SMARTS (Systematic Monitoring of Adverse events Related to TreatmentS): The development of a pragmatic patient-completed checklist to assess antipsychotic drug side effects

Incremental healthcare costs among patients experiencing adverse events on oral antipsychotics: a real-world analysis of U.S. Medicare beneficiaries with schizophrenia

OBJECTIVE

Continuous antipsychotic treatment is fundamental to successful management of schizophrenia. However, many oral antipsychotics are associated with adverse effects (AEs). While prior research has shown antipsychotic AEs to negatively impact patient adherence, no study has examined the incremental costs associated with AEs, especially among Medicare beneficiaries who constitute approximately half of all patients with schizophrenia in the U.S. This study aimed to compare incremental healthcare costs among Medicare beneficiaries with schizophrenia treated with oral antipsychotics who did and did not experience adverse events (AEs).

METHODS

All fee-for-service Medicare beneficiaries with schizophrenia who initiated a new OAP between 01/01/2017 and 12/31/2019 were included in the sample (index date = date of new OAP prescription). All-cause and schizophrenia-related costs were measured while a patient was receiving treatment and were converted into monthly measures given differential follow-up periods. Generalized linear models were used to generate adjusted cost estimates.

RESULTS

In our final sample of 46,452 Medicare beneficiaries with schizophrenia, movement disorders such as tardive dyskinesia and extrapyramidal symptoms were observed in 10.0% of beneficiaries. Metabolic side effects included hyperlipidemia (33.6%), diabetes (33.1%), and hypotension (6.8%). Patients who experienced adverse events consistently had significantly higher all-cause monthly healthcare costs compared to patients who did not experience adverse events. This was true for beneficiaries experiencing movement disorders ($5,281 vs. $4,851, Δ = $430, p = 0.0766), hyperlipidemia ($5,123 vs. $4,768, Δ = $355, p = 0.0179), diabetes ($5,249 vs. $4,698, Δ = $551, p = 0.0049), and hypotension ($6,631 vs. $4,685, Δ = $1,946, p < 0.001). A similar pattern was observed for monthly schizophrenia-related costs.

CONCLUSIONS

Our findings underscore the additional healthcare cost burden associated with adverse events in patients receiving oral antipsychotic treatment. Efforts should be directed towards selecting agents that minimize side effects and/or developing new therapeutic alternatives with improved tolerability profiles.

Effect of bright light therapy on depression in patients with schizophrenia: A pilot study

OBJECTIVE

In this pilot study, we investigated the effects of bright light therapy on depression in schizophrenia using a quasi-experimental design involving random assignment.

METHODS

We included patients with schizophrenia who had stable psychiatric symptoms. Experimental group (n = 16) received light therapy while control group (n = 12) received only regular indoor light. The intervention was administered in the morning once a day for 50 min for three weeks. Scores of the Chinese version of the Calgary Depression Scale for Schizophrenia (CDSS-C), Chinese version of the Positive and Negative Syndrome Scale (PANSS-C), Clinical Global Impression-Schizophrenia Scale (CGI-SCH), and Stressful Life Event Scale (SLES) were measured at baseline (T0), immediately after 5th day of the intervention (T1), immediately after the 15th day of intervention (T2), and at the 14-day follow-up (T3). A generalized estimating equation (GEE) analysis was performed to analyse group × time interaction effects and effect of bright light therapy on depression.

RESULTS

Results indicated that bright light therapy alleviated depressive symptoms in patients with schizophrenia after controlling for internal or surgical diseases and disease duration (in years). However, the effect was not maintained two weeks after the treatment.

CONCLUSION

These findings suggest that bright light therapy is a nonpharmacological adjunct treatment approach for patients with stable psychiatric symptoms.

Reasons for disengagement in first-episode psychosis - perspectives from service users and their caregivers

BACKGROUND

The efforts of early psychosis intervention programmes can be impeded by difficulties in maintaining the engagement of service users. As disengagement is often an autonomous decision made by service users, the main aim of this study was to gain insight into the reasons for service user disengagement through qualitative interviews with the service users themselves, and caregivers as proxies or secondary informants.

METHODS

Participants recruited for the study were enrolled in the Early Psychosis Intervention Programme in Singapore for at least a year, aged 21 and above, able to communicate in English, and had disengaged for at least three months. The recruitment and interview processes were conducted independently for service user and caregiver participants. Potential participants were invited to a face-to-face semi-structured interview over video call or in-person. Each interview spanned one to two hours, and comprised five phases - icebreaker, exploration of the participant's experience with EPIP before deciding to disengage, discussion of reasons for disengagement, exploration of the post-disengagement experience, and feedback and suggestions for EPIP. Recruitment aimed to conclude after 10-15 participants were interviewed for both service user and caregiver groups, with the expectation that data sufficiency would be reached with no new themes being generated.

RESULTS

Ultimately, 12 service user and 12 caregiver participants were recruited. There were six pairs of service user and caregiver dyads, where the caregivers interviewed were caring for service users also enrolled in the study. Valuable qualitative insights were gathered, including the type of disengagement, medication compliance during disengagement, the decision-making process behind disengaging, and circumstances surrounding re-engagement. A total of five categories each with subthemes were identified from the reasons for service user disengagement - individual factors, stigma, progression, treatment factors, and external factors.

CONCLUSIONS

There is a need to narrow down urgent areas of attention, aligning the study themes with established risk factors so that feasible solutions can be developed and appropriate care models can be adopted, to minimise adverse outcomes related to disengagement. It is important to keep an open mind to understand what personal recovery means to the individual service user, so that treatment goals can be better harmonised.

Top 10 Signs and Symptoms of Psychotropic Adverse Drug Events to Monitor in Residents of Long-Term Care Facilities

OBJECTIVES

To produce a consensus list of the top 10 signs and symptoms suggestive of adverse drug events (ADEs) for monitoring in residents of long-term care facilities (LTCFs) who use antipsychotics, benzodiazepines, or antidepressants.

