Antipsychotic Initiation Research Articles

Metabolic events associated with the use of antipsychotics in children, adolescents and young adults: a multinational sequence symmetry study.

It is known that younger patients treated with antipsychotics are at increased risk of metabolic events; however, it is unknown how this risk varies according to ethnicity, the class of antipsychotic and the specific product used, and by age group. We conducted a multinational sequence symmetry study in Asian populations (Hong Kong, Japan, Korea, Taiwan and Thailand) and non-Asian populations (Australia and Denmark) to evaluate the metabolic events associated with antipsychotics in both Asian and non-Asian populations, for typical and atypical antipsychotics, and by the subgroups of children and adolescents, and young adults. Patients aged 6-30years newly initiating oral antipsychotic drugs were included. We defined a composite outcome for metabolic events which included dyslipidemia, hypertension and hyperglycemia. We calculated the sequence ratio (SR) by dividing the number of people for whom a medicine for one of the outcome events was initiated within a 12-month period after antipsychotic initiation by the number before antipsychotic initiation. This study included 346,904 antipsychotic initiators across seven countries. Antipsychotic use was associated with an increased risk of composite metabolic events with a pooled adjusted SR (ASR) of 1.22 (95% CI 1.00-1.50). Pooled ASRs were similar between Asian (ASR, 1.22; 95% CI 0.88-1.70) and non-Asian populations (ASR, 1.22; 95% CI 1.04-1.43). The pooled ASR for typical and atypical antipsychotics was 0.98 (95% CI 0.85-1.12) and 1.24 (95% CI 0.97-1.59), respectively. No difference was observed in the relative effect in children and adolescents compared to young adults. The risk of metabolic events associated with antipsychotics use was similar in magnitude in Asian and non-Asian populations despite the marked difference in drug utilization patterns.

Immediate versus wait-and-gradual discontinuation in antipsychotic switching: A meta-analysis.

In two previous meta-analyses of randomized controlled trials (RCTs) examining antipsychotic switching strategies in patients with schizophrenia, we showed no significant differences in any clinical outcomes between immediate versus gradual and gradual versus wait-and-gradual discontinuation of the pre-switch antipsychotic. In this report, we compared immediate versus wait-and-gradual antipsychotic discontinuation. We identified five RCTs examining immediate versus wait-and-gradual discontinuation of the pre-switch antipsychotic in antipsychotic switching involving patients with schizophrenia. However, no data were available from one RCT. The following clinical outcome data were extracted and meta-analyzed: study discontinuation, psychopathology, extrapyramidal symptoms, and treatment-emergent adverse events that were reported in two or more of the studies. The meta-analysis included four RCTs involving 351 patients (n=175 for immediate and n=176 for wait-and-gradual antipsychotic discontinuation). A significant difference was found in study discontinuation due to all causes (n=4, n=351, risk ratio=1.58, 95% confidence interval 1.15-2.17, p=0.005, I2=0%) between the immediate and wait-and-gradual antipsychotic discontinuation groups, while there was no significant difference in any other clinical outcomes. The group difference in study discontinuation due to all causes remained significant for the studies adopting immediate antipsychotic initiation but not for the studies switching to ziprasidone. Findings suggest that wait-and-gradual antipsychotic discontinuation may be preferable when a more cautious antipsychotic switch is needed. However, further long-term, double-blind RCTs are needed to confirm the present findings.

Title of the article: Sex hormones and psychopathology in drug naïve Schizophrenia.

