Psychoeducational group interventions for adults diagnosed with attention-deficit/ hyperactivity disorder: a scoping review of feasibility, acceptability, and outcome measures.

INTRODUCTION: Although psychoeducational group interventions are increasingly used for adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), a comprehensive review focused on the feasibility and acceptability indicators of these interventions remains lacking. Furthermore, although previous research has explored various aspects of psychoeducation for ADHD, such as its definition and approaches, limited research has focused on the synthesis for outcome measures and patients' experiences related to these interventions. Therefore, this scoping review aims to map the existing evidence reported on psychoeducational group interventions for adults diagnosed with ADHD. The objective is to provide a comprehensive overview of feasibility indicators, acceptability, and outcome measures used in psychoeducational group interventions. METHOD: A comprehensive structured literature search on the topic was performed in seven bibliographic databases, and the resulting records were independently screened, and their data extracted by two reviewers. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-S) to ensure the transparency and rigor of this scoping review. RESULTS: The searches yielded 7510 records. Eight studies met the inclusion criteria. These included studies were conducted in European countries and the United States. Among these, six studies used a randomized control design, one an open feasibility trial, and one a pre-post intervention design. All the studies reported some feasibility and acceptability indicators. While all the studies reported on the severity of symptoms of ADHD as an outcome measure, some also reported on outcomes related to psychological or mental-health problems, quality of life, changes in knowledge regarding ADHD, or the level of self-esteem, functioning, and impairment. CONCLUSION: This scoping review revealed that psychoeducational group interventions are generally acceptable for patients in terms of patient satisfaction with the group intervention. All included studies reported some feasibility indicators, with some reporting good attendance and relatively low dropout rates. Most studies reported positive effects on ADHD and mental health symptoms, suggesting that these interventions are beneficial for adults with ADHD. However, several gaps exist regarding the reporting on the feasibility indicators, acceptability, and outcome measures employed across studies.

Will ChatGPT3 Substitute for us as Clozapine Experts?

BACKGROUND: ChatGPT3 is a new artificial intelligence program released on February 13, 2023. METHOD: The authors tested ChatGPT3 on February 18, 2023, and repeated the test a week later. They used their expertise on the effects of ethnic ancestry in the stratification of clozapine dosing and the new idea that they published in March 2022 that African-Americans need higher clozapine doses because they have higher clozapine clearance. RESULTS: In the first interaction on February 18, ChatGPT3 provided reasonable and very up-to-date information, which included a comment that patients of African ancestry have higher clozapine metabolism. The other 4 interactions became progressively more concerning as we asked ChatGPT3 to provide references to justify the latter statement. ChatGPT3 provided non-existent "references" using articles from real journals, with real authors, false PubMed identifiers, and false titles. Moreover, ChatGPT3 said that the first author wrote in 2003 that African-Americans had higher CYP1A2 activity when that did not happen until 2022. One week later, the second author repeated the same set of questions. This time ChatGPT3 described the opposite, that African-Americans have "lower" CYP1A2 activity and "slower" metabolism. ChatGPT3 provided another set of articles to justify the information; some were real but did not comment on clozapine metabolism in African-Americans while others did not exist. CONCLUSIONS: ChatGPT3 provided a mixture of truth, twisted reality, and non-existent "facts." Within one week it defended opposite positions regarding a clinically relevant issue such as using higher or lower clozapine doses in African-Americans.

Escaping the Long Shadow Cast by Agranulocytosis: Reflections on Clozapine Pharmacovigilance Focused on the United Kingdom.

