Pharmacotherapy and health care costs among patients with schizophrenia and newly diagnosed diabetes

OBJECTIVE: This study investigated how antipsychotic pharmacotherapy and health care costs change after diabetes mellitus is newly diagnosed among patients with schizophrenia. METHODS: Administrative data from the Department of Veterans Affairs were retrospectively reviewed to examine patients with schizophrenia who did not have any history of diabetes and for whom a consistent regimen of antipsychotic monotherapy was prescribed for any three-month period between June 1999 and September 2000. Data for these patients were reviewed through September 2001. Patients who were given a new diagnosis of diabetes were identified, along with a matched comparison group of patients who were not given a diagnosis of diabetes. Medication changes and costs were compared between patients with diabetes and those without and between patients who were taking second-generation antipsychotics and those who were taking first-generation antipsychotics. RESULTS: Of the 56,849 patients who fit the criteria for the study, 4,132 (7.3 percent) were subsequently given a diagnosis of diabetes (7.4 percent were taking second-generation antipsychotics and 7.1 percent were taking first-generation antipsychotics). Differences in the proportions of patients with and without diabetes who switched or discontinued antipsychotics were small and were statistically significant only for patients who were taking risperidone before the diabetes diagnosis date. The average marginal cost of treating a patient with diabetes was 3,104 US dollars over an average follow-up of 15.7 months, or 6.59 US dollars per day. Because the attributable risks of diabetes with second-generation antipsychotics averaged .875 percent, the average additional daily cost per patient that was attributable to each second-generation medication was small, ranging from .003 US dollars for risperidone to .134 US dollars for clozapine. CONCLUSIONS: Surprisingly, a new diagnosis of diabetes did not result in substantial antipsychotic medication changes, even among patients who were taking clozapine or olanzapine. Even though the costs of treating patients with newly diagnosed diabetes were substantial, the increased costs attributable to second-generation antipsychotics were small.     

Unemployment among patients with newly diagnosed first-episode psychosis: prevalence and clinical correlates in a US sample

Purpose  

Although it is well established that people with schizophrenia have markedly high rates of unemployment, less is known about the prevalence and clinical correlates of unemployment in patients newly diagnosed with first-episode psychosis. This analysis documented the prevalence of unemployment and examined previously reported clinical correlates of unemployment in patients with first-episode psychosis hospitalized in an urban, public-sector setting in the southeastern US.     

Disentangling the symptoms of schizophrenia: Network analysis in acute phase patients and in patients with predominant negative symptoms

BackgroundThe Positive and Negative Syndrome Scale (PANSS) is widely used in schizophrenia and has been divided into distinct factors (5-factor models) and subfactors. Network analyses are newer in psychiatry and can help to better understand the relationships and interactions between the symptoms of a psychiatric disorder. The aim of this study was threefold: (a) to evaluate connections between schizophrenia symptoms in two populations of patients (patients in the acutely exacerbated phase of schizophrenia and patients with predominant negative symptoms [PNS]), (b) to test whether network analyses support the Mohr 5 factor model of the PANSS and the Kahn 2 factor model of negative symptoms, and finally (c) to identify the most central symptoms in the two populations.MethodsUsing pooled baseline data from four cariprazine clinical trials in patients with acute exacerbation of schizophrenia (n = 2193) and the cariprazine–risperidone study in patients with PNS (n = 460), separate network analyses were performed. Network structures were estimated for all 30 items of the PANSS.ResultsWhile negative symptoms in patients with an acute exacerbation of schizophrenia are correlated with other PANSS symptoms, these negative symptoms are not correlated with other PANSS symptoms in patients with PNS. The Mohr factors were partially reflected in the network analyses. The two most central symptoms (largest node strength) were delusions and uncooperativeness in acute phase patients and hostility and delusions in patients with PNS.ConclusionsThis network analysis suggests that symptoms of schizophrenia are differently structured in acute and PNS patients. While in the former, negative symptoms are mainly secondary, in patients with PNS, they are mainly primary. Further, primary negative symptoms are better conceptualized as distinct negative symptom dimensions of the PANSS.     

