Antipsychotic Medications In Patients Research Articles

Elevated serum kynurenic acid in individuals with first-episode psychosis and insufficient response to antipsychotics

The tryptophan-metabolizing kynurenine pathway (KP) can be activated by enhanced inflammatory responses and has been implicated in the pathophysiology of schizophrenia. However, there is little evidence for KP dysregulation in the early course of psychotic illness. We aimed to investigate the potential immune-mediated hyperactivity of KP in individuals with first-episode psychosis (FEP) and the relationship with symptom severity and treatment response outcomes. Serum immunoassays were performed to measure peripheral levels of inflammatory cytokines (IL-1β, IL-10, TNF-a), KP rate-limiting enzymes (IDO/TDO), and kynurenic acid (KYNA) metabolite in 104 antipsychotic-naïve patients with FEP and 80 healthy controls (HC). The Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning Scale (GAF) were administered to assess psychopathology and functioning status at admission and following 4-week treatment with antipsychotics. Cytokine and KP components levels were substantially increased in FEP patients compared to HC, before and after antipsychotic treatment. A significant positive correlation between pro-inflammatory IL-1β and KYNA levels was observed among FEP patients, but not in HC. Importantly, within-patient analysis revealed that those with higher baseline KYNA experienced more severe negative symptoms and poorer clinical improvement at follow-up. These findings suggest that KP is upregulated in early psychosis, likely through the induction of IL-1β-dependent pathways, and raised peripheral KYNA might represent a promising indicator of non-response to antipsychotic medication in patients with FEP.

Medication beliefs and adherence to antipsychotic medication in patients diagnosed with schizophrenia: The moderating role of doctor–patient communication

Patients with schizophrenia have higher odds of premature mortality than people in the general population. Adherence to antipsychotic medication can prevent relapse and rehospitalisations and is considered a critical component of schizophrenia treatment. Yet, studies examining the factors associated with medication adherence in this patient population in Ghana are limited. This study examined the association between medication beliefs and adherence, and whether the effect of medication beliefs on adherence is contingent on doctor–patient communication. Patients with schizophrenia (N = 117) provided the data for the current analysis. Data were analyzed using hierarchical linear regression. Results showed a significant positive association between medication beliefs (i.e., necessity beliefs) and adherence. Doctor-patient communication was positively associated with adherence. Further, the association between necessity beliefs and medication adherence was found to be contingent on doctor-patient communication. Specifically, the effect of necessity beliefs on medication adherence weakened at high levels of doctor-patient communication. Other results showed that the mean antipsychotic medication adherence score was 16.70 ± 6.51. Moreover, about 89.3% of the patients were accepting their antipsychotic medication (i.e., having low concerns but high necessity beliefs). Findings suggest that necessity beliefs and doctor-patient communication exert similar effects on medication adherence.

Patterns of care and costs of switching oral antipsychotic medications in patients with schizophrenia initiating monotherapy treatment: A US claims analysis.

