Tag: antipsychotics

Reading of the Week: Polypharmacy & Health – the New AJP Paper; Also, Melatonin Gummies (JAMA) & Mehler Paperny on Involuntary Care (Globe)

May 4, 2023 /

From the Editor

When it comes to antipsychotics, polypharmacy (the use of more than one antipsychotic) has fallen out of fashion – the psychopharmacological equivalent of bell bottoms. Providers worry about side effects and the long-term physical health implications. Are the concerns overstated? In the first selection, Heidi Taipale (of the University of Eastern Finland) and her coauthors analyze Finnish data for The American Journal of Psychiatry. The study includes almost 62,000 patients with schizophrenia with a median follow up period of more than 14 years, and they find that the use of more than one antipsychotic isn’t linked to poorer health outcomes. “The results show that antipsychotic monotherapy is not associated with a lower risk of hospitalization for severe physical health problems when compared with antipsychotic polypharmacy.” We consider the paper and its clinical implications.

Melatonin is a popular recommendation for sleep, but what’s the quality like? In the second selection from JAMA, Dr. Pieter A. Cohen (of Harvard University) and his co-authors try to answer that question with a focus on melatonin gummy products, looking at 30 brands. “The great majority of melatonin gummy products were inaccurately labeled, with most products exceeding the declared amount of melatonin and CBD.”

Gummy melatonin: colourful but what’s the quality?

In the third selection, in an essay for The Globe and Mail, journalist Anna Mehler Paperny writes about the push for more coercive care by different governments. Drawing on her personal experiences, she notes potential problems. “There is a role for coercive care. It’s arguably necessary for some people, sometimes. But used injudiciously, it can sour people on care and set them up for failure.”

There will be no Reading next week.

DG

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Reading of the Week: Antipsychotics – Good for Work Ability? Also, Mental Health Research Funding (CJP) and Murdoch on Her Career (CBC)

January 19, 2023 /

From the Editor

As clinicians, we often think about symptoms and symptom scales – important measures of a patient’s journey. Patients may focus on other things, like functionality, including employment.

Do antipsychotics help those with psychosis for their ability to work? Do some antipsychotics provide more advantage than others? Dr. Marco Solmi (of the University of Ottawa) and his co-authors try to answer these questions in a new American Journal of Psychiatry paper. They draw on Swedish databases involving more 21,000 people. They conclude: “Among individuals with first-episode nonaffective psychosis, antipsychotic treatment (with long-acting injectables in particular) was associated with about 30%–50% lower risk of work disability compared with nonuse of antipsychotics in the same individuals, which held true beyond 5 years after first diagnosis.” We consider the paper and its clinical implications.

In the second selection, Florence Dzierszinski (of the University of Ottawa) and her co-authors look at mental health research funding in Canada. In a Commentary for The Canadian Journal of Psychiatry, they argue that funding is lacking and, in fact, declining. They write that: “Adequate research funding could go a long way to addressing prevention, care, and treatment for the one in four Canadians who experience mental health problems in a given year, improving outcomes for individuals and for Canada’s society and economy.”

And in the third selection, published by CBC First Person, Darleen Murdoch talks about her career and retirement – and her diagnosis. She notes that, during her first hospitalization decades before, she was told by her physician she would never work. She writes: “In my own way, I have proven to the medical field that ‘miracles’ can happen.”

DG

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Reading of the Week: Clozapine Prescribing & Demographics; Also, HBR on Equity in Telemedicine, and Eichler on Her Uncle & His Disappearances

October 21, 2021 /

From the Editor

Is clozapine prescribing effected by demographics?

In the first selection, from Psychiatric Services, Natalie Bareis (of Columbia University) and her co-authors consider medication prescriptions for those with psychotic disorders, drawing on US Medicaid data. “Our results indicate significant variation across states and among racial-ethnic groups in prescription patterns of six types of psychotropic medications, even after we had adjusted for multiple patient factors.” Indeed, they find that clozapine is much more commonly prescribed for those who are White. We consider the paper and its implications.

unknownClozapine: a simple molecule but complicated availability in the US?

In the second selection, Dr. Jonathan Rogg (of the University of Texas) and his co-authors consider equity and telemedicine. In a paper for the Harvard Business Review, they describe the services offered in a low-income area of Texas, and the lessons learned. “The Covid-19 pandemic has forced a rapid evolution in technology with the potential to help the most disadvantaged patients. Our experience during the pandemic has demonstrated that telemedicine can overcome access-related challenges faced by indigent populations. By allowing them to access care in their homes or even their jobs, it can help them address health issues expeditiously with minimal disruption to their lives.”

Finally, in the third selection from The Globe and Mail, writer Leah Eichler writes about her uncle, who probably had an undiagnosed mental illness. She writes about his disappearances and erratic behaviour. “We like to believe our relationships are solid, that love is somehow inextricably linked to permanence. Missing our loved ones, if anything, highlights how impermanent even our closest relationships can be.”

