Development and acceptability testing of a decision aid for considering whether to reduce antipsychotics in individuals with stable schizophrenia

AIM

Continued antipsychotic treatment is the key to preventing relapse. Maintenance antipsychotic monotherapy and optimal dose use are recommended for individuals with stable schizophrenia because of their undesirable effects. Decision aids (DAs) are clinical conversation tools that facilitate shared decision-making (SDM) between patients and health-care providers. This study aimed to describe the development process and results of acceptability testing of a DA for individuals with stable schizophrenia, considering (i) whether to continue high-dose antipsychotics or reduce to the standard dose and (ii) whether to continue two antipsychotics or shift to monotherapy.

METHODS

A DA was developed according to the guidelines for the appropriate use of psychotropic medications and International Patient Decision Aid Standards (IPDAS). First, a DA prototype was developed based on a previous systematic review and meta-analysis conducted for identifying the effects of continuing or reducing antipsychotic treatment. Second, mixed-method survey was performed among individuals with schizophrenia and health-care providers to modify and finalize the DA.

RESULTS

The DA consisted of an explanation of schizophrenia, options to continue high-dose antipsychotics or reduce to the standard dose, options to continue two antipsychotics or shift to monotherapy, pros and cons of each option, and a value-clarification worksheet for each option. The patients (n = 20) reported acceptable language use (75%), adequate information (75%), and well-balanced presentation (79%). Health-care providers (n = 20) also provided favorable overall feedback. The final DA covered six IPDAS qualifying criteria.

CONCLUSION

A DA was successfully developed for schizophrenia, considering whether to reduce antipsychotics, which can be used in the SDM process.

Effectiveness of change from suvorexant to lemborexant drug in the treatment of sleep disorders

BACKGROUND

This study aimed to examine the effects of a change in medication from suvorexant to lemborexant among patients with insomnia.

METHODS

Patients with chronic insomnia who had persistent insomnia for 3 months or longer and who had been taking suvorexant for 3 months or longer were selected. The participants were divided into two groups: the 'modified' group and the 'non-modified' group. Four sub-types of insomnia (i.e., difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening, and non-restorative sleep) were investigated. Logistic regression was used to investigate improvements in both the groups after 12 weeks.

RESULTS

Among the 77 participants, 43 and 34 patients were in the modified drug group and the non-modified drug group, respectively. Comparing sleep disorders between the two groups, we found significant improvement after 12 weeks in the modified drug group in terms of difficulty initiating sleep, compared with the non-modified drug group (odds ratio = 0.036, P = 0.008, 95% CI = 0.003-0.415). However, no significant differences were found between the two groups in terms of difficulty maintaining sleep, early-morning awakening, and non-restorative sleep.

CONCLUSIONS

Sleep disorders can be treated by alleviating difficulties in initiating sleep by changing from suvorexant to lemborexant. In addition, it was confirmed that the drug change caused no serious side effects and that it was highly safe and tolerated.

Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis

BACKGROUND

While recent meta-analyses have reported the superiority of antipsychotic polypharmacy (APP) over antipsychotic monotherapy (APM) in schizophrenia, switching to APM can be beneficial in terms of side effects. To determine whether patients receiving APP should switch to APM or stay on APP, we conducted a systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) examining a switch from APP to APM vs. staying on APP were systematically selected from a previous meta-analysis comparing APP with APM in patients with schizophrenia. In addition, we conducted an updated systematic literature search using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Data on study discontinuation, relapse, psychopathology, neurocognition, extrapyramidal symptoms, and body weight/body mass index (BMI) were extracted and synthesized.

RESULTS

A total of 6 RCTs involving 341 patients were included. All studies examined a switch from 2 antipsychotic agents to a single agent. Clozapine-treated patients were included in 3 studies. There was a significant difference in study discontinuation due to all causes in favor of staying on APP (N = 6, n = 341, RR = 2.28, 95% CI = 1.50-3.46, P < 0.001). There were no significant differences in relapse, any psychopathology, neurocognition, extrapyramidal symptoms, or body weight/BMI between the 2 groups. The quality of evidence was low to very low.