DESIGN

A 3-round Delphi study.

SETTING AND PARTICIPANTS

Geriatricians, psychiatrists, pharmacologists, general practitioners, pharmacists, nurses, and caregivers from 13 Asia Pacific, European, and North American countries.

METHODS

Three survey rounds were completed between April and June 2023. In Round 1, participants indicated their level of agreement on a 9-point Likert scale on whether 41 signs or symptoms identified in a systematic review should be routinely monitored. Participants considered signs and symptoms that reduce quality of life or cause significant harm, are observable or measurable by nurses or care workers, and can be assessed at a single time point. Round 1 statements were included in a list for prioritization in Round 3 if ≥ 70% of participants responded ≥7 on the Likert scale. Statements were excluded if ≤ 30% of participants responded ≥7. In Round 2, participants indicated their level of agreement with statements that did not reach initial consensus, plus amended statements based on Round 1 participant feedback. Round 2 statements were included in Round 3 if ≥ 50% of the participants responded ≥7 on the Likert scale. In Round 3, participants prioritized the signs and symptoms.

RESULTS

Forty-four participants (93.6%) completed all 3 rounds. Four of 41 signs and symptoms reached consensus for inclusion after Round 1, and 9 after Round 2. The top 10 signs and symptoms prioritized in Round 3 were recent falls, daytime drowsiness or sleepiness, abnormal movements (eg, shaking or stiffness), confusion or disorientation, balance problems, dizziness, postural hypotension, reduced self-care, restlessness, and dry mouth.

CONCLUSIONS AND IMPLICATIONS

The top 10 signs and symptoms provide a basis for proactive monitoring for psychotropic ADEs.

Influence of Lifestyle Factors on Metabolic Syndrome in Psychiatric Patients Attending a Community Mental Health Setting: A Cross-sectional Study

Background

Metabolic syndrome (MetS) is a concern in psychiatric patients. We aimed to study the influence of the modifiable lifestyle factors on MetS in adult psychiatric patients along with associated clinical factors and quality of life.

Methods

Factors such as diet (Healthy Eating Index), exercise, substance use, cardiovascular risk (QRISK), illness severity (Clinical Global Impression), medications, adverse events (Systematic Monitoring of Adverse Events Related to Treatments), and quality of life (Recovering Quality of Life Scale) were assessed along with clinical components for MetS in 323 psychiatric patients receiving routine care and monitoring in a Community Mental Health Team.

Results

MetS was present in 50.5% (95% CI: 45.0-55.9). It was significantly associated with higher age, duration of mental illness, body mass index (BMI), QTc, QRISK, and antipsychotic drugs. In logistic regression, age, QTc, QRISK, and BMI remained significantly linked to MetS. Patients with or without MetS were comparable in their lifestyle factors such as diet, exercise, and substance use, along with the family history of metabolic disorders, age at onset of mental illness, duration of antipsychotic medication, side effects, psychiatric diagnoses, and quality of life. However, many patients with or without MetS had poorer diet and physical inactivity, indicating scope for interventions.

Conclusions

Around half of the psychiatric patients had MetS, and modifiable lifestyle factors did not differentiate individuals with or without MetS. The need for further research on the prevention and management of MetS in psychiatric patients is highlighted.

Pharmacogenomics-assisted schizophrenia management: A hybrid type 2 effectiveness-implementation study protocol to compare the clinical utility, cost-effectiveness, and barriers

OBJECTIVES

The response to antipsychotic therapy is highly variable. Pharmacogenomic (PGx) factors play a major role in deciding the effectiveness and safety of antipsychotic drugs. A hybrid type 2 effectiveness-implementation research will be conducted to evaluate the clinical utility (safety and efficacy), cost-effectiveness, and facilitators and barriers in implementing PGx-assisted management compared to standard of care in patients with schizophrenia attending a tertiary care hospital in eastern India.

METHODS

In part 1, a randomized controlled trial will be conducted. Adult patients with schizophrenia will be randomized (2: 1) to receive PGx-assisted treatment (drug and regimen selection depending on the results of single-nucleotide polymorphisms in genes DRD2, HTR1A, HTR2C, ABCB1, CYP2D6, CYP3A5, and CYP1A2) or the standard of care. Serum drug levels will be measured. The patients will be followed up for 12 weeks. The primary endpoint is the difference in the Udvalg for Kliniske Undersøgelser Side-Effect Rating Scale score between the two arms. In part 2, the cost-effectiveness of PGx-assisted treatment will be evaluated. In part 3, the facilitators and barriers to implementing PGx-assisted treatment for schizophrenia will be explored using a qualitative design.

EXPECTED OUTCOME

The study findings will help in understanding whether PGx-assisted management has a clinical utility, whether it is cost-effective, and what are the facilitators and barriers to implementing it in the management of schizophrenia.

TRIAL REGISTRATION

The study has been registered with the Clinical Trials Registry-India (CTRI/2023/08/056210).

Pharmacist-led medicines optimisation service in an inpatient mental health setting

Medicines optimisation ensures that people get the best possible outcomes from their medicines. As those with severe mental illness (SMI) are frequently prescribed psychotropic medicines with potentially significant side-effects, poor adherence to treatment and physical morbidity are common. This results in suboptimal symptom control, physical health problems and negative health outcomes. The specialist mental health pharmacist (SMHP) is best placed to provide leadership for medicines optimisation in the inpatient mental health setting. By adopting a patient-centred approach to providing information, improving adherence, screening, initiating and maintaining medicines, and supporting self-advocacy, the SMHP can ensure the patients' experience of taking medicines is optimised. As there is currently limited understanding of what a baseline clinical pharmacy service in a mental health setting looks like, we aim to outline a framework for pharmacist-led medicines optimisation for those with SMI. This framework is suitable to be scaled and adapted to other settings.

Scales for Antipsychotic-Associated Movement Disorders: Systematic Review, Critique, and Recommendations

BACKGROUND

Antipsychotic-associated movement disorders remain common and disabling. Their screening and assessment are challenging due to clinical heterogeneity and different use of nomenclature between psychiatrists and neurologists.

