Saliva testing as a means to monitor therapeutic lithium levels in patients with psychiatric disorders: Identification of clinical and environmental covariates, and their incorporation into a prediction model.

OBJECTIVE: The narrow therapeutic window of lithium medications necessitates frequent serum monitoring, which can be expensive and inconvenient for the patient. Compared to blood, saliva collection is easier, non-invasive, requires less processing, and can be done without the need for trained personnel. This study investigated the utility of longitudinal salivary lithium level monitoring. METHODS: We measured salivary lithium levels using ICP-OES in n = 169 passive drool samples, collected both as single observations and longitudinally for up to 18 months, from a multi-center cohort of n = 75 patients with bipolar disorder or other psychiatric conditions. RESULTS: Saliva and serum lithium levels were highly correlated. Adjustment for daily lithium dose, diabetes, and smoking improved this relationship (r = 0.77). Using the adjusted intersubject equation and a patient's salivary lithium value, we observed a strong correlation between the predicted vs. observed serum lithium levels (r = 0.70). Most patients had highly stable saliva/serum ratios across multiple visits, with longitudinal variability significantly greater with age. Use of the intrasubject saliva/serum ratio from a single prior observation had similar predictive power to the use of the adjusted intersubject equation. However, the use of the mean intrasubject ratio from three prior observations could robustly predict serum lithium levels (predicted vs. observed r = 0.90). CONCLUSIONS: These findings strongly suggest that saliva could be used for lithium monitoring, and open the door for the development and implementation of a point-of-care salivary lithium device for use at home or the clinic. We propose that the use of saliva will dramatically improve treatment opportunities for patients with mood disorders.

Adherence and Continuation of Treatment with First- and Second-generation Antipsychotics in Schizophrenia.

BACKGROUND: Despite a large body of evidence, the issue of differences in adherence and continuation of treatment with first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) in schizophrenia remains unresolved. This study compared adherence and continuation of treatment between patients on SGAs and FGAs and examined the influence of several socio-demographic and clinical variables on adherence in the two antipsychotic groups. MATERIALS AND METHODS: Two groups, one of 40 patients with schizophrenia on SGAs and the other with 30 patients on FGAs, were compared on clinician-rated and patient-rated measures of adherence over 6 months; a 3-month period prior to intake and a 3-month follow-up period. Mean scores on these measures and the proportion of adherent/non-adherent patients was estimated for both groups. RESULTS: The two groups did not differ in the 3-month period prior to intake. Over the subsequent 3 months of follow-up, a-fifth of the patients on FGAs became non-adherent, while about 10% of those on SGAs became more adherent. These differences in continuation rates resulted in patients on SGAs being rated as significantly more adherent at the end of this 3-month follow-up period and over the entire 6 months of the study. Differences in adherence and continuation rates between the two groups were primarily driven by the differences between olanzapine and the FGAs. Supervision of treatment by relatives emerged as the only consistent determinant of adherence, but explained only 8% of the variance. CONCLUSIONS: Patients on certain SGAs, notably olanzapine, are more likely to continue with their treatment that those on FGAs.

Attitudes towards antipsychotics among patients with schizophrenia on first- or second-generation medications.

BACKGROUND: Given the paucity of research in this area, this study attempted to assess attitudes toward antipsychotic medications and its correlates among patients with schizophrenia, either on first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs) medications. MATERIALS AND METHODS: Structured assessments of attitudes to antipsychotics, psychopathology, insight and side-effects were carried out in 120 patients with DSM-IV schizophrenia; 89 of these were on SGAs and 31 on FGAs. RESULTS: Patients had predominantly positive attitudes toward antipsychotics. Severity of side-effects was the principal correlate of attitudes, explaining 19.5% of the variance, followed by greater insight (4.2% of the variance). Other factors such as younger age, male gender, employment, higher family income, urban residence and lower symptom-severity explained only a negligible proportion of the variance (0.2%) in attitudes. Patients on SGAs had more positive views of their medications than those on FGAs. They felt more normal on their medications, believed that their thoughts were clearer on medications, felt that good things about their medications outweighed the bad and believed that their medications helped them from falling ill again. In addition, they did not feel as tired and sluggish on their medications and did not believe that medications were unnatural or controlled their bodies. CONCLUSIONS: Positive attitudes toward antipsychotics were common among patients with schizophrenia. Attitudes were principally determined by severity of side-effects and insight levels. Patients on SGAs had better attitudes, possibly because of less severe side-effects and greater insight among them. The importance of exploring patients' attitudes toward their antipsychotics is highlighted by this study.

Background, clinical features and treatment of attention deficit hyperactivity disorder in children.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is an early onset, clinically heterogeneous, complex neurobiological disorder, defined by symptoms of inattention and hyperactivity/impulsivity and has been associated with a broad range of impairments for those affected. Additionally, ADHD in children and adolescents is frequently associated with psychiatric comorbidities. This review provides an overview of the epidemiology, neurobiology, genetics, diagnosis and most recent pharmacological approaches for treatment with a focus on safety and efficacy and describes the use of medications used to treat ADHD in special populations. AREAS COVERED: PubMed, Cochrane database, Essential Evidence and Uptodate were searched for relevant articles about stimulant and non-stimulant pharmacological approaches in ADHD. EXPERT OPINION: Data supporting the safety and efficacy of both stimulant and non-stimulant formulations have significantly grown over the past decade and more efforts are being made to tailor medications to the needs of the patients and their families. Pharmacogenomics research is evolving, but predictors of treatment response and side effects remain largely unknown. Other unmet clinical needs include long-term follow-up studies of the safety and efficacy of medications for those with ADHD alone, or with comorbidities and in special populations including preschoolers.