Lithium Neurotoxicity Due to Second-Generation Antipsychotics Combined With Lithium: A Systematic Review

Objective

To study cases of lithium neurotoxicity (LN), both reversible (RLN) and irreversible (ILN), due to second-generation antipsychotics (SGAs) combined with lithium.

Data Sources

A comprehensive search was conducted in MEDLINE, PsycINFO, EMBASE, and the Cochrane Library from their inception to July 31, 2017.

Study Selection

Free terms and MeSH headings were combined as follows: [(lithium) AND (adverse events OR safety OR side effects OR neurotoxicity OR neurologic manifestations OR central nervous system) AND (risperidone OR paliperidone OR olanzapine OR aripiprazole OR clozapine OR quetiapine OR ziprasidone OR amisulpride OR asenapine OR lurasidone OR iloperidone)]. Only English-language articles reporting about LN due to SGAs combined with lithium were selected.

Data Extraction

The age, sex, diagnostic categories, clinical features, lithium doses, serum lithium levels, antipsychotic dosages, causative factors, and preventive measures of 11 cases of LN (8 RLN and 3 ILN) due to the lithium and SGA combination were extracted.

Data Synthesis

Forty-five percent of patients were aged > 60 years. The diagnostic categories were schizoaffective disorders, bipolar disorders, and schizophrenia. Cases of RLN presented as an acute brain syndrome, which recovered completely. Cases of ILN presented as a chronic brain syndrome and only partially recovered. The lithium doses in 9 cases were < 1,200 mg/d. The serum lithium levels in 2 cases in each of the groups were > 1.7 mEq/L. The SGAs implicated were clozapine, risperidone, aripiprazole, and quetiapine. One patient with RLN received 2 different first-generation antipsychotics and 1 patient with ILN received 2 different SGAs with lithium. Both groups had patients with medical comorbidities who were taking prescription medication.

Conclusion

LN, both reversible and irreversible, due to SGAs combined with lithium presents with certain causative factors and a clinical profile. Early detection and prompt management will help prevent LN.

An Economic Evaluation of Coordinated Specialty Care (CSC) Services for First-Episode Psychosis in the U.S. Public Sector

BACKGROUND

Schizophrenia spectrum disorders exert a large and disproportionate economic impact. Early intervention services may be able to alleviate the burden of schizophrenia spectrum disorders on diagnosed individuals, caregivers, and society at large. Economic analyses of observational studies have supported investments in specialized team-based care for early psychosis; however, questions remain regarding the economic viability of first-episode services in the fragmented U.S. healthcare system. The clinic for Specialized Treatment Early in Psychosis (STEP) was established in 2006, to explicitly model a nationally-relevant U.S. public-sector early intervention service. The purpose of this study was to conduct an economic evaluation of STEP, a Coordinated Specialty Care service (CSC) based in a U.S. State-funded community mental health center, relative to usual treatment (UT).

METHODS

Eligible patients were within 5 years of psychosis onset and had no more than 12 weeks of lifetime antipsychotic exposure. Participants were randomized to STEP or UT. The annual per-patient cost of the STEP intervention per se was estimated assuming a steady-state caseload of 30 patients. A cost-offset analysis was conducted to estimate the net value of STEP from a third-party payer perspective. Participant healthcare service utilization was evaluated at 6 months and over the entire 12 months post randomization. Generalized linear model multivariable regressions were used to estimate the effect of STEP on healthcare costs over time, and generate predicted mean costs, which were combined with the per-patient cost of STEP.

RESULTS

The annual per-patient cost of STEP was $1,984. STEP participants were significantly less likely to have any inpatient or ED visits; among individuals who did use such services in a given period, the associated costs were significantly lower for STEP participants at month 12. We did not observe a similar effect with regard to other healthcare services. The predicted average total costs were lower for STEP than UT, indicating a net benefit for STEP of $1,029 at month 6 and $2,991 at month 12; however, the differences were not statistically significant.

CONCLUSIONS

Our findings are promising with regard to the value of STEP to third-party payers.

