An update of safety of clinically used atypical antipsychotics

Effects of cariprazine on reducing symptoms of irritability, hostility, and agitation in patients with manic or mixed episodes of bipolar I disorder

BACKGROUND

Hostility, irritability, and agitation are common in patients with bipolar I disorder. Post hoc analyses evaluated the effect of cariprazine on these symptoms in patients with bipolar I mania.

METHODS

Data were pooled from three randomized, double-blind, placebo-controlled phase 3 cariprazine trials in adults with bipolar I manic/mixed episodes (NCT00488618, NCT01058096, NCT01058668); pooled cariprazine doses (3-12 mg/d) were analyzed. Patients were categorized into hostility/irritability and agitation subgroups by baseline scores: Young Mania Rating Scale (YMRS) irritability and disruptive-aggressive behavior items score ≥ 2; Positive and Negative Syndrome Scale (PANSS) hostility item ≥ 2; PANSS-Excited Component (PANSS-EC) total score ≥ 14 and score ≥ 4 on ≥ 1 individual item. Changes from baseline to week 3 in hostility/irritability- and agitation-related outcomes were evaluated. Adjustments were made for the presence of other manic symptoms, sedation, and akathisia.

RESULTS

Most patients met subgroup inclusion criteria (YMRS hostility = 930; PANSS hostility = 841, PANSS-EC agitation = 486). In the YMRS subgroup, least squares mean differences in change from baseline were statistically significant for cariprazine versus placebo on YMRS hostility/irritability-related items (irritability [-0.93], disruptive-aggressive behavior [-0.79], combined [-1.75]; P ≤ 0.001 each), YMRS total score (-5.92, P ≤ 0.0001), and all individual YMRS items (-0.25 to -0.93, P ≤ 0.0001); differences remained significant after adjustment for other manic symptoms, sedation, and akathisia. Differences in PANSS hostility and PANSS-EC subgroups were significant for cariprazine versus placebo (P ≤ 0.001).

LIMITATIONS

Post hoc analysis.

CONCLUSION

Cariprazine demonstrated specific antihostility/irritability and anti-agitation effects in patients with manic/mixed episodes of bipolar I disorder and baseline hostility, irritability, or agitation.

A case report of LAI two injection start in a 16-year-old adolescent with severe manic episode and comorbid cannabinoid use disorder

There is a lack of randomized clinical trials and few studies regarding long-acting injectable antipsychotics (LAIs) in adolescents. Non-adherence, aggressiveness, comorbid substance use disorder and lack of insight may represent the main reasons for starting LAIs. Hereby we describe a 16-year-old male adolescent subject with bipolar type I disorder and comorbid cannabinoid use disorder, successfully treated with two-injection start regimen of LAI aripiprazole. Two-injection start regime of aripiprazole could represent an effective and safe therapeutic option for adolescents with early onset bipolar disorder.

The Association of Nonmodifiable Patient Factors on Antipsychotic Medication use in the Intensive Care Unit

PURPOSE

We investigated the association of age, sex, race, and insurance status on antipsychotic medication use among intensive care unit (ICU) patients.

MATERIALS AND METHODS

Retrospective study of adults admitted to ICUs at a tertiary academic center. Patient characteristics, hospital course, and medication (olanzapine, quetiapine, and haloperidol) data were collected. Logistic regression models evaluated the independent association of age, sex, race, and insurance status on the use of each antipsychotic, adjusting for prespecified covariates.

RESULTS

Of 27,137 encounters identified, 6191 (22.8%) received antipsychotics. Age was significantly associated with the odds of receiving olanzapine (P < .001), quetiapine (P = .001), and haloperidol (P = .0046). Male sex and public insurance status were associated with increased odds of receiving antipsychotics olanzapine, quetiapine, and haloperidol (Male vs Female: OR 1.13, 95% CI [1.04, 1.24], P = .0005; OR 1.22, 95% CI [1.10, 1.34], P = .0001; OR 1.28, 95% CI [1.17, 1.40], P < .0001, respectively; public insurance vs private insurance: OR 1.32, 95% CI [1.20, 1.46], P < .0001; OR 1.21, 95% CI [1.09, 1.34], P = .0004; OR 1.15, 95% CI [1.04, 1.27], P = .0058, respectively). Black race was also associated with a decreased odds of receiving all antipsychotics (olanzapine (P = .0177), quetiapine (P = .004), haloperidol (P = .0041)).

CONCLUSIONS

Age, sex, race, and insurance status were associated with the use of all antipsychotic medications investigated, highlighting the importance of investigating the potential impact of these prescribing decisions on patient outcomes across diverse populations. Recognizing how nonmodifiable patient factors have the potential to influence prescribing practices may be considered an important factor toward optimizing medication regimens.

Third-Generation Antipsychotics and Lurasidone in the Treatment of Substance-Induced Psychoses: A Narrative Review

This narrative review explores the efficacy and tolerability of third-generation antipsychotics (TGAs)-aripiprazole, cariprazine, brexpiprazole, and lurasidone-for the management of substance-induced psychosis (SIP). SIP is a psychiatric condition triggered by substance misuse or withdrawal, characterized by unique features distinct from those of primary psychotic disorders. These distinctive features include a heightened prevalence of positive symptoms, such as hallucinations and delusions, in addition to a spectrum of mood and cognitive disturbances. This review comprehensively investigates various substances, such as cannabinoids, cocaine, amphetamines, and LSD, which exhibit a greater propensity for inducing psychosis. TGAs exhibit substantial promise in addressing both psychotic symptoms and issues related to substance misuse. This review elucidates the distinctive pharmacological properties of each TGA, their intricate interactions with neurotransmitters, and their potential utility in the treatment of SIP. We advocate for further research to delineate the long-term effects of TGAs in this context and underscore the necessity for adopting an integrated approach that combines pharmacological and psychological interventions. Our findings underscore the intricate and multifaceted nature of treating SIP, highlighting the potential role of TGAs within therapeutic strategies.

Emergency department management of acute agitation in the reproductive age female and pregnancy

BACKGROUND

Agitation is a common presentation within emergent departments (EDs). Agitation during pregnancy should be treated as an obstetric emergency, as the distress may jeopardize both the patient and fetus. The safety of psychotropic medications in the reproductive age female has not been well established. This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy.

METHODS

A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female.

RESULTS

While nonpharmacological management is preferred, ED visits for agitation often require medical management. Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects. Adverse effects are common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal adverse effects. In moderate to severe agitation, high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy. Second generation psychotropics are often utilized as second-line therapy, including risperidone. Benzodiazepines and ketamine have demonstrated adverse fetal outcomes.

CONCLUSION

While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.

Latin American consensus recommendations for the management and treatment of patients with treatment-resistant depression (TRD)

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD, and available treatment pathways for the management of TRD vary across the Latin American region, highlighting the need for a uniform definition and treatment principles to optimize the management of TRD in Latin America.

METHODS

Following a thematic literature review and pre-meeting survey, a Latin America expert panel comprising 14 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA appropriateness method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management.

RESULTS

The expert panel agreed that 'treatment-resistant depression' (TRD) is defined as 'failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode'. A stepwise treatment approach should be employed for the management of TRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Nonpharmacological treatments, such as electroconvulsive therapy, are also appropriate options for patients with TRD.

CONCLUSION

These consensus recommendations on the operational definition of TRD and approved treatments for its management can be adapted to local contexts in the Latin American countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with TRD.

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.

Treatment patterns and clinical outcomes among Medicare beneficiaries using antipsychotic medications for FDA-approved indications before and after transitioning from the community to a nursing home

OBJECTIVES

This study examines the relationships between changes in antipsychotic medication (AP) use and acute clinical events (identified with administrative claims data) for patients with FDA-approved indications for APs following transition from the community (e.g. home) to a nursing home (NH) in a Medicare population.

METHODS

A retrospective analysis was conducted using 100% Medicare fee-for-service (FFS) research identifiable files (RIF) claims data (2016-2018). Medicare beneficiaries with a condition for which APs are approved by the FDA were examined using logistic regression models to determine whether changes in AP use following transition from community to NHs were correlated with the likelihood of experiencing acute clinical events.

