Atypical antipsychotics for insomnia: a systematic review

Establishing a Validation Framework of Treatment Discontinuation in Claims Data Using Natural Language Processing and Electronic Health Records

Measuring medication discontinuation in claims data primarily relies on the gaps between prescription fills, but such definitions are rarely validated. This study aimed to establish a natural language processing (NLP)-based validation framework to evaluate the performance of claims-based discontinuation algorithms for commonly used medications against NLP-based reference standards from electronic health records (EHRs). A total of 36,656 patients receiving antipsychotic medications (APMs), benzodiazepines (BZDs), warfarin, or direct oral anticoagulants (DOACs) were identified from the Mass General Brigham EHRs in 2007-2020. These EHR data were linked with 97,900 Medicare Part D claims. An NLP-aided chart review was applied to determine medication discontinuation from EHR (reference standard). In claims data, discontinuation was defined by having a prescription gap larger than 15-90 days (claims-based algorithms). Sensitivity, specificity, and predictive values of claims-based algorithms against the reference standard were measured. The sensitivity and specificity of 90-day-gap-based algorithms were 0.46 and 0.79 for haloperidol, 0.41 and 0.85 for atypical APMs, 0.47 and 0.75 for BZDs, 0.33 and 0.80 for warfarin, and 0.38 and 0.87 for DOACs, respectively. The corresponding estimates for 15-day-gap-based algorithms were 0.68 and 0.55 for haloperidol, 0.59 and 0.62 for atypical APMs, 0.71 and 0.45 for BZDs, 0.61 and 0.49 for warfarin, and 0.58 and 0.64 for DOACs, respectively. Positive predictive values were primarily affected by medication discontinuation rates and less by gap lengths. The overall accuracy of claims-based discontinuation algorithms differs by medications. This study demonstrates the scalability and utility of the NLP-based validation framework for multiple medications.

The effectiveness of exercise interventions in the improvement of sleep in older adult people: a meta-analysis

Background

Sleep problems are prevalent among the older adult population, with a significant impact on their health and overall well-being. Several randomized controlled trials (RCTs) have yielded controversial results regarding the efficacy of exercise interventions in the improvement of sleep among older adult people. This systematic review and meta-analysis aim to assess the influence of exercise interventions on sleep quality within this demographic.

Methods

A search was conducted across four databases, namely Web of Science, PubMed, Embase, and SportDiscus, in order to identify randomized controlled trials investigating exercise interventions and sleep in the older adult. The quality of the studies included was evaluated by two researchers according to the PEDro scale. Meta-analysis and sensitivity analysis were performed utilizing RevMan 5.4 and Stata 17 software.

Result

A total of fifty studies encompassing 3,937 participants were included in the analysis. Regarding patient-reported sleep parameters, exercise interventions exhibited enhancements in sleep quality (WMD = -2.18, 95%CI: -2.83 to -1.53, p < 0.01) and reductions in insomnia severity (SMD = -0.52, 95%CI: -0.79 to -0.25, p < 0.01), albeit without significant improvements in daytime sleepiness (SMD = -0.66, 95%CI: -1.41 to 0.09, p = 0.09). In terms of clinician-reported sleep parameters, exercise interventions resulted in increased total sleep time (WMD = 8.98, 95%CI: 1.19 to 16.78, p < 0.05) and sleep efficiency (WMD = 3.66, 95%CI: 2.46 to 4.85, p < 0.01), and reduced wake time after sleep onset (WMD = -11.85, 95%CI: -15.58 to -8.11, p < 0.01), but did not decrease sleep onset latency (WMD = -3.05, 95%CI: -6.23 to 0.13, p = 0.06) or the number of awakenings during sleep (WMD = -0.73, 95%CI: -1.98 to 0.52, p = 0.25).

Conclusion

Exercise interventions have demonstrated positive effects on enhancing sleep quality among the older adult population. This study lends support to the utilization of exercise interventions as a safe, feasible, and effective non-pharmacological treatment approach for enhancing sleep among older individuals.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024530227, Identifier CRD42024530227.

Delphi consensus recommendations for the management of chronic insomnia in Canada

OBJECTIVE

The lack of current Canadian practice guidelines for the management of insomnia poses a challenge for healthcare providers (HCP) in selecting the appropriate treatment options. This study aimed to establish expert consensus recommendations for the management of chronic insomnia in Canada.

COMPOSITION OF THE COMMITTEE

Sixteen multidisciplinary experts in sleep medicine and insomnia across Canada developed consensus recommendations based on their knowledge of the literature and their practical experience.

METHODS

The consensus recommendations were developed through a Delphi method. Consensus was reached if at least 75 % of the voting participants "agreed" or "strongly agreed" with the corresponding statements. The quality of supporting evidence was rated using a GRADE rating system.

REPORT

Among 37 recommendations that reached consensus for the management of chronic insomnia, the experts recommend and agree that.

CONCLUSION

These consensus recommendations highlight the need to increase awareness, capacity for, and access to CBT-I; integrate newly approved pharmacotherapy; reduce both self-medication and medications with limited evidence or low risk/benefit ratio.