Electroconvulsive therapy in the continuation and maintenance treatment of depression: Systematic review and meta-analyses

OBJECTIVE

Acute course of electroconvulsive therapy is effective in inducing remission from depression, but recurrence rate is unacceptably high following termination of electroconvulsive therapy despite continued pharmacotherapy. Continuation electroconvulsive therapy and maintenance electroconvulsive therapy have been studied for their efficacy in preventing relapse and recurrence of depression. The purpose of this meta-analysis was to examine the efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy in preventing relapse and recurrence of depression in comparison to antidepressant pharmacotherapy alone.

METHODS

We searched MEDLINE, Embase, PsycINFO, clinicaltrials.gov and Cochrane register of controlled trials from the database inception to December 2016 without restriction on language or publication status for randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. Two independent Cochrane reviewers extracted the data in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses. The risk of bias was assessed using four domains of the Cochrane Collaboration Risk of Bias Tool. Outcomes were pooled using random effect model. The primary outcome was relapse or recurrence of depression.

RESULTS

Five studies involving 436 patients were included in the meta-analysis. Analysis of the pooled data showed that continuation electroconvulsive therapy and maintenance electroconvulsive therapy, both with pharmacotherapy, were associated with significantly fewer relapses and recurrences than pharmacotherapy alone at 6 months and 1 year after a successful acute course of electroconvulsive therapy (risk ratio = 0.64, 95% confidence interval = [0.41, 0.98], p = 0.04, risk ratio = 0.46, 95% confidence interval = [0.21, 0.98], p = 0.05, respectively). There was insufficient data to perform a meta-analysis of stand-alone continuation electroconvulsive therapy or maintenance electroconvulsive therapy beyond 1 year.

CONCLUSION

There are only a few randomized trials of continuation electroconvulsive therapy and maintenance electroconvulsive therapy. The preliminary and limited evidence suggests the modest efficacy of continuation electroconvulsive therapy and maintenance electroconvulsive therapy with concomitant pharmacotherapy in preventing relapse and recurrence of depressive episodes for 1 year after the remission of index episode with the acute course of electroconvulsive therapy.

First-Episode Services for Psychotic Disorders in the U.S. Public Sector: A Pragmatic Randomized Controlled Trial

OBJECTIVE

This study sought to determine the effectiveness of a comprehensive first-episode service, the clinic for Specialized Treatment Early in Psychosis (STEP), in an urban U.S. community mental health center by comparing it with usual treatment.

METHODS

This pragmatic randomized controlled trial enrolled 120 patients with first-episode psychosis within five years of illness onset and 12 weeks of antipsychotic exposure. Referrals were mostly from inpatient psychiatric units, and enrollees were randomly allocated to STEP or usual treatment. Main outcomes included hospital utilization (primary); the ability to work or attend age-appropriate schooling-or to actively seek these opportunities (vocational engagement); and general functioning. Analysis was by modified intent to treat (excluding only three who withdrew consent) for hospitalization; for other outcomes, only data for completers were analyzed.

RESULTS

After one year, STEP participants had less inpatient utilization compared with those in usual treatment: no psychiatric hospitalizations, 77% versus 56% (risk ratio [RR]=1.38, 95% confidence interval [CI]=1.08-1.58); mean hospitalizations, .33±.70 versus .68±.92 (p=.02); and mean bed-days, 5.34±13.53 versus 11.51±15.04 (p=.05). For every five patients allocated to STEP versus usual treatment, one additional patient avoided hospitalization over the first year (number needed to treat=5; CI=2.7-26.5). STEP participants also demonstrated better vocational engagement (91.7% versus 66.7%; RR=1.40, CI=1.18-1.48) and showed salutary trends in global functioning measures.

CONCLUSIONS

This trial demonstrated the feasibility and effectiveness of a U.S. public-sector model of early intervention for psychotic illnesses. Such services can also support translational research and are a relevant model for other serious mental illnesses.