影响新诊断癫(癎)患者初次药物治疗效果的因素

目的 探讨影响新诊断癫(癎)患者初次药物治疗效果的因素.方法 对155例年龄4～68岁新诊断的癫(癎)患者给予单药治疗,至少观察1年,以稳定期初次发作时间和早期治疗失败时间为终点事件,其中治疗失败的原因包括发作控制不佳和/或不能耐受药物不良反应.采用Cox回归分析判断癫(癎)患者临床特点及实验室检查结果对药物治疗效果的影响.结果 多因素Cox回归分析显示:癫(癎)家族史(HR=2.39,P<0.05)、EEG癫(癎)波(HR=2.05,P<0.005)、治疗前发作次数(HR=1.76,P<0.05)是影响稳定期初次发作时间的因素;女性患者(HR=4.25,P<0.001)、部分性发作(HR=2.54,P<0.05)、EEG癫(癎)波(HR=3.11,P<0.005)是影响早期治疗失败时间的因素.结论 EEG癫(癎)波、癫(癎)家族史、治疗前发作次数、发作类型(部分性发作)、女性患者是影响新诊断癫(癎)患者初次药物治疗效果的因素.     

Factors in the neighborhood as risks of suicide in rural china: a multilevel analysis

To estimate the effect of social factors in the neighborhood environment on suicide risks, we studied 392 suicides and 416 controls, all aged 15–34 years, consecutively and randomly selected from 16 rural counties in three provinces of China. The social factors in the village neighborhood were measured by the WHO scale of Community Stress and Problems. The individual scores as well as the sum scores of the Community Stress Problems were compared between the suicides and the controls, and multilevel logit regressions were performed for the social structural stresses and community behavioral problems and other confounding variables to test the roles of community stress and problems in Chinese rural young suicide risks. It is found that neighborhood stresses and problems increase rural Chinese suicide risks, while certain problems, such as in health care, alcohol abuse, job security, family dispute, and transportation, play more important roles than others to increase rural Chinese suicide risks. Social risk factors such as the community stresses and problems can be another area to work on for the suicide prevention.     

初诊未服药帕金森病患者的抑郁特点及危险因素 分析

目的 探讨初诊未服药的帕金森病（PD）患者抑郁的临床特征及危险因素。方法 回顾 性收集 2010 年 10 月至 2019 年 12 月在南京医科大学附属脑科医院神经内科运动障碍门诊初诊未服药的 218 例 PD 患者（PD 组）和 171 名年龄、性别相匹配的健康对照者（对照组）的资料。采用统一 PD 评定量表 （UPDRS）第Ⅱ、Ⅲ、Ⅴ部分评估 PD 患者的运动症状,采用 PD 睡眠量表（PDSS）、蒙特利尔认知评估量表 （MoCA）和非运动症状问卷（NMSQ）评估 PD 患者的非运动症状。采用 24 项汉密尔顿抑郁量表（HAMD- 24）和汉密尔顿焦虑量表（HAMA）评估受试者的抑郁、焦虑程度。比较 PD 组和对照组抑郁发作的发病 率、临床资料的差异,比较帕金森病抑郁（dPD）和非帕金森病抑郁（n-dPD）患者临床症状的差异。采用 多因素 Logistic 回归分析初诊未服药 PD 患者抑郁的危险因素。结果 PD 组 HAMD-24 评分为 8.0（4.0, 13.0）分,dPD 的发病率为 12.4%（27/218）,其中轻度、中度和重度抑郁患者分别为 5 例、18 例和 4 例。对 照组 HAMD-24 评分 2.0（0,2.0）分,抑郁发作的发病率为 6.4%（11/171）,其中轻度、中度和重度抑郁患者 分别为 5 名、5 名和 1 名。两组抑郁程度和抑郁发病率比较,差异有统计学意义（P＜ 0.05）。dPD 组患 者的 HAMD-24 总分及各因子评分、HAMA 评分、NMSQ 评分高于 n-dPD 组,运动分期为早期、姿势异常 步态不稳（PIGD）亚型的患者比例高于 n-dPD 组,UPDRS-Ⅱ评分和 PDSS 评分低于 n-dPD 组（P＜ 0.05）。 HAMA 评分高（OR=1.167,95%CI=1.077～1.265）、NMSQ 评分高（OR=1.235,95%CI=1.052～1.449）和 PIGD 运动障碍亚型（OR=2.024,95%CI=1.053～3.891）是 PD 患者发生抑郁的危险因素（P＜ 0.05）,PDSS 评分高 （OR=0.971,95%CI=0.945～0.997）是 PD 患者发生抑郁的保护因素（P＜ 0.05）。结论 初诊未服药 PD 患 者的抑郁程度以中度抑郁为主,焦虑、非运动症状多、睡眠质量差和 PIGD 型 PD 患者更易患抑郁。     

Time-to-therapy discontinuation in patients newly diagnosed with schizophrenia initiated on long-acting injectable versus oral dopamine receptor blocking agents

Aim

The purpose of this project is to assess the time-to-therapy discontinuation and hospital readmission rate among patients newly diagnosed with schizophrenia who are prescribed long-acting injectable versus oral dopamine receptor blocking agents.

