Does the use of atypical antipsychotics as adjunctive therapy in depression result in cost savings? Comparing healthcare costs and utilization between second-line treatment options.

BACKGROUND: Several atypical antipsychotics (AAPs) are used as second-line agents for treatment resistant depression. AAPs can be expensive compared to other treatment options and can cause several side effects. OBJECTIVES: To estimate healthcare costs and utilization of AAPs compared to other second-line agents. METHODS: Observational study using Medicaid claims data (2006-2011). Subjects were depression-diagnosed adult members with at least two prescriptions of antidepressant medications followed by a second-line agent. Gamma generalized linear models (GLM) produced estimates of the difference in mean expenditures among treatment groups after adjusting for individual baseline characteristics using propensity scores. Negative binomial models produced estimates of the difference in number of hospitalizations and emergency department (ED) visits. RESULTS: A total of 3910 members received second-line treatment. Treatment groups were AAPs (n = 2211), augmentation agents other than AAPs (n = 1008), and antidepressant switching (n = 691). AAPs resulted in higher mean adjusted pharmacy costs and higher mean adjusted total mental health-related costs. Mean adjusted total healthcare costs and number of inpatient and ED visits were not different among treatments. CONCLUSION: The results show no evidence that AAPs used as second-line treatment for depression results in overall cost savings or lower inpatient and ED visits compared to other treatment strategies.

Mental health treatment associated with community-based depression screening: considerations for planning multidisciplinary collaborative care.

BACKGROUND: Depression places a large economic burden on the US health care system. Routine screening has been recognized as a fundamental step in the effective treatment of depression, but should be undertaken only when support systems are available to ensure proper diagnosis, treatment, and follow-up. OBJECTIVE: To estimate differences in prescribing new antidepressants and referral to stress management, psychotherapy, and other mental health (OMH) counseling at physician visits when documented depression screening was and was not performed. METHODS: Cross-sectional physician visit data for adults from the 2005-2007 National Ambulatory Medical Care Survey were used. The final analytical sample included 55,143 visits, representing a national population estimate of 1,741,080,686 physician visits. Four dependent variables were considered: (1) order for new antidepressant(s), and referral to (2) stress management, (3) psycho therapy, or (4) OMH counseling. Bivariable and multivariable associations between depression screening and each measure of depression follow-up care were evaluated using the design-based F statistic and multivariable logistic regression models. RESULTS: New antidepressant prescribing increased significantly (2.12% of visits without depression screening vs 10.61% with depression screening resulted in a new prescription of an antidepressant). Referral to stress management was the behavioral treatment with the greatest absolute change (3.31% of visits without depression screening vs 33.10% of visits with depression screening resulted in a referral to stress management). After controlling for background sociodemographic characteristics, the adjusted odds ratio of a new antidepressant order remained significantly higher at visits involving depression screening (AOR 5.36; 99.9% CI 2.92-9.82), as did referrals for all behavioral health care services (ie, stress management, psychotherapy, and OMH counseling). CONCLUSIONS: At the national level, depression screening was associated with increased new antidepressant prescribing and referral for behavioral health care. It is critical for policy planners to recognize changes in follow-up depression care when implementing screening programs to ensure adequate capacity. Pharmacists are poised to assume a role in collaborative depression care, particularly with antidepressant medication therapy management.

Recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient.

OBJECTIVE: To report a case of recurrent episodes of serotonin-reuptake inhibitor-mediated hyponatremia in an elderly patient and compare it with other reports of similar occurrences. CASE SUMMARY: A 66-year-old white woman was diagnosed with drug-induced syndrome of inappropriate antidiuretic hormone (SIADH) attributed to selective serotonin-norepinephrine-reuptake inhibitor (SNRI) therapy. Duloxetine was initiated following failure of several other antidepressants. The patient was admitted with sudden onset altered mental status, memory loss, personality changes, and a serum-sodium level of 128 mEq/L (range 135-145 mEq/L), despite receiving sodium supplementation. The duloxetine dose was 60 mg daily. Three months later she presented to the emergency department with complaints of lethargy, muscle weakness, nausea, altered mental status, and a serum sodium level of 129 mEq/L. SIADH was diagnosed and attributed to duloxetine therapy. Duloxetine was titrated to 30 mg every other evening. She remained stable on the lower dose, fluid restriction, and sodium supplementation. Diuretic reinitiation and sodium supplementation discontinuation resulted in serum sodium of 123 mEq/L. This increased to low/normal (136 mEq/L) with duloxetine discontinuation. A rechallenge with escitalopram resulted in low serum-sodium levels. DISCUSSION: A PubMed search was done utilizing the terms duloxetine, elderly, hyponatremia, selective serotonin-reuptake inhibitor, SSRI, SNRI, syndrome of inappropriate antidiuretic hormone, SIADH, and selective serotonin-norepinephrine reuptake inhibitor to find similar reports. CONCLUSION: Clinicians evaluating older patients taking serotonin-reuptake inhibitors are encouraged to monitor serum sodium if the patient presents with vague, nonspecific symptoms commonly associated with older age or depression to rule-out SIADH.

