Off-label prescription of quetiapine in psychiatric disorders

Acute Quetiapine Intoxication: Relationship Between Ingested Dose, Serum Concentration and Clinical Presentation-Structured Literature Review and Analysis

Over the past decade, quetiapine has become one of the most commonly used psychotropic drugs in acute intoxication events worldwide. A structured literature review and analysis were conducted to assess the relationship between the kinetic and dynamic profiles in acute quetiapine intoxication. The correlation between dose and peak serum concentration (cmax) was determined using Pearson's correlation coefficient. Binary logistic regression was used to evaluate dose and cmax as predictors of the most common clinical events, signs and symptoms. One hundred and thirty-four cases of acute quetiapine ingestion were included in the analysis, with a median ingested dose of 10 g and a median cmax of 4 mg/L. The typical half-life was estimated to be 16.5 h, significantly longer than at therapeutic doses. For the immediate-release formulation, a biphasic disposition could not be excluded. Dose and cmax demonstrated a weak but significant correlation (r = 0.256; N = 63; p = 0.043). Central nervous system depression and tachycardia were the most common clinical signs. Higher doses and concentrations increased the risk of severe intoxication and were good predictors of intubation, tachycardia, hypotension, QTc prolongation and seizures, but not QRS prolongation, arrhythmia, heart block, hypokalaemia or acidosis. The thresholds for dose and cmax that increased the risk for individual signs and symptoms varied widely. However, doses > 3 g or cmax > 2 mg/L can be considered as alert levels that represent a high risk for severe clinical course of acute quetiapine intoxication.

Research encouraging off-label use of quetiapine: A systematic meta-epidemiological analysis

BACKGROUND

Researchers often conduct small studies on testing a drug's efficacy in off-label indications. If positive results from these exploratory studies are not followed up by larger, randomized, double-blinded trials, physicians cannot be sure of a drug's clinical value. This may lead to off-label prescriptions of ineffective treatments. We aim to describe the way clinical studies fostered off-label prescription of the antipsychotic drug quetiapine (Seroquel).

METHODS

In this systematic meta-epidemiological analysis, we searched EMBASE, MEDLINE, Cochrane CENTRAL and PsycINFO databases and included clinical studies testing quetiapine for unapproved indications between May 1995 and May 2022. We then assessed the frequency with which publications providing low-level evidence suggesting efficacy of quetiapine for off-label indications was not followed up by large, randomized and double-blinded trials within 5 years.

RESULTS

In total, 176 published studies were identified that reported potential efficacy of quetiapine in at least 26 indications. Between 2000 and 2007, publication of exploratory studies suggesting promise for off-label indications rapidly outpaced publication of confirmatory trials. In the 24 indications with a minimum of 5 years of follow-up from the first positive exploratory study, 19 (79%) were not followed up with large confirmatory trials within 5 years. At least nine clinical practice guidelines recommend the use of quetiapine for seven off-label indications in which published confirmatory evidence is lacking.

CONCLUSION

Many small, post-approval studies suggested the promise of quetiapine for numerous off-label indications. These findings generally went unconfirmed in large, blinded, randomized trials years after first being published. The imbalance of exploratory and confirmatory studies likely encourages ineffective off-label treatment.

Direct-To-Definitive Urine and Oral Fluid Test Results for Unscreened and Rarely Screened Drugs in Individuals Applying for Methadone Treatment in 7 U.S. States

The standard protocol in addiction treatment/pain management is to conduct immunoassay screens for major drugs subject to misuse, followed by confirmatory testing of positive results. However, this may miss unscreened or rarely screened drugs that could pose risks, especially to polydrug users. We sought to determine the prevalences of unscreened/rarely screened drugs in a sample of individuals misusing drugs in 7 U.S. states, and to compare the results of urine vs. oral testing for these drugs by direct-to-definitive liquid chromatography/tandem mass spectrometry (LC-MS-MS). The five drugs with the highest prevalences were: gabapentin (16.8%), quetiapine (6.2%), chlorpheniramine (5.3%), hydroxyzine (4.9%), and ephedrine (3.5%). All have clinical significance as indicated by severity of possible side effects, interactions with other drugs, and/or misuse potential. Drugs were generally detected more frequently in oral fluid than urine, but gabapentin was more frequently detected in urine. The prevalences of the included drugs seem high enough, and their clinical significance important enough, to warrant consideration of expanding clinical drug test panels, either by direct-to-definitive testing or the addition of selected immunoassay screens when available. Oral fluid was usually more suitable than urine as the test matrix, given the higher rates of detection in oral fluid for most substances included in this study.