Antipsychotic medications are the mainstay of schizophrenia therapy but may need to be changed over the course of a patient's illness to achieve the desired therapeutic goals or minimize medication side effects. Investigations of real-world treatment patterns and economic consequences associated with antipsychotic changes, including switching, are limited. To describe treatment patterns among patients with schizophrenia who initiated oral antipsychotic medication (OAM) monotherapy and assess switching-related health care resource utilization (HCRU) and costs in US Medicare Advantage and commercially insured patients. Adults with at least 2 claims with a schizophrenia diagnosis who initiated (or reinitiated after ≥6 months) OAM monotherapy between January 1, 2015, and June 30, 2021, were identified in the Optum Research Database. A claims-based algorithm using timing of therapies and treatment gaps identified medication changes, specifically OAM monotherapy switches, among OAM initiators over a period of up to 7 years. Patients who switched from their initial OAM monotherapy to a second OAM monotherapy (initial OAM switchers) were matched based on clinical and demographic characteristics to OAM initiators who had not switched OAMs; switch-related HCRU and costs (incurred up to 3 months before and 3 months after the initial OAM switch) were compared between matched initial OAM switchers and nonswitchers. Among 6,425 OAM monotherapy initiators, 1,505 (23.4%) had at least 1 OAM monotherapy switch at any time during follow-up, with a mean (SD) time to first switch of 209 (333) days (median, 67 days), a rate of 0.65 switches per person-year of follow-up, and 56% of first switches occurring within 3 months of OAM initiation. Of all OAM initiators, 947 (14.7%) were initial OAM switchers. Compared with 865 matched nonswitchers, 865 initial OAM switchers had greater mean counts of all-cause medical visits and greater mean counts of schizophrenia-related emergency and inpatient visits and longer inpatient stays per patient per month. Mean (SD) total schizophrenia-related costs per patient per month were $1,252 ($2,602) for switchers compared with $402 ($2,027) for nonswitchers (P < 0.001). Changes to antipsychotic therapy in our sample of patients with schizophrenia were common, with nearly one-fourth switching OAMs, the majority within the first 3 months of therapy. Initial OAM switchers experienced greater HCRU and costs than nonswitchers. These findings highlight the importance of initiating OAM monotherapy that effectively maintains symptom control and minimizes tolerability issues, which would limit the need to switch OAMs and therefore prevent excess HCRU and treatment costs.

A prospective study on change of QTc interval with antipsychotic medications in patients of schizophrenia and related psychotic disorder

Background: Sudden unexplained death in individuals with mental health problems was described in 1960 and a link with antipsychotic drugs was postulated over 40 years ago. Down the years, a clear relation between electrocardiography (ECG) abnormalities and antipsychotic use was observed with special emphasis on QT prolongation. Various factors modulate the risk of QT prolongation including gender, age, race, and drug choice. An evaluation of antipsychotic use-induced QT changes in Eastern Indian population is the dire need of the hour. Aims and Objectives: The aim and objective are to study the effects of risperidone, olanzapine, and aripiprazole on QT interval after a period of 4 weeks of usage in previously drug-naïve Eastern Indian psychotic patients. Materials and Methods: A total of 78 drug-naïve patients fulfilling inclusion and exclusion criteria were randomly assigned to receive risperidone, olanzapine, and aripiprazole after a baseline ECG. A repeat ECG after 4 weeks of drug usage was done and compared using standard protocols with respect to QT interval. Findings were tabulated and statistical analysis was done using SPSS 25.0 to test for statistical significance at P&lt;0.05. Results: Our study found significant rise in QT values after 4 weeks of using olanzapine and aripiprazole, but not with risperidone. However, none of the patients from either of the groups experienced any incidence of QT prolongation. Rise with olanzapine was significantly higher than that with risperidone. Conclusion: Caution is suggested in patients with risk factors for QT prolongation or a high value of QT during prescribing olanzapine. Studies with larger sample size can be carried out to find genetic predisposition of Indian population to anti-psychotic induced QT interval rise/prolongation.

Treatment adherence and insight in schizophrenia spectrum disorders

IntroductionLack of adherence to antipsychotic medication in patients with schizophrenia spectrum disorders is a major risk factor for relapse and rehospitalizations which contributes to major social and economic consequences. A high proportion of patients with schizophrenia are partially or completely unaware of their mental disorder.ObjectivesThe aim of this study was to investigate the association between insight and medication adherence.MethodsA total number of 30 outpatients with schizophrenia spectrum disorders ,according to (DSM-V) diagnostic criteria who were attending the department of psychiatry A Razi hospital between august and September 30, 2023 were included in this study. Patients’ insight was measured by the birchwood insight scale. The degree of medication adherence was measured by using Medication Adherence Rating Scale (MARS).ResultsPatients enrolled in the study had a mean (SD) age of 43.2 .There was no significant correlation between patients’ insight and patients’ ages, duration of illness and hospitalization times. In addition, there was no significant association between medication adherence and age, duration of illness, number of hospitalization or social level. Impaired insight was associated with poor antipsychotic medication adherence in patients with schizophrenia spectrum disorders .Higher insight was correlated to higher therapeutic adherence. Our results showed that the level of insight and compliance to treatment are positively correlated.Conclusions The results of this study support the hypothesis that insight and treatment adherence are closely related. Interventions to enhance insight may be helpful in improving medication adherence.Disclosure of InterestNone Declared