OBJECTIVE

An International Parkinson and Movement Disorder Society subcommittee aimed to rate psychometric quality of severity and screening instruments for antipsychotic-associated movement disorders.

METHODS

Following the methodology adopted by previous International Parkinson and Movement Disorders Society subcommittee papers, instruments for antipsychotic-associated movement disorders were reviewed, applying a classification as "recommended," "recommended with caveats," "suggested," or "listed."

RESULTS

Our review identified 23 instruments. The highest grade of recommendation reached is "recommended with caveats," assigned to seven severity rating instruments (Extrapyramidal Symptoms Rating Scale, Barnes Akathisia Rating Scale, Abnormal Involuntary Movements Scale, Drug-Induced Extra-Pyramidal Symptoms Scale, Maryland Psychiatric Research Centre involuntary movements scale, Simpson Angus Scale, and Matson Evaluation of Drug Side effects). Only three of these seven (Drug-Induced Extra-Pyramidal Symptoms Scale, Maryland Psychiatric Research Centre, Matson Evaluation of Drug Side effects) were also screening instruments. Their main caveats are insufficient demonstration of psychometric properties (internal consistency, skewing, responsiveness to change) and long duration of administration. Eight "suggested" instruments did not meet requirements for the "recommended" grade also because of insufficient psychometric validation. Other limitations shared by several instruments are lack of comprehensiveness in assessing the spectrum of antipsychotic-associated movement disorders and ambiguous nomenclature.

CONCLUSIONS

The high number of instruments "recommended with caveats" does not support the need for developing new instruments for antipsychotic-associated movement disorders. However, addressing the caveats with new psychometric studies and revising existing instruments to improve the clarity of their nomenclature are recommended next steps. © 2023 International Parkinson and Movement Disorder Society.

Systematic Review of Psychotropic Adverse Drug Event Monitoring Tools for Use in Long-Term Care Facilities

OBJECTIVES

To evaluate properties of psychotropic adverse drug event (ADE) monitoring tools intended for use in long-term care facilities.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Adults aged 18 years and older in nursing homes and other long-term care facilities.

METHODS

Medline, CINAHL, Embase, and PsycInfo were searched from inception to August 2022 for studies reporting the development, validation, or application of tools to monitor psychotropic ADEs. Screening, data extraction, and quality assessment were performed independently by 2 authors. Each tool was assessed under the domains of test-retest reliability, interrater reliability, content validity, and construct validity.

RESULTS

Eight studies that described 6 tools were included. Tools were developed in Wales (n = 2), United States (n = 1), Ireland (n = 1), Canada (n = 1), and Singapore (n = 1). Tools monitored 4 to 95 items related to antipsychotics (n = 6 tools), antidepressants (n = 4), benzodiazepines or hypnotics (n = 4), antiepileptics (n = 4), and dementia medications (n = 1). Tools commonly monitored sedation, tiredness, or sleepiness (n = 6); falls (n = 4); and tremor or extrapyramidal symptoms (n = 4). Tools were designed for application by nurses (n = 4), during family conferences (n = 1), and by general medical practitioners before repeat prescribing (n = 1). Two tools were reported to require 10 to 60 minutes to administer. Four tools were determined to have adequate content validity and 2 tools adequate interrater reliability. No tools reported test-retest reliability or construct validity.

CONCLUSIONS AND IMPLICATIONS

Six published psychotropic ADE monitoring tools are heterogeneous in design and intended application. Existing tools are predominately designed for application by nurses with or without direct involvement of the wider multidisciplinary team. Further research is needed into models of care that facilitate psychotropic ADE monitoring in the long-term care facility setting, and the extent to which application of specific tools is associated with reduced medication-related harm.

A Brief Psychoeducation Intervention to Prevent Rehospitalization in Severe Mental Disorder Inpatients

ABSTRACT

The efficacy of medium- to long-term psychoeducation in preventing relapse and hospitalization in people with severe mental disorders (SMDs) is robust. However, the evidence is inconclusive in brief interventions and individual modalities. The aim of this randomized clinical trial in SMD inpatients is to analyze the efficacy of a brief psychoeducation intervention added to treatment-as-usual, in improving the rehospitalization rate at 3 and 6 months after discharge. Fifty-one SMD inpatients were randomized to the intervention ( n = 24) or control group ( n = 27). Low insight and poor medication adherence were the most prevalent risk factors at admission. No significant differences were observed in the rehospitalization rate at 3 and 6 months after discharge. On the overall sample, the number of previous hospitalizations was a rehospitalization predictor at 3 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.01-1.56; p = 0.04) and 6 months (OR, 1.85; 95% CI, 1.17-2.91; p = 0.009). SMD people require multimodal and persistent approaches focused on insight and medication adherence to prevent rehospitalizations.

Cross talk mechanism of disturbed sleep patterns in neurological and psychological disorders

The incidence and prevalence of sleep disorders continue to increase in the elderly populace, particularly those suffering from neurodegenerative and neuropsychiatric disorders. This not only affects the quality of life but also accelerates the progression of the disease. There are many reasons behind sleep disturbances in such patients, for instance, medication use, nocturia, obesity, environmental factors, nocturnal motor disturbances and depressive symptoms. This review focuses on the mechanism and effects of sleep dysfunction in neurodegenerative and neuropsychiatric disorders. Wherein we discuss disturbed circadian rhythm, signaling cascade and regulation of genes during sleep deprivation. Moreover, we explain the perturbation in brainwaves during disturbed sleep and the ocular perspective of neurodegenerative and neuropsychiatric manifestations in sleep disorders. Further, as the pharmacological approach is often futile and carries side effects, therefore, the non-pharmacological approach opens newer possibilities to treat these disorders and widens the landscape of treatment options for patients.

