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Underuse of recommended treatments among people living with treatment-resistant psychosis

BACKGROUND: International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which th...

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Autores principales: Lappin, Julia M., Davies, Kimberley, O'Donnell, Maryanne, Walpola, Ishan C.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9485552/
https://www.ncbi.nlm.nih.gov/pubmed/36147973
http://dx.doi.org/10.3389/fpsyt.2022.987468
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author Lappin, Julia M.
Davies, Kimberley
O'Donnell, Maryanne
Walpola, Ishan C.
author_facet Lappin, Julia M.
Davies, Kimberley
O'Donnell, Maryanne
Walpola, Ishan C.
author_sort Lappin, Julia M.
collection PubMed
description BACKGROUND: International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which this evidence-base is implemented. SETTING: Statewide public health tertiary referral service, the Tertiary Referral Service for Psychosis (TRSP), NSW, Australia. OBJECTIVES: To (i) describe clinical characteristics of individuals with treatment-resistant psychosis and to detail the proportion who had received a trial of clozapine or ECT at any point during their illness course; (ii) describe the characteristics of the treatment trials in both those currently on clozapine and those previously on clozapine; (iii) document reasons in relevant individuals why clozapine had never been used. METHODS: All TRSP clients who met the criteria for treatment resistance (TR) were included. A detailed casenote review was conducted to examine whether clozapine and/or ECT had ever been prescribed. Characteristics of clozapine and ECT trials were documented. Tertiary service treatment recommendations are described. FINDINGS: Thirty-six of 48 individuals had TR. They had marked clinical and functional impairment. A minority were currently receiving clozapine (n = 14/36). Most had received a clozapine trial at some point (n = 32/36). Most experienced persistent clinical symptoms while on clozapine (n = 29/32). Clozapine plasma levels were very rarely reported (4/32). Augmentation and antipsychotic polypharmacy were common among those currently on clozapine. The median clozapine trial duration was 4.0 (IQR: 3.0–20.3) months in individuals previously prescribed clozapine. Reasons for clozapine discontinuation included intolerable side effects (n = 10/18) and poor adherence (n = 7/18). One-quarter of TR individuals had trialed ECT (n = 9/36). Tertiary service recommendations included routine plasma monitoring to optimize dose among people currently on clozapine; clozapine retrial in those previously treated; and clozapine initiation for those who had never received clozapine. ECT was recommended to augment clozapine and as an alternative where clozapine trial/retrial was not feasible. CONCLUSION: Among people with TR referred to a tertiary service, clozapine and ECT were underutilized. Clozapine trials are typically terminated without an adequate trial. Strategies to optimize the use of clozapine therapy and ECT in clinical settings are needed to increase the therapeutic effectiveness of evidence-based therapies for treatment-resistant psychosis.
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spelling pubmed-94855522022-09-21 Underuse of recommended treatments among people living with treatment-resistant psychosis Lappin, Julia M. Davies, Kimberley O'Donnell, Maryanne Walpola, Ishan C. Front Psychiatry Psychiatry BACKGROUND: International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which this evidence-base is implemented. SETTING: Statewide public health tertiary referral service, the Tertiary Referral Service for Psychosis (TRSP), NSW, Australia. OBJECTIVES: To (i) describe clinical characteristics of individuals with treatment-resistant psychosis and to detail the proportion who had received a trial of clozapine or ECT at any point during their illness course; (ii) describe the characteristics of the treatment trials in both those currently on clozapine and those previously on clozapine; (iii) document reasons in relevant individuals why clozapine had never been used. METHODS: All TRSP clients who met the criteria for treatment resistance (TR) were included. A detailed casenote review was conducted to examine whether clozapine and/or ECT had ever been prescribed. Characteristics of clozapine and ECT trials were documented. Tertiary service treatment recommendations are described. FINDINGS: Thirty-six of 48 individuals had TR. They had marked clinical and functional impairment. A minority were currently receiving clozapine (n = 14/36). Most had received a clozapine trial at some point (n = 32/36). Most experienced persistent clinical symptoms while on clozapine (n = 29/32). Clozapine plasma levels were very rarely reported (4/32). Augmentation and antipsychotic polypharmacy were common among those currently on clozapine. The median clozapine trial duration was 4.0 (IQR: 3.0–20.3) months in individuals previously prescribed clozapine. Reasons for clozapine discontinuation included intolerable side effects (n = 10/18) and poor adherence (n = 7/18). One-quarter of TR individuals had trialed ECT (n = 9/36). Tertiary service recommendations included routine plasma monitoring to optimize dose among people currently on clozapine; clozapine retrial in those previously treated; and clozapine initiation for those who had never received clozapine. ECT was recommended to augment clozapine and as an alternative where clozapine trial/retrial was not feasible. CONCLUSION: Among people with TR referred to a tertiary service, clozapine and ECT were underutilized. Clozapine trials are typically terminated without an adequate trial. Strategies to optimize the use of clozapine therapy and ECT in clinical settings are needed to increase the therapeutic effectiveness of evidence-based therapies for treatment-resistant psychosis. Frontiers Media S.A. 2022-09-06 /pmc/articles/PMC9485552/ /pubmed/36147973 http://dx.doi.org/10.3389/fpsyt.2022.987468 Text en Copyright © 2022 Lappin, Davies, O'Donnell and Walpola. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Psychiatry
Lappin, Julia M.
Davies, Kimberley
O'Donnell, Maryanne
Walpola, Ishan C.
Underuse of recommended treatments among people living with treatment-resistant psychosis
title Underuse of recommended treatments among people living with treatment-resistant psychosis
title_full Underuse of recommended treatments among people living with treatment-resistant psychosis
title_fullStr Underuse of recommended treatments among people living with treatment-resistant psychosis
title_full_unstemmed Underuse of recommended treatments among people living with treatment-resistant psychosis
title_short Underuse of recommended treatments among people living with treatment-resistant psychosis
title_sort underuse of recommended treatments among people living with treatment-resistant psychosis
topic Psychiatry
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9485552/
https://www.ncbi.nlm.nih.gov/pubmed/36147973
http://dx.doi.org/10.3389/fpsyt.2022.987468
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