Association between Prescribing and Intoxication Rates for Selected Psychotropic Drugs: A Longitudinal Observational Study

Psychotropic prescription drugs are commonly involved in intoxication events. The study's aim was to determine a comparative risk for intoxication in relation to prescribing rates for individual drugs. This was a nationwide observational study in Slovenian adults between 2015 and 2021. Intoxication events with psychotropic drugs were collected from the National Register of intoxications. Dispensing data, expressed in defined daily doses, were provided by the Health Insurance Institute of Slovenia. Intoxication/prescribing ratio values were calculated. The correlation between trends in prescribing and intoxication rates was assessed using the Pearson correlation coefficient. In total, 2640 intoxication cases with psychotropic prescription drugs were registered. Anxiolytics and antipsychotics were the predominant groups. Midazolam, chlormethiazole, clonazepam, sulpiride, and quetiapine demonstrated the highest risk of intoxication, while all antidepressants had a risk several times lower. The best trend correlation was found for the prescribing period of 2 years before the intoxication events. An increase of 1,000,000 defined daily doses prescribed resulted in an increase of fifty intoxication events for antipsychotics, twenty events for antiepileptics, and five events for antidepressants. Intoxication/prescribing ratio calculation allowed for a quantitative comparison of the risk for intoxication in relation to the prescribing rates for psychotropic drugs, providing additional understanding of their toxicoepidemiology.

Sleep Quality After Quetiapine Augmentation in Patients With Treatment-Resistant Depression and Personality Disorders

PURPOSE/BACKGROUND

Quetiapine is a first-line augmenting agent for treatment-resistant depression (TRD) and is used off-label in insomnia. Quetiapine and its active metabolite norquetiapine act mostly on 5-HT2A, 5-HT2C, H1, and D2 as antagonists and on 5-HT1A as partial agonists. Patients with TRD often have comorbid personality disorder (PD), and evidence suggests an association between sleep disturbance and recovery among patients with PD. Here, we aimed to evaluate the effects of quetiapine on sleep in TRD patients with and without PD (PD+/PD-).

METHODS/PROCEDURES

We reviewed health records of 38 patients with TRD (20 TRD/PD+) who had been treated with a pharmacotherapy regimen including quetiapine. Clinical outcomes were determined by comparing changes in sleep items of the Hamilton Depression Rating Scale at the beginning (T0) and after 3 months of an unchanged treatment (T3).

FINDINGS/RESULTS

Patients with TRD/PD+ and TRD/PD- taking quetiapine showed significant improvement in sleep items from T0 to T3 (P < 0.001, ηp2 ≥ 0.19). There was a significant personality × time interaction for sleep-maintenance insomnia (P = 0.006, ηp2 = 0.23), with TRD/PD+ showing a greater improvement at T3 compared with TRD/PD- (P = 0.01). While exploring other sleep items, no personality × time interaction was found. In the TRD/PD- group, improvement in sleep items was associated with an overall improvement in depressive symptoms (r = 0.55, P = 0.02).

IMPLICATIONS/CONCLUSIONS

Quetiapine induced greater improvements in sleep-maintenance insomnia among TRD/PD+ patients than TRD/PD-. These findings suggest quetiapine could have a therapeutic role for insomnia in PD underscoring a distinct underlying neurobiological mechanism of sleep disturbance in people living with PD.

Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review

PURPOSE

Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing.

METHODS

A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium.

RESULTS

Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication.

CONCLUSIONS

Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.

Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis

Introduction

Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment.

Methods

A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest.

Results

87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation.

Discussion

Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.

A comprehensive review and meta-analysis of neurological side effects related to second-generation antidepressants in individuals with major depressive disorder

Second-generation antidepressants (SGADs) often cause neurological side effects (SEs). This meta-analysis seeks to quantify the short-term rates of neurological SEs related to routinely used second-generation antidepressants used to treat major depressive disorder (MDD). A search of the PubMed, EMBASE,Cochrane Library databases and Web of Science was done to uncover double-blind, randomized, placebo-controlled studies evaluating the effectiveness of frequently used SGADs medicines in people with MDD. Qualifying studies were required to concentrate on the use of SGADs routinely used in MDD and to uncover data on treatment-emergent neurological SEs occurring within 12 weeks of therapy. Overall, 143 RCT studies containing 188 treatment arms were included in the meta-analyses. Most SGADs increased the risk of neurological SEs compared to placebo. The least tolerated antidepressants on the neurological tract were desvenlafaxine (OR=1.98; CI 0.85-4.65; p-value=0.12) and venlafaxine (OR=1.15; CI 0.96-1.38; p-value=0.13). Agomelatine, bupropion and vortioxetine exhibited reduced neurological SEs, showing diminished risk in insomnia (OR=0.56; CI 0.36-0.88; p-value=0.01), somnolence (OR=0.46; CI 0.27-0.79; p-value=0.01), vision blurred (OR=0.43; CI 0.19-0.96; p-value=0.04), respectively. Most SGADs did not or just marginally increased the risk of headache compared to placebo. In conclusion, frequently used SGADs demonstrated distinct patterns of neurological SEs, which physicians should consider when prescribing antidepressants to promote treatment adherence and favorable outcomes in patients with MDD.

Does partial blockade of dopamine D2 receptors with Amisulpride cause anhedonia? An experimental study in healthy volunteers

BACKGROUND

Anhedonia is a frequent cause of functional im^pairment in psychosis. Although it is plausible that medication-induced D2 receptor blockade could diminish hedonic responding, there is little experimental research testing this hypothesis in humans.