A mechanistic overview of approaches for the treatment of psychostimulant dependence

Psychostimulant use disorder is a major health issue around the world with enormous individual, family-related and societal consequences, yet there are no effective pharmacological treatments available. In this review, a target-based overview of pharmacological treatments toward psychostimulant addiction will be presented. We will go through therapeutic approaches targeting different aspects of psychostimulant addiction with focus on three major areas; 1) drugs targeting signalling, and metabolism of the dopamine system, 2) drugs targeting either AMPA receptors or metabotropic glutamate receptors of the glutamate system and 3) drugs targeting the severe side-effects of quitting long-term psychostimulant use. For each of these major modes of intervention, findings from pre-clinical studies in rodents to clinical trials in humans will be listed, and future perspectives of the different treatment strategies as well as their potential side-effects will be discussed. Pharmaceuticals modulating the dopamine system, such as antipsychotics, DAT-inhibitors, and disulfiram, have shown some promising results. Cognitive enhancers have been found to increase aspects of behavioural control, and drugs targeting the glutamate system such as modulators of metabotropic glutamate receptors and AMPA receptors have provided interesting changes in relapse behaviour. Furthermore, CRF-antagonists directed toward alleviating the symptoms of the withdrawal stage have been examined with interesting resulting changes in behaviour. There are promising results investigating therapeutics for psychostimulant addiction, but further preclinical work and additional human studies with a more stratified patient selection are needed to prove sufficient evidence of efficacy and tolerability.

Abuse and misuse of second-generation antipsychotics: an analysis using VigiBaseTM , the World Health Organisation pharmacovigilance database

The study aim was to assess the abuse/misuse potential of second-generation antipsychotics (SGAPs) using VigiBase^TM data. We extracted individual case safety reports (ICSRs) of 'Drug abuse, dependence, and withdrawal' involving SGAPs up to June 2018. We assessed disproportionate reporting by calculating the Information Component (IC), considering the lower end of the 95% credibility interval for IC (IC₀₂₅ ), and the Proportional Reporting Ratio (PRR). We identified 1,683 ICSRs recorded as 'abuse, dependence, and withdrawal' involving SGAPs, mainly quetiapine (n=1,089) and olanzapine (n=209). The disproportional reporting indicators highlighted an association between 'Drug abuse and dependence', and quetiapine, olanzapine, and ziprasidone, as indicated by the IC₀₂₅ (2.263, 0.259, and 1.051, respectively) and PRR values (3.929, 1.020, and 1.334, respectively). The abuse/misuse potential is confirmed for quetiapine and olanzapine and highlighted for the first time for ziprasidone. Physicians should consider these risks when prescribing these antipsychotics, especially to patients with history of drug abuse.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quetiapine Misuse and Abuse: Is it an Atypical Paradigm of Drug Seeking Behavior?

Recent case reports in medical literatures suggest that more and more second-generation atypical antipsychotics (AAs) have been prescribed for off-label use; quetiapine (Brand name: Seroquel^®) showed increase in its trend for off-label use. Little is known about the reasons behind this trend, although historical sedative and hypnotic prescription patterns suggest that despite relatively superior safety profiles of quetiapine (especially for movement disorders), it may be used for treating substance abuse disorder. In addition, recent studies have shown a strong potential for misuse and abuse (MUA) of quetiapine beyond Food and Drug Administration-approved indications. This includes drug-seeking behaviors, such as feigning symptoms, motivated by quetiapine and use of quetiapine in conjunction with alcohol. Quetiapine appears to be the most documented AA with street values bartered illicitly on the street. A recent report from the Drug Abuse Warning Network has shown a high prevalence of quetiapine-related emergency department visits involving MUA. Several other case studies have found that quetiapine causes seeking behaviors observed in substance use disorder. In fact, the majority of quetiapine MUA involved patients diagnosed with substance use disorder. In the absence of a definitive mechanism of action of quetiapine's reinforcing properties, it is imperative to gather robust evidence to support or refute increasing off-label use of AAs.

