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Biomedical subjects

Leslie Citrome

Publications and source records attributed to Leslie Citrome.

At least 37 records · Page 2Linked to original sources
PubMed2005

Metabolic syndrome and cardiovascular disease.

Metabolic syndrome is a constellation of clinical findings that identify individuals at higher than normal risk of developing diabetes mellitus or cardiovascular disease. There are two principal definitions, one emerging from the American National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, and the other from the World Health Organization. Both definitions share the common elements of abdominal obesity, hypertriglyceridaemia, low HDL-cholesterol, hypertension and abnormal glucose regulation. The syndrome is relatively common across continents, and also among those without marked obesity. It is even more common among patients with major mental health disorders such as schizophrenia. Metabolic syndrome can be used to assess risk for cardiovascular disorder and death, and is an alternative to Framingham Risk Calculations. C-reactive protein may play an additional role in risk prediction. Ongoing monitoring for all components of the metabolic syndrome is necessary. Individuals at high risk require multimodal interventions, including lifestyle interventions and targeted medications as appropriate.

Adult↗
PubMed2005

Diabetes and schizophrenia 2005: are we any closer to understanding the link?

The association between schizophrenia and diabetes has been recognized for well over a century, but the underlying reasons for this association are unclear. In October 2003, an international group of diabetologists and psychiatrists met to review the literature relating to the association, and to create pragmatic guidelines for the management of diabetic risk in patients with severe mental illness. Since that meeting, over 100 additional papers have been published on the association between glucose abnormalities and schizophrenia, and this is a clear reflection of the level of interest in this clinically important area. Diabetes is highly prevalent among the schizophrenia population, but most sufferers remain undiagnosed in the community. The reasons why individuals with schizophrenia are more prone to developing diabetes than the general population are poorly defined, but likely to be multifactorial. The role of antipsychotic medications in the development of diabetes and other pre-diabetic states remains controversial, but it appears that the attributable risk is low. Traditional risk factors most probably account for much of the diabetes seen in schizophrenia populations, suggesting that routine screening and aggressive risk factor management are especially important in this patient group.

Antipsychotic Agents↗
PubMed2005

Do guidelines for severe mental illness promote physical health and well-being?

The effective management of individuals with severe mental illnesses (SMIs) requires an holistic approach that offers reliable symptom control, but also addresses other clinical, emotional and social needs. The physical health of individuals with an SMI is often poor, with many being overweight or obese, having hypertension, diabetes or dyslipidaemia, and at significant risk of developing cardiovascular disease or other comorbidities. We have recently reviewed current UK and US guidelines for the management of individuals with schizophrenia and bipolar disorder, and found very different approaches to the holistic care of people with SMIs, especially in relation to the management of physical health and cardiovascular risk. UK guidelines acknowledge the high risk of physical morbidity and mortality in individuals with an SMI, but fail to address in detail the specifics of physical health monitoring and lifestyle management. US guidelines are more descriptive in terms of the type and extent of monitoring recommended, but there are inconsistencies between the guidelines produced by different organizations, and studies in the field suggest that none of them is being adequately implemented. Clear and consistent recommendations on how and when to monitor weight, cardiovascular function, and metabolic parameters and, importantly, what to do with the results, would support clinicians wishing to integrate physical and mental healthcare. Publication of specific recommendations on evidence-based physical health interventions that can work for people with SMIs would also help primary care and mental health services improve general well-being in their patients with severe mental illnesses.

Bipolar Disorder↗
PubMed2005

The many faces of bipolar disorder. How to tell them apart.

Bipolar disorder is a chronic disease characterized by depressive, manic or hypomanic, and mixed episodes. Bipolar disorder may be confused with unipolar depression, because patients with bipolar disorder are usually symptomatic with depression rather than mania. Bipolar disorder may also be misdiagnosed as schizophrenia, since both disorders can present with psychotic symptoms. For children, the principal differential diagnostic consideration is ADHD. Making the correct diagnosis has important prognostic and treatment implications. Comorbidities with personality disorders, substance and alcohol abuse or dependence, and anxiety disorders complicate assessment, treatment, and recovery. Effective pharmacotherapy and maintenance monitoring are critical in order to minimize the risk of relapse and associated disability, morbidity, and mortality.

