High-dose Antipsychotics Research Articles

Association of Antipsychotic Dose With Survival of Advanced Cancer Patients With Delirium.

Delirium is common in patients with advanced cancer, and antipsychotics are widely used for its management. We aimed to explore the association of the antipsychotic dose with survival of terminally ill cancer patients with delirium. A secondary analysis of a multicenter prospective observational study was conducted. We enrolled adult advanced cancer patients who developed delirium and received antipsychotics at 14 palliative care units in Japan between September 2015 and May 2016. Hazard ratios of survival after starting antipsychotics between groups with different oral chlorpromazine equivalent doses: low: <100 mg, moderate: 100-200 mg, high: ≥200 mg, were calculated with adjustment for potential confounders using Cox regression. The antipsychotic dose-specific mortality risk was estimated with smooth splines. Of 453 patients enrolled, 422 patients were analyzed. The median antipsychotic dose was 92.6 mg: low-dose (N=231), moderate-dose (122), and high-dose (69). The median survival of all patients was 11 days. Compared with the low-dose group, the high-dose group showed a significantly shorter survival (HR: 1.46, 95%CI: 1.08-1.98). Smooth splines demonstrated that HR continuously increased as the antipsychotic dose increased. In patients treated with atypical antipsychotics, the high-dose group showed a significantly shorter survival than the low-dose group (HR: 2.86), while in patients treated with typical antipsychotics, survival was not significantly different (0.99). Higher doses of antipsychotics were associated with increased mortality in terminally ill cancer patients with delirium. To minimize the potential mortality risk, antipsychotics should be started at low doses and titrated carefully.

Late-onset schizophrenia patients with social phobia receive higher doses of antipsychotics compared patients without social phobia: results of an observational study

IntroductionSocial phobia is frequent comorbidity in schizophrenia. It`s clinical correlates and consequencies for clinical practice in late-onset schizophrenia (LoS) are unclear.ObjectivesThe study aimed to compare clinical correlates and therapeutic options in LoS patient with and without social phobia.Methods16 LoS patients with social phobia (ICD-11 diagnosis, age 59,6±6,2, 25% males) were compared with 16 LoS patients without social phobia (69,9±10,9, 0% males). Results of clinical assessment (PANSS, HDRS-17), cognitive examination (MMSE, MoCA), CT data were analysed. Type of antipsychotics (conventional\conconventional) was registed, dose of antipsychotics and antidepressants was randed from 1 (low) to 3 (high). Mann-Whitney test and χ2statistic was used.ResultsThere was no group differences in age, age manifestation, illness duration, number of psychotic episodes, PANSS and HADRS scores, rates results of cognitive tests, atrophy scores, length of hospital state, types of received antipsychotics. LoS patients with social phobia received more frequently medium and high doses of antipsychotics than LoS patient without social phobia (χ2 (2)=6,432, p=0,040).ConclusionsIncreased doses of antypsychotics in patients with social phobia don`t correlate with severity of psychotic symptoms and nay reflect some treatment resistance as well as misinterpretation of symptoms of social phobia as insufficient retreat of the psychosis. Active detection of social phobia is significant for treatment optimization.DisclosureNo significant relationships.

Case Series Evaluating the Use of Combined Long Acting Injectable Antipsychotics in Three Patients Within Forensic Services