[Abuse Liability of Quetiapine (Xeroquel®)]

OBJECTIVE

In recent years, there have been several reports in the literature concerning the misuse and abuse of quetiapine. The aim of this study was to review the data reported to the French Network of the Addictovigilance Centers as well as the published data.

METHODS

Epidemiological data from the studies of French network addictovigilance centers (spontaneous notifications, suspicious presciptions suggesting possible abuse [ ordonnances suspectes indicateur d'abus possibles, OSIAP], observatory of illegal psychotropic substances or delivered substances diverted from their medicinal use survey [observation des produits psychotropes illicites ou détournées de leur utilisation médicamenteuse, OPPIDUM], deaths related to medication and substance abuse survey [décès en relation avec l'abus de médicaments et de substances, DRAMES]) were analyzed between 2011 and 2014. All cases of abuse and dependence with quetiapine in PubMed were reviewed using the MeSH terms "quetiapine," "substances abuse," and "dependence", until October 2014.

RESULTS

The analysis of the literature has identified 21 cases of abuse related to quetiapine, mainly in men (85.7%), with a history of substance abuse (76%). The main route of administration was oral but other routes were also reported (intravenous, intranasal). The main reason for abuse was sedation and anxiolytic. Other characteristics of quetiapine abuse include amplification or even simulation of psychotic symptoms to obtain quetiapine, an increased dose and the existence of street names. The French addictovigilance network reported few cases of abuse with quetiapine.

DISCUSSION-CONCLUSION

The pharmacological mechanism of abuse of quetiapine is not fully understood. However, several arguments are in favor of the abuse liability of quetiapine. Despite the recent availability of quetiapine in France, there have been some isolated signals of abuse. Therefore, it seems important to inform prescribers on the risk of misuse of quetiapine and also of some other antipsychotics.

Quetiapine Ameliorates Schizophrenia-Like Behaviors and Protects Myelin Integrity in Cuprizone Intoxicated Mice: The Involvement of Notch Signaling Pathway

BACKGROUND

White matter disturbances and myelin impairment are key features of schizophrenia. The antipsychotic drug quetiapine can promote the maturation of oligodendrocytes, but the molecular mechanisms remain largely unknown.

METHODS

The schizophrenia-like behaviors, degrees of demyelination, and levels of Notch signaling molecules in forebrains of adult male C57BL/6 mice were examined after fed with cuprizone (0.2% wt/wt) in the presence or absence of 10mg/kg/d quetiapine for 6 weeks. These parameters were also observed after the transcranial injection of Notch signaling inhibitor MW167 (1mM) daily during the last week of the treatment period.

RESULTS

Quetiapine ameliorated the schizophrenia-like behaviors and decreased expression of myelin basic protein and inhibition of Notch signaling molecules, such as Notch1, Hes1, and Hes5, in the forebrain that induced by cuprizone. These beneficial effects of quetiapine were abolished by MW167.

CONCLUSIONS

The antipsychotic and myelin protective effects of quetiapine are mediated by Notch signaling in a mouse model of cuprizone-induced demyelination associated with schizophrenia-like behaviors. The Notch pathway might therefore be a novel target for the development of antipsychotic drugs.

Emergency Department Visits Involving Misuse and Abuse of the Antipsychotic Quetiapine: Results from the Drug Abuse Warning Network (DAWN)

Case reports in medical literature suggest that the atypical antipsychotic quetiapine, a medication not previously considered to have abuse potential, is now being subject to misuse and abuse (MUA; ie, taken when not prescribed for them or used in a way other than instructed by their health professional). Here we present systematic, nationally representative data from the 2005 to 2011 Drug Abuse Warning Network (DAWN) for prevalence of emergency department (ED) visits among the U.S. general population involving quetiapine and related to MUA, suicide attempts, and adverse reactions. Nationally, quetiapine-related ED visits increased 90% between 2005 and 2011, from 35,581 ED visits to 67,497. DAWN data indicate that when used without medical supervision for recreational/self-medication purposes, quetiapine poses health risks for its users, especially among polydrug users and women. These findings suggest that the medical and public health communities should increase vigilance concerning this drug and its potential for MUA.