Sociodemographic profile and prescribing pattern of antipsychotic medication in patients with Schizophrenia

IntroductionSchizophrenia is a complex psychiatric disorder that changes the patient’s life by influencing how they think, behave, express emotions, percept reality and their interpersonal relationships.ObjectivesThe aim of this study was to evaluate sociodemographic and therapeutic factors that act as risk and protective factors in the clinical outcomes of patients diagnosed with schizophrenia.MethodsThis was an observational retrospective study including patients diagnosed with schizophrenia, treated at the “Xhavit Gjata” Psychiatric Hospital, Tirane, Albania, who were discharged between May 1- October 30, 2022. The follow-up period was six months. Data on further hospitalizations during the follow-up were obtained from the Department of Statistics, QSUT, and confirmed by family members for hospitalizations in other psychiatric hospitals in the country. Univariate and multivariate analyses were conducted to identify potential factors associated with emergency room stays, length of stay, and time until the next admission.ResultsA total of 158 patients were included in the study, 63 women and 95 men (p=0.03). The average age of the patients was 42.9 years, with women averaging 45.3 years and men 40.6 years (p=0.01). 43.7% of them had elementary education. The average age of disorder onset was 24.7 years. Haloperidol was the ambulatory therapy used in 54.3% of patients, while atypical antipsychotics were used in 75.1% of patients. The most commonly used atypical antipsychotic was Risperidone in 34.1% of patients, followed by Olanzapine in 17% of cases. Depo antipsychotics were used in 35.1% of patients. Clozapine was administered to 29.3% of patients, where 12.8% for the first time. 54.2% of patients starting Clozapine for the first time had three or more admissions. Clozapine was more frequently used in men, showing a significant difference from women (p=0.05). In 44.7% of cases, monotherapy was prescribed. The average hospital stay was 21.9 days, ranging from 2-68 days. Living with a family member, male gender, and being “married” helped reduce the length of hospital stay. In the 6-month follow-up period, 31.4% were re-hospitalized. Significant factors affecting the reduction of time spent outside the hospital until the next hospitalization were social problems, the number of previous hospitalizations, civil status “not married,” living arrangements, negative symptoms, and alcohol use (nearly significant). Protective factors included Clozapine, which reduced the prevalence of hospitalization by 57% compared to patients not taking it. Additionally, the use of Clozapine and Haloperidol increased the time spent outside the hospital.ConclusionsSocial and family support, positive compliance, and antipsychotic therapy such as Clozapine serve as protective factors for patients diagnosed with schizophrenia.Disclosure of InterestNone Declared

The Risk of Venous Thromboembolism Events Resulting in Hospitalization following Exposure to Antipsychotic Medication in Pre-Disposed Adult Patients.

Introduction: The primary objective of this study was to compare the incidence of antipsychotic use in those with venous thromboembolism (VTE) resulting in hospital admission. This study expands upon current knowledge regarding VTE risk and antipsychotic use and investigates potential risk factors and lab values that may precede antipsychotic-induced coagulopathy. Methods: This retrospective, case-control, chart review investigated patients admitted to an acute care hospital with either a VTE or non-VTE diagnosis. Primary outcome analysis compared the presence of an antipsychotic medication in patients who had a VTE versus those who did not. Secondary analysis included: 1) the duration, class, dose, frequency, and route of antipsychotic and 2) coagulation parameters, patient characteristics, and VTE risk factors. Results: Analysis included 400 participants with 200 participants in each group (VTE and non-VTE). Of the 51 patients who received an antipsychotic, 29 (56.9%) developed or presented with a VTE. However, there was no significant difference in VTE development between groups when controlled for antipsychotic use (OR 1.37, 95% CI 0.76-2.50, P-value=0.30). Conclusion: While primary study findings were not statistically significant, results support a weak association of exposure to antipsychotic(s) in VTE groups compared to control (non-VTE). Obesity significantly increased the odds of VTE whereas a history of type 2 diabetes significantly decreased the odds of VTE.

