Psychotropic medication use, personality disorder and improvement in long-term dynamic psychotherapy

Patients receiving long-term dynamic psychotherapy often have both depression and personality disorders (PDs) and take medications concurrently. Our goal was to determine the extent of medication use in an outpatient sample and the relationships of medication use and PD status to diagnostic and symptom measures. Fifty-three patients (25 of whom were taking medications at intake) who entered a long-term psychodynamic psychotherapy study for the treatment of chronic or recurrent depression, anxiety, and/or PDs were followed up to 7 years. PD patients who received combined therapy showed significant improvement in functioning and distress, while those receiving only psychotherapy showed significant improvement in depression and distress. Non-PD patients receiving only psychotherapy showed significant improvement in functioning. Long-term dynamic psychotherapy was associated with improvement in symptoms and functioning for the sample as a whole. PD pathology and being on medications at intake acted as moderator variables: PD predicted a smaller effect size in depression and functioning, while medications predicted a smaller effect size in depression only.     

Do antipsychotic medications decrease the risk of suicide in patients with schizophrenia?

The lifetime risk of suicide in persons with schizophrenia is much greater than that in the general population. The role of antipsychotic medications in decreasing suicide risk in schizophrenia has been little studied, and results often appear inconclusive and even confusing when issues such as dose-response effect are examined. Yet, evidence exists that both the traditional and newer antipsychotic medications reduce the risk of suicide and suicide attempts in schizophrenia. Because side effects are potentially significant risk factors in suicide, considerable incentive exists to examine whether newer antipsychotic agents that have a lower incidence of extrapyramidal side effects offer greater safety for this population.     

Are clozapine blood dyscrasias associated with concomitant medications?

Clozapine is an atypical antipsychotic agent used for refractory schizophrenia. It has a relatively low affinity for D2 receptors and thus is associated with a lower incidence of extrapyramidal side effects when compared with typical antipsychotics. Clozapine as monotherapy can induce a rare, but serious, blood dyscrasia called agranulocytosis; however, some concomitant medications may contribute to the risk. Examples of these medications are mood-stabilizing antiepileptic drugs, such as carbamazepine, and sulfonamide antibiotics, such as sulfamethoxazole. There were no studies at the writing of this article examining the effect of concomitant medications on clozapine blood dyscrasias, and few published reports describing enhanced bone marrow suppression in those taking clozapine. The primary objective of this study was to evaluate the effect of concomitant medications used in a state psychiatric hospital on clozapine-induced blood dyscrasias. This was a retrospective record review of adverse drug reactions reported at an adult inpatient state psychiatric center. The records for a pilot sample of 26 patients with reported clozapine-related adverse drug reactions between January 1, 2007, and June 30, 2009, were reviewed. Fundamental to this study were reported adverse drug reactions defined as 1) substantial drops in white blood cell or absolute neutrophil count (a substantial drop in white blood cell is >3,000 or absolute neutrophil count is >1,500 over a 3-week period); 2) mild leukopenia/granulocytopenia; and 3) moderate-severe leukopenia/granulocytopenia. Concomitant medications were examined for contributions to an increased potential for clozapine-induced blood dyscrasias. Other data collected included demographic information (age, gender, ethnicity), medical and psychiatric diagnoses, dose and duration of medications, and changes in medications. Medications that had a statistically significant impact on the incidence of clozapine-induced blood dyscrasias are reported in this article, as well as the possible duration of medication use prior to induction of an adverse drug reaction.     

Chronic exposure to anticholinergic medications adversely affects the course of Alzheimer disease.

OBJECTIVE: Authors examined the effect of chronic exposure to anticholinergics in a cohort of Alzheimer disease (AD) patients. METHODS: All patients were examined annually with standard neuropsychologic tests and received the cholinesterase inhibitor donepezil hydrochloride at a dose of 10 mg/day. The study population (N=69) was divided into two groups: those receiving one or more concomitant medications with significant anticholinergic properties (N=16) and those receiving no concomitant medications with anticholinergic properties (N=53). RESULTS: At 2 years, MMSE scores were significantly worse for patients receiving anticholinergic medications than for those not on anticholinergics. CONCLUSION: Although very preliminary, these data suggest that concomitant therapy with anticholinergics may be associated with significant deleterious effects on acetylcholinesterase therapy, or, more speculatively, that chronic exposure to anticholinergics may have adverse effects on the clinical course of AD.     

