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Introduction: Qualitative research methods can be used to obtain a deeper understanding of patient experience by collecting information in the patients’ own words about their encounters, perspectives, and feelings. In this study, patients with schizophrenia were interviewed to capture their voice and to complement the quantitative data typically obtained in clinical trials. Methods: Semi-structured exit interviews were conducted with 41 patients who completed or prematurely discontinued from a phase 3, open-label trial (NCT02873208). The interview guide included open-ended questions on current and prior disease burden, symptoms, quality of life, and treatment experiences. Steps taken to reduce interview stress and secure the validity of data included interviewer sensitivity training specific to mental health conditions and schizophrenia, use of in-person interviews whenever possible and use of videoconferencing for remote interviews to promote trust and comfort, and working closely with clinical site staff to identify patient eligibility and willingness to participate. Transcripts based on audio recordings were content coded and analyzed using thematic analysis; a post-hoc quantitative content analysis was conducted. Results: Patients reported that the symptoms of schizophrenia negatively impacted their work, relationships, self-esteem, emotional health, and daily activities. Most patients had positive experiences with medications that alleviated hallucinations, depression, and anxiety. However, side effects of medications were associated with negative impacts on physical, emotional, behavioral, and cognitive health. Lack of energy/drowsiness, weight gain, mood changes, and involuntary movements were the most common side effects reported with the use of antipsychotic medications. Patients reported unmet treatment needs related to better symptom control and to improved social and physical functioning. Conclusion: Collection of qualitative information within a schizophrenia clinical development process provides value and insights into patients’ views on burden of illness, experiences with previous medications, and experiences following participation in a clinical trial and can inform design for future studies. [ABSTRACT FROM AUTHOR]

Introduction and purpose Cariprazine is an atypical antipsychotic drug approved for the treatment of schizophrenia, as well as manic and mixed episodes associated with bipolar disorder. It functions as a dopamine multifunctional agent, a partial agonist at dopamine and serotonin receptors. Unlike the majority of antipsychotics, which primarily target positive symptoms through dopaminergic antagonism, often neglecting negative, cognitive, and affective symptoms, the unique cariprazine's pharmacological profile, particularly potent blockade of D3 dopamine receptors, suggests the potential for numerous clinical applications. The aim of this study is to present current knowledge of cariprazine, focusing particularly on its mechanism of action, potential applications, adverse effects, and pharmacokinetic properties that could impact its clinical use. Methods and materials A review of the literature available in the PubMed database was performed using the key words: cariprazine; atypical antipsychotic drug; antipsychotic medication; schizophrenia treatment; bipolar disorder treatment; mania treatment; depression treatment, dopamine agonist. Conclusions Cariprazine demonstrates a unique pharmacological profile, offering potential benefits in managing a wide range of psychiatric disorders, including schizophrenia, bipolar disorder (mania, depression, mixed episodes), unipolar depression, and co-occurring substance use disorders. Clinical studies have shown efficacy in reducing symptoms and improving negative and cognitive function, with a favorable metabolic profile, minimal impact on cardiovascular system, and generally mild adverse effect profile. However, further research is necessary to explore its full therapeutic potential and optimize its clinical use in diverse patient populations. [ABSTRACT FROM AUTHOR]

Introduction: This reviews aim was to explore the evidence base for the use of antipsychotic medications in the management of acute symptoms in patients with emotionally unstable personality disorder. Methods: Relevant databases and grey literature were searched for relevant papers. Inclusion/exclusion criteria were applied which resulted in the retrieval of eight papers pertinent to the literature review. The papers were critically appraised, and a thematic analysis was undertaken to collate relevant data. Findings: Five themes emerged from this literature review: different outcome measures, symptom domains (anger, impulsivity, mood instability, pseudopsychotic symptoms, self-harm and suicidal behaviours, adverse effects, the quality of the evidence and bias). Conclusions: The evidence base is not robust enough to allow conclusions to be drawn. Any positive results must be weighed up against the potential for adverse events. This review lays the foundations for further research, which is needed to explore antipsychotic treatment. [ABSTRACT FROM AUTHOR]

Background: 80% of patients value information on treatment options as an important part of recovery, further patients with a history of psychotic episodes feel excluded from decision making about their antipsychotic treatment, and on top of that, mental health staff is prone to be reluctant to support shared decision making and medication tapering for patients with schizophrenia. This case series aims to demonstrate the tapering of antipsychotic medication and how guided tapering affects the patient's feeling of autonomy and psychiatric rehabilitation. Case presentation: We present six patients diagnosed with schizophrenia (International Classification of Mental and Behavioral Disorders– 10th Edition codes F20.0–5, F20.7–9) who underwent professionally guided tapering in our clinic. The clinic aims to guide the patients to identify the lowest possible dose of antipsychotic medication in a safe setting to minimise the risk of severe relapse. Two patients completely discontinued their antipsychotic medication, two suffered a relapse during tapering, one chose to stop the tapering at a low dose, and one patient with treatment resistant schizophrenia, which is still tapering down. Conclusions: Reducing the antipsychotic dose increased emotional awareness in some patients (n = 4) helping them to develop better strategies to handle stress and increased feelings of recovery. Patients felt a greater sense of autonomy and empowerment during the tapering process, even when discontinuation was not possible. Increased awareness in patients and early intervention during relapse may prevent severe relapse. Impact and implications: Some patients with schizophrenia might be over medicated, leading to unwanted side effects and the wish to reduce their medication. The patients in our study illustrate how guided tapering of antipsychotic medication done jointly with the patient can lead to improved emotional awareness and the development of effective symptom management strategies. This may in turn lead to a greater sense of empowerment and identity and give life more meaning, supporting the experience of personal recovery. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on this subject?: The physical health of people with serious mental illness (SMI) is an issue of growing concern in New Zealand and internationally.Metabolic syndrome is prevalent among people with severe mental illness and increases the likelihood of developing cardiovascular disease and diabetes.No previous international research has investigated rates of metabolic monitoring in specialist mental health services and in primary care. What this paper adds to existing knowledge?: Rates of metabolic monitoring are low in this specialist mental health service and in primary care.Primary care nurses are positive in their views of their role in providing care for people with mental illness, and would value further education in this area. What are the implications for practice?: Services need to consider ways in which nurses can be supported to improve rates of metabolic monitoring.Guidelines may have a role to play in improved monitoring but need service‐level support in order to be effective. Introduction: People with serious mental illness experience significant disparities in their physical health compared with the general population. One indicator of health impairment is metabolic syndrome, which increases the likelihood of developing cardiovascular disease and diabetes. No international studies have reported both primary care and mental health nurses' rates of metabolic monitoring among people with serious mental illness, and no New Zealand studies have investigated rates of metabolic monitoring. Aim: To evaluate metabolic monitoring practices within one of New Zealand's 20 district health board regions. Method: An audit of clinical records in primary care (n = 46) and secondary care (n = 47) settings and a survey of practice nurses were conducted. A survey was sent to 127 practice nurses with a response rate of 19% (n = 24). Data were analysed using descriptive statistics. Results: Rates of metabolic monitoring were low in both services. Survey participants expressed positive views towards physical health monitoring and confidence in relating to mental health consumers. Rates of treatment of metabolic abnormalities were low, and communication between primary and secondary services was limited. Conclusion: Despite existence of guidelines and protocols, metabolic monitoring rates in both primary and secondary health services are low. Incorporating metabolic monitoring systems into service delivery, supported by appropriate tools and resourcing, is essential to achieve better clinical outcomes for people experiencing mental illness. [ABSTRACT FROM AUTHOR]

Schizophrenia is a chronic mental illness that affects thought processes, perception, and behavior, and antipsychotic medications are important to control psychotic symptoms. People with schizophrenia who adhere to neuroleptic medication are less likely to relapse than those who do not. This paper reports on a meta-synthesis of qualitative research exploring medication adherence experiences among people with schizophrenia. Published articles written in English from 1999-2019 were searched (January 1999-December 2019), from electronic databases, including CINAHL, PubMed, Science Direct, Scopus, PsycINFO, ProQuest, Dissertations and Theses, and the Thai National Research Repository. Twelve studies were included in the final review. Major components that affect medication adherence in people with schizophrenia positively or negatively were gentle pressure, trust and social support, a positive attitude toward disease and treatment, a sense of understanding of the beneficial and negative impact of medication, and financial constraints. We suggest a gentle medication adherence approach that departs from a joint responsibility between the family network and health providers to push people with schizophrenia towards medication uptake and help them develop coping mechanisms to deal with important side effects. Family members and health care providers should consider the patient's concerns about what is perceived as a normal life and a potential future life, taking into account social stigma and financial barriers. [ABSTRACT FROM AUTHOR]