Maximum fractal dimension of cerebral seizure remains constant through the course of electroconvulsive therapy

Electroconvulsive therapy (ECT), in which electrical current is used to induce seizures, is an effective treatment in psychiatry. Different methods of analyzing the electroencephalogram (EEG) changes during ECT have been studied for predicting clinical outcome. Analysis of the fractal dimension (FD) is one such method. Mid-seizure and post-seizure FD has been shown to correlate with antidepressant effect. In this study, we examined whether the highest fractal dimension achieved during each ECT session changed over the course of 6 ECTs. The sample for this study came from a randomized controlled trial, comparing the efficacy of bifrontal and bitemporal electrode placements in schizophrenia. EEG was recorded using bilateral frontal pole leads during all ECT sessions. In 40 of the 114 randomized patients, we could obtain artifact-free EEGs for the first 6 ECT sessions. FD was calculated using standardized algorithms. For each session, the average of 5 highest FDs was calculated. The change in this value over a course of 6 ECTs was analyzed using repeated-measures analysis of variance. The average highest FD remained virtually unchanged across the 6 ECT sessions. Means (standard deviations) average maximum FDs over the 6 sessions were 1.57 (0.075), 1.57 (0.064), 1.56 (0.064), 1.57 (0.062), 1.55 (0.07), and 1.56 (0.067); occasion effect, F = 0.5, P = .75. Group effect (F = 0.01, P = .92) and group × occasion interaction effect (F = 1.88, P = .1) were not significant, suggesting no influence of electrode placement on maximum FD. Seizure duration, however, showed significant decline over the course of ECT. Maximum FD of ECT-induced EEG seizure remains fairly constant over frontal poles across the first 6 ECT sessions, which is true irrespective of ECT electrode placements.

Seizure duration decreases over a course of bifrontal and not bitemporal electroconvulsive therapy

CONTEXT

Mechanism of action of electroconvulsive therapy (ECT) is unclear. Anticonvulsant action of ECT has also been one among the hypothesized mechanisms. Anticonvulsant effect may manifest during ECT in at least two ways (a) increased seizure threshold (b) decrease in seizure duration. In depression, increased seizure threshold has been shown to be associated with better antidepressant response. However, relationship between seizure duration and antidepressant activity has been inconsistent. These issues are not investigated in conditions other than depression.

AIMS

We examined seizure duration over the course of ECT in schizophrenia patients.

SETTINGS AND DESIGN

Material for this analysis was obtained from a clinical trial examining the differential efficacy of bifrontal ECT (BFECT) versus bitemporal ECT (BTECT) in schizophrenia patients. As a part of study 122 schizophrenia patients who were prescribed ECT were randomized to receive either BFECT or BTECT.

SUBJECTS AND METHODS

Final analysis was conducted on data from 70 patients, as the rest of the data either had artifact or there was a significant change in medication status. Electroencephalogram seizure duration was noted in each session for these patients.

RESULTS

Seizure duration declined significantly from second ECT to 6(th) ECT (repeated measures analysis of variance F = 4.255; P = 0.006). When separate analysis was conducted for BTECT and BFECT patients the decline in seizure duration from 2(nd) to 6(th) ECT was significant only with BFECT (F = 3.94; P = 0.014) and not with BTECT (F = 0.966; P = 0.424).

CONCLUSIONS

Better anticonvulsant effects with BFECT may explain the better therapeutic observed with BFECT in schizophrenia as well as mania in our earlier studies.

Ictal EEG fractal dimension in ECT predicts outcome at 2 weeks in schizophrenia

Studies of electroconvulsive therapy (ECT) have found an association between ictal electroencephalographic (EEG) measures and clinical outcome in depression. Such studies are lacking in schizophrenia. Consenting schizophrenia patients receiving ECT were assessed using the Brief Psychiatric Rating Scale (BPRS) before and 2 weeks after the start of ECT. The patients' seizure was monitored using EEG. In 26 patients, completely artifact-free EEG derived from the left frontal-pole (FP1) channel and electrocardiography (ECG) were available. The fractal dimension (FD) was computed to assess 4-s EEG epochs, and the maximal value from the earliest ECT session (2nd, 3rd or 4th) was used for analysis. There was a significant inverse correlation between the maximum FD and the total score following 6th ECT. An inverse Inverse correlation was also observed between the maximum FD and the total number of ECTs administered as well as the maximum heart rate (HR) and BPRS scores following 6th ECT. In patients with schizophrenia greater intensity of seizures (higher FD) during initial sessions of ECT is associated with better response at the end of 2 weeks.