AimsAntipsychotic polypharmacy is a relatively common practice, despite a lack of robust evidence. In 2018, the National Clinical Audit of Psychosis evaluated the treatment of 8000 patients with a diagnosis of schizophrenia or schizoaffective disorder, and found 10% were receiving non-clozapine antipsychotic polypharmacy. This included 432 patients receiving one oral &amp; one long acting injectable (LAI) antipsychotic and 2 patients receiving two LAI antipsychotics. An audit within our service, found that 24 of 88 (27%) inpatients were receiving non-clozapine antipsychotic polypharmacy. Of these, 3 were prescribed two LAI antipsychotics. A literature review found very limited evidence supporting the use of combined LAI antipsychotics, with publications relating to a total of 18 cases. Presented here is a case series, reviewing the use of LAI antipsychotic polypharmacy in three patients within Devon Partnership Trust.MethodsThe case series reports on three male inpatients, who are under the care of secure services within Devon Partnership Trust. All are currently prescribed two LAI antipsychotics. Two have a diagnosis of treatment resistant schizophrenia and one of schizoaffective disorder. All are complex, necessitating recurrent or lengthy admissions, and present with significant risk to others when unwell. In each case, there have been trials of multiple antipsychotics, but only one has had a previous trial of clozapine.ResultsPublished case reports highlight the positive effects of LAI polypharmacy, noting an improvement in mental state and lack of adverse effects. The cases presented here show significant variability, with one patient improving significantly, the second to a lesser extent, and the third remaining under high level observations.All cases are complex with decisions taken on a background of high risk, after multiple failed trials of medication.Although no specific adverse effects were reported, none of the patients regained sufficient insight to engage in treatment decisions and physical health monitoring. It is therefore difficult to quantify the adverse effect burden and weigh this against perceived efficacy.ConclusionCombined LAI antipsychotic medication is a possible treatment option in complex individual cases. Prescribing decisions are based on perceived clinical benefit, and the evidence base remains limited, with little understanding of long-term effects or consequences.Unlike high dose antipsychotics, there is no formalised guidance for prescribing combined LAI antipsychotics. Treatment targets and review processes were not always explicit. A more robust approach, would provide greater clarity around the practice and aid with future decision making.

The HDAT Helper - Developing an Online Tool to Improve the Safety and Accuracy of Antipsychotic Prescribing

AimsHigh Dose Antipsychotic Therapy (HDAT) prescriptions and combinations of antipsychotic agents are not currently recommended as standard practice by the RCPsych. College guidance (RCPsych, CR 190) advises that there is “little convincing evidence that off-label prescription of doses of antipsychotic medication above the licensed dosage range has any therapeutic advantage in any clinical setting” and that “any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target”. Despite this, both national and local data demonstrate that HDAT has continued to be used regularly across psychiatric inpatient settings, often out of hours and often secondary to the use of PRN Antipsychotics, without a clear treatment plan or rationale. My aim was to create a simple, accessible, online tool that would allow prescribers to quickly and efficiently calculate the BNF percentage of any antipsychotic prescription and that this will enable safer prescribing.MethodsWith the support of a web-developer, I developed an online tool quickly and easily calculate antipsychotic BNF percentages. The tool can be found here: www.hdat.co.ukResultsThe HDAT Helper has been well received at local presentations and I have recently gained the support of senior management at Southern Health NHS Foundation Trust to develop an education programme on HDAT and the HDAT Helper to expand use of the tool across Southern Health.ConclusionThe current expert guidance, clinical research and my own audit work demonstrates that there are ongoing issues with the prescription of high dose antipsychotics and that at times this occurs inadvertently when different agents are combined.I believe that the HDAT Helper can make prescribing of antipsychotic agents clearer and more efficient and as a result significantly improve patient safety.

Prescription of Anticholinergic Drugs in Patients With Schizophrenia: Analysis of Antipsychotic Prescription Patterns and Hospital Characteristics.

In several clinical guidelines for schizophrenia, long-term use of anticholinergic drugs is not recommended. We investigated the characteristics of the use of anticholinergics in patients with schizophrenia by considering psychotropic prescription patterns and differences among hospitals. A cross-sectional, retrospective prescription survey at the time of discharge was conducted on 2027 patients with schizophrenia from 69 Japanese hospitals. We examined the relations among psychotropic drug prescriptions regarding anticholinergic prescription. We divided the hospitals into three groups—low rate group (LG), medium rate group (MG), and high rate group (HG)—according to their anticholinergic prescription rates, and analyzed the relationship between anticholinergic prescription rates and antipsychotic prescription. Anticholinergic drugs were prescribed to 618 patients (30.5%), and the prescription rates were significantly higher for high antipsychotic doses, antipsychotic polypharmacy, and first-generation antipsychotics (FGAs) use. The anticholinergic prescription rate varied considerably among hospitals, ranging from 0 to 66.7%, and it was significantly higher in patients with antipsychotic monotherapy, antipsychotic polypharmacy, and normal and high doses of antipsychotics in HG than in those LG and MG. The anticholinergics prescription rate in patients with second-generation antipsychotic monotherapy in HG was also significantly higher than in those LG and MG; however, the difference was no longer significant in patients with FGA monotherapy. Conclusively, in addition to high antipsychotic doses, antipsychotic polypharmacy, and FGA use, hospital characteristics influence the prescribing of anticholinergic drugs.