RESULTS

We identified 38,448 Medicare FFS beneficiaries meeting our study criteria. A change in AP use after transition to a NH did not have a statistically significant association with acute skeletal events, coronary artery events, or cerebrovascular events (p = .55, p = .69, and p = .59, respectively).

CONCLUSIONS

Between 2016 and 2018, Medicare FFS patients with approved-use indications for APs had lower average AP use following transition to a NH. Changes in the use of other medications of interest largely followed a similar pattern, indicating that these medications did not tend to be used as substitutions for APs. No clear relationship exists between increases or decreases in AP use and adverse events among NH residents who used APs and had FDA-approved conditions in the community setting.

Catecholaminergic and cholinergic neuromodulation in autism spectrum disorder: A comparison to attention-deficit hyperactivity disorder

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by social impairments and restricted, repetitive behaviors. Treatment of ASD is notoriously difficult and might benefit from identification of underlying mechanisms that overlap with those disturbed in other developmental disorders, for which treatment options are more obvious. One example of the latter is attention-deficit hyperactivity disorder (ADHD), given the efficacy of especially stimulants in treatment of ADHD. Deficiencies in catecholaminergic systems [dopamine (DA), norepinephrine (NE)] in ADHD are obvious targets for stimulant treatment. Recent findings suggest that dysfunction in catecholaminergic systems may also be a factor in at least a subgroup of ASD. In this review we scrutinize the evidence for catecholaminergic mechanisms underlying ASD symptoms, and also include in this analysis a third classic ascending arousing system, the acetylcholinergic (ACh) network. We complement this with a comprehensive review of DA-, NE-, and ACh-targeted interventions in ASD, and an exploratory search for potential treatment-response predictors (biomarkers) in ASD, genetically or otherwise. Based on this review and analysis we propose that (1) stimulant treatment may be a viable option for an ASD subcategory, possibly defined by genetic subtyping; (2) cerebellar dysfunction is pronounced for a relatively small ADHD subgroup but much more common in ASD and in both cases may point toward NE- or ACh-directed intervention; (3) deficiency of the cortical salience network is sizable in subgroups of both disorders, and biomarkers such as eye blink rate and pupillometric data may predict the efficacy of targeting this underlying deficiency via DA, NE, or ACh in both ASD and ADHD.

An evidence-based approach to psychopharmacology for posttraumatic stress disorder (PTSD) - 2022 update

Algorithms for posttraumatic stress disorder were published by this team in 1999 and 2011. Developments since then warrant revision. New studies and review articles from January 2011 to November 2021 were identified via PubMed and analyzed for evidence supporting changes. Following consideration of variations required by special patient populations, treatment of sleep impairments remains as the first recommended step. Nightmares and non-nightmare disturbed awakenings are best addressed with the anti-adrenergic agent prazosin, with doxazosin and clonidine as alternatives. First choices for difficulty initiating sleep include hydroxyzine and trazodone. If significant non-sleep PTSD symptoms remain, an SSRI should be tried, followed by a second SSRI or venlafaxine as a third step. Second generation antipsychotics can be considered, particularly for SSRI augmentation when PTSD-associated psychotic symptoms are present, with the caveat that positive evidence is limited and side effects are considerable. Anti-adrenergic agents can also be considered for general PTSD symptoms if not already tried, though evidence for daytime use lags that available for sleep. Regarding other pharmacological and procedural options, e.g., transcranial magnetic stimulation, cannabinoids, ketamine, psychedelics, and stellate ganglion block, evidence does not yet support firm inclusion in the algorithm. An interactive version of this work can be found at www.psychopharm.mobi.

Cannabis-Based Medicinal Products in the Management of Emotionally Unstable Personality Disorder (EUPD): A Narrative Review and Case Series

Emotionally unstable personality disorder (EUPD) is a common mental health disorder, manifesting with a range of chronic and debilitating symptoms, including impaired social functioning, unstable mood, and risky impulsive or self-injurious behaviour. Whilst the exact aetiology has not been fully elucidated, implicated factors seem to include genetic factors, environmental causes such as trauma, and neurotransmitter deficits. The literature suggests that impaired functioning of the endocannabinoid system in key brain regions responsible for emotional processing and stress response may underlie the manifestation of EUPD symptoms. The National Institute for Health and Care Excellence (NICE) 2009 guidelines state that “no drugs have established efficacy in treating or managing EUPD”, and yet, patients are commonly prescribed medication which includes antipsychotics, antidepressants, and mood stabilisers. Here we present a case series of seven participants diagnosed with EUPD and treated with cannabis-based medicinal products (CBMPs). Participants were given an initial assessment and followed up one month after CBMPs prescription. Improvement in symptoms was assessed by the completion of ratified rating scales by the participant and psychiatrist. Our results indicate that CBMPs were effective and well tolerated, as six participants reported a noticeable improvement in their symptoms and functioning. Although promising, further research is needed to ascertain the long-term tolerability, efficacy, and dosing strategy for CBMPs in EUPD.

Atypical antipsychotic drugs in dual disorders: current evidence and clinical guidelines

BACKGROUND

Concurrent disorder or dual diagnosis refers to a combination of substance use disorders and mental disorders that occur in the same patient simultaneously. These conditions pose significant clinical and healthcare impacts and are often underdiagnosed, undertreated, and complex to manage.

OBJECTIVE

We assessed the quality of current pharmacological recommendations for the management of dual diagnosis, particularly by evaluating the use of second-generation antipsychotics (SGA).

METHOD

A literature search was performed using the PubMed and Scopus databases for publications up to September 21, 2021, without any time restrictions. The following search strings were used: (aripiprazole OR brexpiprazole OR cariprazine OR paliperidone OR risperidone OR quetiapine OR clozapine OR olanzapine) AND (psychosis OR schizophrenia OR schizoaffective) AND ("substance use disorder" OR cocaine OR alcohol OR cannabis OR heroin OR "double diagnosis" OR "dual diagnosis")) NOT (animal OR rat OR mouse) NOT (review or meta-analysis).

RESULTS

The search produced a final set of 41 articles. Most patients were males and were affected by schizophrenia, with cannabis the most abused substance, followed by alcohol. Aripiprazole was the most used drug, either orally or by long-acting formulations, followed by risperidone with oral and long-acting formulations, clozapine, olanzapine, and quetiapine.

CONCLUSION

The findings highlight the use of SGA for the treatment of psychotic symptoms in comorbidity with substance use. Future studies on people with dual diagnosis and focused on long-term evaluations are warranted and need to investigate the efficacy of newly introduced molecules, such as partial D2 agonists and long-acting injectable antipsychotics.

Possible involvement of apoptosis in the antipsychotics side effects: A minireview

Antipsychotics are used in the treatment of schizophrenia and other psychiatric disorders. Generally they are divided into typical and atypical ones, according to the fact that atypical antipychotics induce less side effects and are more effective in terms of social and cognitive improvements. Their pharmacological effects are mediated via broad range of receptors that consequently influence different cellular signaling pathways. Antipsychotics produce udesirable side effects that range from relatively minor to life-threatening ones. In vitro and in vivo studies have pointed to neurotoxic effect exerted by some antipsychotics and have shown that apoptosis might play role in some side effects induced by antipsyschotics, including tardive dyskinesia, weight gain, agranulocytosis, osteoporosis, myocarditis, etc. Although cumulative data have suggested safety of atypical antipsychotics use during pregnancy some of them have been shown to induce apoptotic neurodegenerative and structural changes in fetal brains with long-lasting impact on cognitive impairment of offsprings. Typical antipsychotics seem to be more cytotoxic than atypical ones. Recently, epidemiological studies have shown lower incidence of cancer in schizophrenic patients what suggest ability of antipsychotics to suppress risk of cancer development. Some antipsychotics have been reported to inhibit cancer cell proliferation and induce their apoptosis. Thus, antipsychotics apoptotic effect may be used as a tool in the treatmnet of some types of cancer, especially in combinatorial therapies. In this minireview, we focused on pro- and anti-apototic or "Dr. Jekyll and Mr. Hyde" effects of antipsychotics, which can be involved in their side effects, as well as their promising therapeutical indications. This article is protected by copyright. All rights reserved.