Update on SSRI Treatment for Neuropsychiatric Symptoms of Dementia

Neuropsychiatric symptoms (NPS) of dementia including agitation, depression, and psychosis are common and debilitating facets of the disease process. Despite the significant impact of these symptoms on both individuals with dementia and their caregivers, safe and effective treatment options are lacking. From a pharmacological approach, antipsychotics have historically been the treatment of choice, but these medications are only modestly effective with significant adverse effects. Behavioral and psychosocial interventions have been shown to be effective but are difficult to implement in routine clinical practice. SSRI medications have been investigated as an alternative psychopharmacological approach based on evidence that the serotoninergic system is involved in the etiology of NPS in dementia. The evidence base for using SSRI medications in the treatment of NPS is growing, but the applicability of research findings to the utility of SSRIs in general in routine clinical practice is not entirely clear at this point. Further studies of a variety of SSRI medications in targeting NPS are needed to make a more definitive assessment of the efficacy of these medications in the relief of NPS.     

Medications in the treatment of borderline personality disorder 2006

This review covers all significant randomized controlled trials and open trials of medications for the treatment of borderline personality disorder. New developments in the effectiveness of mood stabilizers and antipsychotics are discussed. Differences were found in the effectiveness of medications based on the presence or absence of depression and significant anger symptoms. Medications continue to be recommended as adjuncts to psychotherapy. Most of the trials discussed require replication, and more trials that investigate the effectiveness of medications in combination with psychotherapy are recommended.     

Treatment of rats with antipsychotic drugs: lack of an effect on brain N-acetyl aspartate levels

BACKGROUND: Proton magnetic resonance spectroscopy (1H-MRS) studies of schizophrenia suggest an effect of the disease or of antipsychotic medications on brain N-acetyl aspartate (NAA), a marker of neuronal viability. We studied in the rat the effect of antipsychotic drugs on NAA in several brain regions where NAA reductions have been reported in chronically medicated patients with schizophrenia. METHODS: Three groups of nine rats each were treated with haloperidol (6 mg/kg/day), clozapine (70 mg/kg/day) and vehicle for 6 weeks and were sacrificed. Concentrations of NAA were determined by high-performance liquid chromatography (HPLC) from the following brain regions: cortex, striatum, thalamus, hippocampus and cerebellum. RESULTS: Mixed-factorial ANOVA of NAA concentrations revealed no significant effect of drug group [F(2, 24) = 0.034; p = 0.966] or a group by brain region interaction [F(8, 44) = 0.841; p = 0.572]. There was a significant main effect of region [F(4, 21) = 6.104; p = 0.002] with higher NAA in the cortex. CONCLUSIONS: These results are consistent with the only other study of the effect of typical and atypical antipsychotic drugs on NAA in the rat brain. The well-documented lower NAA in chronically treated schizophrenia patients is probably not a simple effect of antipsychotic medications.     

Self-poisoning with medications in adolescents: a national register study of hospital admissions and readmissions

ObjectiveTo examine characteristics of hospital admissions and risk factors associated with rehospitalization for self-poisoning with medications in adolescents aged 10–19 years.MethodThis study used data from the Norwegian Patient Register from 2008 to 2011. The main outcome was hospital readmission within the observation period. A complementary log–log regression model was used to assess the effect of characteristics at index hospital admission on readmission.ResultsOf 1497 patients, 76.4% were females and 89.8% were aged 15–19 years. At their first hospital admission, about one third received a secondary psychiatric diagnosis. Females (47.5%) were registered with an E-code for intentional self-harm more often than males (33.7%), and females were more often than males discharged to further treatment (27.8% vs. 21.5%). As many as 18.4% were rehospitalized for self-poisoning by medications. Significant predictors for hospital readmission were female sex [hazard ratio (HR)=2.4, 95% confidence interval (CI) 1.7–3.6], discharge to further treatment (HR=2.3, 95% CI 1.8–2.9) and psychiatric secondary diagnoses (HR=1.5, 95% CI 1.2–1.9).ConclusionThis national study demonstrated significant sex differences in adolescents treated in hospital for self-poisoning with medications. Psychiatric secondary diagnoses had a strong predictive effect on readmission, which indicates the importance of psychiatric/psychosocial assessment of adolescents who are admitted to hospital for self-poisoning with medications.     