Ethnic differences in response to atypical antipsychotics in patients with schizophrenia: individual patient data meta-analysis of randomised placebo-controlled registration trials submitted to the Dutch Medicines Evaluation Board.

Little is known about the effect of ethnicity on the response to antipsychotic medication in patients with schizophrenia. To determine whether ethnicity moderates the response to antipsychotic medication in patients with schizophrenia, and whether this moderation is independent of confounders. We analysed 18 short-term, placebo-controlled registration trials of atypical antipsychotic medications in patients with schizophrenia (N = 3880). A two-step, random-effects, individual patient data meta-analysis was applied to establish the moderating effect of ethnicity (White versus Black) on symptom improvement according to the Brief Psychiatric Rating Scale (BPRS) and on response, defined as >30% BPRS reduction. These analyses were corrected for baseline severity, baseline negative symptoms, age and gender. A conventional meta-analysis was performed to determine the effect size of antipsychotic treatment for each ethnic group separately. In the complete data-set, 61% of patients were White, 25.6% of patients were Black and 13.4% of patients were of other ethnicities. Ethnicity did not moderate the efficacy of antipsychotic treatment: pooled β-coefficient for the interaction between treatment and ethnic group was -0.582 (95% CI -2.567 to 1.412) for mean BPRS change, with an odds ratio of 0.875 (95% CI 0.510-1.499) for response. These results were not modified by confounders. Atypical antipsychotic medication is equally effective in both Black and White patients with schizophrenia. In registration trials, White and Black patients were overrepresented relative to other ethnic groups, limiting the generalisability of our findings.

Prescribing pattern of anti-psychotic medications in patients with dementia in Oman: a retrospective observational study

BackgroundAggression, agitation, psychosis, and sleep disturbances are common behavioral symptoms of people with dementia and they can be distressing for both individuals and their carers. Due to their potential side effects, antipsychotic medications are recommended only for severe behavioral and psychological symptoms of dementia (BPSD). This study explores the prevalence, patterns, and associated factors with antipsychotic drug use among patients with dementia attending geriatric psychiatry services at Sultan Qaboos University Hospital (SQUH). Using a retrospective cross-sectional design, this study examines antipsychotic use among elderly patients aged 60 years or older with dementia who attended geriatric psychiatry services from January 2020 to December 2021. The following information was solicited: socio-demographic factors, type and severity of dementia, presence of co-morbid medical or mental illness, the psychotropic medications prescribed, the anti-psychotic medication use, duration of use, and the indication of use were solicited as well. A multivariate logistic regression analysis was conducted.ResultsThe total prevalence of anti-psychotic use among elderly patients with dementia was 56.6%, and among them, 59% were prescribed anti-psychotics for more than 2 years. Being female, having non-Alzheimer’s dementia, experiencing severe stages of dementia, and having other medical or mental co-morbid conditions were independent predictors of antipsychotic drug use (odds ratio [OR] =1.85, confidence interval [CI] =1.04–3.30; OR=2.77, C.I. 1.52–5.04; OR=4.47, C.I. 2.18–9.18; and OR=2.54, C.I. 1.11–5.78, respectively).ConclusionsAntipsychotic medication use is prevalent among elderly patients with dementia in Oman. The results from this study will help the policymakers and psychiatrists in Oman to plan for the use of non-pharmacological strategies as the first line of management for BPSD.