An Examination of Electroconvulsive Therapy and Delivery of Care in Delirious Mania.

Delirious mania is a severe life-threatening syndrome, often misdiagnosed, and eminently treatable as a variant of catatonia. Our aim is to provide a comprehensive examination of electroconvulsive therapy (ECT) parameters and clinical features, as well as describe the delivery of care of the patients with delirious mania. A retrospective study was conducted of the ECT records at Stony Brook University Hospital from years 2014 to 2021. We characterized demographic and clinical variables, including psychiatric diagnoses and ECT parameters of patients identified with delirious mania. We identified 8 cases (3 women) of delirious mania with 8 corresponding acute treatment series. The mean age was 43.2 ± 12.6 years (range, 23-59 years). There were a total of 55 sessions performed with an average of 6.9 ± 2.6 (range, 5-13); 45 (82%) were bilateral (bifrontal or bitemporal) and 10 (18%) were right unilateral electrode placement. In 40 (73%) of the sessions, a high-energy stimulus was used (>60%, or 302 millicoulombs). Seizure duration measured on electroencephalogram was 47.4 ± 25.9 seconds (range, 0-143 seconds). Motor seizure duration measured on electromyogram was 32.7 ± 14.9 seconds (range, 0-66 seconds). In 6 cases, ECT was delayed for 10 days, and patients were given inappropriate treatments. High-dose antipsychotics caused worsened aggression and hemodynamic instability requiring physical restraints in 50% of cases. The clinical presentation of delirious mania remains poorly recognized, and its treatment is often delayed, which may result in negative outcomes. Bilateral ECT with high-energy dosing yielded a rapid remission of symptoms.

Dosing of Mood Stabilizers for Bipolar Disorder Patients in the Research on Asian Psychotropic Prescription Patterns Consortium Study.

Because use and dosing of mood stabilizers (MSs) to treat bipolar disorder (BD) patients in Asia are not well documented, we examined prevalence and clinical correlates of treatment of Asian BD patients with relatively high doses of MSs. We conducted a pharmacoepidemiological survey across 13 Asian countries and territory in the Research on Asian Psychotropic Prescription Patterns Consortium. Mood stabilizer doses were converted to lithium carbonate equivalents (Li-eq milligrams per day). We compared relatively high (>900 Li-eq mg/day) versus lower MS doses by bivariate comparisons, followed by multivariable linear regression to identify factors associated with higher MS doses. Among 1647 participants, MS dose averaged 584 (confidence interval, 565-603 Li-eq mg/d). Preliminarily, the 13.1% of the subjects given greater than 900 mg/d versus those given lower doses were younger, male, currently hospitalized, not currently depressed, and reported lifetime suicidal ideation; they also received relatively high doses of antipsychotics, received electroconvulsive treatment within the previous 12 months, and had greater ratings of tremors and sedation. By linear regression modeling, the mean proportion given high doses of MS was associated significantly and independently with higher doses of antipsychotics, younger age, male sex, hospitalized, more years of illness, country, higher body mass index, recent electroconvulsive treatment, and being in illness remission. Relatively high doses of MSs for BD are prevalent, but vary markedly among Asian countries, and are particularly likely among young males, ill for many years, and given high doses of antipsychotics or ECT. These characteristics allow better identification of patient profiles that can guide treatment of BD patients.

Associations of Antipsychotic Doses with Dysregulated Rest-Activity Rhythms in People with Chronic Schizophrenia

