of Psychiatry, Manhattan Psychiatric Center, New York, New York, USA
| | - Zeeshan Mansuri
- Department of Psychiatry, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Shailesh Jain
- Department of Psychiatry, Texas Tech University Health Science Center at Odessa/Permian Basin Odessa, Midland, Texas, USA
| |
Collapse
|
10
|
Karacetin G, Ermis C, Bulanik Koc E, Saglam Y. Investigating Predictors of Clozapine Response in Adolescents with Schizophrenia and Schizoaffective Disorder. J Child Adolesc Psychopharmacol 2021; 31:504-510. [PMID: 34283936 DOI: 10.1089/cap.2021.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: We aimed to determine the clinical predictors of clozapine response in patients with early-onset schizophrenia (EOS)/schizoaffective disorder and the effect of substance use disorder (SUD) on treatment outcomes. Methods: Medical records of patients with treatment-resistant EOS receiving clozapine were identified for data analysis dated between January 2015 and April 2020. Patients on clozapine were followed in an inpatient unit of a tertiary care mental health hospital. Using the Positive and Negative Symptom Scale (PANSS), ≥30% reduction was defined as the response criteria after clozapine treatment. Results: Of 50 subjects (age: 16.3 ± 1.3 years, 36.0% female), 22 subjects (44.0%) met the defined response criteria. Clozapine responder (CLZ-R) and clozapine nonresponder (CLZ-NR) groups were similar regarding age at illness onset, sex, and duration of untreated psychosis. The CLZ-R group had higher baseline positive PANSS scores (24.8 ± 8.1 vs. 17.1 ± 6.6, p = 0.001, d = 1.0) and total PANSS scores (94.8 ± 17.2 vs. 80.1 ± 19.8, p = 0.008, d = 0.8) compared with the CLZ-NR counterparts. The duration of hospital stay was longer in the CLZ-NR group (122.3 ± 48.2 vs. 87.3 ± 36.2 days, p = 0.007). Among 32 male patients, the presence of SUD (n = 9, 28.1%) was associated with a less reduction in total PANSS scores (F = 7.5, p = 0.010) and higher levels of positive symptoms at the end of the treatment (12.8 ± 4.1 vs. 18.8 ± 7.4, p = 0.006, d = 1.0). Synthetic cannabinoids were the most common substance type used among males with treatment-refractory EOS (25.0%). Conclusions: Our results did not support the role of sociodemographic variables in clozapine response. Positive symptoms and SUD yielded a prognostic value in patients receiving clozapine.
Collapse
Affiliation(s)
- Gul Karacetin
- Clinic of Child and Adolescent Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases, University of Health Sciences, Istanbul, Turkey
| | - Cagatay Ermis
- Department of Child and Adolescent Psychiatry, Dokuz Eylül University, İzmir, Turkey
| | - Esra Bulanik Koc
- Clinic of Child and Adolescent Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases, University of Health Sciences, Istanbul, Turkey
| | - Yesim Saglam
- Clinic of Child and Adolescent Psychiatry, Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases, University of Health Sciences, Istanbul, Turkey
| |
Collapse
|
11
|
Li D, Zhang F, Wang L, Zhang Y, Yang T, Wang K, Zhu C. Decision making under ambiguity and risk in adolescent-onset schizophrenia. BMC Psychiatry 2021; 21:230. [PMID: 33947364 PMCID: PMC8094464 DOI: 10.1186/s12888-021-03230-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/20/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Numerous studies have identified impaired decision making (DM) under both ambiguity and risk in adult patients with schizophrenia. However, the assessment of DM in patients with adolescent-onset schizophrenia (AOS) has been challenging as a result of the instability and heterogeneity of manifestations. The Iowa Gambling Task (IGT) and Game of Dice Task (GDT), which are frequently used to evaluate DM respectively under ambiguity and risk, are sensitive to adolescents and neuropsychiatric patients. Our research intended to examine the performance of DM in a relatively large sample of patients with AOS using the above-mentioned two tasks. We also aimed to take a closer look at the relationship between DM and symptom severity of schizophrenia. METHODS We compared the performance of DM in 71 patients with AOS and 53 well-matched healthy controls using IGT for DM under ambiguity and GDT for DM under risk through net scores, total scores and feedback ration. Neuropsychological tests were conducted in all participants. Clinical symptoms were evaluated by using Positive and Negative Syndrome Scale (PANSS) in 71 patients with AOS. Pearson's correlation revealed the relationship among total score of DM and clinical and neuropsychological data. RESULTS Compared to healthy controls, patients with AOS failed to show learning effect and had a significant difference on the 5th block in IGT and conducted more disadvantageous choices as well as exhibited worse negative feedback rate in GDT. Apart from DM impairment under risk, diminished DM abilities under ambiguity were found related to poor executive function in AOS in the present study. CONCLUSIONS Our findings unveiled the abnormal pattern of DM in AOS, mainly reflected under the risky condition, extending the knowledge on the performance of DM under ambiguity and risk in AOS. Inefficient DM under risk may account for the lagging impulse control and the combined effects of developmental disease. In addition, our study demonstrated that the performance on IGT was related to executive function in AOS.
Collapse
Affiliation(s)
- Dandan Li
- grid.412679.f0000 0004 1771 3402Department of Neurology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022 China ,Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, 230022 China ,Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, 230022 China ,grid.186775.a0000 0000 9490 772XSchool of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022 China
| | - Fengyan Zhang
- grid.33199.310000 0004 0368 7223Children’s Rehabilitation Department, Wuhan Mental Health Center, Wuhan, 430012 China
| | - Lu Wang
- grid.412679.f0000 0004 1771 3402Department of Neurology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022 China
| | - Yifan Zhang
- grid.186775.a0000 0000 9490 772XSchool of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022 China
| | - Tingting Yang
- grid.186775.a0000 0000 9490 772XSchool of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022 China
| | - Kai Wang
- Department of Neurology, the First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China. .,Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, 230022, China. .,Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, 230022, China. .,School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022, China. .,Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, 230022, China.
| | - Chunyan Zhu
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, 230022, China. .,Collaborative Innovation Center of Neuropsychiatric Disorders and Mental Health, Hefei, 230022, China. .,School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, 230022, China.