Existing and emerging pharmacological approaches to the treatment of mania: A critical overview

Manic episodes are a defining, frequent and dramatically disabling occurrence in the course of Bipolar Disorder type I. Current pharmacotherapy of mania lists a good number of agents, but differences in efficacy and safety profiles among these agents must be considered in order to tailor personalized therapies, especially when the long-term course of the illness is considered. There is wide room and need to ameliorate current pharmacological approaches to mania, but ongoing pharmacological research on the topic is scant. In this work we try to critically assess clinical factors and patients' characteristics that may influence the treatment choice for manic episodes. In addition, we conduct a narrative review on experimental pharmacology of bipolar mania and psychotic disorders, presenting a critical overview on agents which could represent treatment alternatives for a manic episode in the next future. Results show limited novel or ongoing research on agents acting as mood stabilizers (Ebselen, Valnoctamide and Eslicarbazepine did not reach statistical significance in demonstrating antimanic efficacy). As for the emerging experimental antipsychotic, some of them (including KarXT, SEP-363856, RO6889450, ALKS3831) have demonstrated good antipsychotic efficacy and a favorable safety profile, but little is known about their use in patients with bipolar disorder and specifically designed trials are needed. Lastly, some benefits for the treatment of mania could be expected to come in the next future from non-mood stabilizers/non-antipsychotic agents (especially PKC inhibitors like Endoxifen): long-term trials are needed to confirm positive results in terms of long-term efficacy and safety.

Dopamine D1- and D2-like receptors oppositely regulate lifespan via a dietary restriction mechanism in Caenorhabditis elegans

BACKGROUND

Despite recent progress in understanding the molecular mechanisms regulating aging and lifespan, and the pathways involved being conserved in different species, a full understanding of the aging process has not been reached. In particular, increasing evidence suggests an active role for the nervous system in lifespan regulation, with sensory neurons, as well as serotonin and GABA signaling, having been shown to regulate lifespan in Caenorhabditis elegans (C. elegans). However, the contribution of additional neural factors, and a broad understanding of the role of the nervous system in regulating aging remains to be established. Here, we examine the impact of the dopamine system in regulating aging in C. elegans.

RESULTS

We report that mutations of DOP-4, a dopamine D1-like receptor (D1R), and DOP-2, a dopamine D2-like receptor (D2R) oppositely affected lifespan, fast body movement span, reproductive lifespan, and developmental rate in C. elegans. Activation of D2R using aripiprazole, an antipsychotic drug, robustly extended both lifespan and healthspan. Conversely, inhibition of D2R using quetiapine shortened worm lifespan, further supporting the role of dopamine receptors in lifespan regulation. Mechanistically, D2R signaling regulates lifespan through a dietary restriction mechanism mediated by the AAK-2-DAF-16 pathway. The DAG-PKC/PKD pathway links signaling between dopamine receptors and the downstream AAK-2-DAF-16 pathway to transmit longevity signals.

CONCLUSIONS

These data demonstrated a novel role of dopamine receptors in lifespan and dietary restriction regulation. The clinically approved antipsychotic aripiprazole holds potential as a novel anti-aging drug.

Chromosome 22 Deletions and Suicidal Behavior in Schizophrenia

BACKGROUND

Studies have shown that the overall copy number variant (CNV) load is associated with schizophrenia. Schizophrenia is a mental disorder that is frequently associated with suicidal behavior.

METHODS

We recruited 263 patients with schizophrenia from the Centre for Addiction and Mental Health. The Columbia Suicide Severity Rating Scale was used to assess the presence of lifetime suicide attempt. Genotyping was completed using the Illumina Omni 2.5 chip. We tested the association between deletion events on chromosome 22 with suicide attempt in our schizophrenia sample.

RESULTS

There was no significant difference between suicide attempters and non-attempters considering the presence/absence of deletion events on chromosome 22.

CONCLUSION

Although our results did not show a significant association between deletions on chromosome 22 and suicide attempt in schizophrenia, CNV studies may reveal important, novel insights and open further investigation for the treatment of neuropsychiatric diseases.

Acne caused by ziprasidone in a young patient with bipolar disorder: A case report

BACKGROUND

Ziprasidone is a second-generation antipsychotic drug commonly used to treat schizophrenia and bipolar disorder. Acne is a common inflammatory disease of sebaceous glands in adolescents that is often co-morbid with anxiety and depression, which may reduce treatment compliance. Through unknown mechanisms, ziprasidone may cause a range of inflammatory responses. Whether ziprasidone can cause acne in young patients with bipolar disorder has not been reported.

CASE SUMMARY

We report a 23-year-old woman with a 5-year history of bipolar disorder who experienced acne during use of ziprasidone. She was admitted to our hospital during 1-month aggravation of her symptoms and was diagnosed with bipolar I disorder (current or most recent episode of depression) with psychotic features. She was given ziprasidone and soon developed acne, which she never had before; the rash worsened substantially when the ziprasidone dose was increased. At the same time, levels of inflammatory factors increased. The rash resolved after ziprasidone therapy was stopped.

CONCLUSION

When prescribing ziprasidone to young people with bipolar disorder, clinicians should consider the potential for adverse skin reactions. It may be useful to assay levels of inflammatory markers during ziprasidone therapy and adjust the dose if necessary in order to ensure treatment compliance.

Depressive and Anxious Temperaments as Predictors of Late Onset Bipolar Disorder? Preliminary Results of a "Real World" Exploratory Study

INTRODUCTION

Bipolar disorder (BD) onset typically occurs between 15 and 30 years, being diagnosed under the age of 50 in 90% of cases, named "non-late onset BD" (non-LOBD). However, clinical observation of late-onset BD (LOBD) raised some concern regarding a differential psychopathological pattern, outcomes and treatment, including a specific affective temperament vulnerability. Therefore, an exploratory study in the "real world" was carried out by investigating psychopathological and temperamental features of a psychogeriatric cohort of LOBD and non-LOBD subjects.

METHODS

A total of 180 patients affected with BD-I, BD-II, and Cyclothymic Disorder were screened in a Mood Disorder Outpatient Service, during the timeframe January 2019-August 2021. Out of 78 enrolled outpatients, 66 (33 non-LOBD, 33 LOBD) were recruited, by the retrospective collection of sociodemographic, cognitive, psychopathological and clinical assessment, including the short-version of the Temperament Evaluation of Memphis, Pisa, and San Diego (TEMPS-M).

RESULTS

LOBD is significantly associated with higher rates of BD-II diagnosis (χ² = 27.692, p < 0.001), depressive episodes (p = 0.025), mixed states (p = 0.009), predominant depressive and anxious affective temperaments (p < 0.001). Non-LOBD is significantly associated with higher endocrinological (χ² = 6.988, p = 0.008) and metabolic comorbidity (χ² = 5.987, p = 0.014), a diagnosis of BD-I, manic episodes, and predominant hyperthymic affective temperaments (p = 0.001). GDS (p < 0.001) and MSRS (p = 0.005) scores were significantly higher in LOBD.

CONCLUSION

Further longitudinal studies with larger sample sizes and a control group are needed to determine whether LOBD may represent a distinct psychopathological entity from non-LOBD and evaluate differences (if any) in terms of prognosis and treatment between non-LOBD and LOBD.

Exosomes in schizophrenia: Pathophysiological mechanisms, biomarkers, and therapeutic targets

While schizophrenia (SCZ) is a devastating psychiatric disorder that detrimentally affects a significant portion of the worldwide population, its diagnosis is traditionally based on a relatively subjective assessment of current symptoms and medical history, devoid of an objective diagnostic modality. Antipsychotic medications are commonly used in the treatment of SCZ; however, some patients have low remission rates or forsake treatment due to the associated multiple side effects, resulting in recurrent episodes of the disease and poor prognosis. These situations imply that the diagnosis, treatment, and prognosis of SCZ need to be improved to increase the odds of a better outcome. Mounting studies have found that extracellular vesicles (EVs) play essential roles in the central nervous system. They are implicated in several mechanisms closely associated with SCZ such as cellular communication and synaptic plasticity. They can additionally exhibit neuroprotective and therapeutic effects. Since they possess distinct constituents, are readily available, easily detectable, and dependent on the internal environment, they can potentially serve as reliable biomarkers for disease diagnosis. Moreover, their biological configuration along with their ability to increase the bioavailability of their constituents and modulate intricate intracellular reactions in target cells, propel EVs as new targets for treatment. This review paper summarizes relevant research pertaining to the roles of EVs in SCZ, with the aim of improving insights into SCZ pathogenesis and evaluating EVs as potential biomarkers in the diagnosis and treatment of SCZ.