Association of Prolactin levels & symptoms in first episode drug naïve Schizophrenia have been equivocal. This cross-sectional comparative study in a tertiary setting was conceived to examine the role of Sex hormones and symptoms in first episode untreated schizophrenia. To measure & compare the circulating estradiol, testosterone & prolactin levels in drug naïve first episode patients with Schizophrenia & healthy age matched controls. To test the association between stress, illness and psychopathology with hormone levels.In a cross-sectional Comparative study 102 subjects (Patients vs Healthy Controls)were enrolled. First episode drug naïve patients (N = 51)with International Classification of Diseases-10 (ICD-10) diagnosis of Schizophrenia were recruited by consecutive sampling. Symptom severity was measured using Positive and Negative Symptom Scale (PANSS).Sex hormone estimation was done at baseline using radioimmunoassay method (RIA) prior to antipsychotic initiation. 51 healthy controls were recruited to participate in the study. Mildly elevated prolactin levels were associated with higher total PANSS scores in women. Hallucinatory behavior and Grandiosity are positively correlated in patients with raised prolactin levels at baseline. Testosterone and estradiol were not associated with psychopathology. Women perceived more stress than men. Elevated prolactin levels in drug naïve Schizophrenia can be a putative marker for predicting gender differences in symptom severity and treatment responses in future.

Frequency and Correlates of Acute Dystonic Reactions After Antipsychotic Initiation in 441 Children and Adolescents.

Objective: To determine the incidence of acute dystonic reactions (ADRs) and risk factors for ADRs in children and adolescents treated with antipsychotics. Methods: This was a retrospective chart review-based cohort study of consecutive patients who attended a university hospital's child and adolescent psychiatry department between 2015 and 2017 and who were treated with antipsychotics and had at least two follow-up visits. Results: Thirty of 441 patients (6.8%) 4-19 years of age who were treated with antipsychotics for conduct disorders (21.5%), attention-deficit/hyperactivity disorder (13.2%) and, irritability and aggression that accompanied intellectual disability (12.9%) and followed for 99.5 ± 223.3 (median: 34) days developed ADRs. ADRs developed in 11/391 patients (2.8%) treated with one antipsychotic and 19/50 patients (38.0%) treated with two antipsychotics (p < 0.001). In patients treated with one antipsychotic that developed ADRs, the time to ADRs was 4.0 ± 4.0 days after antipsychotic initiation and 2.7 ± 2.4 days after an increase in the antipsychotic dose. The time to ADRs in those treated with two antipsychotics was 3.0 ± 2.3 days after the addition of the second antipsychotic and 1.6 ± 0.8 days after a dose increase in the second antipsychotic. The incidence of ADRs during antipsychotic monotherapy was 10.5% with first-generation antipsychotics (FGAs) and 2.2% with second-generation antipsychotics (SGAs; p = 0.037). The antipsychotic was changed due to ADRs in 12/30 (40.0%) of ADR cases. Independent factors associated with ADRs were antipsychotic polypharmacy (p < 0.0001), inpatient treatment (p = 0.013), FGA use (p = 0.015), and diagnoses of schizophrenia (p = 0.039) or bipolar disorder (p < 0.0001). Conclusion: SGAs and low-potency FGA monotherapy in children and adolescents were associated with a relatively low ADR risk, whereas high- and mid-potency FGAs were associated with a high risk. Independent predictors of ADRs were antipsychotic polypharmacy, inpatient treatment, FGAs, and schizophrenia or bipolar disorder diagnoses, which may be related to more aggressive antipsychotic dosing.

Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study

BackgroundThere is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry.AimsTo examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs.MethodsA retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality.ResultsIn the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0–3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18–1.22) and without dementia (1.28, 1.24–1.31).ConclusionInitiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.

Immune and Neuroendocrine Trait and State Markers in Psychotic Illness: Decreased Kynurenines Marking Psychotic Exacerbations.