METHODS

To inspect possible effects of partial D2 blockade on hedonic experiences, we administered 300 mg of Amisulpride or placebo to 85 participants in a randomized, double-blind, placebo-controlled trial. Participants were then subjected to an emotional evocation task utilizing standardized pictorial pleasant, neutral, and unpleasant stimuli.

RESULTS

We observed lower positivity ratings in the Amisulpride group compared to placebo across all stimulus categories (p = .026, f = 0.25) and no group differences in negativity or arousal ratings. The Amisulpride group also showed lower electrodermal responses across all stimulus categories compared to placebo (p = .017, f = 0.27). The electrodermal response was especially diminished for pleasant stimuli.

CONCLUSION

We interpret our findings as evidence that D2 blockade via Amisulpride can reduce at-the-moment hedonic responsivity in healthy volunteers. If these results can be confirmed in drug-naïve clinical samples, this would indicate that antipsychotic medication contributes to clinical anhedonia, probably via antagonistic effects at the dopamine D2 receptor.

[The effectiveness of remote methods of cognitive behavioral therapy for chronic insomnia and the possibilities of combined interventions]

Chronic insomnia is one of the most common sleep disorders in the world. The representation of chronic insomnia in the general population reaches 10-20% according to various sources. The most effective method of treating chronic insomnia with a sustained effect is cognitive behavioral therapy of insomnia (CBT-I). Among the disadvantages of CBT-I is its low availability (due to the lack of specialists) and high cost. Methods of delivered CBT-I are becoming increasingly relevant. The advantage of such type of CBT-I is the possibility of its use by a wide group of people. There are different ways of conducting delivered CBT, including those that do not require the direct participation of a specialist. The effectiveness of this method of treatment is comparable to full-time CBT-I.

Prescription Drugs Used in Insomnia

In insomnia, the subjective aspects of the sleep complaint are paramount in the diagnostic criteria. Epidemiologic studies increasingly point to a link between insomnia and somatic morbidity and mortality, but until now, only in the subgroup of objectively poor sleepers. Although pharmacologic treatment might offer some benefits to this subgroup of insomnia patients, to date, there is no evidence that hypnotics can ameliorate their health risks. Further unraveling of the neurobiology and genetics of sleep regulation and the pathophysiology of insomnia will help the development of drugs that not only improve subjective sleep complaints but also objective health outcomes.

Australian Consultant Pharmacists' Potential Roles in Sleep Health Care: Exploring a New Avenue for Improving the Management of Insomnia

BACKGROUND

The first-line treatment for insomnia is cognitive-behavioral therapy. However, there is persistent use of pharmacotherapy, particularly, sedative-hypnotics. Consultant pharmacists can provide medication review services for people using multiple medications. Therefore, they are well placed to provide sleep health/insomnia care with regard to sedative-hypnotic use and behavioral treatment recommendations/sleep health education. However, this avenue is, as yet, unexplored.

OBJECTIVES

To explore consultant pharmacists' current sleep health-related provisions and what their perspectives are around developing/implementing a consultant pharmacist-led behavioral service for insomnia.

METHODS

Qualitative semi-structured interviews were conducted with a convenience-based sample of consultant pharmacists. Interviews were audio-recorded, transcribed, and inductively analyzed.

RESULTS

Twenty-four consultant pharmacists were interviewed. Three themes were gauged: 1) Trivializing insomnia and sleep health, 2) Providing patient-centered care, 3) Service implementation - What do we need to consider? Participants commonly dealt with older patients and frequently encountered patients with sleep complaints/taking sleep medications. Generally, it was believed that sleep health was given minimal priority, with other comorbidities taking precedence in health provisions. Patients' attitudes toward management approaches were regarded critical to future treatment developments. While interested in expanding their sleep health/insomnia practice, participants expressed the need for appropriate education/training, funding, and collaborative treatment frameworks.

CONCLUSION

Insomnia/sleep health concerns are growing. Primary health professionals need to scale up their sleep health-care provisions to accommodate for this health demand. Consultant pharmacists are interested/willing to expand their sleep-related practice and provide evidence-based insomnia therapies; however, factors such as education/training, service configuration support, and patient attitudes should be addressed.

Central Composite Optimization of Glycerosomes for the Enhanced Oral Bioavailability and Brain Delivery of Quetiapine Fumarate

This study aimed to formulate and statistically optimize glycerosomal formulations of Quetiapine fumarate (QTF) to increase its oral bioavailability and enhance its brain delivery. The study was designed using a Central composite rotatable design using Design-Expert^® software. The independent variables in the study were glycerol % w/v and cholesterol % w/v, while the dependent variables were vesicle size (VS), zeta potential (ZP), and entrapment efficiency percent (EE%). The numerical optimization process resulted in an optimum formula composed of 29.645 (w/v%) glycerol, 0.8 (w/v%) cholesterol, and 5 (w/v%) lecithin. It showed a vesicle size of 290.4 nm, zeta potential of −34.58, and entrapment efficiency of 80.85%. The optimum formula was further characterized for DSC, XRD, TEM, in-vitro release, the effect of aging, and pharmacokinetic study. DSC thermogram confirmed the compatibility of the drug with the ingredients. XRD revealed the encapsulation of the drug in the glycerosomal nanovesicles. TEM image revealed spherical vesicles with no aggregates. Additionally, it showed enhanced drug release when compared to a drug suspension and also exhibited good stability for one month. Moreover, it showed higher brain C_max, AUC_0–24, and AUC_0–∞ and plasma AUC_0–24 and AUC_0–∞ in comparison to drug suspension. It showed brain and plasma bioavailability enhancement of 153.15 and 179.85%, respectively, compared to the drug suspension. So, the optimum glycerosomal formula may be regarded as a promising carrier to enhance the oral bioavailability and brain delivery of Quetiapine fumarate.