Objectives: Decision aids (DAs) are promising tools to foster evidence‐based shared decision‐making between practitioners and service users. Nevertheless, it is still obscure how an evidence‐based DA for people with severe mental illness, especially psychosis, should look in an inpatient treatment setting to be useful and feasible. Therefore, we conducted focus groups with psychiatrists and service users to collect and assess their expectations and wishes regarding an evidence‐based DA. From these findings, we derived immediate recommendations for the future development of DAs. Methods: We held two group interviews with service users (n = 8) and three group interviews with psychiatrists (n = 10). We used an open, large‐scale topic guide. First, we presented data from a current meta‐analysis on antipsychotics to the interviewees and, in a second step, asked for their expectations and wishes towards a DA that integrates these data. Results: Our thematic analysis revealed six key themes addressed by the respondents: (1) general considerations on the importance and usefulness of such a DA, (2) critical comments on psychiatry and psychopharmacotherapy, (3) communicative prerequisites for the use of a DA, (4) form and content of the DA, (5) data input, data processing and output as well as (6) application of the DA and possible obstacles. Conclusions: Participants identified several important features for the development of DAs for selecting antipsychotics in inpatient psychiatric treatment. The digital format was met with the greatest approval. Especially the adaptability to different needs, users and psychopathologies and the possibility to outsource information dissemination via app seemed to be a decisive convincing argument. Further research is required to test specific features of DAs to be developed in clinical settings. Patient or Public Contribution: The entire project is supported by an advisory board, including also experienced users. The members are regularly updated about the process and give important feedback. [ABSTRACT FROM AUTHOR]

Antipsychotic medication has been the mainstay of treatment for psychotic illnesses for over 60 years. This has been associated with improvements in positive psychotic symptoms and a reduction in relapse rates. However, there has been little improvement in functional outcomes for people with psychosis. At the same time there is increasing evidence that medications contribute to life shortening metabolic and cardiovascular illnesses. There is also uncertainty as to the role played by antipsychotic medication in brain volume changes. Aim: The primary aim of the study is, in a population of young people with first‐episode psychosis, to compare functional outcomes between an antipsychotic dose reduction strategy with evidence‐based intensive recovery treatment (EBIRT) group (DRS+) and an antipsychotic maintenance treatment with EBIRT group (AMTx+) at 24‐months follow‐up. Methods: Our single‐blind randomized controlled trial, within a specialist early psychosis treatment setting, will test the whether the DRS+ group leads to better vocational and social recovery than, the AMTx+ group over a 2‐year period in 180 remitted first‐episode psychosis patients. Additionally, we will examine the effect of DRS+ vs AMTx+ on physical health, brain volume and cognitive functioning. This study will also determine whether the group receiving DRS+ will be no worse off in terms of psychotic relapses over 2 years follow‐up. Results: This paper presents the protocol, rationale and hypotheses for this study which commenced recruitment in July 2017. Conclusion: This study will provide evidence as to whether an antipsychotic dose‐reduction recovery treatment leads to improved functioning and safer outcomes in first‐episode psychosis patients. In addition, it will be the first‐controlled experiment of the effect of exposure to antipsychotic maintenance treatment on brain volume changes in this population. [ABSTRACT FROM AUTHOR]

There are many case reports of seizures apparently associated with the prescription of antipsychotics. This study aimed to examine whether there is an association between the prescription of antipsychotics and incident seizures in individuals with autism spectrum disorder using retrospective data based on patients' chart review. A cohort study was conducted to compare the rate of incident seizure between 3923 users of antipsychotics with 10,086 users of other psychotropics. This was followed by a self-controlled case series (SCCS) analysis of 149 patients to eliminate the effect of time-invariant confounders. The results showed no evidence of increased risk of seizure after exposure to antipsychotic agents (Hazard Ratio 1.28, 95% CI 0.74–2.19) compared to other psychotropics. [ABSTRACT FROM AUTHOR]

We investigated whether a functional insertion/deletion (I/D) polymorphism of angiotensin-converting enzyme (ACE) influenced antipsychotic treatment. At baseline, and after 8 weeks of treatment with various antipsychotic medications, we assessed patients' Positive and Negative Syndrome Scale (PANSS) scores, PANSS factors, and metabolic-syndrome-related parameters (fasting plasma lipid and glucose levels, and body mass index). A total of 186 antipsychotic-naïve first-episode psychosis patients or nonadherent chronic psychosis individuals (99 males and 87 females) were genotyped by polymerase chain reaction analysis. The ACE-I/D polymorphism was significantly associated with changes in PANSS psychopathology only (p < 0.05). Compared to ACE-II homozygous males, ACE-DD homozygous and ACE-ID heterozygous males manifested significantly greater decreases in PANSS positive score, PANSS excitement factor, and PANSS cognitive factor. ACE-DD homozygous females manifested higher decreases in PANSS depression factor compared to ACE-II homozygous and ACE-ID heterozygous females. The polymorphism's effect size was estimated as moderate to strong, while its contribution to the PANSS psychopathology ranged from ~5.4 to 8.7%, with the lowest contribution observed for PANSS positive score changes and the highest for PANSS depressive factor changes. Our results indicate that ACE-I/D polymorphism had a statistically significant but weak gender-specific impact on psychopathology data, and showed no association between ACE-I/D polymorphism and metabolic-syndrome-related parameters. [ABSTRACT FROM AUTHOR]

Background: Studies that examine course and outcome in psychosis have reported considerable heterogeneity in terms of recovery, remission, employment, symptom presentation, social outcomes, and antipsychotic medication effects. Even with demonstrated heterogeneity in course and outcome, prophylactic antipsychotic maintenance therapy remains the prominent practice, particularly in participants with schizophrenia. Lack of efficacy in maintenance antipsychotic treatment and concerns over health detriments gives cause to re-examine guidelines. Methods: This study was conducted as part of the Chicago follow-up study designed as a naturalistic prospective longitudinal research study to investigate the course, outcome, symptomatology, and effects of antipsychotic medication on recovery and rehospitalization in participants with serious mental illness disorders. A total of 139 participants with 734 observations were included in the analysis. GEE logistic models were applied to adjust for confounding factors measured at index hospitalization and follow-ups. Results: Our data show that the majority of participants with schizophrenia or affective psychosis experience future episodes of psychosis at some point during the 20-year follow-up. There was a significant diagnostic difference between groups showing an increase in the number of future episodes of psychosis in participants with schizophrenia. Participants with schizophrenia not on antipsychotics after the first 2 years have better outcomes than participants prescribed antipsychotics. The adjusted odds ratio of not on antipsychotic medication was 5.989 (95% CI 3.588–9.993) for recovery and 0.134 (95% CI 0.070–0.259) for rehospitalization. That is, regardless of diagnosis, after the second year, the absence of antipsychotics predicted a higher probability of recovery and lower probability of rehospitalization at subsequent follow-ups after adjusting for confounders. Conclusion: This study reports multiple findings that bring into question the use of continuous antipsychotic medications, regardless of diagnosis. Even when the confound by indication for prescribing antipsychotic medication is controlled for, participants with schizophrenia and affective psychosis do better than their medicated cohorts, strongly confirming the importance of exposing the role of aiDSP and antipsychotic drug resistance. [ABSTRACT FROM AUTHOR]

Introduction: Metabolic-associated Fatty Liver Disease (MAFLD) is a term for Non-alcoholic Fatty Liver Disease (NAFLD) that highlights its association with components of the Metabolic Syndrome (MetS). MAFLD is becoming a clinically significant problem due to its increasing role in the pathogenesis of cryptogenic cirrhosis of the liver. Material and methods: The resulting work is a review of the most important information on the risk of MAFLD development in the context of the use of particular groups of psychotropic drugs. The study presents the epidemiology, with particular emphasis on the population of psychiatric patients, pathophysiology and scientific reports analyzing the effect of the psychotropic medications on MAFLD development. Results: The drugs that can have the greatest impact on the development of MAFLD are atypical antipsychotics, especially olanzapine, and mood stabilizers (MS) - valproic acid (VPA). Their effect is indirect, mainly through dysregulation of organism's carbohydrate and lipid metabolism. Conclusions: The population of psychiatric patients is particularly vulnerable to the development of MAFLD. At the root of this disorder lies the specificity of mental disorders, improper dietary habits, low level of physical activity and tendency to addictions. Also, the negative impact of the psychotropic drugs on the systemic metabolism indirectly contributes to the development of MAFLD. In order to prevent fatty liver disease, it is necessary to monitor metabolic and liver parameters regularly, and patients should be screened by ultrasound examination of the liver. There are also important preventive actions from the medical professionals, including education of patients and sensitizing to healthy lifestyle. [ABSTRACT FROM AUTHOR]

