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Chan SKW, Chan HYV, Honer WG, Bastiampillai T, Suen YN, Yeung WS, Lam M, Lee WK, Ng RMK, Hui CLM, Chang WC, Lee EHM, Chen EYH. Predictors of Treatment-Resistant and Clozapine-Resistant Schizophrenia: A 12-Year Follow-up Study of First-Episode Schizophrenia-Spectrum Disorders. Schizophr Bull 2020; 47:485-494. [PMID: 33043960 PMCID: PMC7965066 DOI: 10.1093/schbul/sbaa145] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Studies on the long-term development and early predictors of treatment-resistant schizophrenia (TRS) and clozapine-resistant TRS (CR-TRS) in patients with first-episode schizophrenia-spectrum disorders (FES) are limited and have not considered the impact of early intervention services (EIS). This study aimed to explore the development of TRS and CR-TRS among patients with FES over 12 years of follow-up. Of the 1234 patients with FES, 15% developed TRS. A total of 450 patients with schizophrenia or schizoaffective disorder were included in a nested case-control study (157 TRS and 293 non-TRS). Younger age of onset, poorer premorbid social adjustment during adulthood, longer duration of first episode, a greater number of relapses, and a higher antipsychotic dose in the first 24 months were associated with earlier TRS. CR-TRS patients, constituting 25% of TRS patients, had a poorer premorbid social adjustment in late adolescence and longer delay before clozapine initiation compared with non-CR-TRS. CR-TRS had poorer clinical and functional outcomes at 12-year follow-up. However, TRS patients on clozapine had a lower mortality rate compared with non-TRS patients. EIS did not have a significant impact on the development of TRS, but patients in the EIS group had a shorter delay of clozapine initiation. Results suggested that neurodevelopmental factors, early clinical characteristics, and requirement for higher antipsychotic dose may be associated with TRS development, highlighting multiple pathways leading to this form of illness. Specific interventions including relapse prevention and early initiation of clozapine during the early course of illness may reduce the rate of TRS and improve patient outcomes.
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Affiliation(s)
- Sherry Kit Wa Chan
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR,To whom correspondence should be addressed; Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Room 219, New Clinical Building, 102 Pokfulam Road, Hong Kong; tel: (852)-2255-4488, fax: (852)-2255-1345, e-mail:
| | - Hei Yan Veronica Chan
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - William G Honer
- Department of Psychiatry, The University of British Columbia, Vancouver, Canada
| | | | - Yi Nam Suen
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Wai Song Yeung
- Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR
| | - Ming Lam
- Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR
| | - Wing King Lee
- Department of Psychiatry, Kwai Chung Hospital, Hong Kong SAR
| | | | - Christy Lai Ming Hui
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Wing Chung Chang
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
| | - Edwin Ho Ming Lee
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR
| | - Eric Yu Hai Chen
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong SAR
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Gaughran F, Stahl D, Patel A, Ismail K, Smith S, Greenwood K, Atakan Z, Gardner-Sood P, Stringer D, Hopkins D, Lally J, Forti MD, Stubbs B, Lowe P, Arbuthnott M, Heslin M, David AS, Murray RM. A health promotion intervention to improve lifestyle choices and
health outcomes in people with psychosis: a research programme including the
IMPaCT RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2020. [DOI: 10.3310/pgfar08010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background
People with psychotic disorders have reduced life expectancy largely because
of physical health problems, especially cardiovascular disease, that are
complicated by the use of tobacco and cannabis.
Objectives
We set out to (1) chart lifestyle and substance use choices and the emergence
of cardiometabolic risk from the earliest presentation with psychosis, (2)
develop a pragmatic health promotion intervention integrated within the
clinical teams to improve the lifestyle choices and health outcomes of
people with psychosis and (3) evaluate the clinical effectiveness and
cost-effectiveness of that health promotion intervention.
Design
We performed a longitudinal cohort study of people presenting with their
first episode of psychosis in three mental health trusts and followed up
participants for 1 year [work package 1, physical health and substance use
measures in first episode of psychosis (PUMP)]. We used an iterative Delphi
methodology to develop and refine a modular health promotion intervention,
improving physical health and reducing substance use in psychosis (IMPaCT)
therapy, which was to be delivered by the patient’s usual care
co-ordinator and used motivational interviewing techniques and
cognitive–behavioural therapy to improve health choices of people
with psychosis (work package 2). We then conducted a multicentre, two-arm,
parallel-cluster, randomised controlled trial to determine the clinical
effectiveness and cost-effectiveness of using the intervention with people
with established psychosis (work package 3: IMPaCT randomised controlled
trial) in five UK mental health trusts. The work took place between 2008 and
2014.