Gender differences in the response to antipsychotic medication in patients with schizophrenia: An individual patient data meta-analysis of placebo-controlled studies

ObjectiveTo determine whether gender and menopausal status moderate the response to antipsychotic medication in patients with schizophrenia. MethodsWe analyzed data of 22 short-term placebo-controlled registration trials of antipsychotic medications, which included 5,231 patients with schizophrenia. We applied two-step individual patient data meta-regression analyses to establish the influence of gender and menopausal status on treatment response in mean difference in symptom severity and difference in response (>30% symptom reduction). Analyses were performed both with and without correction for baseline (negative) symptom severity. ResultsAntipsychotic treatment is associated with larger mean symptom reduction in women than in men with schizophrenia. The number needed to treat (NNT) for a response in women was 6.9, in men 9.4. Although, we found an age by gender effect, the gender by treatment effect was independent of premenopausal status and baseline (negative) symptom severity. ConclusionIn the treatment of schizophrenia we found evidence of a higher response to antipsychotic medication in women relative to men. We found no evidence that this effect was driven by menopausal status, or baseline (negative) symptom severity. Despite the impact of gender and age on effect size in acute antipsychotic treatment, efficacy was clinically relevant in all subgroups.

Treatment persistence in patients with schizophrenia treated with lurasidone in Italian clinical practice

Background and rationaleTreatment persistence combines clinician and patient judgment of efficacy, tolerability and safety into a comprehensive measure of effectiveness and is defined as the act of continuing a treatment over time. Studies have reported poor treatment persistence to antipsychotic medications in patients with schizophrenia. This study evaluated treatment persistence to lurasidone (LUR) in patients with schizophrenia in a real-world Italian setting.MethodsThis was a retrospective observational study of patients with schizophrenia who started treatment with LUR ≥ 6 months before inclusion. Following informed consent, data were collected starting from the index date (start of LUR treatment) at all visits occurring as per clinical practice. The primary endpoint was treatment persistence during the first 6 months, defined as the time between index date and all-cause discontinuation. Patients treated with LUR > 180 days were considered persistent. As secondary endpoint, treatment persistence was evaluated for a period of ≥ 18 months.ResultsForty-five patients were enrolled and 41 (91.11%) completed the study. Forty-one patients (91.11%) were included in the eligible population as they initiated LUR treatment ≥ 6 months before data collection.Patients were 43.0 ± 15.89 years old and 61% were female. Twenty-two patients (53.66%) started LUR treatment in a hospital setting and 19 (46.34%) in an outpatient setting. Based on Clinical Global Impression—Severity scale (CGI-S) at LUR initiation, 12 patients (29.27%) were severely ill, 17.07% markedly ill, 19.51% moderately ill, 2.44% mildly ill and 4.88% borderline mentally ill. Thirty-two patients (78.05%) were treatment persistent for ≥ 180 days. Among the 19 patients observed for ≥ 18 months, 11 (57.89%) were persistent for ≥ 18 months. Among the 22 study patients observed for < 18 months, 12 (54.54%) were persistent. An improvement in schizophrenia severity according to CGI-S was observed at inclusion (following LUR therapy) compared to the index date. Six patients (14.63%) experienced at least one adverse drug reaction: akathisia (7.32%), extrapyramidal disorder (4.88%), hyperprolactinemia (2.44%), restlessness (2.44%), and galactorrhea (2.44%). None were serious.ConclusionsPersistence to LUR in patients with schizophrenia was relatively high: 78% and 58% of patients were still on LUR after 6 and 18 months of treatment, respectively. This may reflect LUR’s relatively favorable balance between efficacy and tolerability, as well as favorable patient satisfaction and acceptance.

Halting the Metabolic Complications of Antipsychotic Medication in Patients with a First Episode of Psychosis: How Far Can We Go with the Mediterranean Diet? A Pilot Study

Patients with first-episode psychosis (FEP) often adopt unhealthy dietary patterns, with a risk of weight gain and metabolic and cardiovascular disease. In 21 FEP patients receiving nutritional intervention based on the Mediterranean diet (MedDiet), we explored differences in anthropometric and biometric parameters, according to their antipsychotic (AP) medication: AP1, associated with a lower risk, or AP2, associated with a higher risk of weight gain and metabolic complications. The blood biochemical profile was recorded before and after dietary intervention, and dietary habits and body composition were monitored for six months. Following intervention, all of the patients recorded significant increases in the consumption of fruit and vegetables and decreases in red meat and poultry consumption, with closer adherence to the MedDiet and a reduction in the daily intake of calories, carbohydrates, and sodium. Vegetable consumption and energy, protein, and carbohydrate intake were lower in AP1 patients than in AP2 patients. There was no significant weight gain overall. A reduction was demonstrated in total and LDL cholesterol, sodium, urea, and iron (lower in AP1 patients). It was evident that AP medication affected blood levels of lipids, urea, and iron of FEP patients, but MedDiet nutritional intervention led to a significant improvement in their eating habits, with a restriction in weight gain and a decrease in blood sodium and urea.