Objective: Different patterns of immune system upregulation are present in the acute vs. post-treatment states of psychotic illness. We explored the existence of state and trait markers in the peripheral immune system and two immune-associated neuroendocrine pathways (IDO and GTP-CH1 pathway) in a longitudinal sample of psychosis patients. We also evaluated the association of these markers with neuropsychiatric symptomatology.Method: Plasma concentrations of peripheral blood markers were measured in a transdiagnostic group of 49 inpatients with acute psychosis and 52 matched healthy control subjects. Samples were obtained in patients within 48 h after hospital admission for an acute psychotic episode (before initiation of antipsychotics), after 1–2 weeks and again after 8 weeks of treatment. Kynurenine, kynurenic acid (KA), 3-hydroxykynurenine (3-HK), quinolinic acid (QA), phenylalanine, tyrosine, nitrite, and neopterin were measured using HPLC and LC-MS/MS analysis. Concentrations of CRP, CCL2 (MCP1) and cytokines were determined with multiplex immunoassay. PANSS interviews and cognitive tests were performed at baseline and follow-up. Mixed model analyses were used to identify trait and state markers.Results: Patients had significantly higher plasma concentrations of CRP, CCL2, IL1RA, and lower concentrations of KA and KA/Kyn at all time points (F7.5–17.5, all p < 0.001). Increased concentrations of IL6, IL8, IL1RA, TNFα, and CCL2 and decreased QA and 3-HK (F8.7–21.0, all p < 0.005) were found in the acute psychotic state and normalized after treatment. Low nitrite concentrations at admission rose sharply after initiation of antipsychotic medication (F42.4, p < 0.001). PANSS positive scale scores during the acute episode correlated with pro-inflammatory immune markers (r ≥ |0.5|), while negative scale scores correlated inversely with IDO pathway markers (r ≥ |0.4|). Normalization of KA and 3-HK levels between admission and follow-up corresponded to a larger improvement of negative symptoms (r = 0.5, p < 0.030) A reverse association was found between relative improvement of SDST scores and decreasing KA levels (r = 0.5, p < 0.010).Conclusion: The acute psychotic state is marked by state-specific increases of immune markers and decreases in peripheral IDO pathway markers. Increased CRP, CCL2, and IL1RA, and decreased KA and KA/Kyn are trait markers of psychotic illness.

Real-World Treatment Patterns and Characteristics Among Patients with Agitation and Dementia in the United States: Findings from a Large, Observational, Retrospective Chart Review.

Background:Few studies have examined patient characteristics and treatment patterns among patients with dementia and agitation in the United States (US).Objective:To examine real-world treatment patterns and characteristics of patients with agitation related to dementia who were treated with antipsychotics in US residential care and community-based settings.Methods:This retrospective chart review collected US physician-level data from patients 55 to 90 years old initiated on an antipsychotic medication for the treatment of agitation related to dementia from January 2018 to May 2018. Clinical characteristics and treatment patterns were assessed overall and stratified by residential care and community-based settings.Results:A total of 313 participating physicians, 59.5% of whom were primary care physicians, abstracted 801 patient charts (residential care: n = 312; community-based: n = 489). Of patients with agitation who were initiated on an antipsychotic, most patients (74.5%) were initiated within 3 months of the onset of their studied agitation episode, and 62.8% experienced multiple agitation episodes before initiation. While non-pharmacological therapies are recommended first-line approach for agitation in dementia, use of non-pharmacological therapy before initiation of antipsychotics was reported for only 37.8% of patients in residential care and 21.3% in community-based settings.Conclusion:Most patients were initiated on an antipsychotic treatment after multiple episodes of agitation and largely without initial non-pharmacological therapy, suggesting that current treatment guideline recommendations for first-line non-pharmacological intervention may not be adequately followed in clinical practice. Understanding the clinical burden and treatment patterns among dementia patients with agitation is imperative for effective disease management.

P.220 Early cardio-metabolic occurrences after atypical antipsychotic treatment initiation: Real world evidence from a large Italian claim database

P.220 Early cardio-metabolic occurrences after atypical antipsychotic treatment initiation: Real world evidence from a large Italian claim database

Acute kidney injury as a risk factor of hyperactive delirium: A case control study

PurposeDelirium and acute kidney injury (AKI) are common organ dysfunctions during critical illness. Both conditions are associated with serious short- and long-term complications. We investigated whether AKI is a risk factor for hyperactive delirium. MethodsThis was a single-centre case control study conducted in a 30 bedded mixed Intensive Care Unit in the UK. Hyperactive delirium cases were identified by antipsychotic initiation and confirmation of delirium diagnosis through validated chart review. Cases were compared with non-delirium controls matched by Acute Physiology and Chronic Health Evaluation II score and gender. AKI was defined by the KDIGO criteria. Results142 cases and 142 matched controls were identified. AKI stage 3 was independently associated with hyperactive delirium [Odds ratio (OR) 5.40 (95% confidence interval (CI) 2.33–12.51]. Other independent risk factors were mechanical ventilation [OR 2.70 (95% CI 1.40–5.21)], alcohol use disorder [OR 5.80 (95% CI 1.90–17.72)], and dementia [OR 9.76 (95% CI 1.09–87.56)]. Hospital length of stay was significantly longer in delirium cases (29 versus 20 days; p = .004) but hospital mortality was not different. ConclusionsAKI stage 3 is independently associated with hyperactive delirium. Further research is required to explore the factors that contribute to this association.