Adverse Childhood Experiences and Trust in the Medical Profession among Young Adults.

Attachment theory suggests that adverse childhood experiences (ACEs) should predict lower trust in the medical profession. To test this theory, a cross-sectional survey was administered to young adults self-identifying as homeless. The purpose of the survey was to examine the relationship of ACEs, attachment style, and trust in the medical profession. Hierarchical linear regression was used to determine if ACEs predict variance in trust in the medical profession after controlling for participants' attachment style and demographics. Results indicated ACEs were a robust predictor of lower trust in the medical profession over the controls. Since lower trust in the medical profession is associated with less willingness to seek care and follow provider recommendations, the established link between poorer health and ACEs may partially result from lower trust in the medical profession. The paper concludes with a discussion of the results' implications for future research and practice with ACE survivors.

Buspirone for autistic disorder in a woman with an intellectual disability.

OBJECTIVE: To describe a case of an intellectually disabled patient who was diagnosed with autistic disorder (AD) and responded positively to buspirone, demonstrated by a reduction in target behaviors of self-injury, property destruction, and physical aggression. CASE SUMMARY: A 33-year-old, white, nonverbal, profoundly intellectually impaired woman (IQ <20-25), residing in a state-run facility, exhibited worsening aggressive behaviors associated with AD. These behaviors were characterized by a history of self-injurious behavior (eg, slapping and scratching herself); property destruction, including breaking windows; and head butting of staff and peers. Additional diagnoses included a seizure disorder, hyperprolactinemia, and osteoporosis. At the time of admission, her drug regimen included 3 atypical antipsychotic agents: risperidone, clozapine, and aripiprazole. Antipsychotic agents have been reported to lower the seizure threshold, and elevated prolactin levels have been associated with risperidone use. Aripiprazole and clozapine were discontinued on admission, and risperidone was discontinued one month later following increased behavioral deterioration. Buspirone was considered an appropriate replacement medication, as it has not been associated with elevated prolactin levels or a lowered seizure threshold, and was initiated at 15 mg/day. Significant reductions in aggression were noted following titration to a total daily dose of 90 mg. DISCUSSION: Buspirone is approved for treatment of generalized anxiety disorder in adults. Dopaminergic agonist/antagonist actions have been reported with use of higher doses. These receptor effects have been beneficial for aggressive behaviors in the AD population that were exhibited by our patient, but effectiveness for aggression in the intellectually disabled population is uncertain. In our patient, problematic behaviors associated with AD responded positively to buspirone. CONCLUSIONS: The reduction in target aggressive behaviors achieved with buspirone therapy allowed other treatment interventions to proceed more effectively in our patient. Clinicians may wish to consider use of buspirone in patients with AD who do not respond to or have risk factors for use of other therapy.

Risperidone for the treatment of fecal smearing in a developmentally disabled adult.

PURPOSE: The use of risperidone in decreasing fecal smearing behavior as an expression of nonverbal aggression in a developmentally disabled adult is discussed. SUMMARY: A 36-year-old Caucasian man had a history of fecal smearing when he did not get his way or was upset. The patient had profound mental retardation, had an IQ in the range of less than 20 to 25, and was nonverbal. For this patient, fecal smearing was not only a behavioral issue but also a medical concern because he was hepatitis B positive with noncarrier status. Serology also confirmed previous infection with hepatitis A. Risperidone was started at 0.5 mg twice daily. Smearing frequencies during baseline and after risperidone intervention were tracked. During the course of treatment, the risperidone dosage was increased to a total daily dose of 4 mg. The mean +/- S.D. number of episodes per month decreased from 15.2 +/- 3 in the pretreatment period to 6.0 +/- 1.8 at 6 months and 6.7 +/- 1.2 at 12 months posttreatment with risperidone. On follow-up in October 2003, fecal smearing had further decreased to the point where it was no longer formally tracked. A diagnosis of mental retardation, developmental disability, or pervasive developmental disorder increases the possibility for emotional and behavioral problems. Previous medication classes tried in the management of aggressive behaviors have not produced consistent results. Risperidone has been used in the treatment of self-abuse, aggression toward others, and violent behaviors. CONCLUSION: Risperidone was effective in decreasing episodes of fecal smearing as an expression of nonverbal aggression in a developmentally disabled adult.