Validation of the Glasgow Antipsychotic Side-Effect Scale (GASS) in an Italian Sample of Patients with Stable Schizophrenia and Bipolar Spectrum Disorders

Antipsychotics are a class of psychotropic drugs that improve psychotic symptoms and reduce relapse risk. However, they may cause side effects (SE) that impact patients’ quality of life and psychosocial functioning. Therefore, there is a need for practical tools to identify them and possibly intervene. The objective of the present study was to translate into Italian the Glasgow Antipsychotic Side Effect Scale (GASS), which is suggested as the questionnaire of choice to collect SE reported by patients treated with antipsychotics. We administered the GASS and the Udvalg for Kliniske Undersøgelser (UKU) SE scale—which is considered the gold standard—to 100 stable patients with schizophrenia and bipolar spectrum disorders. We measured the structural validity, internal consistency, concurrent criterion validity, construct validity, and clinical feasibility. GASS was characterized by modest structural validity and good internal consistency. The binary correlations concerning the presence of specific symptoms investigated with the GASS and the UKU were strong or relatively strong for only half of them. The GASS total scale score was inversely related to patients’ quality of life and psychosocial functioning. The GASS is useful to briefly assess the burden of antipsychotic SE (~5 min) but is not optimal in identifying them.

Development of a Trigger Tool to Identify Adverse Events and Harm in a Neuropsychiatry Setting

BACKGROUND OBJECTIVES

Adverse drug events (ADEs) present the greatest risk of harm to patients in hospitals, especially those receiving neuropsychiatric treatment. The objective of the present record-based study was to test the appropriateness of the neuropsychiatry trigger tool (NPTT) to identify and measure harm due to adverse events (AEs).

METHODS

A total of 1324 clinical case notes of discharged patients from 2017 to 2018 with a hospital stay >24 hours to <70 days were examined.

RESULTS

One hundred forty-four (10.88%) patients experienced 166 AEs. A total of 854 triggers (range, 1-12 triggers per patient) were identified in 296 (22.36%) and 39 (2.94%) patients presented with triggers at admission. The overall AE rate per 1000 patient days was 12.73 (intensive care unit, 21; inpatient department, 11.54). Triggers at admission were altered sensorium and abnormal behavior followed by headache, ataxia, and aspiration pneumonia. A small number of triggers accounted for most AEs (laxative, rising liver function test (LFT), hypokalemia, hyponatremia, health care-associated infections, intubation, abnormal behavior/sensorium, hepatic encephalopathy, antiemetics), although type of AE reported differed by level of care. Most AEs caused minor harm, and relatively fewer patients experienced temporary harm requiring intervention (110; 8.29%), permanent harm (45; 3.39%), harm requiring initial/prolonged hospitalization (10; 0.75%), interventions to sustain life (24; 1.81%), and death (109; 8%). The higher the number of AEs, the longer was the length of stay (average increased from 9.32 to 17.33 days). The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Medication-related ADEs were found in 130 (90%) of 144 patients who experienced AEs. Antitubercular drugs caused most ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation). Care is needed in attributing harm because some triggers (abnormal sensorium/behavior, intubation, headache/dizziness, laxatives) may overlap with neurological illnesses (cerebrovascular accident [CVA]/meningitis/stroke). If the triggers are identified early, harm/discomfort to the patients can be reduced. The NPTT can be used in patient safety improvement projects. Harm occurred in 296 (22.28%) patients (temporary, 120 [9%]; permanent, 178 [13%]). Adverse events prolonged hospital stay (14.29 days) compared with 9.32 days in patients without AEs.

CONCLUSIONS

A higher number of triggers per patient (≥5), trigger nature (intubation, cardiac arrest/shock), or the presenting illness (CVA/neuroinfections/status epilepticus/prolonged seizures) were correlated with the highest harm, that is, death. Because some triggers (abnormal sensorium/behavior, headache/dizziness, laxatives, intubation) may overlap with neurological illness (CVA/meningitis/stroke), care is needed in attributing harm. The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Antitubercular drugs caused ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation) and, if identified early, can reduce harm/discomfort to the patients.

Patient-Reported Questionnaires to Identify Adverse Drug Reactions: A Systematic Review

Background: This systematic review aims to summarise available patient-reported questionnaires to detect adverse drug reactions (ADRs) that can be utilised by healthcare professionals in clinical practice and to summarise the psychometric properties (validity, reliability, and responsiveness) of the questionnaires. Methods: A systematic literature search was conducted using Medline, Pubmed, Embase, and Emcare databases to screen for articles published between January 2000 and July 2020. Data items regarding validity, reliability, and responsiveness were extracted independently by two authors. The methodological quality was assessed using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Results: A total of 1563 unique article titles were identified after removing duplicates. Following shortlisting of relevant articles, 19 patient-reported ADR questionnaires were identified. Questionnaires most commonly focused on mental health medications (42.1%, n = 8), followed by general questionnaires applicable to any medication (21.1%, n = 4). Many questionnaires did not report assessing the validity and reliability of the measurement tool. For example, only 11 questionnaires (58%) mentioned assessing content validity, in addition to criterion or construct testing. Conclusion: This systematic review summarised the available patient-reported questionnaires that can be used in research and clinical practice to identify ADRs. Results of this systematic review highlight the need for more robust validity and reliability testing when developing patient-reported ADR questionnaires.

Psychological intervention, antipsychotic medication or a combined treatment for adolescents with a first episode of psychosis: the MAPS feasibility three-arm RCT

BACKGROUND

When psychosis emerges in young people there is a risk of poorer outcomes, and access to evidence-based treatments is paramount. The current evidence base is limited. Antipsychotic medications show only a small benefit over placebo, but young people experience more side effects than adults. There is sparse evidence for psychological intervention. Research is needed to determine the clinical effectiveness and cost-effectiveness of psychological intervention versus antipsychotic medication versus a combined treatment for adolescents with psychosis.

OBJECTIVES

The objective of Managing Adolescent first-episode Psychosis: a feasibility Study (MAPS) was to determine the feasibility of conducting a definitive trial to answer the question of clinical effectiveness and cost-effectiveness of these three treatment options.