<h3>Introduction</h3> Peoplewith schizophrenia (PwS) have a shortened lifespan by 15 to 20 years, primarily due to metabolic disturbances and cardiovascular disease. Increased metabolic risk in PwS is partly due to sedentary lifestyles, unhealthy diets, inadequate healthcare, and side effects from antipsychotics. Dysregulated rest-activity rhythms (RARs) are a key risk factor for metabolic health that are common yet understudied in PwS and could be a potential treatment target. This study aims to objectively assess and compare RAR variables in PwS and a non-psychiatric comparison group (NCs). We also examined how RAR variables were associated with sociodemographic factors and daily antipsychotic dose. We hypothesized that PwS would have more dysregulated RAR measures than NCs. Among PwS, we explored how antipsychotic dose was associated with RAR variables. <h3>Methods</h3> Studyparticipants included 26 PwS (DSM-IV-TR criteria) and 36 NCs from the greater San Diego Area. We collected sociodemographic variables, clinical data (e.g., antipsychotic dose as defined by the WHO, symptom severity, physical well-being measured by the 36-Item Short Form Survey or SF-36), and subjective sleep quality (Pittsburgh Sleep Quality Index or PSQI). Participants wore wrist-worn actigraphy devices for up to 7 days to record 24-hour sleep-wake activity patterns. We analyzed the raw data using non-parametric and extended-cosine modeling approaches (RAR variables included: interdaily stability [IS], interdaily variability [IV], relative amplitude [RA], most active 10 hours [M10], least active 5 hours [L5], peak activity time [acrophase], active period start-time [t-left], period start-time [t-right], and relative width of active to rest periods [alpha]). We compared sociodemographic, physical well-being, and subjective sleep between PwS and NCs using independent sample t-tests and chi-square tests. Among the PwS group, we used general linear models to examine associations of antipsychotic doses, age, race, sex, and education with RAR variables. <h3>Results</h3> Meanage and % female of PwS and NCs were similar to each other (51.4 years vs. 53.0 years and 50% vs. 53.8%, respectively). PwS were 34.6% of non-Caucasian ethnicity, and PwS were 19.4% of non-Caucasian ethnicity. PwS had worse physical well-being (p=0.004) and poorer sleep quality (p=0.004) compared to NCs. Among PwS, 91.3% of the group was currently taking atypical antipsychotic medications. The PwS group had significantly higher alpha (mean -0.3 [SD 0.3] vs. mean 0.8 [SD 0.2], t(60) = 3.03, p=0.004, d=0.75), lower RA (mean 0.8 [SD 0.3] vs. mean 0.9 [SD 0.2], t(60) = -2.18, p=0.03, d=-0.53), and lower M10 (mean 2160 [SD 816] vs. mean 2650 [SD 673], t(60) = -2.58, p=0.01, d=-0.65), compared to the NCs. AmongPwS, female sex was associated with lower alpha (B=0.262, p=0.024, η_p²=0.038) and having earlier t_right (B=-2.905, p=0.029, η_p²=0.216). Among PwS, Caucasian ethnicity was associated with higher RA (B=0.15, p=0.028, η_p²=0.22) and lower L5 (B=-272.814, p=0.015, η_p²=0.263). Higher antipsychotic doses were associated with lower IS (B=-0.027, p=0.036, η_p²=0.203). <h3>Conclusions</h3> Wefound that RAR variables differed between PwS and NCs, and that among PwS, higher antipsychotic doses were associated with less day-to-day stability of RARs. This finding is consistent with two other studies that showed antipsychotic exposure may be related to decreased motor activity. The impact of antipsychotics on dysregulated RARs suggests a possible mechanistic pathway for antipsychotic-mediated metabolic risk. Limitations of the study include the modest sample size and predominant use of atypical antipsychotic medications. Further understanding of the impact of antipsychotic medications on RARs could help to develop and tailor interventions to mitigate antipsychotic-related side effects and improve health among PwS. <h3>This research was funded by</h3> This work was supported, in part, by the National Institute of Mental Health [an R01 grant (R01MH094151-01 to Dilip Jeste [PI]), and a K23 grant (K23 MH119375-01 to EEL [PI], National Institute on Aging T35 grant AG26757 (PI: Dilip V. Jeste, MD and Alison Moore, MD, MPH), and National Institutes of Health Grant NIH UL1TR001442 of CTSA (PI: Gary Firestein, MD), as well as the Stein Institute for Research on Aging at the University of California San Diego. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Aside from the funding sources listed above, the authors have no conflicts of interest to report.

Antipsychotic Polypharmacy and High-Dose Antipsychotic Regimens in the Residential Italian Forensic Psychiatric Population (REMS).

