Activating and Tranquilizing Effects of First-Time Treatment with Aripiprazole, Olanzapine, Quetiapine, and Risperidone in Youth.

OBJECTIVE: To assess activating and tranquilizing effects of second-generation antipsychotics (SGAs) in youth. METHODS: As part of the naturalistic inception cohort study, "Second-generation Antipsychotic Treatment Indication, Effectiveness and Tolerability in Youth (SATIETY)," subjective ratings of activating and tranquilizing symptoms were obtained monthly for 3 months from antipsychotic-naïve youth initiating SGAs using the Treatment Emergent Symptoms Scale (TESS). Discontinuation rates, and TESS-reported symptom rates, and severity were related to clinical and treatment parameters. Two compound measures of TESS were defined: presence of any daytime activating (ACTIVATION+) and sedating symptoms (SEDATION+). RESULTS: In 327 antipsychotic-naïve youth originally initiating the four studied SGAs, discontinuation due to sedation was marginally highest with quetiapine (13.0%) followed by olanzapine (7.3%), risperidone (4.2%), and aripiprazole (2.0%) (p = 0.056). Two hundred fifty-seven antipsychotic-naïve youth (13.8 ± 3.6 years, male = 57.8%) initiated aripiprazole (n = 40), olanzapine (n = 45), quetiapine (n = 36), or risperidone (n = 135) and completed ≥1 postbaseline follow-up visit. Baseline prevalence of ACTIVATION+ (39.9%) or SEDATION+ (54.1%) did not differ between SGAs. Rates of both compound measures changed significantly over time (decrease for ACTIVATION+, p = 0.0002; increase for SEDATION+, p < 0.0001) with slight differences between SGAs, explained by lower rates of ACTIVATION+ with olanzapine (p = 0.002) and slightly higher rates of ACTIVATION+ with aripiprazole (p = 0.018) during follow-up, and lower rates of SEDATION+ with aripiprazole (p = 0.018). All four SGAs reduced insomnia (p = 0.001) and increased hypersomnia (p < 0.001). Postbaseline prevalence of drowsiness, the most frequent, but mild TESS complaint was 85%, without SGA differences. Younger age was associated with activating symptoms, higher age with sedating symptoms, and lower baseline functioning increased both. Psychomotor retardation rates were high in subjects with schizophrenia-spectrum disorders, whereas stimulant comedication was associated with psychomotor activation, regardless of diagnosis. CONCLUSIONS: Although small SGA-specific differences in activating/sedating compound side effect measures were noted, independent predictors of single TESS ratings included clinical parameters, rather than specific SGAs, suggesting a need for carefully individualized treatment strategies.

Acanthosis nigricans during treatment with aripiprazole.

Aripiprazole is typically regarded as a metabolically sparing agent, in contrast to other second-generation antipsychotics, which are widely known to lead to weight gain and increase the cardiometabolic risk. We report for the first time the emergence of Acanthosis nigricans, a dermatological correlate of insulin resistance, during treatment with aripiprazole in an adolescent with a family history of diabetes mellitus.

Elevated blood urea nitrogen and medical outcome of psychiatric inpatients.

Elevated blood urea nitrogen (BUN) is associated with increased severity of illness and mortality, but its predictive value has not been studied in patients admitted to free-standing psychiatric hospitals. To determine the clinical outcome of psychiatric inpatients with elevated BUN on admission and to create a quantitative method of using BUN for predicting deteriorations requiring transfers of psychiatric inpatients to a general hospital we conducted a retrospective cohort study of 939 adults consecutively admitted to a free-standing psychiatric hospital in 2010. Transfer to a general hospital was used as a proxy marker for poor medical outcome. The score Age (years) plus BUN (mg/dL) was used in sensitivity analyses to identify patients with medical deterioration in derivation (N = 523) and validation (N = 414) samples. Fifty-two (5.5%) patients had admission azotemia (BUN >25 mg/dL). Medical deteriorations requiring emergency transfer to a general hospital occurred in 24 (46.2%; 95% confidence interval = 32.6-49.8%) of azotemic patients and 112 (12.6%; 95% confidence interval = 10.4-14.8%) of those with normal BUN (p < 0.0001). Age + BUN ≥ 90 identified 51 transferred patients and had positive and negative predictive values of 39.8 and 89.5%, respectively, in the entire sample. We conclude that psychiatric inpatients with BUN >25 mg/dL or Age + BUN ≥ 90 are at risk for medical deterioration. Free-standing psychiatric hospitals should develop models of care requiring frequent, scheduled medical follow-up and enhanced monitoring for this vulnerable populations.