2.3 COHORT ANALYSIS OF ANTIPSYCHOTIC TREATMENT IN ADHD

Significant concern exists over treating youth with ADHD with antipsychotic medications, yet little is known about the factors that promote antipsychotic treatment. This presentation aims to describe the percentage of youth who fill antipsychotic prescriptions in the year after a new diagnosis of ADHD and to characterize the clinical and demographic factors associated with antipsychotic initiation.

Measuring the Effectiveness of Safety Warnings on the Risk of Stroke in Older Antipsychotic Users: A Nationwide Cohort Study in Two Large Electronic Medical Records Databases in the United Kingdom and Italy.

Safety warnings relating to antipsychotic-associated stroke among older persons in the UK and Italy were issued.However, the impact of these safety warnings on stroke risk has not been measured to date. The aim of this study was to measure the change in stroke incidence after two safety warnings in both the UK and Italy. A cohort study was conducted using electronic medical records representative of the UK (The Health Improvement Network) and Italy (Health Search-IQVIA Health LPD), containing data on 11million and 1 million patients, respectively. After each drug safety warning, elderly antipsychotic new initiators were propensity-score matched 1:1:1 on antipsychotic initiators before any safety warning. Stroke incidence within 6months of antipsychotic initiation, using an intention-to-treat approach, was the main outcome. In the UK and Italy, 6342 and 7587 elderly antipsychotic initiators were identified, respectively. A 42% stroke incidence reduction was seen in the UK after the first safety warning [42.3 (95% confidence interval (CI) 35.2-50.8) vs. 24.4 [95% CI 19.0-31.2] events per 1000 person-years (PYs)], while there was a 60% stroke incidence reduction after the second warning (16.9 [95% CI 12.2-23.4] events per 1000 PYs)compared to before the first warning. There was no significant reduction in stroke incidence in Italy. Antipsychotic safety warnings were followed by a reduction in stroke incidence among older antipsychotic users in the UK, but not Italy.

Accumulation of Hospital Days Among Antipsychotic Initiators With Alzheimer's Disease

ObjectivesTo compare the accumulation of hospital days, a proposed proxy for overall drug safety, between antipsychotic initiators and noninitiators with Alzheimer's disease (AD). DesignNationwide exposure-matched cohort. Setting and ParticipantsFinnish community dwellers who received an incident AD diagnosis in 2005‒2011 (n = 70,718). For each antipsychotic initiator, 1 noninitiator was matched on age, sex, and time since AD diagnosis (n = 19,909 matched pairs). MeasuresAccumulation of hospital days was measured during a 2-year follow-up from the national hospital discharge register. Antipsychotic use was ascertained from the National Prescription Register. Association between antipsychotic initiation and accumulation of hospital days was analyzed using negative binomial model. ResultsDuring the 2-year follow-up, antipsychotic initiators were hospitalized on average for 52.5 (standard deviation 97.7) days and matched noninitiators for 34.7 (standard deviation 72.4) days. Of antipsychotic initiators 23.8% and of noninitiators, 34.1% did not have any hospital days. Antipsychotic initiators had 53% more hospital days (adjusted incidence rate ratio 1.53; 95% confidence interval 1.47‒1.59) than noninitiators. Strongest associations were observed during the first 6 months. Antipsychotic initiators had more hospital days with primary diagnosis codes of dementia; mental and behavioral disorders; factors influencing health status; diseases of the respiratory, genitourinary, and circulatory system; certain infectious and parasitic diseases; and symptoms not elsewhere classified, than noninitiators. Conclusions and implicationsAntipsychotic initiators accumulated more hospital days than noninitiators, especially within the first 6 months after initiation. This may indicate adverse events or difficulties in treating the most severe behavioral and psychological symptoms of dementia and health problems triggering them. After initiating antipsychotics, careful and regular monitoring is needed to assess response and decrease the risk of adverse effects and events.

