Resolution without discontinuation: heart failure during clozapine treatment.

Clozapine is an atypical antipsychotic recommended for patients with treatment-resistant schizophrenia whose illness has not responded adequately to treatment despite the sequential use of at least two different antipsychotic drugs at therapeutic doses. Unfortunately, clozapine is frequently discontinued due to both real and perceived serious, and potentially life-threatening, adverse effects, contributing to the underutilisation of the most effective treatment in refractory psychotic disorders. Here, we present the case of a 51-year-old man with treatment-resistant schizoaffective disorder, who was admitted to a locked rehabilitation unit for a clozapine rechallenge. Within 6 months after the clozapine rechallenge, he was diagnosed with heart failure likely secondary to his antipsychotic treatment. Clozapine-induced heart failure usually prompts immediate cessation of treatment. However, in this case, clozapine was continued with cardiology consultation. Ramipril and bisoprolol were initiated and the patient's cardiac condition progressively improved over time. Clozapine-induced heart failure is a serious cardiovascular complication of treatment, usually resulting in discontinuation of treatment. Although there are cases of successful rechallenge, temporary cessation of treatment can lead to severe psychotic exacerbation and non-engagement with cardiac specialists. More evidence is required for continued use of clozapine in a patient with clozapine-induced cardiac complications.

Need to bleed? Clozapine haematological monitoring approaches a time for change.

Regular haematological monitoring during clozapine treatment reduces the risk of complications and death from clozapine-related blood dyscrasias. However, many patients in the course of clozapine treatment develop neutropenia unrelated to drug treatment which leads to treatment discontinuation. The minimum haematological threshold allowed for the continuation of clozapine treatment was recently lowered in the US, but not in the UK. In this case series, we present four cases where lowering the haematological cut-off to that used in the US, allowed treatment continuation. Lowering the current UK threshold for clozapine cessation could avoid unnecessary interruptions in treatment with minimal impact on safety.

Clozapine, HIV and neutropenia: a case report.

There is paucity of information on the use of clozapine in patients with HIV. Ethnicity, co-prescribed medications and possible drug-drug interactions are important considerations in evaluating risk of blood dyscrasias during clozapine treatment. Individuals with HIV should not be denied access to the most effective antipsychotic, but a multidisciplinary approach is essential for optimal outcome in such complex patients.

The Impact of co-morbid severe mental illness and HIV upon mental and physical health and social outcomes: a systematic review.

Our aim was to review the evidence related to the impact of co-morbid severe mental illness SMI (schizophrenia, schizoaffective and bipolar disorder) and HIV upon mental health, physical health and social outcomes. We carried out a systematic review of scientific evidence, searching online databases (MEDLINE, PsychInfo, EMBASE, Global Health and Scopus) for studies between 1983 and 2017 using search terms for SMI and HIV. Studies were included if they compared health or social outcomes between people living with co-morbid SMI and HIV and people living with either: a) HIV only; or b) SMI only. Outcomes of interest were: mortality, health service use, HIV/SMI-related, co-morbidities, and social outcomes. We identified 20 studies which met our inclusion criteria. Although studies were generally high quality, there was heterogeneity in both selection of outcomes and choice of measure. It was therefore difficult to draw strong conclusions regarding the impact of co-morbid SMI and HIV across any outcome. We found little evidence that co-morbid SMI and HIV were associated with lower levels of treatment, care or poorer clinical outcomes compared to people living with SMI or HIV alone. However, mortality appeared to be higher among the co-morbid group in three out of four analyses identified. Physical and mental co-morbidities and social outcomes were rarely measured. Limited data mean that the impact of co-morbid SMI and HIV is uncertain. In order to develop evidence-based guidelines, there is an urgent need for further research. This may be realized by exploring opportunities for using data from existing cohort studies, routinely collected data and data linkage to investigate important questions relating to this neglected but potentially important area.

Harnessing clinical psychiatric data with an electronic assessment tool (OPCRIT+): the utility of symptom dimensions.

Progress in personalised psychiatry is dependent on researchers having access to systematic and accurately acquired symptom data across clinical diagnoses. We have developed a structured psychiatric assessment tool, OPCRIT+, that is being introduced into the electronic medical records system of the South London and Maudsley NHS Foundation Trust which can help to achieve this. In this report we examine the utility of the symptom data being collected with the tool. Cross-sectional mental state data from a mixed-diagnostic cohort of 876 inpatients was subjected to a principal components analysis (PCA). Six components, explaining 46% of the variance in recorded symptoms, were extracted. The components represented dimensions of mania, depression, positive symptoms, anxiety, negative symptoms and disorganization. As indicated by component scores, different clinical diagnoses demonstrated distinct symptom profiles characterized by wide-ranging levels of severity. When comparing the predictive value of symptoms against diagnosis for a variety of clinical outcome measures (e.g. 'Overactive, aggressive behaviour'), symptoms proved superior in five instances (R(2) range: 0.06-0.28) whereas diagnosis was best just once (R(2):0.25). This report demonstrates that symptom data being routinely gathered in an NHS trust, when documented on the appropriate tool, have considerable potential for onward use in a variety of clinical and research applications via representation as dimensions of psychopathology.