Evaluation and Comparison of the Effectiveness of Atropine Eye Drops, Ipratropium Bromide Nasal Spray, and Amitriptyline Tablet in the Management of Clozapine-Associated Sialorrhea in Patients With Refractory Schizophrenia: A Randomized Clinical Trial.

PURPOSE: Clozapine, a second-generation antipsychotic medication, is mainly indicated for managing treatment-resistant schizophrenia. Among all the nonthreatening adverse effects of clozapine, sialorrhea is a stigmatizing complication occurring in approximately 31.0% to 97.4% of patients. In this study, 2 topical agents (atropine eye drop and ipratropium nasal spray) and a systemic medication (amitriptyline) were compared simultaneously for the management of clozapine-associated sialorrhea. METHODS: We conducted a randomized, single-blinded, non-placebo-controlled clinical trial from June 2022 to January 2023. Eligible patients were randomly allocated into 3 mentioned groups. Patients were monitored for sialorrhea weekly based on scales, including the Toronto Nocturnal Hypersalivation Scale, Clinical Global Impression-Improvement, and Clinical Global Impression-Severity for 1 month. Possible adverse drug reactions and adherence were also recorded. RESULTS: Twenty-four patients, including 6, 10, and 8 individuals in ipratropium bromide nasal spray, atropine eye drop, and amitriptyline groups, completed the study, respectively. The cohort's demographic, baseline clinical, and sociocultural characteristics were comparable among the 3 groups. Within-group comparisons, between times baseline and week 4, demonstrated that significant differences were in groups atropine and amitriptyline based on Toronto Nocturnal Hypersalivation Scale, in 3 groups based on Clinical Global Impression-Improvement, and also in only-atropine group based on Clinical Global Impression-Severity. Likewise, between-group comparisons showed that atropine was significantly more effective in clozapine-associated sialorrhea management than amitriptyline and ipratropium, in the first 2 weeks and second 2 weeks of study, respectively. Regarding safety, the interventions were tolerated relatively well. CONCLUSIONS: Conclusively, atropine is more efficacious than amitriptyline, within the first 2 weeks of study and also relative to ipratropium, overall. As time effect was significant between atropine and amitriptyline, according to analysis of covariance test, further investigation with longer follow-up duration would be prudent. In addition, expanding patient population with larger sample size should be conducted for more precision.

Family-centered collaborative care for patients with chronic mental illness: A systematic review.

Background: Chronic mental illnesses (CMI) are long lasting and reoccurring and require continuous care as well as an integrated and collaborative approach to organize the care. This study sought to examine whether family centered collaborative care is an acceptable treatment option for individuals with CMI. Materials and Methods: From the years 2000 to 2021, ten electronic databases relating to family centered collaborative care for mental illness were searched adopting Preferred Reporting Items for Systematic Reviews and Meta Analysis checklist. Twenty seven relevant articles and a thesis from among 6956 studies retrieved, were assessed their quality appraisal through four standardized tools. The studies were rated as good, moderate, or poor. Studies were calibrated, different opinions were discussed, and extracted data were done. Results: Evidence included 11 randomized controlled trials (from 19 articles), one randomized control trial, three mixed methods studies (from 3 articles and 1 thesis), and a qualitative study (from 4 articles). The quality of seven studies was good, 15 were moderate quality, and seven were poor quality. According to moderate to high quality qualitative research, family centered collaborative care was considered an acceptable intervention; though a few studies supported it. Conclusion: The findings demonstrated that family involvement in the care of patients with CMI affects no recurrence of the disease, and no re hospitalization of patients with this disorder. As a result, engaging family members in the care process can have a positive impact on the health and well being of these patients.

How can healthcare providers involve with families in the care of patients with chronic mental illness? A mixed methods protocol study to adapt the clinical practice guideline.

BACKGROUND: Chronic mental illnesses have long periods, are recurring, and require continuous care as well as an integrated and collaborative approach to organize the care. The purpose of this article is to summarize the most important steps necessary for adapting a clinical practice guideline for family-centered collaborative care of patients with chronic mental illnesses referring to the medical centers. MATERIALS AND METHODS: As the study will be an exploratory mixed methods study, the design will be carried out as a sequential qualitative-quantitative study (QUAL quan), consisting of 3 phases, 9 modules, and 24 sequential steps, which is based on the Guidelines International Network to adapt the guideline manual. In the first phase, the prerequisites for adaptation of the clinical guideline were established. In the second phase, to collect evidence, a qualitative study (semi-structured interview) will be conducted to explore the dimensions and components of the care needs of patients with chronic mental disorders and their families from the perspectives of patients, caregivers, and healthcare providers. Additionally, a literature review to extract relevant clinical guidelines and articles will be done. A panel of experts will screen and evaluate potential clinical guidelines, and a draft guideline will be developed. DISCUSSION: It is expected that these findings will meet the needs of patients with mental illness and their caregivers by providing integrated care and improving collaborative care within the sociocultural context of Iran.

