Volume 74June 2013Number 6

Original Research

568 Efficacy and Effectiveness of Depot Versus Oral Antipsychotics in Schizophrenia: Synthesizing Results Across Different Research Designs [Free Access]

Clinical Points
  • The comparative effectiveness of depot and oral formulations of antipsychotics in schizophrenia varies by study design. We found that observational designs tend to show favorable outcomes for depot therapy, whereas randomized controlled trials tend to find no differences between oral and depot formulations.
  • In weighing the published clinical evidence, clinicians should carefully consider the possible effects of study design on comparative effectiveness of antipsychotic treatment formulations.

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578 Examining the Comorbidity of Bipolar Disorder and Autism Spectrum Disorders: A Large Controlled Analysis of Phenotypic and Familial Correlates in a Referred Population of Youth With Bipolar I Disorder With and Without Autism Spectrum Disorders

Clinical Points
  • A clinically significant minority of youth with bipolar disorder suffers from autism spectrum disorders (ASD) comorbidity.
  • The age at onset of bipolar I disorder is significantly earlier in the presence of ASD comorbidity.
  • The phenotypic and familial correlates of bipolar I disorder are typical of the disorder in the presence of ASD comorbidity.

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587 The Efficacy of Agomelatine in Elderly Patients With Recurrent Major Depressive Disorder: A Placebo-Controlled Study

Clinical Points
  • The 8-week treatment with agomelatine 25–50 mg/d is both effective and well tolerated in elderly depressed patients over 65 years of age.
  • In clinical practice, agomelatine should be considered as an attractive option for treating major depressive disorder patients 65 years old and older with regard to its efficacy for depressive symptoms and social functioning, its benign adverse effect profile, and good tolerability by a medically complex population.

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614 Cytochrome P450 2D6 Phenoconversion Is Common in Patients Being Treated for Depression: Implications for Personalized Medicine

Clinical Points
  • Genotyping in clinical practice may significantly underestimate the incidence of CYP2D6 poor metabolic capacity in depressed patients for whom multiple drugs are prescribed.
  • Differences in CYP2D6 drug metabolic capacity, whether genetically determined or due to phenoconversion, can affect clinical outcomes in patients treated with drugs substantially metabolized by CYP2D6.
  • When prescribing treatment for depressed patients, particularly those with chronic medical disorders taking concomitant medications, it is important for clinicians to consider their current functional capacity (ie, phenotype) to metabolize and clear a drug, which is more clinically relevant than their genetic potential capacity to do so.

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622 Participants With Schizophrenia Retain the Information Necessary for Informed Consent During Clinical Trials

Clinical Points
  • People with schizophrenia who have stable psychotic symptoms have no meaningful loss of consent-related information during the first 8 weeks of participation in a clinical trial.
  • Therapeutic misconception, or confusion between research and clinical care, was not prominent in this sample of people with stable schizophrenia.

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Meta-Analysis

595 Patient Preference for Psychological vs Pharmacologic Treatment of Psychiatric Disorders: A Meta-Analytic Review

Clinical Points
  • Patient preference for the treatment of psychiatric disorders is a core component of evidence-based mental health care and has been shown to impact treatment retention and outcome.
  • Studies across diverse settings indicate that, on average, patients prefer psychological treatment to pharmacologic treatment for depression and anxiety at a rate of 3 to 1.
  • Consideration of patient preference, along with treatment efficacy and clinical expertise, may be important to optimizing outcomes in clinical settings.

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CME Background

CME Article

506 Posttest

 

603 Termination of Clozapine Treatment Due to Medical Reasons: When Is It Warranted and How Can It Be Avoided?

Clinical Points
  • Psychiatrists should be aware that the discontinuation of clozapine treatment may exclude patients from effective treatment and can increase the risk of relapse, aggression, and suicidal behavior.
  • Neutropenia, leukocytosis, seizures, orthostatic hypotension, severe constipation, weight gain, and metabolic abnormalities, including metabolic syndrome and its components, as well as moderately prolonged myocardial repolarization, need to be managed but do not generally warrant clozapine discontinuation.
  • Side effects such as eosinophilia, leukocytosis, drug-induced fever without another medical cause, and sinus tachycardia can be managed and should rarely lead to the discontinuation of clozapine treatment.
  • Clozapine discontinuation with potential rechallenge (providing there is appropriate surveillance and management or prophylactic therapy) is indicated for ileus or subileus, neuroleptic malignant syndrome, venous thromboembolism, and diabetic ketoacidosis or hyperosmolar coma. Other side effects, such as agranulocytosis, myocarditis, cardiomyopathy, and a QTc interval > 500 milliseconds that is confirmed and derived with the appropriate correction method warrant the immediate discontinuation of clozapine treatment.