The natural efficacy based trials of the atypical antipsychotics are required to yield extensive information concerning the efficiency, security, tolerance and safety among the patients suffering from schizophrenia who are treated in the hospital-based outpatient care centre based practice. In this study, the men and women were taken with the age range of 14 to 90 y with recognition of schizophrenia. There were a total of 103 patients considered for this study, who were enrolled between July 2017 to August 2021. This study analyzed the treatment with aripiprazole along with the standard of care based treatment procedure. The patient data reviewed in this study during the screening process moved closer to an interactive voice response system after obtaining informed consent. In the aripiprazole treatment group (n=49), the results were significantly better and effective in comparison to the standard of care treatment group (n=54; p<0.001; w 26, last observation carried forward) as reflected by the interactive voice response system total score. Similar results were noted in patients who duly completed the study design where aripiprazole was significantly associated with effectiveness at all phases in comparison to the standard of care group. The patients treated with aripiprazole also showed a significantly higher increase in quality of life and lesser adverse effects at w 26 (p<0.001). A high percentage of patients who received aripiprazole as a study medication was termed as “much better’’ on the preference scale of the medication questionnaire in comparison to the standard of care. The schizophrenia trial of aripiprazole provides a detailed overview of the real-world rendering and the enhanced benefits of aripiprazole compared to other major atypical antipsychotics advised in the hospital. [ABSTRACT FROM AUTHOR]

Background: More than half of people who use antipsychotic medication for psychosis report having sexual dysfunction. The REMEDY trial aimed to find out if switching antipsychotic medication provides an effective way to reduce sexual dysfunction among people with psychosis. We set out to recruit 216 participants over a two-year period, but recruitment was stopped after an extended 12-month pilot phase, during which we recruited only 10 participants. As part of a nested process evaluation, we conducted qualitative interviews with front-line clinicians to examine barriers to recruitment to the trial. Methods: We developed a semi-structured interview schedule to explore staff views on factors that influenced whether they referred potential participants to the study. We interviewed a purposive sample of 51 staff from four National Health Service (NHS) Trusts in England, ensuring a range of different backgrounds, seniority, and levels of involvement in the trial. Audio recordings of interviews were transcribed for verbatim, and data were analysed using an inductive approach to thematic analysis. Results: Nine interconnected themes were generated. Six themes concerned barriers to recruitment; including; prioritising patients' mental stability, mutual discomfort and embarrassment about discussing a "taboo" subject, and concerns about unintended consequences of asking people with psychosis about their sexual functioning. Three themes, including the quality of treatment relationships and strategies for opening dialogue suggested ways to improve recognition of these "hidden" side effects. Conclusion: The identification and management of sexual dysfunction among people with psychosis are not priorities for mental health services in England at this time. Many staff working in front-line services feel unprepared and uncomfortable asking people with psychosis about these problems. While greater use of screening tools may improve the identification of sexual dysfunction among people with psychosis, the evaluation and implementation of interventions to manage them will continue to be challenging unless NHS leaders and senior clinicians demonstrate greater commitment to changing current clinical practice. Trial registration: Current Controlled Trials ISRCTN12307891. [ABSTRACT FROM AUTHOR]

Accessible summary: What is known on the subject?: In the United States, 15.5% of nursing home residents without qualifying diagnoses of schizophrenia, Huntington's' Disease, and/or Tourette Syndrome receive antipsychotic medications.Antipsychotic medications are used off‐label (i.e., used in a manner the United States Food and Drug Administration's packaging insert does not specify) to treat neuropsychiatric symptoms, often before attempting nonpharmacologic interventions, despite evidence that this drug class is associated with significant adverse events including death.Less than optimal staffing resources and lack of access to geropsychiatric specialists are barriers to reducing antipsychotic use. What the paper adds to existing knowledge?: Antipsychotic use occurred in 11.6% of nursing home residents without qualifying or potentially qualifying diagnoses (bipolar disorder and psychotic disorder); antipsychotic use was more prevalent in residents with a dementia diagnosis than those without.One additional registered nurse hour per resident day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively. What are the implications for practice?: Given the influence of total staffing and professional staff mix on risk of antipsychotic use, nursing home administrators may want to consider aspects of facility operation that impact antipsychotic use.More stringent Unites States' survey and certification standards for dementia care implemented in 2017 demand proactive person‐centered care that promotes maximal well‐being and functioning without risk of harm from inappropriate psychoactive medications.Mental health nurses have requisite training to provide expert person‐centered care to nursing home residents with mental illness and geropsychiatric disorders. Introduction: Antipsychotic use in nursing homes varies widely across the United States; inadequate staffing, skill mix, and geropsychiatric training impede sustained improvement. Aim: This study identified risk factors of antipsychotic use in long‐stay residents lacking qualifying or potentially qualifying diagnoses. Method: This secondary analysis used 2015 Minimum Data Set and cost report data from 458 Missouri nursing homes. The full sample (N = 29,679) was split into two subsamples: residents with (N = 15,114) and without (N = 14,565) a dementia diagnosis. Separate logistic regression models were run. Results: Almost 15% of the dementia subsample and 8.4% of the nondementia subsample received an antipsychotic medication in the past week. Post‐traumatic stress disorder, psychosis indicators, behavioral symptoms, anxiety medication with and without anxiety diagnosis, depression medication with and without depression diagnosis, and nurse staffing were among the strongest predictors of antipsychotic use in both subsamples. Simulation analyses showed decreased odds of receiving an antipsychotic in both subsamples when registered nurse hours matched the national average. Discussion: Matching nurse staffing mix to the national average may improve antipsychotic use in nursing homes. Implications: Knowledge of antipsychotic use risk factors use can inform care planning and staff education to minimize use of these medications in all but severe cases. [ABSTRACT FROM AUTHOR]

The paper describes the Antipsychotic Medication Management Fidelity Scale and its psychometric properties, including interrater reliability, frequency distribution, sensitivity to change and feasibility. Fidelity assessors conducted fidelity reviews four times over 18 months at eight sites receiving implementation support for evidence-based antipsychotic medication management. Data analyses shows good to fair interrater reliability, adequate sensitivity to change over time and good feasibility. At 18 months, item ratings varied from poor to full fidelity on most items. Use of the scale can assess fidelity to evidence-based guidelines for antipsychotic medication management and guide efforts to improve practice. Further research should improve and better calibrate some items, and improve the procedures for access to information. Trial registration: ClinicalTrials.gov Identifier: NCT03271242. [ABSTRACT FROM AUTHOR]

Aim: There is an ongoing debate regarding the optimal timing of discontinuation of antipsychotic drugs for patients with first episode psychosis. Although most guidelines recommend maintenance therapy for at least 1 or 2 years after reaching remission, study results indicate that early discontinuation may be beneficial for at least a subsample of patients. To date, little is known about which medication strategies are applied in patients recovering from a first psychotic episode. In this study, we examined the beliefs and practices of clinicians on medication discontinuation. Methods: We performed a survey among 50 experienced Dutch psychiatrists to assess how often specific treatment strategies have been applied in the past 12 months, as well as their knowledge and expectations with respect to medication discontinuation. Results: Psychiatrists estimated that, after remission, they continued medication at the same dose for at least 12 months in 51.2% of cases, continued in a reduced dose in 33.8% of cases and discontinued medication in 9.1% of cases after 4.4 months of remission on average. Although the medication is discontinued in only a relatively small proportion of patients, almost half of all clinicians (45.9%) used this strategy at least once in the past 12 months. Conclusions: There is substantial practice variation in antipsychotic medication strategies after remission from a first psychotic episode. Future research on long‐term effects of early medication discontinuation can guide clinicians in making evidence‐based decisions when treating first‐episode patients. [ABSTRACT FROM AUTHOR]