Please note that there will be no Reading next week.

DG

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Reading of the Week: Which Antipsychotics are Patients Less Likely to Discontinue? The New AJP Paper; Also, Dr. Lawrence on Mental Health (Guardian)

August 12, 2021 /

From the Editor

Is new really better?

With several new antipsychotic medications on the market, this question is very relevant clinically. For the patient in your office, should you opt for a new antipsychotic or something older?

In the first selection, Dr. Mark Weiser (of the Stanley Medical Research Institute) and his co-authors draw on a large database – and the experience of tens of thousands of people – to compare antipsychotics. “Among veterans with schizophrenia, those who initiated antipsychotic treatment with clozapine, long-acting injectable second-generation medications, and antipsychotic polypharmacy experienced longer episodes of continuous therapy and lower rates of treatment discontinuation.” We consider this paper, and the clinical implications.

new-2Is new better – or just eye catching?

In the other selection, Dr. Rebecca Lawrence, a practicing psychiatrist, writes for The Guardian. In her essay, she distinguishes between mental health and mental illness, noting that they are not the same thing, and worrying that we are increasingly as a society focused on the former at the expense of the latter. She thinks about her work as a physician: “As a doctor, I can talk with someone and give them pills, but I can’t easily get them any help with losing weight or trying to exercise. I can tell them it would be good for them, but I don’t necessarily have any practical ways to help.”

DG

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Reading of the Week: ED Visits & Follow Ups – the New Psych Services Paper; Also, Antipsychotics and Brains (JAMA Psych) and Physician Biases (NEJM)

March 5, 2020 /

From the Editor

How accessible is urgent outpatient mental health care in Canada? Do antipsychotics affect the brain structure of people with psychotic depression? How can physician biases change cardiac care?

This week, we consider three very different selections, drawing from the latest in the literature.

Outpatient Sign over a Hospital Outpatient Services Entrance

In the first selection, Dr. Lucy C. Barker (University of Toronto) and her co-authors look at follow-ups after an ED visit. As the authors note: “Urgent outpatient mental health care is crucial for ongoing assessment and management and for preventing repeat visits to the ED and other negative outcomes.” Drawing on Ontario data, they find that “fewer than half had a physician follow-up visit within 14 days of the ED visit for outpatient mental health care.” Ouch.

In the second selection, we consider a new paper by Dr. Aristotle N. Voineskos (University of Toronto) et al. In an impressive study across multiple sites, they find a connection between cortical thinning and the use of antipsychotics: “olanzapine exposure was associated with a significant reduction compared with placebo exposure for cortical thickness.” Ouch.

Finally, it’s said about health care that “geography is destiny” – so much of the patient experience is tied to her or his place of care, with incredible variations in services between, say, rural and urban centres. In an unusual research letter for The New England Journal of Medicine, Andrew R. Olenski (Columbia University) and his co-authors consider heart surgery and patient age – that is, within two weeks of a patient’s 80th birthday. They argue that numbers are destiny, with heart surgery influenced by “the occurrence of left-digit bias in clinical decision-making…” Ouch.

Please note that there will be no Readings for the next two weeks.

DG

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Reading of the Week: Many Medications, Better Outcomes? Paul Kurdyak on the New JAMA Psychiatry Paper Considering Antipsychotics and Schizophrenia

May 23, 2019 /

From a Contributing Editor

For individuals with schizophrenia who are failed by trials of single antipsychotics, what’s next?

This week, we discuss a paper that addresses a treatment controversy. Antipsychotic polypharmacy (the use of more than one antipsychotic) is generally discouraged because the efficacy evidence is weak, and there is risk of increasing adverse events and effects with the addition of a second antipsychotic. Choosing Wisely is an initiative that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures; among their psychiatric recommendations is to avoid the use of multiple antipsychotics. The American Psychiatric Association contributed this to the Choosing Wisely initiative:

Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.

 This is where this week’s selection comes in. The study, “Association of Antipsychotic Polypharmacy vs Monotherapy With Psychiatric Rehospitalization Among Adults With Schizophrenia,” is from Finland by Karolinska Institutet’s Jari Tiihonen and his colleagues. This paper uses Finnish population-based health administrative data to evaluate the association between antipsychotic polypharmacy and psychiatric hospitalization. They conclude: “These results indicate that rational antipsychotic polypharmacy seems to be feasible by using 2 particular antipsychotics with different types of receptor profiles.”

kakslauttanen_aurora_augustFinland: home to big Northern Lights (and big databases)

In this Reading, we consider this paper and wonder if it should change our prescribing choices.

Paul Kurdyak, MD, PhD, FRCPC

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