Efficacy and safety of lurasidone in children and adolescents: Recommendations for clinical management and future research

Lurasidone is a novel azapirone derivative, and atypical antipsychotic agent with a high binding affinity for dopaminergic (D2), serotoninergic (5-HT2A), and 5-HT7 receptors (antagonist), a moderate affinity for 5-HT1A receptors (partial agonist), and no appreciable affinity for histaminergic (H1) and muscarinic (M1) receptors. It was recently included by the European Medication Agency among the in-label pharmacological treatments for children and adolescents affected by early onset schizophrenia. As a dopamine and serotonin antagonist, lurasidone acts on a variety of receptors and showed its efficacy both as an antipsychotic and an activating compound. Administered with food or within 30 minutes from a meal, it presents sufficient bioavailability and does not interact ith most of the other drugs during metabolism. With little effects on hormones and weight gain, potential procognitive profile due to its 5-HT7 antagonism, and reduced extrapyramidal side effects, lurasidone could be a good choice in terms of both effectiveness and tolerability, particularly for patients headed towards a long-term treatment. This article aims to summarize the available scientific evidence from the literature on the use of lurasidone in children and adolescents and to provide recommendations for clinical management and future research.

Severe and persistent mental illness (SPMI) in pregnancy and breastfeeding: focus on second-generation long acting injectable antipsychotics

Introduction: Pregnant women and fetuses are more likely than ever to be exposed to antipsychotic drugs (APs) during pregnancy and postpartum period. Second-generation APs (SGA) are increasingly used among women in reproductive age. Key outcomes (i.e., congenital malformations, pregnancy and maternal outcomes, neonatal/infant risks, and developmental/long-term outcomes) following the exposure to APs remain limited in number and size and yield of inconsistent findings overall, particularly regarding long-acting injectable AP (LAI-APs) formulations.Areas covered: The review aims at providing a summary of current knowledge on potential risks and safety profile of LAI-APs during pregnancy and breastfeeding, specifically focusing on SGA.Expert opinion: The management of safety and tolerability of long-acting injectable AP (LAI-APs) is far from having solid scientific evidence. In fact, due to ethical reasons, there is a lack of randomized clinical trials that limits the reliability and generalizability of the available data on LAI-APs safety profile during the perinatal period, being limited in the scientific literature only to isolated case reports. Therefore, it seems to be important for the future pathways to perinatal mental health care, providing a network of specialized clinicians and systematically collecting data of pregnant/puerperal women on oral and/or LAI APs-therapy about mother and infant outcomes.

Use of Charlson Comorbidity Index and Nomogram to Predict Mortality in Elderly Patients with Late-Life Schizophrenia

Objectives: Comorbid illness burden signifies a poor prognosis in schizophrenia. The aims of this study were to estimate the severity of comorbidities in elderly patients with schizophrenia, determine risk factors associated with mortality, and establish a reliable nomogram for predicting 1-, 3- and 5-year mortality and survival. Methods: This population-based study rigorously selected schizophrenia patients (≥65 years) having their first admission due to schizophrenia during the study period (2000–2013). Comorbidity was scored using the updated Charlson Comorbidity Index (CCI). Results: This study comprised 3827 subjects. The mean stay of first admission due to schizophrenia was 26 days. Mean numbers of schizophrenia and non-schizophrenia-related hospitalization (not including the first admission) were 1.80 and 3.58, respectively. Mean ages at death were 73.50, 82.14 and 89.32 years old, and the mean times from first admission to death were 4.24, 3.33, and 1.87 years in three different age groups, respectively. Nearly 30% were diagnosed with ≥3 comorbidities. The most frequent comorbidities were dementia, chronic pulmonary disease and diabetes. The estimated 1-, 3- and 5-year survival rates were 90%, 70%, and 64%, respectively. Schizophrenia patients with comorbid diseases are at increased risk of hospitalization and mortality (p < 0.05). Conclusion: The nomogram, composed of age, sex, the severity of comorbidity burden, and working type could be applied to predict mortality risk in the extremely fragile patients.

Long-term treatment of bipolar disorder type I: A systematic and critical review of clinical guidelines with derived practice algorithms

OBJECTIVES

This systematic review aimed at providing a critical, comprehensive synthesis of international guidelines' recommendations on the long-term treatment of bipolar disorder type I (BD-I).

METHODS

MEDLINE/PubMed and EMBASE databases were searched from inception to January 15th, 2019 following PRISMA and PICAR rules. International guidelines providing recommendations for the long-term treatment of BD-I were included. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II.

RESULTS

The final selection yielded five international guidelines, with overall good quality. The evaluation of applicability was the weakest aspect across the guidelines. Differences in their updating strategies and the rating of the evidence, particularly for meta-analyses, randomized clinical trials (RCTs) and observational studies, could be responsible of some level of heterogeneity among recommendations. Nonetheless, the guidelines recommended lithium as the 'gold standard' in the long-term treatment of BD-I. Quetiapine was another possible first-line option as well as aripiprazole (for the prevention of mania). Long-term treatment should contemplate monotherapy, at least initially. Clinicians should check regularly for efficacy and side effects and if necessary, switch to first-line alternatives (i.e. Valproate), combine first-line compounds with different mechanisms of action or switch to second-line options or combinations.

CONCLUSIONS

The possibility to monitor improvements in long-term outcomes, namely relapse prevention and inter-episode subthreshold depressive symptoms, based on the application of their recommendations is an unmet need of clinical guidelines. In terms of evidence of clinical guidelines, there is a need for more efficacious treatment strategies for the prevention of bipolar depression.

Comparative cardiometabolic risk of antipsychotics in children, adolescents and young adults

Understanding different cardiometabolic safety profiles of antipsychotics helps avoid unintended outcomes among young patients. We conducted a population-based study to compare cardiometabolic risk among different antipsychotics in children, adolescents and young adults. From Taiwan's National Health Insurance Database, 2001-2013, we identified two patient cohorts aged 5-18 (children and adolescents) and 19-30 (young adults), diagnosed with psychiatric disorders and newly receiving antipsychotics, including haloperidol and sulpiride, and second generation antipsychotics (SGA, including olanzapine, quetiapine, risperidone, amisulpride, aripiprazole, paliperidone, and ziprasidone). Risperidone users were considered the reference group. We analyzed electronic medical records from seven hospitals in Taiwan and confirmed findings with validation analyses of identical design. Primary outcomes were composite cardiometabolic events, including type 2 diabetes mellitus, hypertension, dyslipidemia, and major adverse cardiovascular events. Multivariable Cox proportional hazards regression models compared cardiometabolic risk among antipsychotics. Among 29,030 patients aged 5-18 and 50,359 patients aged 19-30 years, we found 1200 cardiometabolic event cases during the total follow-up time of 37,420 person-years with an incidence of 32.1 per 1000 person-years. Compared to risperidone, olanzapine was associated with a significantly higher risk of cardiometabolic events in young adults (adjusted hazard ratio, 1.57; 95% CIs 1.13-2.18) but not in children and adolescents (1.85; 0.79-4.32). Specifically, we found young adult patients receiving haloperidol (1.52; 1.06-2.20) or olanzapine (1.75; 1.18-2.61) had higher risk of hypertension compared with risperidone users. Results from validation analyses concurred with main analyses. Antipsychotics' various risk profiles for cardiometabolic events merit consideration when selecting appropriate regimes. Due to cardiometabolic risk, we suggest clinicians may consider to select alternative antipsychotics to olanzapine in children, adolescents and young adults.

