Adjunct Aripiprazole Reduces Prolactin and Prolactin-Related Adverse Effects in Premenopausal Women With Psychosis: Results From the DAAMSEL Clinical Trial.

PURPOSE/BACKGROUND: Prolactin-related adverse effects contribute to nonadherence and adverse health consequences, particularly in women with severe mental illness. Treating these adverse effects may improve treatment acceptability, adherence, and long-term outcomes. METHODS/PROCEDURES: Premenopausal women with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder were recruited for a randomized, double-blind, placebo-controlled 16-week trial of adjunct aripiprazole (5-15 mg/d). Participants had elevated prolactin (>24 ng/mL) and were experiencing galactorrhea, amenorrhea, oligomenorrhea, or sexual dysfunction on a prolactin-elevating antipsychotic. Participants were evaluated biweekly for prolactin elevation and galactorrhea and completed a menstrual diary review. Psychiatric symptoms and adverse effects were closely monitored. FINDINGS/RESULTS: Forty-six women were randomized (n = 25 aripiprazole, n = 21 placebo). Thirty-seven completed at least 8 weeks of the study (n = 20 [80%] aripiprazole and n = 17 [81%] placebo). Aripiprazole (mean dose, 11.7 ± 2.4 mg/d) was effective for lowering prolactin relative to placebo (P = 0.04). In addition, 45% (9/20) of the aripiprazole group had a normalized prolactin (<24 mg/mL) compared with 12% (2/17) of the placebo group (P = 0.028). Galactorrhea resolved in 77% (10/13) of the aripiprazole-treated participants compared with 33% (4/12) in the placebo group (P = 0.028). Normalization of sexual function (<16 on the Arizona Sexual Experience Scale) occurred in 50% on aripiprazole (7/14) versus 9% (1/11) on placebo (P = 0.030). No differences between groups in symptoms or adverse effects were noted. Overall, women rated a mean score of 4.6 ± 0.6 on a 5-point Likert scale for sexual function improvement, suggesting their particular satisfaction with improvement in this domain. IMPLICATIONS/CONCLUSIONS: Building upon prior studies, this rigorous evaluation confirms the utility of adjunctive aripiprazole as a strategy for improving prolactin and managing prolactin-related adverse effects in premenopausal women with psychosis.

Clozapine in Reducing Aggression and Violence in Forensic Populations.

Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.

The RAISE Connection Program: Psychopharmacological Treatment of People With a First Episode of Schizophrenia.

OBJECTIVE: This study examined the adherence of psychiatrists to the Schedule of Recommended First and Second Line Antipsychotic Medications ("Antipsychotic Schedule"), which was implemented in two Recovery After an Initial Schizophrenia Episode (RAISE) Connection Program Implementation and Evaluation Study clinics. METHODS: Sixty-five individuals with a first episode of psychosis were enrolled in the RAISE Connection Program clinics. Two psychiatrists received training and ongoing consultation on use of a shared decision-making approach to prescribing antipsychotic medications according to the Antipsychotic Schedule. Information about participants, prescribed antipsychotic medications, and completion of side-effect assessments were obtained from standardized research assessments and chart extractions. Descriptive statistics were used to characterize the extent to which patterns of antipsychotic prescribing and side-effect monitoring were consistent with the Antipsychotic Schedule. RESULTS: Ninety-two percent of participants were prescribed an antipsychotic medication and received the medication on 76%±35% of the days they were in treatment. Seventy-seven percent of participants were prescribed at least one Antipsychotic Schedule first-line antipsychotic, 20% were prescribed olanzapine, and 10% received a trial of clozapine. Regarding monitoring for metabolic side effects, 92% of participants had at least one weight recorded, 72% had at least one blood glucose measure recorded, and 62% had at least one lipid profile recorded. CONCLUSIONS: In the context of a study in which training and ongoing clinical supervision by experts was provided to psychiatrists and shared decision making was encouraged, antipsychotic prescribing patterns closely adhered to recommendations established by the RAISE Connection Program.

Use of the internet and other media for health information among clinic outpatients with serious mental illness.

OBJECTIVE: This study examined how people with serious mental illness access and use media to receive health information. METHODS: One hundred people with serious mental illness were interviewed regarding their media use, with a focus on how they get their health information. RESULTS: Among these participants, 91% had a television (M+/-SD=5.7+/-4.6 hours per day), and 74% indicated it was a primary health information source. One third of the sample had used the Internet. Of these participants, about half (53%) had gone online for health information. Younger participants and those with more education were significantly more likely to use the Internet. Among Internet nonusers, there was still interest in finding health information online; however, expense, lack of computer skills or knowledge, and difficulties with typing and reading prevented doing so. CONCLUSIONS: Although this sample used television more often than the Internet as a resource, there appears to be interest among persons with serious mental illness in using the Internet as a source of health information and support.

Transitioning clients from assertive community treatment to traditional mental health services.

The original assertive community treatment (ACT) model included time-unlimited treatment. However, resource restrictions and subsequent research call into question the feasibility and necessity of time-unlimited services. This study compares the outcomes of 48 individuals who successfully transitioned from ACT to less intensive Community Mental Health Center (CMHC) services to 19 persons who required return to ACT or did not remain in CMHC treatment. There were no statistically significant differences in demographics, diagnoses, and other treatment factors between the two groups.

Psychiatrists and primary caring: what are our boundaries of responsibility?

This column provides a framework for considering the extent of psychiatrists' responsibility for patients' medical conditions. Psychiatrists have the greatest responsibility for medical conditions that occur as a result of their own actions. Next on the continuum of responsibility is psychiatrists' obligation to remain alert for medical conditions that can cause, trigger, or exacerbate psychiatric conditions or interfere with treatment. Another potential responsibility is for preventive monitoring, screening, and education for medical conditions that disproportionately affect psychiatric patients. Characteristics of the setting, practitioner, and patient that affect how such responsibilities are fulfilled are also discussed.

Use of emergency department services for somatic reasons by people with serious mental illness.

OBJECTIVE: This study identified factors associated with use of the emergency department for medical reasons among individuals with serious mental illness. METHODS: A total of 200 randomly selected outpatients who were receiving community-based psychiatric care were recruited for the study and interviewed with items from the National Health Interview Survey and other national health surveys. RESULTS: Emergency department use (37 percent of the sample) was negatively associated with older age and positively associated with the number of co-occurring medical conditions, smoking, recent injury, and recent change in health care provider. CONCLUSIONS: The relatively high rate of emergency department use may be suggestive of inappropriate use or may reflect perceived barriers to care. Future work should identify specific reasons for seeking care in the emergency department and develop interventions to optimize appropriate emergency department use.