Ahmed Okasha

World Psychiatric Association Pharmacopsychiatry Section statement on comparative effectiveness of antipsychotics in the treatment of schizophrenia

Data from two major government-funded studies of comparative antipsychotic effectiveness in schizophrenia contradict the widely prevalent belief that the newer second-generation medications are vastly superior to the older first-generation drugs. This has caused uncertainty among patients, clinicians and policy-makers about the relative utility of first- and second- generation antipsychotic agents in its treatment. To reduce confusion and provide a contextual understanding of the new data, the World Psychiatry Association Section on Pharmacopsychiatry comprehensively reviewed the literature on the comparative effectiveness of different antipsychotic treatments for schizophrenia and developed this update. Utilizing data from the approximately 1,600 randomized controlled trials of antipsychotic treatment in schizophrenia, we applied the two indirect and one direct method to comparing the effectiveness of 62 currently-available antipsychotic agents. The subclasses of 51 first-generation and 11 second-generation antipsychotics were both found to be very heterogeneous, with substantial differences in side-effect profiles among members. Second-generation antipsychotic agents were found to be inconsistently more effective than first-generation agents in alleviating negative, cognitive, and depressive symptoms and had a lower liability to cause tardive dyskinesia; these modest benefits were principally driven by the ability of second-generation antipsychotics to provide equivalent improvement in positive symptoms along with a lower risk of causing extrapyramidal side-effects. Clozapine was found to be more efficacious than other agents in treatment-refractory schizophrenia. There were no consistent differences in efficacy among other second-generation antipsychotic agents; if such differences exist, they are likely small in magnitude. Dosing was found to be a key variable in optimizing effectiveness of both first- and second- generation antipsychotic agents. There was enormous individual variability in antipsychotic response and vulnerability to various adverse effects. In contrast to their relatively similar efficacy in treating positive symptoms, there were substantial differences among both first- and second- generation antipsychotic agents with regard to their propensity to cause extrapyramidal, metabolic and other adverse effects; second-generation agents have a lower liability to cause acute extrapyramidal symptoms and tardive dyskinesia along with a tendency to cause greater metabolic side-effects than first-generation agents. Based on these data about the comparative effectiveness of different antipsychotic treatment options, we summarize elements of current best antipsychotic practice for the treatment of schizophrenia and discuss the role of government and the pharmaceutical industry in obtaining and disseminating information which can facilitate best practice.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine–fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

WCA Recommendations for the Long-Term Treatment of Obsessive-Compulsive Disorder in Adults

What are the latest psychotherapeutic and pharmacotherapeutic treatment recommendations for obsessive-compulsive disorder (OCD)? OCD is a relatively common disorder with a lifetime prevalence of approximately 2% in the general population. It often has an early onset, usually in childhood or adolescence, and frequently becomes chronic and disabling if left untreated. High associated healthcare utilization and costs, and reduced productivity resulting in loss of earning, pose a huge economic burden to OCD patients and their families, employers, and society. OCD is characterized by the presence of obsessions and compulsions that are time-consuming, cause marked distress, or significantly interfere with a persons functioning. Most patients with OCD experience symptoms throughout their lives and benefit from long-term treatment. Both psychotherapy and pharmacotherapy are recommended, either alone or in combination, for the treatment of OCD. Cognitive-behavioral therapy is the psychotherapy of choice. Pharmacologic treatment options include the tricyclic antidepressant clomipramine and the selective serotonin reuptake inhibitors (SSRIs) citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. These have all shown benefit in acute treatment trials; clomipramine, fluvoxamine, fluoxetine, and sertraline have also demonstrated benefit in long-term treatment trials (at least 24 weeks), and clomipramine, sertraline, and fluvoxamine have United States Food and Drug Administration approvals for use in children and adolescents. Available treatment guidelines recommend first-line use of an SSRI (ie, fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram) in preference to clomipramine, due to the latters less favorable adverse-event profile. Further, pharmacotherapy for a minimum of 1-2 years is recommended before very gradual withdrawal may be considered.

Mental health services in the Arab world

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.

Mental health in the middle east: An egyptian perspective

This article introduces the reader to mental health in the Middle East with an Egyptian perspective, from the Pharaonic era through the Islamic Renaissance, up until the current state. During Pharaonic times, mental illness was not known as such, as there was no separator between Soma and Psyche. Actually, mental disorders were described as symptoms of the heart and uterine diseases, as stated in Ebers and Kahouns papyri. In spite of the mystical culture, mental disorders were attributed and treated on a somatic basis. In the Islamic era, mental patients were never subjected to any torture or maltreatment because of the inherited belief that they may be possessed by a good Moslem genie. The first mental hospital in Europe was located in Spain, following the Arab invasion, and from then on it propagated to other European countries. The 14th century Kalawoon Hospital in Cairo had four departments, including medicine, surgery, ophthalmology, and mental disorders. Six centuries earlier, psychiatry in general hospitals was recognized in Europe. The influence of Avicenna and Elrazi and their contributions to European medicine is well-known. This article discusses further the current state of the mental health services in Egypt and the transcultural studies of the prevalence and phenomenology of anxiety, schizophrenia, depression, suicide, conversion, and obsessive compulsive disorders. An outline of psychiatric disorders in children is discussed. The problem of drug abuse is also addressed, especially that in Egypt after 1983, where drugs like heroine replaced the common habit of hashish.