PURPOSE/BACKGROUND: A recent article in this journal presented a US perspective regarding the modernization of clozapine prescription and proposed an escape from the long shadow cast by agranulocytosis. METHODS: Here, an international group of collaborators discusses a point of view complementary to the US view by focusing on worldwide outcomes of clozapine usage that may be uneven in terms of frequency of clozapine adverse drug reactions. FINDINGS/RESULTS: Studies from the Scandinavian national registries (Finland and Denmark) did not find increased mortality in clozapine patients or any clear evidence of the alleged toxicity of clozapine. Data on clozapine-associated fatal outcomes were obtained from 2 recently published pharmacovigilance studies and from the UK pharmacovigilance database. A pharmacovigilance study focused on physician reports to assess worldwide lethality of drugs from 2010 to 2019 found 968 clozapine-associated fatal outcomes in the United Kingdom. Moreover, the United Kingdom accounted for 55% (968 of 1761) of worldwide and 90% (968 of 1073) of European fatal clozapine-associated outcomes. In a pharmacovigilance study from the UK database (from 2008 to 2017), clozapine was associated with 383 fatal outcomes/year including all reports from physicians and nonphysicians. From 2018 to 2021, UK clozapine-associated fatal outcomes increased to 440/year. IMPLICATIONS/CONCLUSIONS: The interpretation of fatal outcomes in each country using pharmacovigilance databases is limited and only allows gross comparisons; even with those limitations, the UK data seem concerning. Pneumonia and myocarditis may be more important than agranulocytosis in explaining the uneven distribution of fatal outcomes in clozapine patients across countries.

Evaluating the Effect of a Telepsychiatry Educational Program on the Awareness, Knowledge, Attitude, and Skills of Telepsychiatry Among Spanish Psychiatrists during COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has renewed the interest in telepsychiatry as a way to help psychiatrists care for their patients, but mental health providers' unfamiliarity and concerns may impede implementation of such services. This study aimed to determine the effect of an online educational intervention on awareness, knowledge, attitude, and skills (AKAS) of telepsychiatry among psychiatrists. Methods: The study used a pre-post-test design to compare AKAS of telepsychiatry among psychiatrists participating in an online course of practical telepsychiatry. The telemedicine AKAS questionnaire adapted to telepsychiatry was applied before and after the educational intervention, during the months of October to December 2020. Results: Responses from 213 participants were analyzed before the educational intervention and from 152 after it. The knowledge showed by Spanish psychiatrists before the educational intervention was good in 61% of participants, fair in 37%, and inadequate in 2%. With respect to attitudes toward telepsychiatry, 62% self-reported a high attitude, 33% moderate, and 5% low. With regard self-reported skills, 57% of the participating psychiatrists were highly skilled or experts, 22% moderately skilled, and 9% unskilled in handling telepsychiatry equipment. Despite the high baseline values, the educational intervention significantly improved psychiatrists' awareness, knowledge and attitudes toward telepsychiatry although not their skills. Conclusions: Online course of practical telepsychiatry was effective although future editions need to improve its focus on skills. This educational intervention represents an effort to promote the implementation of telepsychiatry as a health care alternative.

An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels.

This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.

Clinimetric Criteria for Patient-Reported Outcome Measures.

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients' subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini-metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

Exploring patterns in psychiatric outpatients' preferences for involvement in decision-making: a latent class analysis approach.

BACKGROUND: Shared decision-making (SDM), a collaborative approach that includes and respects patients' preferences for involvement in decision-making about their treatment, is increasingly advocated. However, in the practice of clinical psychiatry, implementing SDM seems difficult to accomplish. Although the number of studies related to psychiatric patients' preferences for involvement is increasing, studies have largely focused on understanding patients in public mental healthcare settings. Thus, investigating patient preferences for involvement in both public and private settings is of particular importance in psychiatric research. The objectives of this study were to identify different latent class typologies of patient preferences for involvement in the decision-making process, and to investigate how patient characteristics predict these typologies in mental healthcare settings. METHODS: We conducted latent class analysis (LCA) to identify groups of psychiatric outpatients with similar preferences for involvement in decision-making to estimate the probability that each patient belonged to a certain class based on sociodemographic, clinical and health belief variables. RESULTS: The LCA included 224 consecutive psychiatric outpatients' preferences for involvement in treatment decisions in public and private psychiatric settings. The LCA identified three distinct preference typologies, two collaborative and one passive, accounting for 78% of the variance. Class 1 (26%) included collaborative men aged 34-44 years with an average level of education who were treated by public services for a depressive disorder, had high psychological reactance, believed they controlled their disease and had a pharmacophobic attitude. Class 2 (29%) included collaborative women younger than 33 years with an average level of education, who were treated by public services for an anxiety disorder, had low psychological reactance or health control belief and had an unconcerned attitude toward medication. Class 3 (45%) included passive women older than 55 years with lower education levels who had a depressive disorder, had low psychological reactance, attributed the control of their disease to their psychiatrists and had a pharmacophilic attitude. CONCLUSIONS: Our findings highlight how psychiatric patients vary in pattern of preferences for treatment involvement regarding demographic variables and health status, providing insight into understanding the pattern of preferences and comprising a significant advance in mental healthcare research.

