[Switching and combining strategies of antidepressant medications]

What about the relevance of PIP of psychotropics in older psychiatric inpatients?

OBJECTIVE

In 2019, a regional survey of potentially inappropriate prescriptions (PIP) of psychotropic drugs in elderly psychiatric inpatients was carried out highlighting their inappropriate use in this population. The aim of this study was to assess the clinical relevance - defined as the provision of an appropriate and necessary treatment, chosen from other alternatives as being the most likely to produce the expected results for a given patient - of these prescriptions considered inappropriate according to current established criteria.

MATERIAL AND METHOD

Patients aged over 75, or 64 to 75 and polypathological with at least one PIP of psychotropic drugs or drugs with a high anticholinergic burden, identified by an audit grid established on the basis of STOPP/STARTv2 criteria and the Laroche list on the prescription at 48h of hospitalization, were included. The weighing of the inappropriateness nature of the prescription (resistance to treatment, period of crisis, comorbidities…) was established by a pharmacist-psychiatrist pair on the entire computerized record of the current episode. The clinical relevance of the PIP and the overall prescription was rated as 0 (irrelevant), 1 (partially relevant) or 2 (relevant).

RESULTS

Thirty-four patients were included. One hundred and twenty-five PIP of psychotropic drugs were noted: 50.4% concerned benzodiazepines and non-benzodiazepines anxiolytics (BZD/Z), 25.6% neuroleptics (NL), 12% antidepressants (ATD) and 12% drugs with a high anticholinergic burden. On one hand, 49.2% of PIP of BZD/Z, 50% of PIP of NL and 20% of PIP of ATD were considered irrelevant. On the other hand, 49.2% of PIP of BZD/Z, 31.3% of PIP of NL and 13.3% of PIP of ATD were considered partially relevant. Furthermore, 1.6% of PIP of BZD/Z, 18.8% of PIP of NL and 66.7% of PIP of ATD were considered relevant. For PIPs of drugs with a high anticholinergic burden, 80% were deemed irrelevant, 13.3% partially relevant and 6.7% relevant. In all, of the 34 drug prescriptions studied, three (8.8%) were considered irrelevant, 11 (32.4%) partially relevant and 20 (58.8%) clinically relevant.

CONCLUSION

This study highlighted the clinical relevance of more than half the prescriptions considered inappropriate according to current PPI criteria in the elderly. It underlines the interest of a new PPI detection tool for elderly patients with psychiatric disorders.

Clinical Pharmacy in Psychiatry: Towards Promoting Clinical Expertise in Psychopharmacology

Although clinical pharmacy is a discipline that emerged in the 1960s, the question of precisely how pharmacists can play a role in therapeutic optimization remains unanswered. In the field of mental health, psychiatric pharmacists are increasingly involved in medication reconciliation and therapeutic patient education (or psychoeducation) to improve medication management and enhance medication adherence, respectively. However, psychiatric pharmacists must now assume a growing role in team-based models of care and engage in shared expertise in psychopharmacology in order to truly invest in therapeutic optimization of psychotropics. The increased skills in psychopharmacology and expertise in psychotherapeutic drug monitoring can contribute to future strengthening of the partnership between psychiatrists and psychiatric pharmacists. We propose a narrative review of the literature in order to show the relevance of a clinical pharmacist specializing in psychiatry. With this in mind, herein we will address: (i) briefly, the areas considered the basis of the deployment of clinical pharmacy in mental health, with medication reconciliation, therapeutic education of the patient, as well as the growing involvement of clinical pharmacists in the multidisciplinary reflection on pharmacotherapeutic decisions; (ii) in more depth, we present data concerning the use of therapeutic drug monitoring and shared expertise in psychopharmacology between psychiatric pharmacists and psychiatrists. These last two points are currently in full development in France through the deployment of Resource and Expertise Centers in PsychoPharmacology (CREPP in French).

Cost-utility analysis of transcranial direct current stimulation (tDCS) in non-treatment-resistant depression: the DISCO randomised controlled study protocol

INTRODUCTION

Depression is among the most widespread psychiatric disorders in France. Psychiatric disorders are associated with considerable social costs, amounting to €22.6 billion for treatment and psychotropic medication in 2011. Treatment as usual (TAU), mainly consisting of pharmacotherapy and psychotherapy, is effective for only a third of patients and in most cases fails to prevent treatment resistance and chronicity. Transcranial direct current stimulation (tDCS) consists in a non-invasive and painless application of low-intensity electric current to the cerebral cortex through the scalp. Having proved effective in depressed patients, it could be used in combination with TAU to great advantage. The objective is to compare, for the first time ever, the cost-utility of tDCS-TAU and of TAU alone for the treatment of a depressive episode that has been refractory to one or two drug treatments.