Drugs Affecting Body Weight, Body Fat Distribution, and Metabolic Function-Mechanisms and Possible Therapeutic or Preventive Measures: an Update

PURPOSE OF REVIEW

Weight gain and body fat redistribution are common side effects of many widely used drugs. We summarize recent literature on prevalence data and mechanisms associated with drug-induced body fat changes and mechanisms to prevent or treat metabolic side effects.

RECENT FINDINGS

The highest prevalence of metabolic complications is seen with antipsychotics and antiretroviral drugs used in the treatment of HIV and may, at least partly, be responsible for the increased risk for co-morbid diseases such as diabetes, steatosis of the liver, and cardiovascular disease. The pathogenetic mechanisms leading to weight gain from antipsychotics are increasingly known and help to unravel the complex interaction that exists between psychopathology and metabolic complications. Although the classic lipodystrophy mainly occurred with older HIV drugs, also with the newer HIV treatment, weight gain seems to be a major side effect. Early detection of the metabolic consequences of drugs can lead to an early diagnosis of the complications and their treatment. Different medications, including the newer antidiabetics, are being studied in the therapy of drug-induced obesity. Future research should focus on identifying individuals at risk for metabolic side effects and on early markers to identify individuals with side effects so that timely treatment of metabolic complications can be initiated.

Late-Onset Neutropenia in Long-Term Clozapine Use and Its Management Utilizing Prophylactic G-CSF

This case outlines recurrent neutropenia after fourteen years of successful clozapine use. The patient has a diagnosis of treatment-resistant schizophrenia which has been complicated by sensitivity to side effects of haloperidol and past failure of antipsychotics to manage her symptoms. It was necessary for our patient to follow a complicated treatment path involving close monitoring of blood levels, admissions, the initiation of lithium and the regular use of filgrastim (Neupogen), granulocyte colony stimulating factor (G-CSF). Following a failure of rescue filgrastim to increase her neutrophil levels, a management protocol was designed with input from the on-site hematology team. This protocol involved the use of filgrastim on a regular prophylactic basis. This management plan has worked for the patient who has been able to continue use of clozapine and has not suffered from any neutropenic episodes in over six months.

Towards personalized pharmacology: Antipsychotics and schizophrenia

Since the discovery of the first antipsychotic in 1952, many antipsychotic drugs have been developed, each with different pharmacokinetic and pharmacodynamic properties. The pharmacological heterogeneity of antipsychotic drugs should allow a personalized drug prescription adapted to the different clinical picture of schizophrenia. Schizophrenia is a chronic disease, during which 3 stages of pharmacological intervention can be identified: the first episode psychotic (FEP), the phase of therapeutic stabilization that can progress to situations of resistance, and the question of long-term prescription. During FEP, the choice of the first antipsychotic treatment seems to be underpinned by its safety profile in relation to the patient for whom it is prescribed, according to the adage start low and go-slow. The therapeutic stabilization phase is based on treatment optimization through a rigorous evaluation of the benefits-harm balance, with the use of tools such as personalized therapeutic drug monitoring and pharmacogenetics. Generally speaking, while some antipsychotic drugs seem to present a more favorable efficacy profile in certain situations, the differences are small, whereas the differences in safety are more important and should be considered in the first line. Individual factors such as the presence of co-morbidities, as well as previously experienced treatments must also be taken into account. Finally, the question of maintaining the prescription of antipsychotic drugs over the long term arises in view of the iatrogenic risk with controversial current data. Overall, the personalized prescription of antipsychotic drugs in schizophrenia remains limited by a lack of data in the literature, justifying the development of clinical studies in this field. But at present, the dogma remains that of primum non nocere.

Do Leptin Play a Role in Metabolism-Related Psychopathological Symptoms?

Objectives: Leptin is a crucial regulator of energy balance and is associated with obesity. In recent years, it has also been recognized as involved in the psychopathological mechanism. Our study aimed to elucidate the relationships between serum leptin levels, body mass index (BMI), and psychopathology symptoms in patients with schizophrenia. Methods: A cross-sectional assessment of 324 inpatients with schizophrenia was conducted. Schizophrenia symptoms were measured using the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). Serum leptin levels were assessed by the Enzyme-Linked Immunosorbent Assay (ELISA). Results: Significant differences in sex, BMI, and negative symptom subscale (PANSS-N) scores were found between the groups with high and low leptin levels in the study. Leptin levels were positively correlated with BMI (B = 2.322, t = 9.557, P < 0.001) and negatively correlated with PANSS-N scores (B = -0.303, t = -2.784, P = 0.006). Conclusions: Our results suggest that the increase in leptin levels is responsible for antipsychotic-induced weight gain and improved psychopathological symptoms.

The Effect of Yijinjing on the Cognitive Function of Patients With Chronic Schizophrenia

Background: Patients with chronic schizophrenia present cognitive impairment, which affects their social function and prevents them from reintegrating into society. Yijinjing is a traditional Chinese aerobic exercise that has a putative psychosomatic effect on improving cognitive function. Methods: From January to May 2021, 40 patients with chronic schizophrenia were recruited and randomly divided into a control group and a Yijinjing group. In the 12-week intervention, the patients in the control group received conventional treatment, whereas patients in the Yijinjing group performed Yijinjing exercise (40 min/session, twice a week) in addition to receiving conventional treatment. The Positive and Negative Syndrome Scale (PANSS), the Insight and Treatment Attitude Questionnaire (ITAQ), the Rosenberg Self-esteem Scale (SES), and the Mini Mental State Examination (MMSE) were used to measure clinical symptoms and cognitive function at 0, 6, and 12 weeks. Results: The demographic information was not significantly different between groups. At baseline, the scores of all the scales were not statistically different between groups. After 12 weeks of intervention, compared to those at baseline, the scores of the negative scale (t = 19.00, p < 0.0001), general psychopathology scale (t = 15.98, p < 0.0001), and total score (t = 15.47, p < 0.0001) of the PANSS and SES (t = 5.378, p < 0.0001) had significantly decreased, and the scores of the ITAQ (t = 7.984, p < 0.0001) and MMSE (t = 6.750, p < 0.0001) had significantly increased in Yijinjing group; the score of the MMSE increased in the control group as well (t = 2.491, p = 0.0222). Compared to the respective scores in the control group, the negative scale score (t = 2.953, p = 0.0054) significantly decreased, and the ITAQ (t = 3.043, p = 0.0042) and MMSE (t = 2.2.68, p = 0.0291) scores significantly increased in the Yijinjing group after 12 weeks of intervention. Conclusion: These results provide a preliminary indication that Yijinjing exercise had the potential to improve cognitive function and negative symptoms in patients with chronic schizophrenia. A larger-scale study to determine the trajectory of change in the longer term should be undertaken.

The Safety and Effectiveness of High-Dose Propranolol as a Treatment for Challenging Behaviors in Individuals With Autism Spectrum Disorders

PURPOSE/BACKGROUND

Individuals with autism spectrum disorders present with social communication deficits and a rigid adherence to sameness. Along with these symptoms, many individuals also present with severe challenging behaviors that place themselves as well as their families and communities at risk for injury. For these individuals, new and effective treatments are acutely needed. Propranolol has been used worldwide for over 50 years. Its primary indication is for hypertension, but there is evidence that, at higher doses, propranolol inhibits rage and anger through its effects on the central nervous system. This effect has been demonstrated in a variety of neuropsychiatric disorders.

METHODS/PROCEDURES

Here, we present 46 retrospective analyses of clinical cases that were followed by a psychiatrist. Propranolol was prescribed as an add-on to the patients' existing medications. The doses ranged from 120 to 960 mg per day (mean = 462 mg).

FINDINGS/RESULTS

Thirty-nine (85%) of 46 patients were found to be much improved or very much improved on the physician-rated Clinical Global Impression Improvement scale. There were few side effects noted, with only 2 subjects unable to tolerate the propranolol.

IMPLICATIONS/CONCLUSIONS

It appears that high-dose propranolol can be given safely with minimal adverse cardiovascular problems, provided that close clinical monitoring is maintained. A more rigorous clinical trial is needed to elucidate and verify its clinical utility, clinical practice parameters, and the effects of propranolol as a monotherapy versus as an add-on to the patient's existing medication regimen.

