Antipsychotics Rapidly Boost Cardiovascular Risk

The risk for cardiovascular disease in people with psychosis increases after their first exposure to antipsychotic drugs, according to new research published online February 7 in the Archives of General Psychiatry.

“This change in risk is evident early in the course of treatment, within several weeks of continuous use, but may continue over years,” study investigator Debra L. Foley, PhD, of the University of Melbourne in Australia, told Medscape Medical News.

Schizophrenia is associated with a reduced life expectancy, and most early deaths are due to cardiovascular disease.

“We wanted to review what was known about the role of antipsychotic drugs in altering early risk factors for cardiovascular disease,” Dr. Foley explained.

Dr. Foley and coauthor Katherine I. Morley, PhD, from the Wellcome Trust Sanger Institute, Hinxton, United Kingdom, undertook a systematic review of baseline and posttreatment risk factors for cardiovascular disease in patients receiving drug treatment for psychosis for the first time. The analysis included 25 studies published between January 1990 and June 2010.

All subjects were experiencing their first treated episode of psychosis and were either antipsychotic naive or had been exposed to antipsychotics for between 9 days and 16 weeks. Eight of the studies also included controls that were recruited from hospital staff, universities, the general community, and a workplace-screening program.

Rapid Metabolic Change

The investigators found that changes in weight, body mass index, and waist circumference were evident in the patients receiving the antipsychotic drugs after 1 month.

After 6 weeks, there was a significant increase in interleukin 12. After 10 weeks, there was a significant increase in subcutaneous and intra-abdominal fat, a 3-fold increase in leptin level, and a significant increase in total and low-density lipoprotein cholesterol, triglyceride, and nonfasting glucose levels.

After 6 to 12 months, total body weight increased by 10% to 12%, and most of this increase occurred in the first 6 months. Between 36% and 42% of patients were overweight or obese at baseline, the same as in the broader community, but after 6 months, 58% to 71% were overweight or obese, the study authors report…….

Reported by Fran Lowry
Medscape Medical News

Outpatient Psychotherapy “Not Keeping Pace” With Increasing Use of Psychotropics

Although the overall use of outpatient psychotherapy by the general population remained stable between the years 1998 and 2007, the levels decreased by more than 5% for those using outpatient mental care facilities, according to a new national trends survey.

In addition, use of psychotherapy and psychotropic medication together also decreased by almost 8% in this setting, whereas treatment with psychotropic medication alone increased by more than 13%.

“We found that for an increasing number of Americans, mental healthcare involves medications but not psychotherapy, and this trend is evident especially for depression and for bipolar, anxiety, and child disorders,” Mark Olfson, MD, MPH, professor of clinical psychiatry at Columbia University in New York City, told Medscape Medical News.

“The absolute proportion of the population that is receiving psychotherapy is really very little changed over the last 10 or even 20 years. But it’s contributing a smaller proportion of overall mental healthcare because it’s not keeping pace with the big growth in the use of psychotropic medications,” added Dr. Olfson…..

Reported by Deborah Brauser
Medscape Medical News

Risks With Antipsychotics in Pregnancy Stressed in New Label

Antipsychotic drug labels will bear an updated warning to pregnant women about the potential risk for abnormal muscle movements and withdrawal symptoms in neonates, the US Food and Drug Administration (FDA) announced today.

More than 20 antipsychotic drugs affected by today’s action include such well-known agents as risperidone (Risperdal, Ortho-McNeil-Janssen Pharmaceuticals), aripiprazole (Abilify, Otsuka America Pharmaceutical), haloperidol (Haldol, Ortho-McNeil-Janssen Pharmaceuticals), and clozapine (Clorazil).

The new drug labels will spell out in more detail and consistency the potential risk for extrapyramidal signs (EPS) and withdrawal symptoms for newborns whose mothers took these placenta-crossing medications during the third trimester of pregnancy.