Effect of necessity-concern framework and polypharmacy on treatment adherence in psychiatric patients. Comparing an Argentinian with a Spanish sample.

OBJECTIVE: We aimed to replicate a prior Spanish study of medication adherence where logistic regression models provided highly significant odds ratios (ORs) for three continuous scores: necessity, concern and the necessity-concern differential, and a dichotomous variable: skeptical attitude. Adherence ORs in the necessity-concern framework were very strong in patients taking five or six medications. METHODS: The sample comprised consecutive adult psychiatric outpatients in Mendoza, Argentina. The necessity-concerns framework was assessed using a subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to prescribed psychiatric medications was assessed by the Sidorkiewicz adherence tool. RESULTS: When compared with the Spanish sample, the Argentinian group (508 patients with 875 medications) was characterized by: (1) significantly stronger adherence ORs with the necessity-concern framework, (2) significantly lower number of medications per patient and percentage of patients with marked psychiatric polypharmacy (≥4 medications), (3) though a higher number of medications still was significantly associated with poor adherence. CONCLUSIONS: The Argentinian sample replicated the previous finding that patient beliefs regarding necessity and concern were associated with poor adherence to prescribed medications. Polypharmacy had an additive role decreasing adherence in both samples. In both samples, when prescribed ≥4 psychiatric medications, patients reported adherence to only two-third of the medications.

What is the dominant treatment attitude of psychiatric patients?

Background: Patients' attitude towards drug treatment is of prognostic value regarding adherence. However, few detailed analyses have been performed regarding the influencing factors of the treatment attitude of psychiatric patients. Methods: We enrolled in the study 295 psychiatric inpatients and analyzed the data obtained using the recently developed Patient's Health Belief Questionnaire on Psychiatric Treatment (PHBQPT), the Behavioural Inhibition/ Activation System (BIS/BAS) Scale, and the Hospital Anxiety and Depression Scale. We created a 'dominant treatment attitude' (DTA) variable from the 5 subscales of the PHBQPT. Results: The most common DTA was the Doctor HLOC and the rarest proved to be the Psychological Reactance. The double DTA carriers were the most frequently occurring multiple DTAs. We found that the Doctor-HLOC coupled most frequently with the Positive Aspect and the DoctorHLOC with the Internal-HLOC. The Doctor-HLOC score was higher while the BAS Fun seeking score lower in the case of patients treated for affective disorders compared to patients who belonged to the psychosis and personality disorder subgroups. Conclusions: Screening of DTAs in psychiatric patients can provide useful information for the planning of a more effective therapeutic strategy. (Neuropsychopharmacol Hung 2021; 23(2): 308-318).

[Validation and analysis of the Patient's Health Belief Questionnaire on Psychiatric Treatment in a sample of Hungarian psychiatric patients].