Barriers to family involvement in the care of patients with chronic mental illnesses: A qualitative study.

Introduction: Caregivers are patients' family members or intimate friends who take care of individuals suffering from chronic mental illnesses without being paid. Evidence has supported the role of family-centered collaborative care in the treatment of patients with chronic mental illnesses. It has also been emphasized by national policies. However, carrying out this type of care is accompanied by challenges in Iran. Considering the importance of family participation in taking care of these patients as well as the necessity to determine its effective factors, the present study aimed to assess the barriers to family involvement in the care of patients with chronic mental illnesses. Method: A conventional content analysis was used to conduct this qualitative study. Thirty four health care providers, patients, and caregivers were interviewed unstructured in-depth face-to-face using purposive sampling. Until saturation of data, sampling and data analysis were conducted simultaneously. Graneheim and Lundman's method was used to record, transcribe, and analyze the interviews. Result: The results showed that there were many barriers to the collaboration of family in the care of patients with chronic mental illnesses. Accordingly, four main categories and twelve subcategories were extracted from the data as follows: "family-related barriers", "treatment-related factors", "disease nature threatening care", and "mental disease-associated stigma in the society". Conclusion: The findings presented the barriers to family centers' collaborative care in patients with chronic mental illnesses and the necessary components of family involvement in the care to be used by healthcare managers and policymakers. The reported barriers emphasize the need for the development of structured approaches whose implementation is easy for health care providers, does not require a lot of time and resources, and can improve patient and family outcomes.

A quality assessment of clinical practice guidelines with recommendations for family involvement in the care of individuals diagnosed with schizophrenia, bipolar mood disorder, and major depressive disorder: Critical appraisal utilizing AGREE II.

Introduction: Evidence suggests that family-center collaborative care is useful for individuals identified with chronic mental illness. Clinical practice guidelines offer specific recommendations primarily based on to be had studies and are beneficial in informing evidence-based practice and guiding destiny studies. Objective: Identify current scientific practice guidelines including family-center collaborative care suggestions for individuals with Bipolar Mood Disorder, Schizophrenia, and Major Depressive Disorder and analyze the selection of guidelines for their methodological quality. Methods: A systematic search was conducted on seven electronic databases (G-I-N), (NICE), (MOH), (SIGN), (WHO), (NIH) and (APA) and additional sources. Three referees independently reviewed articles and selected guidelines for inclusion criteria. Subsequently, 18 trained appraisers independently assessed all 15 guidelines using AGREE II. Results: The mean scores for domains and overall quality were computed. For the overall assessment of the guidelines, 60% reached the quality threshold with domain scores of 60%. The overall average quality rating for these guidelines was 58/29%. Conclusion: The applicability of the guidelines needs to be improved in order to improve their relevance and clinical utilization. As individuals with chronic mental illnesses progress through their disease course, families and health care providers play a crucial role in helping them. The analysis of research knowledge on effective rehabilitation techniques, including the involvement of families in treatment, can be enhanced by using well-developed and appropriate methods.

Psychiatric Adverse Drug Reactions and Potential Anti-COVID-19 Drug Interactions with Psychotropic Medications.

Coronavirus disease 2019 (COVID-19) management in patients with predisposing psychiatric disorders would be challenging due to potential drug-drug interactions (PDDIs) and precipitation of their disease severity. Furthermore, COVID-19 itself might precipitate or induce unpredicted psychiatry and neuropsychiatry complications in these patients. In this literature review study, the psychological impacts of COVID-19 and major psychiatric adverse drug reactions (ADRs) of COVID-19 treatment options have been discussed. A detailed Table has been provided to assess potential drug-drug interactions of COVID-19 treatment options with psychotropic medications to avoid unwanted major drug-drug interactions. Finally, potential mechanisms of these major drug-drug interactions and possible management of them have been summarized. The most common type of major PDDIs is pharmacokinetics. Hydroxychloroquine/chloroquine and lopinavir/ritonavir were the most involved anti-COVID-19 agents in these major PDDIs.

Is Sitagliptin Effective for Modulating Metabolic Disturbances Associated With Olanzapine in Schizophrenia Patients? A Double-blind Placebo-controlled Clinical Trial.

