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Real-World Outcomes in the Management of Refractory Psychosis

Krivoy, Amir, Joyce, Dan, Tracy, Derek, Gaughran, Fiona, MacCabe, James, Lally, John, Whiskey, Eromona, Sarkar, S. Neil, Shergill, Sukhwinder S. (2019) Real-World Outcomes in the Management of Refractory Psychosis. Journal of Clinical Psychiatry, 80 (5). ISSN 0160-6689. (doi:10.4088/JCP.18m12716) (The full text of this publication is not currently available from this repository. You may be able to access a copy if URLs are provided) (KAR id:96394)

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BACKGROUND: Clozapine is the only medication approved for those patients with schizophrenia who do not achieve a clinical response to standard antipsychotic treatment, yet it is still underused. Furthermore, in the case of a partial or minimal response to clozapine treatment, there is no clarity on the next pharmacologic intervention. METHODS: The National Psychosis Service is a tertiary referral inpatient unit for individuals with refractory psychosis. Data from 2 pooled data sets (for a total of 325 medical records) were analyzed for treatment trajectories between admission and discharge (2001-2016). Effectiveness of pharmacologic treatment was determined using change in symptoms, assessed using the Operational Criteria (OPCRIT) system applied retrospectively to the medical records. Analysis was focused on identifying the optimal medication regimens impacting clinical status during the admission. RESULTS: Less than a quarter of the patients were on clozapine treatment at the time of admission; this rate increased to 63.4 at the time of discharge. Initiating clozapine during admission (n = 136) was associated with a 47.9 reduction of symptoms as reflected by their OPCRIT score. In cases in which clozapine monotherapy did not achieve sufficient improvement in symptoms, the most effective clozapine augmentation strategy was adding amisulpride (n = 22, 60.8 reduction of symptoms), followed by adding a mood stabilizer (n = 36, 53.7 reduction). A less favorable option was addition of quetiapine (n = 15, 26.7 reduction). CONCLUSIONS: Many people with longer-term and complex refractory illness do respond to clozapine treatment with suitable augmentation strategies when necessary. Furthermore, it is possible to advance clozapine prescribing in these complex patients when they are supported by a skilled and dedicated multidisciplinary team. The optimal therapeutic approach relies on confirmation of diagnosis and compliance and optimization of clozapine dose using therapeutic drug monitoring, followed by augmentation of clozapine with amisulpride or mood stabilizers. There is some preliminary evidence suggesting that augmentation strategies may impact differentially depending on the symptom profile.

Item Type: Article
DOI/Identification number: 10.4088/JCP.18m12716
Additional information: Dr Gaughran has received honoraria for advisory work and lectures or Continuing Medical Education activity support from Roche, Bristol-Myers Squibb, Lundbeck, Otsuka, Janssen, and Sunovion; is a collaborator on a National Health Service (NHS) Innovations project co-funded by Janssen; and has a family member with professional links, including shares, to Lilly and GlaxoSmithKline. Dr Shergill is supported by a European Research Council Consolidator Award (#311686). This study represents independent research partly funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London and a joint infrastructure grant from Guy’s and St Thomas’ Charity and the Maudsley Charity.
Subjects: R Medicine
Divisions: Divisions > Division of Natural Sciences > Kent and Medway Medical School
Depositing User: Rachael Heller
Date Deposited: 29 Sep 2022 12:12 UTC
Last Modified: 29 Sep 2022 12:12 UTC
Resource URI: (The current URI for this page, for reference purposes)

University of Kent Author Information

Shergill, Sukhwinder S..

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