METHODS AND ANALYSIS

This paper, based on the DISCO study protocol, focuses on the design of a prospective, randomised, controlled, open-label multicentre economic study to be conducted in France. It will include 214 patients with unipolar or bipolar depression, assigning them to two parallel arms: group A (tDCS-TAU) and group B (TAU alone). The primary outcome is the incremental cost-effectiveness ratio, that is, the ratio of the difference in cost between each strategy to the difference in their effects. Their effects will be expressed as numbers of quality-adjusted life-years, determined through administration of the EuroQol Five-Dimension questionnaire over a 12-month period to patients (EQ-5D-5L). Expected benefits are the reduction of treatment resistance and suicidal ideation as well as social and professional costs of depression. Should depression-related costs fall significantly, tDCS might be considered an efficient treatment for depression.

ETHICS AND DISSEMINATION

This protocol has been approved by a French ethics committee, the CPP--Est IV (Comité de Protection des Personnes-Strasbourg). Data are to be published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

RCB 2018-A00474-51; NCT03758105.

Using Pharmacogenomic Testing in Primary Care: Protocol for a Pilot Randomized Controlled Study

Background

Antidepressants are used by primary care providers to treat a variety of conditions, including (but not limited to) depression and anxiety. A trial-and-error approach is typically used to identify effective therapy, as treatment efficacy and safety can vary based on the response, which is affected by certain gene types. Pharmacokinetic pharmacogenomic (PGx) testing provides phenotypic classification of individuals as poor, intermediate, extensive, and ultrarapid CYP450 metabolizers, providing information for optimal drug selection.

Objective

The objective of this pilot study is to examine the feasibility, acceptability, and preliminary effectiveness of PGx testing when used after starting a new antidepressant medication.

Methods

We are conducting a pilot study with physicians from 6 Department of Family Medicine clinics at the University of Michigan who are willing to use PGx test results to manage antidepressant medication use. From enrolled physicians, patients were recruited to participate in a 6-month randomized, wait-list controlled trial in which patient participants newly prescribed an antidepressant had PGx testing and were randomized equally to have the results released to their primary care physician as soon as results were available or after 3 months. Patients were excluded if they had been taking the antidepressant for more than 4 weeks or if they had undergone PGx testing in the past. Physician participants completed a baseline survey to assess demographics, as well as knowledge, feasibility, and acceptability of PGx testing for this population. At the conclusion of the study, physician participants will complete a survey to assess knowledge, satisfaction, feasibility, acceptability, perceived effectiveness, and barriers to widespread adoption of PGx testing. Patient participants will complete a baseline, 3-month, and 6-month assessment, and control patient participants will have an additional 9-month assessment. Data collected will include the reason for antidepressant use, self-reported medication adherence, side effects, patient health questionnaire 8-item depression scale, generalized anxiety disorder 7-item scale, 12-Item Short-Form Health Survey, work status or changes, and physician and emergency department visits. PGx knowledge and perceptions (including acceptability and feasibility) as well as demographic information will also be obtained.

Results

We recruited 23 physician participants between November 2017 and January 2019, and 52 patient participants between January 2018 and April 2019. Currently, all physician and patient participants have been recruited, and we expect data collection to conclude in January 2020.

Conclusions

This study will examine the preliminary effectiveness of PGx testing after treatment initiation and determine the feasibility and acceptability of PGx testing for use in primary care. Through this study, we expect to demonstrate the benefit of PGx testing and lay the foundation for translating this approach into use within primary care.

Trial Registration

ClinicalTrials.gov NCT03270891; https://clinicaltrials.gov/ct2/show/NCT03270891

International Registered Report Identifier (IRRID)

RR1-10.2196/13848

Patterns of antidepressant use during pregnancy: a nationwide population-based cohort study

AIMS

We explored the patterns of antidepressant use during pregnancy.

METHODS

A cohort of women who started a pregnancy in 2014 was identified using data from the French reimbursement healthcare system (covering approximately 99% of the population). Antidepressant usage (initiated before or during pregnancy) was assessed. Explored changes in antidepressant treatment were: associations, switches, discontinuation and resumption of antidepressants during pregnancy.

RESULTS

The cohort included 766 508 pregnancies (755 519 women). Antidepressant use during pregnancy was 25.7 per 1000 [95% CI: 25.3-26.0]. New use concerned 3.9 per 1000 [95% CI: 3.7-4.0]; the most initiated class during pregnancy was selective serotonin reuptake inhibitors (SSRIs), while the most prescribed individual drug in second and third trimesters was amitriptyline, a tricyclic. Most changes were observed before pregnancy and during the first trimester: 63% of ongoing treatments in the year before pregnancy were discontinued before conception; 68% of treatments maintained after conception were discontinued during the first trimester; switches or antidepressant associations mostly occurred during the periconceptional period or during the first trimester. Regardless of initial antidepressant, switches to sertraline were the most frequent. Associations mainly consisted of a prescription of tri-/tetracyclic or mirtazapine/mianserin in addition to an SSRI. Discontinuation during pregnancy led to treatment resumption in 22% of pregnancies.

CONCLUSIONS

These results suggest that pregnancy was planned or the treatment especially adapted in accordance with existing recommendations in a large proportion of women under antidepressants or in whom such treatments have been initiated after starting a pregnancy.