Yehuda Baruch

High-dose escitalopram for the treatment of obsessive-compulsive disorder.

The aim of this study was to evaluate the efficacy and tolerability of high-dose escitalopram in patients suffering from obsessive–compulsive disorder (OCD). In an open-label, 16-week prospective study, patients with OCD received escitalopram at a dose of 20 mg/day for 3 weeks, after a 1-week titration at 10 mg/day. Patients who did not achieve a ≥25% reduction from baseline in the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) score during these 4 weeks were continued on higher doses of escitalopram (maximum 50 mg/day) for 12 weeks. The primary efficacy measure of OCD symptoms was change from baseline in the Y-BOCS score. Overall, 67 patients (33 women, 34 men) with a mean Y-BOCS score of 29.6 entered the study. After 4 weeks of standard-dose escitalopram treatment, one patient discontinued owing to pregnancy, and two patients achieved a reduction in Y-BOCS ≥25%. Consequently, 64 patients were eligible to receive high-dose escitalopram (mean dose, 33.8 mg/day at endpoint). At endpoint, high-dose escitalopram had significantly improved the OCD symptoms (Y-BOCS score) and all the other efficacy measures (P<0.001), compared with baseline. Escitalopram was also well tolerated, with no discontinuations during the 12-week high-dose phase. The only reported adverse drug reactions were dry mouth (n=8, 12.1%) and decreased sexual desire (n=21, 31.8%). Preliminary investigation shows that high-dose escitalopram is an efficacious and well tolerated treatment for patients suffering from severe OCD. Randomized, blinded studies are needed to reinforce these findings.

Suicide attempts of schizophrenia patients: A case-controlled study in tertiary care

BACKGROUND Schizophrenia is one of the disorders in which suicide attempts and death by suicide are pronounced. However, there is paucity of data regarding suicide attempts by schizophrenia patients. The aim of the present study was to characterize a large sample of schizophrenia patients in tertiary care who had attempted suicide. METHOD Over a 15-year period all computerized records of admissions of adult schizophrenia patients were examined. Patients who had attempted suicide were defined as the index group and the comparison group was comprised of the next admission of a patient suffering from schizophrenia who did not attempt suicide prior to hospitalization. RESULTS There were 10,006 admissions of patients suffering from schizophrenia during the study period. Of these, 1094 (10.9%) records comprise the index group (patients who had attempted suicide), 380 women and 714 men, mean age for the group 39.6+/-12.9 years. The comparison group of patients matched for diagnosis (N=1094), consisted of 302 women and 792 men, mean age for this group was 42.9+/-13.7 years. Four variables significantly differentiated between groups. Patients who had attempted suicide were younger (39.6 vs. 42.9 years; p=0.00), higher percentage of females (34.7% vs. 27.6%; p=0.00), with increased rates of co-morbid physical illness (27.5% vs. 20.4%; p=0.00) notably cardiovascular and diabetes and with a higher rate of alcohol and drug abuse (32.1% vs. 12.4%; p=0.00). CONCLUSIONS The present study emphasizes several significant factors associated with attempted suicide amongst schizophrenia patients notably physical co-morbidity and abuse of alcohol and drugs. These need be integrated into existing risk assessment schemes thus aiding in decreasing adverse outcomes in this vulnerable group of patients.

Asenapine for elderly bipolar manic patients.

BACKGROUND Bipolar disorder (BPD) in the elderly is probably heterogeneous and its etiopathogenesis is complex. The data for the treatment of late-life BPD are limited. Asenapine is approved in the United States for acute treatment of manic or mixed episodes of bipolar I disorder with or without psychotic features. AIM We report the results of acute treatment with asenapine in elderly patients with BPD. METHOD Elderly patients (N=11), mean age: 67.7 ± 6.1 years, consecutively admitted to the psychogeriatric ward due to acute bipolar mania were treated by asenapine 10mg/BID monotherapy for 4 weeks. Safety and tolerability assessments included adverse events (AEs), laboratory values, and anthropometric measures. Response, a secondary assessment, was measured as change in Young Mania Rating Scale (YMRS) total score from baseline to week 4. RESULTS One patient developed a rash on day 6 of treatment and one patient developed peripheral edema on day 14 of treatment. Both AEs resolved rapidly following discontinuation of asenapine. Only mild sedation was reported by three patients. In all cases, mean (± SD) change (improvement) in YMRS total score at week 4 was -21.4 ± 12.9 and 7/11 (63.6%) of patients remitted (YMRS≤12). CONCLUSION In this small open-label study of elderly patients with bipolar mania, acute treatment with asenapine was well tolerated and effective.