PURPOSE/BACKGROUND: The mortality rate of patients with schizophrenia due to metabolic disturbances is high. Our aim is to survey the effects of sitagliptin on metabolic disturbances associated with olanzapine in patients with schizophrenia. METHODS/PROCEDURES: In this 12-week double-blind placebo-controlled clinical trial, 71 patients taking olanzapine (10 to 30 mg) for at least 1 month were randomly allocated to enter 1 of the 2 treatment groups (olanzapine plus placebo or olanzapine plus sitagliptin). Sitagliptin was added to patients 'current medications with the dose of 100 mg/d. Physical examinations and measurement of anthropometric (body mass index and waist circumference) and laboratory parameters (fasting blood sugar, glycated hemoglobin, total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglyceride) were measured at baseline, week 4, and week 12. The patients were assessed for any side effects of the medications in each visit. FINDINGS/RESULTS: Sixty-one patients (30 in the sitagliptin and 31 in the placebo group) completed the trial. The anthropometric measurements at the end of the study did not differ between the 2 groups. glycated hemoglobin and total cholesterol were significantly lower in the sitagliptin group after 12 weeks. Other metabolic profile revealed either no change or minimal magnitude changes. No major side effect was reported. IMPLICATIONS/CONCLUSIONS: Metabolic disturbances associated with olanzapine treatment in patients with schizophrenia can be modulated by sitagliptin.

Effects of chronic methamphetamine abuse on the retinal nerve fiber layer, ganglion cell layer and Bruch's membrane opening minimum rim width.

BACKGROUND: Methamphetamine (Meth) is a highly addictive and hallucinogenic agent which is used as the second most common illicit drug globally. Meth could affect the retina and optic nerve by inducing the release of vasoconstrictive agents such as endothelin 1 and induction of severe oxidative stress with accumulation of reactive oxygen species. AIM: To evaluate the effects of chronic Meth abuse on the retinal nerve fiber layer (RNFL), ganglion cell layer (GCL) and the Bruch's membrane opening minimum rim width (MRW). METHOD: In this case-control study, we recruited 55 Meth abusers and 49 healthy individuals with mean age of 44.63 ± 0.97 and 43.08 ± 0.91 years, respectively. RNFL thickness, GCL thickness and MRW were evaluated using optical coherence tomography. RESULTS: We found statistically significant decrease in RNFL, MRW thickness in Meth abusers (P: 0.002 and P: 0.006, respectively). We did not detect statistically significant difference regarding GCL thickness between the groups (P = 0.320). Our results showed a weak but statistically significant correlation of Meth dose increment and decrement of RNFL thickness ((P: 0.005, r = -0.193) and MRW (P: 0.013, r = -0.174). We found no correlation between duration of Meth consumption with RNFL and MRW thickness (P: 0.205, r= -0.124; P: 0.771, r= -0.029, respectively). CONCLUSION: We found a statistically significant adverse association in meth abusers with RNFL thickness and MRW. These two parameters were also statistically associated with the meth dose as measured by daily dose of Meth. Although we found a decrease in the GCL thickness, it did not reach statistical significance.

Orexin/Hypocretin Type 2 Receptor (HCRTR2) Gene as a Candidate Gene in Sertraline-Associated Insomnia in Depressed Patients.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are considered as first-line drugs for treating depressive disorders. Among the adverse effects reported with sertraline is sleep disturbances; however, the etiology lying beneath is obscure. Orexin, the most recently discovered neurotransmitter, is involved in the sleep cycle. It exerts its physiological actions through orexin or hypocretin type 1 and 2 receptors (HCRTR1 and HCRTR2). Dysfunction of the orexin system contributes to various psychiatric, neurologic and neuropsychiatric disorders. Thus, our study aimed to assess the possible association of genetic variation of HCRTR2 G1246A with hypersomnia reported with sertraline in a group of major depressive disorder (MDD) patients. PATIENTS AND METHODS: Ninety-six newly diagnosed MDD patients were enrolled in our cohort study. MDD was assessed using DSM-V criteria. Insomnia Severity Index (ISI) was used to assess insomnia at baseline (week 0) and week 4. Blood samples were collected for further genotyping of HCRTR2 G1246A (rs2653349) using polymerase chain reaction-restriction fragment length polymorphism. RESULTS: A significant association between G1264A polymorphism of HCRTR2 and insomnia was observed. Insomnia with sertraline happens by 2.5-fold (P=0.022; odds ratio (OR)=2.5; 95% confidence interval (CI): 1.1-5.7) in patients having GG genotype. Patients with G allele experience insomnia by 2.1-fold more than A allele carriers (P=0.022; OR=2.1; 95% CI= 1.1-4.0). Subgroup analysis showed a significant association between GG genotype as well as the G allele and insomnia only in female MDD patients (P=0.011; OR=4.0; 95% CI=1.3-12.0 and P=0.033; OR=2.4; 95% CI=1.02-5.7, respectively). CONCLUSION: In conclusion, the G1246A variant might be a predictor for insomnia in MDD patients treated with sertraline. Our findings support the idea that some variants of the HCRTR might contribute to inter-individual variability in the sleep pattern of patients receiving antidepressants.