Adolescent↗
PubMed2005

Latest therapies for bipolar disorder. Looking beyond lithium.

Effective treatments of bipolar disorder now extend to a panoply of choices that include various anticonvulsants and antipsychotics. Although lithium still has an important role, particularly in "classic" mania and suicide prevention, the other FDA-approved agents are better tolerated and more efficacious for mixed states and rapid cycling. It is not uncommon to use combination therapy for this challenging disorder. The FDA has approved olanzapine, risperidone, and quetiapine in combination with either lithium or divalproex for acute mania and the combination medication of olanzapine and fluoxetine for acute bipolar depression. Maintenance treatments that have received FDA approval include olanzapine and lamotrigine. Off-label use of adjunctive medications may be required to target residual symptoms.

Anticonvulsants↗
PubMed2005

Efficacy of aripiprazole against hostility in schizophrenia and schizoaffective disorder: data from 5 double-blind studies.

OBJECTIVE: The objective was to determine the effects of aripiprazole on hostility. METHOD: A total of 1476 patients diagnosed with DSM-IV schizophrenia or schizoaffective disorder were the subjects in 5 short-term, double-blind studies comparing aripiprazole with placebo; 3 of these studies also included a comparison with haloperidol. The studies were conducted between December 1993 and January 2001. The Positive and Negative Syndrome Scale (PANSS) was the principal outcome measure in these studies. To determine the effect of aripiprazole on hostility, post hoc analyses of the hostility item from the PANSS were conducted for the first 4 weeks of treatment. RESULTS: Aripiprazole was superior to placebo and not significantly different from haloperidol in reducing hostility. CONCLUSION: Aripiprazole is an effective treatment for hostility in patients with schizophrenia or schizoaffective disorder.

Adolescent↗
PubMed2005

Dosing of quetiapine in schizophrenia: how clinical practice differs from registration studies.

BACKGROUND: A substantial number of patients with psychosis receive quetiapine in amounts that are greater than what is recommended in the product labeling approved by drug regulatory agencies. The purpose of this article is to review the past and present dosing patterns of quetiapine for the treatment of schizophrenia. METHOD: A PubMed search for the period January 1, 1990, to July 1, 2005, was conducted to identify English-language articles related to quetiapine dose in schizophrenia using the search terms quetiapine, dose, and schizophrenia. Trends in dosing of quetiapine in a large, state-operated psychiatric hospital system and the anecdotal evidence describing the use of quetiapine in excess of 800 mg/day were also reviewed. RESULTS: The registration studies of quetiapine suggest a target dose range of 300 to 500 mg/day for schizophrenia. In contrast, among inpatients hospitalized in New York State in the period of April 1, 2004, to June 30, 2004, the mean dose of quetiapine prescribed was 620 mg/day, with 33.6% receiving doses in excess of 750 mg/day. Patients with nonwhite ethnicity, length of stay of at least 1 year, or history of prior state hospital admission were more likely to receive doses greater than 750 mg/day. Patients receiving quetiapine as antipsychotic monotherapy or in combination with other antipsychotics were equally likely to receive doses greater than 750 mg/day. Published anecdotal reports describe the use of quetiapine in excess of 800 mg/day and up to 2400 mg/day among patients not responding to lower doses, but currently there are no published reports from double-blind randomized clinical trials establishing the utility of this high-dose treatment strategy. CONCLUSIONS: Dosing of quetiapine in clinical practice is higher than what has been established in the registration program for schizophrenia. Although there is anecdotal evidence describing the use of quetiapine in excess of 800 mg/day, double-blind randomized clinical trials are needed.

Antipsychotic Agents↗
PubMed2004

COMT158 polymorphism and hostility.