| |
Collapse
|
12
|
Berel C, Mossé U, Wils J, Cousin L, Imbert L, Gerardin P, Chaumette B, Lamoureux F, Ferrafiat V. Interest of Fluvoxamine as an Add-On to Clozapine in Children With Severe Psychiatric Disorder According to CYP Polymorphisms: Experience From a Case Series. Front Psychiatry 2021; 12:669446. [PMID: 34234701 PMCID: PMC8255476 DOI: 10.3389/fpsyt.2021.669446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/21/2021] [Indexed: 01/24/2023] Open
Abstract
Despite its drastic efficacy in resistant psychiatric disorders, clozapine remains rarely used in youth due to its side effects. Clozapine plasma level is determined through its metabolism involving several isoforms of cytochromes 450 (CYP450) family. Isoform CYP1A2 appears as a limiting enzyme involved in the metabolism of clozapine, while isoforms 2C19, 2D6, 3A4, and 3A5 also contribute in a minor way. Clozapine efficacy is limited by a significant inter-patient variability in exposure according to CYP's polymorphisms. Clozapine plasma levels may be increased with CYP inhibitors such as fluvoxamine. This drug is a potent enzymatic inhibitor of CYP1A2 and, to a lesser extent, of CYP3A4 and CYP2D6. Hence, in case of CYP's polymorphisms in youth, the use of fluvoxamine as add-on to clozapine could help in reaching clinical and biological efficacy and allowing lower clozapine dosage and a better tolerance profile as it has already been described in adults. We report four pediatric cases with severe psychiatric disorders underlying our experience with CYP polymorphism explorations and the use of fluvoxamine as add-on to clozapine. Our four patients clinically improved after the introduction of fluvoxamine, enhancing clozapine metabolism and therefore the clozapine plasma level within therapeutic range. Despite the interesting results of fluvoxamine, we report a severe issue of tolerance for one patient, emphasizing the need for caution regarding possible drug interactions when fluvoxamine is considered. Hence, we propose a detailed step-by-step multidisciplinary protocol.
Collapse
Affiliation(s)
- Camille Berel
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Ulysse Mossé
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France
| | - Julien Wils
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Lauriane Cousin
- Child and Adolescent Psychiatric Department, CHRU Lille, Lille, France
| | - Laurent Imbert
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France
| | - Priscille Gerardin
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
| | - Boris Chaumette
- Institut de Psychiatrie et Neurosciences de Paris, INSERM UMR 1266, Université de Paris, GDR3557-Institut de Psychiatrie, Paris, France.,GHU Paris Psychiatrie et Neurosciences, Paris, France.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Fabien Lamoureux
- Department of Pharmacology - Toxicology and Pharmacogenetics, Rouen University Hospital, Rouen, France.,Normandie Univ, UNIROUEN, Inserm U1096, Rouen, France
| | - Vladimir Ferrafiat
- Child and Adolescent Psychiatric Unit, URHEA, CHSR Sotteville les Rouen, Sotteville les Rouen, France.,Child and Adolescent Psychiatric Department, CHU Charles Nicolle, Rouen, France
| |
Collapse
|
13
|
Beex‐Oosterhuis MM, Samb A, Heerdink ER, Souverein PC, Van Gool AR, Meyboom RHB, Marum RJ. Safety of clozapine use during pregnancy: Analysis of international pharmacovigilance data. Pharmacoepidemiol Drug Saf 2020; 29:725-735. [DOI: 10.1002/pds.5016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Marieke M. Beex‐Oosterhuis
- Department of Clinical Pharmacy Albert Schweitzer Hospital Dordrecht The Netherlands
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research VU University Medical Center Amsterdam The Netherlands
| | - Amadou Samb
- Division of Pharmacoepidemiology and Clinical Pharmacology Utrecht Institute for Pharmaceutical Sciences, Utrecht University Utrecht The Netherlands
| | - Eibert R. Heerdink
- Division of Pharmacoepidemiology and Clinical Pharmacology Utrecht Institute for Pharmaceutical Sciences, Utrecht University Utrecht The Netherlands
- Department of Clinical Pharmacy Utrecht University Medical Center Utrecht The Netherlands
- Research Group Innovation of Pharmaceutical Care University of Applied Sciences Utrecht Utrecht The Netherlands
| | - Patrick C. Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology Utrecht Institute for Pharmaceutical Sciences, Utrecht University Utrecht The Netherlands
| | | | - Ronald H. B. Meyboom
- Division of Pharmacoepidemiology and Clinical Pharmacology Utrecht Institute for Pharmaceutical Sciences, Utrecht University Utrecht The Netherlands
| | - Rob J. Marum
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research VU University Medical Center Amsterdam The Netherlands
- Geriatric Department and Center for Clinical Pharmacology Jeroen Bosch Hospital 's‐Hertogenbosch The Netherlands
| |
Collapse
|
14
|
Xu L, Guo Y, Cao Q, Li X, Mei T, Ma Z, Tang X, Ji Z, Yang L, Liu J. Predictors of outcome in early onset schizophrenia: a 10-year follow-up study. BMC Psychiatry 2020; 20:67. [PMID: 32059664 PMCID: PMC7023710 DOI: 10.1186/s12888-020-2484-x] [Citation(s) in RCA: 4] [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] [Received: 06/04/2019] [Accepted: 02/05/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Younger age at onset is generally thought to be a predictor of poor outcome in Early Onset Schizophrenia (EOS), but there is a paucity of epidemiological data supporting this belief. This study aims to describe long-term outcomes and predictors of patient functioning in EOS, with a focus on the effect of age at onset. METHODS We consecutively enrolled 118 EOS patients who were hospitalized in 2006. Mean age at baseline was 13.3 ± 2.3 years. Sixty-five subjects were successfully interviewed. Mean length of follow up was 10.4 ± 0.3 years. Baseline data were collected from inpatient medical records, while follow up was conducted primarily through telephone interviews of patient relatives. WHODAS 2.0 was used to measure global functioning at follow up. Outcomes included education, employment, marriage status, physical health, subsequent diagnoses and treatment, and patient functioning. Univariate and multivariate regression models were used to assess predictors of outcome, while propensity scores were used to adjust for confounding in analyzing the effect of age at onset on functional outcome. RESULTS Of the 65 subjects where follow-up data were available, 3 were deceased at follow up. Five (8%) discontinued treatment. Diagnostic stability was 76%. Nearly a quarter (24%) were using clozapine at follow up. In male and female patients, 61 and 55% respectively were overweight, while 29 and 32% respectively were obese. Sixteen (26%) were economically self-sufficient, while 34 (55%) were unemployed. Thirteen (21%) patients had ever been married. The median WHODAS score was 15 (IQR 2 to 35), roughly corresponding to the 78th percentile on population norms. Extroverted personality (p = 0.01), suspicious personality (p = 0.02), and high level of education (p = 0.001) predicted better functioning. Age of onset was not associated with function in either the univariate model (p = 0.24), full model (p = 0.17) or the final risk factor model (p = 0.11), nor after using propensity scores to further adjust for confounders. CONCLUSION The long-term functional outcome of EOS is more optimistic than generally believed. Age at disease onset does not predict long-term functional outcome in EOS populations.