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ASCP Corner

628 Bipolar Disorder and Attention-Deficit/Hyperactivity Disorder Comorbidity in Children and Adolescents: Evidence-Based Approach to Diagnosis and Treatment

Letters to the Editor

630 Deliberate Self-Poisoning With Prescribed Drugs Is Not Related to Medical Severity of Acts

630 Suicide Attempts in Patients With Bipolar Disorder Tend to Precede, Not Follow, Initiation of Antiepileptic Drugs

631 Brain Volume in Depression

Online Exclusives

Original Research

e520 Neuropsychiatric Symptoms and the Use of Mind-Body Therapies

Clinical Points
  • Neuropsychiatric symptoms are common in the general population, and these symptoms can be difficult to treat with standard treatments.
  • Patients in significant numbers are seeking treatment elsewhere, most commonly using mind-body therapies. However, many patients do not discuss these treatments with conventional providers.
  • It might be necessary for providers to initiate discussion of any alternative treatments patients may be using in addition to standard treatments.

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e527 Double-Blind, Placebo-Controlled, Pilot Trial of Paliperidone Augmentation in Serotonin Reuptake Inhibitor–Resistant Obsessive-Compulsive Disorder

Clinical Points
  • Although atypical antipsychotic augmentation shows promise in patients with treatment-resistant obsessive-compulsive disorder (OCD), there are mixed results, and many do not experience an adequate response.
  • Further investigation of augmentation strategies is needed among patients with treatment-resistant OCD.

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e533 First Experience With a Wireless System Incorporating Physiologic Assessments and Direct Confirmation of Digital Tablet Ingestions in Ambulatory Patients With Schizophrenia or Bipolar Disorder

Clinical Points
  • Management of many chronic diseases suffers from problems with continued medication adherence, which in turn contributes to an enormous proportion of avoidable emergency department visits and hospital days, as well as poor overall outcomes.
  • In appropriately selected patients, the use of a digital health feedback system (DHFS) provides a means of acquiring, summarizing, and communicating data on medication use, health status, and activities of daily living.
  • Acquiring such information through a DHFS system may facilitate earlier and more targeted interventions for patients at risk of disease progression or relapse.

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e551 Where and How People With Schizophrenia Die: A Population-Based, Matched Cohort Study in Manitoba, Canada

Clinical Points
  • People with schizophrenia have a median age of death of 77 years, underscoring the importance of end of life for the elderly patient in a setting providing appropriate physical and mental care.
  • People with schizophrenia are twice as likely to die in a nursing home compared to a matched cohort (29.7% vs 13.9%), and this finding holds true for deaths for most chronic diseases. Hence, clinicians need to ensure that disease-specific palliative care needs are met.
  • For older adults (age ≥ 60 years) with schizophrenia, the top 3 causes of death compared to a matched cohort of decedents were circulatory system (35.8% vs 36.8% of deaths), cancer (15.2% vs 27.2%), and respiratory system (12.7% vs 8.6%). However, these results do not point out the underlying rate of mortality, which could be double for those with schizophrenia. Hence, these findings translate into a potentially elevated risk of both circulatory and respiratory disease and similar rates of cancer deaths. Appropriate treatment for chronic disease and lifestyle management of those with schizophrenia (such as smoking cessation and dietary considerations) need to be part of the clinician’s treatment plan.

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Meta-Analysis

e541 Meta-Analysis of the Efficacy of Treatments for Posttraumatic Stress Disorder

Clinical Points
  • A large number of effective treatments exist for posttraumatic stress disorder (PTSD), including psychotherapies and medications.
  • No single treatment is most effective or the preferred treatment for PTSD.

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Practical Psychopharmacology

e558 Low-Dose Amisulpride and Elevation in Serum Prolactin

Clinical Points
  • At low doses, substituted benzamides such as sulpiride, levosulpiride, and amisulpride increase dopaminergic neurotransmission in the brain by preferentially blocking the higher affinity presynaptic dopamine autoreceptors. At high doses, these drugs decrease dopaminergic neurotransmission in the brain by also blocking the lower affinity dopamine postsynaptic receptors.
  • Both low and high doses raise serum prolactin levels.
  • This article discusses the reason for the absence of a biphasic effect on prolactin. Strategies are suggested for managing hyperprolactinemia associated with low-dose substituted benzamides.

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Book Reviews

e561 Casebook of Interpersonal Psychotherapy

e563 Resilience and Mental Health: Challenges Across the Lifespan

Free Online Activities

e11 Unmet Needs in the Assessment and Management of Bipolar I Depression [CME]

e12 Tools to Assess Negative Symptoms in Schizophrenia [CME]

Information for Authors

see www.psychiatrist.com/author.htm