The main study was designed primarily to compare the clinical effects of four antipsychotics in 157 patients with schizophrenia or schizoaffective disorder. The secondary genetic study, reported here, is based on a subset of 60 patients who consented to genotyping assays. Based on previous work with the catechol-O-methyltransferase (COMT) 158 polymorphism, we hypothesized that the Met-Met homozygotes would be more hostile than the heterozygotes and the Val-Val homozygotes. Hostility ratings at baseline were used to test this hypothesis. The Met-Met homozygotes (N = 7) were found to have significantly higher levels of hostility than the other patients (N = 53). The hypothesis was thus supported. The finding should be replicated in a larger sample.

Antipsychotic Agents↗
PubMed2004

New treatments for agitation.

Acute agitation is a frequent reason for emergency psychiatric intervention. It is important to intervene early to avoid escalation of agitation to aggression. Reducing risk by using effective treatments will result in fewer instances of seclusion and restraint, and fewer injuries to staff and patients. This paper will first review the epidemiology of aggressive behavior and mental disorders, followed by a discussion of assessment and diagnostic considerations. The pathophysiology of safety risk is discussed within the context of the model of the "triune brain." Pharmacological treatment strategies for acute episodes of agitated behavior will be discussed in detail. This includes newer formulations of novel antipsychotics such as liquids and rapidly disintegrating tablets, as well as intramuscular preparations.

Acute Disease↗
PubMed2004

Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or haloperidol.

The subjects were 157 treatment-resistant inpatients diagnosed with chronic schizophrenia or schizoaffective disorder. They were randomly assigned to treatment with clozapine, olanzapine, risperidone, or haloperidol in a 14-week, double-blind trial. Incidents of overt aggression were recorded and their severity was scored. The Positive and Negative Syndrome Scale was administered. Atypical antipsychotics showed an overall superiority over haloperidol, particularly after the first 24 days of the study when the dose escalation of clozapine was completed. Once an adequate therapeutic dose of clozapine was reached, it was superior to haloperidol in reducing the number and severity of aggressive incidents. Patients exhibiting persistent aggressive behavior showed less improvement of psychotic symptoms than the other patients. There was an interaction between aggressiveness, medication type, and antipsychotic response: risperidone and olanzapine showed better antipsychotic efficacy in patients exhibiting less aggressive behavior; the opposite was true for clozapine. Clozapine appears to have superior antiaggresive effects in treatment-resistant patients; this superiority develops after the patient has been exposed to an adequate dose regimen.

Aggression↗
PubMed2004

A study of the safety, efficacy, and tolerability of switching from the standard delayed release preparation of divalproex sodium to the extended release formulation in patients with schizophrenia.

OBJECTIVE: To assess the safety, efficacy, and tolerability of switching from a multiple dose preparation of divalproex sodium delayed release (DR) to once-daily dosing with divalproex sodium extended release (ER) in patients with schizophrenia already receiving the standard DR formulation. METHOD: Thirty subjects with schizophrenia were switched from divalproex DR to a 4-week open-label treatment trial of the ER formulation. Baseline plasma levels of valproate were obtained 12 hours postdose. Patients were converted from divalproex DR to ER on a 1.0:1.0 mg basis (rounded up to the nearest 500-mg increment) if baseline valproate plasma levels were > or =85 microg/mL; otherwise, the conversion rate was 1.0:1.2 mg rounded up. Measured at baseline and end point were the Brief Psychiatric Rating Scale and the Udvalg for Kliniske Undersogelser Side Effect Rating Scale. End point plasma levels were obtained at both 12 and 24 hours postdose. RESULTS: Patients who switched from divalproex DR to ER had a small (and probably clinically insignificant) improvement noted on the total Brief Psychiatric Rating Scale at end point (mean change +/- SD = -2.3 +/- 5.4; t = -2.2538; df = 28; P = 0.0322) and on the Udvalg for Kliniske Undersogelser (mean change+/- SD = -2.2+/- 4.1; t = -2.7361; df = 26; P = 0.0111). Baseline and end point trough plasma levels were 80.1 +/- 20.4 and 73.1 +/- 24.2 microg/mL, respectively. Patients who converted on a 1.0:1.0 mg basis had lower end point valproate trough plasma levels than at baseline but did not experience deterioration on their psychopathology. For all patients, end point valproate peak and trough plasma levels were statistically significantly different (t = -3.8706; df = 27; P = 0.0006), but these differences were small in magnitude (mean +/- SD = 14.6 +/-19.6 microg/mL). Seven patients experienced spontaneously reported adverse events, but none required early termination from the protocol. CONCLUSIONS: Switching to a once-daily formulation of ER divalproex can be accomplished without a deterioration in psychopathology. The ER formulation of divalproex sodium appears well tolerated. A parallel group design will be necessary to confirm these findings.