DESIGN

This was a prospective, randomised, open-blinded, evaluation feasibility trial with a single blind. Participants were allocated 1 : 1 : 1 to receive antipsychotic medication, psychological intervention or a combination of both. A thematic qualitative study explored the acceptability and feasibility of the trial.

SETTING

Early intervention in psychosis services and child and adolescent mental health services in Manchester, Oxford, Lancashire, Sussex, Birmingham, Norfolk and Suffolk, and Northumberland, Tyne and Wear.

PARTICIPANTS

People aged 14-18 years experiencing a first episode of psychosis either with an International Classification of Diseases, Tenth Revision, schizophrenia spectrum diagnosis or meeting the entry criteria for early intervention in psychosis who had not received antipsychotic medication or psychological intervention within the last 3 months.

INTERVENTIONS

Psychological intervention involved up to 26 hours of cognitive-behavioural therapy and six family intervention sessions over 6 months, with up to four booster sessions. Antipsychotic medication was prescribed by the participant's psychiatrist in line with usual practice. Combined treatment was a combination of psychological intervention and antipsychotic medication.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (recruitment, treatment adherence and retention). We used a three-stage progression criterion to determine feasibility. Secondary outcomes were psychosis symptoms, recovery, anxiety and depression, social and educational/occupational functioning, drug and alcohol use, health economics, adverse/metabolic side effects and adverse/serious adverse events.

RESULTS

We recruited 61 out of 90 (67.8%; amber zone) potential participants (psychological intervention, n = 18; antipsychotic medication, n = 22; combined treatment, n = 21). Retention to follow-up was 51 out of 61 participants (83.6%; green zone). In the psychological intervention arm and the combined treatment arm, 32 out of 39 (82.1%) participants received six or more sessions of cognitive-behavioural therapy (green zone). In the combined treatment arm and the antipsychotic medication arm, 28 out of 43 (65.1%) participants received antipsychotic medication for 6 consecutive weeks (amber zone). There were no serious adverse events related to the trial and one related adverse event. Overall, the number of completed secondary outcome measures, including health economics, was small.

LIMITATIONS

Medication adherence was determined by clinician report, which can be biased. The response to secondary outcomes was low, including health economics. The small sample size obtained means that the study lacked statistical power and there will be considerable uncertainty regarding estimates of treatment effects.

CONCLUSIONS

It is feasible to conduct a trial comparing psychological intervention with antipsychotic medication and a combination treatment in young people with psychosis with some adaptations to the design, including adaptations to collection of health economic data to determine cost-effectiveness.

FUTURE WORK

An adequately powered definitive trial is required to provide robust evidence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80567433.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 4. See the NIHR Journals Library website for further project information.

Clinical validation of the self-reported Glasgow Antipsychotic Side-effect Scale using the clinician-rated UKU side-effect scale as gold standard reference

BACKGROUND

Antipsychotics are key for the treatment of psychotic and several non-psychotic disorders. Unfortunately, antipsychotic medications are associated with side effects, which may reduce quality of life and treatment adherence. Therefore, regular screening of antipsychotic side effects is essential. The Glasgow Antipsychotic Side-effect Scale is a patient self-report scale developed for this purpose. However, the Glasgow Antipsychotic Side-effect Scale has only been validated against another self-report side effect measure, which is suboptimal.

OBJECTIVE

We aimed to validate the Glasgow Antipsychotic Side-effect Scale using the clinician-rated Udvalg for Kliniske Undersøgelser side-effect rating scale as the gold standard reference.

RESULTS

81 antipsychotic-treated outpatients with schizophrenia-spectrum disorders (age = 42±13 years; males = 43%, schizophrenia = 77%, illness duration: median = 11 years) completed the Glasgow Antipsychotic Side-effect Scale and were subsequently scored on the Udvalg for Kliniske Undersøgelser by trained raters. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for paired Glasgow Antipsychotic Side-effect Scale and Udvalg for Kliniske Undersøgelser items. Sensitivity of Glasgow Antipsychotic Side-effect Scale items ranged from 33-96%, with 19 (86%) having >75% sensitivity. Lowest sensitivity emerged for "nocturnal enuresis" (33%), "galactorrhea" (50%) and "hyperkinesia" 14-99%, with 14 items (64%) having >75% specificity, being lowest for "asthenia" (14%), "polyuria/polydipsia" (35%), "sedation" (41%), "akathisia" (53%), "dystonia" (65%), "hyperkinesia" (68%), "hypokinesia" (70%) and "accommodation" (70%). Positive predictive value ranged from 7-85%, with six items (27%) having a positive predictive value >75%. Negative predictive value ranged from 40-98%, with 21 items (95%) having a negative predictive value >75%. The mean time to complete the Glasgow Antipsychotic Side-effect Scale was 4±2 minutes.

CONCLUSION

The Glasgow Antipsychotic Side-effect Scale demonstrated satisfactory validity as a self-rated tool for antipsychotic side effects and may aid measurement-based care and decision-making.

Rapid improvement of obsessive-compulsive disorder associated with schizophrenia with cariprazine add-on in a subject under paliperidone long-acting injection: a case report

Obsessive-compulsive disorder is often associated with schizophrenia and may represent a significant challenge in the treatment as this comorbidity may not respond properly to antipsychotic medication and usually require a pharmacological and psychotherapeutic add-on. In the present case report, we present the case of a 26-year-old male blue-collar subject who developed obsessive-compulsive disorder after a year of complete remission of schizophrenia symptoms under paliperidone long-acting injection that rapidly resolved after low-dosage cariprazine add-on. No adverse effects were reported due to cariprazine- paliperidone long-acting injection combination.

Check the effects: systematic assessment of antipsychotic side-effects in an inpatient cohort

BACKGROUND

Antipsychotics are associated with a range of side-effects that can influence patients' subjective well-being negatively resulting in poor adherence. In order to limit the negative consequences of side-effects, they should be regularly systematically assessed. The aim of this study was to systematically assess antipsychotic side-effects in an inpatient cohort using validated rating scales.