Participants
All people aged between 16 and 65 years within 6 months of their first
presentation with a non-organic psychosis and who were proficient in English
were eligible for inclusion in the PUMP study. Participants in the work
package 2 training development were staff selected from a range of settings,
working with psychosis. Participants in the phase 3 Delphi consensus and
manual development comprised three expert groups of (1)
therapists/researchers recruited from the local and national community, (2)
clinicians and (3) service users, each of whom took part in two iterative
review and feedback sessions. For work package 3, IMPaCT randomised
controlled trial, care co-ordinators in participating community mental
health teams who were permanently employed and had a minimum of four
eligible patients (i.e. aged between 18 and 65 years with a diagnosis of a
psychotic disorder) on their caseload were eligible to participate. In
studies 1 and 3, patient participants were ineligible if they were pregnant
or had a major illness that would have had an impact on their metabolic
status or if they had a significant learning disability. All participants
were included in the study only after giving written confirmed consent.
Main outcome measures
Cardiometabolic risk markers, including rates of obesity and central obesity,
and levels of glycated haemoglobin (HbA1c) and lipids, were the
main outcomes in work package 1 (PUMP), with descriptive data presented on
substance use. Our primary outcome measure for the IMPaCT randomised
controlled trial was the physical or mental health component Short Form
questionnaire-36 items quality-of-life scores at 12 months.
Results
Obesity rates rose from 18% at first presentation with psychosis to 24% by 1
year, but cardiometabolic risk was not associated with baseline lifestyle
and substance use choices. Patterns of increase in the levels of
HbA1c over the year following first presentation showed
variation by ethnic group. We recruited 104 care co-ordinators, of whom 52
(with 213 patients) were randomised to deliver IMPaCT therapy and 52 (with
193 patients) were randomised to deliver treatment as usual, in keeping with
our power calculations. Of these 406 participants with established
psychosis, 318 (78%) and 301 (74%) participants, respectively, attended the
12- and 15-month follow-ups. We found no significant effect of IMPaCT
therapy compared with treatment as usual on the physical or mental health
component Short Form questionnaire-36 items scores at either time point in
an intention-to-treat analysis [physical health score (‘d’)
–0.17 at 12 months and –0.09 at 15 months; mental health score
(‘d’) 0.03 at 12 months and –0.05 at 15 months] or on
costs. Nor did we find an effect on other cardiovascular risk indicators,
including diabetes, except in the case of high-density lipoprotein
cholesterol, which showed a trend for greater benefit with IMPaCT therapy
than with treatment as usual (treatment effect 0.085, 95% confidence
interval 0.007 to 0.16; p = 0.034).
Limitations
Follow-up in work package 1 was challenging, with 127 out of 293 participants
attending; however, there was no difference in cardiometabolic measures or
demographic factors at baseline between those who attended for follow-up and
those who did not. In work package 3, the IMPaCT randomised controlled
trial, care co-ordinators struggled to provide additional time to their
patients that was devoted to the health promotion intervention on top of
their usual clinical care contact with them.
Conclusions
Cardiometabolic risk is prominent even soon after first presentation with
psychosis and increases over time. Lifestyle choices and substance use
habits at first presentation do not predict those who will be most
cardiometabolically compromised 1 year later. Training and supervising care
co-ordinators to deliver a health promotion intervention to their own
patients on top of routine care is not effective in the NHS for improving
quality of life or reducing cardiometabolic risk.
Future work
Further work is needed to develop and evaluate effective, cost-effective and
affordable ways of preventing the emergence of and reversing existing
cardiometabolic risk indicators in people with psychosis.
Trial registration
Current Controlled Trials ISRCTN58667926.
Funding
This project was funded by the National Institute for Health Research (NIHR)
Programme Grants for Applied Research programme and will be published in
full in Programme Grants for Applied Research; Vol. 8, No.
1. See the NIHR Journals Library website for further project
information.