OBJECTIVES: Patients' attitude towards treatment is one of the most signifi cant factors which has determining eff ect on suffi cient adherence. Data are lacking on Hungarian patients' attitude towards psychiatric treatment, however, high prevalence of suicide suggests that eff ectiveness of psychiatric treatments need to be improved. To pave the way for such studies, we performed the validation of the recently developed Patients' Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) in a sample of Hungarian psychiatric patients. METHODS: We enrolled 188 Hungarian patients diagnosed with psychiatric disorders. The PHBQPT was translated into Hungarian by our group. Comparison of item and subscale mean scores with the original data are presented. Internal consistency, item-total and item-item correlations were calculated and factorial structure was analysed. RESULTS: Single item means, the highest item score and subscale mean scores were similar to data published in the original article. The factorial analysis confi rmed the validity of a fi ve-subscale structure in our sample. The eff ects of gender and age were not signifi cant on any of the subscales. CONCLUSIONS: The PHBQPT is a valid, reliable instrument with replicable psychometric properties. The Hungarian version is suitable for clinical practice and for further investigations on attitudes towards psychiatric treatment.

Practical Approach to Measuring and Predicting Medication Adherence by Outpatient's SelfReport After More than 10 Years of Research in Psychopharmacology.

Schizophrenia, bipolar disorder and major depression are associated with nonadherence registered mean figures of around 50%, highlighting the relevance of having simple adherence tools to incorporate into daily clinical practice. For 10 years we have focused on self-report as an assessment method and have studied thousands of outpatients taking thousands of psychiatric medications in three countries. Measurement of treatment adherence during use of polypharmacy is a really complex task as patients could adhere differently to the various medications prescribed, making it essential to assess adherence to each individual medication. This was not possible until the introduction of the Sidorkiewicz Adherence Tool that allows one to separate adherence to each medication, whether poor or not. Health psychologists have developed the Health Belief Model which has not received enough attention by psychiatrists. Based on this model, we have focused on personality styles and specific beliefs concerning specific medications as possible predictors of poor adherence. We developed the Patient Health Beliefs Questionnaire on Psychiatric Treatment which provides 5 self-reported personality dimensions: negative aspects of medication (pharmacophobia), positive aspects of medication (pharmacophilia), high/low psychological reactance, high/low doctor health locus of control (HLOC) and high/low internal HLOC. Based on the Beliefs about Medicines Questionnaire we have developed a measure of skepticism, defined as a patient's high concern about adverse reaction to an individual medication and a low belief in its necessity. Our research experience based on the tools for assessing and predicting adherence is presented in a practical manner by using seven boxes and examples. (Neuropsychopharmacol Hung 2021; 23(4): 336-346).

Adherence to psychiatric medications: Comparing patients with schizophrenia, bipolar disorder and major depression.

Findings of three articles reporting results in 1372 stabilized outpatients taking 2454 medications in Spain, Argentina, and Venezuela were combined. Prevalence of good adherence was not obviously different across diagnoses: 69.5% (N=212) for schizophrenia, 66.3% (N=142) for bipolar disorder, and 69.8% (N=521) for depression. Besides the focus on stabilized outpatients, other study biases included use of a research sample; limited to oral medications, ignoring long-acting injectable antipsychotics; and lack of data on active substance abuse, clinical severity, and insight. Logistic regression models explored predictors of good vs. poor adherence. The six self-reported variables studied were pharmacophobia, pharmacophilia, high psychological reactance, high internal health locus of control (LOC), high doctor LOC, and skepticism concerning specific medications. ORs were significant in 56% (47/84) of the statistical tests vs. 24% (23/98) of ORs significant in case of 7 demographic/clinical variables (p=0.001). At least 2/3 of the ORs for pharmacophobia, pharmacophilia and skepticism were significantly associated with adherence in cases and controls, indicating their independence from diagnoses. In need of replication, three other self-reported measures had differential effects on adherence across diagnoses. High psychological reactance was associated with decreased adherence to antidepressant medications in general, or for patients with mood disorders. High internal LOC as associated with poor adherence may reflect the distrust patients with schizophrenia or severe bipolar disorder have of other people. High doctor LOC was significantly associated with increased adherence only in patients with bipolar disorder, but was significant for all medications, mood stabilizers and antipsychotics, indicating the relevance of the patient-psychiatrist relationship in these patients. (Neuropsychopharmacol Hung 2021; 23(4): 363-373).