Provide the first national description across the US of variations in healthcare measures in 2018 among Medicaid beneficiaries with schizophrenia. Adult beneficiaries with ≥2 diagnoses for schizophrenia, and continuous enrollment with consistent geographical data in all of 2018 were identified from Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) data for 45 of 50 states. Antipsychotic (AP) utilization rates, including long-acting injectable APs (LAIs), quality metrics, and all-cause healthcare resource utilization and costs for claims submitted to Medicaid were reported nationally and by state. Pearson correlation evaluated associations between LAI utilization and total healthcare costs at state and county levels. Across the US 688,437 patients with schizophrenia were identified. The AP utilization rate was 51% (state range: 24–77%), while the LAI utilization rate was 13% (range: 4–26%). The proportion of patients adherent to any AP was 56% (range: 19–73%). Within 30 days post-discharge from an inpatient admission, 22% (range: 8–58%) of patients had an outpatient visit, and 12% (range: 4–48%) had a readmission. The proportion of patients with ≥1 inpatient admission and ≥1 emergency room visit was 34% (range: 19–82%) and 45% (range: 20–70%). Per-patient-per-year total healthcare costs averaged $32,920 (range: $717–$93,972). At the county level, a weak negative correlation was observed between LAI utilization and total healthcare costs. This study included Medicaid beneficiaries enrolled with pharmacy and medical benefits, including beneficiaries dually eligible for Medicare; results cannot be generalized to the overall schizophrenia population or those with other payer coverage. In 2018, half of beneficiaries with schizophrenia did not submit any claims for APs to Medicaid, nearly half had an emergency room visit, and one-third had an inpatient admission. Moreover, healthcare measures varied considerably across states. These findings may indicate unmet treatment needs for Medicaid beneficiaries with schizophrenia. Schizophrenia is a severe mental disorder that poses a large health, social, and cost burden to patients and society. While treatment with antipsychotic medications can reduce the number of relapses and hospitalizations, many patients do not adhere to treatment, which can lead to poor symptom control and further use of healthcare services. Interestingly, these measures of schizophrenia care seem to vary across US states. Therefore, we ran the first study to describe the regional differences in antipsychotic use, measures of quality of care, healthcare use, and healthcare costs among Medicaid-insured patients across the US in 2018. Our results showed that only half of patients used antipsychotics in 2018 (with a range of 24–77% across states) and the proportion of patients adherent to antipsychotic treatment was low (range of 19–73%). Additionally, nearly half of all patients had an emergency room visit (range of 20–70%), and one-third had an inpatient admission (range of 19–82%). These findings highlight large variations in antipsychotic use, performance measures, and healthcare use, possibly due to regional differences in unmet needs in schizophrenia care for Medicaid-insured patients in the US. Since use of inpatient and emergency room services was consistently high in specific states or regions, and yearly healthcare costs per patient varied from $717–$93,972 (mean = $32,920), there may be a particularly high burden in certain areas of the country where patients with schizophrenia may potentially be experiencing multiple relapses. Further research is needed to identify policies that may help narrow these regional differences. [ABSTRACT FROM AUTHOR]

Background: In 2014, nursing home administration and government officials were facing increasing public and media scrutiny around the variation of antipsychotic medication (APM) prescribing across Ontario nursing homes. In response, policy makers partnered to test an academic detailing (AD) intervention to address appropriate prescribing of APM in nursing homes in a cluster-randomized trial. This mixed-methods study aimed to explore how and why the AD intervention may have resulted in changes in the nursing home context. The objectives were to understand how the intervention was implemented, explore contextual factors associated with implementation, and examine impact of the intervention on prescribing.Methods: Administrative data for the primary outcome of the full randomized trial will not be available for a minimum of 1 year. Therefore, this paper reports the findings of a planned, quantitative interim trial analysis assessed mean APM dose and prescribing prevalence at baseline and 3 and 6 months across 40 nursing homes (18 intervention, 22 control). Patient-level administrative data regarding prescribing were analyzed using generalized linear mixed effects regression. Semi-structured interviews were conducted with nursing home staff from the intervention group to explore opinions and experiences of the AD intervention. Interviews were analyzed using the framework method, with constructs from the Consolidated Framework for Implementation Research (CFIR) applied as pre-defined deductive codes. Open coding was applied when emerging themes did not align with CFIR constructs. Qualitative and quantitative findings were triangulated to examine points of divergence to understand how the intervention may work and to identify areas for future opportunities and areas for improvement.Results: No significant differences were observed in prescribing outcomes. A total of 22 interviews were conducted, including four academic detailers and 18 nursing home staff. Constructs within the CFIR domains of Outer Setting, Inner Setting, and Characteristics of Individuals presented barriers to antipsychotic prescribing. Intervention Source, Evidence Strength and Quality, and Adaptability explained participant engagement in the AD intervention; nursing homes that exhibited a Tension for Change and Leadership Engagement reported positive changes in processes and communication.Conclusions: Participants described their experiences with the intervention against the backdrop of a range of factors that influence APM prescribing in nursing homes that exist at the system, facility, provider, and resident levels. In this context, the perceived credibility and flexibility of the intervention were critical features that explained engagement with and potential impact of the intervention. Development of a common language across the team to enable communication was reported as a proximal outcome that may eventually have an effect on APM prescribing rates. Process evaluations may be useful during early stages of evaluation to understand how the intervention is working and how it might work better. Qualitative results suggest the lack of early changes observed in prescribing may reflect the number of upstream factors that need to change for APM rates to decrease.Trial Registration: ClinicalTrials.gov, NCT02604056. [ABSTRACT FROM AUTHOR]

Objective: The Multilevel Facilitation of Long-Acting Antipsychotic Medication Program (MAP) is a novel intervention to increase the appropriate use of long-acting injectable (LAI) antipsychotics in community mental health clinics. The authors investigated the feasibility of MAP, facilitators and barriers to use, and preliminary impact on LAI medication use.Methods: Two clinics in Texas and two in Ohio serving 750 and 617 individuals with schizophrenia receiving oral antipsychotics, respectively, were asked to change clinical procedures for 1 year by using either the not receiving optimum benefit (NOB) checklist or the checklist plus MAP. Providers used the NOB checklist to identify individuals who could benefit from switching to LAI antipsychotics. MAP clinics used the NOB checklist plus nonbranded academic detailing for providers and a shared-decision-making video and tool for consumers. Use of MAP components was tracked, and barriers and facilitators were collected quarterly. Antipsychotic prescription counts were provided by participating clinics.Results: Barriers to use of MAP included loss of local champions and administrators, difficulty with provider buy-in, limited availability of peer specialists, and a lack of infrastructural support to integrate MAP into clinic flow. Higher scores on the NOB checklist were associated with more provider LAI medication offers and greater patient acceptance of LAI antipsychotics. LAI medication use increased in clinics over time, but it is unclear whether this increase was due to MAP.Conclusions: Changing MAP components to fit local procedures and to circumvent unique barriers could aid implementation. Further research should investigate the potential impact of MAP components on LAI medication use. [ABSTRACT FROM AUTHOR]

Background: Cannabis use is an important risk factor for development of psychosis and further transition to schizophrenia. The prevalence of patients with psychosis and comorbid cannabis use (dual diagnosis) is rising with no approved specialized pharmacological treatment option. Cannabidiol, a constituent of the Cannabis sativa plant, has potential both as an antipsychotic and as a cannabis substituting agent. The aim of this study is to evaluate the efficacy of cannabidiol versus a first-choice second-generation antipsychotic (risperidone) in patients with early psychosis and comorbid cannabis use. Methods: The study is a phase II randomized, double-blinded, parallel-group, active-comparator clinical trial. We plan to include 130 patients aged between 18 and 64 years with a recent diagnosis of psychosis, comorbid cannabis use, and currently not treated with antipsychotics. The participants will be randomized to seven weeks of treatment with either cannabidiol 600 mg (300 mg BID) or risperidone 4 mg (2 mg BID). Participants will undergo clinical assessment after 1, 3, 5 and 7 weeks, telephone assessment the weeks in between, and a safety visit two weeks after end of treatment. The primary outcomes are cessation of cannabis use (self-reported) and psychotic symptom severity. The secondary outcomes include frequency and quantity of cannabis use, global illness severity, psychosocial functioning, subjective well-being, cognition, sleep, circadian rhythmicity, and metabolomics. Discussion: The results of this trial can potentially contribute with a new treatment paradigm for patients suffering from dual diagnosis. Trial registration: ClinicalTrials.gov, NCT04105231, registered April 23rd, 2021 [ABSTRACT FROM AUTHOR]

Background: Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support. Aim: To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input. Design & setting: Realist review in general practice settings. Method: A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews. Results: Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory. Conclusions: The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users. [ABSTRACT FROM AUTHOR]

