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.”

A Schizophrenic’s Search for Logic by Aaron Samuel Wallman

A Schizophrenic’s Search for Logic is a book about one man’s experiences with schizophrenia and his search for true logic as his cure.

Local writer and former college teacher Aaron Samuel Wallman has an imaginary journey through hell and heaven along with a real journey back to Los Angeles from Tokyo, Japan which occurs at the same time as this imaginary journey.

“During these two trips as one journey, I mainly talk to Albert Einstein and the 17th philosopher, David Hume. In addition, I talk to other historical figures, social workers, psychologists, psychiatrists, and other people like my Japanese friend, Suga. In my conversations with the characters in this book, I discuss the reasoning of my schizophrenia and the reasoning of normal people and true logic or the logic of God. Also during my journey, I reveal my experiences with my schizophrenia as events and reveal my attempts to reach my goals and become cured with true logic. All in all, I leave it up to the reader to decide what is real and what is fantasy in this book.”

From The U.S. Review of Books:

Told in a series of thirty-eight short chapters, the author has charted a journey of untold mental suffering. A window into the inner world of one suffering from mental illness, the endless cycle of psychosis, hospitalization, medication, and relapse is described in painful detail. Dramatic interest is kept up by the intriguing discussions about perception, reason, and truth he has with Albert Einstein and David Hume, who seem to show up to discuss the problem of reality in the most strange situations. Matter-of-fact descriptions of his interactions with friends, women, policemen, and doctors shed light onto the stigma and shame of schizophrenia. A person of obvious intelligence, the author has managed to map his tortuous journey in starkly honest terms. This book is a testament to the will to survive—and also a riveting read. The language is simple and straightforward. The theme is human suffering, thereby approaching a universality, though its subject matter is indeed unique. (c) 2014 Gregory Reade.

Wallman and his family have been long-time members of NAMI South Bay. A Schizophrenic’s Search for Logic is published by Trafford Publishing and is available in print and as an e-book from these major online outlets:

 

Stopping Schizophrenia in its Tracks

By Darcy Gruttadaro, Director, NAMI Child and Adolescent Action Center
FROM NAMI BLOG

For those experiencing psychosis, early identification and intervention matter—a lot. It lessens the long-term severity and often prevents psychosis from worsening. An effective early identification and intervention program should include the following coordinated array of services and supports:

  • Supported education and employment.
  • Cognitive behavioral therapy.
  • Peer support.
  • Family support and education.
  • Case management.
  • Community outreach.
  • Low dose antipsychotic medication.

These services work so well because they are offered together to provide the skills and support that youth and young adults need to get better. They also take into account the context of a young person’s life and the key role that peers and families play in recovery.

FEP programs reduce costly hospitalizations and put youth and young adults with psychosis on an early path to recovery.

When you fund upstream interventions, you can prevent the tragedies associated with untreated mental illness: school failure, unemployment, hospitalizations, homelessness, jail and suicide. Investing in effective programs that intervene early produces far better outcomes for individuals, families and communities.

There are effective strategies available, so why aren’t more young people getting help? One of the main reasons is that these services and supports are simply not available in communities. However, there has been progress made recently that to help ensure the availability of these resources in more towns and cities across the U.S.

One significant event is that Congress has now required states to use 5 percent of their Mental Health Block Grant for First Episode Psychosis (FEP) programs. This means that states are obligated to set aside a certain amount of their federal funding to address the importance of early intervention.

How Is NAMI Helping

We recognize the urgency in expanding these programs. Our advocacy work and involvement in these programs is happening at all levels of the organization.

NAMI NYC Metro is partnering with OnTrackNY, an FEP program, in providing support groups and peer support for youth and young adults experiencing early psychosis. NAMI Connecticut is offering peer-run young adult support groups located close to FEP programs to make it easy for young adults to join. NAMI Minnesota has partnered with an FEP program and is creating education and support programs for youth experiencing early psychosis and their families.

Oregon was an early adopter of these services and supports, having witnessed the success of these programs in Australia. Tamara Sale, the director of the Early Assessment and Support Alliance (EASA) in Oregon and a former long-time NAMI Oregon board member, shared how their program works successfully with youth and young adults experiencing early psychosis.

The EASA program recognizes that it can be difficult to engage youth and young adults experiencing early psychosis, so it uses strategic community approaches that meet young people where they are with messages of hope and relevance to their lives. They are flexible and persistent, even with youth and young adults that seem entirely uninterested in mental health care.

What You Can Do

FEP programs exist in a handful of communities and more must be done to spread these programs across the country. Here is how you can make sure that happens.

  • Learn more about FEP programs. Understand why these programs are pivotal in creating better outcomes.
  • Email or Tweet your Congressional members to thank them and to ask for their continued support of FEP programs.
  • Connect with your NAMI Affiliate in advocating at the state and federal levels for FEP programs so that youth and young adults experiencing early psychosis can access effective services and supports.

We can and must change the trajectory of people’s lives by intervening early with recovery-oriented and effective services. We simply cannot afford to wait.

Next Meeting Addressing the Assessment and Prevention of Prodromal States

This month’s speakers are – Carla Means Ransom, M.A., LMFT, intensive services manager and Carissa Hsu, MFTI Clinical Therapist. They will present information about the Center for the Assessment and Prevention of Prodromal States (CAPPS), which is a family therapy based program that targets the transitional age youth ages 16 – 25 years. The program is funded by the Los Angeles County Department of Mental Health and located at Harbor UCLA. CAPPS works with the population who are showing prodromal symptoms, which are what an individual may experience prior to developing a mental illness.