Poor Adherence to Oral Psychiatric Medication in Adults with Bipolar Disorder: The Psychiatrist May have More Influence than in Other Severe Mental Illnesses.

Objective: Medication adherence in bipolar disorder (BD) may be influenced by 6 selfreported dimensions: 1) high/low psychological reactance, 2) high/low internal healthlocus of control (HLOC), 3) high/low doctor HLOC, 4) pharmacophobia, 5) pharmacophilia, and 6) skepticism about a specific medication. This study in Spain, Argentina, and Venezuela included 142 outpatients with BD prescribed 320 psychiatric medications and 1230 other psychiatric outpatients prescribed 2134 medications. Methods: Logistic regression models included adherence for each psychiatric medication, measured by the Sidorkiewicz Adherence Tool as the dependent variable. The models provided adjusted odds ratios (ORs) of dichotomous independent variables: clinical variables and 6 self-reported dimensions. Results: ORs significant in both groups were: 1) high doctor HLOC (OR=1.87 in BD, OR=1.25 in other patients), 2) high psychological reactance (respectively OR=0.572, OR=0.798), 3) pharmacophobia (respectively OR=0.361, OR=0.614), and 4) skepticism about a specific medication (respectively OR=0.300, OR=0.556). Two ORs were only significant in BD patients: medication duration > 1 year (OR=0.449), and extreme polypharmacy (OR=2.49). The study included 104 BD patients prescribed 122 mood stabilizers and 136 other patients prescribed 140 mood stabilizers. Two ORs were significant for mood stabilizer adherence only in BD patients: high doctor HLOC and skepticism (respective ORs=2.38, OR=0.390). The study included 87 BD patients prescribed 97 antipsychotics and 417 other patients prescribed 458 antipsychotics. Four ORs were significant for antipsychotic adherence only in the BD group. Conclusions: Future studies of adherence to all/specific medications should explore the specific city/commonality of these dimensions, particularly doctor HLOC, in BD versus other psychiatric patients. (Neuropsychopharmacol Hung 2021; 23(4): 347-362).

Poor Adherence to Oral Psychiatric Medication in Adults with Depression: Psychological Reactance May Have Specific Effects in Depression.

Objective: Medication adherence in psychiatric disorders, including depression, may be influenced by 6 self-reported dimensions: 1) high/low doctor health locus of control (HLOC), 2) high/low internal HLOC, 3) high/low psychological reactance, 4) pharmacophilia, 5) pharmacophobia, and 6) skepticism about a specific medication. This study in Spain, Argentina, and Venezuela included 521 outpatients with depression prescribed 920 psychiatric medications and 851 other psychiatric outpatients prescribed 1534 medications. Methods: Logistic regression models were completed in patients with depression and psychiatric controls. The dependent variable was adherence for each psychiatric medication (Sidorkiewicz Adherence Tool). The models provided adjusted odds ratios (ORs) of dichotomous independent variables: clinical variables, and 6 self-reported dimensions. Results: ORs significant in both diagnostic groups were: 1) pharmacophobia (OR=0.500 in depression, OR=0.599 in other patients), 2) pharmacophilia (respectively OR=1.51, OR=1.65), 3) treatment for 1 year (respectively OR=0.731, OR=0.608), 4) geriatric age (respectively OR=2.28, OR=3.02), and 5) skepticism about a specific medication (respectively OR=0.443, OR=0.569). Two ORs were significant in the depression group, but not in the controls: the country of Spain (OR=0.744), and high psychological reactance (OR=0.685). The study included 470 depression patients prescribed 510 antidepressants and 348 other patients prescribed 370 antidepressants. One OR was significant for antidepressant adherence in both groups: high psychological reactance (respectively OR=0.597, OR=0.561). Conclusions: All clinical studies using self-report include biases but the most important is lack of access to patients not coming for treatment. Future studies should further explore the specificity/commonality of these dimensions, particularly psychological reactance, in depression versus other psychiatric disorders. (Neuropsychopharmacol Hung 2021; 23(4): 374-387).