Collapse
Affiliation(s)
- Lingzi Xu
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Yanqing Guo
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Qingjiu Cao
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Xue Li
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Ting Mei
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Zenghui Ma
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Xinzhou Tang
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Zhaozheng Ji
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Liu Yang
- grid.11135.370000 0001 2256 9319Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191 China
| | - Jing Liu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), 51 Huayuanbei Road, Haidian District, Beijing, 100191, China.
| |
Collapse
|
15
|
Giannitelli M, Levinson DF, Cohen D, Xavier J, Laurent-Levinson C. Developmental and symptom profiles in early-onset psychosis. Schizophr Res 2020; 216:470-478. [PMID: 31874744 DOI: 10.1016/j.schres.2019.10.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 08/23/2019] [Accepted: 10/12/2019] [Indexed: 01/01/2023]
Abstract
Psychotic disorders in children are more heterogeneous than is captured by categorical diagnoses. In a new cohort of children and adolescents, we evaluated the relationships among age at onset (AAO), clinical symptoms and developmental impairments. Patients with schizophrenia and other "spectrum" psychotic diagnoses (N = 88; AAO 6-17, mean 12.6) were evaluated with diagnostic interviews, a new clinical scale (Lifetime Dimensions of Psychosis Scale-Child and Adolescent), and neuropsychological and medical evaluations. Key findings were replicated in an adult cohort of 2420 cases, including 127 with retrospective AAO<13. Factor and cluster analyses were carried out to identify clinical profiles. Five clinical factors were identified in each cohort: Positive, Bizarre Positive, Negative/Formal Thought Disorder, Depression and Mania. Earlier AAO predicted severity of bizarre positive symptoms in children and of bizarre and other symptoms in adults. Four clinical clusters in the child cohort were characterized by: more severe bizarre positive symptoms (N = 31); negative symptoms (N = 15); premorbid autism spectrum features and developmental delay (N = 12); and depressive symptoms with heterogeneous diagnoses and mild positive/negative symptoms (N = 25). Previous factor-analytic studies of childhood psychosis did not specifically consider bizarre positive symptoms. Here, bizarre positive symptoms emerged as clinical markers of severe, childhood-onset psychosis similar to adult schizophrenia. The four clusters are clinically meaningful and useful for treatment planning and potentially for biological research. Childhood-onset cases are rare and thus difficult to study, but additional, larger cohorts may be useful in dissecting the biological and developmental heterogeneity of psychotic disorders.
Collapse
Affiliation(s)
- Marianna Giannitelli
- Faculté de Médecine Sorbonne Université, Groupe de Recherche Clinique n°15 - Troubles Psychiatriques et Développement (PSYDEV), 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France; Centre de Référence des Maladies Rares à Expression Psychiatrique, Department of Child and Adolescent Psychiatry, AP-HP, Hôpital Universitaire de la Pitié-Salpêtrière, 47 - 83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Douglas F Levinson
- Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd., Stanford, CA, 94305, USA.
| | - David Cohen
- Faculté de Médecine Sorbonne Université, Groupe de Recherche Clinique n°15 - Troubles Psychiatriques et Développement (PSYDEV), 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France; Centre de Référence des Maladies Rares à Expression Psychiatrique, Department of Child and Adolescent Psychiatry, AP-HP, Hôpital Universitaire de la Pitié-Salpêtrière, 47 - 83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France; Institut des Systèmes Intelligents et de Robotique (ISIR), CNRS UMR7222, Sorbonne Université, Campus Pierre et Marie Curie, Faculté des Sciences et Ingénierie, Pyramide, Tour 55, Boîte courrier 173, 4 Place Jussieu, 75252, Paris Cedex 05, France.
| | - Jean Xavier
- Centre Hospitalier Spécialisé Henri Laborit, Poitiers, France; CNRS UMR 7295 Centre de Recherches sur la Cognition et l'Apprentissage, Bâtiment A5, 5, rue Théodore Lefebvre, 86000, Poitiers, France.
| | | | - Claudine Laurent-Levinson
- Faculté de Médecine Sorbonne Université, Groupe de Recherche Clinique n°15 - Troubles Psychiatriques et Développement (PSYDEV), 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France; Centre de Référence des Maladies Rares à Expression Psychiatrique, Department of Child and Adolescent Psychiatry, AP-HP, Hôpital Universitaire de la Pitié-Salpêtrière, 47 - 83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
| |
Collapse
|
16
|
|
17
|
Thien K, O'Donoghue B. Delays and barriers to the commencement of clozapine in eligible people with a psychotic disorder: A literature review. Early Interv Psychiatry 2019; 13:18-23. [PMID: 29984888 DOI: 10.1111/eip.12683] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 05/16/2018] [Indexed: 01/08/2023]
Abstract
AIM While the majority of individuals with a first episode of psychosis (FEP) achieve symptomatic remission with the appropriate treatment, there is a small but significant proportion who do not achieve remission of symptoms despite adequate treatment with at least two antipsychotic medications (termed treatment resistance). Clozapine is indicated in individuals who fulfil the criteria for treatment-resistant schizophrenia, however, despite it being the most effective antipsychotic medication, there can be delays in the commencement of clozapine in eligible patients. METHODS A systematic search was performed to identify articles reporting either the time taken to commence clozapine (or delays) in eligible individuals or articles reporting barriers to the commencement of clozapine. The initial search generated 5588 articles and of these, 18 were eligible. RESULTS 13 studies described delays in commencing clozapine and five studies reported on the barriers to the commencement of clozapine. The duration of delay from when an individual was deemed eligible for clozapine treatment to the time of clozapine commencement ranged from 19.3 weeks to 5.5 years. In addition, the duration of illness prior to clozapine initiation ranged from 1.1 to 9.7 years. It was found that some clinicians were more inclined to prescribe antipsychotic polypharmacy or doses higher than recommended than to prescribe clozapine. CONCLUSIONS Delays in commencing clozapine have been consistently demonstrated. Early intervention for psychosis services are the ideal settings to identify individuals with persistent positive psychotic symptoms and commence clozapine if indicated.