Purpose: New hospitalizations after first episode psychosis (FEP) may be viewed as an indicator of instability in a psychotic disorder. In the current study we wanted to analyse long term risk for psychosis hospitalizations after FEP. We also wanted to analyse predictors for late hospitalizations, with focus on early antipsychotic medication. Methods: First episode psychosis cases were recruited to the Swedish Parachute project in 1996–1997. The program offered highly available and continuous psychosocial support and a cautious use of antipsychotic medication for 5 years from inclusion. Longitudinal data from population registers on psychiatric hospitalizations up to 14 years after inclusion were analysed. One hundred and sixty-one cases were included of the original 175 in the project. Associations with possible early predictive factors from the original project data were analysed with COX regression. Results: A majority of the cases (67%) had hospitalizations in the first year after inclusion in the study. The cohort then diverged into a group (46%) with new hospitalizations for psychosis after the first year, most of them multiple times, and another group (54%) without new hospitalizations for psychosis, many without any late antipsychotic medication. Forty-two percentage of the cases had antipsychotic medication by month 12, and it was significantly associated with later psychosis hospitalizations (HR = 2.5, p value < 0.001). Conclusions: The study demonstrates that a large part of FEP cases have a good outcome as measured by absence of new hospitalizations for psychosis, and that many cases may terminate antipsychotic medication within a year of FEP onset without later relapses needing hospitalizations. [ABSTRACT FROM AUTHOR]

Importance: The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long‐term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative. Objective: Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long‐term care residents in hospice. Design: Interrupted time‐series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017. Setting: Long‐term care nursing facilities. Participants: Older adults ≥65 residing in long‐term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610). Main outcome: Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long‐term care residents; overall and among residents with dementia, stratified by hospice enrollment. Results: From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long‐term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non‐hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time. Conclusions and relevance: Declines in antipsychotic prescribing during the CMS National Partnership occurred among long‐term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end‐of‐life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation. [ABSTRACT FROM AUTHOR]

Background and Aims: Weight gain is a major adverse effect of antipsychotic medication, negatively affecting physical and mental well-being. The objective of this study was to explore if dose reduction, discontinuation, switch to a partial agonist, or switch from polypharmacy to monotherapy will lead to weight loss. Methods: Controlled and uncontrolled studies reporting the effects of discontinuation, dose reduction, switch to a partial agonist, or switch from polypharmacy to monotherapy on weight were included. Primary outcome was difference in weight compared to maintenance groups based on controlled studies. Secondary outcome was change in weight from initiation of one of the included interventions until follow-up in a pre-post analysis. Results: We identified 40 randomized controlled trials and 15 uncontrolled studies including 12,279 individuals. The effect of the interventions, i.e. dose reduction, drug discontinuation, or switch to a partial agonis, reduced the weight with 1.5 kg (95% CI −2.03 to −0.98; P < 0.001) compared to maintenance treatment. The weight change from pre to post was a reduction of 1.13 kg (95% CI −1.36 to −0.90; P < 0.001). Conclusion: We found a significant but small reduction in weight, suggesting that antipsychotic-induced weight gain can be reversed to some degree. Only a few studies were designed to address the question as primary outcome, which limits the generalizability of our findings. [ABSTRACT FROM AUTHOR]

Background: Despite the growing number of studies on the use of non-invasive brain stimulation in people with schizophrenia, there is limited research on participant views of such treatment methods. Aim: Explore participant experiences and perceptions of transcranial direct current stimulation (tDCS). Methods: Twelve people with schizophrenia took part in semi-structured interviews after having completed 5 sessions of tDCS. Thematic analysis was used to identify codes and themes. Results: Five themes were identified: (1) motivation for study enrolment; (2) concerns about tDCS; (3) factors reducing the fear of tDCS; (4) experience of tDCS; (5) perceived effects of tDCS. Conclusions: The study provides insight into the perceptions and experiences of each individual. Participants were concerned about the safety of tDCS and associated it with invasive procedures such as electroconvulsive therapy and lobotomy. Educational materials and a good relationship with the researcher played an important role in reducing the fear of brain stimulation. All participants described tDCS as uncomfortable, however, agreed that unpleasant sensations only lasted for a short while (20 s−5 min). After the first session, participants no longer felt anxious about the remaining ones. Strategies to improve treatment experience and study recruitment have been identified. [ABSTRACT FROM AUTHOR]

Accessible summary What is known on the subject? The only previous quantitative study that examined nurses' use of assessment tools to identify antipsychotic medication side effects found that about 25% of mental health nurses were using assessment tools., No previous studies have examined factors that influence the manner in which mental health nurses assess antipsychotic medication side effects., What this paper adds to existing knowledge? One-third of the respondents were not aware of any antipsychotic medication side-effect assessment tool, and only one-quarter were currently using an assessment tool., 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools, indicating that respondents with more positive attitudes to their service were more likely to continue using antipsychotic medication assessment tools., What are the implications for practice? The low level of awareness and use of antipsychotic medication side-effect assessment tools indicates that nursing educational institutions should incorporate more detail about these tools in course content, and emphasize in particular the benefits that result from the use of these tools in clinical practice., Service processes contributed significantly to the use of antipsychotic medication assessment tools, which indicates that managers need to foster workplace cultures that promote routine use of these tools., Abstract Introduction Limited evidence suggests that only a minority of mental health nurses regularly use standardized assessment tools to assess antipsychotic medication side effects, but the factors that contribute to the non-routine use of these tools remain unknown. Aim To examine Australian mental health nurses' awareness of, and attitudes towards, side-effect assessment tools, and also identify factors the influence the use of these tools. Methods A cross-sectional survey was undertaken through distributing an online questionnaire via email to members of the Australian College of Mental Health Nurses. Completed questionnaires were received from 171 respondents. Linear regression was used to examine the relationship between the 'service responsibility' and 'personal confidence' scale scores, and awareness, previous use and ongoing use of antipsychotic medication assessment tools. Results Only one-quarter of the respondents (26.5%) were currently using an assessment tool. 'Service responsibility' was significantly associated with ongoing use of antipsychotic medication assessment tools ( Β = 3.26; 95% CI 0.83-5.69). 'Personal confidence' did not influence the ongoing use of assessment tools ( Β = −0.05; 95% CI −1.06-1.50). Implications for clinical practice Stakeholders can incorporate 'service responsibility' processes to foster increased use of assessment tools, which may enhance the identification antipsychotic medication side effects and improve the quality of care for service users. [ABSTRACT FROM AUTHOR]

Eliciting clinicians' views about antipsychotic medication side-effects may assist in understanding strategies that could enhance the identification and management of these side-effects. The present paper details the development and psychometric evaluation of a questionnaire that captures clinicians' perceptions about these issues. An initial item set was derived from a literature review, and then refined by an expert content validity panel that assessed the relevance of the items. The online questionnaire was distributed to Australian mental health nurses and 140 fully completed questionnaires were returned. Principal components analysis yielded two robust scales that conceptually tapped 'system responsibility' and 'personal confidence'. These scales may be used to advance knowledge about how mental health nurses' attitudes towards the assessment and management of antipsychotic medication side-effects influences their clinical behaviour. [ABSTRACT FROM AUTHOR]

Individuals with schizophrenia have problems with visual contrast processing. The current study investigated contrast sensitivity (CS) in schizophrenia/schizoaffective disorder to elucidate the underlying neural mechanisms affected by this disorder and to identify critical testing conditions that distinguish individuals with the disorder from healthy individuals. Principal component analysis was applied to the data (N = 143) to separate responses from distinct visual pathways. Participants were 68 patients and 75 age‐similar controls. CS was obtained using a forced‐choice psychophysical paradigm with grating patterns of low to high spatial frequency presented at short and long durations. Linear mixed‐effects models were used to examine differences in log CS with respect to group, duration, and stimulus condition. Lower CSs were found in patients compared to controls over all stimulus conditions with the magnitude of deficits dependent on both spatial frequency and stimulus duration. Log CSs to low and high spatial frequencies loaded onto separate principal components, supporting the existence of two psychophysical mechanisms, transient and sustained. Critical conditions were identified to tap each mechanism. Visual acuity was correlated moderately with log CS to high, but not low, spatial frequencies, and deficits found for acuity and CS to moderate/high spatial frequencies (4–21 cycles/degree) appear to reflect dysfunction in the sustained mechanism. CS deficits found at the lowest spatial frequency tested (0.5 cycles/degree) appear to reflect dysfunction in the transient mechanism. Both types of CS deficits may have diagnostic value and implications for social and neurocognitive deficits in this disorder. [ABSTRACT FROM AUTHOR]

Obesity, diabetes, cardiac disease, severe mental illness (SMI), psychosis, metabolism, depression, antipsychotic medication Given the impact of antipsychotic medications on weight gain and its metabolic complications, it might be reasonable to expect that reducing the dose or discontinuing the antipsychotic or switching to a partial agonist might reverse the weight. Keywords: obesity; severe mental illness (SMI); diabetes; cardiac disease; psychosis; metabolism; depression; antipsychotic medication EN obesity severe mental illness (SMI) diabetes cardiac disease psychosis metabolism depression antipsychotic medication 1 3 3 01/06/22 20220103 NES 220103 "I welcome this I Frontiers i series on a research area that really matters to families like mine. [Extracted from the article]