Poor Adherence to Oral Psychiatric Medication in Adults with Schizophrenia May Be Influenced by Pharmacophobia, High Internal Health Locus of Control and Treatment Duration.

Objective: This study in Spain, Argentina, and Venezuela included 212 schizophrenia outpatients prescribed 387 psychiatric medications and 1,160 other psychiatric outpatients prescribed 2,067 medications. Methods: Logistic regression models included adherence for each psychiatric medication, measured by the Sidorkiewicz Adherence Tool, as the dependent variable. The models provided adjusted odds ratios (ORs) of dichotomous independent variables: 1) clinical variables, 2) subscales from the Patient Health Beliefs Questionnaire on Psychiatric Treatment (presence/absence of pharmacophobia and pharmacophilia and high/low psychological reactance, internal health locus of control [HLOC] and doctor's HLOC) and 3) presence/absence of skepticism toward each medication measured by the Beliefs about Medicines Questionnaire (BMQ). Results: ORs significant in both groups were: 1) pharmacophobia (OR=0.389 in schizophrenia, OR=0.591 in other patients and not significantly different) and 2) pharmacophilia (respectively OR=2.18, OR=1.59 and significantly higher in schizophrenia: p=0.012). Prescribing the medication for >1 year increased adherence in schizophrenia (OR=1.92) while decreasing it in others (OR=0.687). Four ORs were significant in the schizophrenia group but not in the controls: treatment for >1 year (OR=0.161), high internal LOC (OR=0.389), extreme polypharmacy (OR=1.92) and the country of Spain (OR=0.575). Regarding antipsychotics, the study included 204 schizophrenia patients prescribed 240 antipsychotic medications and 301 other patients prescribed 315 antipsychotic drugs. Three ORs were significant for antipsychotic adherence in the schizophrenia group: pharmacophobia (OR=0.324), treatment for >1 year (OR=0.362), and skepticism about specific antipsychotics (OR=0.535). Conclusions: Future adherence studies for antipsychotic/all medications should further explore the specificity/commonality of these dimensions in schizophrenia versus other psychiatric patients. (Neuropsychopharmacol Hung 2021; 23(4): 388-404).

A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology.

Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.

The necessity-concern framework in the assessment of treatment adherence of psychiatric patients and the role of polypharmacy in a Spanish sample.

OBJECTIVE: This study compares three measures (necessity and concern scores, the necessity-concern differential, and a skeptical attitude vs. three other attitudes) for studying the relationship between the necessity-concern framework and treatment adherence after considering the number of prescribed drugs. METHODS: The sample included 588 consecutive adult psychiatric outpatients in the Canary Islands, Spain. The necessity-concern framework was assessed using a specific subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to 1,101 prescribed psychiatric drugs was assessed using the Sidorkiewicz adherence tool. RESULTS: In the three logistic regression models including 1,101 drugs, with adherence as the dependent variable, the highly significant odds ratios (ORs) and their 95% confidence intervals (CIs) were (a) OR = 1.57 (CI = 1.37-1.79) for necessity and OR = 0.747 (CI = 0.660-0.847) for concern; (b) OR = 1.44 (CI = 1.32-1.58) for the necessity-concern differential; and (c) OR = 0.452 (CI = 0.343-0.597) for a skeptical attitude (yes/no), defined as low necessity and high concern. In patients taking five or six drugs, adherence was associated with extremely high/low ORs for necessity, concern, and the differential. CONCLUSION: If replicated, our results suggest clinicians need to pay careful attention to each drug in each patient taking five or six drugs, emphasize necessity, and listen carefully to patient concerns.

Psychometric properties of the Five-item World Health Organization Well-being Index used in mental health services: Protocol for a systematic review.

