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Abstract: People with serious mental illness have higher morbidity and mortality rates of chronic diseases than the general population. This discussion paper explores the complex reasons for these disparities in health, such as limitations of health services, the effects of having a serious mental illness, health behaviours and the effects of psychotropic medication. Physical health can be enhanced by improved monitoring and lifestyle interventions initiated at the start of treatment. There are opportunities for mental health nurses to play a significant role in improving both the physical and mental health of people with serious mental illness. [Copyright &y& Elsevier]

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]

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]

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]

Background: Antipsychotic medications offer limited long-term benefit to about 30% of patients with schizophrenia. We aimed to explore the individual-specific imaging markers to predict 1-year treatment response of schizophrenia. Methods: Structural morphology and functional topological features related to treatment response were identified using an individualized parcellation analysis in conjunction with machine learning (ML). We performed dimensionality reductions using the Pearson correlation coefficient and three feature selection analyses and classifications using 10 ML classifiers. The results were assessed through a 5-fold cross-validation (training and validation cohorts, n = 51) and validated using the external test cohort (n = 17). Results: ML algorithms based on individual-specific brain network proved more effective than those based on group-level brain network in predicting outcomes. The most predictive features based on individual-specific parcellation involved the GMV of the default network and the degree of the control, limbic, and default networks. The AUCs for the training, validation, and test cohorts were 0.947, 0.939, and 0.883, respectively. Additionally, the prediction performance of the models constructed by the different feature selection methods and classifiers showed no significant differences. Conclusion: Our study highlighted the potential of individual-specific network parcellation in treatment resistant schizophrenia prediction and underscored the crucial role of feature attributes in predictive model accuracy. [ABSTRACT FROM AUTHOR]

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]

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]

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]

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 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]

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]

Individuals experiencing a first episode of psychosis are likely to respond well to treatment with antipsychotic medications. Of those treated for a first episode of schizophrenia, three out of four can expect to achieve remission. The question of how long antipsychotic medication should be continued has been a topic of heated debate in the field. Longitudinal studies of individuals diagnosed with a first episode of psychosis have reported that as many as 30% may be able to come off of medications without relapsing while treatment discontinuation studies have found that very few patients remain in remission off of medication. This paper reviews the literature on relapse rates following a first episode of schizophrenia and identifies factors that contribute to the discrepancies in the rates reported. These factors include sampling considerations, the distribution of psychiatric diagnoses, the duration of follow-up, the rate of medication discontinuation and the criteria used to define illness recurrence. We propose that individuals for whom the diagnosis of their first psychotic episode is determined with ongoing follow-up to be due to schizophrenia are at extremely high risk of relapse and should be advised to continue antipsychotic medication for the long-term. Those whose first episode of psychosis is determined to be due to other causes are also at high risk of illness recurrence off medications. Recommendations for maintenance treatment should be tailored to reflect the risk of relapse and sequelae of relapse associated with specific causes of first episode psychosis. [ABSTRACT FROM AUTHOR]

Sexual dysfunction is one of the most frequently occurring side-effects of antipsychotic medication, impacting both quality of life and adherence to treatment. Despite this, limited evidence-based guidance on treatment options is available. To synthesize and analyze the evidence on management of antipsychotic-related sexual dysfunction, specifically taking note of the more recently developed antipsychotics that have been incorporated in studies over the past decade. EMBASE, Medline, and PsychINFO databases were searched using search terms related to sexual or erectile dysfunction, treatments, and antipsychotics. 2 reviewers independently assessed papers for the inclusion criteria for randomized controlled trials (RCTs) of treatments for antipsychotic-related sexual dysfunction, including adjunctive medications and a switch of antipsychotic. Studies were excluded if participants did not have recorded sexual dysfunction at baseline. The primary outcome measure was any change in sexual function. 6 RCTs were identified, all of which investigated different interventions; hence, it was not possible to synthesize the data quantitatively. Results were overall limited by small sample size, brief treatment duration, and the potential for bias. 2 studies, one assessing adjunctive sildenafil and the other adjunctive aripiprazole, reported a reduction in antipsychotic-related sexual dysfunction. Due to the lack of high-quality data, no clinical recommendations can be made. A comprehensive search strategy was used with an extensive number of relevant search terms including "erectile dysfunction" and newer antipsychotics such as aripiprazole. In light of evidence that prolactin is not a reliable marker for sexual dysfunction, this review focused its inclusion criteria on participants presenting with sexual dysfunction rather than with hyperprolactinemia, which should give its recommendations more validity. However, only 6 RCTs were identified, and results were overall limited by small sample size, brief treatment duration, and the potential for bias. Our findings highlight the paucity of high-quality research in this area, and conjecture that it may be difficult to recruit participants with antipsychotic-related sexual dysfunction. Future research may be necessary to unlock and address these difficulties. Furthermore, fully powered future studies should focus on the management of sexual dysfunction rather than the surrogate marker of hyperprolactinemia. Allen K, Baban A, Munjiza J, et al. Management of Antipsychotic-Related Sexual Dysfunction: Systematic Review. J Sex Med 2019;16:1978–1987. [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]

