Ganesh Gopalakrishna

Long-acting injectable aripiprazole: how might it fit in our tool box?

Schizophrenia is a severe mental illness with a lifetime prevalence of approximately one percent worldwide. Maintenance antipsychotic treatment has been effective in preventing relapses in long-term follow-up studies. Logically it can be proposed that long-acting injectable antipsychotics (LAI) might reduce both unintentional and intentional nonadherence. Long-acting injectable aripiprazole was approved for the treatment of schizophrenia by the U.S. FDA on 28th February 2013 and will be marketed under the name Abilify Maintena. Aripiprazole LAI (ALAI) is a lyophilized powder that needs to be reconstituted with sterile water to form an injectable suspension without affecting the original molecule. The monthly injection interval is very attractive since patients prefer fewer injections. From a tolerability perspective, ALAI appears to be both weight neutral and lacking metabolic side effects. This can confer an advantage over the other currently available second-generation antipsychotic LAIs. Simple constitution with sterile water and no requirement to refrigerate make storage and administration easier. Like all medications, there are always potential disadvantages to ALAI. There is a period of oral coverage, while not as long as for long-acting risperidone microspheres (RLAI), that is required. Care must be taken to review concomitant medications for the presence of metabolic inducers and inhibitors. One would also expect some patients to be sensitive to extrapyramidal symptoms, especially akathisia which is well documented in the oral preparation. All things considered, we welcome our new tool, ALAI, to our work-place and predict both clinical practice and post marketing analysis and studies will discover its true value.

Predictors of Length of Stay in an Acute Psychiatric Hospital

Length of stay (LOS) in acute psychiatric hospitals has been heightened in recent years with the current economic climate and a growing realization that health care costs need to be contained. This study was designed to identify predictors of LOS which are available at the time of admission. Charts of 391 admissions to an acute psychiatric hospital were reviewed on the basis of a pre-constructed checklist. Regression modeling with the natural logarithm of LOS as the dependent variable was used to identify a multivariate model for LOS. Age, marital status, involuntary admission and diagnosis of an affective disorder or a psychotic disorder were shown to be independent variables that predicted length of stay. These variables in a multivariate model accounted for approximately 19% of the variance in LOS.

Predictors of length of stay in a psychiatric hospital

Objective. This article reviews the available evidence for predicting length of stay in a psychiatric hospital based on several patient characteristics. Methods. An OVID Medline search was done for studies in this area with terms: length of stay, acute psychiatric hospital and predictors. Indexed articles were searched for additional references and subsequently cross referenced. The variables described in various studies were classified into demographic, diagnostic, treatment related and system-based variables (Table 1). Results. Substance abuse has been consistently shown to be associated with a shorter length of stay. Mood and psychotic disorders have shown to lengthen the stay in an acute psychiatric hospital. Women tend to stay longer in an acute psychiatric hospital. Other demographic variables like age and education have had equivocal results, while a married marital status and employment are consistently related to a shorter length of stay. Use of restraints and ECT during hospitalization has shown to lengthen the stay in the hospital. Conclusions. Many studies have explored the relationship between the demographics, diagnosis and treatment variables on length of stay in an acute psychiatric hospital. These studies have been able to account for about 10–37% of the variance in the length of stay. The relevant findings impacting the length of stay are shown in Table 2.

Aripiprazole Lauroxil Long-Acting Injectable: The Latest Addition to Second-Generation Long-Acting Agents.

Antipsychotics have long been the mainstay for the treatment of schizophrenia and other psychotic disorders. Long-acting injectables (LAI) of antipsychotics-provided once every two weeks to once every three months-promise to reduce the incidence of nonadherence. ARISTADA(™) (aripiprazole lauroxil; ALLAI) extended-release injectable suspension was approved by the U.S. Food and Drug Administration in October 2015 for the treatment of schizophrenia, and is the newest entrant in the LAI market. ALLAI is available as a single-use, pre-filled syringe, can be started in three different dosages, and also has the option of every six-week dosing. Treatment with oral aripiprazole is recommended for the first twenty-one days after the first ALLAI injection, which is a potential disadvantage. Adverse effects include sensitivity to extrapyramidal symptoms, especially akathisia, which is well documented in other aripiprazole preparations. There is no available data comparing ALLAI to other antipsychotics, and more head-to-head trials comparing different LAI formulations are needed. Based on the available data, ALLAI is an effective and safe option for treatment of schizophrenia. Further studies and post-marketing data will provide better understanding of this formulation.