Methods

A retrospective review of medical records was performed for adult patients admitted to an 80-bed inpatient behavioural health facility with a new diagnosis of schizophrenia. The primary outcome studied was time to therapy discontinuation within 1 year of discharge, while secondary outcomes assessed were time-to-therapy discontinuation within 90 days and readmission rate at 30-days, 6 months, and 1 year. Multivariate Cox proportional hazard and linear regression modelling were used for statistical analysis.

Results

A total of 425 patients were included in the analysis, with 66.4% (n = 282) discharged on oral and 33.6% (n = 143) on long-acting injectable dopamine receptor blocking agents. At 1 year post-discharge, the rates of discontinuation were 49.7% for those prescribed long-acting injectable and 55.7% for those prescribed oral formulations (adjusted hazard ratio = 0.54, p = .012). There was no statistically significant difference in readmission rate between the patients prescribed long-acting injectable and oral dopamine receptor blocking agents at any timepoint tested.

Conclusions

The use of long-acting injectable dopamine receptor blocking agents was associated with longer time-to-discontinuation compared to oral agents when prescribed to patients newly diagnosed with schizophrenia in the inpatient setting. However, this was not associated with significant reductions in rehospitalization, calling into question the clinical impact. Future studies will seek to confirm these findings using a prospective study design.     

Frequency of seizures in patients with newly diagnosed brain tumors: a retrospective review

Brain tumors may lead to symptomatic epilepsy. A retrospective analysis was undertaken to evaluate the frequency of seizure as the presenting symptom leading to brain tumor diagnosis in adults. One hundred and forty-seven consecutive patients with newly diagnosed brain tumors were analyzed regarding the frequency of seizures as the initial presenting symptoms and those subsequently developing seizures. One hundred twelve patients had primary central nervous system tumors (CNS) and 35 had metastatic lesions. Statistical evaluation was carried out using the Chi-square test with p values of <0.05 considered to be statistically significant. Astrocytomas and meningiomas were the most common primary CNS tumors in this study. Of these, oligodendrogliomas and grade 2 astrocytomas were significantly more likely to present with seizures (p<0.001). Seizures were a frequent presenting symptom, occurring in over 38% of those with primary brain neoplasms and 20% of those with cerebral metastases. Primary location of tumor also correlated amongst primary CNS tumors and was associated with a trend in seizure risk: parietal (80%); temporal (74%); frontal (62%); and occipital (0%) (p<0.5). The findings highlight the importance of obtaining appropriate evaluation for underlying malignancy in adults with new-onset seizures as well as provide more information to the patient for prognosis and counseling.     

Screening for alcohol use disorders among medical outpatients: the influence of individual and facility characteristics

OBJECTIVE: Screening of adults in primary care has been recommended to reduce alcohol misuse. This study determined the rates and predictors of alcohol screening, screening positive, follow-up evaluation, and subsequently diagnosed alcohol use disorder in a national sample of Department of Veterans Affairs (VA) medical outpatients. METHOD: Chart-abstracted quality improvement data from the VA's 2002 External Peer Review Program were merged with records for 15,580 medical outpatients drawn from 139 VA facilities nationwide. RESULTS: Nearly three-quarters of eligible patients (N=11,553) had chart-documented alcohol screening in the past year. Of these, 4.2% (N=484) screened positive. Of those who screened positive, three-fourths (N=370) received follow-up evaluation, and of these, 53.5% (N=198) were subsequently diagnosed with an alcohol use disorder-1.7% of the originally screened sample. Multivariate logistic regression revealed that several factors generally associated with increased risk of alcohol use disorders-including being younger, unmarried, and disabled, as well as having greater medical and psychiatric comorbidities-were actually associated with a decreased likelihood of alcohol screening. At the facility level, screening was less likely at more academically affiliated centers, and follow-up evaluation of a positive screening was less likely at the largest facilities. CONCLUSIONS: Routine alcohol screening yielded relatively few positive cases, raising questions about its cost-effectiveness. Targeted strategies may increase the value of case-finding activities among patients at greatest risk for alcohol use disorders and at more academically affiliated facilities. Targeted efforts are also needed to ensure proper follow-up evaluation at larger medical centers where patients may experience greater system-level barriers.     

