All Slides and Presentation Copyright ©PFBuckley 2014

Letters From America Refractory Psychosis in the U.S.

Royal College of Psychiatrists International Congress June 24, 2014

Peter F. Buckley, M.D. Dean, Medical College of Georgia

Georgia Regents University

Great doctors, Great Medicine Since 1828

Risperidone Olanzapine Clozapine Decanoate

N= 109 156 49 58

%= 12 13 14 34

1 Year Rehospitalization Rates in

Maryland Mental Health System

Love et al, 1998

Great doctors, Great Medicine Since 1828

CATIE-2 Study:

Five Major Conclusions

1. Results of this study are consistent with previous studies finding clozapine more effective than conventional antipsychotics

2. Patients receiving clozapine were less likely to discontinue for inadequate therapeutic response [compared with] any of the newer antipsychotics

3. Treatment with clozapine was significantly more effective than switching to any other of the newer atypical[s]

4. Despite its therapeutic advantages, clozapine has been underused…

5. We should develop models of service delivery that would encourage clozapine’s greater use

*McEvoy J, et al. Am J Psychiatry. 2006;163:600-610.

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Use of High Doses of Second-

Generation Antipsychotics:

Conclusions (from limited data!)

• Dosing of second-generation antipsychotic medications informative from CATIE

• There is a conspicuous absence of published fixed-dose studies

• The dosing profiles differ between second-generation agents

• Use of high doses differs by drug

• There is not compelling evidence for preferential use of high dose strategies instead of switching to another drug or adding another drug

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Adjunctive Agents Used With

Antipsychotics

• Minocycline

• Nitroprusside

• NSAIDS

• Lithium

• Valproate

• B-Blockers

• Glutamatergic agents

• Carbamazepine

• Antidepressants

• Benzodiazepines

• Lamotrigine

• Antipsychotic polypharmacy

Results:

­ Limited trials

­ Mixed results

­ No clear option

• 629,809 initiations (January 2002 to December 2005)

• Clozapine use rate: 2.5% ­ State rates vary between 0.9% and 7.8% ­ County rates vary from 0% to >15% ­ 1240 of 2885 counties have no clozapine initiations

• 79,934 met criteria of treatment resistance

• Clozapine use rate: 5.5% ­ Similar geographic variation

• Treatment resistance definition shows face validity

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• Manages his or her own life with mental illness

• Provides mental health services to others with mental illness (peers)

“Community Peer Specialist”

or “Peer Support Specialist”

Gaining Traction in the U.S.

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CPS Professional Role in Georgia

• Most CPSs earn between $10,000 to $20,000 per year

• Unemployment rate of CPSs is high at 38.30%

• Peer specialists reported working 18.47 hours a week on average (range = 0-85 hrs)

• Majority feel included as part of the treatment team

• Majority of respondents at least “Mostly Satisfied” with their role

• 72.4% received no employment benefit

• Over 40% reported relapse while functioning as CPS, almost all took effective steps to manage relapse Ahmed et al

• Refractoriness is still a part of trajectory of schizophrenia

• Medication non-adherence is a major rule-out

• Switching or adding medications are viable

strategies, though risk-benefit ratio remains

individualized and more of a ‘trial and error’ process

• Unlike cancer, pharmacogenetic promise of

personalized medicine appears way off

• Clozapine usage- despite unequivocal efficacy- remains low

• Recovery & recovery-based principles are another important part of care

Conclusions

All Slides and Presentation Copyright ©PFBuckley 2014

Letters From America Refractory Psychosis in the U.S.

Royal College of Psychiatrists International Congress June 24, 2014

Peter F. Buckley, M.D. Dean, Medical College of Georgia

Georgia Regents University