Collapse
Affiliation(s)
- Kristen Thien
- Research Organisation, Orygen, the National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Brian O'Donoghue
- Research Organisation, Orygen, the National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria, Australia.,Youth Mental Health Clinical Service, Orygen Youth Health, Parkville, Victoria, Australia
| |
Collapse
|
18
|
Downs J, Dean H, Lechler S, Sears N, Patel R, Shetty H, Hotopf M, Ford T, Kyriakopoulos M, Diaz-Caneja CM, Arango C, MacCabe JH, Hayes RD, Pina-Camacho L. Negative Symptoms in Early-Onset Psychosis and Their Association With Antipsychotic Treatment Failure. Schizophr Bull 2019; 45:69-79. [PMID: 29370404 PMCID: PMC6293208 DOI: 10.1093/schbul/sbx197] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The prevalence of negative symptoms (NS) at first episode of early-onset psychosis (EOP), and their effect on psychosis prognosis is unclear. In a sample of 638 children with EOP (aged 10-17 y, 51% male), we assessed (1) the prevalence of NS at first presentation to mental health services and (2) whether NS predicted eventual development of multiple treatment failure (MTF) prior to the age of 18 (defined by initiation of a third trial of novel antipsychotic due to prior insufficient response, intolerable adverse-effects or non-adherence). Data were extracted from the electronic health records held by child inpatient and community-based services in South London, United Kingdom. Natural Language Processing tools were used to measure the presence of Marder Factor NS and antipsychotic use. The association between presenting with ≥2 NS and the development of MTF over a 5-year period was modeled using Cox regression. Out of the 638 children, 37.5% showed ≥2 NS at first presentation, and 124 (19.3%) developed MTF prior to the age of 18. The presence of NS at first episode was significantly associated with MTF (adjusted hazard ratio 1.62, 95% CI 1.07-2.46; P = .02) after controlling for a number of potential confounders including psychosis diagnostic classification, positive symptoms, comorbid depression, and family history of psychosis. Other factors associated with MTF included comorbid autism spectrum disorder, older age at first presentation, Black ethnicity, and family history of psychosis. In EOP, NS at first episode are prevalent and may help identify a subset of children at higher risk of responding poorly to antipsychotics.
Collapse
Affiliation(s)
- Johnny Downs
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK,South London and Maudsley NHS Foundation Trust, UK,Department of Child and Adolescent Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King’s College London, UK
| | - Harry Dean
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | - Suzannah Lechler
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | - Nicola Sears
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | - Rashmi Patel
- South London and Maudsley NHS Foundation Trust, UK,Department of Psychosis Studies, Institute of Psychiatry Psychology Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | | | - Matthew Hotopf
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK,South London and Maudsley NHS Foundation Trust, UK
| | | | - Marinos Kyriakopoulos
- South London and Maudsley NHS Foundation Trust, UK,Department of Child and Adolescent Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King’s College London, UK,Department of Psychiatry, Icahn School of Medicine at Mount Sinai
| | - Covadonga M Diaz-Caneja
- Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Spain
| | - Celso Arango
- Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Spain
| | - James H MacCabe
- South London and Maudsley NHS Foundation Trust, UK,Department of Psychosis Studies, Institute of Psychiatry Psychology Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | - Richard D Hayes
- Department of Psychological Medicine, Institute of Psychiatry Psychology and Neuroscience, King’s College London & NIHR South London and Maudsley Biomedical Research Centre, UK
| | - Laura Pina-Camacho
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King’s College London, UK,Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Spain,To whom correspondence should be addressed; Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, Ibiza 43, 28009 Madrid, Spain; tel: +34-914265005, fax: +34-914265004, e-mail:
| |
Collapse
|
19
|
Steinauer LM, Leung JG, Burkey BW, McGrane IR, Letts V, Goren JL, Hoeft DM, Mullen S, Maroney M, Schak KM, Vande Voort JL. A Retrospective Multicenter Evaluation of Clozapine Use in Pediatric Patients Admitted for Acute Psychiatric Hospitalization. J Child Adolesc Psychopharmacol 2018; 28:615-619. [PMID: 30358422 DOI: 10.1089/cap.2018.0036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Clozapine is the drug of choice for treatment-resistant schizophrenia. While pediatric clozapine use is not contraindicated, the literature describing its clinical application is limited. The primary objective of this study was to assess the use of clozapine in a child and adolescent population by characterizing the documented safety and clinical benefits of the medication. METHODS A multicenter retrospective study at sites in the United States and Australia included children and adolescents admitted to a psychiatric unit who were administered at least one dose of clozapine. Information related to demographics, patient history, past treatments, clozapine, and adverse events was collected. RESULTS Eighty-two patients from eight sites were included in this study. Patients were predominantly clozapine naive (76.8%), and most had a discharge diagnosis of a primary psychotic disorder (61%) or bipolar disorder (25.6%). Four clozapine discontinuations occurred during hospitalization due to severe neutropenia, ileus, need for diagnostic clarification, and significant psychomotor retardation. The remainder (n = 78) were discharged on a mean clozapine dose of 218.1 ± 142.2 mg. Sedation (26.8%) and sialorrhea (17.1%) were the most common documented adverse events. The mean number of previously trialed antipsychotics before clozapine was 3.5 ± 1.4 (range 1-10). Improvement with clozapine was documented as significant (31.7%), moderate (32.9%), minimal (12.2%), no improvement (2.4%), and not described (20.7%). CONCLUSIONS In this cohort, 95% of pediatric patients admitted with or started on clozapine during an acute psychiatric hospitalization were discharged on the medication. The high incidence of adverse events should reinforce to clinicians the need for vigilant monitoring. Pediatric guidelines recommend clozapine for refractory schizophrenia but stress the critical need to ensure an accurate diagnosis. Limited data exist for the use of clozapine in pediatric patients with other diagnoses.