新型和传统抗癫痫药治疗新诊断癫痫患者的评价

目的评价新型和传统抗癫痫药(AEDs)单药治疗新诊断癫痫患者的疗效及安全性。方法前瞻性收集143例新诊断癫痫患者,分为卡马西平(CBZ)、丙戊酸钠(VPA)、托吡酯(TPM)和拉莫三嗪(LTG)治疗组,其中CBZ用于癫痫部分性发作,VPA用于癫痫全面性发作,而TPM和LTG用于各种类型癫痫发作,至少观察1年。采用生存分析Kaplan-Meier法比较治疗后癫痫初次发作时间、治疗失败时间,同时比较各组患者达"6月、1年无发作"比例和药物不良反应。结果 4组AEDs单药治疗后至癫痫初次发作时间、治疗失败时间的差异均无统计学意义(P0.05);CBZ、VPA、TPM和LTG组"6月无发作"率分别为80%、78%、87.9%、63.3%(均P0.05);"1年无发作"率分别为70%、66%、66.7%、50%(均P0.05)。TPM组不良反应率为63.3%,高于CBZ组(20%)、VPA组(24%)(均P0.01),而LTG组不良反应率为16.7%,与CBZ、VPA组相当(均P0.05)。结论从疗效和安全性综合考虑,新型AEDs治疗癫痫并不优于传统AEDs,其中TPM轻、中度不良反应还明显高于传统AEDs。     

Shared social environment and psychiatric disorder: a multilevel analysis of individual and ecological effects

We examined associations, in terms of relative and population-attributable risks, between shared social environment at the neighbourhood level and (1) treated incidence of non-psychotic, non-organic disorders, and (2) subsequent level of service consumption. The multilevel analysis used linked records of all individuals in contact for the first time with any catchment area mental health service for non-psychotic, non-organic disorder over various specified time periods between 1981 and 1995. Socioeconomic indicators of 36 neighbourhoods in the city of Maastricht yielded a multivariately defined neighbourhood deprivation score. There were significant linear trends in the association between level of deprivation and treated incidence, especially in the population under 35 years of age (adjusted rate ratio for linear trend 1.17, 95% confident interval 1.11–1.23), who constituted around half of the patient population. The fraction of the incidence of psychiatric disorder attributable to deprivation was 17.8%. Multilevel analyses of rates of a second cohort, with cases divided according to level of service use over a standardised follow-up of 5 years after first contact with psychiatric services, revealed that the effect of deprivation scores on rates declined with intensity of out-patient service use, but increased with level of in-patient use. Up to 50% of in-patient episodes in this group could be attributed to neighbourhood level of deprivation. The increase in risk conferred by neighbourhood deprivation remained after adjustment for the individual-level equivalent. The findings therefore suggest that elements in the shared social environment influence both incidence and severity of non-psychotic, non-organic disorders, over and above any individual-level effect. Accepted: 21 April 1998     

Quantitative analysis of ataxic gait in patients with schizophrenia: the influence of age and visual control

Previous research has determined that patients with schizophrenia classically exhibit ataxic gait. Age and visual controls of balance are important factors, and may influence gait, but have not been controlled. A total of 100 patients with schizophrenia were included in this study, along with 50 age- and sex-matched healthy controls. They were sampled with methods which stratified both groups according to age and sex. Tandem gait tests were conducted with eyes open and closed, and gait parameters were assessed by the footprint method. Ataxic gait was found to be significantly more frequent in the schizophrenic group. With eyes open, ataxic gait showed a significant increase with age in the schizophrenic group, but not in the healthy control group. Adjusting ataxic gait of the patients on the basis of the normal age effects measured in the healthy control group, the ataxic gait in the schizophrenic group increased according to age. Multiple logistic regression analysis revealed that old age and previous history of alcohol dependence/abuse were the risk factors for ataxic gait with eyes open. This implies that a dysfunction of the visuo-cerebellar circuit in patients with schizophrenia increases according to age.     