Overview of schizophrenia research and treatment in Pakistan

Mental health is the most neglected health sector in Pakistan, and the majority of citizens have limited or no access to primary and secondary psychiatric services. The incidence of schizophrenia (SCZ) has increased at an alarming rate in Pakistan, relative to that of other psychiatric disorders. While numerous studies have investigated SCZ, few have addressed the issue about the Pakistani population. In the present review, the researchers discuss current data integral to the prevalence, pathophysiology, and molecular genetics of SCZ; treatment approaches to the disease; and patient responses to drugs prescribed for SCZ in Pakistan. Most Pakistani patients exhibit poor responses to antipsychotic drugs. Based on our review, the researchers hypothesize that genetic dissimilarities between Pakistani and Western populations contribute to such poor responses. Consequently, an understanding of such genetic differences and the provision of personalized treatment may simultaneously aid in improving SCZ treatment in Pakistan.

Effect on Body Weight and Adipose Tissue by Cariprazine: A Head-to-Head Comparison Study to Olanzapine and Aripiprazole in Rats

Cariprazine (Car) is a recently approved second generation antipsychotic (SGA) with unique pharmacodynamic profile, being a partial agonist at both dopamine D2/3 receptor subtypes, with almost 10 times greater affinity towards D3. SGAs are known to increase body weight, alter serum lipids, and stimulate adipogenesis but so far, limited information about the adverse effects is available with this drug. In order to study this new SGA with such a unique mechanism of action, we compared Car to substances that are considered references and are well characterized: olanzapine (Ola) and aripiprazole (Ari). We studied the effects on body weight and also assessed the adipogenesis in rats. The drugs were self-administered in two different doses to female, adult, Wistar rats for six weeks. Weekly body weight change, vacuole size of adipocytes, Sterol Regulatory Element Binding Protein-1 (SREBP-1) and Uncoupling Protein-1 (UCP-1) expression were measured from the visceral adipose tissue (AT). The adipocyte’s vacuole size, and UCP-1 expression were increased while body weight gain was diminished by Car. by increasing UCP-1 might stimulate the thermogenesis, that could potentially explain the weight gain lowering effect through enhanced lipolysis.

Anti-Stress Properties of Atypical Antipsychotics

Stress exposure represents a major environmental risk factor for schizophrenia and other psychiatric disorders, as it plays a pivotal role in the etiology as well as in the manifestation of disease symptomatology. It may be inferred that pharmacological treatments must be able to modulate the behavioral, functional, and molecular alterations produced by stress exposure to achieve significant clinical outcomes. This review aims at examining existing clinical and preclinical evidence that supports the ability of atypical antipsychotic drugs (AAPDs) to modulate stress-related alterations. Indeed, while the pharmacodynamic differences between AAPDs have been extensively characterized, less is known on their ability to regulate downstream mechanisms that are critical for functional recovery and patient stabilization. We will discuss stress-related mechanisms, spanning from neuroendocrine function to inflammation and neuronal plasticity, which are relevant for the manifestation of schizophrenic symptomatology, and we will discuss if and how AAPDs may interfere with such mechanisms. Considering the impact of stress in everyday life, we believe that a better understanding of the potential effects of AAPDs on stress-related mechanisms may provide novel and important insights for improving therapeutic strategies aimed at promoting coping mechanisms and enhancing the quality of life of patients affected by psychiatric disorders.

Characteristics of U.S. adults taking prescription antipsychotic medications, National Health and Nutrition Examination Survey 2013-2018

BACKGROUND

Global 12-month psychosis prevalence is estimated at roughly 0.4%, although prevalence of antipsychotic use in the U.S. is estimated at roughly 1.7%. Antipsychotics are frequently prescribed for off label uses, but have also been shown to carry risk factors for certain comorbid conditions and with other prescription medications. The study aims to describe the socio-demographic and health characteristics of U.S. adults taking prescription antipsychotic medications, and to better understand the association of antipsychotic medications and comorbid chronic diseases.

METHODS

The study pools 2013-2018 data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey of non-institutionalized U.S. residents (n = 17,691). Survey staff record prescription medications taken within the past 30 days for each respondent, from which typical and atypical antipsychotic medications were identified.

RESULTS

Prevalence of antipsychotic use among U.S. adults was 1.6% (n = 320). Over 90% of individuals taking antipsychotics reported having health insurance and a usual place for care, significantly more than their counterparts not taking antipsychotics. Further, those taking antipsychotics reported higher prevalence of comorbid chronic diseases and took an average of 2.3 prescription medications more than individuals not taking antipsychotics. Individuals taking antipsychotics were more likely to sleep 9 or more hours per night, be a current smoker, and have a body mass index greater than 30 kg/m².

CONCLUSIONS

U.S. adults who take antipsychotic medications report more consistent health care access and higher prevalence of comorbid chronic diseases compared to those not taking antipsychotics. The higher comorbidity prevalence and number of total prescriptions highlight the need for careful assessment and monitoring of existing comorbidities and potential drug-drug interactions among adults taking antipsychotics in the U.S.

'Precision' or 'personalized' psychiatry: different terms - same content?

Due to the increased lifetime prevalence and personal, social, and economic burden of mental disorders, psychiatry is in need of a significant change in several aspects of its clinical and research approaches. Over the last few decades, the development of personalized / precision medicine in psychiatry focusing on tailored therapies that fit each patient's unique individual, physiological, and genetic profile has not achieved the same results as those obtained in other branches, such as oncology. The long-awaited revolution has not yet surfaced. There are various explanations for this including imprecise diagnostic criteria, incomplete understanding of the molecular pathology involved, absence of available clinical tools and, finally, the characteristics of the patient. Since then, the co-existence of the two terms has sparked a great deal of discussion around the definition and differentiation between the two types of psychiatry, as they often seem similar or even superimposable. Generally, the two terminologies are used indiscriminately, alternatively, and / or separately, within the same scientific works. In this paper, an overview is provided on the overlap between the application and meaning of the terms 'precision psychiatry' and 'personalized psychiatry'.

Up-to-date expert opinion on the safety of recently developed antipsychotics

Introduction There are several new and emerging antipsychotic medication strategies recently marketed or under clinical development for the treatment of several mental disorders. There is the need to provide an up-to-date overview on the safety of this new generation of antipsychotic medications, which includes also the third-generation antipsychotics (TGA). Areas covered The authors aimed at providing a synthesis of the most current evidence about the safety profile of the recently developed and/or marketed antipsychotics. Qualitative synthesis followed an electronic search made inquiring of the following databases: MEDLINE, Embase, PsycINFO, and the Cochrane Library from inception until March 2020, combining free terms and MESH headings for the topics of TGA and recently developed and/or marketed antipsychotics as following: ((safety OR adverse events OR side effects) AND ((brexpiprazole OR cariprazine OR inhaled loxapine OR lumateperone (ITI-007) OR lurasidone OR pimavanserin OR roluperidone (MIN-101) OR transdermal patch asenapine)). Expert opinion Overall, newer antipsychotics display a good safety profile, with a well-demonstrated lower metabolic liability compared to second-generation antipsychotics. Furthermore, TGA appear to specifically target negative symptomatology and improving cognitive domains. Abbreviations Aps=Antipsychotic Drugs; AEs = Adverse Effects; EPS = Extrapyramidal Symptoms; NMS = Neuroleptic malignant syndrome; D = Dopamine; K_i = Inhibitory Constant; 5-HT = Serotonin; ECG = Electrocardiogram; H = Histamine; M = Muscarinic; BMI = Body Mass Index.

Efficacy and safety of cariprazine in bipolar I depression: A double-blind, placebo-controlled phase 3 study

OBJECTIVE

To assess the efficacy, safety, and tolerability of cariprazine in the treatment of the depressed phase of bipolar I disorder in adults (NCT02670538).