METHODS

Eligible individuals prescribed an antipsychotic for at least 2 weeks were invited to have their side-effects assessed systematically.

RESULTS

A total of 208 individuals were assessed systematically for antipsychotic side-effects; 71.5% (n = 138) stated that they had not reported side-effects to their clinician prior to the assessment. The most commonly reported side-effects were daytime drowsiness (75%), dry mouth (58.2%) and weight gain (50.0%), while the most distressing side-effects reported were erectile dysfunction (35.0%), sexual dysfunction (26.3%) and amenorrhoea (26.3%). There was no evidence of an association between side-effect severity/number of side-effects reported/distress caused by those taking high dose/combination antipsychotics versus standard dose monotherapy.

CONCLUSION

Side-effects must be regularly and systematically assessed using a validated rating scale. As distress caused by side-effects plays a major role in non-adherence, assessment should examine distress and data on distressing side-effects should be available to those choosing an antipsychotic. Given the lack of correlation between high dose/combination antipsychotics and side-effects, treatment should be tailored to the individual based on response/tolerance and dose reduction/avoidance of polypharmacy should not be recommended to minimise side-effects.

Drug-Induced Extrapyramidal Symptoms Scale of the Norwegian version: inter-rater and test-retest reliability

Background: The Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) is a multidimensional rating scale designed for the fast, easy and reliable assessment of extrapyramidal symptoms (EPSs) induced by antipsychotics. Aim: The aim of this study was to validate the level of inter-rater and test-retest reliability of the Norwegian translation of this scale. Methods: A total of 125 video clips showing a variety of or no signs of EPSs were used in the present study. The participants recorded were Japanese psychiatric patients receiving first- and/or second-generation antipsychotics. A total of 103 patients (47 males and 56 females), diagnosed with schizophrenia (n = 68) or mood disorders (n = 35) appeared in the video clips. Their mean age was 48.7 ± 16.3 years (range 18-80) at the time of video recording. Inter-rater agreement was assessed with five raters and test-retest reliability with three. Results: Inter-rater reliability analyses showed interclass correlation coefficients (ICCs) ranging from 0.74 to 0.93 for each individual item. Test-retest reliability analysed independently for each rater ranged from 0.71 to 0.96. Conclusions: Inter-rater and test-retest agreement exhibited satisfactory ICC levels above 0.70. The Norwegian version of the DIEPSS is a reliable instrument for the assessment of drug-induced EPSs.

Clozapine: why wait to start a laxative?

Clozapine, the antipsychotic of choice for treatment-resistant schizophrenia, has a number of side-effects, some of which are potentially life-threatening. Historically viewed as a relatively minor side-effect, there is increasing awareness of the potentially severe sequalae of constipation secondary to clozapine-induced gastrointestinal hypomotility (CIGH). These include ileus, intestinal obstruction, bowel ischaemia, gastrointestinal necrosis, toxic megacolon and death. CIGH is significantly more common than clozapine-induced blood dyscrasias and has a higher mortality rate. Although strict criteria must be followed to assertively monitor, detect and treat blood dyscrasias in patients taking clozapine, no such framework exists for CIGH. We recommend that prescribing guidelines, regulatory agencies and information from manufacturers should more clearly highlight the risks identified in the literature. Furthermore, we recommend that, in people taking clozapine, constipation should be prevented by prophylactic treatment with laxatives rather than treated only when clinically identified.

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Retrospective Accounts of the Process of Using and Discontinuing Psychiatric Medication

Refusal to take psychiatric medication as prescribed is often considered negative, harmful, and even reflective of a sign of one's illness. However, recent research from diverse sources has challenged this axiom. The current study investigated the reasons, processes, experiences, and perceived impacts of medication discontinuation. The study was carried out using the narrative approach to life stories method. Participants were 12 women and 9 men who had discontinued their prescribed medication following psychiatric hospitalization. Four main themes were revealed in the data analysis: (a) the experience with medication, (b) the process of discontinuing medication, (c) elements that helped achieve successful medication discontinuation, and (d) the perceived impact of medication discontinuation. Our findings challenge the widespread notion that discontinuing psychiatric medication is necessarily negative and suggest that, for some, it is a legitimate and meaningful life choice.

A Review of Methods for Monitoring Adverse Events in Pediatric Psychopharmacology Clinical Trials

Pediatric psychotropic prescription rates are rising, emphasizing the need for careful monitoring of drug safety in this population. Currently, no standardized assessments are used in clinical trials for adverse event (AE) elicitation focused on long-term drug treatment in pediatric patients. Despite a lack of standardized AE elicitation methods in psychiatric clinical trials, it is clear that psychiatric medications have developmentally dependent AEs that differ from those observed in adults. In this review, we discuss the use of general inquiry elicitation, drug-specific checklists, and systematic elicitation scales for AE reporting in pediatric psychopharmacology trials. The checklists evaluated include the Barkley Side Effect Rating Scales (SERS), the Pittsburg side effect rating scale, and the Systematic Monitoring of Adverse events Related to TreatmentS (SMARTS) checklist. The systematic assessment scales discussed include the Systematic Assessment for Treatment of Emergent Events (SAFTEE) and the Safety Monitoring Uniform Report Form (SMURF). We review the advantages and disadvantages of each method and discuss the need for optimal assessment of AEs. AE instruments that are created and utilized for pediatric psychiatric trials must begin to incorporate symptoms that are relevant to this population and account for the nature of the disorders to better characterize treatment-emergent AEs and monitor long-term safety.

What side effects are problematic for patients prescribed antipsychotic medication? The Maudsley Side Effects (MSE) measure for antipsychotic medication

BACKGROUND

Capturing service users' perspectives can highlight additional and different concerns to those of clinicians, but there are no up to date, self-report psychometrically sound measures of side effects of antipsychotic medications. Aim To develop a psychometrically sound measure to identify antipsychotic side effects important to service users, the Maudsley Side Effects (MSE) measure.