Early versus late remission in a cohort of patients with newly diagnosed epilepsy

Purpose:  To count patients with newly diagnosed epilepsy entering early and late remission and to identify prognostic predictors of late remission.
Methods:  Children and adults with previously untreated epilepsy from two Italian tertiary centers (Monza, Bari) were the study population. All patients received monotherapy at treatment start; drug choice and schedule were left to the physician's judgment. A retrospective audit was performed and the following prognostic predictors were identified: age, gender, putative etiology, first electroencephalography (EEG) record, neurologic and psychiatric examination, disease duration at diagnosis, seizure type(s) and number prior to starting treatment, epilepsy syndrome, and first antiepileptic drug. Early remission was defined by 2-year seizure control immediately after treatment start. Late remission was defined by 2-year seizure control achieved at least 24 months after treatment start. Prognostic predictors were assessed by logistic regression analysis, adjusting for age, gender, and center.
Results:  One hundred seventy-four women and 178 men (mean age 31.5 years) were included and followed for 2399.6 person-years. The cumulative time-dependent probability of 2-year remission was 56.3% at 2 years after treatment start, and 62.6, 69.4, and 79.5% at 3, 5, and 10 years. One hundred fifteen patients (23.0%) achieved early remission and 38 patients (10.8%) achieved late remission. The interaction between partial seizures and number of seizures prior to treatment was the only independent predictor of late remission.
Discussion:  The course of epilepsy and the chance of remission are together a complex and dynamic process, possibly explained by the diversity of the mechanisms underlying drug response and the use of an increasing number of drugs.     

Historical data in the design and interpretation of trials with newly diagnosed patients

An International League Against Epilepsy (ILAE) subcommission is exploring the possibility of utilizing historical data from treated and control (untreated or under-treated) patients who have been enrolled in monotherapy trials in newly diagnosed epilepsy. Active-control trials have not convincingly distinguished between equivalent effectiveness and equivalent ineffectiveness. Thus, there is insufficient historical evidence of sensitivity to drug effects. Noninferiority trials are based upon experience acquired with previous trials. Optimizing the exploitation of historical data obtained in newly diagnosed patients may be a way to improve the validity of future trials. A concern about use of historical controls is lack of assurance that historical populations and newly recruited populations are similar. The best approach to pooling and modeling data may be an Individual Patient Data (IPD) approach as (1) analysis of data from active-control trials, (2) demonstration that the subpopulation carrying an intermediate probability of recurrence is the most sensitive to drug effect, by comparison to similar subpopulations who received a placebo or a pseudoplacebo in historical studies. This subpopulation could become a reference for patient selection or stratification in future trials to improve assay sensitivity.     

Contradictory cognitive capacities among substance-abusing patients with schizophrenia: a meta-analysis

Although a substance use disorder (SUD) is traditionally associated with psycho–bio-social impairments, recent investigations among persons with schizophrenia (Sz) generated divergent results. Certain persons with Sz + SUD might in fact present better social and cognitive functioning than persons with Sz without SUD. This meta-analysis was conducted to verify this counterintuitive possibility and to determine whether factors such as substance type, severity or nature of psychotic symptoms and age of the patients help discriminate these subgroups. Twenty-three studies met the inclusion criteria and data from 1807 persons with schizophrenia, with or without comorbid SUD, were available for analyses. As a group, persons with Sz + SUD did not obtain significantly higher scores at a Global Cognitive Index than persons with Sz without SUD, although they were better at the Trail Making Task and the speed processing domain. Secondary analyses showed the importance of considering intermediate factors, particularly the preferred substance used and the mean age. While consumption of alcohol was associated with a global cognitive scores similar to that of persons with Sz without an SUD and lower working memory capacities, preferential use of cannabis was instead associated with higher scores for problem solving and reasoning and visual memory. Age was inversely related to the size of the effects. It is concluded that previous mixed results obtained with cognitive evaluations of persons with Sz + SUD might reflect the heterogeneity of participants and that subgroups of patients might be defined on the basis of intermediate factors.     

Multicentre prospective collection of newly diagnosed glioblastoma patients: update on the Lombardia experience

A prospective collection of newly diagnosed cases of grade IV glioma in Lombardia, Italy, was started in 2003. In the present report, data are shown on 349 adult patients recruited up to 2005. The clinical features, pattern of care and outcome are discussed, together with the main prognostic factors. Males were affected more frequently than women; median age at onset was 60. Overall, gross total tumour resection was performed in roughly 50% of the patients, and partial resection and biopsy in 25% each; only 5 patients did not undergo histology. Adjuvant radiotherapy was delivered to 89% and chemotherapy to 82% of patients. Median survival was of 54 weeks. Most patients received protracted therapy with antiepileptic drugs, despite absence of seizures; over the course of the study, the practice pattern tended to change, shifting to the use of non-enzyme-inducing anti-epileptic drugs.