Adult↗
PubMed2004

Adjunctive divalproex and hostility among patients with schizophrenia receiving olanzapine or risperidone.

OBJECTIVE: This study compared the specific antihostility effects of atypical antipsychotic monotherapy (olanzapine or risperidone) with that of combination treatment with divalproex sodium among patients with schizophrenia experiencing an acute psychotic episode. METHODS: A total of 249 inpatients with schizophrenia were randomly assigned to receive olanzapine plus placebo, olanzapine plus divalproex, risperidone plus placebo, or risperidone plus divalproex in a double-blind, 28-day multicenter trial. The target daily dose was 15 milligrams for olanzapine, 6 milligrams for risperidone, and up to 30 milligrams per kilogram (minimum, 15 milligrams per kilogram) for divalproex. The hostility item of the Positive and Negative Syndrome Scale (PANSS) was the principal outcome measure. Covariates included the PANSS items reflecting positive symptoms of schizophrenia (delusions, suspiciousness/persecution, grandiosity, unusual thought content, conceptual disorganization, and hallucinatory behavior). RESULTS: Combination treatment with risperidone or olanzapine plus divalproex was associated with different scores on the hostility item of the PANSS compared with antipsychotic monotherapy. Combination therapy had a significantly greater antihostility effect at days 3 and 7 than monotherapy. This result was not seen beyond the first week of treatment, but there was a trend toward a difference in effect for the entire treatment period. The effect on hostility appears to be statistically independent of antipsychotic effect on other PANSS items reflecting delusional thinking, a formal thought disorder, or hallucinations. CONCLUSIONS: Divalproex sodium may be useful as an adjunctive agent in specifically reducing hostility in the first week of treatment with risperidone or olanzapine among patients with schizophrenia experiencing an acute psychotic episode.

Aggression↗
PubMed2004

Relationship between antipsychotic medication treatment and new cases of diabetes among psychiatric inpatients.

OBJECTIVE: This study examined data on patients with serious and persistent mental illness in a large state hospital system to determine whether patients who took second-generation antipsychotics were more likely to develop diabetes mellitus than patients who took first-generation antipsychotics. METHODS: A case-control study design was used. A new prescription of an antidiabetic medication was used to identify new cases of diabetes mellitus. Odds ratios were calculated for exposure to second-generation antipsychotics (clozapine, risperidone, olanzapine, quetiapine, and multiple second-generation antipsychotics) compared with exposure to first-generation antipsychotics. Cases and controls were identified by using a database that contained drug prescription information from the inpatient facilities that were operated by the New York State Office of Mental Health. Data from January 1, 2000, to December 31, 2002, were examined. Among 13,611 unique patients who received antipsychotics, 8,461 met entry criteria of being hospitalized for at least 60 days and not having an antidiabetic medication prescribed in the past. A total of 181 of these inpatients received prescriptions for an antidiabetic medication at least 30 days after their admission. Eight controls (N=1,448) for each case (N=181) were matched by calendar year, length of observation period, race, age group, and diagnosis, giving a total sample of 1,629 patients. RESULTS: Statistically significant elevations in risk were seen among patients who received more than one second-generation antipsychotic or clozapine or quetiapine, compared with patients who received first-generation antipsychotics alone. Although not statistically significant, odds ratios for olanzapine and risperidone were also elevated. Conditional logistic regression adjusting for gender and age did not change the results. CONCLUSIONS: Exposure to multiple second-generation antipsychotics or clozapine or quetiapine significantly increased the risk of treatment-emergent diabetes mellitus.

Adult↗