Collapse
Affiliation(s)
| | | | - Betsy Walters Burkey
- 2 Department of Pharmacy, Fairview Hospital/Cleveland Clinic Children's Hospital , Cleveland, Ohio
| | - Ian R McGrane
- 3 Department of Pharmacy, Shodair Children's Hospital , Helena, Montana.,4 Department of Pharmacy Practice, The University of Montana , Missoula, Montana
| | - Victoria Letts
- 5 Department of Pharmacy, The Royal Children's Hospital , Melbourne, Australia
| | - Jessica L Goren
- 6 Department of Pharmacy, Cambridge Health Alliance , Cambridge, Massachusetts
| | - Dawn M Hoeft
- 7 Department of Pharmacy, The University of Minnesota Medical Center , Minneapolis, Minnesota
| | - Sandra Mullen
- 8 Department of Pharmacy, VCU Health to Virginia Commonwealth University Health, Richmond, Virginia
| | - Megan Maroney
- 9 Department of Pharmacy, Monmouth Medical Center , Long Branch, New Jersey
| | - Kathryn M Schak
- 10 Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
20
|
Ruhe AM, Qureshi I, Procaccini D. Clozapine-induced myocarditis in an adolescent male with DiGeorge Syndrome. Ment Health Clin 2018; 8:313-316. [PMID: 30397574 PMCID: PMC6213892 DOI: 10.9740/mhc.2018.11.313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
DiGeorge Syndrome (22q11.2 deletion syndrome) is a chromosomal disorder associated with both congenital heart malformations and schizophrenia, which is often treatment-resistant and may warrant treatment with clozapine. Clozapine-induced myocarditis (CIM) is a rare complication of clozapine therapy, with a reported incidence ranging from 0.015% to 3%. Fulminant CIM has a nonspecific presentation in both adult and pediatric populations and a mortality rate approaching 50%. Few cases of pediatric CIM have been documented in the literature. This report highlights a case of CIM in an adolescent male with DiGeorge Syndrome whose clinical course was characterized by a subtle, nonspecific presentation and resolution with supportive care.
Collapse
Affiliation(s)
- Ann Marie Ruhe
- (Corresponding author) Clinical Pharmacy Specialist, Psychiatry, Sheppard Pratt Health System, Baltimore, Maryland,
| | - Imran Qureshi
- Clinical Pharmacy Specialist, Psychiatry, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David Procaccini
- Clinical Pharmacy Specialist, Pediatric Intensive Care and Cardiology/Heart Transplant, The Johns Hopkins Hospital, Baltimore, Maryland
| |
Collapse
|
21
|
Hayes D, Kyriakopoulos M. Dilemmas in the treatment of early-onset first-episode psychosis. Ther Adv Psychopharmacol 2018; 8:231-239. [PMID: 30065814 PMCID: PMC6058451 DOI: 10.1177/2045125318765725] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/26/2018] [Indexed: 12/20/2022] Open
Abstract
Early-onset first-episode psychosis (EOP) is a severe mental disorder that can pose a number of challenges to clinicians, young people and their families. Its assessment and differentiation from other neurodevelopmental and mental health conditions may at times be difficult, its treatment may not always lead to optimal outcomes and can be associated with significant side effects, and its long-term course and prognosis seem to be less favourable compared with the adult-onset disorder. In this paper, we discuss some dilemmas associated with the evaluation and management of EOP and propose approaches that can be used in the clinical decision-making process. A detailed and well-informed assessment of psychotic symptoms and comorbidities, a systematic approach to treatment with minimum possible medication doses and close monitoring of its effectiveness and adverse effects, and multidimensional interventions taking into consideration risks and expectations associated with EOP, are paramount in the achievement of the most favourable outcomes for affected children and young people.
Collapse
Affiliation(s)
- Daniel Hayes
- National and Specialist Bethlem Adolescent Unit, Bethlem Royal Hospital, Child and Adolescent Mental Health Clinical Academic Group, South London and the Maudsley NHS Foundation Trust, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
| | - Marinos Kyriakopoulos
- National and Specialist Acorn Lodge Inpatient Children's Unit, South London and the Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
22
|
Pina-Camacho L, Parellada M, Kyriakopoulos M. Autism spectrum disorder and schizophrenia: boundaries and uncertainties. BJPSYCH ADVANCES 2018. [DOI: 10.1192/apt.bp.115.014720] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
SummaryAutism and schizophrenia were placed in different diagnostic categories in DSM-III, having previously been considered as related diagnostic entities. New evidence suggests that these disorders show clinical and cognitive deficit overlaps and shared neurobiological characteristics. Furthermore, children presenting with both autism spectrum disorder (ASD) and psychotic experiences may represent a subgroup of ASD more closely linked to psychosis. The study of ASD and childhood schizophrenia, and their clinical boundaries and overlapping pathophysiological characteristics, may clarify their relationship and lead to more effective interventions. This article discusses the relationship through a critical review of current and historical dilemmas surrounding the phenomenology and pathophysiology of these disorders. It provides a framework for working with children and young people with mixed clinical presentations, illustrated by three brief fictional case vignettes.
