Outcomes of a co-located approach for metabolic health care for people with schizophrenia.

OBJECTIVE: Metabolic syndrome is highly prevalent among people with schizophrenia. This study aims to assess the impact on metabolic and attendance outcomes of a co-located, dedicated, endocrinologist-led metabolic clinic in a stand-alone public community mental health service. METHODS: Demographic and metabolic data on the first 48 consecutive referrals over a 12-month period were retrospectively collected and analysed. Attendance rates at the co-located clinic were compared to the general hospital obesity and diabetes clinics. RESULTS: Clinic attendees had significant reductions in triglycerides and total cholesterol, but not mean weight, BMI, waist circumference, blood pressure or HbA1c. Attendance rates were significantly higher in the co-located clinic compared to the general hospital obesity and diabetes clinics for both initial consult (80.0% vs 51.2%, p < 0.001) and review appointment (64.3% vs 47.6%, p < 0.001). CONCLUSION: The co-location of a specialist metabolic clinic within a mental health service resulted in enhanced engagement and improvement of metabolic health in people with schizophrenia.

Augmentation strategies for clozapine refractory schizophrenia: A systematic review and meta-analysis.

BACKGROUND: Although clozapine is the most effective medication for treatment refractory schizophrenia, only 40% of people will meet response criteria. We therefore undertook a systematic review and meta-analysis of global literature on clozapine augmentation strategies. METHODS: We systematically reviewed PubMed, PsycInfo, Embase, Cochrane Database, Chinese Biomedical Literature Service System and China Knowledge Resource Integrated Database for randomised control trials of augmentation strategies for clozapine resistant schizophrenia. We undertook pairwise meta-analyses of within-class interventions and, where possible, frequentist mixed treatment comparisons to differentiate treatment effectiveness Results: We identified 46 studies of 25 interventions. On pairwise meta-analyses, the most effective augmentation agents for total psychosis symptoms were aripiprazole (standardised mean difference: 0.48; 95% confidence interval: -0.89 to -0.07) fluoxetine (standardised mean difference: 0.73; 95% confidence interval: -0.97 to -0.50) and, sodium valproate (standardised mean difference: 2.36 95% confidence interval: -3.96 to -0.75). Memantine was effective for negative symptoms (standardised mean difference: -0.56 95% confidence interval: -0.93 to -0.20). However, many of these results included poor-quality studies. Single studies of certain antipsychotics (penfluridol), antidepressants (paroxetine, duloxetine), lithium and Ginkgo biloba showed potential, while electroconvulsive therapy was highly promising. Mixed treatment comparisons were only possible for antipsychotics, and these gave similar results to the pairwise meta-analyses. CONCLUSIONS: On the basis of the limited data available, the best evidence is for the use of aripiprazole, fluoxetine and sodium valproate as augmentation agents for total psychosis symptoms and memantine for negative symptoms. However, these conclusions are tempered by generally short follow-up periods and poor study quality.

Going the distance: reviewing antipsychotic depot or long-acting injectable treatments in Australasia.

OBJECTIVES: The aim of this study is to provide an opinion paper reviewing the role of depot or long-acting injectable (LAI) antipsychotic medications, with comments on individual newer LAIs such aripiprazole maintena and paliperidone palmitate. In particular, we share our recent experience of using paliperidone three-monthly LAI. We also reflect on the associated benefits and potential harms of LAIs, and when they may be used. CONCLUSIONS: LAI antipsychotics are an important and arguably under-utilised therapeutic option, particularly where medication adherence is a priority, and where an informed patient opts for this formulation. Paliperidone is the first three-monthly LAI antipsychotic, and as such represents a significant advance in the range of treatment choices.

On being supervised: getting value from a clinical supervisor and making the relationship work when it is not.

OBJECTIVE: The importance of clinical supervision is emphasised in psychiatric training programs. Despite this, the purpose and processes of supervision are often poorly defined. There is limited guidance available for trainees about their role in making supervision work. This paper considers the nature of supervision in psychiatric training and provides practical advice to help supervisees take active steps to make supervision work. CONCLUSIONS: In obtaining value from supervision, the active role of the supervisee in seeking feedback, finding value in criticism and building autonomy is emphasised. Additionally, the importance of exploring what value a supervisor can offer and maintaining realistic expectations is considered. Trainees can benefit from taking an active role in planning and managing their supervision to maximise their learning.

Practical guidelines on the use of paliperidone palmitate in schizophrenia.

OBJECTIVE: Paliperidone palmitate is an atypical long-acting injectable (LAI) antipsychotic that has been approved for use in the US, EU, Australia and numerous other countries for acute and maintenance therapy of schizophrenia. LAI antipsychotics are often viewed as a 'last-resort' treatment for difficult-to-treat patients, however this article considers their role more broadly in the management of partial or non-adherence in schizophrenia. METHOD: A search of MedLine, CTR and PsychInfo was conducted to identify relevant publications and clinical trials (search term 'paliperidone palmitate', up to December 2010). The findings were discussed in a number of teleconferences and the manuscript was finalized with a face-to-face meeting of the authors group. MAIN FINDINGS: Relapse prevention in schizophrenia requires a comprehensive approach to treatment, which includes antipsychotic medication and psychosocial measures as well as family and/or carer involvement. Good symptom control and the interconnected issue of treatment adherence are arguably the most crucial factors for success. Carer and patient feedback should be carefully considered. Negotiation about commencing LAI therapy done early in course of disease is easier than many clinicians believe, although it is not often attempted in practice. Paliperidone palmitate is useful in both the acute and maintenance phases of treatment. COMMENTARY: A case-based approach is presented to suggest various opportunities where use of paliperidone palmitate could be considered within the disease course of schizophrenia. CONCLUSIONS: Paliperidone palmitate offers some advantages in terms of tolerability, simplicity of treatment initiation and long duration between injections. The consensus of the authors is that rather than reserving paliperidone palmitate for use in difficult-to-treat or refractory patients, it could be used to promote adherence and prevent relapse earlier in the course of the illness.