Associations between off-label low-dose olanzapine or quetiapine and cardiometabolic mortality

Olanzapine and quetiapine are routinely used off-label at lower doses, though it remains unclear whether treatment is associated with mortality. Here, we examined the associations between low-dose olanzapine/quetiapine, defined as 5 mg/day of olanzapine equivalents (OE) with cardiometabolic mortality in a population-based, longitudinal cohort of individuals who sought specialized psychiatric services. Through cross-linked Swedish registries, 428,525 individuals without psychotic, bipolar, or cardiometabolic disorders, or previous treatment with antipsychotics or cardiometabolic-related drugs were followed for up to 10.5 years. Extended stratified Cox proportional hazards regressions were employed to estimate the hazard ratios (HR) of cardiometabolic mortality as a function of cumulative OE exposures, adjusted for age, sex, inpatient care, and time-dependent psychiatric diagnoses and treatments. Individuals were followed for a total of 2.1 million person-years. Treatment with olanzapine/quetiapine occurred in 18,317 of the cohort. In total, 2606 cardiometabolic-related deaths occurred. Treatment status (treated vs. untreated) was not significantly associated with cardiometabolic mortality (adjusted HR 0.86, 95% CI 0.64-1.15, P = 0.307). However, compared to no treatment, treatment for <6 months was significantly associated with a reduced risk (adjusted HR 0.56, 95% CI 0.37-0.87, P = 0.010) whereas treatment for 6-12 months was significantly associated with an increased risk (adjusted HR 1.89, 95% CI 1.22-2.92, P = 0.004), but not significantly beyond 12 months. Among those treated, each year exposed to an average 5 mg/day was significantly associated with increased cardiometabolic mortality (adjusted HR 1.45, 95% CI 1.06-1.99, P = 0.019). Overall, low-dose olanzapine/quetiapine treatment was weakly associated with cardiometabolic mortality. Clinicians should consider potential cardiometabolic sequelae at lower doses.

The Many Faces of Sleep Disorders in Post-Traumatic Stress Disorder: An Update on Clinical Features and Treatment

Sleep disorders and nightmares are core symptoms of post-traumatic stress disorder (PTSD). The relationship seems to be bidirectional, and persistent disturbed sleep may influence the course of the disorder. With regard to sleep quality, insomnia and nocturnal anxiety symptoms, as well as nightmares and stressful dreams, are the most prominent sleep symptoms. Polysomnographic measurements reveal alterations of the sleep architecture and fragmentation of rapid eye movement sleep. In addition, sleep disorders, such as sleep-related breathing disorders and parasomnias are frequent comorbid conditions. The complex etiology and symptomatology of trauma-related sleep disorders with frequent psychiatric comorbidity require the application of multimodal treatment concepts, including psychological and pharmacological interventions. However, there is little empirical evidence on the effectiveness of long-term drug treatment for insomnia and nightmares. For nondrug interventions, challenges arise from the current lack of PTSD-treatment concepts integrating sleep- and trauma-focused therapies. Effective therapy for sleep disturbances may consequently also improve well-being during the day and probably even the course of PTSD. Whether early sleep interventions exert a preventive effect on the development of PTSD remains to be clarified in future studies.

Management of insomnia in primary care

Insomnia can have significant health and economic impacts. In contrast, sleep disturbance is common but does not usually affect daytime activity

Short-term approaches for acute insomnia are often appropriate. These include dealing with precipitating factors such as stress

Chronic insomnia has a high relapse and recurrence rate. It is best managed with cognitive behavioural therapy which includes sleep hygiene, stimulus control and sleep restriction

In primary care, brief behavioural therapy for insomnia is an accessible and effective management strategy. If there is no response, referral should be considered

Adjuvant use of drugs in insomnia may be appropriate in some cases. Prescription should be for a limited duration

Sleep Disorders and Mood, Anxiety, and Post-Traumatic Stress Disorders: Overview of Clinical Treatments in the Context of Sleep Disturbances

Sleep disruptions are frequently reported by persons with mood, anxiety, and post-traumatic stress disorders, and co-occur with psychiatric disorders. There is evidence that sleep disorders can predict the likelihood of developing a future psychiatric disorder and exacerbate existing symptoms. Understanding the inter-relationships between sleep and psychiatric disorders is important. The primary goals of this article are to describe the interactions between psychiatric and sleep disorders in the context of sleep disturbances, underscore the bidirectional effects of mental health treatments on sleep disorder outcomes, and provide general recommendations to optimize treatment in the context of sleep disturbances.

Differences in antipsychotic treatment between depressive patients with and without a suicide attempt

BACKGROUND

Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders.

METHODS

The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed.

RESULTS

Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms.

CONCLUSIONS

This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.