The FDA uncovered 69 cases of neonatal EPS or withdrawal associated with antipsychotic drugs through October 29, 2008, in a search of the agency’s Adverse Event Reporting System (AERS) database. Symptoms included hypotonia, hypertonia, somnolence, tremor, respiratory distress, and feeding disorder. Most of the 69 cases involved confounding factors, such as the concomitant use of other psychoactive drugs, prematurity, and obstetric complications. “However, there were some cases which suggest that neonatal EPS and withdrawal may occur with antipsychotics alone,” the agency stated.

The FDA is advising clinicians to monitor neonates displaying EPS or withdrawal symptoms, noting that while some recover within hours or days, others may require prolonged hospitalization.

The drugs that will bear an updated warning about the risks of EPS and withdrawal are as follows:

aripiprazole (Abilify)
clozapine (Clozaril; FazaClo ODT)
iloperidone (Fanapt)
ziprasidone (Geodon)
haloperidol (Haldol)
paliperidone (Invega; Invega Sustenna)
loxapine (Loxitane)
molindone (Moban)
thiothixene (Navane)
pimozide (Orap)
risperidone (Risperdal; Risperdal Consta)
asenapine (Saphris)
quetiapine (Seroquel; Seroquel XR)
trifluoperazine (Stelazine)
chlorpromazine (Thorazine)
olanzapine (Zyprexa; Zyprexa Relprevv; Zyprexa Zydis)
olanzapine and fluoxetine (Symbyax)
perphenazine and amitriptyline

More information about today’s announcement is available on the FDA Website.

To report adverse events related to antipsychotic drugs, contact MedWatch, the FDA’s safety information and adverse event reporting program, by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at, or by mail to MedWatch, FDA, 5600 Fishers Lane, Rockville, Maryland 20852-9787.

Reported by Robert Lowes
Medscape Medical News

No Benefit, More Side Effects With Injectable Risperidone

Long-acting, injectable risperidone, the first second-generation antipsychotic available in the United States in this formulation, is no better than oral antipsychotics for the treatment of unstable schizophrenia, a new study published in the March 3 issue of the New England Journal of Medicine suggests.

In a randomized study of more than 300 Veterans Affairs (VA) patients, investigators found injectable risperidone did not significantly decrease hospitalization rates or improve symptoms, social function, or quality of life compared with those treated with “clinicians’ choice” of oral antipsychotics. The risperidone-treated group also reported more adverse effects.

Reported by Deborah Brauser
Medscape Medical News

Iloperidone: A New Drug for the Treatment of Schizophrenia


Purpose. The pharmacology, pharmacokinetics, pharmacogenomics, clinical efficacy, and safety and tolerability profile of iloperidone for the treatment of schizophrenia are reviewed.
Summary. Iloperidone is an atypical antipsychotic that recently received marketing approval from the Food and Drug Administration for the acute treatment of schizophrenia. Iloperidone is a pure antagonist and the first antipsychotic to have pharmacogenomic studies indicate predictive response based on six identified polymorphisms. Pharmacokinetic studies have determined that iloperidone is well absorbed orally, with a bioavailability of 96%. Phase II and III clinical trials have shown iloperidone to improve symptoms of schizophrenia, based on the Positive and Negative Symptom Scale, Brief Psychiatric Rating Scale, and Clinical Global Impressions–Severity scores (p < 0.05). Iloperidone has established tolerability at recommended dosages of up to 24 mg daily; however, the dosage must be slowly increased over seven days, and twice-daily administration is required to avoid orthostatic hypotension. The most common adverse effects associated with iloperidone were dizziness, dry mouth, fatigue, nasal congestion, orthostatic hypotension, somnolence, tachycardia, and weight gain. Safety studies have also found that iloperidone increases the risk of Q-Tc interval prolongation, similar to that seen with ziprasidone. Minimal changes in glucose and lipid abnormalities were seen in short-term (4- and 6-week) and long-term (52-week) studies, indicating a low chance of metabolic disturbance with iloperidone.
Conclusion. Iloperidone may be a viable and safe option for the treatment of schizophrenia in adult patients, especially for patients who cannot tolerate other antipsychotic agents. However, iloperidone lacks a clear benefit over other antipsychotic agents.