Quetiapine for acute mania in bipolar disorder.

PURPOSE: The efficacy and tolerability of quetiapine in the treatment of acute mania were reviewed. SUMMARY: Five randomized, placebo-controlled trials involving quetiapine as monotherapy or adjunct therapy in combination with either divalproex or lithium in the treatment of bipolar mania in either adolescents or adults were identified and reviewed. The primary outcome measure used in the trials was a change in Young Mania Rating Scale total scores. Monotherapy trials evaluated quetiapine, lithium, haloperidol, and placebo. Quetiapine was superior to placebo in both trials. Quetiapine and lithium showed comparable efficacy in one study, though lithium serum concentrations may have been suboptimal. Haloperidol was superior to quetiapine in efficacy at day 21 but similar at day 84. In the two trials evaluating quetiapine or placebo as adjunct therapy to lithium or divalproex, quetiapine was significantly more efficacious than placebo in one trial. In adolescents, quetiapine was more effective than placebo as an adjunct to divalproex. The most common adverse effects clearly attributable to quetiapine in these trials were somnolence and dry mouth. Quetiapine did not induce extrapyramidal effects, but weight gain was notable with the drug. CONCLUSION: While quetiapine treatment demonstrated efficacy in the majority of the studies, the robustness of its efficacy is questionable. The use of quetiapine as first-line therapy for acute mania is not recommended based on the available results and cost considerations. However, it may be a useful second-line agent, particularly when sensitivity to extrapyramidal symptoms limits treatment options.

Potential aripiprazole-mediated extrapyramidal symptoms in an adult with developmental disabilities.

PURPOSE: A case of extrapyramidal symptoms (EPS) following administration of aripiprazole to a man with developmental disabilities who had never received antipsychotic medications and had no history of movement disorders is presented. SUMMARY: The patient was a 40-year-old male with developmental disabilities. He was nonverbal, profoundly mentally retarded, and diagnosed with obsessive compulsive disorder (OCD) and orthopedic problems. He developed episodic movements possibly consistent with EPS secondary to aripiprazole usage. The patient was antipsychotic naive before initiation of aripiprazole 5 mg daily. Concurrent medications at the time of EPS onset included oxazepam, baclofen, and citalopram. Baclofen and oxazepam were prescribed secondary to right-sided hemiparesis contractures. Aripiprazole, 5 mg daily, was initiated in November 2004 as an augmentation strategy for the diagnosis of OCD. Facial, tongue, and arm movements were first reported approximately five weeks after the initiation of aripiprazole. Initial symptoms resolved after approximately 24 hours. The dosage was increased to 10 mg daily two weeks later. Dystonic episodes continued on an intermittent basis, and the patient presented with lower-lip thrusting and upper-limb athetosis. These movements interfered with the patient's eating, chewing, and holding of utensils. Several of the standard treatment strategies for EPS were used. Initially, diphenhydramine hydrochloride 25 mg was administered orally every six hours. The patient's movements resolved following diphenhydramine administration. Aripiprazole was subsequently discontinued secondary to its lack of efficacy for OCD and the development of a movement disorder. CONCLUSION: A patient with developmental disabilities who had no history of movement disorders developed EPS following initiation of aripiprazole.

Bedlam Community Health Clinic: a collaborative interdisciplinary health care service for the medically indigent.