Sleep problems and complexity of mental health needs in adolescent psychiatric inpatients

Sleep problems are highly co-morbid with psychiatric disorders and are part of the complex and multiple factors contributing to symptoms and functional disability. The current study aimed to determine how sleep problems in the period preceding psychiatric admission relate to profiles of mental health needs in adolescent inpatients. This retrospective study included 424 adolescents (13-17 years) admitted over a five-year period to an acute crisis stabilization unit in a tertiary care pediatric hospital. Adolescents were divided into two age- and sex-matched groups based on the presence of moderate to severe sleep problems. Profiles of mental health needs were assessed at admission using the Child and Adolescent Needs and Strengths - Mental Health Acute (CANS-MH) and a complexity score was calculated as the total number of actionable CANS-MH items. Results showed a positive association between sleep problems and needs pertaining to eating disturbances, adjustment to trauma, and school attendance. Odds ratios for sleep problems increased progressively as the complexity scores increased, reaching a plateau at six needs beyond which odds ratios remained at their highest level. Adolescents with sleep problems were more likely to undergo medication changes during psychiatric hospitalization and were more likely to be discharged with antipsychotic medication. These findings suggest that sleep difficulties in adolescent inpatients may be associated with distinct and more complex profiles of mental health needs. The evaluation of sleep problems early in the course of psychiatric hospitalization may be an important part of the psychiatric assessment process to inform the global treatment plan.

Second-generation antipsychotic use during pregnancy and risk of congenital malformations

Purpose

To study if second-generation antipsychotic (S-GA) use during the first trimester of pregnancy is associated with an increased risk of major congenital malformations (MCM).

Methods

A population-based birth cohort study using national register data extracted from the Drugs and Pregnancy database in Finland, years 1996–2017. The sampling frame included 1,273,987 pregnant women. We included singleton pregnancies ending in live or stillbirth or termination of pregnancy due to severe malformation. Pregnancies with exposure to known teratogens were excluded. Women were categorized into three groups: exposed to S-GAs (n = 3478), exposed to first-generation antipsychotics (F-GAs) (n = 1030), and unexposed (no purchases of S-GAs or F-GAs during pregnancy, n = 22,540). We excluded genetic conditions and compared the prevalence of MCMs in S-GA users to the two comparison groups using multiple logistic regression models.

Results

Use of S-GAs during early pregnancy was not associated with an increased risk of overall MCMs compared to unexposed (adjusted odds ratio, OR 0.92; 95% CI 0.72–1.19) or to F-GA users (OR 0.82; 95% CI 0.56–1.20). Of individual S-GAs, olanzapine use was associated with an increased risk of overall MCMs (OR 2.12; 95% CI 1.19–3.76), and specifically, an increased risk of musculoskeletal malformations (OR 3.71; 95% CI 1.35–10.1) when compared to unexposed, while comparisons to F-GA users did not show significant results.

Conclusions

Olanzapine use is associated with an increased risk of major congenital malformations and specifically, musculoskeletal malformations. Use during pregnancy should be restricted to situations where no safer alternatives exist.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03169-y.

Assessment of sleep quality and its predictors among newly diagnosed psychiatric patients

OBJECTIVES

Poor sleep is a vital symptom observed in many psychiatric conditions and is the most neglected and underdiagnosed. The current study aims at assessment of sleep quality among psychiatric patients using the Pittsburgh Sleep Quality Index (PSQI) scale and to identify the predictors of sleep quality.

METHODS

A hospital-based cross-sectional observational study conducted in the Psychiatry department with a sample size of 256 patients for six months. PSQI scale was used to assess sleep quality and multiple logistic regression was used (to identify) the predictors for poor sleep quality.

RESULTS

The mean age of the study population was 37.95 ± 14.11 years, with 148 (58%) male study participants. 192 (75%) of the study population had poor sleep quality with respect to PSQI scale with a mean score of 9.05 ± 4.65 that was well above the expected range (0-5) suggestive of compromised quality of sleep (p=0.001). Poor sleep satisfaction, waking up after the sleep onset, anorexia, day time drowsiness and at least one completely sleepless night in the past one week of admission were identified as good predictors for poor sleep quality.

CONCLUSIONS

Our study addresses the importance of assessing sleep quality regardless of the psychiatric conditions. We recommend screening patients if they have Poor sleep satisfaction, waking up after the sleep onset, anorexia, day time drowsiness or at least one completely sleepless night in the past one week of admission predictors for comorbid sleep disorders.

Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation

The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.

Guidance for appropriate use of psychotropic drugs in older people

Psychotropic drugs are widely prescribed in older people although their use is associated with important risks. In this position paper, we discuss the appropriateness of using these medications in older people in terms of different aspects such as indications, contraindications, dosing, adverse drug reactions, interactions and duration of therapy. Consequently, we discuss different strategies to increase the appropriateness of therapy while formulating some practical recommendations to keep in mind when (de)prescribing psychotropic drugs in older people.

Prescription Drugs Used in Insomnia

The scope of this article is to review the effects on sleep of prescription drugs that are commonly prescribed for chronic insomnia in adults. The following groups are discussed: benzodiazepines and its receptor agonists, the dual orexin receptor antagonist suvorexant, melatonin and its receptor agonists, sedating antidepressants, and antipsychotics. Together with the neurobiologic and pharmacologic properties of these drugs, clinical effects are described, including subjective and objective effects on sleep duration, continuity, and architecture. Medical prescription information is given when available. Recently published American and European guidelines for the treatment of insomnia serve as reference frame.