Smoke, GPx activity and symptoms improvement in patients with drug-naive first-episode schizophrenia: A large-scale 12-week follow-up study.

The relationship between tobacco smoke and schizophrenia (SZ) is well established. Smoking is hypothesized to alleviate symptoms and reduce the adverse effects of antipsychotic medications in patients with SZ. However, the underlying biological mechanisms by which smoke improves symptoms in SZ remain unclear. The aim of this study was to investigate the effect of smoking on clinical symptoms and antioxidant enzyme activity after risperidone treatment in a 12-week prospective cohort study of drug-naïve first-episode (DNFE) SZ patients. Two hundred and fifteen DNFE patients were recruited and received 12 weeks of risperidone monotherapy. The Positive and Negative Syndrome Scale (PANSS) was used to assess the severity of patient's symptoms at baseline and post-treatment. Plasma GPx activity was also measured at baseline and at the end of 12 weeks. Smokers showed greater improvement in negative symptoms relative to nonsmokers with DNFE SZ. In addition, repeated ANCOVA analysis showed no significant interaction of time and group on GPx activity. Improvement in negative symptoms was not associated with changes in GPx activity. However, in nonsmokers, increased GPx activity was correlated with improvement in positive symptoms.

Graph-Theory-Based Degree Centrality Combined with Machine Learning Algorithms Can Predict Response to Treatment with Antipsychotic Medications in Patients with First-Episode Schizophrenia

Objectives Schizophrenia (SCZ) is associated with disrupted functional brain connectivity, and antipsychotic medications are the primary and most commonly used treatment for schizophrenia. However, not all patients respond to antipsychotic medications. Methods The study is aimed at investigating whether the graph-theory-based degree centrality (DC), derived from resting-state functional MRI (rs-fMRI), can predict the treatment outcomes. rs-fMRI data from 38 SCZ patients were collected and compared with findings from 38 age- and gender-matched healthy controls (HCs). The patients were treated with antipsychotic medications for 16 weeks before undergoing a second rs-fMRI scan. DC data were processed using DPABI and SPM12 software. Results SCZ patients at baseline showed increased DC in the frontal and temporal gyrus, anterior cingulate cortex, and precuneus and reduced DC in bilateral subcortical gray matter structures. However, those abnormalities showed a clear renormalization after antipsychotic medication treatments. Support vector machine analysis using leave-one-out cross-validation achieved a correct classification rate of 84.2% (sensitivity 78.9%, specificity 89.5%, and area under the receiver operating characteristic curve (AUC) 0.925) for differentiating effective subjects from ineffective subjects. Brain areas that contributed most to the classification model were mainly located within the bilateral putamen, left inferior frontal gyrus, left middle occipital cortex, bilateral middle frontal gyrus, left cerebellum, left medial frontal gyrus, left inferior temporal gyrus, and left angular. Furthermore, the DC change within the bilateral putamen is negatively correlated with the symptom improvements after treatment. Conclusions Our study confirmed that graph-theory-based measures, combined with machine-learning algorithms, can provide crucial insights into pathophysiological mechanisms and the effectiveness of antipsychotic medications.

Tapered discontinuation vs. maintenance therapy of antipsychotic medication in patients with first-episode schizophrenia: Obstacles, findings, and lessons learned in the terminated randomized clinical trial TAILOR.