CONCLUSIONS

The findings suggest that clinicians should closely monitor patient condition when switching to APM after receiving 2 antipsychotics. Given the low to very low overall quality of the evidence, the findings should be considered preliminary and inconclusive.

Clinical Characteristics of Women with ADHD in Japan

PURPOSE

Although gender differences have been reported in various aspects of adult attention-deficit hyperactivity disorder (ADHD), such as prevalence, comorbidities, and social functioning, there have been few such studies conducted in Japan. Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men. We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.

PATIENTS AND METHODS

The subjects were 335 outpatients with a DSM-5 ADHD diagnosis, who visited our ADHD specialty clinic at Showa University Karasuyama Hospital in central Tokyo between April 2015 and March 2016. Sociodemographic and clinical characteristics were collected, and gender differences were compared.

RESULTS

Results fully supported our hypotheses: women had a significantly higher psychiatric comorbidity rate, were significantly less likely to be a full-time employee, and were significantly more likely to be divorced than men with ADHD.

CONCLUSION

Consistent with research in other countries, women with ADHD have greater impairments than men with ADHD in Japan. The importance of understanding gender differences of ADHD-diagnosed adults within a sociocultural context is highlighted.

The effect of visual cues on performance in the ultimatum game in individuals with autism spectrum disorder

The Ultimatum Game (UG) allows for the assessment of altruistic behavior as well as the perception of fairness. We examined the effects of visual social cues (gaze of others), factors associated with autism, and trust on UG performance in typical adults (TAs) and individuals with autism spectrum disorder (ASD). We hypothesized that individuals with ASD would be less affected by visual social cues than TAs. We recruited 30 TAs and 30 individuals with ASD. Participants completed 30 trials of the UG, during which the visual background was altered to include either stylized eyespots, flowers, or a neutral background. Reaction times and money distributed in each condition were recorded. Reaction times did not vary among background conditions in either group, although individuals with ASD responded more slowly overall. TAs distributed less money in the neutral background and flowers conditions than in the eyespots condition, while no significant differences in the amount of money distributed were observed among background conditions for individuals with ASD, who also distributed more money overall than TAs. Such findings may be due to decreased susceptibility to social cues among individuals with ASD.

A molecular dynamics study of nuclear quantum effect on diffusivity of hydrogen molecule

In this paper, the nuclear quantum effect of the hydrogen molecule on its diffusivity was analyzed using the molecular dynamics (MD) method. The centroid MD (CMD) method was applied to reproduce the time evolution of the molecules. The diffusion coefficient of hydrogen was calculated using the Green-Kubo method over a wide temperature region, and the temperature dependence of the quantum effect of the hydrogen molecule on its diffusivity was addressed. The calculated results were compared with classical MD results based on the principle of corresponding state (PCS). It was confirmed that the difference in the diffusion coefficient calculated in the CMD and classical MD methods was small, and the PCS appears to be satisfied on the temperature dependence of the diffusion coefficient, even though the quantum effect of the hydrogen molecules was taken into account. It was clarified that this result did not suggest that the quantum effect on the diffusivity of the hydrogen molecule was small but that the two changes in the intermolecular interaction of hydrogen due to the quantum effect offset each other. Moreover, it was found that this tendency was related to the temperature dependence of the ratio of the kinetic energy of the quantum fluctuational motion to the classical kinetic energy.

Induction of a B1-receptor mediating hypotensive response in young brown Norway rats

A hypotensive response to intravenously injected des-Arg9-bradykinin was elicited in young male Brown Norway rats (8-12 weeks-old), when the rats were intravenously injected with endotoxin (30 micrograms/kg) 24 h before they were repeatedly injected with bradykinin or des-Arg9-bradykinin. The potency of this inducible dose-dependent hypotensive response to des-Arg9-bradykinin was comparable to that induced by bradykinin on a molar base (3-30 nmol/kg). A hypotensive response to des-Arg9-bradykinin could also be induced when the rats were pretreated with endotoxin 6 h before. However, the potency of the response was less than that induced by 24-h pretreatment. This inducible response to des-Arg9-bradykinin did not occur in old rats (8-10 months old). Intravenous infusion of a B1-receptor antagonist, des-Arg9-[Leu8]-bradykinin, suppressed the hypotensive response of des-Arg9-bradykinin. These results suggest that the B1-receptor, mediating hypotension in rats, was inducible through time-dependent and age-dependent sensitization by endotoxin pretreatment.