Reversible lithium neurotoxicity: review of the literatur

OBJECTIVE

Lithium neurotoxicity may be reversible or irreversible. Reversible lithium neurotoxicity has been defined as cases of lithium neurotoxicity in which patients recovered without any permanent neurologic sequelae, even after 2 months of an episode of lithium toxicity. Cases of reversible lithium neurotoxicity differ in clinical presentation from those of irreversible lithium neurotoxicity and have important implications in clinical practice. This review aims to study the clinical presentation of cases of reversible lithium neurotoxicity.

DATA SOURCES

A comprehensive electronic search was conducted in the following databases: MEDLINE (PubMed), 1950 to November 2010; PsycINFO, 1967 to November 2010; and SCOPUS (EMBASE), 1950 to November 2010. MEDLINE and PsycINFO were searched by using the OvidSP interface.

STUDY SELECTION

A combination of the following search terms was used: lithium AND adverse effects AND central nervous system OR neurologic manifestation. Publications cited include articles concerned with reversible lithium neurotoxicity.

DATA EXTRACTION

The age, sex, clinical features, diagnostic categories, lithium doses, serum lithium levels, precipitating factors, and preventive measures of 52 cases of reversible lithium neurotoxicity were extracted.

DATA SYNTHESIS

Among the 52 cases of reversible lithium neurotoxicity, patients ranged in age from 10 to 80 years and a greater number were female (P = .008). Most patients had affective disorders, schizoaffective disorders, and/or depression (P < .001) and presented mainly with acute organic brain syndrome. In most cases, the therapeutic serum lithium levels were less than or equal to 1.5 mEq/L (P < .001), and dosage regimens were less than 2,000 mg/day. Specific drug combinations with lithium, underlying brain pathology, abnormal tissue levels, specific diagnostic categories, and elderly populations were some of the precipitating factors reported for reversible lithium neurotoxicity. The preventive measures were also described.

CONCLUSIONS

Reversible lithium neurotoxicity presents with a certain clinical profile and precipitating factors for which there are appropriate preventive measures. This recognition will help in early diagnosis and prompt treatment of lithium neurotoxicity.

Cardiovascular mortality in schizophrenia: defining a critical period for prevention

OBJECTIVE

Better understanding of the temporal development of cardiovascular risk will permit more targeted prevention of premature cardiovascular mortality in schizophrenia.

METHODS

The sample for this analysis was drawn from referrals (between 2006 and '11) to an early psychosis clinic based in a U.S. urban community mental health center. 76 individuals with schizophrenia who were young (mean 22.4 years, SD 4.8), early course (median duration of illness 31 weeks) and with minimal prior antipsychotic exposure (median 2 weeks) were compared to age-, gender-, and race-matched peers drawn from the National Health and Nutrition Survey (2007-'08). Measures of cardiovascular risk at baseline, 6 months, and 1 year are reported.

RESULTS

While indistinguishable from peers at entry, patients suffered pervasive adverse trajectories of cardiovascular risk factors over the subsequent year. 16 of 44 initial non-smokers became nicotine dependent and none of 32 entering smokers quit. 17 patients transitioned to overweight (BMI 25-29.9, n = 3) or obese (BMI>30, n = 14) categories, while only 24 of 38 (63%) sustained normal weight over one year. Similar adverse trends in blood pressure, lipids, and fasting glucose led to an increase in prevalence of metabolic syndrome (1.31% to 5.26%). 10-year cardiovascular risk estimates showed a small and significant increase although remaining in the low risk (<10%) category.

CONCLUSIONS

The early emergence of obesity and smoking in younger schizophrenia samples provides a rational focus for primary prevention of premature cardiovascular mortality. The first year of treatment constitutes the beginning of a critical period for such preventive efforts.