Aim and objective of the audit. The purpose of this audit was to identify the number of people prescribed antipsychotic medication who are at risk of developing metabolic syndrome in a community mental health service area with the aim of improving and standardising metabolic screening practices within this setting. Community mental health services are secondary care services in which individuals are referred from Primary Care (General Practitioners). The catchment area of this audit is within the South East Region of Ireland and offers adults community mental health services to a population of approximately 57 000. For the purpose of this audit we focused on one community mental health team within the service. [ABSTRACT FROM AUTHOR]

Background: The literature on antipsychotic medication in psychosis lack systematization of the empirical knowledge base on patients' subjective experiences of using antipsychotic drugs. Such investigations are pivotal to inform large-scale trials with clinically relevant hypotheses and to illuminate clinical implications for different sub-groups of individuals. Aims: To re-analyze and summarize existing qualitative research literature on patient perspectives of using antipsychotic medication. Method: A systematic literature search was performed in September 2018 (Protocol registration no. CRD42017074394). Using an existing framework of meta-analyzing qualitative research, full text evaluation was conducted for 41 articles. Thirty-two articles were included for the final synthesis. Results: Four meta-themes were identified: (1) short-term benefits; (2) adverse effects and coping processes; (3) surrender and autonomy; (4) long-term compromise of functional recovery. Conclusions: While largely positive about acute and short-term use, patients are more skeptical about using antipsychotic drugs in the longer term. The latter specifically relates to processes of functional and social recovery. The clinical conversations about antipsychotic medication need to include evaluations of contexts of patient experience level, patient autonomy processes, patient values and risk preferences, and patient knowledge and knowledge needs in addition to assessing the severity of symptoms of psychosis. [ABSTRACT FROM AUTHOR]

Introduction: Antipsychotic medications are mainstays in the treatment of schizophrenia and a range of other psychotic disorders. Sources of data: Recent meta-analyses of antipsychotic efficacy and tolerability have been included in this review, along with key papers on antipsychotic use in schizophrenia and other psychotic illnesses. Areas of agreement: The heterogeneity in terms of individuals' response to antipsychotic treatment and the current inability to predict response leads to a trial-and-error strategy with treatment choice. Clozapine is the only effectivemedication for treatment-resistant schizophrenia. Areas of controversy: There are a significant number of side effects associated with antipsychotic use. With a reduction in the frequency of extrapyramidal side effects with the use of second-generation antipsychotics, there has been a significant shift in the side effect burden, with an increase in the risk of cardiometabolic dysfunction. Growing points: There exist small and robust efficacy differences between medications (other than clozapine), and response and tolerability to each antipsychotic drug vary, with there being no first-line antipsychotic drug that is suitable for all patients. Areas timely for developing research: A focus on the different symptom domains of schizophrenia may lead to endophenotypic markers being identified, e.g. for negative symptoms and cognitive deficits (as well as for positive symptoms) that can promote the development of novel therapeutics, which will rationally target cellular and molecular targets, rather than just the dopamine 2 receptor. Future developments will target additional processes, including glutamatergic, cholinergic and cannabinoid receptor targets and will utilize personalized medicine techniques, such as pharmacogenetic variants and biomarkers allowing for a tailored and safer use of antipsychotics. [ABSTRACT FROM AUTHOR]

Background: The relative benefits and risks of long-term maintenance treatment with antipsychotics have not been well studied in patients with bipolar disorder and major depressive disorder. For example, while antipsychotic dose reduction has been recommended in the management of serious side effects associated with antipsychotics, there is limited evidence on the impact of lowering doses on the course of underlying mood disorders. Methods: This retrospective cohort study analyzed the impact of antipsychotic dose reduction in patients with bipolar disorder or major depressive disorder. Medical claims from six US states over a 6-year period were analyzed for patients with ≥10% or ≥ 30% reductions in antipsychotic dose (cases) and compared using survival analyses with matched controls receiving a stable dosage. Outcomes included hospitalizations for disease-specific mood disorders, other psychiatric disorders and all-cause emergency room visits, and claims for tardive dyskinesia. Results: A total of 23,992 patients with bipolar disorder and 17,766 with major depressive disorder had a ≥ 10% dose reduction, while 19,308 and 14,728, respectively, had a ≥ 30% dose reduction. In multivariate analyses, cases with a ≥ 10% dose reduction had a significantly increased risk of disease-specific admission (bipolar disorder: hazard ratio [95% confidence interval], 1.22 [1.15–1.31]; major depressive disorder: 1.22 [1.11–1.34]), other psychiatric admission (bipolar disorder: 1.19 [1.13–1.24]; major depressive disorder: 1.17 [1.11–1.23]), all-cause admission (bipolar disorder: 1.17 [1.12–1.23]; major depressive disorder: 1.11 [1.05–1.16]), and all-cause emergency room visits (bipolar disorder: 1.09 [1.05–1.13]; major depressive disorder: 1.07 [1.02–1.11]) (all P < 0.01). Similar results were observed following an ≥30% dose reduction. Dose reduction was not associated with decreased claims for tardive dyskinesia. Conclusions: Patients with mood disorders who had antipsychotic dose reductions showed small but statistically significant increases in all-cause and mental health-related hospitalizations, which may lead to increased healthcare costs. These results highlight the need for additional long-term studies of the necessity and safety of maintenance antipsychotic treatment in mood disorders. [ABSTRACT FROM AUTHOR]

The 22q11.2 deletion syndrome (22q11.2DS) is a multisystem condition and the most prevalent microdeletion syndrome in humans. Approximately 25% of individuals with 22q11.2DS receive antipsychotic treatment. To assess whether patients with 22q11.2DS are vulnerable to adverse effects of antipsychotic medication, we carried out a literature review. A systematic search strategy was performed using PubMed (Medline), Embase, PsychInfo, and Cochrane Database of Systematic Reviews. Publications describing adverse effects of antipsychotic medication in patients with 22q11.2DS were included in the review and assessed for their methodological quality. A total of 11 publications reporting on eight trials, cross‐sectional or cohort studies, and 30 case reports were included. The most commonly reported adverse effects can be classified into the following categories: movement disorders, weight gain, seizures, cardiac side effects, and cytopenias. Many of these symptoms are manifestations of 22q11.2DS, also in the absence of antipsychotic medication. Based on the reviewed literature, a causal relation between antipsychotic medication and the reported adverse effects could not be established in the majority of cases. Randomized clinical trials are needed to make firm conclusions regarding risk of adverse effects of antipsychotics in patients with 22q11.2DS. [ABSTRACT FROM AUTHOR]

Purpose - People with intellectual disability are subject to increased health morbidity when compared to the general population. This paper assesses the monitoring of metabolic syndrome in people with an intellectual disability who have been prescribed antipsychotic medication.Design/methodology/approach - A pre-audit analysis was followed by an audit of 32 patients. The height, weight and body mass index was recorded in 34 per cent prior to initiation, which decreased to 22 per cent at the three monthly follow up. Blood pressure was recorded in 6 per cent of the patients at baseline, but there was no record during treatment. The biochemical parameters including plasma glucose and plasma cholesterol were measured in 40 per cent of the patients on initiation which decreased to 33 per cent at three monthly follow up in the first year. In total, 21 per cent of patients received four monthly monitoring of the biochemical parameters, i.e. their height and weight, 25 per cent of the patients had an annual monitoring of all parameters.Findings - The results indicate inconsistent monitoring of metabolic syndrome in people with intellectual disability being treated with antipsychotic medication. While a proportion of patients may have been monitored in primary care, these data indicate the need for remedial action to improve the standard of metabolic syndrome detection in those people with intellectual disability receiving antipsychotic medication.Originality/value - This study highlights the inadequate monitoring of biochemical and physical parameters of metabolic syndrome in people with an intellectual disability who are prescribed antipsychotic medication. National criteria for monitoring the prescription of antipsychotic medication in people with intellectual disability who are prescribed antipsychotic medication is proposed. [ABSTRACT FROM AUTHOR]