The mediators involved in endotoxin-induced vascular permeability increase in the rat skin and their interactions

The injection of lipopolysaccharide (LPS) from E. Coli into the dorsal skin of rats caused a dose-dependent increase in vascular permeability as measured by the extravasation over a 40-min period of intravenously injected dye. This increase caused by LPS was attenuated by pretreatment with the bradykinin (BK) receptor antagonist HOE140, the selective platelet-activating factor (PAF) antagonist TCV309, and by combined treatment with mepyramine and methysergide. Combined treatment with HOE140 and TCV309 resulted in further suppression than that achieved with a single treatment alone. By the simultaneous pretreatment with all antagonists, the response was almost totally abolished. On the other hand, indomethacin also inhibited the response induced by LPS, but not those induced by BK and PAF itself. A small dose of BK or histamine synergistically potentiated the effect of PAF when simultaneously injected. These results suggest that BK, PAF, histamine/serotonin and prostaglandins are involved in the LPS-induced increase in vascular permeability, where PAF, in addition to its direct action, potentiates the response to BK and histamine, and prostaglandins potentiate the actions of other mediators without its direct action.

Involvement of bradykinin in endotoxin-induced vascular permeability increase in the skin of rats

The aim of the present study was to investigate the role of bradykinin as well as that of platelet-activating factor in the endotoxin-induced acute vascular permeability increase in the dorsal skin of rats by use of kininogen-deficient and normal Brown-Norway rats. In the kininogen-deficient rats, the dose-dependent dye exudation induced by endotoxin was about one half of that in the normal rats at any doses of endotoxin tested (0.1-1.0 mg per site), whereas the dose-response curves obtained by bradykinin (1-100 nmol per site), platelet-activating factor (0.1-1 nmol per site) or histamine (50-500 nmol per site) were the same in both rats. This effect induced by endotoxin in the kininogen-deficient rats was not changed by pretreatment with a bradykinin B2 receptor antagonist, HOE140 (D-Arg-[Hyp3,Thi5,D-Tic7,Oic8]bradykinin, 1 mg kg-1 i.v.), whereas the endotoxin-induced response in the normal rats was attenuated by the receptor antagonist. These responses in both kininogen-deficient and normal rats were significantly inhibited by a selective platelet-activating factor antagonist, TCV309 (3-bromo-5-[N-phenyl-N-[2-[[2-(1,2,3,4,-tetrahydro-2- isoquinolylcarbonyl-oxy)-ethyl]-carbamoyl]-ethyl]carbamoyl]-1-prop yl- pyridinium nitrate, 0.1 mg kg-1 i.v.). These results suggest that bradykinin could be one of the major mediators in the endotoxin-induced vascular permeability increase in rat skin in addition to platelet-activating factor.

A hypotensive response induced by des-Arg9-bradykinin in young brown/Norway rats pretreated with endotoxin

A hypotensive effect of intravenously injected des-Arg9-bradykinin was found in Brown/Norway strain young male rats which were pretreated with a small amount of endotoxin 24 h before the experiment, whereas the hypotensive effect of bradykinin was unaffected by the endotoxin. The potency of des-Arg9-bradykinin for the hypotensive effect was comparable to that of bradykinin. On the other hand, in endotoxin-pretreated aged rats, this effect of des-Arg9-bradykinin was not observed. Only during the intravenous infusion of des-Arg9[Leu8]bradykinin, a bradykinin B1 receptor antagonist, was the hypotensive effect of des-Arg9-bradykinin inhibited, whereas that of bradykinin was potentiated. After the end of infusion of des-Arg9[Leu8]bradykinin, the response to des-Arg9-bradykinin rapidly recovered. The results suggest the possibility that des-Arg9-bradykinin might play a role in inflammatory diseases.