Few data exist regarding treatment with antipsychotics in forensic psychiatric patient populations with high social dangerousness. We performed a secondary analysis of 681 patients treated with at least one antipsychotic, extracted from a 1-year observational retrospective study, conducted on 730 patients treated in the Italian Residencies for Execution of Security Measures (REMS) (96.4% of the REMS population). We aimed at investigating antipsychotic polypharmacy (prescription of two or more concomitant antipsychotics) and high dose/very high-dose antipsychotics, as well as the possible factors associated with such therapeutic regimens. High dose/very high-dose antipsychotics were defined as a prescribed daily dose to WHO-defined daily dose ratio greater than 1.5 or 3.0, respectively. Binary logistic regression analysis was used in three models to test possible predictors of antipsychotic polypharmacy, high-dose antipsychotics, and very high-dose antipsychotic prescription. Antipsychotic polypharmacy resulted in n = 308 (45.2%) of the patients, n = 346 (50.8%) received high-dose antipsychotics, and n = 96 (14.1%) very high-dose antipsychotics. The multivariate analysis disclosed an association between antipsychotic polypharmacy and male gender (odds ratio (OR): 2.75 and 95% CI: 1.34–5.65), long-acting injectable (LAI) antipsychotic prescription (OR: 2.62 and 95% CI: 1.84–3.74), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.13–2.36). High-dose antipsychotics were also associated with male gender (OR: 2.01 and 95% CI: 1.02–3.95), LAI antipsychotic prescription (OR: 2.78 and 95% CI: 1.95–3.97), and aggressive behavior in REMS (OR: 1.63 and 95% CI: 1.12–2.36). The use of antipsychotic polypharmacy and high-dose antipsychotics is frequent in the REMS population. These results might depend on regulatory and organizational aspects of the REMS system, including variability in structures, lack of a common model of care, and lack of stratified therapeutic security.

Sexual dysfunction in people treated with long‐acting injectable antipsychotics in monotherapy or polypharmacy: a naturalistic study

Sexual dysfunction, psychosis, and antipsychotics are known to be related, but the precise association between them is still unknown. Most evidence about the prevalence of sexual dysfunction in people treated with antipsychotic drugs comes from studies with restrictive samples. That is why our main objective was to determine the prevalence of sexual dysfunction in a real-life sample of outpatients treated with antipsychotics, considering gender. A cross-sectional naturalistic study was developed, including people treated with long-acting injectable antipsychotics, with or without other psychotropic drugs. Participants were interviewed to assess sexual satisfaction through a Likert scale (0 to 10) and the presence of sexual dysfunction (the Psychotropic-Related Sexual Dysfunction Questionnaire, PRSexDQ-SALSEX). The participants also had a blood test to determine prolactin (men and women) and testosterone levels (men only). A total of 131 people participated in the study (90 men and 41 women). Some extent of sexual dysfunction was found in 62.2% of men and 51.2% of women. The most frequent sexual dysfunction symptom for both genders was the loss of libido (45%). Hyperprolactinemia was present in 56% of men and 61% of women. The presence of sexual dysfunction was associated with higher doses of antipsychotics, hyperprolactinemia, and smoking in men and with smoking and hyperprolactinemia in postmenopausal women. This study provides real-life evidence of sexual dysfunction and hyperprolactinemia in persons treated with long-acting injectable antipsychotics segregated by gender. The high rates of sexual dysfunction and hyperprolactinemia detected corroborate the need to consider these aspects in clinical practice.

Impact on hospital-wide antipsychotic prescribing practices through physician peer comparison letters.

Peer comparison is a behavioral strategy that provides feedback to individuals on how they compare with others. It is used to improve health care quality, reduce inappropriate prescribing, and improve physician performance. There is very little data on peer comparison and the impact on system-wide prescribing practices, particularly with antipsychotics. To that end, the Maryland statewide pharmacy and therapeutics committee reviews hospital-level antipsychotic data for 5 facilities on a quarterly basis, including high doses and polypharmacy. One facility, Springfield Hospital Center, consistently stood out in 2016 as having higher rates of high doses of haloperidol, olanzapine, and quetiapine as well as patients receiving 3 or more antipsychotics. The pharmacist began to send out individual letters to the psychiatrists detailing their prescribing habits in these areas compared with other psychiatrists and the other state facilities. Over the course of 4 years, the percentage of patients on high doses of 3 antipsychotics substantially decreased. The percentage of patients on polypharmacy in the facility decreased, but not at the same rate as the other hospitals, leaving the facility even higher than the state average at the end of the 4-year period. Pharmacist-initiated physician peer comparison letters were associated with a considerable decrease in the prevalence of high-dose olanzapine, haloperidol, and quetiapine but did not appear to impact antipsychotic polypharmacy. This type of communication may be beneficial for stimulating system-wide changes in prescribing practices for high doses of antipsychotics; however, more individualized interventions are likely needed to reduce antipsychotic polypharmacy.

