On July 19th, 2014, Dr. Randall White was invited to speak at The Western Washington Chapter of Physicians for a National Health Program’s Ninth Annual Public Meeting. This year’s theme was: “Health Care is a Human Right: Making it Real in Washington State.” As a physician who has practiced both in Canada and the US, Randall brings a unique perspective to the table. Dr. White is a known advocate for health care equality, and stresses that financial access to health care is a major source of inequality. He says “Inequality has greater effects on Health Care than the actions of doctors and caregivers. In Canada, Health Care is a human right.” He goes on to encourage his American colleagues to continue to strive for universal health care.
A large consortium of researchers in Europe, North American and Australia performed a genome-wide association study (GWAS) of single-nucleotide polymorphisms, which are uncommon variants of genes, among people with schizophrenia in two stages. In the first stage, a discovery analysis of pre-existing GWAS cohorts, they included, 9,394 people with schizophrenia and 12,462 controls, all of European ancestry. In the second-stage independent replication, they used a sample of 8,442 cases and 21,397 controls. In the combined stage-1-and-2 dataset, five alleles had a significant and novel association with schizophrenia, whereas two alleles identified in previous research had significant association. The most robustly newly associated allele was rs1625579 on chromosome 1p21.3, in intron 3 of AK094607. This region codes for the primary transcript of MIR137, a microRNA involved in adult neurogenesis and neuronal maturation. Two previous studies cited in the present report found an association of this regulatory mechanism with schizophrenia. Moreover, four genes identified as possibly associated with schizophrenia in the present study are targets of MIR137.
Although the evidence is circumstantial, the researchers assert a possible pathophysiologic role for the MIR137 mechanism in schizophrenia. Linkage studies, an older approach to identify candidate genes, have identified schizophrenia-related genes such as DISC1, and studies of patients with copy-number variants such as 22q11 deletion syndrome have suggested additional genetic etiologies of psychosis. The heterogeneity of “the group of schizophrenias,” as Bleuler called this disorder (2), is being borne out in genetic research, and psychiatrists should pay attention. We can hope that such work will bear fruit in improved treatments for our patients.
1. The Schizophrenia Psychiatric Genome-Wide Association Study (GWAS) Consortium. Genome-wide association study identifies five new schizophrenia loci. Nat Genet. 2011.18;43:969-976. Full text
2. Bleuler, Eugen. Dementia praecox or the group of schizophrenias. Leipzig, Germany; 1911.
We are pleased to announce that Dr. Randall White has been invited to be the third speaker at The Western Washington Chapter of Physicians for a National Health Program’s Ninth Annual Public Meeting. This year’s theme is: “Health Care is a Human Right: Making it Real in Washington State”, and includes a promising keynote to be delivered by Kshama Sawant, PHD, Seattle City Council Member. Sawant champions the rights of the working poor and disenfranchised, and is most recently recognized for her work on the successful $15Now campaign, a grass-roots living wage campaign.
Another highlight will be Philip Caper, MD, who was a staff member on Senator Edward Kennedy’s US Senate Labor and Human Resources Subcommittee on Health, a PNHP national Board Member and active in Maine AllCare.
Randall will be contributing “Remarks from a Canadian / American Perspective.” He will mention how commercialized mental health care compromises quality, provides less service for the severely mentally ill, and has been implicated in known corruption in the U.S.
We hope you will join us!
Attending the event? Or following from home? Use hashtag #HCHR2014 and @BCPsychosis
Saturday, July 19th, at 7PM at
Kane Hall Room 120, on the University of Washington Campus
Admission is free and open to the public.
There is free parking beneath Kane Hall.
Researchers from Australia have conducted the first controlled trial of estrogen in premenopausal women with treatment-resistant psychosis (1). They recruited 183 women with schizophrenia or schizoaffective disorder who were not pregnant, lactating, or postmenopausal; and who had no history of breast cancer, endocrine disorders, migraine with aura, or thromboembolism. Patients with acute mania were excluded. Patients were randomly assigned to receive either transdermal estradiol 100 mcg daily, transdermal estradiol 200 mcg daily, or placebo patch. The primary outcome measure during the 56-day trial was the Positive and Negative Syndrome Scale (PANSS). Other measures included the Montgomery-Asberg Depression Rating Scale (MADRS), the Repeatable Battery of Neuropsychological Status, adverse-effects monitoring, and serum estradiol concentration at the baseline and during treatment.
The baseline demographic, illness, and treatment characteristics did not differ among the placebo, 100 mcg-estradiol, and 200-mcg estradiol groups. Most subjects were outpatients, and the three groups had mean PANSS total scores of 72-75. Compared with the placebo group, both treatment groups had significant increases in serum estradiol concentration; and greater decreases in mean PANSS positive, general, and total scores. The effect size for positive symptoms, however, was 0.0 for the 100 mcg group and 0.44 for the 200 mcg group, which reflected a mean 3.3-point reduction in PANSS-positive score with the higher dose. No significant treatment effect was found for negative symptoms or cognition. The only significant adverse effect was an increase of irregular menses in the 200 mcg group compared with the placebo group.