METHOD

An initial item bank was subjected to a Delphi exercise (n = 9) with psychiatrists and pharmacists, followed by service user focus groups and expert panels (n = 15) to determine item relevance and language. Feasibility and comprehensive psychometric properties were established in two samples (N43 and N50). We investigated whether we could predict the three most important side effects for individuals from their frequency, severity and life impact.

RESULTS

MSE is a 53-item measure with good reliability and validity. Poorer mental and physical health, but not psychotic symptoms, was related to side-effect burden. Seventy-nine percent of items were chosen as one of the three most important effects. Severity, impact and distress only predicted 'putting on weight' which was more distressing, more severe and had more life impact in those for whom it was most important.

CONCLUSIONS

MSE is a self-report questionnaire that identifies reliably the side-effect burden as experienced by patients. Identifying key side effects important to patients can act as a starting point for joint decision making on the type and the dose of medication.

Drug-induced Extrapyramidal Symptoms Scale (DIEPSS) Serbian Language version: Inter-rater and Test-retest Reliability

Drug-induced Extrapyramidal Symptoms Scale (DIEPSS) is developed in the era of second-generation antipsychotics and is suitable for evaluation of the low incidence of extrapyramidal symptoms occurring in the treatment of atypical antipsychotics, as well as the relationship between personal and social functioning. The study was carried out at the Institute of Mental Health in Serbia in 2015 Study used the 127 DIEPSS video clips material, recorded from 1987 till 2015. Four raters performed the assessment simultaneously, individually rating one assigned item immediately after seeing the video clip. For the purpose of evaluating test-retest reliability the second assessment of the same material was performed nine months after the first assessment. Inter-rater reliability was high for each individual item, with ICCs ranging from 0.769 to 0.949. The inter-rater reliability was highest for akathisia item and lowest for dyskinesia. The test-retest reliability was high for each individual item, with ICC ranging from 0.713 to 0.935. The test-retest reliability was highest for bradykinesia item and lowest for dystonia. The Serbian version of DIEPSS has high level of inter-rater and test-retest reliability. High values of concordance rates (ICC > 0.7) for each evaluated individual item suggest that items of DIEPSS are well defined.

[What can we expect from clinical trials in psychiatry?]

Clinical trials in psychiatry allow to build the regulatory dossiers for market authorization but also to document the mechanism of action of new drugs, to build pharmacodynamics models, evaluate the treatment effects, propose prognosis, efficacy or tolerability biomarkers and altogether to assess the impact of drugs for patient, caregiver and society. However, clinical trials have shown some limitations. Number of recent dossiers failed to convince the regulators. The clinical and biological heterogeneity of psychiatric disorders, the pharmacokinetic and pharmacodynamics properties of the compounds, the lack of translatable biomarkers possibly explain these difficulties. Several breakthrough options are now available: quantitative system pharmacology analysis of drug effects variability, pharmacometry and pharmacoepidemiology, Big Data analysis, brain modelling. In addition to more classical approaches, these opportunities lead to a paradigm change for clinical trials in psychiatry.

Antipsychotic medication side effect assessment tools: A systematic review

OBJECTIVE

The aim of this systematic review was to critically appraise the psychometric properties of antipsychotic medication side effect assessment tools.

METHODS

Systematic searches were undertaken in PubMed, CINAHL and CENTRAL from inception to October 2014. Studies were included if they detailed the evaluation of psychometric properties of antipsychotic medication side effect assessment tools in mental health populations. Studies were excluded if they examined the use of antipsychotic medication side effect assessment tools in non-mental health populations, including people suffering from dementia, Parkinsonism and Alzheimer's. Narrative reviews and studies published in any language other than English were also excluded.

RESULTS

Content validity was appropriately established for only one of the tools, reliability was inappropriately evaluated for all but one tool, and the assessment of responsiveness was not acceptable for any tool.

CONCLUSION

Further psychometric studies are warranted to consolidate the psychometric properties of the included antipsychotic medication side effect assessment tools before any of these tools can be confidently recommended for either research or clinical purposes.

Glasgow Antipsychotic Side-effects Scale for Clozapine - Development and validation of a clozapine-specific side-effects scale

OBJECTIVE

The authors developed and validated a clozapine-specific side-effects scale capable of eliciting the subjectively unpleasant side-effects of clozapine.

METHODS

Questions from the original Glasgow Antipsychotic Side-effects Scale (GASS) were compared to a list of the most commonly reported clozapine side-effects and those with a significant subjective burden were included in the GASS for Clozapine (GASS-C). The original authors of the GASS and a group of mental health professionals from the UK and Ireland were enlisted to comment on the questions in the GASS-C based on their clinical experience. 110 clozapine outpatients from two sites completed the GASS-C, the original GASS and a repeat GASS-C. Statistical analyses were performed using SPSS for Windows version 19.

RESULTS

The GASS-C was shown to have construct validity, in that Spearman's correlation coefficient was 0.816 (p<0.001) with the original GASS, whilst Cohen's kappa coefficient was >0.77 (p<0.001) for one question and >0.81 (p<0.001) for remaining relevant questions. GASS-C was also shown to have strong test-retest reliability, in that Cronbach's alpha coefficient was >0.907 (p<0.001), whilst Cohen's kappa coefficient was >0.81 (p<0.001) for 12 questions and >0.61 (p<0.001) for the remaining four questions.

CONCLUSION

The GASS-C is a valid and reliable clinical tool to enable a systematic assessment of the subjectively unpleasant side-effects of clozapine. Future research should focus on how the scale can be utilised as a clinical tool to improve real-world outcomes such as adherence to clozapine therapy and quality of life.

Rating scales to measure side effects of antipsychotic medication: A systematic review

INTRODUCTION

Many patients experience side effects during treatment with antipsychotics. This article reviews the clinical use and psychometric characteristics of rating scales used to assess side effects in patients treated with antipsychotics.