OBJECTIVE: To describe a collaborative interdisciplinary health care service delivery system for the medically indigent in the Tulsa and northeastern Oklahoma area independent of state or federal funding. SETTING: Northeastern Oklahoma and Tulsa. PRACTICE DESCRIPTION: Community and ambulatory care for indigent patients. PRACTICE INNOVATION: Bedlam Community Health Clinic (BCHC), which opened in August 2003, provides services to patients through partnerships among the health care disciplines of the University of Oklahoma College of Pharmacy, Nursing, and Medicine; is staffed by community physicians and pharmacists who volunteer their time and expertise; and is funded by the local community. MAIN OUTCOME MEASURES: Experiences and patients served. RESULTS: BCHC is a collaborative interdisciplinary clinic that addresses the needs of the medically indigent in Tulsa and northeastern Oklahoma. Conceived, developed, and funded by the local community, it does not depend on state or federal funding. A variety of services, both general medicine and specialty, are provided through BCHC. Since its opening in August 2003, the clinic has provided hands-on training for students from a variety of health care disciplines. The pharmacist-patient encounters provide helpful, meaningful drug information. The participation of volunteer pharmacists enables medically underserved or indigent patients to access pharmaceutical care and addresses the diverse health care needs of this often overlooked population. CONCLUSION: Health professionals and students in the Tulsa area have created an innovative mechanism for serving indigent patients who otherwise would lack adequate health care services.

Evaluating antidepressant treatment prior to adding second-line therapies among patients with treatment-resistant depression.

BACKGROUND: Patients with depression can be mistakenly labeled as treatment-resistant if they fail to receive an adequate first-line antidepressant trial. Adding second-line agents to the treatment regimens can create an additional burden on both the patients and the healthcare system. OBJECTIVES: To determine if depressed patients receive an adequate antidepressant trial prior to starting second-line therapy and to investigate the association between the type of second-line treatment and severity of illness or depression among unipolar versus bipolar patients. SETTING: Oklahoma Medicaid claims data between 2006 and 2011. METHODS: Subjects were depression-diagnosed adult patients with at least two prescriptions of antidepressants followed by a second-line agent. Patients were categorized into one of three groups: an atypical antipsychotic, other augmentation agents (lithium, buspirone, and triiodothyronine), or adding antidepressants, based on the type of second-line therapy. An adequate trial was defined per the American Psychiatric Association guidelines. Factors associated with the type of treatment were tested using multinomial logistic regression models stratified by type of depression (unipolar vs. bipolar patients). MAIN OUTCOME MEASURE: Variables used to measure receiving an adequate antidepressant trial included: trial duration, adherence, dose adequacy, and number of distinct antidepressant trials. RESULTS: A total of 3910 patients were included in the analysis. Most subjects reached the recommended antidepressant dose. However, 28 % of patients had an antidepressant trial duration <4 weeks and only 60 % tried at least two antidepressant regimens prior to adding second-line therapy. Approximately 50 % of the subjects were non-adherent across all groups. Severity of illness and receipt of an adequate antidepressant trial were not predictors of the type of second-line treatment. CONCLUSION: Many patients do not receive an adequate antidepressant trial before starting a second-line agent. The type of second-line treatment was independent of severity of depression. These findings support policies that require reviewing the recommended dose and duration of the first-line antidepressant before adding second-line agents. Healthcare providers need to review the patient's history and reconsider the evidence for prescribing second-line agents.

Use of visual cueing for blood glucose documentation in a person with schizophrenia and diabetes.

Persons diagnosed with schizophrenia are also at-risk for medical comorbidities. We present the case of one such patient with the comorbidity of diabetes. By applying the research on visual cueing for this population, we developed a glucose monitoring form that increased documentation. We encourage other healthcare practitioners to develop visually appealing or interesting documentation forms for their patients to help empower them for self-care.

National antidepressant prescribing in children and adolescents with mental health disorders after an FDA boxed warning.

BACKGROUND: In October 2004, the U.S. Food and Drug Administration (FDA) issued a boxed warning about an increased risk of suicidality (i.e., suicidal ideation, behavior, or attempts) related to all antidepressants in children and adolescents. OBJECTIVE: To describe national antidepressant prescribing patterns in children and adolescents before, during, and after the introduction of the FDA boxed warning. METHODS: Cross-sectional data from the 2002-2009 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to describe antidepressant prescribing patterns within a nationally-representative sample of 4035 physician visits for children and adolescents diagnosed with depression or other psychiatric disorder(s) [i.e., anxiety disorders or attention deficit/hyperactivity disorder (ADHD)]. RESULTS: In 2002-2003, antidepressants were prescribed in 4.1 million (36.1%) visits, followed by 3.2 million (28.8%) visits in 2004-2005 and 2.8 million (26.8%) visits in 2006-2007. However, antidepressant prescribing patterns reversed during 2008-2009, with an increase to 3.6 million (32.5%) visits. Compared to the period preceding the FDA boxed warning (2002-2003), a significant decline in visits related to antidepressant prescribing detected in the immediate post-FDA boxed warning period (2006-2007) (AOR = 0.67, 95% CI: 0.47-0.96). No association between the FDA boxed warning and antidepressant prescribing visits was detected during the FDA boxed warning period (2004-2005) (AOR = 0.80, 95% CI: 0.53-1.21) and in the late post-FDA boxed warning period (2008-2009) (AOR = 1.01, 95% CI: 0.63-1.60). CONCLUSIONS: After a 2-year lag period, antidepressant prescribing for visits of children and adolescents diagnosed with depression or other psychiatric disorder(s) in community-based and outpatient clinic settings declined when compared to the period preceding the FDA boxed warning. This decline was not sustained in the period of five years after implementation of the FDA boxed warning.