Reduced total complement haemolytic activity in schizophrenic patients

Serum concentrations of the third and fourth components of the complement system and total complement haemolytic activity were measured in 167 psychiatric patients. Total complement haemolytic activity was decreased in chronic schizophrenic patients as compared to healthy controls and bipolar patients. The relatively diminished total haemolytic activity was not attributable to drug treatment. It is not clear if the reduced total haemolytic activity is an epiphenomenon or related to the involvement of an autoimmune process in the pathophysiology of schizophrenia.

A study of the complement system in psychiatric patients

For nearly a century, abnormal functioning of the immune system in psychiatric patients has been repeatedly suggested, and many components of this system have accordingly been studied. Though no clear evidence to prove any relationship between psychiatric disorders and immune system dysfunction has been brought forth, many authors continue to accumulate information on immune system disturbances in some patients, which suggests that autoimmune factors may be etiologically important in psychiatric disorders, particularly in schizophrenia (De Lisi 1984). We undertook a study of the serum complement system because it is one of the most important components of humoral immunity; it consists of at least 11 separate plasma proteins that react in a specific sequence with antigenantibody complexes. The result of this sequence of reactions is increased vascular pe~eability, attraction of polymorphonuclear leukocytes, enhancement of phagocytosis, and alterations in cell membranes that lead to lysis and cell death. The complement system is evaluated in patients mainly to detect depleted levels in order to de-

Venlafaxine or a second SSRI: Switching after treatment failure with an SSRI among depressed inpatients: A retrospective analysis ☆

BACKGROUND Approximately 50% of patients with major depressive disorder (MDD) do not respond after adequate first-line treatment with a selective serotonin reuptake inhibitor (SSRI). Special interest is paid to whether specialist level inpatient psychiatric care results differ from community studies. AIM To compare switching alternatives after treatment failure with an SSRI; switching to venlafaxine (Dexcel Pharma Israel) versus switching to another SSRI in depressed inpatients. METHOD A retrospective register study of inpatients was undertaken in a psychiatric tertiary care university center serving an urban catchment area in Israel with a population of more than 900,000. RESULTS A total of 401 MDD inpatients were assigned to antidepressant treatment. Of these, 232 records (47 venlafaxine, 185 SSRI) were included in the analysis. Patients assigned to venlafaxine treatment were older (mean age 64.3 ± 15 years versus 53.6 ± 17; p<0.01) and had more comorbid physical disorders (80% versus 57%; p<0.001). In the primary analysis, there was no statistical difference between groups in reduction in CGI-S total scores. The secondary end point of achieving a CGI-S score of 2 or less (1 = normal, not at all ill or 2 = borderline mentally ill) was statistically significantly better for the venlafaxine treated inpatients (P=0.02). AEs were reported less than 10% of patients in both groups. CONCLUSION Patients who remain severely depressed following treatment with an SSRI may gain benefit from the dual-action drug venlafaxine, rather than switching to another SSRI. These findings need to be further supported by prospective studies.

Acute electroconvulsive therapy followed by maintenance electroconvulsive therapy decreases hospital re-admission rates of older patients with severe mental illness.