METHODS

A systematic literature search was performed using the electronic databases PubMed and Embase, with predefined search terms.

RESULTS

In total, 52 different scales were used in the 440 articles retrieved. For multiple side effects measured with one scale, the Udvalg for Kliniske Undersøgelser Side Effects Rating Scale for Clinicians was used the most, whereas the Liverpool University Neuroleptic Side Effect Rating Scale had the best psychometric characteristics (Cronbach's α 0.81 and test-retest reliability 0.89). The Simpson Angus Scale was used the most to rate extrapyramidal side effects, although the Maryland Psychiatric Research Center scale had the best characteristics (Cronbach's α 0.80, test-retest reliability 0.92 and inter-rater reliability 0.81-0.90). The Arizona Sexual Experience Scale was used the most to assess sexual dysfunction, but the Antipsychotics and Sexual Functioning Questionnaire and the Nagoya Sexual Functioning Questionnaire had the best characteristics.

CONCLUSION

This review will help researchers and clinicians make a purpose-oriented choice of which scale to use.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42014013010.

Construction and validation of the My Medicines and Me Questionnaire for assessment of the self-reported side effects of psychotropic medication

We aimed to construct and assess the psychometric properties of the My Medicines and Me Questionnaire (M3Q), a self-report side-effect questionnaire for mental health patients. Thirty individuals taking a psychotropic medication completed the M3Q side-effect checklist along with the Liverpool University Neuroleptic Side Effect Rating Scale. Thirty healthy comparison individuals also completed the M3Q checklist. Data were analyzed using factorial analysis. Psychometric evaluations including validity and reliability testing were carried out on the questionnaire's checklist. The original 54-item checklist of the M3Q was shortened to include only those items found to be significant in the factorial analysis. The revised 32-item checklist of the M3Q was found to be valid and reliable. The M3Q is a simple, valid and reliable questionnaire that can be used routinely in clinical practice for detecting bothersome side effects of a range of psychotropic medications. This will provide a platform for improved communication between the clinician and the patient.

Australian case managers' perceptions of mental health consumers use of antipsychotic medications and associated side-effects

The present study explores Australian case managers' perceptions of mental health consumers' use of antipsychotic medications and the side-effects resulting from these medications. Semistructured interviews were used to elicit material from nine case managers in a community care setting in South-East Queensland, Australia. Content analysis was used to examine the transcripts, and the audio-recordings were replayed to identify important contextual cues. The analysis identified several main themes, including perceptions of the use of antipsychotic medications and associated side-effects, the provision of information about antipsychotic medication side-effects; the assessment of antipsychotic medication side-effects; and the promotion of effective management of antipsychotic medication side-effects. The participants believed that antipsychotic medication provided clear benefits to mental health consumers. Most participants believed that consumers adapted to side-effects and came to accept them. The case managers themselves often felt poorly informed about antipsychotic medication side-effects, leading them to request more succinct types of information. It was notable to find that there was a lack of systematic approach to the assessment of side-effects. This finding highlighted the need to incorporate the routine structured assessment of antipsychotic medication side-effects in providing care to mental health consumers in the community.

Measuring adherence to medication in schizophrenia: the relationship between attitudes toward drug therapy and plasma levels of new-generation antipsychotics

BACKGROUND

Nonadherence to medication is still a major problem in the treatment of schizophrenia. The current longitudinal study investigated whether the patients' attitudes toward treatment correlated with the ratio of observed vs expected plasma levels of antipsychotic drugs as an objective measurement of adherence.

METHODS

Data of patients starting monotherapy with a new-generation antipsychotic were collected 2, 4, and 12 weeks after the initiation of treatment. Next to the assessment of patients' attitudes toward medication by means of the Drug Attitude Inventory, the ratio of the observed vs expected plasma level was calculated. Antipsychotic-induced side effects were evaluated by means of the Udvalg for Kliniske Undersogelser Side Effect Rating Scale.

RESULTS

A total of 93 patients were eligible for statistical analysis. About one-half of the ratios of observed vs expected plasma levels ranged from 0.5 to 2 and were considered normal, whereas the other ratios were considered either too low (<0.5) or too high (>2). No consistent correlation between patients' attitude toward drug therapy and the individual ratios of observed vs expected plasma levels of medication was detected. This finding was not affected by side effects.

CONCLUSIONS

Our results highlight the importance of recognizing the complex nature of adherence to medication in schizophrenia patients. Importantly, we found no consistent correlation between subjective and objective measures of medication adherence. Therefore, monitoring adherence to medication remains a challenge in clinical practice.

The concomitant use of second-generation antipsychotics and long-term antiretroviral therapy may be associated with increased cardiovascular risk

To study the effect of concurrent use of second-generation antipsychotics (SGAs) on metabolic syndrome (MetS) components conferring increased cardiovascular risk in a sample of human immunodeficiency virus (HIV)-infected adults taking antiretroviral therapy (ART). A retrospective study of participants consecutively recruited at the UCSD HIV Neurobehavioral Research Program examined effects of combined ART and SGAs on body mass index (BMI), nonfasting serum lipids, diabetes mellitus (DM) incidence, and mean arterial pressure (MAP). Metabolic outcome variables and covariates were compared using t-tests, Chi-squared or Fisher's exact tests. Linear and logistic multivariable models explored metabolic outcomes for participants taking (SGA+) or not taking (SGA-) concomitant SGAs, after controlling for demographic and HIV disease- and ART-related covariates. Of 2229 HIV-infected participants, 12% (N=258) were treated with SGAs. In multivariable models adjusted for relevant covariates, the SGA+ group had significantly higher mean triglycerides, significantly higher odds of DM, significantly higher MAPs and marginally higher BMI. The use of SGAs in HIV-infected adults taking ART was independently associated with worse indicators of MetS and cardiovascular risk. Aggressive monitoring for the metabolic complications from concurrent SGA and ART is indicated in all patients receiving these medication combinations.

Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies

Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness's association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.