Problems and solutions to filling the drying drug pipeline for psychiatric disorders: a report from the inaugural 2012 CINP Think Tank

The inaugural Collegium Internationale Neuro-Psychopharmacologicum (CINP) Think Tank, a small open meeting sponsored by the CINP, discussed impediments to developing new drugs for psychiatric disorders and approaches to overcome these impediments. Whilst neuropsycharmacology has a rich pharmacopeia (current treatments benefiting many individuals), issues of treatment resistance, sub-optimal response and unwanted side effects remain problematic. Many scientific, economic and social issues are impeding the development of drugs (e.g. higher risk of failure, placebo effects, problematic regulatory environments, pressures imposed by patent protection, downward pressure on reimbursements and financial, legal and social risk aversion). A consensus of the meeting was that efforts to understanding the core pathophysiology of psychiatric disorders are fundamental to increasing the chance of developing new drugs. However, findings from disorders such as Huntington's chorea, have shown that knowing the cause of a disorder may not reveal new drug targets. By contrast, clinically useful biomarkers that define target populations for new drugs and models that allow findings to be accurately translated from animals to humans will increase the likelihood of developing new drugs. In addition, a greater accent on experimental medicine, creative clinical investigations and improved communication between preclinical neuropsychopharmacologists, clinicians committed to neuropsychopharmacological research, industry and the regulators would also be a driver to the development of new treatments. Finally, it was agreed that the CINP must continue its role as a conduit facilitating vibrant interactions between industry and academia as such communications are a central component in identifying new drug targets, developing new drugs and transitioning new drugs into the clinic.

Prevalence, chronicity, burden and borders of bipolar disorder

Bipolar disorder (BD) has traditionally been thought of as an episodic condition, characterized by periods of hypomania/mania and depression. However, evidence is accumulating to suggest that this condition is associated with significant chronicity. For a large proportion of patients with BD, residual, sub-syndromal symptoms persist between major syndromal episodes, and studies have shown that many patients with bipolar disorder are symptomatic for approximately 50% of the time over follow-up periods of greater than 10 years. Moreover, while the prevalence of BD has been estimated to be around 1-2%, there is growing evidence that this may be a substantial underestimation. There are a number of reasons for this potential underestimation, including difficulties in diagnosis. Adding to the burden of BD is the issue of comorbidity, with an increased prevalence of many chronic conditions in those with a primary diagnosis of BD. Conversely, for many patients with chronic conditions, both medical and psychiatric, BD frequently exists as a comorbid secondary diagnosis. This issue of comorbidity complicates estimates of use of pharmaceutical agents for BD, such as mood stabilizers, which are known to be used off-label in conditions such as borderline personality or substance use disorder. We speculate that such off-label prescribing may not be truly off-label but may be instead fully justified by an overlooked secondary diagnosis of BD. Finally, we discuss the association of bipolar disorder with a significant economic burden, to the individual and to society, both due to the direct costs of medical expenditure and indirect costs such as loss of productivity and increased mortality.

Trends in quetiapine use and non-fatal quetiapine-related ambulance attendances

INTRODUCTION AND AIMS

Concern about the non-medical use of quetiapine and related acute harms is growing. Case series cite quetiapine as a potential drug of misuse, while recent research questions its relative safety in comparison with other atypical antipsychotic preparations. This paper explores population-level patterns of quetiapine-related ambulance attendances over time, identifying associated risk factors and potential subpopulations at-risk of acute harms.

DESIGN AND METHODS

A retrospective analysis of quetiapine-, olanzapine- and risperidone-related ambulance attendances in metropolitan Melbourne and prescription data in Victoria, Australia. Trends in ambulance attendance and prescription rates, attendance characteristics, and associated risk factors were explored from 2001 to 2010.

RESULTS

Quetiapine was consistently associated with substantially higher rates of ambulance attendances relative to prescription availability than olanzapine or risperidone. Quetiapine prescribing rates increased at a significantly greater magnitude than olanzapine or risperidone, leading to substantial increases in quetiapine attendances by population. Quetiapine-related attendances were associated with concurrent heroin and opioid replacement therapy toxicity, history of heroin and alcohol misuse, mood disorders, low Glasgow Coma Scale and women.

