Alexandra Kaufmann

MEASURING ADHERENCE TO MEDICATION IN SCHIZOPHRENIA: THE RELATIONSHIP BETWEEN ATTITUDES TOWARD DRUG THERAPY AND PLASMA LEVELS OF NEW-GENERATION ANTIPSYCHOTICS

Background: Nonadherence to medication is still a major problem in the treatment of schizophrenia. The current longitudinal study investigated whether the patients’ attitudes toward treatment correlated with the ratio of observed vs expected plasma levels of antipsychotic drugs as an objective measurement of adherence. Methods: Data of patients starting monotherapy with a new-generation antipsychotic were collected 2, 4, and 12 weeks after the initiation of treatment. Next to the assessment of patients’ attitudes toward medication by means of the Drug Attitude Inventory, the ratio of the observed vs expected plasma level was calculated. Antipsychotic-induced side effects were evaluated by means of the Udvalg for Kliniske Undersogelser Side Effect Rating Scale. Results: A total of 93 patients were eligible for statistical analysis. About one-half of the ratios of observed vs expected plasma levels ranged from 0.5 to 2 and were considered normal, whereas the other ratios were considered either too low (<0.5) or too high (>2). No consistent correlation between patients’ attitude toward drug therapy and the individual ratios of observed vs expected plasma levels of medication was detected. This finding was not affected by side effects. Conclusions: Our results highlight the importance of recognizing the complex nature of adherence to medication in schizophrenia patients. Importantly, we found no consistent correlation between subjective and objective measures of medication adherence. Therefore, monitoring adherence to medication remains a challenge in clinical practice.

Management of a risperidone-induced tardive Pisa syndrome: a case report.

likely caused by quetiapine or the combination of quetiapine with divalproex. This is supported by the temporal improvement in his WBC count and ANC after quetiapine, the proposed offending agent, was stopped. There is also a suggestion that his WBC count was dropping acutely when he was only on quetiapine for 3 days before admission because his WBC count and ANC nearly halved (WBC count from 7 to 4.5 109/L, ANC from 5.88 to 2.52 10/L) from the night of admission to the morning after admission. However, it cannot be known for certain that he continued downtrending to acutely become neutropenic at that point because no other CBCs were checked for several more months. It is possible that polypharmacy contributed to his neutropenia because both mirtazapine and divalproex are known to cause neutropenia in rare cases. However, after withdrawal of the quetiapine, his WBC count normalized while still on mirtazapine and divalproex and has been stable for several months. Also, the precipitous drop seen on admission to the hospital was after just one dose of divalproex and before starting mirtazapine. Despite this, polypharmacy could have played a part in the notably slow return to normal levels of WBC’s. The mechanism by which antipsychotics induce neutropenia is thought to be caused by toxicity by interruption of protein synthesis or cell replication leading to bone marrow suppression. This is thought to be the primary mechanism of clozapine-induced leukopenia, and given its similar structure, could be the mechanism by which quetiapine causes neutropenia as well. This type of neutropenia is generally thought to be dose related. We are aware of no other case in the literature in which ziprasidone was used without resulting neutropenia after an atypical antipsychotic induced neutropenia. To our knowledge, there is only one case in the literature of ziprasidoneinduced neutropenia, which could suggest a lower risk of leucopenia-related problems compared with some other atypical antipsychotics. Thus, it may be considered as an alternative for patients with neutropenia caused by other atypical antipsychotics. There are currently no guidelines for monitoring CBCs for atypical antipsychotic use outside of clozapine. However, there is growing literature of hematologic abnormalities from newer generation antipsychotics, which suggests that more research is needed to determine if screening for neutropenia is warranted in terms of risk, cost, and benefit. This case also highlights the potential usefulness of monitoring trends in laboratory values to guide further monitoring, even when values fall within the normal range. Additional research to establish prevalence rates and working to define the possible increased risks of neutropenia associated with polypharmacy would be helpful areas of future study.

Affective prosody perception in symptomatically remitted patients with schizophrenia and bipolar disorder

Affect perception has frequently been shown to be impaired in patients suffering from schizophrenia or bipolar disorder (BD), but it remains unclear whether these impairments exist during symptomatic remission and whether the two disorders differ from each other in this regard. Most previous studies have investigated facial affect recognition, but not the ability to decode mental states from emotional tone of voice, i.e. affective prosody perception (APP). Accordingly, the present study directly compared APP in symptomatically remitted patients with schizophrenia or BD and healthy control subjects and investigated its relationship with residual symptomatology in patients. Patients with schizophrenia and BD showed comparable APP impairments despite being symptomatically remitted. In comparison to healthy control subjects, overall APP deficits were found in BD but not in schizophrenia patients. Both patient groups were particularly impaired in the identification of anger and confounded it with neutral prosody. In addition, schizophrenia patients frequently confused sadness with happiness, anger, or fright. There was an inverse association between the degree of residual positive symptoms and the ability to correctly recognize happiness in schizophrenia patients. Overall, these data indicate that impairments in APP represent an enduring deficit and a trait marker of both schizophrenia and BD and that the level of impairment is comparable between disorders.