AimEvidence is insufficient regarding the consequences of discontinuing vs. maintaining antipsychotic medication in patients with first-episode schizophrenia. Our aim was to examine tapered discontinuation vs. maintenance treatment regarding remission of psychotic symptoms and impact on other areas.MethodsPatients included had a diagnosis of schizophrenia, were treated with antipsychotic medication, and were in remission of psychotic symptoms. Participants were randomized to tapered discontinuation or maintenance treatment with antipsychotic medication. Assessments were undertaken at baseline and after 1-year. The primary outcome was remission of psychotic symptoms without antipsychotic medication.ResultsThe trial was terminated due to insufficient recruitment. In total, 29 participants were included: 14 in the tapering/discontinuation group and 15 in the maintenance group. Adherence to maintenance treatment was poor. At 1-year follow-up, remission of psychotic symptoms without antipsychotic medication for 3 months was observed in five participants in the tapering/discontinuation group and two in the maintenance group.ConclusionDue to insufficient recruitment this study does not provide a conclusion on whether unfavorable outcomes or advantages follow tapering of antipsychotic medication. Recruitment and adherence to maintenance treatment encountered obstacles. Based on experiences from this trial, we discussed alternative study designs as consistent evidence is still needed on whether to continue or discontinue antipsychotic medication in remitted patients with first-episode schizophrenia.Clinical trial registrationhttps://www.clinicaltrialsregister.eu/ctr-search/trial/2016-000565-23/DK, EU Clinical Trials Register—EudraCT no. 2016–000565–23.

Correlates of Conversion from Mild Cognitive Impairment to Dementia with Lewy Bodies: Data from the National Alzheimer's Coordinating Center.

Many patients with dementia with Lewy bodies (DLB) miss out on the best standards of care and psychosocial support due to diagnostic delays or inaccuracies following symptom onset. This study seeks to identify baseline characteristics in individuals with mild cognitive impairment (MCI) that correlate with eventual conversion to DLB or Alzheimer's disease (AD). Baseline neuropsychological and neuropsychiatric data were analyzed in National Alzheimer's Coordinating Center participants who completed the Uniform Data Set between 2006 and 2020 and subsequently converted from MCI to DLB or AD (n = 1632). Only 6% of participants with MCI converted to DLB. Among those who converted to DLB, multidomain amnestic MCI (aMCI) was the most common subtype at study entry. As part of logistic regression analyses, odds ratios (ORs) were estimated for conversion to DLB versus AD based on study-entry characteristics, adjusting for age, sex, education, and years to diagnosis. The strongest predictors of conversion to DLB (p≤0.0001) were nonamnestic MCI versus aMCI (OR 8.2, CI [5.0, 14]), multidomain MCI versus single-domain MCI (OR 2.7, CI [1.7. 4.2]), male sex (OR 4.2, CI [2.5, 7.1]), and presence of nighttime behaviors (OR 4.4 CI [2.8, 6.9]). A diagnosis of prodromal DLB should be considered in individuals with MCI who present with prominent executive/visuospatial deficits, neuropsychiatric symptoms, and less memory impairment. Early diagnosis of DLB may guide treatment planning, including the avoidance of antipsychotic medications in patients who develop psychotic symptoms, caregiver support, and initiation of early treatment(s) once medications become available.

Low-Value Care at the Actionable Level of Individual Health Systems

Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability. To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. This retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. Use of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions. Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs -0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs -0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs -0.06 [95% CI, -0.16 to 0.03] for systems with ≤20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with -0.09 [95% CI, -0.26 to 0.08] for the Northeast and -0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs -0.24 [95% CI, -0.36 to -0.12] for areas below the median level of spending; P < .001). The findings of this large cohort study suggest that system-level measurement and reporting of specific low-value services is feasible, enables cross-system comparisons, and reveals a broad range of low-value care use.

Association of Temporolimbic Volumes with Treatment Response to Antipsychotic Medication for Delusion in Patients with Alzheimer's Disease.

