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Letter to the Editor
Aripiprazole and Perphenazine: No Difference
Background: There have been few systematic studies of individuals with pyromania, and this paucity of research has hindered our understanding and treatment of this disorder. This study details the demographic and phenomenological features of individuals with DSM-IV lifetime pyromania.
Method: Twenty-one adult and adolescent subjects (recruited from inpatient and outpatient studies of impulse-control disorders) with lifetime DSM-IV pyromania were administered a semistructured interview to elicit demographic data and information on the phenomenology, age at onset, and associated features of the disorder. Data were collected from October 2003 to September 2006.
Results: Twenty-one subjects (10 female [47.6%]) with lifetime pyromania (mean ± SD age = 26.1 ± 11.8 years; range, 15-49 years) were studied. The mean ± SD age at onset for pyromania was 18.1 ± 5.8 years. Eighteen subjects (85.7%) reported urges to set fires. Subjects reported a mean ± SD frequency of setting 1 fire every 5.9 ± 3.8 weeks. Much of the fire setting did not meet the legal definition of arson. Thirteen (61.9%) had a current comorbid Axis I mood disorder, and 10 (47.6%) met criteria for a current impulse-control disorder.
Conclusion: Pyromania appears to be associated with high rates of psychiatric comorbidity. Research is needed to optimize patient care for individuals with this disorder.
Reply to Aripiprazole and Perphenazine: No Difference
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This article summarizes recommendations from a recently published supplement, Translating the Psychopharmacology of Antipsychotics to Individualized Treatment for Severe Mental Illness: A Roadmap. The President's New Freedom Commission on Mental Health stressed the importance of incorporating the latest scientific information into mainstream health care as rapidly as possible. In keeping with this goal, the Roadmap drew on clinical trial data, information on antipsychotic pharmacology, practice guidelines, consensus statements, and expert opinion to develop recommendations for achieving best outcomes for individual patients.
Objective: Prior early prediction models for antipsychotic treatment response demonstrate good specificity but poor sensitivity (i.e., high false-negative rates). The purpose of this study was to refine the early prediction model in schizophrenia patients taking an atypical antipsychotic agent, zotepine.
Method: 135 acutely ill inpatients with DSM-IV-defined schizophrenia received 4 weeks of 150 mg/day zotepine treatment. Psychopathology severity was assessed weekly with the Brief Psychiatric Rating Scale (BPRS) and subscales for positive, negative, and general symptoms. Clinical response was defined as a reduction of 20% or more in the BPRS total score at week 4. A logistic regression model was used to obtain early predictors. The receiver operating characteristic curve was employed to determine the optimal cutoff points of the variables for predicting response. The study was conducted from June 2004 to April 2005.
Results: The most significant early predictors for ultimate response at week 4 were BPRS positive subscale score changes at week 1 and, better, at week 2 (p < .001 at both timepoints). At week 1, a BPRS positive score reduction of 4 appeared to be the optimal cutoff point for predicting eventual response, providing a sensitivity of 0.77 and specificity of 0.77. At week 2, a BPRS positive score reduction of 6 was the best for prediction, with a sensitivity of 0.83 and specificity of 0.91.
Conclusions: These findings suggest that using the first 2 weeks' improvement in positive symptoms to predict the fourth week's treatment response is favorable in terms of both specificity and sensitivity. Further studies are needed. Moreover, whether this model could be applied to establish a prediction system for other antipsychotics or other psychotropics also deserves research.Â
Objective: The objective of the present study was to investigate the effect of age, gender, and various comedications on the pharmacokinetics of quetiapine in a naturalistic setting.
Method: In total, 2111 serum samples analyzed for quetiapine during the period from June 2001 to December 2004 were included in the study. The samples had been collected for routine therapeutic drug monitoring purposes from 1179 patients treated with quetiapine. A log-linear mixed model was used to identify factors influencing the dose-corrected quetiapine serum concentration, expressed as the quetiapine concentration-to-dose (C/D) ratio. Variables included in the analysis were age, gender, and concomitant treatment with a total of 41 drugs most often used in combination with quetiapine.
Results: Age >= 70 years (p = .001) and comedication with alimemazine (p = .002), fluvoxamine (p = .001), citalopram/escitalopram (p =.041), or clozapine (p < .001) significantly increased the serum concentrations of quetiapine, while age < 18 years (p = .044) and comedication with lamotrigine (p = .024), levomepromazine (p = .011), oxazepam (p < .001), or carbamazepine (p = 70 years (+67%), and carbamazepine (-86%). In 18% of the samples, the daily dose exceeded the currently recommended maximum of 800 mg/day.
Conclusion: Due to the increased serum levels of quetiapine, a lower dose than usual should be considered when quetiapine is administered to elderly patients and to patients comedicated with clozapine or fluvoxamine. As the inducing effect of carbamazepine on quetiapine metabolism is very potent, cotreatment with carbamazepine cannot be recommended. On the basis of our data and pharmacokinetic considerations, the majority of drugs commonly used in psychiatry can safely be given in combination with quetiapine.' ‹
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Weight gain and the associated increased risk of diabetes and cardiovascular disease may be problems for individuals who receive long-term treatment with atypical antipsychotics. Atypical antipsychotics differ in their propensity to cause obesity and other metabolic disturbances. If a patient gains substantial weight while taking atypical antipsychotics, the physician should consider switching him or her to a drug with a lower risk of weight gain. The physician should also address patient lifestyle issues such as poor diet and lack of exercise.
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