Read more:

By Sally A. Arif, Pharm.D., BCPS; Melissa M. Mitchell, Pharm.D., BCPS, BCPP, CGP
American Journal of Health-System Pharmacy
American Journal of Health-System Pharmacy. 2011;68(4):301-308

Are Antipsychotics Overprescribed?

Editor’s note: Antipsychotics are now the top-selling class of medications in the United States, with prescription sales of $14.6 billion in 2009.[1] Many clinicians worry these agents are being overprescribed and used inappropriately. Medscape recently hosted an email discussion between Dr. Nassir Ghaemi, a psychiatrist, and Dr. Larry Culpepper, a primary care physician with expertise in psychiatry, exploring the question of whether antipsychotics are being used appropriately by prescribing clinicians.

Are Antipsychotics Overprescribed? Introduction

Nassir Ghaemi, MD, MPH: I think antipsychotics are overprescribed. Let’s first think about the most legitimate uses, and then we can identify how and why they’re overprescribed. These agents are most legitimately used, obviously, for schizophrenia in both the short term and long term.[2] They are also legitimately used in the short term (meaning a few months) for acute mania.[3] That’s about it, in my view.

Now, some antipsychotics are US Food and Drug Administration (FDA) indicated for maintenance treatment of bipolar disorder. But for various scientific reasons, I believe the studies on which these approvals are based are deeply flawed.[4,5] So despite the president’s stamp of approval, I don’t think we can give a scientific stamp of approval. I think [antipsychotics] are scientifically proven for only a few months of mania, and then they should be stopped in general, both due to lack of proven efficacy (despite what the FDA says) and for safety concerns associated with some of the drugs.[4,5]

Antipsychotics are also used for bipolar depression, and some have FDA indications for the condition. Here too I am skeptical about the related studies. But even if accepted, the evidence only supports short-term use (8 weeks), not long-term use for prevention; hardly any data exist with any antipsychotics by themselves in the prevention of bipolar depression, and what little data does exist are subject to many scientific problems.[4,5]

Then there is so-called major depressive disorder, or plain old depression. Certain antipsychotics have an FDA indication here, but again only for short-term use. Hence, short-term use might be justifiable, but scientifically long-term use is not.[6]

By Larry Culpepper, MD, MPH; Nassir Ghaemi, MD, MPH
Medscape Psychiatry

Sen. John Kerry: Legislation Would End Mental Health Discrimination in Medicare

WASHINGTON, D.C. – Senators John Kerry (D-Mass.) and Olympia J. Snowe (R-Maine) today introduced legislation to end discrimination against Medicare patients who suffer from mental illness.

Current Medicare beneficiaries are eligible to receive a total of 190 days of inpatient psychiatric hospital care throughout their lifetimes regardless of their need. This arbitrary cap on benefits discriminates against the mentally ill in that it does not impose a lifetime limit for any other Medicare specialty inpatient hospital service. The Medicare Mental Health Inpatient Equity Act (S. 374) would eliminate this limit and equalize Medicare mental health coverage with private health insurance coverage. The legislation would also expand beneficiaries’ choices for inpatient psychiatric care providers, increase access for the seriously ill, and improve continuity of care.

Read more:

Reported by Staff of The State Column

‘Henry’s Demons’: Mental Illness From The Inside

On a snowy February day in 2002, British journalist Patrick Cockburn was in Kabul, Afghanistan, covering the fall of the Taliban. He picked up his satellite phone to call his wife, Jan, back in Canterbury, England. Even over that shaky, hollow telephone line, Jan sounded anxious.

“I could not make out the details, but I grasped that Henry, our 20-year-old son, had nearly died when he swam Newhaven Estuary, fully clothed, and was rescued by fishermen as he left the near-freezing water,” Cockburn writes.

Henry was taken first to a regular emergency room, and then to a mental hospital, where doctors diagnosed him as being in the first stages of schizophrenia. Now, almost 10 years later, Henry is beginning to recover, and he and his father have collaborated on a memoir of his experiences, Henry’s Demons: Living With Schizophrenia, a Father and Son’s Story………

by NPR Staff


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