Retrospective chart review of duloxetine and pregabalin in the treatment of painful neuropathy

The primary aims of our study were to compare pregabalin and duloxetine in a neuromuscular clinic for diabetic neuropathic pain (DPN) and to study the effect of these medications in cryptogenic sensory polyneuropathy. We performed a retrospective chart review of 143 patients who were started on pregabalin or duloxetine during a 10-month period in a tertiary neuromuscular outpatient center for neuropathic pain. Duloxetine and pregabalin were started in 103 and 91 patients, respectively. Ninety-two patients tried only one of the two medications while both medications were used at different time periods in 51 patients. Follow-up was available for 87 patients on pregabalin and 89 patients on duloxetine. More patients with neuropathic pain reported an improvement with pregabalin (33%) than duloxetine (21%). Duloxetine (38%) had a higher frequency of side effects compared to pregabalin (30%). However, these differences between pregabalin and duloxetine were not statistically significant. Despite the study's limitations of retrospective design, these findings suggest that both pregabalin and duloxetine are probably effective for neuropathic pain, secondary to diabetes or cryptogenic sensory peripheral neuropathy in a tertiary care academic neuromuscular center. Prospective randomized controlled comparative effectiveness studies are required for both drugs in the treatment of neuropathic pain.     

利培酮和氟哌啶醇对精神分裂症白细胞介素的作用及其与疗效的关系

目的　探讨典型、非典型抗精神病药对精神分裂症白细胞介素 (IL)的影响及其与疗效之间的关系 ,以及免疫状态与精神症状的关系。方法　采用随机、双盲法应用固定剂量的利培酮和氟哌啶醇对 78例慢性精神分裂症进行 12周治疗 ,并在治疗前后评定PANSS量表。以 18例健康人为对照。同时在治疗前后测定血浆IL 2、IL -6和IL -8含量。结果①利培酮和氟哌啶醇治疗均降低精神分裂症过高的IL 2水平 ,两者之间无明显差异。②两种药物对患者过高的IL -6、IL 8水平均无明显影响。③治疗前IL 2、IL 8越低 ,则疗效越好。④治疗后IL 8水平与精神症状、主要是阳性症状有关。结论非典型和典型抗精神病药对精神分裂症免疫应答产生一定程度的抑制作用 ,两者之间无明显差异 ;患者治疗前的免疫水平与疗效之间存在一定的关系     

Increasing group attendance on a psychiatric unit: an alternating treatments design comparison

Compliance is a critical factor for success in the treatment of chronic psychiatric patients. Major reasons for therapeutic failure are that patients discontinue their medications, fail to keep therapist appointments, or do not participate in recommended psychosocial activities. An alternating treatments design was employed to assess the use of verbal instructions and feedback to promote group attendance on a psychiatric unit. Results showed these methods served to significantly increase group attendance but had no significant effect on patient satisfaction. These results are discussed with regard to cost-efficient methods for promoting treatment compliance with psychiatric inpatients.     

Practice-related improvement in information processing with novel antipsychotic treatment

BACKGROUND: Attentional deficits are prominent in schizophrenia, and skill learning is impaired. Novel antipsychotic treatment has been reported to improve certain cognitive skills in schizophrenic patients, but no information is yet available about the effect of newer medications on skill learning. METHODS: Clinically stable patients with schizophrenia (n=16) and chronically hospitalized inpatients (n=8) were recruited while receiving conventional antipsychotic treatment. Subjects were tested at baseline on a visual continuous performance test (CPT), performed alone and simultaneously with an auditory CPT. Normal controls (n=8) were also tested at baseline. The inpatients and half of the outpatients were switched to treatment with risperidone. All patients then performed the visual CPT on a daily basis and performed the dual tasks once per week, for 4weeks. RESULTS: Patients who remained on conventional medications did not improve in their performance despite the extensive practice on the test. Both chronic and stable patients receiving risperidone treatment manifested a statistically significant (P<0.05) improvement from baseline on both single and dual-task visual CPT. Stable outpatients performed significantly better at the end of the protocol than the normal controls performance at baseline (P<0.05). IMPLICATIONS: These results suggest that practice-related improvements in the performance of information processing tests are enhanced by novel antipsychotic medications. Although the specific biological mechanism of this effect is not yet known, the results may suggest that use of newer medications will enhance skill development and perhaps facilitate rehabilitation of patients with schizophrenia.     