Barriers to discharge of patients from a government-run day-care psychiatric rehabilitation center in India

OBJECTIVE

Many psychiatric patients undergoing vocational training do not achieve successful transition to regular work. In this study, we evaluated the barriers for discharge from day care center to actual work place.

MATERIALS AND METHODS

In a cross-sectional study at a government-run day-care center at National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, we studied 76 patients who were undergoing vocational training for more than 1 year. We did a semi-structured interview with patients, their family members, and instructors of various occupational sections. We used a questionnaire of 17 different barriers to assess the obstacles in their discharge from day-care center to actual work place.

RESULTS

The majority of them had a diagnosis of mental retardation (n=47) followed by schizophrenia (n=29), and bipolar disorder (n=9). The mean (SD) age and duration of illness was 33.6 (9.7) years and 12.5 (9.3) years, respectively. Patients had more than one diagnosis. The median duration of stay in day-care center was 5.9 years. Doubts regarding performance at a new work place (n=60), fear of performance at new work place (n=65), and the fear of transition to regular work (n=64) were the most common barriers reported by patients, their family members and instructors of various occupational sections, respectively.

DISCUSSION

Educating patients and their family members, gradual exposure to new working environment, and increased community level vocational opportunities may potentially overcome above barriers. Getting them to the actual job early in their course of treatment will improve their adjustment to a new work place and overall outcome.

Who is paying the price? Loss of health insurance coverage early in psychosis

OBJECTIVE

Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome. This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center.

METHODS

Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services.

RESULTS

A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months. Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance. By the 12-month assessment, 13 (72%) privately insured and five (38%) publicly insured participants had lost coverage; less than one-third of the 48 participants (N=14) maintained continuous coverage.

CONCLUSIONS

Specialty services for individuals experiencing early psychosis should address the difficulty of maintaining health insurance coverage during a period of illness in which continuity of care is critical to recovery.

Who is paying the price? Loss of health insurance coverage early in psychosis

OBJECTIVE

Discontinuities in health insurance coverage may make it difficult for individuals early in psychosis to receive the services that are critical in determining long-term outcome. This study reports on the rates and continuity of insurance coverage among a cohort of early-psychosis patients enrolled in Specialized Treatment Early in Psychosis (STEP) at the Connecticut Mental Health Center.

METHODS

Insurance status at baseline, six months, and 12 months was collected from 82 participants from a combination of self-reports, clinical chart review, clinician reports, and a database maintained by the state Department of Social Services.

RESULTS

A total of 34 participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months. Among the remaining 48 participants, at baseline 18 had private insurance, 13 had public insurance, and 16 had no insurance. By the 12-month assessment, 13 (72%) privately insured and five (38%) publicly insured participants had lost coverage; less than one-third of the 48 participants (N=14) maintained continuous coverage.

CONCLUSIONS

Specialty services for individuals experiencing early psychosis should address the difficulty of maintaining health insurance coverage during a period of illness in which continuity of care is critical to recovery.

Cardiovascular risk in a first-episode psychosis sample: a 'critical period' for prevention?

OBJECTIVE

Studies in first episode psychosis samples about status of cardiovascular risk factors have shown discordant results. We aimed to determine the 10-year risk of developing coronary heart disease in a sample of first episode psychosis patients referred to an early intervention clinic and compared the same with age, gender, and race matched controls from the U.S. National Health and Nutrition Examination Survey (NHANES).

METHOD

We conducted a cross-sectional analysis of baseline data of 56 subjects enrolled in first episode psychosis clinic from April 2006 to January 2010. This sample was compared with age, gender, and race matched 145 individuals drawn from NHANES 2005-2006 database. Sociodemographic and clinical variables were collected. Physical examination including laboratory evaluation was used to screen for common medical illnesses. The 10-year risk of developing coronary heart disease was calculated by using a tool developed by the National Cholesterol Education Program (NCEP-ATP III).

RESULTS

There were elevated rates of smoking (46%) and hypertension (11%) albeit statistically significant differences from the control could not be demonstrated for these measures or weight, body mass index, or total or HDL cholesterol, fasting plasma glucose, status of diabetes and impaired fasting plasma glucose, HbA1C level. The 10-year median (range) risk of developing coronary heart disease in patients and controls was 1 (0-5)% and 0 (0-9)% respectively. The difference was not statistically significant.