The “prodromal syndrome” is not a diagnosis, but the technical term used by mental health professionals to describe a specific group of symptoms that may precede the onset of a mental illness. For example, a fever is “prodromal” to measles, which means that a fever may be a risk factor for developing this illness. However, not everyone who has a fever goes on to develop measles. In order to prevent measles from developing, you would try to get rid of your fever and take care of any other symptoms you might have. “At CAPPS, we focus on taking care of symptoms that may precede the onset of psychosis.”

Psychosis affects between 1% and 3% of the population, and typically emerges between the ages of 15 and 30. The prodromal phase of psychosis is the critical time period when individuals are showing signs that they are at risk for developing a psychotic illness.  This at risk phase may last anywhere from a couple of days to a couple of years. During this time, individuals often experience symptoms of psychosis at a subthreshold level of intensity or at full intensity for short periods of time. Individuals and their families may also notice changes in functioning, such as trouble with school or work and social withdrawal or anxiety.

Genomic Analysis: Eight Distinct Types of Schizophrenia

From Psychiatric News Alert. Schizophrenia appears to be “heterogenous”—that is, comprising a group of related disorders each of which present with distinct clinical syndromes; and those syndromes now appear to be associated with eight separate networks of genetic mutations.

That’s the finding from a remarkable genetic analysis titled “Uncovering the Hidden Risk Architecture of the Schizophrenias: Confirmation in Three Independent Genome-Wide Association Studies,” appearing in AJP in Advance.

Schizophrenia (Sepultura album)

Schizophrenia (Sepultura album) (Photo credit: Wikipedia)

In a large genome-wide association study of cases with schizophrenia and controls, researchers with the Molecular Genetics of Schizophrenia Consortium (an international group of researchers) examined single nucleotide polymorphisms (SNPs) that grouped or clustered together and assessed the risk for schizophrenia by comparing the cases and noncases. They then looked at relationships between the SNP clusters and various ways that patients present symptomatically across three separate studies.

The authors identified 42 SNP sets associated with a 70 percent or greater risk of schizophrenia and confirmed 34 (81 percent) or more with similar high risk of schizophrenia in two independent samples. These SNP sets or genotypic networks were linked to the different ways that patients present with schizophrenia, yielding eight distinct clinical syndromes varying in symptoms and severity.

“We found that some genetic pathways increasing susceptibility involved deficient control of healthy brain development, and other pathways involved increased susceptibility to brain injury and toxicity,”

Claude Robert Cloninger, M.D., a study coauthor and a professor of psychiatry at Washington University School of Medicine, told Psychiatric News. “Regulation of the plasticity of glutamate receptors was important in some classes of schizophrenia and not others.

A Single Nucleotide Polymorphism is a change o...

“The main take home message is that there are many pathways to schizophrenia, which converge on eight classes of the disorder,” he said.

Full coverage of this study will appear in a future issue of Psychiatric News. For more information on psychiatric genetics, see the Psychiatric News article, “Revolution in Psychiatric Genetics Rapidly Gains Steam.

Some of the “Other” Common Symptoms in Schizophrenia

Schizophrenia is most easily recognized by the symptoms that define it, such as visual and auditory hallucinations (e.g., “seeing things” and “hearing voices”) and delusions, including paranoia. But other symptoms are also extremely common.

Apathy, for instance, is often observed. If a person is experiencing auditory or visual delusions and paranoia – “psychosis” – they they are less likely to engage in day to day activities because the voices and suspicions are controlling the majority of their life. A Person living with schizophrenia can still experience depression even when they are not having other symptoms, the person will show signs of apathy, which can be attributed to the depression. Excessive doses of antipsychotics can also sometimes contribute to apathy.

Negative Symptoms Associated with Schizophrenia

Between 40% and 50% of people living with schizophrenia who have been treated and are recovering

will show evidence of negative symptoms. Negative symptoms include:

• Emotional flatness or lack of expressiveness.
• Inability to start and follow through with activities.
• Lack of pleasure or interest in life.

One distinction of some people living with schizophrenia is they do not expect enjoyable activities to give them pleasure, which likely causes them to not engage in pleasure-seeking behaviors.

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Reprograming Skin Cells Into Brain Cells

Using skin cells from patients with mental disorders, scientists are creating brain cells that are now providing extraordinary insights into schizophrenia and Parkinson’s disease.

For many poorly understood mental disorders, such as schizophrenia or autism, scientists often wish they could turn back the clock to uncover what has gone wrong in the brain. Now thanks to recent developments in the lab, this is coming true.

Salk Institute for Biological Studies, La Joll...

Salk Institute for Biological Studies, La Jolla, California (Photo credit: Wikipedia)

Researchers are using genetic engineering and growth factors to reprogram the skin cells of patients and grow them into brain cells. In the lab under careful watch, investigators can detect inherent defects in how neurons develop or function, or see what environmental toxins or other factors prod them to misbehave in the Petri dish. With these “diseases in a dish” they can also test the effectiveness of drugs that can right missteps in development, or counter the harm of environmental insults.

“It’s quite amazing that we can replicate a psychiatric disease in a petri dish,” says neuroscientist Fred Gage, a professor of genetics at the Salk Institute of Biological Studies. “This allows us to identify subtle changes in the functioning of neuronal circuits that we never had access to before.”