Sleep therapeutics and neuropsychiatric illness

Alterations in sleep are extremely common in patients with neuropsychiatric illness. In addition, sleep disorders such as insomnia, obstructive sleep apnea, rapid eye movement sleep behavior disorder, and circadian rhythm disorders commonly occur at a rate greater than the general population in neuropsychiatric conditions. Historically, sleep problems have been viewed as symptoms of associated neuropsychiatric disorders. However, there is increasing evidence suggesting a complex inter-relationship with possible bidirectional causality. The inter-relatedness of these conditions represents an opportunity for understanding mechanisms and improving clinical treatment. To the extent that sleep problems affect neuropsychiatric conditions, it may be possible to address sleep problems and have a positive impact on the course of neuropsychiatric illnesses. Further, some treatments for sleep disorders have direct effects on neuropsychiatric illnesses that may be unrelated to their effects on sleep disorders. Similarly, neuropsychiatric conditions and their treatments can affect sleep and sleep disorders. This article reviews available evidence on the effects of therapies for sleep disorders on neuropsychiatric conditions and also secondarily considers the impacts of therapies for neuropsychiatric conditions on sleep. Primary goals of this review are to identify gaps in current research, to determine the extent to which the cross-therapeutic effects of these treatments help to elucidate therapeutic or pathological mechanisms, and to assist clinicians in optimizing therapeutic choice in patients with sleep disorders and neuropsychiatric conditions.

Off-label use of antipsychotics and associated factors in community living older adults. Aging Ment Health 2019;23:158-165. [PMID: 29156947 DOI: 10.1080/13607863.2017.1401583]

BACKGROUND

Given the common off-label use of antipsychotics (AP), we aimed to assess the factors associated with this use in community living older adults.

METHODS

The study sample consisted of a large representative sample of older adults (n = 4108), covered under a public drug insurance plan in Canada. Off-label use of antipsychotics was defined by the absence of an approved indication for this use, according to Health Canada's drug product database. Multinomial logistic regression was used to assess the factors associated with off-label use.

RESULTS

The prevalence of antipsychotics use was 2.5%, of which 78% was off-label. Compared to non-use, off-label antipsychotics use was negatively associated with advanced age (≥75 vs. 65-74 years old) (OR: 0.46; 95%CI: 0.27-0.78); and positively associated with higher education level (OR: 2.68; 95% CI: 1.64-4.40), higher number of outpatient visits (≥6) (OR: 2.39; 95%CI: 1.34-4.25), antidepressant or benzodiazepine use (OR: 5.81; 95%CI: 3.31-10.21), and the presence of an organic brain syndrome & Alzheimer's (OR: 5.73; 95%CI: 1.74-18.89). Compared to labeled use, off-label use was less likely in those with major depression (OR: 0.02; 95%CI: <0.01-0.11) and with insomnia (OR: 0.13; 95%CI: 0.02-0.91).

CONCLUSIONS

The majority of antipsychotics prescribed to community living older adults were off-label. This off-label use was more likely in complex clinical cases with multiple outpatient visits and other psychotropic drugs use. Further research should focus on the long-term effects associated with off-label use of antipsychotics.

Implications and recommendations for addressing insomnia disorder

Sleep disorders, such as insomnia, are a common complication of many physical and mental health problems. This article reviews insomnia disorder, including assessment, comorbidities, and management. It is imperative that primary care providers understand how to provide the safest pharmacologic and nonpharmacologic treatments to patients with insomnia.

Neuroleptic Prescribing and Monitoring Practices in Pediatric Inpatient Medical and Psychiatric Settings

BACKGROUND

Pediatric use of second-generation antipsychotics, or neuroleptics, has increased over the past decade. Neuroleptic use can have significant and lasting adverse neurologic, metabolic, and cardiovascular effects. In the current literature, neuroleptic prescribing and monitoring is described in outpatient settings, with little description of inpatient pediatric practice. In this study, we are the first to explore prescribing and monitoring in inpatient pediatrics, highlighting similarities and differences in practice between pediatric medicine and psychiatry.

METHODS

This retrospective study included patients <18 years of age who received a neuroleptic during inpatient hospitalization between September 2014 and March 2015, within either the pediatric inpatient medical or psychiatric setting. Data collected included sex, age, race, height, weight, length of stay, service providing care, details involving the neuroleptic(s) administered, comorbidities, lipid and glycemic monitoring, and results, monitoring for extrapyramidal symptoms, and mental health consultation.

RESULTS

Factors associated with improved neuroleptic monitoring included longer length of stay and evidence of an adverse drug effect. Clearly specified indication for use was associated with improved neuroleptic monitoring. Although neuroleptic initiation during admission had improved indication documentation and monitoring practices compared with initiation before admission, a significant gap exists between inpatient psychiatry and medical settings in adverse drug effect monitoring, particularly extrapyramidal symptom monitoring and lipid collection.