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Affiliation(s)
- Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
| | - Daniel Stahl
- Department of Biostatistics and Health Informatics, Institute
of Psychiatry, Psychology & Neuroscience, King’s College
London, London, UK
| | - Anita Patel
- Anita Patel Health Economics Consulting Ltd, London, UK
- Centre for Primary Care and Public Health, Blizard Institute,
Queen Mary University of London, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
| | - Shubulade Smith
- Department of Forensic and Neurodevelopmental Science,
Institute of Psychiatry, Psychology & Neuroscience, King’s
College London, London, UK
- Forensic Services, South London and Maudsley NHS Foundation
Trust, London, UK
| | - Kathryn Greenwood
- Sussex Partnership NHS Foundation Trust, Worthing, UK
- School of Psychology, University of Sussex, Brighton, UK
| | - Zerrin Atakan
- Department of Psychosis Studies, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
| | - Poonam Gardner-Sood
- Department of Psychosis Studies, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
| | - Dominic Stringer
- Department of Biostatistics and Health Informatics, Institute
of Psychiatry, Psychology & Neuroscience, King’s College
London, London, UK
| | - David Hopkins
- Institute of Diabetes, Endocrinology and Obesity, King’s
Health Partners, London, UK
| | - John Lally
- National Psychosis Service, South London and Maudsley NHS
Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
- Department of Psychiatry, Royal College of Surgeons in Ireland,
Beaumont Hospital, Dublin, Ireland
| | - Marta Di Forti
- Social, Genetic & Developmental Psychiatry Centre,
Institute of Psychiatry, Psychology & Neuroscience, King’s
College, London, UK
- Department of Psychiatry, Experimental Biomedicine and Clinical
Neuroscience (BIONEC), University of Palermo, Palermo, Italy
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
- Physiotherapy Department, South London and Maudsley NHS
Foundation Trust, London, UK
| | | | | | - Margaret Heslin
- King’s Health Economics, Health Service & Population
Research Department, Institute of Psychiatry, Psychology &
Neuroscience, King’s College London, London, UK
| | - Anthony S David
- Institute of Mental Health, Division of Psychiatry, University
College London, London, UK
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry,
Psychology & Neuroscience, King’s College
London, London, UK
- Department of Psychiatry, Experimental Biomedicine and Clinical
Neuroscience (BIONEC), University of Palermo, Palermo, Italy
- South London and Maudsley NHS Foundation Trust, London, UK
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Cargnin S, Massarotti A, Terrazzino S. BDNF Val66Met and clinical response to antipsychotic drugs: A systematic review and meta-analysis. Eur Psychiatry 2016; 33:45-53. [PMID: 26854986 DOI: 10.1016/j.eurpsy.2015.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The polymorphic brain-derived neurotrophic factor (BDNF) gene has been postulated to be involved in inter-individual variability response to antipsychotic drugs. PURPOSE To perform a qualitative and quantitative synthesis of studies evaluating the influence of BDNF genetic variation on clinical response to antipsychotics. METHODS The review protocol was published in the PROSPERO database (Reg. n(o) CRD42015024614). A comprehensive search was performed through PubMed, Web of Knowledge and Cochrane databases up to July 2015. The methodological quality of identified studies was assessed using the MINORS criteria. Publication bias was estimated and potential sources of heterogeneity were investigated via meta-regression, subgroup and sensitivity analyses. RESULTS Nine studies including a total of 2461 antipsychotic-treated patients fulfilled inclusion criteria for meta-analysis of BDNF Val66Met. Using the random-effects model, the pooled results showed no significant association with antipsychotic response for the dominant (Met carriers vs Val/Val, OR: 0.93, 95% CI: 0.72-1.19, P=0.55), codominant (Met/Met vs Val/Val, OR: 0.82, 95% CI: 0.59-1.15, P=0.25), recessive (Met/Met vs Val carriers, OR: 0.81, 95% CI 0.60-1.10, P=0.18) or the allelic contrast (Met vs Val, OR: 0.92, 95% CI 0.76-1.10, P=0.34). Visual inspection of funnel plots and further evaluation with Egger's test did not suggest evidence of publication bias. Despite lack of significant heterogeneity in most comparisons, no evidence of association also emerged in the subgroup and sensitivity analyses conducted. CONCLUSION The present meta-analysis excludes a clinically relevant effect of BDNF Val66Met on antipsychotic drug response per se. Nevertheless, further investigation is still needed to clarify in well-designed, large sample-based studies, the impact of BDNF haplotypes containing the Val66Met polymorphism.
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Affiliation(s)
- S Cargnin
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy
| | - A Massarotti
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy
| | - S Terrazzino
- Dipartimento di Scienze del Farmaco and Centro di Ricerca Interdipartimentale di Farmacogenetica e Farmacogenomica (CRIFF), Università del Piemonte Orientale "A. Avogadro", Largo Donegani 2, 28100 Novara, Italy.
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Terzić T, Kastelic M, Dolžan V, Plesničar BK. Genetic variability testing of neurodevelopmental genes in schizophrenic patients. J Mol Neurosci 2014; 56:205-11. [PMID: 25529856 DOI: 10.1007/s12031-014-0482-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/14/2014] [Indexed: 10/24/2022]
Abstract
This study investigated the associations between single nucleotide polymorphisms in the neurodevelopmental Disrupted In Schizophrenia 1 (DISC1 ), neuregulin 1 (NRG1), brain-derived neurotrophic factor (BDNF) and NOTCH4 genes and the clinical symptoms and the occurrence of treatment-resistant schizophrenia in the Slovenian population. We included 138 schizophrenia patients, divided into treatment-responsive and treatment-resistant group and 94 healthy blood donors. All subjects were genotyped for eight polymorphisms (DISC1 rs6675281, DISC1 rs821616, NRG1 rs3735781, NRG1 rs3735782, NRG1 rs10503929, NRG1 rs3924999, BDNF rs6265, NOTCH rs367398) and investigated for associations with clinical variables. NOTCH4 rs367398 AA/AG was significantly associated with worse Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression (CGI) score. NOTCH4 rs367398 was not statistically significantly associated with the occurrence of treatment-resistant schizophrenia after the correction for multiple testing. Our data indicate that NOTCH4 polymorphism can influence clinical symptoms in Slovenian patients with schizophrenia.