Collapse
|
23
|
Wimberley T, Gasse C, Meier SM, Agerbo E, MacCabe JH, Horsdal HT. Polygenic Risk Score for Schizophrenia and Treatment-Resistant Schizophrenia. Schizophr Bull 2017; 43:1064-1069. [PMID: 28184875 PMCID: PMC5581885 DOI: 10.1093/schbul/sbx007] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Treatment-resistant schizophrenia (TRS) affects around one-third of individuals with schizophrenia. Although a number of sociodemographic and clinical predictors of TRS have been identified, data on the genetic risk of TRS are sparse. We aimed to investigate the association between a polygenic risk score for schizophrenia and treatment resistance in patients with schizophrenia. We conducted a nationwide, population-based follow-up study among all Danish individuals born after 1981 and with an incident diagnosis of schizophrenia between 1999 and 2007. Based on genome-wide data polygenic risk scores for schizophrenia were calculated in 862 individuals with schizophrenia. TRS was defined as either clozapine initiation or at least 2 periods of different antipsychotic monotherapies and still being hospitalized. We estimated hazard rate ratios (HRs) for TRS in relation to the polygenic risk score while adjusting for population stratification, age, sex, geographical area at birth, clinical treatment setting, psychiatric comorbidity, and calendar year. Among the 862 individuals with schizophrenia, 181 (21.0%) met criteria for TRS during 4674 person-years of follow-up. We found no significant association between the polygenic risk score and TRS, adjusted HR = 1.13 (95% CI: 0.95-1.35). Based on these results, the use of the polygenic risk score for schizophrenia to identify individuals with TRS is at present inadequate to be of clinical utility at the individual patient level. Future research should include larger genetic samples in combination with non-genetic markers. Moreover, a TRS-specific developed polygenic risk score would be of great interest towards early prediction of TRS.
Collapse
Affiliation(s)
- Theresa Wimberley
- National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark;,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark;,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark;,To whom correspondence should be addressed; National Centre for Register-based Research, Aarhus BSS, Aarhus University, Fuglesangs allé 4, Building K, DK-8210 Aarhus V, Denmark; tel: +45-87165976, fax: +45-8715-0201, e-mail:
| | - Christiane Gasse
- National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark;,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark;,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| | - Sandra Melanie Meier
- National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark;,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark;,Child and Adolescent Mental Health Centre—Mental Health Services Capital Region, Copenhagen, Denmark;,Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark
| | - Esben Agerbo
- National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark;,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark;,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Henriette Thisted Horsdal
- National Centre for Register-based Research, Aarhus BSS, Aarhus University, Aarhus, Denmark;,iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark;,Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| |
Collapse
|
24
|
Bachmann CJ, Aagaard L, Bernardo M, Brandt L, Cartabia M, Clavenna A, Coma Fusté A, Furu K, Garuoliené K, Hoffmann F, Hollingworth S, Huybrechts KF, Kalverdijk LJ, Kawakami K, Kieler H, Kinoshita T, López SC, Machado-Alba JE, Machado-Duque ME, Mahesri M, Nishtala PS, Piovani D, Reutfors J, Saastamoinen LK, Sato I, Schuiling-Veninga CCM, Shyu YC, Siskind D, Skurtveit S, Verdoux H, Wang LJ, Zara Yahni C, Zoëga H, Taylor D. International trends in clozapine use: a study in 17 countries. Acta Psychiatr Scand 2017; 136:37-51. [PMID: 28502099 DOI: 10.1111/acps.12742] [Citation(s) in RCA: 183] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis. METHOD A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide. RESULTS In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000). CONCLUSION While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.
Collapse
Affiliation(s)
| | - L Aagaard
- Life Science Team, Bech-Bruun Law Firm, Copenhagen, Denmark
| | - M Bernardo
- Barcelona Clinic Schizophrenia Unit, Neuroscience Institute, and Hospital Clínic, Department of Medicine, Barcelona University, and Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - L Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Cartabia
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Clavenna
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Coma Fusté
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - K Furu
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - K Garuoliené
- Medicines Reimbursement Department, National Health Insurance Fund of the Republic of Lithuania, Vilnius, Lithuania.,Faculty of Medicine, Department of Pathology, Forensic Medicine and Pharmacology, Vilnius University, Vilnius, Lithuania
| | - F Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - S Hollingworth
- School of Pharmacy, University of Queensland, Woolloongabba, Qld, Australia
| | - K F Huybrechts
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L J Kalverdijk
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands
| | - K Kawakami
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - H Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - T Kinoshita
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - S C López
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - J E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M Mahesri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P S Nishtala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - D Piovani
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - J Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - L K Saastamoinen
- Kela Research, The Social Insurance Institution, Helsinki, Finland
| | - I Sato
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - C C M Schuiling-Veninga
- Unit of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Y-C Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Molecular Biology, Academia Sinica, Taipei, Qld, Taiwan.,Department of Nutrition, Chang Gung University of Science and Technology, Kwei-Shan, Taiwan
| | - D Siskind
- School of Medicine, University of Queensland, Woolloongabba, Qld, Australia
| | - S Skurtveit
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - H Verdoux
- University Bordeaux, INSERM, Bordeaux Population Health Research Center, team Pharmaco-epidemiology, UMR 1219, F-33000, Bordeaux, France
| | - L-J Wang
- Department of Child & Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C Zara Yahni
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - H Zoëga
- Bordeaux Population Health Research Center, INSERM, Univ. Bordeaux, team Pharmaco-epidemiology, UMR 1219, Bordeaux, France
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| |
Collapse
|
25
|
Downs JM, Lechler S, Dean H, Sears N, Patel R, Shetty H, Simonoff E, Hotopf M, Ford TJ, Diaz-Caneja CM, Arango C, MacCabe JH, Hayes RD, Pina-Camacho L. The Association Between Comorbid Autism Spectrum Disorders and Antipsychotic Treatment Failure in Early-Onset Psychosis: A Historical Cohort Study Using Electronic Health Records. J Clin Psychiatry 2017; 78:e1233-e1241. [PMID: 29125721 PMCID: PMC6037287 DOI: 10.4088/jcp.16m11422] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/12/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In a sample of children and adolescents with first-episode psychosis, we investigated whether multiple treatment failure (MTF, defined as the initiation of a third trial of novel antipsychotic due to nonadherence, adverse effects, or insufficient response) was associated with comorbid autism spectrum disorders. METHODS Data were from the electronic health records of 638 children (51% male) aged from 10 to 17 years with first-episode psychosis (per ICD-10 criteria) from January 1, 2008, to November 1, 2014, referred to mental health services in South London, United Kingdom; data were extracted using the Clinical Record Interactive Search (CRIS) system. The effect of autism spectrum disorder comorbidity on the development of MTF during a 5-year period was modeled using Cox regression. RESULTS There were 124 cases of MTF prior to the age of 18 (19.4% of the sample). Comorbid autism spectrum disorders were significantly associated with MTF (adjusted hazard ratio = 1.99; 95% CI, 1.19-3.31; P = .008) after controlling for a range of potential confounders. Other factors significantly associated with MTF included higher age at first presentation (P = .001), black ethnicity (P = .03), and frequency of clinical contact (P < .001). No significant association between other comorbid neurodevelopmental disorders (hyperkinetic disorder or intellectual disability) and MTF was found. CONCLUSIONS Children with first-episode psychosis and comorbid autism spectrum disorders at first presentation are less likely to have a beneficial response to antipsychotics.