METHODS

In this phase 3 double-blind placebo-controlled study, adult patients with bipolar I disorder according to the Diagnostic and Statistical Manual - 5th Edition criteria and a current depressive episode were randomized to placebo (n = 167), cariprazine 1.5 mg/day (n = 168) or cariprazine 3.0 mg/day (n = 158). Efficacy parameters were changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) total scores (primary) and Clinical Global Impressions - Severity (CGI-S) scores (secondary) from baseline to Week 6 compared to placebo. A mixed-model for repeated measures was used to estimate the least-squares mean differences (LSMD); P-values were adjusted for multiplicity. Adverse events (AEs), laboratory results, vital signs, and suicide risk were monitored.

RESULTS

Cariprazine 1.5 mg/day significantly reduced depressive symptoms on the primary (MADRS LSMD = -2.5; adjusted P = .0417) and secondary (CGI-S LSMD = -0.3; adjusted P = .0417) efficacy parameters vs placebo; differences were not statistically significant for cariprazine 3.0 mg/day. Common treatment-emergent AEs (≥5% in either cariprazine group and at least twice the incidence of placebo) were akathisia, restlessness, nausea, and fatigue. Mean metabolic parameter changes were low and generally comparable among groups; mean weight increases were ≤0.5 kg for all groups.

CONCLUSIONS

Cariprazine 1.5 mg/day significantly reduced depressive symptoms in adults with bipolar I depression compared to placebo, but differences were not significant for cariprazine 3.0 mg/day. The safety and tolerability profiles were similar to previous studies of cariprazine.

The Effect of Valproic Acid on Olanzapine Serum Concentration: A Study Including 2791 Patients Treated With Olanzapine Tablets or Long-Acting Injections

BACKGROUND

The combination of olanzapine and valproic acid (VPA) is regularly prescribed in the treatment of bipolar or schizoaffective disorders. The VPA has been shown to reduce olanzapine concentration, but the mechanism behind this interaction remains unknown. We aimed to investigate the effect of VPA on olanzapine concentration during oral versus long-acting injectable (LAI) formulation in a real-life setting.

METHODS

From a therapeutic drug monitoring service, prescribed doses and serum concentrations from 2791 olanzapine-treated patients (9433 measurements) were included.

RESULTS

The number of patients on olanzapine-LAI treatment was 328, whereas 2463 were using oral olanzapine. The frequency of patients comedicated with VPA was 9.4% for olanzapine tablets and 5.8% for olanzapine-LAI. The VPA had no effect on olanzapine dose-adjusted concentrations in LAI users (1.6 vs 1.7 [ng/mL]/[mg/d]; P = 0.38), whereas in the oral group the dose-adjusted olanzapine concentration was lower in VPA users (2.2 vs 2.7 [ng/mL]/[mg/d]; P < 0.001). For smokers in the oral olanzapine group using VPA, 8.7% of the measurements were in the subtherapeutic range (<10 ng/mL) compared with 6.0% in nonusers (P = 0.003).

IMPLICATIONS

These findings show that the VPA-olanzapine interaction involves a presystemic mechanism and is therefore restricted to oral olanzapine treatment. For oral treatment of olanzapine, comedication with VPA implies a risk of insufficient effect, which may be of clinical relevance in smokers in particular. Thus, it is important to be aware of the interaction potential with VPA during oral olanzapine use, whereas for LAI-treated patients fewer precautions are required from a pharmacokinetic point of view.

Dopamine Receptor Partial Agonists for the Treatment of Bipolar Disorder

Bipolar disorder is a chronic, disabling, and costly illness with frequent relapses and recurrences, high rates of co-morbid conditions, and poor adherence to treatment. Mood stabilizers and antipsychotics are the cornerstones of treatment. Dopamine receptor partial agonists are a novel class of antipsychotic agents with original pharmacodynamic properties. Among them, two have been approved by the US Food and Drug Administration for the treatment of bipolar disorder. Aripiprazole (oral formulation) has been approved as monotherapy for the treatment of manic/mixed episodes in adult and pediatric populations and for maintenance treatment in adults, and as adjunctive treatment to mood stabilizers, for the acute treatment of manic/mixed episodes and for maintenance in adults. An intramuscular formulation of aripiprazole has been approved for the treatment of agitation in mania and a long-acting injectable formulation has been approved as maintenance treatment. In the USA, cariprazine has been approved as monotherapy for the acute treatment of manic/mixed as well as bipolar depressive episodes. Brexpiprazole is not yet approved to treat bipolar disorder. The evidence supporting these indications is reviewed via an analysis of clinical registration trials as well as additional studies, on the basis of a systematic literature search. Further studies dealing with other aspects of bipolar illness are also presented. Aripiprazole and cariprazine are efficacious and generally well tolerated agents that have shown cost effectiveness, and may therefore enrich our therapeutic armamentarium for bipolar illness. Brexpiprazole, which displays an overall promising tolerability profile, deserves further efficacy studies.

Efficacy and safety of lurasidone versus placebo as adjunctive to mood stabilizers in bipolar I depression: A meta-analysis

BACKGROUND

Few evidence-based treatments and guidelines reflect greater uncertainty regarding consensus treatment algorithms than those for unipolar disorder. This meta-analysis aimed to evaluate the efficacy and side effects of lurasidone by comparing with placebo in bipolar I depression.

METHODS

Electronic databases, such as PubMed, the Cochrane Library, Web of Science, and Embase, were searched until May 30, 2018, for randomized controlled trials on comparison lurasidone therapy with placebo. The primary efficacy assessment included MADRS total score and CGI-BP-S total score, the secondary efficacy assessment included the response and the remission rates and the safety and tolerability were also evaluated applying the Simpson-Angus Scale.

RESULTS

The meta-analysis compromised 7 studies. Efficacy analysis suggested that lurasidone was more effective than placebo: MADRS total score (MD:-4.31, 95%CI: (-6.93,-1.7), P = 0.001) and the CGI-BP-S total score (MD:-0.37, 95%CI: (-0.59,-0.15), P = 0.0008) were obtained for both lurasidone-treated and placebo groups. Response rates (RR: 1.73, 95%CI: (1.46, 2.05), P < 0.00001) and Remission rates (RR: 1.57, 95%CI: (1.38, 1.79), P < 0.00001). The safety analysis between lurasidone and placebo showed no difference: at least one event (RR: 1.12, 95% CI :(1.00, 1.26), p = 0.05 and the influence on glucose (MD: 0.35, 95% CI :(-1.09, 1.79), p = 0.63.

LIMITATION

The present conclusion is limited by the limited included studies. The different dose of lurasidone should be considered in the future.

CONCLUSION

Compared with placebo, adjunctive lurasidone significantly improved depressive symptoms and is very well tolerated with minimal side effects on the endocrine and cardiovascular systems in clinical patients with bipolar I depression. Key words: Bipolar I depression; Lurasidone; Meta-analysis; Remission rates; Adverse effect.

Rehospitalization Risk of Receptor-Affinity Profile in Antipsychotic Drug Treatment: A Propensity Score Matching Analysis Using a Japanese Employment-Based Health Insurance Database

PURPOSE

The aim of this study was to examine whether there is a difference in the risk of rehospitalization when antipsychotics are classified into two groups treated using drugs with a higher or lower affinity to H1 or α1 receptors than to D2 receptors (histamine H1 receptors, adrenaline α1 receptors [HA] high- and HA low-affinity drug group, respectively) based on affinity to receptors related to sedation using a nationwide insurance claims database in Japan.

PATIENTS AND METHODS

We identified eligible patients by the following two criteria: (i) hospitalization due to schizophrenia (International Classification of Disease [ICD]-10 code: F20 or F25) in psychiatric wards between January 1st, 2005 and August 31st, 2017, and (ii) administration of HA high- or HA low-affinity drugs in the next month after discharge from the earliest hospitalization due to schizophrenia (index month). The primary endpoint was rehospitalization due to schizophrenia. The secondary endpoints were (i) involuntary rehospitalization, (ii) concomitant use of anxiolytics/hypnotics, mood stabilizers, and antiparkinsonian drugs, (iii) all-cause death, and (iv) medication discontinuation. Propensity score (PS) matching analysis was applied, and the hazard ratio (HR) of the event rate in the HA high-affinity drug group relative to the HA low-affinity drug group was calculated using Cox's proportional hazards model.