Background: The need for psychological therapies for psychosis has become apparent since long-term antipsychotic drug treatment has a range of adverse side effects, with moderate therapeutic effects at best. Aims: To investigate whether the psychotherapeutic approach, dialogue therapy (DT) is associated with improvements of symptoms and functioning beyond standard psychiatric treatment (ST) in both schizophrenia and other psychosis. Methods: A retrospective case-control design, comparing 54 patients with different psychoses who received DT with 54 patients in a control group receiving ST was carried out. The groups were matched on diagnosis, age, sex, and treatment start. Outcome measures were Global assessment of functioning (GAF) scores, medications at follow up, and hospital stays after completed outpatient treatment. Results: Mean time in treatment from inclusion to follow-up was 3 years and 5 months. At follow-up, GAF functioning (GAF-F) and GAF symptom (GAF-S) scores both were significantly higher in the DT group than the ST group. Effect sizes (Cohen's d) were large; 1.8 for GAF-S and 2.1 for GAF-F. At follow-up, the use of psychoactive drugs was significantly reduced despite a shorter time in psychotherapy in the DT group compared to the ST group. Days of hospitalizations after end of treatment in the study period were significantly reduced in both groups compared to the period before start of treatment. Conclusions: The findings from this exploratory study are consistent with the possibility that dialogue therapy may lead to improvements in symptoms and functioning compared to standard treatment in psychosis. [ABSTRACT FROM AUTHOR]

Rationale: Weight gain during treatment with antipsychotics is a prominent side-effect, especially with some second-generation antipsychotics, such as olanzapine and clozapine, and pharmacological treatments which ameliorate this side-effect are important to investigate. Decreases in histaminergic transmission in the brain induced by antipsychotics may be one of the mechanisms contributing to weight gain. Since betahistine is a histaminergic agonist, it may potentially counteract the weight gain effects of antipsychotics.Method: We conducted a double-blind placebo-controlled study to evaluate the effects of 12 weeks of treatment with betahistine (N = 29) or placebo (N = 22) in adolescents and adults on anthropomorphically measured weight-related parameters, appetite, and fasting glucose-lipid and leptin levels in 51 patients treated with first and/or second-generation antipsychotics who had gained weight during treatment or had high body-mass-index (BMI). Psychopathology and side-effects were also assessed with relevant scales.Results: In a sub-group of patients being treated with olanzapine or clozapine (n = 26), betahistine was significantly (P < .05) better than placebo in preventing increases in weight (3.1 kg less weight gain than placebo), BMI, and waist circumference. Betahistine did not decrease weight or BMI in patients treated with other antipsychotics. There was also no effect of betahistine on preventing weight or BMI gain in the total combined sample of all subjects. Betahistine did not significantly improve appetite or glucose-lipid measures in either subgroup. There were no significant differences in side-effects or psychopathology changes in the betahistine- vs. placebo-treated patients.Conclusions: These results suggest that betahistine may potentially be a useful adjunctive drug for decreasing weight gain in patients treated with antipsychotics that are potent histamine antagonists, such as olanzapine or clozapine, but may not be useful for this purpose in patients on other antipsychotic medications. The results justify larger placebo-controlled studies to further confirm these effects before specific recommendations can be made for routine use. [ABSTRACT FROM AUTHOR]

There is considerable variation among the antipsychotic drugs in terms of their capacity to increase serum prolactin, but the clinical relevance of this to osteoporosis is unclear. This paper describes an audit of bone density measurement in a long-term psychiatric population specifically conducted to examine any association between prolactin level and use of antipsychotic medication. A sample of 31 female patients from one high security hospital underwent dual energy X-ray absorptiometry of their wrist bones. Information relating to risk factors for osteoporosis was collected by questionnaire from the patients, and the pharmacy department provided details of current medications. A logistic regression was carried out on the dependent variable of osteoporosis (i.e., osteopenia/osteoporosis and normal) as determined from the distal T score of the bone density measurement, with age at interview, smoking, length of time on antipsychotic medication, serum prolactin measurement, whether or not the patient was taking thyroxine, and body mass index all entered as independent variables. The only variable found to have a significant independent effect on osteopenia/osteoporosis was body mass index: the higher the body mass index, the higher the distal T score. This suggests that weight, rather than antipsychotic medication use, appears to influence bone density more than prolactin level, with obesity seemingly having a protective role. [ABSTRACT FROM AUTHOR]

Background: Physical illnesses are more prevalent among patients with serious and enduring mental illnesses. This is mainly due to the association between mental and physical illnesses, complications of the mental illness itself and as a side effect of medication. Medical problems can be overlooked by psychiatrists due to several reasons. More research and audit of the existing services are necessary to establish the physical needs of patients with complex mental health problems. Aim: To give an account of the causes of excessive mortality and physical morbidity among patients with serious mental health problems. Method: Review of the worldwide literature. Results: Physical problems are more common and the standardised mortality rate (SMR) is higher in psychiatric patients compared to the general population. The main causes are association between mental and physical illnesses, lifestyle including lack of physical activity, smoking and poor dietary habits, metabolic syndrome, diabetes mellitus and other cardiac risk factors. There is a close association between treatment with antipsychotic medication and weight gain, diabetes mellitus, sudden death, cardiac and endocrine complications such as QT prolongation and also hyperprolactinemia. Conclusion: The paper highlights the importance of monitoring physical problems in patients with serious and enduring mental illnesses. Good practice points include help with smoking cessation, psychoeducation about healthy lifestyle, close liaison between carers and professionals, the importance of taking baseline investigations before commencing antipsychotics, a shared care approach with primary care, early identification of the risk factors for physical illnesses and regular monitoring of physical health. Also important are social interventions such as appropriate accommodation and structured day, leisure and sporting activities. [ABSTRACT FROM AUTHOR]

Objectives: This paper gives an overview of studies on the association between dopaminergic neurotransmission and the subjective experience of patients with schizophrenia.Methods: We undertook a review of the literature.Results: Dopaminergic neurotransmission may be relevant for subjective experience. Higher striatal D2 receptor occupancy by typical and atypical antipsychotics is related to worse subjective experience, more severe negative symptoms, and depression. Individuals with lower baseline dopamine function are at an increased risk for dysphoric responses during antipsychotic therapy with dopaminergic-blocking drugs. There is preliminary evidence that a window of striatal D2 receptor occupancy between 60% and 70% is optimal for the subjective experience of patients. These occupancies are often reached even with low dosages of antipsychotic drugs.Conclusions: Reaching an optimal dopamine D2 receptor occupancy is clinically relevant, since subjective experience associated with antipsychotic medication is related to medication compliance. Antipsychotic drug dosages often need to be lower than levels in common use. [ABSTRACT FROM AUTHOR]

Summary The present paper documents a retrospective evaluation of a specialist challenging behaviour unit for individuals with severe learning disabilities according to two criteria: (1) its efficacy at reducing the frequency and severity of violent incidents; and (2) the level of reliance upon antipsychotic medication for behavioural purposes. The results were placed within the perspective of the specific approach to challenging behaviour adopted by the unit, which emphasizes communication as the fundamental tenet within the management and reduction of challenging behaviour. The results demonstrate a 92% reduction in incidents of violence towards others over the 6 years since the unit opened, alongside a 95% reduction in violence towards property. During the same period, the levels of antipsychotic medication used for behavioural purposes fell in the cases of three out of the four clients under examination. An attempt is made to highlight the predominant factors underlying this success as potential indicators for the development of services for those who exhibit challenging and violent behaviours. [ABSTRACT FROM AUTHOR]

The article presents the exploratory statistical analysis of antipsychotic medication use by people with dementia who are residing in residential aged care facilities. It discusses how the study was conducted at a major urban centre in southeastern Australia. The results reportedly revealed that only a small percentage of participants were suffering from psychotic comorbidity.