CONCLUSIONS

First episode psychosis patients do not present with significantly higher cardiovascular risk than age and race-matched controls despite clinically significant prevalence of individual risk factors. This sample presents an opportunity for early intervention for the primary prevention of cardiovascular morbidity and mortality.

Why do we prescribe ECT to schizophrenia patients?

Electroconvulsive therapy (ECT) is prescribed for schizophrenia patients for various indications, in our country. However, official guidelines in other countries have been cautious in prescribing ECT for schizophrenia. To study the indications for which patients with schizophrenia receive ECT. We studied records of schizophrenia inpatients receiving ECT in one year (2005) (n=101) retrospectively, as well as the consecutive data of patients between May 2007 and June 2008 (n=101) prospectively. The various indications for ECT in schizophrenia were studied by frequency analysis. Of the 202 schizophrenia patients who received ECT, the most common reason was 'to augment pharmacotherapy' in (n=116) cases. The target symptoms for which ECT was prescribed the most was catatonia (n=72). The mean number of ECTs (SD) received was 8.4 (2.8). Augmentation of pharmacotherapy was the most common indication of ECT in patients with schizophrenia.

Does catatonic schizophrenia improve faster with electroconvulsive therapy than other subtypes of schizophrenia?

OBJECTIVE

Electroconvulsive therapy (ECT) is generally recommended for treating catatonic schizophrenia. Non-catatonic schizophrenia patients also receive ECT. We compared the speed of response to ECT among patients with catatonic and other subtypes of schizophrenia.

METHODS AND MATERIALS

Consecutive schizophrenia patients referred for ECT within 3 months of starting antipsychotic treatment were studied (19 with catatonic and 34 with non-catatonic schizophrenia). Nurse's Observation Scale for Inpatient Evaluation (NOSIE-30) and Clinical Global Impression (CGI) were used to rate improvement. Referring psychiatrists stopped ECTs based on clinical impression of improvement. Total number of ECTs was taken as an indirect measure of speed of response. NOSIE-30 scores were compared using repeated measures analysis of variance.

RESULTS

Catatonic schizophrenia patients required significantly fewer ECTs to achieve clinically significant improvement. There was a significant group x occasion effect in NOSIE scores, suggesting faster response to ECT in the catatonia group (F=41.6; P<0.001). Survival analysis suggested that patients with catatonic schizophrenia required significantly fewer ECTs (one less session on an average) to achieve clinical improvement (Log-rank statistic =5.31; P=0.02).

CONCLUSIONS

Catatonic schizophrenia responds faster to ECT than non-catatonic schizophrenia. However, the magnitude of the difference is modest.

[Adolescent onset obsessive compulsive disorder presented as dissociative disorders: role of drug assisted interview]

Paediatric Obsessive Compulsive Disorder (OCD) is still under-diagnosed, despite significant advances made in identifying obsessive-compulsive symptoms. The authors report a case of adolescent-onset OCD presenting as a mixed dissociative disorder. The drug assisted interview provided a breakthrough in revising the correct diagnosis of the clinical condition. The psychopathology of the patient contains sexual and aggressive obsessions without any compulsions. Adolescent OCD can present as dissociative disorders and a thiopentone interview can be helpful in revealing the distress associated with OCD.

Research on electroconvulsive therapy in India: An overview

The contribution of researchers from India in the field of electroconvulsive therapy (ECT) has been substantial. Over 250 papers have been published by authors from India in the past five decades on this issue; about half of these have appeared in the Indian Journal of Psychiatry. This article summarizes the papers on ECT research that have appeared in the Journal. A bulk of these articles has focused on establishing the efficacy in different disorders. Considerable numbers of papers describe refinement in the ECT procedure, including anesthetic modification, ECT machine and EEG monitoring. Papers on neurobiology of ECT and long-term follow-up of ECT-treated patients form a minority. Despite the decline in the use of ECT across the globe, papers on ECT have only increased in the recent decades in the Journal.