Antipsychotic Treatment Among Youths With Attention-Deficit/Hyperactivity Disorder

Significant concern exists over treating youths with attention-deficit/hyperactivity disorder (ADHD) with antipsychotic medications, yet little is known about the factors associated with antipsychotic treatment. To describe the percentage of youths who fill antipsychotic prescriptions in the year following a new diagnosis of ADHD and characterize the clinical and demographic factors associated with antipsychotic initiation. A retrospective longitudinal cohort analysis of antipsychotic treatment was performed in 187 563 youths, aged 3 to 24 years, with a new diagnosis of ADHD (without recent diagnosis of any US Food and Drug Administration [FDA]-indicated conditions for antipsychotic treatment). The sample was derived from the 2010 to 2015 MarketScan Commercial Database, with the analysis completed between November 1, 2018, and May 30, 2019. The percentage of youths prescribed an antipsychotic in the first year following a new diagnosis of ADHD. Among those prescribed antipsychotic medications, the percentage who received a diagnosis of conduct disorder, oppositional defiant disorder, or a disorder for which 1 or more antipsychotic medication has received an indication for use in youths from the FDA (schizophrenia, bipolar disorder, and Tourette disorder) and the percentage that filled an antipsychotic prescription before filling a stimulant prescription (methylphenidate or amphetamine derivative). Of the 187 563 youths included in the study, 114 305 (60.9%) were male with a mean (SD) age of 13.74 (5.61) years. In the year following a new ADHD diagnosis, 4869 youths (2.6%; 95% CI, 2.5%-2.7%) with ADHD were prescribed an antipsychotic. Youths treated with antipsychotics with ADHD were more likely than their peers who were not receiving an antipsychotic to have recently received diagnoses of self-harm and/or suicidal ideation (adjusted odds ratio [aOR], 7.5; 95% CI, 5.9-9.6), oppositional defiant disorder (aOR, 4.4; 95% CI, 3.9-4.9), and substance use disorder (aOR, 4.0; 95% CI, 3.6-4.5). The youths who received antipsychotics were also more likely to have received inpatient treatment (aOR, 7.9; 95% CI, 6.7-9.3). During the year following the new ADHD diagnosis, 52.7% (95% CI, 51.3%-54.1%) of youths treated with antipsychotics received a diagnosis for which antipsychotics have either an FDA or evidence-supported indication for their use. Among youths who initiated antipsychotic medications, 47.9% (95% CI, 46.5%-49.3%) did not receive a stimulant prescription between their ADHD diagnosis and antipsychotic initiation. Antipsychotic prescribing was proportionally highest for preschool-aged children (4.3%) and associated with neurodevelopmental disorders (aOR, 3.9; 95% CI, 1.3-11.2) and recent inpatient mental health treatment (aOR, 8.9; 95% CI, 1.7-45.8). Approximately half of youths with a new ADHD diagnosis may have an evidence-supported indication for an antipsychotic medication. Less than half of these youths received a stimulant; the evidence-supported first line treatment for ADHD, before the antipsychotic was initiated. Use of antipsychotic prescribing appears to be associated with high levels of psychiatric comorbidity.

Antipsychotic initiation among adults with intellectual and developmental disabilities in Ontario: a population-based cohort study

ObjectivesTo describe factors associated with initiating antipsychotics and patterns of persistence to antipsychotic therapy in a large cohort of adults with intellectual and developmental disabilities.DesignPopulation-based cohort study.SettingOntario, Canada.ParticipantsAdults with intellectual...

Initiation and continuation of antipsychotic medicines in older people following non-psychiatric hospital admission.