Collapse
Affiliation(s)
- Johnny M. Downs
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Suzannah Lechler
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Harry Dean
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Nicola Sears
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Rashmi Patel
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Hitesh Shetty
- NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Emily Simonoff
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Matthew Hotopf
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | | | - Covadonga M. Diaz-Caneja
- Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Madrid, Spain
| | - Celso Arango
- Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Madrid, Spain
| | - James H. MacCabe
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Richard D. Hayes
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK
| | - Laura Pina-Camacho
- Institute of Psychiatry, Psychology Neuroscience, King’s College London, UK,NIHR South London and Maudsley NHS Foundation Trust Biomedical Research Centre, UK,Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, IiSGM, School of Medicine, Universidad Complutense, CIBERSAM, Madrid, Spain
| |
Collapse
|
26
|
Pieterse D, Temmingh H, Vogel W. Factors associated with readmission in South African adolescents discharged from two inpatient psychosocial rehabilitation units. J Child Adolesc Ment Health 2016; 28:199-212. [PMID: 27998264 DOI: 10.2989/17280583.2016.1259165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to describe the socio-demographic and clinical factors associated with readmission in an adolescent population discharged from two inpatient psychosocial rehabilitation (PSR) units in Cape Town, South Africa. METHOD Data were obtained from 97 consecutive patients discharged from two adolescent psychiatric PSR units over a period of one year. Patients were followed up for readmission to hospitals offering specialised psychiatric care in the Western Cape Province over a period of 18 months. RESULTS 35 patients (36%) were readmitted during the study period. Multivariable analysis showed that previous admission increased readmission rate (Incidence Rate Ratio (IRR): 8.01, p < 0.001). Adolescents who were still schooling (IRR: 0.29, p < 0.001) or had a higher level of education (IRR: 0.45, p = 0.001) were less likely to be readmitted. No association was seen with type of diagnosis and readmission, although 51 adolescents (53%) were diagnosed on the schizophrenia spectrum of disorders. CONCLUSION Study findings highlight the need for increased collaboration between the Departments of Health and Education. Furthermore, the study illustrates the need for specific post-discharge community follow-up for adolescents. Prospective research in this particular population group is needed to contribute to the literature on factors associated with readmission in South African adolescent patients.
Collapse
Affiliation(s)
- Deirdre Pieterse
- a Department of Psychiatry and Mental Health , University of Cape Town , South Africa
| | - Henk Temmingh
- a Department of Psychiatry and Mental Health , University of Cape Town , South Africa
| | - Wendy Vogel
- a Department of Psychiatry and Mental Health , University of Cape Town , South Africa
| |
Collapse
|
27
|
Lally J, Ajnakina O, Di Forti M, Trotta A, Demjaha A, Kolliakou A, Mondelli V, Reis Marques T, Pariante C, Dazzan P, Shergil SS, Howes OD, David AS, MacCabe JH, Gaughran F, Murray RM. Two distinct patterns of treatment resistance: clinical predictors of treatment resistance in first-episode schizophrenia spectrum psychoses. Psychol Med 2016; 46:3231-3240. [PMID: 27605254 DOI: 10.1017/s0033291716002014] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Clozapine remains the only evidence-based antipsychotic for treatment-resistant schizophrenia (TRS). The ability to predict which patients with their first onset of schizophrenia would subsequently meet criteria for treatment resistance (TR) could help to diminish the severe functional disability which may ensue if TR is not recognized and correctly treated. METHOD This is a 5-year longitudinal assessment of clinical outcomes in a cohort of 246 first-episode schizophrenia spectrum patients recruited as part of the NIHR Genetics and Psychosis (GAP) study conducted in South London from 2005 to 2010. We examined the relationship between baseline demographic and clinical measures and the emergence of TR. TR status was determined from a review of electronic case records. We assessed for associations with early-, and late-onset TR, and non-TR, and differences between those TR patients treated with clozapine and those who were not. RESULTS Seventy per cent (n = 56) of TR patients, and 23% of the total study population (n = 246) were treatment resistant from illness onset. Those who met criteria for TR during the first 5 years of illness were more likely to have an early age of first contact for psychosis (<20 years) [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.25-4.94] compared to those with non-TR. The relationship between an early age of first contact (<20 years) and TR was significant in patients of Black ethnicity (OR 3.71, 95% CI 1.44-9.56); and patients of male gender (OR 3.13 95% CI 1.35-7.23). CONCLUSIONS For the majority of the TR group, antipsychotic TR is present from illness onset, necessitating increased consideration for the earlier use of clozapine.