DISCUSSION AND CONCLUSIONS

Trends in quetiapine-related ambulance attendances indicate rising community-level harms and greater harm relative to other atypical antipsychotics, while prescription patterns suggest increasing quetiapine availability. The association of quetiapine-related attendances with concurrent heroin and opioid replacement therapy toxicity as well as previous heroin and alcohol misuse suggest illicit and poly-drug users are a subpopulation at greater risk of quetiapine-related harms, consistent with emerging evidence of the use, misuse and diversion of quetiapine.

Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study

OBJECTIVES

Second-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not reach conclusive results, and none have compared monotherapy with polytherapy involving other psychotropic medications.

DESIGN

Descriptive cohort study using a prospectively collected database.

SETTING

Motherisk Program, The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

133 women exposed to SGAs and other psychotropic drugs and 133 matched healthy controls were assessed and analysed. Outcomes of mother-child pairs exposed to SGAs in monotherapy (N=37) were compared with those exposed to SGAs with other psychotropic medications (in polytherapy; N=96).

MAIN OUTCOME MEASURES

Maternal, pregnancy, delivery and neonatal outcomes.

RESULTS

72% of exposed women received SGAs in polytherapy, and 101 women took their medications throughout pregnancy. These women had significantly higher pre-pregnancy weight, experienced more associated comorbidities and instrumental deliveries, and delivered a greater proportion of large for gestational age neonates. There were no differences in maternal weight gain in pregnancy between the exposed and comparison groups and between the monotherapy-exposed and polytherapy-exposed subgroups. The exposed neonates were more likely to be born premature, were admitted more often to the neonatal intensive care unit, presented with poor neonatal adaptation signs and had higher rates of congenital malformations. All the aforementioned neonatal outcomes were found mainly in the polytherapy subgroup.

CONCLUSIONS

The use of SGAs in polytherapy was prevalent in the assessed cohort and was associated with adverse pregnancy outcomes for both the mother and the child. In utero exposure to SGA monotherapy appears to be associated with less risk to the fetus. Future research should focus on polytherapy in pregnancy in order to define its reproductive safety and to separate the effects of medication exposure, underlying psychopathology and associated comorbidities.

Pharmacological treatment of PTSD - established and new approaches

A large proportion of humans will experience a traumatic event at least once in their lifetime, with up to 10% then going on to developing posttraumatic stress disorder (PTSD). In this review we will discuss established pharmacological interventions for PTSD as well as highlight novel therapeutic strategies undergoing extensive pre-clinical research as well as ongoing clinical research. Such strategies include prophylactic treatments and use of pharmacotherapy as adjunctive treatment with established trauma-focused psychological therapies. These potential treatment approaches include modulation of stress effects on memory consolidation after trauma (e.g., glucocorticoid, corticotropin-releasing factor and norepinephrine signalling modulators), as well as putative cognitive enhancers that target mechanisms of conditioned fear extinction and reconsolidation (e.g., glucocorticoid receptor modulators and modulators of glutamate signalling such as positive allosteric modulators of glutamate receptors, glycine transporter inhibitors, or glycine agonists). We will discuss evidence for and against these potential novel treatment strategies and their limitations. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Bipolar depression: clinically missed, pharmacologically mismanaged

Bipolar affective disorders are common and frequently debilitating mental illnesses. Diagnostic criteria mean they are defined by the presence of pathological mood elevation, but research shows greater disease burden is inflicted by depressive phases (bipolar depression) both in terms of duration and impact of symptoms. Despite this there is consistent evidence for the underdiagnosis of bipolar depression and its misdiagnosis as a unipolar disorder, with significant subsequent impact on medication management. There is currently less robust evidence for the appropriate pharmacological approach in such individuals than in unipolar depression, and fewer guidelines for clinicians. Despite this there is clear and growing evidence that 'treatment as usual' of depressive symptomatology is ineffective at best, harmful at worst, and that there is little role for the use of antidepressants. Both mood stabilizers and antipsychotics demonstrate efficacy, and whilst there are emerging data on intraclass differences, more research is needed, particularly concerning bipolar II disorder. Present treatment strategies are limited by insufficient large randomized control trials, an inadequate understanding of the neuropathology of bipolar illnesses and a lack of tailored medications. Better clinical training, understanding and recognition of this common condition are essential.