Background Internationally, antipsychotics are frequently initiated during hospital admission for older patients and use often continues post-discharge without indication. We located no Australian studies on this topic. Objective to identify the hospital admissions (excluding psychosis) associated with antipsychotic initiation and continuation in older Australians. Setting Australian Government Department of Veterans' Affairs. Method Retrospective analysis of administrative claims data for people admitted to hospital from 1 January 2014 to 31 December 2014, aged ≥ 65years, who were antipsychotic naïve. Main outcome measure number of admissions associated with antipsychotic initiation, and the major diagnosis groups for these admissions. Where antipsychotics were initiated, we determined the time to cessation of antipsychotics after discharge. Results There were 142,009 hospital admissions for 66,415 people with a median age of 86years. 921 (0.65%) admissions were associated with antipsychotic initiation, most commonly where the primary diagnoses were for mental and behavioural disorders excluding psychosis (17.8%) and injuries (16%). Fourteen percent of antipsychotic initiations were for primary diagnoses of delirium or dementia. When secondary diagnoses were considered, 55% of antipsychotic initiations were associated with delirium, dementia or both. The median duration of use among people who used antipsychotics was 132 days, and 40% continued use until death or one year follow-up. Conclusion Initiation of antipsychotics during hospital admissions was not frequent in this Australian population. Amongst those who did initiate antipsychotics, for almost half no diagnosis corresponding with an approved indication for use was recorded and long-term use of up to one year was common.

Venous Thromboembolism as an Adverse Effect During Treatment With Olanzapine: A Case Series.

Objective: Venous thromboembolism (VTE) is a serious multifactorial disorder. Patients with severe mental illness have a higher risk of developing the condition compared to the general population. Methods: We observed 10 cases of VTE in patients with mental illness who were treated with the antipsychotic drug olanzapine. The diagnosis of VTE was made at the University Hospital Hradec Kralove (UH HK) from 2004 to 2013. VTE was objectively determined by imaging techniques (duplex ultrasonography, CT angiography) and laboratory tests (D-dimer). The average age was 46 years. The clinical manifestation of VTE was deep vein thrombosis in nine cases, including one case of simultaneous pulmonary embolism and one case of a concurrent ischemic cerebrovascular accident (iCVA). None of our patients had a history of malignant disease, trauma, or surgery. Results: Apart from antipsychotic medication, all the patients had clinical or laboratory risk factors for VTE. The most frequent clinical risk factors were obesity (n = 7) and smoking (n = 6). The most frequent laboratory risk factors were increased levels of FVIII (n = 4), mild hyperhomocysteinemia (n = 3), and factor V Leiden mutation (n = 2). VTE developed within 3 months after antipsychotic drug initiation in three patients and within 6 months in three patients. Conclusion: Olanzapine can be considered a precipitating factor for VTE formation. When olanzapine is administered, we need to monitor for clinical signs and symptoms of VTE, especially when other risk factors are present.

Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review.

Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40days of antipsychotic initiation. Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.

Psychiatric Services Preceding Initiation of Antipsychotic Medication Among Youth in Foster Care.

Objectives: To characterize psychotropic use preceding antipsychotic initiation in a population of youth in foster care and to determine whether the use of intensive psychiatric services before initiating an antipsychotic differs across subgroup of youth defined by past psychotropic use. Methods: We identified youth in foster care in one U.S. State who initiated an antipsychotic from 2010 to 2015 and were aged ≤21 years at initiation. No antipsychotic use 1-year before the index prescription defined new use. Psychotropic class use in the year preceding the index antipsychotic prescription distinguished three subgroups: no psychotropic use, single-class use, and concomitant (>1 class) use. The temporal association of antipsychotic initiation with intensive services (psychiatric hospitalizations or emergency department visits) was estimated through regression models adjusted for psychiatric diagnoses and demographic characteristics. Logistic regression models assessed the interaction between psychotropic class subgroup and psychiatric diagnosis with the odds of hospitalization. Results: Of the 753 youth initiating an antipsychotic, 279 (37%) had no psychotropic use, 304 (40%) had single-class use, and 170 (23%) had concomitant use in the year before. In the year preceding antipsychotic initiation, 183 (24%) were hospitalized and 118 (16%) were hospitalized 1 month before antipsychotic initiation. The number of days between hospital discharge and antipsychotic initiation was 47 (SE = 19) days longer in concomitant users relative to youth with no psychotropic use (p = 0.01). In the year preceding antipsychotic initiation, concomitant users with severe mental illness were less likely to have a hospitalization (OR = 0.24; 95% CI = 0.06-0.93) than youth with no psychotropic use diagnosed with severe mental illness. Conclusions: Variation in psychotropic medication treatment, hospitalizations, and psychiatric diagnosis before antipsychotic initiation distinguished subgroups of youth initiating an antipsychotic. Single-class and concomitant users may have initiated an antipsychotic to augment existing regimen, whereas youth with no psychotropic use may have initiated an antipsychotic following a first episode crisis.