Abstract- Poster

INTRODUCTION:A person with schizophrenia is more prone to obsessive-compulsive disorder (OCD) and obsessive-compulsive symptoms (OCS) when compared to the general population. Schizo-obsessive disorder is diagnosed when a person has schizophrenia with co-existing OCD or OCS. It is associated with depressive symptoms, no definitive diagnostic criteria and has poor response to polypharmacotherapy.CASE SUMMARY:A 23-year-old-man with no significant family history and symptoms suggestive of paranoid schizophrenia, was on intermittent treatment for 6 years. Since the past one year, he also had OCS and depressive symptoms – constantly checking himself if he passed stools, reduced appetite, disturbed sleep, suicidal thoughts. He has multiple hospital visits where they have changed the anti-psychotics and their dosage, given electro-convulsive therapy, but couldn’t be relieved of his symptoms. He was started on high dose antipsychotics of two different classes and serotonin agonists, but still did not improve.CONCLUSION:Schizo-obsessive disorder is a diagnostic difficulty to the clinician, reported to have poor prognosis. It significantly affects one’s general, social and occupational functioning. Research is required on its psychopathology, treatment protocols and its diagnostic criteria is yet to be established. Antidepressant, depression, insight, internalized stigma

Exploring Hidden Issues in the Use of Antipsychotic Polypharmacy in the Treatment of Schizophrenia.

The mainstay of schizophrenia treatment is pharmacological therapy using various antipsychotics including first- and second-generation antipsychotics which have different pharmacokinetic and pharmacodynamic property leading to differential presentation of adverse events (AEs) and treatment effects such as negative symptoms, cognitive symptoms and cormorbid symptoms. Major treatment guidelines suggest the use of antipsychotic monotherapy (APM) as a gold standard in the treatment of schizophrenia. However, the effects of APM is inadequate and less potent to achieve symptom remission as well as functional recovery in real practice which has been consistently reported in numerous controlled clinical trials, large practical trials, independent small studies and systematic reviews till today. Therefore antipsychotic polypharmacy (APP) regardless of the class of antipsychotics has been also commonly utilized for many reasons in real world practice. However, APP has also crucial pitfalls including increase of total psychotics including antipsychotics, high-doses of antipsychotics used, poor compliance, drug-drug interaction and risks for developing AEs, all of which are paradoxically related to poor clinical outcomes, whereas APP has also substantial advantages in reduction of re-hospitalization, severe psychopathology and targeted control of concurrent symptoms. Given currently limited therapeutic options, it is also important to properly utilize APP in order to maximize its clinical utility and minimize its risk for better treatment outcomes for patients with schizophrenia, based on risk/benefit with full understanding of pharmacological and clinical issues on APP. The present paper intends to address intriguing and important issues in the use of APP in real world practice.

Further evidence that antipsychotic medication does not prevent long-term psychosis in higher-risk individuals.

Although existing guidelines have discouraged use of antipsychotics for general clinical high-risk (CHR) individuals, it is unclear if antipsychotics can prevent psychosis in higher-risk population. We aimed to study the comparative real-world effectiveness of antipsychotic treatments for preventing psychosis in higher-risk CHR individuals. A total of 300 CHR individuals were identified using the structured interview for prodromal syndromes (SIPS) and followed the participants for 3 years. In total, 228(76.0%) individuals completed baseline assessments using the NAPLS-2 risk calculator (NAPLS-2-RC), and 210(92.1%) completed the follow-up. The sample was further stratified according to risk level. "Higher-risk" was defined based on the NAPLS-2-RC risk score (≥ 20%) and SIPS positive symptom total scores (≥ 10). The main outcome was conversion to psychosis and poor functional outcomes, defined as a global assessment of function (GAF) score lower than 60 at follow-up. In higher-risk CHR individuals, we found no significant difference in the rate of conversion to psychosis or poor functional outcomes between the antipsychotic and no-antipsychotic groups. Low-risk individuals treated with antipsychotic drugs were more likely exhibit poor functional outcomes compared with the no-antipsychotics group(NAPLS-2-RC estimated risk: χ2 = 8.330, p = 0.004; Positive symptom severity: χ2 = 12.997, p < 0.001). No significant effective factors were identified for prevention of the conversion to psychosis; conversely, CHR individuals who were treated with high dose antipsychotics (olanzapine, aripiprazole) showed a significantly increased risk of poor functional outcomes. In CHR individuals, antipsychotic treatment should be provided with caution because of the risk of poor functional outcomes. Further, antipsychotic treatment does not appear to prevent onset of psychosis in real-world settings.