Collapse
Affiliation(s)
- J Lally
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - O Ajnakina
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - M Di Forti
- MRC Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK
| | - A Trotta
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - A Demjaha
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - A Kolliakou
- Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience, Kings College London,UK
| | - V Mondelli
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London,UK
| | - T Reis Marques
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - C Pariante
- National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London,UK
| | - P Dazzan
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - S S Shergil
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - O D Howes
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - A S David
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - J H MacCabe
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - F Gaughran
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| | - R M Murray
- Department of Psychosis Studies,Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London,London,UK
| |
Collapse
|
28
|
Aksu H, Demirkaya SK. Treatment of Schizophrenia by Clozapine in an Adolescent Girl with DiGeorge Syndrome. J Child Adolesc Psychopharmacol 2016; 26:652. [PMID: 27305589 DOI: 10.1089/cap.2016.0044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hatice Aksu
- Department of Child and Adolescent Psychiatry, Adnan Menderes University Faculty of Medicine , Aydın, Turkey
| | - Sevcan Karakoç Demirkaya
- Department of Child and Adolescent Psychiatry, Adnan Menderes University Faculty of Medicine , Aydın, Turkey
| |
Collapse
|
29
|
Kasoff LI, Ahn K, Gochman P, Broadnax DD, Rapoport JL. Strong Treatment Response and High Maintenance Rates of Clozapine in Childhood-Onset Schizophrenia. J Child Adolesc Psychopharmacol 2016; 26:428-35. [PMID: 26784704 PMCID: PMC4931305 DOI: 10.1089/cap.2015.0103] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Childhood-onset schizophrenia (COS) is a rare but severe form of the disorder, which is often treatment refractory. Short-term studies have indicated a greater differential efficacy, evident through effect sizes, favoring clozapine over other agents in alleviating negative symptoms in COS patients compared with adult-onset patients (AOS). There have been no data for COS patients on long-term compliance with clozapine treatment. Therefore, we wanted to know, over a span of up to 24 years, how many of our COS cohort had remained on clozapine for at least 2 years. We review short-term treatment data and present updated long-term data on compliance and functioning for our patients. METHODS We present the results for long-term medication maintenance over a 24 year observation period for our cohort of 131 patients. Of this cohort, 91.6% (120) were available for follow-up information from either in-person or telephone contact with the patient and/or family members. We defined clozapine compliance as ≥2 years receiving this medication and doing well. RESULTS We were able to contact 120 of the 131 patients. In spite of the additional cost and inconvenience of regular blood monitoring, 87 patients (72.5%, 87/120) adhered to long-term clozapine maintenance therapy with dosages ranging from 50 to 900 mg, and a median dosage of 500 mg. This rate exceeds the long-term clozapine maintenance rates reported for AOS patients. CONCLUSIONS Short-term data on differential efficacy and long-term maintenance data suggest a possibly greater efficacy of clozapine, relative to other antipsychotics, in COS than in AOS. Our overall findings indicate that very early-onset schizophrenic patients may be more responsive to clozapine. This extends other support for clozapine as an option in the treatment of early-onset schizophrenia.
Collapse
Affiliation(s)
- Lauren I. Kasoff
- Child Psychiatry Branch, Division of Intramural Research Program, National Institutes of Mental Health (NIMH), Bethesda, Maryland
| | - Kwangmi Ahn
- Child Psychiatry Branch, Division of Intramural Research Program, National Institutes of Mental Health (NIMH), Bethesda, Maryland
| | - Peter Gochman
- Child Psychiatry Branch, Division of Intramural Research Program, National Institutes of Mental Health (NIMH), Bethesda, Maryland
| | - Diane D. Broadnax
- Child Psychiatry Branch, Division of Intramural Research Program, National Institutes of Mental Health (NIMH), Bethesda, Maryland
| | - Judith L. Rapoport
- Child Psychiatry Branch, Division of Intramural Research Program, National Institutes of Mental Health (NIMH), Bethesda, Maryland
| |
Collapse
|
30
|
Wimberley T, Støvring H, Sørensen HJ, Horsdal HT, MacCabe JH, Gasse C. Predictors of treatment resistance in patients with schizophrenia: a population-based cohort study. Lancet Psychiatry 2016; 3:358-66. [PMID: 26922475 DOI: 10.1016/s2215-0366(15)00575-1] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/06/2015] [Accepted: 12/11/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Identification of patients at high risk of treatment-resistant schizophrenia at the time of schizophrenia diagnosis would be of great clinical benefit in minimising the delay to clozapine treatment in patients unlikely to respond to non-clozapine antipsychotics. However, little is known about predictors of treatment resistance in this patient population. We used a treatment-based proxy for treatment-resistant schizophrenia to identify candidate predictors of treatment resistance at first hospital contact with a schizophrenia diagnosis. METHODS In this population-based cohort study, we obtained Danish national registry data for all adult patients (≥18 years) with incident schizophrenia diagnosed between Jan 1, 1996, and Dec 31, 2006, and followed up until Dec 31, 2010. Our main proxy definition of treatment-resistant schizophrenia was the earliest instance of either clozapine initiation or hospital admission for schizophrenia after having had two periods of different antipsychotic monotherapy. We did multivariable Cox proportional hazards regression analysis to estimate the association between baseline candidate predictors and treatment resistance. FINDINGS 8624 patients fulfilled the criteria for inclusion. In multivariable complete-case analyses, 1703 (21%) of 8044 patients fulfilled the main proxy definition of treatment-resistant schizophrenia during a median follow-up of 9·1 years (IQR 6·3-11·9). Younger age (hazard ratio 0·96 [95% CI 0·95-0·97]), living in a less urban area (provincial 1·38 [1·23-1·56], rural 1·44 [1·25-1·65]), primary education level (0·88 [0·79-0·98]), more than 30 bed-days in psychiatric hospital in the year before first schizophrenia diagnosis (1·54 [1·35-1·75]), inpatient at first schizophrenia diagnosis (2·07 [1·87-2·29]), paranoid subtype (1·24 [1·13-1·37]), comorbid personality disorder (1·24 [1·11-1·39]), psychotropic drug use (antipsychotics 1·51 [1·35-1·69], antidepressants 1·15 [1·03-1·29], and benzodiazepines 1·22 [1·10-1·37]), and previous suicide attempt (1·21 [1·07-1·39]) were all significantly associated with treatment-resistant schizophrenia. INTERPRETATION Our study identifies several candidate predictors that could potentially be included in future prediction models for treatment-resistant schizophrenia. Notably, established risk factors for schizophrenia did not predict treatment resistance, suggesting that treatment-resistant disease might be a distinct subtype of schizophrenia and not merely a more severe form. FUNDING European Community's Seventh Framework Programme.
Collapse
Affiliation(s)
- Theresa Wimberley
- National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark.
| | - Henrik Støvring
- Section of Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Holger J Sørensen
- The Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus University, Aarhus, Denmark; Research Unit, Mental Health Centre Copenhagen, Faculty of Health Sciences, University of Copenhagen, Gentofte, Denmark
| | - Henriette T Horsdal
- National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - James H MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christiane Gasse
- National Centre for Register-based Research, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark; Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark
| |
Collapse
|