Exploring the Demographic Factors and Facilitators to Addiction Abstinence.

BACKGROUND: Accumulating evidence indicates a remarkable increase in substance addiction. Substance abuse and addiction impose severe social, political, economic, cultural and health-related damages on societies. Little is known, however, about demographic factors and facilitators to addiction abstinence. The purpose of the current study was to explore the factors associated with opioid avoidance. MATERIALS AND METHODS: This cross-sectional study was performed to record socio-demographic data and facilitating factors to abstinence in 600 interviews, according to data collecting forms, with patients who had drug abuse disorders at Shiraz city during 2016. Correlation test, T-test, and ANOVA were employed for data analysis. P value <0.05 was considered as the significance level. RESULT: There was a significant difference between mean abstinence time and demographic factors such as age, sex, occupation and marital status. Also, 53% of people reported that they had the longest abstinence time using the narcotics anonymous (NA) method. TO 33% of patients, the most important facilitating factor in abstinence according to the patient's opinion was family support. CONCLUSION: Individual, social, psychosocial and medical variables affect the abstinence duration of substance abuse. Identifying the factors associated with longer abstinence can be helpful in designing prevention and treatment programs for variables that affect the recurrence.

Anger management in substance abuse based on cognitive behavioral therapy: an interventional study.

BACKGROUND: Anger and aggression have been developing notably in societies, especially among patients depending on substance abuse. Therefore, this study aimed to investigate the effect of anger management based on group education among patients depending on substances according to Patrick Reilly's cognitive behavioral approach. METHODS: In a quasi- experimental study, all patients who met the inclusion criteria were evaluated regarding their aggression level. The participants were assigned to 12 educational sessions based on group therapy and Patrick-Reilly's anger management by focusing on using a combination of cognitive intervention, relaxation, and communication skills. The data were analyzed using the SPSS statistical software, version 16. RESULTS: The findings showed a significant difference between the two groups regarding aggression level after the intervention (p = 0.001). No significant relationship was observed between aggression level and demographic variables (p > 0.05). CONCLUSION: The intervention of this study can be used for establishing self-management and decreasing anger among patients depending on substances. They can also be used as a therapeutic program in addition to pharmacotherapy. TRIAL REGISTRATION: IRCT2016102030398N1 .

A randomized double blind placebo controlled clinical trial of N-Acetylcysteine added to risperidone for treating autistic disorders.

BACKGROUND: This study examined the efficacy and safety of N-acetylcysteine (NAC) augmentation for treating irritability in children and adolescents with autism spectrum disorders (ASD). METHOD: Forty children and adolescents met diagnostic criteria for ASD according to DSM-IV. They were randomly allocated into one of the two groups of NAC (1200 mg/day)+risperidone or placebo+risperidone. NAC and placebo were administered in the form of effervescent and in two divided doses for 8 weeks. Irritability subscale score of Aberrant Behavior Checklist (ABC) was considered as the main outcome measure. Adverse effects were also checked. RESULTS: The mean score of irritability in the NAC+risperidone and placebo+risperidone groups at baseline was 13.2(5.3) and 16.7(7.8), respectively. The scores after 8 weeks were 9.7(4.1) and 15.1(7.8), respectively. Repeated measures of ANOVA showed that there was a significant difference between the two groups after 8 weeks. The most common adverse effects in the NAC+risperidone group were constipation (16.1%), increased appetite (16.1%), fatigue (12.9%), nervousness (12.9%), and daytime drowsiness (12.9%). There was no fatal adverse effect. CONCLUSIONS: Risperidone plus NAC more than risperidone plus placebo decreased irritability in children and adolescents with ASD. Meanwhile, it did not change the core symptoms of autism. Adverse effects were not common and NAC was generally tolerated well. TRIAL REGISTRATION: This trial was registered at http://www.irct.ir. The registration number of this trial was IRCT201106103930N6.