CONCLUSIONS

In our study, we describe current practice in the use and monitoring of neuroleptics in inpatient pediatric medical and psychiatric settings. In this study, we suggest that the use of neuroleptics in inpatient pediatrics, particularly inpatient medical settings, is conducted with suboptimal monitoring and, at times, without clear documented indication.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α2δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H1 antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Newly Initiated In-Hospital Antipsychotics Continued at Discharge in Non-psychiatric Patients

Objectives: Antipsychotics are commonly initiated in the hospital for agitation and delirium and may be inappropriately continued upon floor transfer and at discharge. We sought to evaluate the magnitude of this issue within our health care system. Methods: We conducted a multicenter, retrospective cohort study within a 22-hospital health care system to evaluate the proportion of patients without identifiable psychiatric illness who received newly initiated inpatient antipsychotics and were then continued on an antipsychotic at hospital discharge. Results: Of 23 049 patients who received at least 1 in-hospital dose of haloperidol, olanzapine, quetiapine, risperidone, or ziprasidone, 8297 patients were included in the final analysis after applying exclusion for identifiable psychiatric illness or previous antipsychotic use. Ultimately, 334 patients (4%) were discharged with a new antipsychotic prescription. Patients receiving antipsychotics at discharge were more likely as an inpatient to receive quetiapine (77.2% vs 35.9%; odds ratio [OR]: 6.1, 95% confidence interval [CI]: 4.7-8.0; P < .001) and less likely to receive haloperidol (15% vs 47%; OR: 0.2, 95% CI: 0.14-0.27; P < .001) or olanzapine (16.2% vs 20.9%; OR: 0.73, 95% CI: 0.53-0.98; P < .04). Conclusions: Antipsychotics may be inappropriately continued in non-psychiatric patients at hospital discharge. Strategies to limit potentially unnecessary antipsychotics upon discharge should be evaluated.

Paradoxical insomnia and subjective-objective sleep discrepancy: A review

Paradoxical insomnia is characterized by discrepancy between subjective and objective assessments of sleep and is challenging to diagnosis and treat. Typically, polysomnographic (PSG) findings show significantly longer total sleep time than patients' report of sleep, and the difference between subjective and PSG sleep is greater than that seen in other insomnia subtypes. Subjective-objective sleep discrepancy may also present in different clinical pictures, as marked discrepancies between patients' perception of sleep and objective findings are common in a variety of medical, sleep and psychiatric disorders. However, there is a paucity of literature about the etiology and treatment of sleep discrepancy and paradoxical insomnia. Therefore, the underlying neurophysiological mechanisms of sleep discrepancy and paradoxical insomnia should be further investigated. Additionally, well-controlled clinical trials are needed to establish an evidence based intervention for treatment.

Antidopaminergic medication in healthy subjects provokes subjective and objective mental impairments tightly correlated with perturbation of biogenic monoamine metabolism and prolactin secretion

OBJECTIVES

Off-label prescription of antipsychotics to patients without psychotic symptoms has become a routine matter for many psychiatrists and also some general practitioners. Nonetheless, little is known about the possibly detrimental effects of antidopaminergic medications on general psychopathology, subjective mental state, or a possible association with physiological parameters in nonpsychotic individuals.

METHODS

In this randomized, single-blinded study, groups of healthy volunteers (n=18) received low doses of reserpine, aripiprazole, haloperidol, or placebo on 7 successive days. Relevant physiological parameters (plasma prolactin, concentrations of catecholamine metabolites in plasma, and 24-hour urine) and each subject's mental state (Positive and Negative Syndrome Scale, Hamilton Rating Scale for Depression, visual analogue scale, Beck Depression Inventory II) were assessed at the start and end of the trial.

RESULTS

Of the three active treatments, only reserpine caused a significant increase in some plasma- and urine-catecholamine metabolites, but all three medications evoked objective and subjective changes in general psychopathology scores, which correlated with individual increases in plasma homovanillic acid concentrations. Both objective and subjective impairments were significantly more pronounced in the subgroup with greatest increase of plasma prolactin. Subjects experiencing the most pronounced side effects under haloperidol, which compelled them to drop out, showed significantly higher prolactin concentration increases than those who tolerated haloperidol well.

CONCLUSION

We found consistent associations between altered markers of dopamine transmission and several objective and subjective mental impairments in healthy volunteers after 1 week's treatment with antidopaminergic medications. These findings should draw attention to a more intensive risk-benefit evaluation in cases of off-label prescription of antipsychotic medications.

Time Trends in the Family Physician Management of Insomnia: The Australian Experience (2000-2015)

STUDY OBJECTIVES

To evaluate changes in rates of family physician (FP) management of insomnia in Australia from 2000-2015.

METHODS

The Bettering the Evaluation And Care of Health (BEACH) program is a nationally representative cross-sectional survey of 1,000 newly randomly sampled family physicians' activity in Australia per year, who each record details of 100 consecutive patient encounters. This provided records of approximately 100,000 encounters each year. We identified all encounters with patients older than 15 years where insomnia or difficulty sleeping was managed and assessed trends in these encounters from 2000-2015.

RESULTS

There was no change in the management rate of insomnia from 2000-2007 (1.54 per 100 encounters [95% confidence interval [CI]: 1.49-1.58]). This rate was lower from 2008-2015 (1.31 per 100 encounters [95% CI: 1.27-1.35]). There was no change in FP management: pharmacotherapy was used in approximately 90% of encounters; nonpharmacological advice was given at approximately 20%; and onward referral at approximately 1% of encounters. Prescription of temazepam changed from 54.6 [95% CI: 51.4-57.9] per 100 insomnia problems in 2000-2001 to 43.6 [95% CI: 40.1-47.0] in 2014-2015, whereas zolpidem increased steadily from introduction in 2000 to 14.6 [95% CI: 12.2-17.1] per 100 insomnia problems in 2006-2007, and then decreased to 7.3 [95% CI: 5.4-9.2] by 2014-2015.