Investigating the effectiveness, safety and tolerability of quetiapine in the treatment of anorexia nervosa in young people: a pilot study

To investigate the safety and tolerability of the atypical antipsychotic quetiapine in anorexia nervosa patients, and to determine the effect of quetiapine treatment on anorexic psychopathology and other key outcome measures including weight and body image, we conducted a naturalistic, open-label, 12-week randomized controlled trial of low-dose (100-400 mg/day) quetiapine treatment versus treatment as usual in 33 anorexia nervosa patients from our Eating Disorder Clinics. To monitor the effects of treatment over the medium term, the participants were then followed up with assessment visits at 6 and 12 months after the end of the treatment phase. Low-dose quetiapine treatment resulted in both psychological and physical improvements, with minimal associated side-effects. Given the overall trend toward improvement that we observed, quetiapine appears to be a promising candidate for the treatment of anorexia nervosa. Further large-scale placebo-controlled clinical trials will be necessary to fully evaluate the benefits of quetiapine treatment for this disorder.

Patterns of antipsychotic medication use in Australia 2002-2007

OBJECTIVE

Atypical antipsychotic medications that are primarily used to treat schizophrenia and bipolar disorder cost the Pharmaceutical Benefits Scheme (PBS) AUD$334.4m in 2007. There are indications that they have also been used outside the approved indications to treat behavioural disturbances in the elderly. The aim of the present study was therefore to examine (i) trends in prescribing of subsidized atypical antipsychotic drugs in the Australian population from 2002 to 2007; and (ii) gender and age differences in the utilization of these drugs.

METHODS

Government (Medicare Australia) data on numbers of prescriptions, quantity and doses for atypical and typical antipsychotics from 2002 to 2007 were analysed. Defined daily dose per 1000 population per day were estimated for age and sex groups using Australian Bureau of Statistics population data.

RESULTS

The proportion of prescribed antipsychotics that were atypical increased from 61% in 2002 to 77% in 2007. In male subjects, olanzapine was most often prescribed between the ages of 25 and 55 years. In female subjects, in contrast, the highest rates of prescribing were in those > or = 75 years. Lower doses of these drugs were prescribed in older adults.

CONCLUSIONS

Atypical antipsychotic drugs were most commonly used to treat schizophrenia in younger men and behavioural disturbances in older women with dementia. They appear to have been used outside of the approved indication for schizophrenia and bipolar disorder with significant financial costs to the PBS. Research into the reasons for their extensive use in elderly women is needed to inform more rational prescribing of these medicines.

The uses and outcomes of quetiapine in depressive and bipolar mood disorders in clinical practice

We conducted an electronic chart review of a sample of all people attending secondary mental health care, in the county of Lanarkshire, Scotland, who were commenced on quetiapine for the following mood disorders: non-psychotic depression (n = 171), psychotic depression (n = 39), bipolar mania (n = 24), bipolar depression (n = 38) and bipolar mixed states (n = 31), between 2002 and 2007. We retrospectively assigned severity and improvement Clinical Global Impression (CGI) scores to measure effectiveness. Quetiapine was co-prescribed with antidepressants in 75-97% of depressive disorders. Commencing quetiapine was associated with clinical improvement in >64% of all patients, median doses (200-400 mg/day). For all depressive subtypes (non-psychotic, psychotic and bipolar) quetiapine was associated with improvement in 69% of patients. Across CGI measures, bipolar mania patients had the best outcome (89% improved). In bipolar mania, higher maximum doses were associated with greater improvement and 45% were continued on antidepressants. The results should be interpreted with caution due to the observational nature of the study and findings may not be attributed to the effects of quetiapine alone. Quetiapine was used mainly as an adjunct to other antidepressant and mood stabilising agents. The pharmacological profile of quetiapine suggests its properties extend beyond antipsychotic action, to antidepressant, anxiolytic and mood stabilising effects.

