Advantages of Long-Acting Injectable Antipsychotics

With studies showing schizophrenia to be treatment refractory in one-fifth of those affected, psychiatrists are exploring other options to the delivery of effective treatment. At APA’s Institute on Psychiatric Services in San Francisco, some of the leading experts in psychopharmacology led a research symposium on the benefits of long-acting injectable (LAI) antipsychotic medications.Said Steven Potkin, M.D., director of clinical research at the University of California, Irvine:

“Psychiatrists who were trained during my time of training, think that long-acting injectable antipsychotics should be used for the most refractory, noncompliant, and difficult to treat patients. However, there is accumulating evidence that very early in the course of illness that this should be offered as an option, since half of the patients with first-episode psychosis discontinue medication after they are discharged from a hospital.”

Research on part of the “accumulating evidence” on long-acting injectable antipsychotics was presented by Keith Nuechterlein, Ph.D., a distinguished professor of psychiatry at the University of California, Los Angeles, who led a randomized study comparing LAI risperidone with oral rispiderone in 83 individuals who had a first psychotic episode within the two years prior to the study. The results showed that after one year of treatment, participants who received the daily oral form of risperidone had a 33%relapse rate, compared with 5% in those treated weekly with LAI risperidone. In addition, individuals in the oral risperidone cohort were four times more likely to be hospitalized than those taking the LAI version.

“We were struck that these were among the most dramatic results that have occurred for long-acting injectables—and it was in first-episode patients,” said Nuechterlein, adding that not only did patients experience advantages regarding outcomes associated with LAIs, but the patients accepted LAI medication quite readily. (The study was funded by the National Institutes of Health and Janssen Pharmaceuticals.)

“This symposium was an invitation for psychiatrists to rethink when is it appropriate to offer patients long-acting injectable medication. Should it be reserved only for refractory patients, or should it be offered to people earlier in the course [of illness]… or at any stage of illness? Of course, LAIs are not for everyone, but our patients should definitely be given options.”

New Depression Medication: Brintellix

The U.S. Food and Drug Administration (FDA) approved a new medication to treat clinical depression in Adults. A total of six clinical studies were conducted to garner FDA’s drug approval. The new drug is called Brintellix by Takeda Pharmaceutical & H. Lundbeck. Brintellix will be available in 5 mg, 10 mg, 15 mg, and 20 mg tablets. Nausea appears to be a side effect reported by some patients.

The manufacturer reports that the new drug is an inhibitor of serotonin (5-HT) reuptake, and also acts as an agonist at 5-HT1A receptors, a partial agonist at 5-HT1B receptors and an antagonist at 5-HT3, 5-HT1D and 5-HT7 receptors.

Since medications affect everyone differently, it is important to have a variety of treatment options for depression.

Short Hospitalizations Found to Be Risk Factor for Readmission of Schizophrenia Patients

From Psychiatric News Alert. Short hospital stays for patients with schizophrenia are associated with risk of early readmission, possibly because the person is insufficiently stabilized, according to a report in Psychiatric Services in Advance. Researchers at the University of South Florida and other institutions used Medicaid and service-use data to identify adults with schizophrenia discharged from hospitals and crisis units who were taking anti-psychotics. Data were extracted on demographic characteristics, service use before admission, psychopharmacologic treatment after discharge, and readmission to acute behavioral health care.

Study subjects had 6,633 inpatient episodes. Readmission occurred for 84 percent of the episodes, 23 percent of them within 30 days after initial discharge. Variables associated with an increased readmission risk in the first 30 days were shorter hospital stay, shorter time on medication before discharge, greater prehospitalization use of acute care, serious general medical comorbidity, and prior substance abuse treatment.

“This finding suggests that some patients may have been discharged before they were sufficiently stabilized,” the researchers said. “Patients with shorter stays and those not sufficiently stabilized on their medication should receive more vigorous discharge planning and follow-up care to ensure smoother transition to treatment in the community.”

Psychotic Symptoms, Rather than Antipsychotic Meds, Linked to Alzheimer Patient Death & Institutionalization

It is the presence of psychiatric symptoms, including psychosis and agitation, not the use of antipsychotic medications that appears to raise the risk for institutionalization or death among patients with Alzheimer’s disease (AD), according to a new study published in AJP in Advance.