Purpose of Review: Despite clear evidence that sex differences largely impact the efficacy and tolerability of antipsychotic medication, current treatment guidelines for schizophrenia spectrum disorders (SSD) do not differentiate between men and women. This review summarizes the available evidence on strategies that may improve pharmacotherapy for women and provides evidence-based recommendations to optimize treatment for women with schizophrenia. Recent Findings: We systematically searched PubMed and Embase for peer-reviewed studies on three topics: (1) sex differences in dose-adjusted antipsychotic serum concentrations, (2) hormonal augmentation therapy with estrogen and estrogen-like compounds to improve symptom severity, and (3) strategies to reduce antipsychotic-induced hyperprolactinemia. Based on three database studies and one RCT, we found higher dose-adjusted concentrations in women compared to men for most antipsychotics. For quetiapine, higher concentrations were specifically found in older women. Based on two recent meta-analyses, both estrogen and raloxifene improved overall symptomatology. Most consistent findings were found for raloxifene augmentation in postmenopausal women. No studies evaluated the effects of estrogenic contraceptives on symptoms. Based on two meta-analyses and one RCT, adjunctive aripiprazole was the best-studied and safest strategy for lowering antipsychotic-induced hyperprolactinemia. Summary: Evidence-based recommendations for female-specific pharmacotherapy for SSD consist of (1) female-specific dosing for antipsychotics (guided by therapeutic drug monitoring), (2) hormonal replacement with raloxifene in postmenopausal women, and (3) aripiprazole addition as best evidenced option in case of antipsychotic-induced hyperprolactinemia. Combining these strategies could reduce side effects and improve outcome of women with SSD, which should be confirmed in future longitudinal RCTs. [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]

Introduction: Data from the literature suggests that some first episode psychosis (FEP) patients may recover without antipsychotic medication. There is however no reliable way to identify them. In a previous paper we found, in a cohort of 584 FEP patients, that those consistently refusing medication had poorer pre-morbid functioning, less insight, higher rate of substance use and poorer outcome. However, some medication refusers, had a favourable outcome. The study aim was to identify predictors of good short term outcome despite non-exposure to medication.Methods: The Early Psychosis Prevention and Intervention Centre (EPPIC) admitted 786 FEP patients between 1998 and 2000. Data were collected from patients' files using a standardized questionnaire. Data on medication adherence was available in 584 patients. Among the 17.9% of patients who consistently refused medication over the entire treatment phase we compared patients who had a favourable symptomatic and functional outcome with those who did not.Results: Among patients who consistently refused medication, 41% achieved symptomatic remission and 33% reached functional recovery. Predictors of symptomatic remission were a better premorbid functioning level, higher education and employment status at baseline. Predictors of functional recovery were a shorter duration of the prodrome phase, less severe psychopathology at baseline and lower cannabis use.Conclusions: Despite limitations mainly linked to the fact that non-exposure to antipsychotic medication was based on patient's treatment refusal, this study identified some characteristics which may contribute to the identification of a sub-group of FEP patients who may have good short term outcome without antipsychotic treatment. [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]

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.

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 • 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]

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]