Evaluation of serum prolactin levels in intellectually disabled patients using antipsychotic medications.

BACKGROUND: Patients with intellectual disabilities may be treated with antipsychotic medications for a variety of diagnoses. Use of this category of medication can increase prolactin levels and place the patient at risk for sexual dysfunction and lower bone mineral density. The proposed mechanism of action is affinity for the dopamine receptor. Use of bromocriptine, a dopamine receptor antagonist, was proposed to attenuate hyperprolactinemia. OBJECTIVES: The objectives of this study were to (1) review serum prolactin (PRL) elevations associated with the use of antipsychotic (AP) medications in an intellectually disabled adult population and (2) determine if any association existed between the level of elevation and AP used. PATIENTS AND METHODS: Medical records for adult patients at two Oklahoma facilities for the intellectually disabled were reviewed to evaluate prolactin levels for individuals prescribed antipsychotics. A linear regression model was used to evaluate the relationship between prolactin levels with intellectual disability level, bromocriptine use, demographics, and antipsychotic. RESULTS: 73 (n = 53 males, n = 20 females) patients met criteria. The average age was 41.2 years. Nearly 70% of the patients had severe to profound levels of disability. 77% were prescribed second generation antipsychotics; 19% received first generation agents. Two variables, gender and bromocriptine use, were found to be significant predictors of prolactin levels. Mean prolactin level for females was 44 ng/mL (normal range: 4-30 ng/mL, males = 4-23 ng/mL). Patients who did not receive bromocriptine had mean levels of 23 ng/mL. No significant difference in prolactin levels was found for type of AP. CONCLUSIONS: Mean prolactin levels for females were significantly higher than for males. Both sexes were found to have higher-than-normal levels. Use of bromocriptine was associated with higher prolactin levels. In this population of patients, the type of AP used had no significance on prolactin levels.

Evaluation of monitoring for metabolic effects in children treated with second generation antipsychotics in a pediatric clinic.

OBJECTIVES: The aim of this retrospective study was to identify the frequency of recommended metabolic monitoring and follow-up in pediatric patients on second-generation antipsychotic (SGA) medications from a pediatric clinic. METHODS: A retrospective review of electronic medical records of all patients on antipsychotics from an academic medical center pediatric clinic was conducted. Inclusion criteria required patients to be established members of the pediatric clinic, < 19 years of age, and on ≥ 1 SGA for at least 1 year, regardless of medical diagnosis. Data collection consisted of patient demographic information and frequency of family history, vital signs, and recommended laboratory monitoring. RESULTS: A total of 67 patients on antipsychotics were identified. After the application of inclusion criteria, 32 patients qualified for review. The average age was 13.5 ± 4 years and gender distribution included 72% males. Only 4 (13%) patients had documented baseline monitoring that included weight, blood pressure, and fasting lipid panel. No patient had a fasting plasma glucose recorded at any point during antipsychotic therapy. Follow-up monitoring decreased over time, with the exception of quarterly weight and annual blood pressure. CONCLUSIONS: The results of this study highlight the lack of baseline and periodic monitoring that occur when pediatric patients are prescribed antipsychotic medications, putting the patient at risk for adverse events. The marked increase in antipsychotic prescribing and concerns related to their safety emphasize the need for improvement in monitoring of antipsychotic medications. This gap in patient care and safety opens an excellent opportunity for a clinical pharmacy team to provide education and assistance with SGA monitoring for the purpose of providing optimal patient care.

Schizophrenia and the immune system: pathophysiology, prevention, and treatment.