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Affiliation(s)
- Tea Terzić
- University Psychiatric Clinic Ljubljana, Studenec 48, 1260, Ljubljana, Slovenia
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Schennach-Wolff R, Jäger M, Obermeier M, Schmauss M, Laux G, Pfeiffer H, Naber D, Schmidt LG, Gaebel W, Klosterkötter J, Heuser I, Kühn KU, Lemke MR, Rüther E, Klingberg S, Gastpar M, Seemüller F, Möller HJ, Riedel M. Quality of life and subjective well-being in schizophrenia and schizophrenia spectrum disorders: valid predictors of symptomatic response and remission? World J Biol Psychiatry 2010; 11:729-38. [PMID: 20380620 DOI: 10.3109/15622971003690289] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To examine quality of life and subjective well-being as predictors of symptomatic treatment outcome. METHODS Biweekly PANSS ratings were performed in 285 inpatients with schizophrenia spectrum disorders within a multicenter trial by the German Research Network on Schizophrenia. Quality of life and subjective well-being were assessed using the Medical Outcomes Study-Short Form 36-Item Health Survey (SF-36), the Subjective Well-being Under Neuroleptic Treatment Scale (SWN-K) and the Adjective Mood Scale (AMS). Response was defined as an initial 20% PANSS total score reduction and remission according to the consensus criteria. Correlation analysis, logistic regression and CART-analysis were performed. RESULTS In total, 81% of the sample achieved symptom response and 48% symptom remission. The statistical analyses revealed early improvement within the first two treatment weeks in the SWN-K scale to be a significant predictor for symptomatic response. Concerning symptomatic remission the SF-36 and SWN-K baseline scores as well as SWN-K early improvement showed significant predictive value. CONCLUSIONS These results highlight the importance of the patient's self-perception and especially of early improvement of quality of life and subjective well-being for symptomatic treatment outcome.
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Kelly DL, Feldman S, Boggs DL, Gale E, Conley RR. Nonresponse to clozapine and premorbid functioning in treatment of refractory schizophrenia. Compr Psychiatry 2010; 51:298-302. [PMID: 20399340 DOI: 10.1016/j.comppsych.2009.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 06/25/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION It is recognized that early treatment can improve outcomes and generally improve recovery potential for those with schizophrenia. Data suggest that poor premorbid functioning has been found to be related to more severe symptoms and poor antipsychotic response; however, little is known about premorbid functioning in patients who have no response to clozapine treatment. METHODS This study compares the premorbid functioning among patients who responded to clozapine treatment (20% decrease in total Brief Psychiatric Rating Scale [BPRS] score; n = 35) and those who did not respond (n = 50) to 8 weeks of clozapine treatment. Premorbid functioning was assessed using the Cannon-Spoor Premorbid Adjustment Scale. RESULTS Patients who did not respond to clozapine had significantly lower total BPRS scores (P = .01) at baseline, driven primarily by lower ratings in hostility (P = .007) and activation (P = .02), compared with those who responded to clozapine. Responders and nonresponders did not differ in their age, race, level of education, marital status, age of onset, characterization of the deficit syndrome, and positive or negative symptoms. Nonresponders to clozapine did not improve in any area of symptoms or global functioning, whereas there were significant improvements in BPRS total scores (analysis of covariance) and all symptom domains in the responder groups (P < .0001). Level of functioning scores in those who responded to clozapine was significantly higher at end point (P = .02). As for premorbid functioning, there were no differences in scores between responders and nonresponders at the time of early and late adolescence; however, there was a trend toward lower premorbid functioning in the clozapine nonresponders on most childhood measures (before the age of 11 years). Clozapine nonresponders tended to be less social and more withdrawn as compared with those who responded to clozapine (P = .08), as well as tended to have poorer adaptation to school (P = .06) and fewer peer relationships (P = .08). These results did not reach significance. Work and/or school performance changed more insidiously in the nonresponders group before illness onset (P = .045). DISCUSSION Clozapine is beneficial to many patients with treatment-resistant symptoms; however, nonresponse to this medication may represent a subtype of patients who may present differently with symptoms. These findings should encourage further examination of early childhood indicators and opportunities for appropriate and effective intervention.
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Affiliation(s)
- Deanna L Kelly
- Maryland Psychiatric Research Center, University of Maryland School of Medicine, P.O. Box 21247, Baltimore, MD 21228, USA.
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