Prescription Patterns for Bipolar Disorder in Asian Countries:Findings from Research on Asian Prescription Pattern-Bipolar Disorder

Objective@#Pharmacotherapy including mood stabilizers and antipsychotics are frequently used in bipolar disorder (BD); however, the lack of consensus regarding the definition of polypharmacy hinders conducting comparative studies across different settings and countries. Research on Asian Prescription Pattern (REAP) is the largest and the longest lasting international collaborative research in psychiatry in Asia. The objective of REAP BD was to investigate the prescription patterns of psychotropic medications across Asian countries. The rates of polypharmacy and psychotropic drug load were also analyzed. @*Methods@#The data collection was web-based. Prescription patterns were categorized as (1) mood stabilizer monotherapy: one mood stabilizer; (2) antipsychotic monotherapy: one antipsychotic; (3) simple polypharmacy: one mood stabilizer and one antipsychotic; and (4) complex polypharmacy: ≥ 2 mood stabilizers or/and antipsychotics. The psychotropic drug load in each patient was calculated using the defined daily dose method. @*Results@#Among 2003 patients with BD (52.1% female, 42.4 years) from 12 countries, 1,619 (80.8%) patients received mood stabilizers, 1,644 (82.14%) received antipsychotics, and 424 (21.2%) received antidepressants, with 14.7% mood stabilizer monotherapy, 13.4% antipsychotic monotherapy, 48.9% simple polypharmacy, 20.3% complex polypharmacy, and 2.6% other therapy. The average psychotropic drug load was 2.05 ± 1.40. Results varied widely between countries. @*Conclusion@#Over 70% of psychotropic regimens involved polypharmacy, which accords with the high prevalence of polypharmacy in BD under a permissive criterion (2 or more core psychotropic drugs) worldwide. Notably, ≥ 80% of our sample received antipsychotics, which may indicate an increasing trend in antipsychotic use for BD treatment.

A Call for a Rational Polypharmacy Policy: International Insights From Psychiatrists

Objective@#Recently, rational polypharmacy approaches have been proposed, regardless of the lower risk and cost of monotherapy. Considering monotherapy as first-line treatment and polypharmacy as rational treatment, a balanced attitude toward polypharmacy is recommended. However, the high prevalence of polypharmacy led the Japanese government to establish a polypharmacy reduction policy. Based on this, the association between the policy and psychiatrists’ attitude toward polypharmacy has been under debate. @*Methods@#We developed an original questionnaire about Psychiatrists’ attitudes toward polypharmacy (PAP). We compared the PAP scores with the treatment decision-making in clinical case vignettes. Multiple regression analyses were performed to quantify associations of explanatory variables including policy factors and PAP scores. The anonymous questionnaires were administered to psychiatrists worldwide. @*Results@#The study included 347 psychiatrists from 34 countries. Decision-making toward polypharmacy was associated with high PAP scores. Multiple regression analysis revealed that low PAP scores were associated with the policy factor (β=-0.20, p=0.004). The culture in Korea was associated with high PAP scores (β=0.34, p<0.001), whereas the culture in India and Nepal were associated with low scores (β=-0.15, p=0.01, and β=-0.17, p=0.006, respectively). @*Conclusion@#Policy on polypharmacy may influence psychiatrists’ decision-making. Thus, policies considering rational polypharmacy should be established.

Late Onset Agranulocytosis with Clozapine Associated with HLA DR4 Responding to Treatment with Granulocyte Colony-stimulating Factor: A Case Report and Review of Literature

Agranulocytosis as a side effect of clozapine has been reported to be associated with initial phases of treatment, i.e., first six months. Agranulocytosis with clozapine during the initial phases of treatment has been linked to genetic vulnerability in the form of variations in the human leukocyte-antigen haplotypes. However, there is limited literature on late onset agranulocytosis with clozapine and this has very rarely been linked to human leukocyte-antigen haplotypes vulnerability. In this report we review the existing data on late onset agranulocytosis with clozapine and describe the case of a young man, who developed agranulocytosis with clozapine after 35 months of treatment and was found to have genetic vulnerability in form of being positive for HLA DR4. This case highlights underlying autoimmune immune mechanism in clozapine-induced agranulocytosis and the need for frequent blood count monitoring on clozapine even after the initial 6 months of starting treatment especially in patients with genetic vulnerability to develop this condition.

Evaluation of a novel, non contact, automated focal laser with integrated [NAVILAS[restricted] ] fluorescein angiography for diabetic macular edema

To evaluate the procedural experience and complications of a novel integrated laser delivery system [NAVILAS; OD-OS Teltow, Germany] that combines automated laser delivery with color fundus photography, fluorescein angiography [FA], fundus autofluorescence [FAF] and infrared imaging with a frequency doubled YAG laser. This prospective study evaluated surgical experience with the NAVILAS automated photocoagulation system for the treatment of patients with diabetic macular edema [DME]. Subjective assessment of the accuracy of laser spot placement and postoperative complications were documented. Twelve patients [7 males, 5 females] were enrolled in this pilot study. Five patients were phakic and 7 were pseudophakic. Image overlays and the tracking system allowed accurate delivery of laser spots of varying size, duration and power. None of the patients reported any pain and tolerated the procedure well. No complications were reported in the study. In this pilot study, the NAVILAS system allowed accurate laser spot placement with no complications in patients with DME. However a larger sample with longer follow up is required to determine the safety of this procedure

Cost of illness of schizophrenia

Economic evaluation provides a methodology that allows policy makers, managers and clinicians to make choices between differing treatments, settings and illnesses in order to facilitate the judicious use of scarce resources. There are several methods of economic evaluation, cost of illness being one of them. Schizophrenia imposes huge economic impact on individuals, families, and communities. This paper attempts to review the issues related to carrying out cost of illness studies, the findings of cost of illness studies done for schizophrenia from various countries and various sociodemographic and illness factors which influence cost of illness of schizophrenia