This study investigated the association between gray matter volume and the treatment response to antipsychotic medication in patients with Alzheimer's disease (AD). We included 26 AD patients with delusions from the Memory Impairment Center of the Pusan National University Hospital in South Korea. All participants underwent baseline brain magnetic resonance imaging and took risperidone as an antipsychotic medication for 6 weeks. Gray matter volumes were measured using voxel-based morphometry at baseline. Treatment response with respect to delusional symptoms was defined as the change in delusion item scores in the Korean version of the Neuropsychiatry Inventory (K-NPI), from baseline to 6 weeks later. A voxel-based multiple linear regression model integrated with statistical parametric mapping was used to investigate the association between gray matter volume and treatment response after controlling for covariates. The treatment response was significantly positively correlated with gray matter volume in the temporal lobe (both the fusiform gyri and the left superior and inferior temporal gyri) and the limbic system (the left parahippocampal gyrus and left amygdala) after controlling for age, sex, education level, total intracranial volume, risperidone dosage, baseline Korean version of the Mini-Mental Status Examination scores, and baseline K-NPI scores for the delusion and non-delusion domains (P < .001, uncorrected, KE > 100 voxels). Our findings suggest that specific gray matter volumes, including those of the temporal region and the limbic system, may affect treatment response to antipsychotic medication in terms of delusional symptoms in patients with AD.

Before writing that script: use of antipsychotic medication in patients with dementia in a CMHTOA

AimsA 2009 independent review commissioned by the UK government to review the use of antipsychotic medication in patients diagnosed with dementia produced the Time for Action report, often referred to as the Banerjee Report. It highlighted the common practise of using antipsychotics in the treatment of Behavioural and Psychological Symptoms of Dementia (BPSD) and the clinical issues this could raise especially when these medications were not being regularly reviewed. The audti was therefore carried out to determine whether patinets with BPSD in a Community Mental Health Team for Older adults (CMHTOA) in Mid Surrey, who had been diagnosed with BPSD, were being adequately assessed and managed in line with the current guidelines.MethodPatients with a diagnosis of dementia open to one of three teams in the CMHTOA during the months of October and November 2019 were identified, those being prescribed antipsychotic medication were selected and data from their electronic records collected and analysed to determine if clinicians: a) identified and documented the target behaviours, b) carried out a structured assessment using an ABC chart before commencing medication, c) reviewed the antipsychotic medication 6 weeks after it was commenced.ResultOf the 87 patients with a diagnosis of Dementia from October to November 2019, 18 were on antipsychotic medication. 100% of these had target behaviours identified and clearly documented, a sixth had a structured assessment prior to starting medication and 61% had been reviewed after the first 6 weeks of starting antipsychotics.ConclusionThe findings showed that a good proprotion of patients did not have the required structured assessment before commencement of treatment and that more needed to be done by way of improving regular reviews after antipsychotic treatment is commenced.

Effects of khat use on response to antipsychotic medications in patients with newly diagnosed schizophrenia: a retrospective study

Khat contains the amphetamine-like cathinone, and can trigger onset of schizophrenia and exacerbate pre-existing psychosis. However, it remains unknown whether the use of khat complicates the outcome of schizophrenia treatment. We tested the hypothesis that patients with schizophrenia who are using khat will fail to respond to standard antipsychotic treatment. We retrospectively studied a consecutive series of patients who presented to an adult psychiatric clinic in Al-Amal Psychiatric Hospital in Jazan, Saudi Arabia, between January 1, 2013 and December 31, 2016. Patients with newly diagnosed schizophrenia on antipsychotic monotherapy (n = 1007, 817 men) were included and categorized into khat and non-khat users. A khat chewing index was developed to further categorize low, mild, moderate and heavy khat users. Antipsychotic medications were reviewed to determine their potential and the cause of substitution in association with khat use. There were 483 (48%) khat users. Olanzapine, haloperidol and aripiprazole were the most frequently used drugs (46.3%, 15.6% and 10%, respectively). The retention rate of the initial drug differed between the khat users and nonusers (53.8% and 78.4%, respectively). The proportion of moderate and heavy users (55% and 49%, respectively) who changed their initial drug was greater than that of low and mild users (35.6% and 44.7%, respectively). Lack of drug efficacy was the most appealing reason for switching the initial drug among moderate (51.7%) and heavy khat users (48.4%). Khat use hinders an individual's response to initial antipsychotic drug treatment for schizophrenia. Further studies are warranted to investigate the treatment decisions for this group of patients.