Detecting self-harming activities with wearable devices

In the United States, there are more than 35, 000 reported suicides with approximately 1, 800 of them being psychiatric inpatients. Staff perform intermittent or continuous observations in order to prevent such tragedies, but a study of 98 articles over time showed that 20% to 62% of suicides happened while inpatients were on an observation schedule. Reducing the instances of suicides of inpatients is a problem of critical importance to both patients and healthcare providers. In this paper, we introduce SHARE - A Self-Harm Activity Recognition Engine, which attempts to infer self-harming activities from sensing accelerometer data using smart devices worn on a subjects wrist. Preliminary classification accuracy of 80% was achieved using data acquired from 4 subjects performing a series of activities (both self-harming and not). The results, application, and proposed technology platform are discussed in-depth.

Does indication drive use, or does use drive indication?

I this issue of The Journal of Clinical Psychiatry, Fu et al1 report on the results of a study of paliperidone palmitate once-monthly in patients diagnosed with schizoaffective disorder. In this well-designed and well-executed trial, paliperidone monthly was used either as monotherapy or as an adjunct to mood stabilizers or antidepressants. The subjects were randomized to continue paliperidone monthly or switch to placebo after a 12-week fixed-dose stabilization phase. The groups were stratified on the basis of use of mood stabilizers or antidepressants (monotherapy vs adjunctive arms). In both groups, paliperidone monthly significantly reduced relapse compared to placebo, with placebo having a 2.5 times greater risk of relapse overall. As one might expect, the relapse risk was a bit more pronounced in the monotherapy arm compared to the augmentation arm (3.3 times vs 2.0 times). The effectiveness of paliperidone monthly was not particularly surprising, as oral paliperidone has been US Food and Drug Administration (FDA)–approved for treatment of schizoaffective disorder since July 2009. The positive results of this clinical trial led to the approval of paliperidone monthly by the FDA for the treatment of schizoaffective disorder as a monotherapy or an adjunct to mood stabilizers or antidepressants on November 13, 2014. For any medication, FDA approval for additional indications has significant effects. It allows the medication to be marketed by the pharmaceutical company for that use, when prior to the indication this was expressly forbidden. In addition, it can remove potential roadblocks by insurers hesitant to approve a medication for non–FDA-approved indications. In some cases, a new indication dramatically broadens a medication’s use, an example being antipsychotics for antidepressant augmentation. In some cases, formerly generic medications are “repackaged” as proprietary medications for novel usage. Balancing the benefits of expanded use is the possibility that a larger number of patients will be exposed to the risks of these potent compounds. A concern that is not often fully appreciated by clinicians and patients is the potential for the long-term risks of antipsychotics (eg, tardive dyskinesia). Whether these risks are equal, lesser, or even greater in illnesses other than schizophrenia has not been extensively studied.2 The use of paliperidone monthly for schizoaffective disorder is an important development, but it raises the following question: Were patients with schizoaffective disorder not receiving paliperidone monthly before the

Videoconferencing for Civil Commitment: Preserving the Dignity [Leading Edge]

The paper states that teleconferencing saves time, improves productivity, enhances safety, and helps preserve patient dignity.

Is easier always better

A common theme in modern advertisements is that the product or service that is being offered is better because it is easier or faster. Every year, advancements in technology make the daily chores of life easier. These innovations have accelerated in the last two decades. We have GPS devices to give step-by-step directions, phones to remember a phone directory of numbers, and digital calendars to remind us up to the minute on our appointments. We also have new software, which has made staying in touch with friends, paying bills and filing our taxes a child’s play. This has indeed helped most people to focus their energy and time on their jobs productively. Technology has freed us from the heaviest of manual labors and the tedium of mundanemental tasks, but has there been a cost? Apart from the reduction of exercise endurance and increase in the incidence of obesity, there may be just as significant effects on the mental health of individuals in the long term. There are multiple studies to suggest that people who have higher pre-morbid cognitive functioning (are cognitively very active) have slower onset of dementia and better prognosis (Daffner, 2010). The current young and middle age population is the future geriatric cohort at risk for cognitive disorders. This could imply that the incidence of dementia and other cognitive disorders is likely to drastically rise in the years to come. ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly) study was a multicenter, randomized controlled trial to examine the long-term outcomes of cognitive interventions on the daily functioning of older individuals living independently. This study showed that cognitive training could delay the rate of the neurocognitive decline (Willis et al., 2006, Ball et al., 2002). Cognitive stimulation therapy has shown to benefit cognition in people with mild to moderate dementia over and above any medication effects (Woods et al., 2012). Some neurologists, in fact, encourage patients with mild cognitive impairment to work on crosswords or other activities to slow the progress of the disease. This could imply that neurologists or even primary care physicians may advise their patients in the future to limit the use of electronic devices used for navigation, calendars and other activities. Is this trend of easing the human effort—physical or mental—beneficial for the mankind? Is this system, where a fraction of the human work force works hard tomake the life of the rest easier and better, advantageous to the evolution of the human race? Are we at risk of losing our intellect and memory as a species in this course ofmodernization? Long-term longitudinal studies may throw some light on this issue.