Objectives Electroconvulsive therapy (ECT) is a highly effective treatment for patients with severe mental illness (SMI). Maintenance ECT (M-ECT) is required for many elderly patients experiencing severe recurrent forms of mood disorders, whereas M-ECT for schizophrenia patients is a poorly studied treatment. We report on the outcomes in aged patients with SMI: schizophrenia and severe affective disorders treated by M-ECT of varying duration to prevent relapse after a successful course of acute ECT. The study measured the effectiveness of M-ECT in preventing hospital readmissions and reducing admission days. Method A retrospective chart review of 42 consecutive patients comparing the number and length of psychiatric admissions before and after the start of M-ECT was used. We analyzed diagnoses, previous ECT treatments, number of ECT treatments, and number and length of psychiatric admissions before and after M-ECT. Results Mean age in our sample was 71.5 (6.9) years. Twenty-two (52%) patients experienced severe affective disorders and 20 (48%) experienced schizophrenia. Patients were administered 92.8 (85.9) M-ECT treatments. Average duration of the M-ECT course was 34 (29.8) months. There were on average 1.88 admissions before M-ECT and only 0.38 admissions in the M-ECT period (P < 0.001). Duration of mean hospitalization stay decreased from 215.9 to 12.4 days during the M-ECT (P < 0.01). Conclusions Our findings suggest that acute ECT followed by M-ECT is highly effective in selected elderly patients with SMIs.

Risk of prostate cancer in patients with schizophrenia

OBJECTIVES To examine the rate of prostate cancer in a cohort of schizophrenia in-patients in the PSA-era as compared to expected rates. There is conflicting evidence on the relative risk of prostate cancer in men with schizophrenia. METHODS the study sample was comprised of schizophrenia patients who had been admitted to a tertiary care mental health center between 1990 and 2011. The data for the sample was cross-referenced with the National Cancer Registry. Analyses of Standardized Incidence Rates (SIR) for prostate cancer and for lung cancer (representing an organ system not sensitive to sex hormones) were performed. RESULTS Of 4,326 schizophrenia patients included in the present study, 181 (4.2%) were diagnosed with cancer at any site. Only 10 of these patients were diagnosed with prostate cancer. This reflects a reduced risk; SIR of 0.56 (95% CI 0.27-1.03). In the same cohort, 33 schizophrenia patients were diagnosed with lung cancer presenting a SIR of 1.43 (95% CI 0.98-2.01) in this sample. CONCLUSIONS The present study suggests a reduced rate of prostate cancer in patients admitted for schizophrenia. There are several possible explanations for this finding including chronic state of hyperprolactinemia induced by antipsychotic drugs.

Psychosocial and medical aspects of older suicide completers in Israel: a 10-year survey

The rate of completed suicide among the elderly continues to be the highest of any age group worldwide. The aim of the present study was to investigate the sociodemographic data, mental and physical health characteristics, and suicide methods of the elderly population who completed suicide in Israel.

Amisulpride for older patients with long-standing schizophrenia.

Abstract A large and growing number of older people across the world experience schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. The present study was designed to evaluate the efficacy and safety of amisulpride monotherapy in a diagnostically homogeneous group of elderly patients without cognitive impairment experiencing schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for schizophrenia). Mortality and rehospitalization for a 5-year period were the predefined outcome measures. We conducted a retrospective chart review of all elderly (60 years and older) schizophrenia patients treated in a large tertiary care center. Of the 527 elderly schizophrenia patients for a 5-year period (2007–2013), 30 patients, mean (SD) age of 67.5 (5.8) years, were treated with amisulpride monotherapy. There were 19 women and 11 men in the analyzed group. Mean duration of disease was 34.4 years. All had been exposed to at least 3 first- and second-generation antipsychotics before amisulpride treatment. Amisulpride was very well tolerated by the patients, and mortality rate (10% vs 19%) was significantly lower than that of other first- and second-generation antipsychotics (P < 0.02). Rehospitalization rates with amisulpride were significantly lower than those with other second-generation antipsychotics (P < 0.001). We tentatively conclude that our preliminary results demonstrate that amisulpride is an efficacious and safe atypical antipsychotic for the treatment for elderly schizophrenia patients.