CONCLUSIONS

Insomnia management frequency decreased after 2007 in conjunction with ecologically associated Australian media reporting of adverse effects linked to zolpidem use. Australian FPs remain reliant on pharmacotherapy for the management of insomnia.

Treatment of Sleep Dysfunction in Parkinson's Disease

OPINION STATEMENT

Impaired sleep and alertness affect the majority of Parkinson's disease (PD) patients, negatively impacting safety and quality of life. The etiology of impaired sleep-wake cycle in PD is multifactorial and encompasses medication side effects, nocturnal PD motor symptoms, and presence of co-existent sleep and neuropsychiatric disorders. The primary neurodegenerative process of PD involves brain regions that regulate the sleep-wake cycle, such as brainstem and hypothalamic nuclei. Sleep disorders in PD include insomnia, REM sleep behavior disorder (RBD), sleep disordered breathing (SDB), restless legs syndrome (RLS), and circadian disruption. Despite its high prevalence in the PD population, there is a paucity of clinical studies that have investigated treatment of sleep dysfunction associated with PD. Therefore, we aim to review available evidence and outline treatment strategies for improvement of disorders of sleep and wakefulness in PD patients. Evidence supporting the efficacy of pharmacological and non-pharmacological treatment strategies in PD is limited. There is thus a great need but also opportunity for development of well-designed clinical trials for impaired sleep and alertness in PD. Providing education about sleep hygiene and strategies for its implementation represents the initial step in management. Prompt diagnosis and treatment of co-existent primary sleep and psychiatric disorders are critical, as this may significantly improve sleep and alertness. While the optimal treatment for insomnia in PD has not been established, available strategies include cognitive-behavioral therapy, medications with soporific properties, and light therapy. Safety measures, clonazepam, and melatonin are the mainstay of treatment for RBD. Continuous positive airway pressure is an effective treatment for SDB in PD. The treatment algorithm for RLS associated with PD mirrors that used for idiopathic RLS. Circadian disruption has emerged as an important etiology of impaired sleep-wake cycles in PD, and circadian-based interventions hold promise for novel treatment approaches.

Dopamine D2 receptors and the circadian clock reciprocally mediate antipsychotic drug-induced metabolic disturbances

Antipsychotic drugs are widely prescribed medications, used for numerous psychiatric illnesses. However, antipsychotic drugs cause serious metabolic side effects that can lead to substantial weight gain and increased risk for type 2 diabetes. While individual drugs differ, all antipsychotic drugs may cause these important side effects to varying degrees. Given that the single unifying property shared by these medications is blockade of dopamine D₂ and D₃ receptors, these receptors likely play a role in antipsychotic drug-induced metabolic side effects. Dopamine D₂ and dopamine D₃ receptors are expressed in brain regions critical for metabolic regulation and appetite. Surprisingly, these receptors are also expressed peripherally in insulin-secreting pancreatic beta cells. By inhibiting glucose-stimulated insulin secretion, dopamine D₂ and dopamine D₃ receptors are important mediators of pancreatic insulin release. Crucially, antipsychotic drugs disrupt this peripheral metabolic regulatory mechanism. At the same time, disruptions to circadian timing have been increasingly recognized as a risk factor for metabolic disturbance. Reciprocal dopamine and circadian signaling is important for the timing of appetitive/feeding behaviors and insulin release, thereby coordinating cell metabolism with caloric intake. In particular, circadian regulation of dopamine D₂ receptor/dopamine D₃ receptor signaling may play a critical role in metabolism. Therefore, we propose that antipsychotic drugs’ blockade of dopamine D₂ receptor and dopamine D₃ receptors in pancreatic beta cells, hypothalamus, and striatum disrupts the cellular timing mechanisms that regulate metabolism. Ultimately, understanding the relationships between the dopamine system and circadian clocks may yield critical new biological insights into mechanisms of antipsychotic drug action, which can then be applied into clinical practice.

Effects of Antidepressants on Sleep

PURPOSE OF REVIEW

The aim of this review article was to summarize recent publications on effects of antidepressants on sleep and to show that these effects not only depend on the kind of antidepressant drugs but are also related to the dose, the time of drug administration, and the duration of the treatment.

RECENT FINDINGS

Complaints of disrupted sleep are very common in patients suffering from depression, and they are listed among diagnostic criteria for this disorder. Moreover, midnocturnal insomnia is the most frequent residual symptom of depression. Thus, all antidepressants should normalize sleep. However, at least in short-term treatment, many antidepressants with so-called activating effects (e.g. fluoxetine, venlafaxine) may disrupt sleep, while others with sedative properties (e.g., doxepin, mirtazapine, trazodone) rapidly improve sleep, but may cause problems in long-term treatment due to oversedation.For sleep-promoting action, the best effects can frequently be achieved with a very low dose, administered early enough before bedtime and importantly, always as a part of more complex interventions based on the cognitive-behavioral protocol to treat insomnia (CBT-I). For successful treatment of depression, it is necessary to understand the effects of antidepressants on sleep. Each physician should also be aware that some antidepressants may worsen or induce primary sleep disorders like restless legs syndrome, sleep bruxism, REM sleep behavior disorder, nightmares, and sleep apnea, which may result from an antidepressant-induced weight gain.