Is Obesity in Young People With Psychosis a Foregone Conclusion? Markedly Excessive Energy Intake Is Evident Soon After Antipsychotic Initiation.

Introduction: Antipsychotic medication (APM) initiation is associated with rapid and substantial weight-gain and high rates of obesity. Obesity leads to premature onset of cardiometabolic diseases and contributes to the 15–20 year shortfall in life expectancy in those experiencing severe mental illness. Dietary energy intake excess is critical to weight management but is yet to be quantified in youth with first episode psychosis (FEP) receiving APM. This study aimed to describe the degree of energy overconsumption and the food sources contributing to this in youth with FEP.Materials and Methods: People aged 15–30 years with FEP receiving APM completed diet histories through qualified dietitians to assess energy imbalance and food sources. Outcome measures were: (i) energy balance; and (ii) intake of core and discretionary foods.Results: Participants (n = 93) were aged 15–29 years (mean = 21.4 ± 2.9 years) and exposed to APMs for a median for 8 months (Interquartile Range (IQR) 11 months). Energy balance was exceeded by 26%, by a median 1,837 kJ per day (IQR 5,365 kJ). APM polypharmacy and olanzapine were linked to larger excesses in dietary energy intake. The greatest contributors to energy intake were refined grain foods (33%) and discretionary foods (31%).Conclusion: Young people with FEP receiving APMs appear to have markedly excessive energy consumption, likely contributing to rapid weight-gain, and thereby seeding future poor physical health. Larger, prospective studies are needed to gain a greater understanding of dietary intake, and its effects on health, in people with FEP.

Incidence and predictors of acute akathisia in severely ill patients with first-episode schizophrenia treated with aripiprazole or risperidone: secondary analysis of an observational study.

In the antipsychotic treatment of schizophrenia with little medication history, especially in drug-naïve cases, predictors of side effects are important. However, predictors of antipsychotic-induced akathisia remain unclear. This study aimed to investigate the incidence and predictors of acute akathisia in severely ill patients with first-episode schizophrenia spectrum disorders (FES). This is a secondary analysis of our retrospective observational study. Data were obtained from 129 consecutive patients with FES involuntarily hospitalized in a tertiary psychiatric public hospital and treated with aripiprazole or risperidone. The primary outcome was the presence of acute akathisia during the first 1month. A Cox proportional hazard model was used to examine significant predictors of the onset of akathisia. Acute akathisia was diagnosed in 54 patients (42%). Neither antipsychotics (aripiprazole or risperidone), duration of untreated psychosis, iron deficiency, sex, age nor baseline symptomatic severity was identified as an independent predictor of akathisia. Rapid risperidone initiation significantly increased the onset of akathisia (adjusted hazard ratio [HR], 6.47; 95%; 95% confidence interval [CI], 1.94-21.65; p = 0.002), but rapid aripiprazole initiation did not (adjusted HR, 1.08; 95% CI, 0.50-2.31; p = 0.84). A significant interaction was found between rapid antipsychotic initiation and the risk of akathisia with aripiprazole versus risperidone (p = 0.027). Severely ill patients with FES initiating aripiprazole or risperidone could have a high risk for akathisia. Rapid risperidone initiation should be avoided because of the risk for akathisia, and careful monitoring of akathisia may be necessary for all patients initiating aripiprazole.