PURPOSE: Published evidence on established and theoretical connections between immune system dysfunction and schizophrenia is reviewed, with a discussion of developments in the search for immunologically-targeted treatments. SUMMARY: A growing body of evidence indicates that immunologic influences may play an important role in the etiology and course of schizophrenia. A literature search identified more than 100 articles pertaining to suspected immunologic influences on schizophrenia published over the past 15 years. Schizophrenia researchers have explored a wide range of potential immune system-related causal or contributory factors, including neurobiological and neuroanatomical disorders, genetic abnormalities, and environmental influences such as maternal perinatal infection. Efforts to establish an immunologic basis for schizophrenia and identify reliable immune markers continue to be hindered by sampling challenges and methodological problems. In aggregate, the available evidence indicates that at least some cases of schizophrenia have an immunologic component, suggesting that immune-focused prevention strategies (e.g., counseling of pregnant women to avoid immune stressors) and close monitoring of at-risk children are appropriate. While antipsychotics remain the standard treatments for schizophrenia, a variety of drugs with immunologic effects have been investigated as adjunctive therapies, with variable and sometimes conflicting results; these include the cyclooxygenase-2 inhibitor celecoxib, immune-modulating agents (e.g., azathioprine and various anticytokine agents such as atlizumab, anakinra, and tumor necrosis factor-α blockers), and an investigational anti-interferon-γ agent. CONCLUSION: The published evidence indicates that immune system dysfunction related to genetic, environmental, and neurobiological influences may play a role in the etiology of schizophrenia in a subset of patients.

Case report: increased patient response to intramuscular haloperidol decanoate following a change in needle length.

INTRODUCTION: Intramuscular (IM) injection is a commonly used administration route for a variety of medications. Determining the optimum needle length for administration of IM formulations based on individual patient variables has not been extensively reported in patients receiving antipsychotic medication via IM administration. CASE REPORT: The patient, a 23-year-old African American female diagnosed with schizophrenia, was referred to a community-based treatment program following multiple inpatient admissions. At age 19, she began experiencing psychiatric symptoms that resulted in assault and incarceration. Treatment included separate trials of haloperidol and fluphenazine decanoate formulations with minimal success reported. At the time of evaluation, she was experiencing constant positive psychiatric symptomatology. Oral haloperidol was started. Haloperidol decanoate 150 mg by IM injection using a 1.5-inch needle was added and titrated to 350 mg IM over 11 months. Auditory hallucinations continued. Following refusal of a haloperidol level, the physician changed to a 2-inch needle for decanoate injections. Noticeable and continued slow improvement of her psychotic symptoms resulted. CONCLUSION: Needle length may be of new importance to practitioners. If anticipated results of IM antipsychotic medication administration are not realized, practitioners are urged to consider patient variables, notably the amount of adipose tissue in the administration area.

Antipsychotic treatment of adolescent dual diagnosis patients.

BACKGROUND: A diagnosis of schizophrenia requires development of a pharmacotherapy regimen that balances many factors in the therapeutic decision-making process. Patient age and the presence or absence of comorbid chemical dependency represent two factors. Comorbid chemical dependency can have a profound impact on the successful treatment of schizophrenia, making patients with dual diagnoses of schizophrenia and chemical dependence a uniquely challenging population. There is little information regarding treatment of schizophrenia and chemical dependence in the pediatric population. Existing data from pediatric and adult populations may facilitate a well-guided and knowledgeable approach to treating pediatric dual diagnosis patients. METHODS: A review of the literature for medication trials evaluating antipsychotic medication used to treat schizophrenia in childhood and adolescence as well as antipsychotic use in the treatment of the dual diagnoses of schizophrenia and chemical dependence was done. Databases for Ovid MEDLINE, PubMed, and PsycInfo were searched using the terms "addiction," "adolescence," "childhood," "dual diagnosis," "schizophrenia," and "substance abuse." Results were limited to English-language articles. RESULTS: Seven articles were identified related to psychotic disorders and substance abuse in pediatric populations. Psychosis measurement instruments included the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale, and Clinical Global Impression. Mean improvements were insignificant in most cases. Medication trials included clozapine, olanzapine, risperidone, and molindone. Trial safety concerns included metabolic effects, increased prolactin levels, and akathisia. One study with random assignment to olanzapine was discontinued early because of substantial weight gain without evidence of superior efficacy. Clozapine treatment was associated with more adverse drug events. CONCLUSION: There is a great need for more research and use of available data to develop safe and effective treatment guidelines for childhood and adolescent dual diagnosis patients. When appropriate decisions are made regarding treatment of patients with comorbid schizophrenia and chemical dependence, both conditions may benefit with increased remission.

Violence among persons diagnosed with schizophrenia: how pharmacists can help.

Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court.