Researchers at several institutions, led by Oscar Lopez, M.D., of the University of Pittsburgh, examined time to nursing home admission and time to death in nearly 1,000 patients with a diagnosis of probable AD, taking into account a range of variables, including dementia severity, physical illnesses, extrapyramidal signs, depression, psychosis, aggression, agitation, and dementia medication use. A total of 241 patients (25 percent) were exposed to antipsychotics at some time during follow-up. A higher proportion of patients exposed to antipsychotic medications, especially conventional antipsychotics, were admitted to a nursing home or died compared with those who never took these medications, but the association was no longer significant after adjustment for psychiatric symptoms. Psychosis was strongly associated with nursing home admission and time to death, but neither conventional nor atypical antipsychotics were associated with time to death.

“This observational study does not support the association between mortality and antipsychotic use that has been reported in institutionalized elderly patients,” the researchers stated.

Geriatric psychiatrist and immediate past APA President Dilip Jeste, M.D., who reviewed the study, called it “an important contribution to the literature on mortality related to psychosis and antipsychotics in persons with Alzheimer’s disease.”

“The results from various published studies have often been at variance with one another. The present study’s finding that psychosis itself is associated with increased mortality is consistent with several other reports, suggesting the need to treat these symptoms. Although there are no FDA-approved safe and effective treatments for psychosis in dementia, a number of pharmacological and psychosocial approaches are available. The treating clinician needs to take into account the risk-benefit ratios for various treatments as well as no specific treatment.”

For more information about AD, see American Psychiatric Publishing’s Clinical Manual of Alzheimer Disease and Other Dementias here and Psychiatric News here.

Antidepressants May Help Avert Depression in Head and Neck Cancer Patients

Antidepressant use appears to prevent depression in patients with head and neck cancer, a large double-blind, placebo-controlled clinical trial has found. The study was headed by William Lydiatt, M.D., of the Department of Otolaryngology-Head and Neck Surgery at the University of Nebraska. The results appear in JAMA Otolaryngology-Head and Neck Surgery.

“This study is important in many ways,” Michelle Riba, M.D., a former APA president, a professor of psychiatry at the University of Michigan, and a psycho-oncologist, told Psychiatric News. “It looked at a population of patients—those with head and neck cancer—in whom depression is a very prominent and serious condition. It studied a way to help patients in a preventive paradigm, using [the SSRI antidepressant] escitalopram. Furthermore, even though the  study wasn’t designed to study quality of life, patients in the escitalopram arm had an overall improved quality of life during the study and three months consecutively after the cessation of drug therapy.”

More information about how psychiatrists can help cancer patients can be found inPsychiatric News. Information about the mental health challenges that cancer patients and survivors face is presented in the new American Psychiatric Publishing book, Psycho-Oncology.

From: Psychiatric News Alert (Image: Tyler Olson/Shutterstock.com) 

New Analysis Compares 15 Antipsychotics

From APA Psychiatric News Alert: An analysis of 212 clinical trials of 15 antipsychotic medications found that all were significantly more effective than placebo, and the differences between them in efficacy were “small but robust.” The study, which was published online yesterday in Lancet, included data from randomized controlled trials involving more than 43,000 participants. In addition to assessing efficacy, the study also analyzed discontinuation of the medications and their side effects.

The researchers found that clozapine, amisulpride, and olanzapine showed, respectively, the greatest efficacy, while lurasidone and iloperidone showed the least. Assessment of all-cause discontinuation (when compared with placebo) showed that the best drug on this measure was amisulpride, and the worst was haloperidol. For extrapyramidal side effects, clozapine had the best odds ratio, and haloperidol the worst, while for sedation, amisulpride had the highest odds ratio, and clozapine the worst. Weight gain was also evaluated in comparison with placebo, and haloperidol was linked with the least weight gain, and olanzapine with the most. The researchers said as well that their findings “challenge the straightforward classification of antipsychotics into first-generation and second-generation groupings. Rather, hierarchies in the different domains should help clinicians to adapt the choice of antipsychotic drug to the needs of individual patients.”

To read about decision making in choosing a psychoactive medication, see the From the Experts column in Psychiatric News here.