AIMS: To synthesize evidence of the psychometric properties of the Five-item World Health Organization Well-being Index in mental health settings and critically appraise the methodologies of the included studies. DESIGN: Protocol for a systematic psychometric review. METHODS: The review protocol has been registered in the International Prospective Register for Systematic Reviews. The bibliographic databases MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science will be searched for relevant studies. The psychometric properties of each study will be evaluated according to the Consensus-based Standards for the Selection of Health Measurements Instruments. DISCUSSION: The results of our psychometric review will synthesize the psychometric properties of the Five-item World Health Organization Well-being Index in mental health settings and identify possible gaps in the literature regarding methodological quality and its reliability, validity, and responsiveness to change. IMPACT: The evaluation of patient well-being is important, and the Five-item World Health Organization Well-being Index is an increasingly used patient-reported outcome measure. It is simple to collect, free to use, and consists of five questions using positive health statements. Although the number of studies assessing the validity, reliability, and responsiveness of the questionnaire is increasing worldwide, there is a need to summarize the existing evidence of the psychometric properties of this questionnaire. The proposed study's findings will contribute to future research recommendations and help midwives and nurses in different settings pick an effective, appropriate questionnaire to evaluate patient well-being.

Ethnopsychopharmacology study of patients' beliefs regarding concerns about and necessity of taking psychiatric medications.

OBJECTIVE: The aim of this study was to examine whether or not cultural differences influence beliefs about the necessity of taking prescribed psychiatric drugs and concern about their adverse effects in psychiatric outpatients in Spain, Argentina, and Venezuela. METHODS: This cross-sectional study included 1,372 adult psychiatric outpatients using 2,438 psychotropic drugs and was designed to assess outpatients' beliefs about their prescribed medication. Patients completed sociodemographic, clinical questionnaires, and the Beliefs about Medicines Questionnaire Specific Scale and registered scores ranging from 1 to 5 on each of two subscales: concern and necessity. A "necessity-concern differential" was obtained by calculating the difference (range -4 to +4). RESULTS: The global score, including all drugs in the total sample, had a mean necessity score of 3.50 ± 0.95, a mean concern score of 2.97 ± 0.99, and a mean differential score of 0.54 ± 1.42. The concern and necessity mean scores varied significantly across these three culturally Hispanic countries, probably across drug classes, and were associated with treatment duration. On the other hand, age and education played a very limited role. CONCLUSIONS: Understanding the diverse effects of culture and society on these attitudes is highly relevant for the development of responsive mental health services in multicultural societies.

The Art of Pharmacotherapy: Reflections on Pharmacophobia.

PURPOSE/BACKGROUND: This commentary deals with the neglected issue of the art of psychopharmacology by recounting the authors' journeys. METHODS/PROCEDURES: First, a model of medical science situated within the history of medicine is described including (1) a limitation of the mathematical model of science, (2) the distinction between mechanistic science and mathematical science, (3) how this distinction is applied to medicine, and (4) how this distinction is applied to explain pharmacology to psychiatrists. Second, the neglected art of psychopharmacology is addressed by explaining (1) where the art of psychopharmacotherapy was hiding in the first author's psychopharmacology research, (2) how the Health Belief Model was applied to the art of medicine, (3) how the second author became interested in the Health Belief Model, and (4) his studies introducing the Health Belief Model in psychopharmacology. The authors' collaboration led to: (1) study of the effect of pharmacophobia on poor adherence and (2) reflection on the limits of the art of psychopharmacology. FINDINGS/RESULTS: Low adherence was found in 45% (116/258) of psychiatric patients with pharmacophobia versus 22% (149/682) in those with no pharmacophobia, providing an odds ratio of 2.9 (95% confidence interval, 2.2-4.0) and an adjusted odds ratio of 2.5 (95% confidence interval, 1.8-3.5) after adjusting for other variables contributing to poor adherence. IMPLICATIONS/CONCLUSIONS: Different cognitive patterns in different patients may contribute to poor adherence. Specific interventions targeting these varying cognitive styles may be needed in different patients to improve drug adherence.