WCA recommendations for the long-term treatment of panic disorder.

What are the symptoms of panic disorder and how is the disorder most effectively treated? One of the most commonly encountered anxiety disorders in the primary care setting, panic disorder is a chronic and debilitating illness. The core symptoms are recurrent panic attacks coupled with anticipatory anxiety and phobic avoidance, which together impair the patients professional, social, and familial functioning. Patients with panic disorder have medically unexplained symptoms that lead to overutilization of healthcare services. Panic disorder is often comorbid with agoraphobia and major depression, and patients may be at increased risk of cardiovascular disease and, possibly, suicide. Research into the optimal treatment of this disorder has been undertaken in the past 2 decades, and numerous randomized, controlled trials have been published. Selective serotonin reuptake inhibitors have emerged as the most favorable treatment, as they have a beneficial side-effect profile, are relatively safe (even if taken in overdose), and do not produce physical dependency. High-potency benzodiazepines, reversible monoamine oxidase inhibitors, and tricyclic antidepressants have also shown antipanic efficacy. In addition, cognitive-behavioral therapy has demonstrated efficacy in the acute and long-term treatment of panic disorder. An integrated treatment approach that combines pharmacotherapy with cognitive-behavioral therapy may provide the best treatment. Long-term efficacy and ease of use are important considerations in treatment selection, as maintenance treatment is recommended for at least 12-24 months, and in some cases, indefinitely.

WCA recommendations for the long-term treatment of social phobia.

What is the best approach for treating patients with social phobia (social anxiety disorder) over the long term? Social phobia is the most common anxiety disorder, with reported prevalence rates of up to 18.7%. Social phobia is characterized by a marked and persistent fear of being observed or evaluated by others in social performance or interaction situations and is associated with physical, cognitive, and behavioral (ie, avoidance) symptoms. The onset of social phobia typically occurs in childhood or adolescence and the clinical course, if left untreated, is usually chronic, unremitting, and associated with significant functional impairment. Social phobia exhibits a high degree of comorbidity with other psychiatric disorders, including mood disorders, anxiety disorders, and substance abuse/dependence. Few people with social phobia seek professional help despite the existence of beneficial treatment approaches. The efficacy, tolerability, and safety of the selective serotonin reuptake inhibitors (SSRIs), evidenced in randomized clinical trials, support these agents as first-line treatment. The benzodiazepine clonazepam and certain monoamine oxidase inhibitors (representing both reversible and nonreversible inhibitors) may also be of benefit. Treatment of social phobia may need to be continued for several months to consolidate response and achieve full remission. The SSRIs have shown benefit in long-term treatment trials, while long-term treatment data from clinical studies of clonazepam are limited but support the drugs efficacy. There is also evidence for the effectiveness of exposure-based strategies of cognitive-behavioral therapy, and controlled studies suggest that the effects of treatment are generally maintained at long-term follow-up. In light of the chronicity and disability associated with social phobia, as well as the high relapse rate after short-term therapy, it is recommended that effective treatment be continued for at least 12 months.

A Psychiatric Study of Nonorganic Chronic Headache Patients

Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.

WCA Recommendations for the Long-Term Treatment of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a common and disabling condition. In addition to combat-related PTSD, the disorder occurs in civilians exposed to severe traumatic events, with the community prevalence rate for the combined populations reaching as high as 12%. If left untreated, PTSD may continue for years after the stressor event, resulting in severe functional and emotional impairment and a dramatic reduction in quality of life, with negative economic consequences for both the sufferer and society as a whole. Although PTSD is often overlooked, diagnosis is relatively straightforward once a triggering stressor event and the triad of persistent symptoms-reexperiencing the traumatic event, avoiding stimuli associated with the trauma, and hyperarousal have been identified. However, comorbid conditions of anxiety and depression frequently hamper accurate diagnosis. Treatment for PTSD includes psychotherapy and pharmacotherapy. The latter includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors. Only SSRIs have been proven effective and safe in long-term randomized controlled trials. Current guidelines from the Expert Consensus Panel for PTSD recommend treatment of chronic PTSD for a minimum of 12-24 months.

Would the use of dimensions instead of categories remove problems related to subthreshold disorders

Scientific progress fostered in DSM and ICD over the past quarter of century has significantly increased awareness of the limitation of categorical definitions of mental illness. Disorders highly merge into another with no natural boundary in between. The addition of continuous, “dimensional” measures into the various diagnostic domains might help resolve some of the critical taxonomic issues currently facing the field of mental health. It was overtly recognized that both categorical and dimensional approaches to diagnosis are important both for clinical work and for research, and that the ideal taxonomy would offer both. Within each diagnostic entity, there are multiple options for creating a dimensional scale based on a categorical definition. The ICD 10 and DSM IV have no place for subthreshold disorders except in atypical, not otherwise specified or to marginalize its existence with subsequent suffering and impairment of the patients. The chapter will discuss how the subthreshold affective, psychotic, anxiety, cognitive and substance abuse and other psychiatric disorders contribute to psychiatric morbidity and impairment. The chapter discusses the impairment and suffering of patients with subthreshold various psychiatric disorders and how its inclusion in a dimensional approach may result in ameliorating the suffering of that group as their current status may initiate some ethical considerations for their management.