How to Approach Delirium: A Case Report

Throughout our clinical practice, we all have encountered delirium at some point in time and have been confused about what we should do. We as practitioners are naturally inclined to using high-dose antipsychotics for agitation which can increase all cause mortality [1]. Delirium is a hypocholinergic-hyperdopaminergic state [1]. This case report helps simplify the steps a provider should take in approaching Delirium to minimize all-cause mortality, for which FDA has issued a black box warning [1]. As Delirium can be seen in any hospital unit, all healthcare providers would benefit from this case report, so the primary team, in any setting, can handle this presentation appropriately in an acute situation. The first approach should be nonpharmacological. After exhausting nonpharmacological approaches, pharmacological approaches may be used, including low-dose antipsychotics, with a maximum daily dose of the lower limit of the therapeutic range of that antipsychotic [1]. Providers must be mindful that delirium may last indefinitely, and that medications discussed in this case report are not to cure, rather to manage the symptoms [1].

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics.

Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

Antipsychotic Polypharmacy Among Patients With Schizophrenia in Africa: A Systematic Review and Meta-Analysis.

ObjectivesIn Africa, antipsychotic polypharmacy (APP) is increasing due to a high antipsychotic dose prescribing, repeated psychiatric hospitalization, uncontrolled psychotic symptoms, and greater side effect burden. Therefore, the aim of this review and meta-analysis is to assess the prevalence and correlates of APP among patients with schizophrenia in Africa.MethodsA systematic search was performed from August 1 to 31, 2020, on PubMed, MEDLINE, Google Scholar, and Science Direct databases to select articles based on the inclusion criteria. Meta-Analysis of Observational studies in Epidemiology guidelines were employed. Cross-sectional observational studies that reported APP and/or its correlates in schizophrenia patients in English language published in peer-reviewed journals without time limits were included in the review. The quality of included articles was assessed using Newcastle-Ottawa quality assessment tool. Prevalence and correlates of APP were the outcome measures of this review and meta-analysis. Open Meta Analyst and RevMan version 5.3 software were used for meta-analysis. A random effect model was used to synthesize data based on the heterogeneity test.ResultsSix studies that involved 2154 schizophrenia patients met the inclusion criteria in this review and meta-analysis. The quality of included studies ranges from 6.5 to 10 based on the Newcastle-Ottawa quality assessment tool. The pooled prevalence of APP among patients with schizophrenia was 40.6% with 95% confidence interval: 27.6% to 53.7%. Depot first-generation antipsychotics and oral first-generation antipsychotics were the most commonly prescribed APP combinations. Socio-demographic, clinical, and antipsychotic treatment characteristics were significantly associated with APP. There was a wide variation in the correlates of APP assessed by studies and the way that association/correlations was determined and reported.ConclusionsAPP is common and highly prevalent. Advanced age, male gender, longer duration of schizophrenia, hospital admission, and longer antipsychotic treatment were correlates of APP in Africa.

Case of refractory delirious mania responsive to lithium.

Delirious mania is an uncommon condition that is challenging to diagnose and treat. More often seen in patients with a history of bipolar disorder, it frequently presents with prominent catatonic features and overlaps with other diseases in the catatonic spectrum, such as neuroleptic malignant syndrome, serotonin syndrome and malignant catatonia. We present a case of delirious mania refractory to high doses of lorazepam, several antipsychotics and valproic acid, which responded dramatically to therapy with lithium after 26 days of minimal improvement with the other medications. The pathophysiology of delirious mania is reviewed, and the unique actions of lithium are discussed, highlighting possible reasons as to why lithium might offer advantages in the treatment of this disease.