The investigators acknowledge that this trial was short-term and that the risks of thromboembolism and endometrial carcinoma may accumulate during longer-duration therapy. Raloxifene, a selective estrogen receptor modulator, entails a lower risk of these adverse effects. In 2011, investigators from Spain reported on a randomized trial of 16 postmenopausal women who had significant mean reduction of positive, negative, and general symptoms compared with a comparable placebo group (2). Case reports exist of raloxifene use in premenopausal women with treatment-resistant schizophrenia (3,4), but controlled trials in this population have not been published.
1. Kulkarni J, Gavrilidis E, Wang W. Estradiol for treatment-resistant schizophrenia: a large-scale randomized-controlled trial in women of child-bearing age. Molecular Psychiatry. Published online 15 Apr 2014. Abstract
2. Usall J, Huerta-Ramos E, et al. Raloxifene as an adjunctive treatment for postmenopausal women with schizophrenia: a double-blind, randomized, placebo-controlled trial. J Clin Psychiatry. 2011;72(11):1552-1557. Abstract
3. Raveendranathan D, Shivakumar V, Jayaram N, Rao NP, Venkatasubramanian G. Beneficial effects of add-on raloxifene in schizophrenia. Arch Womens Ment Health. 2012;15(2):147-148. Abstract
4. Shivakumar V, Venkatasubramanian G. Successful use of adjuvant raloxifene treatment in clozapine-resistant schizophrenia. Indian J Psychiatry. 2012;54(4):394. Full text
A team of BC psychologists has performed the first meta-analysis of cognitive-behavioral therapy for medication-resistant psychosis. The 16 published studies that met their inclusion criteria comprised 12 trials and 639 individual patients. Medication resistance was defined as inadequate response of positive symptoms to at least one medication at adequate dose and duration, or treatment with clozapine. All the trials entailed assignment to either individual CBT for 10 to 24 sessions, or to a control intervention such as treatment as usual, psychoeducation or befriending. Four trials lacked masked raters. Outcome measures were typically PANSS or BPRS, and most studies had a follow-up assessment 3 to 18 months after completion of treatment. Based on pooled outcome data, effect size was derived with Hedge’s g.
For improving positive symptoms, the effect size of CBT compared to control intervention at the end of treatment was 0.47. At follow-up 3-18 months after treatment, the effect size was 0.41. Among studies with an outcome measurement for general psychopathology, such as depression and anxiety, the effect sizes were 0.52 at treatment end and 0.40 at follow-up. According to the researchers, excluding studies without masked raters did not significantly change the effect sizes.
This meta-analysis yielded a medium effect size for time-limited CBT in medication-treated patients with residual positive symptoms. The results suggest improvement may be maintained beyond a year. These were not necessarily treatment-resistant patients as typically defined, although some were on clozapine. Research on other important outcomes such as hospital admission, psychosocial functioning, and suicide would help determine the place of CBT in managing treatment-resistant psychosis.
Burns AM, Erickson DH, Brenner CA. Cognitive-behavioral therapy for medication-resistant psychosis: a meta-analytic review. Psychiatr Serv. Published online 1 Apr 2014. Abstract
Clozapine is associated with an elevated risk of seizures, especially with doses of 600 mg or greater. At such doses and with elevated serum levels, many psychiatrists consider adding a prophylactic antiepileptic, which was first recommended in the journal Neurology in 1991 (1). Caetano has reviewed available studies in an effort to determine if this is sound practice, and he concludes it is not (2). According to him, the risk of clozapine-induced seizures is greatest when the serum level is 1300 ng/ml or more, the equivalent of 4000 nmol/L. The evidence for this finding is skimpy, however, and consists of case reports: one from 1994, two from 1978, and one from 2001. To accurately determine the dose-response relationship between seizures and clozapine serum levels, prospective studies would be necessary.
Despite this shortcoming, Caetano’s recommendation against prophylaxis makes sense, at least if the serum level is not approaching 4000 nmol/L and the patient doesn’t have other risk factors such as coarse brain disease. The risk of pharmacokinetic interactions and additional adverse effects with anticonvulsants is high; for instance, phenytoin can decrease and lamotrigine can increase clozapine levels. He recommends other measures for managing seizure risk and what to do if a patient does have a seizure.