Effect of quetiapine vs. placebo on response to two virtual public speaking exposures in individuals with social phobia

OBJECTIVE

Clinical practice and open-label studies suggest that quetiapine (an atypical anti-psychotic) might improve symptoms for individuals with social anxiety disorder (SAD). The purpose of this study was to provide a rigorous test of the acute impact of a single dose of quetiapine (25mg) on SAD symptoms.

METHOD

Individuals with SAD (N=20) were exposed to a 4-min virtual reality (VR) public speaking challenge after having received quetiapine or placebo (double-blind) 1h earlier. A parallel VR challenge occurred 1 week later using a counter-balanced cross-over (within subject) design for the medication-placebo order between the two sessions.

RESULT

There was no significant drug effect for quetiapine on the primary outcome measures. However, quetiapine was associated with significantly elevated heart rate and sleepiness compared with placebo.

CONCLUSION

Study findings suggest that a single dose of 25mg quetiapine is not effective in alleviating SAD symptoms in individuals with fears of public speaking.

The co-administration of quetiapine or placebo to cognitive-behavior therapy in treatment refractory depression: a preliminary trial

BACKGROUND

Patients with major depression refractory to repeated pharmacological trials (TRD) may remain symptomatic for many years after their index episode. Augmentation strategies (with lithium or an atypical antipsychotic) or combining an antidepressant with short-term psychotherapy have been used with relative success in these patients. The aim of this study was to assess the effectiveness of the concomitant administration of quetiapine, an atypical antipsychotic, or placebo, to cognitive-behavior therapy (CBT) in TRD.

METHODS

Thirty-one patients who met entrance criteria for unipolar major depression (TRD stage II or greater) underwent 3 weeks of lithium augmentation after which non-responders (N = 22) were randomized to receive either quetiapine or placebo as an adjunct to their 12 weekly CBT sessions (quetiapine/CBT or placebo/CBT groups). Primary efficacy measures were the Hamilton and the Montgomery-Asberg rating scales for depression.

RESULTS

Overall, there was a significant reduction in both primary efficacy measure scores at LOCF for the 11 patients in the quetiapine/CBT group but not in the placebo/CBT treated patients. Patients in the quetiapine/CBT group, compared to those receiving placebo/CBT, showed a significantly greater degree of improvement on one primary and one secondary efficacy measure, were more likely to complete the trial and, completed a greater number of CBT sessions.

CONCLUSION

Although preliminary, our results suggest that the adjunctive administration of quetiapine to CBT may prove useful in the treatment of stage II TRD.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12638696.

Antipsychotic prescriptions in a university hospital outpatient population in Turkey: a retrospective database analysis, 2005-2006

OBJECTIVE

The aim of this study is to document the sociodemographic and the clinical profile of patients who are on antipsychotic (AP) medication prescribed in outpatient mental health clinic of a university hospital.

METHODS

A retrospective chart review was conducted for all outpatient files between 2005 and 2006 at the Zonguldak Karaelmas University, Medical Faculty Hospital, Department of Psychiatry in Turkey. All patients prescribed AP with regular follow up were recruited for the study. The type of AP and the route of administration were recorded. The diagnosis, age and gender of the patients were also evaluated.

RESULTS

We reviewed 1606 patients' files. APs were prescribed in 27.6% of the patients. Atypical antipsychotics (AAPs) represented 75.1% and typical antipsychotics (TAPs) represented 24.9% of all antipsychotic prescriptions in our study. The main psychiatric diagnoses associated with a TAP prescription were: psychotic disorders (6.5%), major affective disorders (49.5%), anxiety disorders (36.4%), and other psychiatric diseases (7.4%). The main psychiatric diagnoses associated with an AAP prescription were: psychotic disorders (35.1%), major affective disorders (31.1%), anxiety disorders (27.8%), somatoform disorders (2.4%) and other psychiatric diseases (6.4%). Twenty-eight of these patients (6.3%) were prescribed more than one AP, 45 patients were prescribed mood stabilizer (10.2%) and 272 patients were prescribed antidepressant agents (61.2%) in addition to AP.

CONCLUSIONS

The results reflect the particular use of AAPs in present study population. In line with the published data, the results of this study show that AAPs and TAPs are widely used in those with major affective disorders and psychotic disorders. These findings also underline the widespread off-label use of APs in the treatment of other psychiatric disorders.