Prescribing and monitoring high dose and combined antipsychotics in community mental health team

AimsThe aim was to establish the prevalence of prescription of combined and high dose antipsychotics in the community mental health team and to see if such patients were being offered regular monitoring as advised by NICE guidelines.BackgroundThe use of high dose antipsychotic treatment (HDAT) should be in line with the recommendations of the Royal College of Psychiatrists Consensus statement on high dose antipsychotic Treatment. Such treatment should be initiated only when standard treatments have failed. As high dose prescribing of antipsychotic medications can potentially harm than benefit causing serious side effects and sudden death. Close monitoring and documentation are required. Also, reviewing these patients at regular intervals is recommended.MethodA retrospective audit of 50 case notes of patients currently on antipsychotics was done. Case notes were selected randomly from a pool of 300 plus patients under the care of Isle of Wight NHS Trust in the HoNos Cluster 11 and 12 care pathways. Data were gathered on patients` demographics, diagnosis, medication monitoring. Data were analysed and discussed with consultant psychiatrist and senior mental health pharmacist. Patients who were not on any antipsychotic medications were not included in the audit.Result90% of the patients were on single antipsychotic (45 out of 50), 4.45% (2 out of 45)were above BNF recommended dose. 10% (5) patients were prescribed combined antipsychotics. 40% (2)of them were above BNF recommended maximum dose. A total of 8% (4 out of 50) patients were on above BNF recommended maximum dose. All the patients on high dose antipsychotics had a clear plan documented in the system. Documented monitoring of Full blood count was found in 75%, blood glucose in 50%, lipid in 75%, cardiac monitoring (Electrocardiogram or ECG) in 0%, physical health monitoring in 0%ConclusionAs far as we know, this is the first time an audit has been done on the patients under the Community Mental Health Team on high dose antipsychotic treatment. The data showed areas of good practice as the majority of the patients were on monotherapy, and all the patients on a high dose or combined antipsychotics had clear management plans outlined in their notes. However, the audit also highlighted areas that currently need improvements such as regular monitoring of the patients on high dose and combined antipsychotics. It should also be clearly documented, recorded, and reviewed at six-monthly intervals.

Audit of high dose antipsychotic prescribing in the havering community recovery team

AimsThe main aim of this audit was to determine the prevalence of HDAP in Havering Community Recovery Team (CRT). The secondary aim was to determine how well HDAP has been monitored and documented - specifically, whether discussions around the reasons for continuing and the risks and benefits have been discussed.BackgroundThere is a focus to reduce high dose antipsychotic prescribing (HDAP) due to the lack of evidence that it is efficacious and that smaller doses have an equivalent effect and are better tolerated. Similarly, the consensus by the Royal College of Psychiatrists is that any prescribing of high dose antipsychotics should be an 'explicit, time-limited individual trial’ with a distinct treatment target. There should be a clear plan for regular clinical review including safety monitoring. The high-dose regimen should only be continued if the trial shows evidence of benefit that is not outweighed by tolerability or safety problems.' Following a CQC inspection in 2014 of NELFT which found that the trust was failing to comply with the relevant requirements of the Health and Social Care Act 2008 with regards to safe use of medicines, yearly audits of inpatient HDAP have been undertaken. Although improvements have been made in the inpatient setting, no such audits have been performed in the community setting and consequently there is no data in NELFT regarding community services compliance with the above regulations.MethodAll 349 patients in Havering CRT clinical records were screen by either using RIO or GP letters from recent CPA reviews. A data collection and analysis tool was created using Microsoft Excel. Data collection and analysis was carried out by the project lead and checked by a fellow project member.ResultOf the 349 patients included for analysis: 16 (4.58%) of patients were prescribed a high-dose antipsychoticOf the 16 prescribed high dose antipsychotics: 0 out of 16 had the high dose antipsychotic monitoring form available12 (75%) had well documented evidence of review of HDAP.4 (25%) had no documented evidence of review of HDAP.ConclusionThere is a small group of patients receiving high dose antipsychotic therapy for which better monitoring is needed. This should include education of staff regarding HDAP, better documentation in their care plans and working with pharmacy to make HDAP monitoring forms available widely in the community.