Comparative effect of atypical and conventional antipsychotic drugs on neurocognition in first-episode psychosis: a randomized, double-blind trial of olanzapine versus low doses of haloperidol

OBJECTIVE: The effect of antipsychotic medication on neurocognitive function remains controversial, especially since most previous work has compared the effects of novel antipsychotic medications with those of high doses of conventional medications. This study compares the neurocognitive effects of olanzapine and low doses of haloperidol in patients with first-episode psychosis. METHOD: Patients with a first episode of schizophrenia, schizoaffective disorder, or schizophreniform disorder (N=167) were randomly assigned to double-blind treatment with olanzapine (mean modal dose= 9.63 mg/day) or haloperidol (mean modal dose=4.60 mg/day) for the 12-week acute phase of a 2-year study. The patients were assessed with a battery of neurocognitive tests at baseline and 12 weeks after beginning treatment. RESULTS: An unweighted neurocognitive composite score, composed of measures of verbal fluency, motor functions, working memory, verbal memory, and vigilance, improved significantly with both haloperidol and olanzapine treatment (effect sizes of 0.20 and 0.36, respectively, no significant difference between groups). A weighted composite score developed from a principal-component analysis of the same measures improved to a significantly greater degree with olanzapine, compared with haloperidol. Anticholinergic use, extrapyramidal symptoms, and estimated IQ had little effect on the statistical differentiation of the medications, although duration of illness had a modest effect. The correlations of cognitive improvement with changes in clinical characteristics and with side effects of treatment were significant for patients who received haloperidol but not for patients who received olanzapine. CONCLUSIONS: Olanzapine has a beneficial effect on neurocognitive function in patients with a first episode of psychosis. However, in a comparison of the effects of olanzapine and low doses of haloperidol, the difference in benefit is small.     

Impact of Taking Antiepileptic Drugs at School in a Group of Children and Adolescents

The impact of epilepsy on the quality of life can be significant. Peer acceptance is important for the social adjustment of children. Even children with controlled seizures may appear different from their peers if they are required to leave the classroom to take antiepileptic drugs. The objective of this pilot study was to determine if there is a measurable effect on peer relationships in children having to leave the classroom or recess time to take antiepileptic medications in a school setting. Results of surveys mailed or distributed by a pharmacist were obtained from 47 children, aged 6 to 18 years. Children who reported poor seizure control were significantly more likely to have trouble making friends compared with those with seizures controlled (70% vs 27%, P = 0.02). Even though the majority reported good seizure control (7/8), the children who left the classroom to take medications reported that they had significantly more trouble making friends than those who did not leave the classroom (63% vs 21%, P = 0.03). Therefore, the effect of taking medication at school may be associated with a significant decrease in social and peer relationships, even in children with self-reported good seizure control.     

Pharmacological Management of Insomnia

Insomnia is a highly prevalent condition associated with significant morbidity, reduction in quality of life, and increase in healthcare costs, and is a risk factor for multiple physical and mental disorders. The primary treatment modality is cognitive behavioral therapy for insomnia (CBT-I) but this is associated with difficulties with access and higher cost as well as poor response in some patients. Therefore, pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States. Older medications for insomnia are limited by their side effect burden and narrow therapeutic window. Newer hypnotics, on the other hand, have been shown to have a better safety profile and longer term efficacy. While some studies have shown that long-term hypnotic use is associated with adverse outcomes, the current evidence is equivocal. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations. This clinical review discusses the currently available medication options to treat insomnia, their mechanisms of action, dosing, and side effect profiles. This review also provides guidance on long-term management of hypnotics and the use of these medications in the elderly, those with medical comorbidities, and other special populations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13311-021-01010-z.Key Words: Insomnia, hypnotics, pharmacotherapy, sedatives, sleep, medication, treatment     

Is dopamine agonist therapy associated with developing pathological gambling in Parkinson's disease patients?

In recent years, improving the quality of life and the level of functioning in Parkinson's disease patients has become the main challenge of all therapeutic protocols for this chronic disease. Hence, identifying comorbid psychiatric conditions is the ambition of many studies in the field. To date, a few research studies have investigated the development of problem gambling as a potential side effect of dopamine agonist medications. However, there are still controversies among experts in the field. Thus far, published reports have been able to neither demonstrate the extent of risk for gambling-related problems nor study the correlation of dosage with this potential adverse effect among Parkinson's disease patients treated with dopaminergic medications. In fact, prospective epidemiologic studies are needed to technically estimate the incidence rate and the relative risk of pathological gambling among patients with Parkinson's disease and to determine the correlation between dosage of these medications and the development of pathological gambling.