RESULTS

Two thousand nine hundred and forty patients were identified as eligible patients. Among PS-matched patients (819 in each group), the HR in the HA high-affinity drug group compared with the HA low-affinity drug group was 1.018 (0.822-1.260, P = 0.870). Other outcomes did not differ significantly between the two groups.

CONCLUSION

No significant difference was observed in the rehospitalization risk due to schizophrenia associated with HA high-affinity antipsychotic drugs. Although this study was a retrospective PS-matched cohort study, the possibility of masking of the rehospitalization risk cannot be excluded because more than 80% of the patients were administered an anxiolytic/hypnotic at the time of admission.

Synthesis and Biological Evaluation of Five-Atom-Linker-Based Arylpiperazine Derivatives with an Atypical Antipsychotic Profile

Herein we describe a focused set of new arylpiperazine derivatives as potential broad-spectrum antipsychotics. The general structure contains a quinolinone-like moiety, an arylpiperazine moiety, and a five-atom linker. Among them, 7-(5-(4-(benzo[d]isothiazol-4-yl)piperazin-1-yl)pentyl)quinolin-2(1H)-one (S6) shows a promising preclinical profile. Compound S6, characterized by partial D₂ R agonism, 5-HT_1A R agonism, 5-HT_2A R antagonism, and blockade of SERT activities, was found to decrease psychosis- and depressive-like symptoms in rodents. The polypharmacological profile of S6 could provide opportunities for the treatment of various other central nervous system disorders such as anxiety, depression, and psychoses associated with dementia. Furthermore, S6 demonstrated acceptable safety, toxicology, and pharmacokinetic profiles, and has been selected as a preclinical candidate for further evaluation in schizophrenia.

The Eminence of Co-Expressed Ties in Schizophrenia Network Communities

Exploring gene networks is crucial for identifying significant biological interactions occurring in a disease condition. These interactions can be acknowledged by modeling the tie structure of networks. Such tie orientations are often detected within embedded community structures. However, most of the prevailing community detection modules are intended to capture information from nodes and its attributes, usually ignoring the ties. In this study, a modularity maximization algorithm is proposed based on nonlinear representation of local tangent space alignment (LTSA). Initially, the tangent coordinates are computed locally to identify k-nearest neighbors across the genes. These local neighbors are further optimized by generating a nonlinear network embedding function for detecting gene communities based on eigenvector decomposition. Experimental results suggest that this algorithm detects gene modules with a better modularity index of 0.9256, compared to other traditional community detection algorithms. Furthermore, co-expressed genes across these communities are identified by discovering the characteristic tie structures. These detected ties are known to have substantial biological influence in the progression of schizophrenia, thereby signifying the influence of tie patterns in biological networks. This technique can be extended logically on other diseases networks for detecting substantial gene “hotspots”.

Treatment Options for Acute Agitation in Psychiatric Patients: Theoretical and Empirical Evidence

Acute agitation is a common presenting symptom in the emergency ward and is also dealt with on a routine basis in psychiatry. Usually a symptom of an underlying mental illness, it is considered urgent and immediate treatment is indicated. The practice of treating agitation on an acute care basis is also referred to as rapid tranquilization. A variety of psychotropic drugs and combinations thereof can be used. The decision is usually made based on availability and the clinician's experience, with the typical antipsychotic haloperidol (alone or in combination with antihistaminergic and anticholinergic drugs such as promethazine), the benzodiazepines lorazepam, diazepam and midazolam as well as a variety of atypical antipsychotics being used for this purpose. Haloperidol is associated with extrapyramidal symptoms (which can be controlled by co-administration of promethazine) and may control agitation without inducing sedation, while benzodiazepines have a more pronounced sedating activity. The atypical antipsychotics aripiprazole and ziprasidone are better tolerated, while olanzapine is also a powerful sedative. Clinical trials evaluating the efficacy of different treatment options have been conducted but they are extremely heterogenous and most have numerous methodological flaws, leading to a poor overall quality of evidence upon which guidelines for the appropriate treatment could be based. The combination of haloperidol and promethazine, which combines the sedative properties of the antihistamine with the more selective calming action of haloperidol (with a reduced risk of extrapyramidal effects compared to haloperidol alone because of the anticholinergic properties of promethazine) may be the best choice based on empirical evidence.

Effectiveness of Electroacupuncture and Electroconvulsive Therapy as Additional Treatment in Hospitalized Patients With Schizophrenia: A Retrospective Controlled Study

Electroacupuncture (EA) and electroconvulsive therapy (ECT) are often used in the management of schizophrenia. This study sought to determine whether additional EA and ECT could augment antipsychotic response and reduce related side effects. In this retrospective controlled study, 287 hospitalized schizophrenic patients who received antipsychotics (controls, n = 50) alone or combined with EA (n = 101), ECT (n = 55) or both (EA + ECT, n = 81) were identified. EA and ECT were conducted for 5 and 3 sessions per week, respectively, with a maximum of 12 sessions for ECT during hospitalization. The Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS) were used to assess the severity of psychotic symptoms. Clinical response on SAPS and SANS, weight gain, and adverse events were compared. Survival analysis revealed that the ECT and EA + ECT groups had markedly greater clinical response rate than controls on SAPS [72.7 and 90.1% vs. 64.0%; relative risk (RR), 1.974 and 2.628, respectively, P ≤ 0.004] and on SANS (67.3 and 70.4% vs. 42.0%; RR, 1.951 and 2.009, respectively, P ≤ 0.015). A significantly greater response rate on SANS than controls was also observed in the EA group (64.4% vs. 42.0%; RR = 1.938, P = 0.008). EA-containing regimens remarkably reduced weight gain and incidences of headache, insomnia, dry mouth, and electrocardiographic abnormalities. These results suggest that EA and ECT can serve as additional treatment for enhancing antipsychotic response and reduce the side effects in hospitalized patients with schizophrenia. Clinical Trial Registration: http://www.chictr.org.cn/showprojen.aspx?proj=38901, identifier ChiCTR1900023563.

Treatment discontinuation of long-acting injectables or oral atypical antipsychotics among Medicaid recipients with schizophrenia

Aims: Among patients with schizophrenia, poor adherence and persistence with oral atypical antipsychotics (OAA) often results in relapse and hospitalization. Second-generation antipsychotic long-acting injectables (SGA LAI) have demonstrated higher adherence than first-generation antipsychotic LAI and OAA therapies. This study aimed to determine whether SGA LAIs are associated with better persistency compared to OAA among Medicaid recipients with schizophrenia. Materials and methods: From the MarketScan Medicaid Database (January 1, 2010-June 30, 2016), patients aged ≥18 years with schizophrenia and ≥2 pharmacy claims more than 90 days apart for the same SGA LAI or OAA were selected. New users of the specific antipsychotic agent were classified, based on their index agent, as: OAA, paliperidone palmitate LAI (PPLAI), aripiprazole LAI (ALAI), and risperidone LAI (RLAI). Discontinuation during 1 year of follow-up was defined as a ≥ 60-day gap in the index OAA or SGA LAI medication past the exhaustion of the previous claim's supply. Inverse probability of treatment weights (IPTW) balanced the cohort characteristics, and weight outliers (<0.1 or >0.9) were excluded. IPTW-weighted Cox proportional hazards regression estimated hazard ratios for discontinuation. Results: Cohorts included 7,029 OAA, 4,302 PPLAI, 586 ALAI, and 1,456 RLAI patients. Mean age was 38.0-41.0 years and 44.0-46.6% were female. Persistence was significantly longer in the SGA LAI cohorts than in the OAA cohort. Adjusted hazard ratios (95% confidence intervals) for discontinuation were 0.60 (0.56-0.64) for PPLAI, 0.69 (0.60-0.79) for ALAI, and 0.70 (0.64-0.77) for RLAI vs OAA. Limitations: Results may not be generalizable to patients covered by commercial or Medicare insurance, and limitations inherent to any claims-based retrospective analysis apply. Conclusions: SGA LAI may be a valuable option for treating schizophrenia given the improvement in persistence.