1. Devinsky O, Honigfeld G and Patin J. Clozapine-related seizures. Neurology. 1991;41:369–371. Abstract
2. Caetano D. Use of anticonvulsants as prophylaxis for seizures in patients on clozapine. Australas Psychiatry. 2014;22:78-82. Abstract
Many clinicians have suspected and some evidence indicates that patients with the disorganized subtype of schizophrenia, or hebephrenia, do not respond as well to non-clozapine antipsychotics as do other subtypes. Investigators examined this hypothesis in 93 consecutively admitted schizophrenia patients at one hospital in Brazil. They confirmed the diagnosis with the Structured Clinical Interview for DSM-IV, and classified patients as either paranoid or disorganized subtype based upon the predominance of hallucinations and delusions versus disorganized speech and behavior using relevant PANSS items. Only 8 patients, who had either catatonic or residual schizophrenia, were excluded. Treatment resistance was defined as failure of two different antipsychotics, and these patients were offered either clozapine or “combination therapy.”
The mean age of the patients was about 32 years and 56% were male. The demographic profiles did not differ between the 25 disorganized and the 60 paranoid patients; however, the disorganized patients had significantly earlier age of onset, more severe symptoms, and lower functioning as measured by the Global Assessment of Functioning scale. Among the disorganized cohort, 60% were treatment-resistant compared with 20% of the paranoid cohort (p < 0.001). The clozapine response rate, as measured by at least 40% reduction in the total PANSS score, was greater than 60% in both groups.
Although DSM-5 has eliminated subtypes of schizophrenia, this study suggests that the disorganized-paranoid axis may retain prognostic and hence diagnostic significance. Another interpretation is merely that positive symptoms respond better to non-clozapine antipsychotics than do disorganized features, which may respond better to clozapine.
The study did not have masked raters and the total number of patients is small, so replication is necessary. The Brazilian researchers nonetheless advocate for clozapine use earlier in the course of treatment for disorganized-type patients. If this were adopted widely, clinical subtyping would likely require a more careful approach to evaluation than is carried out in usual practice, such as the use of standardized rating instruments.
Ortiz BB, Araújo Filho GM, Araripe Neto AG, Medeiros D, Bressan RA. Is disorganized schizophrenia a predictor of treatment resistance? Evidence from an observational study. Rev Bras Psiquiatr. 2013;35(4):432-434. Full text
In what they call the largest study to date of clozapine discontinuation, researchers examined a Veterans Administration cohort in the United States of 320 patients with schizophrenia or schizoaffective disorder, 91% male, who received clozapine. The Brief Psychiatric Rating Scale (BPRS) was used to assess symptoms. During 15 years of follow-up, 57% of patients had at least one discontinuation, which occurred most often between 3 and 6 months after treatment initiation.
Factors associated with an elevated likelihood of discontinuation were:
• African-American race
• Older age
• Lower disability award from the VA
• Smaller reduction in BPRS score
The top three causes of discontinuation were nonadherence (35%), adverse effects (28%), and administrative reasons (19%). The adverse effects related to discontinuation in order of frequency were:
• Hematologic, most often neutropenia
• Nervous system including sedation and seizures
• Cardiovascular including hypotension and tachycardia
• Autonomic including sialorrhea
• Weight gain
Agranulocytosis occurred in 3 patients, whereas lesser cases of granulocytopenia which still eliminated the possibility of rechallenge occurred in 4 patients; 3.3% of discontinuations therefore precluded restarting clozapine. One patient died of agranulocytosis; the only other clozapine-related death was in a patient with adynamic bowel and consequent aspiration.
The investigators looked at outcomes following discontinuation. Among 183 patients who stopped clozapine, only 16% restarted it and about half of those continued it. Among the approximately 170 patients who remained off clozapine and who received at least 3 months treatment with another antipsychotic, the mean BPRS score rose significantly from 39 to 52.
The limitations of the study include its naturalistic design and retrospective method.
The data confirm clinical impression that clozapine trials often do not succeed, and the chief challenges are managing adherence and adverse effects. Patients who can’t tolerate clozapine do poorly. We need more options for treatment-resistant psychosis.
Davis MC, Fuller MA, Strauss ME, Konicki PE, Jaskiw GE. Discontinuation of clozapine: a 15-year naturalistic retrospective study of 320 patients. Acta Psychiatr Scand. Published online 2 Dec 2013. Abstract
A study from the UK examined 67 cases of neuroleptic malignant syndrome and 254 controls (1). The researchers made several interesting findings, in particular that patients on 3 or more antipsychotics had an odds ratio of 5.4 for NMS. This, along with evidence for increased risk of diabetes in patients on multiple antipsychotics (2), give reason to be cautious about antipsychotic polypharmacy.
1. Retrospective chart review on exposure to psychotropic medications associated with neuroleptic malignant syndrome. Su Y-P, Chang C-K, Hayes RD, et al. Acta Psychiatr Scand. Published online 15 November 2013. Abstract
2. Treatment with antipsychotics and the risk of diabetes in clinical practice. Kessing LV, Thomsen AF, Mogensen UB, Andersen PK. Br J Psychiatry. 2010;197:266–271. Full text