Risperidone use at a state hospital: a clinical audit 2 years after the first wave of risperidone prescriptions.

BACKGROUND: In spite of some inherent limitations, naturalistic data can provide information on populations that have greater heterogeneity than can controlled clinical trials and on functional outcomes that may be especially important in clinical practice. In the present retrospective naturalistic study, we evaluated key clinical outcomes among the first wave of risperidone-treated patients at a state psychiatric hospital. METHOD: Outcome data were extracted from the charts of 142 patients 2 years after initiation of treatment with risperidone. Their diagnoses included DSM-III-R schizophrenia (57%), schizoaffective disorder (22%), dementia and other organic conditions (7%), bipolar disorder (5%), and other psychiatric disorders (9%). RESULTS: During the 2-year period, 92 of 142 patients were discharged from the hospital: 61 (43%) were discharged on risperidone treatment and 31 (22%) were discharged on treatment with other drugs. At the time of the study, 50 of 142 patients were still in the hospital: of these, 18 (13%) were still receiving risperidone. The modal maximum daily dose of risperidone was 4.1 mg in patients discharged on risperidone treatment and 7.5 mg in patients still in the hospital. All groups were granted more ward privileges after starting risperidone, the most being granted to patients discharged from the hospital on risperidone treatment (p<.05 versus patients discharged on treatment with other drugs) and those still receiving risperidone in the hospital. Significantly fewer patients discharged on risperidone treatment than on treatment with other drugs were readmitted to the hospital within 2 years after discharge (p<.01). CONCLUSION: Improved privilege levels and a reduced readmission rate indicate that risperidone was an effective antipsychotic agent among a heterogeneous patient population in a state hospital. These factors may be especially important to justify use of this agent in the current fiscal climate.

Clozapine: its impact on aggressive behavior among patients in a state psychiatric hospital.

Clozapine has shown consistent efficacy against positive symptoms of psychoses, and emerging reports indicate improvements in aggression and suicidality. This study evaluated the impact of clozapine aggression in a psychiatric hospital. Over a three year period, 137 subjects with schizophrenia or schizoaffective disorder received clozapine, of whom nearly 50% (n=69) experienced seclusion or restraint. Using a mirror-image study design, seclusion and restraint rates were computed per patient-month pre-clozapine and compared during clozapine treatment to a maximum of 12 months in either direction. The rest of the hospital not receiving clozapine served as a comparator group. Statistically significant reductions occurred in both seclusion (0.44+/-0.46 vs. 0.16+/-0.32, z=-3.91, p=0.0003) and restraint (0.34+/-0.47 vs. 0.08+/-0.23, z=-2.27, p=0.032) during clozapine treatment as compared with the pre-clozapine period. The comparator group experienced a low rate of seclusion and restraint throughout. While there are limitations to a mirror-image design, this study supports the emerging data on the benefits of clozapine for aggressive and violent patients with psychoses. Preliminary data suggests other second generation antipsychotic agents may have similar effects.

Prevalence of glomerulopathies in autopsies of patients infected with the hepatitis C virus.

BACKGROUND: Several reports have shown hepatitis C virus (HCV) infection to be associated with various extrahepatic manifestations, including certain forms of glomerulopathy. The most frequently reported glomerulonephritis in patients infected with HCV is either membranoproliferative glomerulonephritis (MPGN) or cryoglobulinemic glomerulonephritis, and HCV has been directly implicated in their pathogenesis. Other investigators have reported a higher prevalence of HCV infection in patients with membranous glomerulonephritis, IgA nephropathy, and focal segmental glomerulosclerosis (FSGS). However, the prevalence of these glomerulopathies in patients infected with HCV is unknown. METHODS: We conducted a 5-year retrospective review to determine prevalence of glomerulopathies in autopsies of patients infected with HCV. The renal histology on the autopsy reports was carefully reviewed for appropriate diagnosis of glomerulonephritis. RESULTS: Of the 114 autopsies of patients infected with HCV during this period, the majority had been incarcerated and had state-mandated autopsies. The mean age of the patients was 46.8 +/- 10 years (+/- SD; range, 19-87). Of the 114 patients, 46 were white, 37 were African American, and 31 were Hispanic. The glomerulopathies seen were 3 MPGN, 2 membranous, 3 HIV-associated nephropathy, 1 idiopathic FSGS, 1 minimal change glomerulonephritis, and 3 diabetic nephropathy. CONCLUSION: We conclude that although HCV is reported to be associated with membranoproliferative and membranous glomerulonephritis, their prevalence in these patients is not common.

The treatment of clozapine-associated agranulocytosis with granulocyte colony-stimulating factor (G-CSF).

During a 5-year period, 6 patients with clozapine-associated agranulocytosis who received granulocyte colony-stimulating factor (G-CSF) were compared with 5 subjects who did not receive this treatment. Seven patients were asymptomatic, and the weekly leukocyte count alone indicated agranulocytosis. The average duration of agranulocytosis was not significantly different between the treated and untreated groups (6.5 vs. 6.6 days), though the treated group had a significantly shorter average duration of hospitalization (8.2 vs. 13.5 days). G-CSF administration was well tolerated, and no adverse effects were noted. Incidentally noted was the recent addition of ranitidine (with the potential for bone marrow toxicity) to clozapine for 2 patients. Currently, weekly white cell and differential counts remain the main tools for detecting incipient or occurring agranulocytosis. Until efficacy studies prove otherwise, G-CSF administered soon after the diagnosis of clozapine-associated agranulocytosis may shorten the duration of hospitalization and thus prove cost-effective.

Impact of risperidone on seclusion and restraint at a state psychiatric hospital.

OBJECTIVE: To evaluate the impact of risperidone on seclusion and restraint in patients at a state psychiatric facility, shortly after risperidone's release. METHODS: Patients who were in the hospital for at least 3 months prior to receiving risperidone and subsequently received risperidone for at least 3 months formed the cohort. A mirror-image design was used with duration to a maximum of 1 year before and 1 year after initiation of risperidone. The hospital population that did not receive either risperidone or clozapine during the same time period was used for comparison of trends of seclusion and restraint. RESULTS: Seventy-four patients (most with schizophrenia) met the inclusion criteria of the risperidone group. There were statistically significant decreases in the number of seclusion hours (2.2 [SD 5.5] to 0.26 [SD 0.06]) and of events (0.23 [SD 0.59] to 0.05 [SD 0.14]) per person per month during risperidone treatment, compared with the prerisperidone treatment period (P = 0.01). The comparison group also evidenced decreases on these measures during the same time period, but the risperidone-treated cohort achieved a proportionally greater reduction. There were similar trends toward reduction in the restraint measures during risperidone treatment compared with prerisperidone, but these did not achieve statistical significance. The comparison group also showed slightly decreased use of restraints over the study period. CONCLUSIONS: Risperidone appears to have had a positive impact on seclusion in this state-hospital psychiatric population. These data support the positive impact of risperidone on violence found in other studies. Violence and aggression are major factors that affect morale among psychiatric patients and staff. So, any benefit in this regard as a result of antipsychotic drug treatment is salutary for patients, families, and health care providers.