Mental health caregivers commonly have detailed insight about consumers' lives, and therefore often have developed an understanding of the manner in which antipsychotic medication affects consumers. This study explored caregivers' perspectives of key factors that influence mental health consumers' use of antipsychotic medications. The analysis was based on transcripts of interviews which were conducted with caregivers of mental health consumers. Each transcript was categorically coded across 12 variables to generate a series of data profiles. The data set was then analysed using multidimensional scalogram analysis to identify associations between subsets of variables. The findings demonstrated that mental health consumers tended to adhere to prescribed antipsychotic medications despite experiencing troubling side effects. Such adherence occurred when caregivers participated in discussions about medications, and health professionals monitored side effects vigilantly and altered medications to reduce side effects. Also, caregivers were generally unsettled about the impact of medication side effects on consumers' lives, but conceded that benefits of medications typically outweighed the adverse effects. Further studies are warranted to strengthen the findings of this study. [ABSTRACT FROM AUTHOR]

Abstract: The present study is a review of a cardiometabolic clinic for consumers taking clozapine. This clinic was recently established and co‐located with the clozapine clinic at a regional hospital in New South Wales, Australia, to enhance engagement and improve the physical health outcomes of consumers taking antipsychotic medication. A descriptive analysis of clients’ (n = 73) information collected during routine care for the first 6 months of the clinic's operation, from January 2016 to July 2016, was conducted. First‐visit data were analysed to establish a client profile, consisting of weight, height, blood pressure, pulse, a range of blood measurements, smoking status, alcohol consumption, and eating and exercise habits. Data collected for clients who had three or more visits with the general practitioner (n = 40) were analysed separately for outcomes. Two case studies are used to depict the service received and client profile. At the first appointment, the majority of clients had metabolic syndrome that was mostly left untreated; many of these clients were commenced on metformin. The outcomes are positive, and show that the majority of clients lost weight (82.5%) and had a reduction in body mass index (84.6%); nearly half (44.4%) had a reduction in waist circumference. The majority of clients self‐reported increased physical activity (72.5%, n = 29) and positive dietary changes (77.5%, n = 31) since their first appointment. The model trialled by the cardiometabolic clinic integrated a specialist mental health and primary care service, and demonstrates success in engaging clients with severe mental illness in physical health care. Co‐location is conceptualized as critical for positive patient outcomes and high levels of engagement. [ABSTRACT FROM AUTHOR]

Accessible summary • The attitudes of mental health professionals towards medication play a crucial and influential role in service users' uptake of treatments. Evidence suggests that when service users receive their medication via depot injection, compliance improves and relapse rates are reduced. It is vital that mental health service users are involved in decision making about the mode by which their antipsychotic medication is delivered. Despite this, few studies have investigated the attitudes and beliefs that healthcare professionals hold about depot medication. No reviews have looked at health professionals' attitudes towards depot medication alone. • Depots are seen as old fashioned, stigmatizing, causing side effects and being costly, and they are often not prescribed because of a presumed adherence to oral medication. • In the current study it has been found that research in this field is sparse, and studies have mixed quality. An issue that should be investigated when looking at prescribing of depot medication is that of non-medical prescribers, especially nurses. Nurses have a different relationship to the service users when compared with consultant psychiatrists, and this can have an impact on service users' choice of medication. Healthcare professionals are key providers of information about antipsychotic medication and may have a significant influence on the decisions that service users make about how their medication is delivered. This systematic review aimed to explore health professionals' attitudes and beliefs towards antipsychotic depot medication. A systematic search of AMED, BNI, CINAHL, EMBASE, HEALTH BUSINESS ELITE, HMIC, MEDLINE and PsycINFO was carried out, as well as hand searches of journals and citation searches. Studies were selected if the terms ‘attitudes/beliefs’ and ‘depot/injection’ were included in the title or abstract, if health professionals were participants in the study and if original data were included. The search strategy produced 131 papers. Eight relevant studies were then selected for the review. They included six cross-sectional surveys and two qualitative studies. It was shown that the research carried out is still very sparse. Depots are seen as old fashioned, stigmatizing, causing side effects and being costly, and they are often not prescribed because of a presumed adherence to oral medication. More research needs to be carried out to further explore these issues, to look at the role of non-medical prescribers and explore the relationship between health professionals' attitudes and those of service users. [ABSTRACT FROM AUTHOR]

Background: The aim of the TAILOR trial is to investigate the effect of closely monitored tapering/discontinuation versus maintenance therapy with antipsychotic medication in patients with newly diagnosed schizophrenia or persistent delusional disorder and with minimum 3 months' remission of psychotic symptoms.Methods and Design: Two hundred and fifty patients will be included from the psychiatric early intervention program, OPUS, in two regions in Denmark. Inclusion criteria are: ICD-10 diagnoses schizophrenia (F20, except F20.6) or persistent delusional disorder (F22), minimum 3 months' remission of psychotic symptoms and in treatment with antipsychotic medication (except clozapine). The patients will be randomized to maintenance therapy or tapering/discontinuation with antipsychotic medication in a 1-year intervention. The tapering/discontinuation group will be using a smartphone application to monitor early warning signs of psychotic relapse. Patients will be assessed at baseline, 1-, 2- and 5-year follow-up regarding psychotic and negative symptoms, side-effects of antipsychotic medication, social functioning, cognitive functioning, perceived health status, patient satisfaction, substance and alcohol use, sexual functioning and quality of life. The primary outcome will be remission of psychotic symptoms and no antipsychotic medication after 1 year. Secondary outcome measures will include: co-occurrence of remission of psychotic symptoms and 0-1-mg haloperidol equivalents of antipsychotic medication after 1-year intervention; antipsychotic dose; antipsychotic side effects; negative symptoms; social functioning; cognitive functioning; and patient satisfaction. Exploratory outcomes will include remission, clinical recovery, substance and alcohol use, sexual functioning, quality of life, self-beliefs of coping and user experience of support from health workers. Safety measures will include death, admissions to psychiatric hospital, severe self-harm and psychotic relapses.Discussion: The TAILOR trial will contribute knowledge about the effect of tapering/discontinuation of antipsychotic medication in the early phases of schizophrenia and related disorders and the results may guide future clinical treatment regimens of antipsychotic treatment.Trial Registration: EU Clinical Trials Register - EudraCT number: 2016-000565-23 . Registered on 5 February 2016. [ABSTRACT FROM AUTHOR]

Background: Previous evidence suggests that how an individual conceptualises the cause of a health problem can impact on subsequent perceptions and behaviour. Aims: This study explored the beliefs about the causes of psychosis in a group of mental health professionals. The study also sought to examine the relationship between causal beliefs and the perceived helpfulness of different treatments. Methods: A total of 219 clinicians completed a questionnaire about the provision of cognitive behavioural therapy (CBT) and antipsychotic medication for their clients who were experiencing psychosis and their opinions about the helpfulness of these treatments. Causal beliefs were also assessed. Results and conclusions: Clients were twice as likely to be offered medication compared to CBT. Clinicians held a multifactorial model of aetiology, but were more likely to endorse psychosocial causes than biological factors. Clinicians with psychosocial beliefs were more likely to rate CBT as effective, whereas those with biological models were more likely to endorse the helpfulness of medication. Clinicians adopt a multi-causal approach when conceptualising the aetiology of psychosis and these beliefs were related to opinions about the helpfulness of treatment. Beliefs about the aetiology of their client’s experiences could blind clinicians to the benefits of offering different approaches. [ABSTRACT FROM AUTHOR]

Aims: Ongoing NICE guidance recommends research on the clinical and cost effectiveness of psychological treatment alone, compared to antipsychotic medication and compared to psychological treatment and antipsychotic medication combined. The COMPARE study (Cognitive behaviour therapy or Medication for Psychosis- A Randomised Evaluation) was a pilot trial designed to inform a definitive trial to answer this question. Method: COMPARE was a single-site pilot randomised controlled trial to compare a standardised Cognitive Behaviour Therapy (CBT) intervention to treatment with antipsychotic medication (APs) and a combined treatment (CBT plus APs) in adults with psychosis. Participants were assessed using the Positive and Negative Syndrome Scale (PANSS) and followed up at 6, 12, 24 and 52 weeks. The primary outcomes were recruitment and retention of participants. We surveyed a wider population of staff and service users to further inform feasibility of a definitive trial. Results: We report the characteristics of the recruited sample at baseline (n = 75) and results from surveys. Conclusions: The study recruited to target demonstrating it is feasible to identify and recruit participants to a study of this kind. The survey results also suggest that such trials are feasible. [ABSTRACT FROM AUTHOR]

Background: There is lack of long-term controlled studies evaluating treatment effects of antipsychotic medication. A complete investigation should include the service user perspective. Aims: To investigate experiences of clinically recovered service users of antipsychotic medications during and after a first episode of psychosis. Method: We used a thematic analytic approach within an interpretative-phenomenological framework. 20 clinically recovered service users were interviewed. Results: Themes: (1) Antipsychotic drugs reduce mental chaos during the acute phase, (2) Non-stigmatizing environments were perceived to increase chances of successful use, (3) Antipsychotic drugs beyond the acute phase – considered to compromise the contribution of individual effort in recovery, (4) Prolonged use – perceived to reduce likelihood of functional recovery, (5) Antipsychotic medication was considered as a supplement to trustful relationships. Conclusions: Acute phase antipsychotic treatment was mostly perceived as advantageous by this sample, who was in clinical recovery. However, costs were often seen as outweighing benefits beyond the acute stage. Findings clearly emphasize the need for a collaborative approach to be integrated across all phases of care. This study underscores the need to investigate sub-group differences with regard to long-term antipsychotic treatment. [ABSTRACT FROM AUTHOR]